* PAPER -
False and Highly Questionable Allegations of Munchausen Syndrome by Proxy
FALSE ACCUSATIONS OF MUNCHAUSEN SYNDROME by PROXY
presented by Dr Helen Hayward-Brown.
This Newsletter written in 2002 was originally requested by a government agency but there has been no confirmation of publication.
For references please refer to the paper on False and Highly Questionable Allegations of Munchausen Syndrome by Proxy for the short list, or the PHD for the full list. Thankyou.
* * * * *Over the last ten years there has developed a disturbing trend where many mothers are being falsely accused of Munchausen Syndrome by Proxy (MSBP). This has been the subject of my recently completed doctoral thesis. Mothers whose children suffer illnesses which cannot be easily diagnosed are at risk of being accused, particularly in the hospital context. The prejudice of this label is so great that a mother's credibility is completely destroyed. Children are usually removed from their care, often without adequate investigation, and mothers are only allowed minimal supervised contact with their children.
My research entailed interviews, perusal of documentation in many cases, and fieldwork with parents whose children had suffered difficult to diagnose illnesses. I made MSBP the main focus of my work when I discovered that a number of parents had been falsely accused or had been accused in highly questionable circumstances. In a few cases I recognised that a parent may have been suspected of MSBP without realising it. When these parents undertook a Freedom of Information audit of hospital files, this was found to be the case. Other parents did not access their files but realised why they had been treated in a strange way by medical professionals. I investigated a number of families who had been accused/suspected of MSBP over approximately 4-5 years.
What is MSBP?
Briefly, MSBP purportedly involves a mother deliberately making her child sick. According to Schreier and Libow (1993), this occurs because the mother wants attention from medical professionals. They argue that 95% of perpetrators are mothers. These mothers, apparently, are 'not wholly passive in their interactions with the medical profession'. It is therefore no surprise to find that many of the mothers in my research who had been accused were assertive mothers who asked questions about their children's illnesses and medical management.
It should be noted that the MSBP diagnosis lacks scientific validity. It is not a definitive category in the DSM IV (1994), only appearing in the appendix. It is a recent and extremely controversial diagnosis (Allison and Roberts, 1998). Expert testimony is often unreliable and usually does not fit the criteria established in the U.S in Daubert v Merrell Dow Parm. Inc. Despite its highly controversial nature, MSBP is being used extensively in the medical profession, by social services, and in court.
Parents and professionals should be aware that there are many similar labels to MSBP, which include the following: somatisation disorder, abnormal illness behaviour, folie a deux, pervasive refusal syndrome, hysteria, and factitious illness. Often the MSBP label will be combined with other labels. For example, a mother may be accused of both MSBP and shaken baby syndrome.
Who is at Risk?
Any parent who visits a medical practitioner with a child who is suffering from an unusual illness, an illness which is difficult to diagnose, or an illness which is disputed within the medical profession, is at risk of an MSBP accusation. Additionally, any child who undergoes surgery which may not be successful, is also at risk of a MSBP allegation. For example, the surgical procedure of fundoplication (mobilisation of lower end of the esophagus and plication of the fundus of the stomach around it [fundic wrapping] in treatment of reflux esophagitis) is often a catalyst for a MSBP allegation.
This risk is multiplied many times if the parent takes the child to a specialist at a children's hospital. Generally the MSBP allegation will occur in the hospital context. The family practitioner and even the family paediatrician's opinion will be disregarded because they will be seen as 'colluding' with the parents. Therefore, doctors who know very little about the family and their medical history, and who have had very little first-hand contact with them, will make the MSBP allegation.
Parents of children with specific illnesses will particularly be at risk. In my research, which is continuing, the following illnesses caused MSBP allegations: epilepsy, gastro difficulties including reflux and bleeding from the bowel, chronic fatigue syndrome, neurological disorders, immune difficulties, pesticide poisoning, multiple chemical sensitivity, congenital/genetic disorders, apnoea, attention deficit disorder, tonsil inflammation, vaccination reactions and drug reactions (for example, Cisapride, commonly used in Autralia but now withdrawn in U.S. and U.K.). Parents of children who have been premature also appear to be gravely at risk. These children suffer problems which are poorly understood and which have only evolved in recent times, as more premature babies are kept alive. Another illness which may be misinterpreted by the medical profession is 'brittle bone disease'. Many of the above illnesses overlap in relation to symptoms and may be inter-related. For example, severe reflux is a symptom of chronic fatigue syndrome, as is ulceration of the throat, which is also indicative of immune difficulties. If more than one child suffers similar problems in a family, the parent is more likely to be accused. This is particularly the case with apnoea and sudden infant death syndrome.
The issue of cot death is complex. Recently, the UK Criminal Court of Appeal found that statistics used by Sir Roy Meadow in terms of cot deaths were erroneous and had contributed to the wrongful conviction of Sally Clark. Meadow's Law had stated that one death is a tragedy, two is suspicious and three is murder. Meadow stated that there was a one in one million, later changed to one in 73 million chance of two deaths occurring in the same family. In fact, Dr David Drucker has recently found a cot death gene and suggests the chances may be as high as one in four.
Mothers who are assertive and ask questions are at risk of being suspected/accused. In particular, parents who make complaints are in a very high risk category. Single mothers are at risk, as they have no spouse to support them, and are often in hospital alone with their children. Single mothers on low incomes cannot afford the legal defence needed in order to retain their children. They seem ill-equipped to sense danger, and unlike the 'middle-class' mothers I interviewed, did not take action fast enough e.g. leaving the hospital at the first sign of strange medical behaviour. Mothers who accused ex-husbands of sexual abuse may also find themselves accused of MSBP as a counter allegation in the family court. Recently, it has also been indicated by Ryan (2000) that parents of children with unusual names are also likely to be suspect.
Profiling of Mothers and Indicators of MSBP
In addition to the above risk factors, mothers are often 'profiled' as MSBP perpetrators. This means that any mother who fits into these categories is profiled as 'MSBP'. Since many of these categories contain paradoxes, it is impossible for the parent to prove their innocence. For example, an over-protective parent is part of the MSBP profile, but so is a negligent parent. The use of profiling is extremely prejudicial, inaccurate, paradoxical and often nonsensical. For example a number of mothers in my research were accused of being too familiar with hospital personnel because they called them by their first names. See table below for the difficulties I have identified for the different characteristics of a MSBP perpetrator.
Of further concern is the tendency for doctors to engage in blackmail, as indicated by Morley (1995). Mothers are told that they must confess to MSBP or they are unlikely to get their children back. Mart (1999) also raises the notion of the 'anti-profile'. He asserts that the opposite of the behaviours listed would be far more abnormal than the profile behaviours themselves.
Recently further disturbing trends have emerged. Adherents to the MSBP diagnosis are now including 'exaggerating a child's illness' as a symptom of MSBP. This is alarming because one of the main difficulties for parents of children with difficult to diagnose illnesses is the fact that the child's symptoms are trivialised by the medical professional. For example, Davina spoke to me about the fact that her daughter's chronic fatigue syndrome was dismissed as a series of trivial symptoms: shortness of breath became hyperventilation, pharyngeal ulcerations became self-injury, facial swelling became subjective puffiness, cardiac symptoms became 'lack of social life' and pathology venepuncture sites became IV drug abuse. Once I asked a psychologist at a conference how he knew that a mother was exaggerating her child's illness. He was unable to answer this question.
Even more alarming is the fact that an eventual diagnosis of a child's illness will generally not protect the mother from MSBP accusations. Most parents accused of MSBP engage in a desperate search for a valid diagnosis for their child. However, access to a second opinion is usually blocked by a MSBP diagnosis. Parents will be accused of 'doctor shopping'. In one of the cases I studied, both parents were charged with contempt of court when they took their daughter to a gastroenterologist, despite the fact that they obtained a diagnosis for her bowel complaint. If the parent does obtain a diagnosis, the medical profession will argue that an identified illness may co-exist with MSBP. This argument protects professionals from being sued for negligence (for example, lack of diagnosis delaying treatment, wrongful removal of the child etc).
Paediatric versus Psychiatric 'Diagnosis' of MSBP and Diagnosis by Immaculate Perception
Meadow was the first practitioner in 1977 to use the term Munchausen Sydnrome by Proxy. For practitioners such as Meadow, Southall and Davis, the 'diagnosis' of MSBP is a paediatric one. It is labelled child abuse and a psychiatric diagnosis of the mother is given low priority. But how can we consider the child's condition, without reference to the mother's behaviour, when the mother is being accused of making the child ill? Unfortunately, this emphasis on the child often means that the mother may not be interviewed. It also leads to diagnoses which may exclude genetic and other factors. Dr Southall was suspended from child protection work for two years during the Griffiths Inquiry into his research work and MSBP accusations. Despite reinstatement this year, he is facing a full investigation by the British General Medical Council in relation to MSBP accusations. Many of these concerns involve a recording device for breathing which other specialists have argued is highly inaccurate, leading to false accusations of mothers.
In the U.S., the 'diagnosis' is seen as a psychiatric one, led by practitioners such as Schreier and Feldman. The mother is diagnosed with a mental illness. Despite the focus on the mother, interviews may still not be conducted. For example, Schreier testified in the Storck case that 'it was not important to interview the mother [He offered that such an interview would have served no useful clinical purpose since he] cannot discern from parent interviews who is telling the truth and who is not' (Bergeron 1996). Recently, there has been a shift in the diagnosis in the US, with more paediatricians becoming involved. This has also caused some psychiatrists in the US to voice concerns about paediatricians making diagnoses when they may be using toxic drugs on children which were originally intended for adults with mental health difficulties. In some ways, this can be seen as a battle over territory and authority by psychiatrists and paediatricians.
Both versions of the diagnosis lead to what parents colloquially refer to as 'diagnosis by immaculate perception' (Bryan, pers. com.). The mother is not interviewed, and in many cases the child may not be seen by social services before removal from the mother. In Australia, the diagnosisí flits from the paediatric to the psychiatric. If a parent receives a psychiatric report refuting MSBP, then this report is deemed irrelevant. The 'diagnosis' turns into a paediatric one, despite the fact that the medical professionals requested the psychiatristís report in the first place. I have watched a psychiatrist in court give a psychiatric evaluation of a mother, despite the fact that he had never consulted with her and had only met her briefly in court on one other occasion.
It is true that some parents harm their children. However, as Morley argues, rather than resorting to a label such as MSBP which is prejudicial and inaccurate, the situation should simply be described. If it is suffocation or poisoining, call it that. It is interesting that many parents have had their children removed, but criminal charges are rarely laid against them. The evidence simply does not exist to convict them. It is of some concern that many innocent parents are being accused of MSBP and much time is spent by the authorities pursuing them in court.
Difficulties Faced in the Process of a MSBP Accusation
Once an accusation of MSBP is made, it is almost impossible to stop the process. Baldwin (2000) refers to this as the 'trajectory' of MSBP. If a mother is suspected or accused, she will lose all credibility. She will be seen as a liar and pretender. Her normal caring motherly attention will be interpreted as 'imposturing' and pretence. References from upstanding members of the community will not protect her. The opinion of her local doctor will not protect her. She will be seen as guilty. She may often be given little indication that her child is about to be removed and she may be given very little time to prepare herself for court For example, in one of my research studies, Fiona had to defend herself in the district court against three lawyers. Recently there appear to have been a couple of shifts in tactics in Australia. Children are now being removed 'without notification' so that the parents have no time to prepare themselves or defend themselves against the child's removal. Additionally, both the mother and father may be accused of MSBP. This will stop the father acting as an advocate for his wife.
Within the wider community, doctors may alert the child's school and neighbours may also be interviewed. This makes the mother a pariah in her local area. Some parents spoke to me about their inability to get work after an accusation, whilst others spoke about their terror in case their employers should find out .
There is not enough space to detail the many difficulties in the processes involved in a MSBP accusation. Parents have outlined repeated patterns which include the following: breaches of social services policies and procedures, breaches of child protection unit policies and procedures, refusal and/or inability of social services to investigate a medical doctor's notification which is accepted without qualification, refusal of doctors to accept social service assessment of children if they believe the mother is innocent, exclusion of documents indicating innocence, tampering with files, fabrication of evidence, hearsay evidence in court, intimidation, blackmail, cruelty to the child involved, withdrawal of treatment, hospital errors and mismanagement, lack of knowledge of overseas expertise or lack of expertise in the relevant specialty, and attribution of father's comments to the mother. Most parents provided me with documentary evidence of many of these practices.
The Ramifications of a False Accusation of MSBP
First, a truly sick child may have medical treatment withdrawn. In some cases the child may die. In other situations, mothers become too terrified to take their child to the doctor for fear of being accused of 'doctor shopping'. Doctors use a 'snowballing' technique, where they inform each other of the mother's problem, so that she is unable to access appropriate care for her child. For example, in a case where a child suffered the ill effects of vaccination, and the child was removed as a MSBP victim, I sighted a medical document which indicated that the foster mother was not to be trained in resuscitation techniques, as there was nothing wrong with the child.
In addition to medical damage, there is the fiscal damage which ensues. Parents often become involved in lengthy court battles, which leave the family bankrupt. Homes and cars must be sold. Often employment is lost, due to stress and the time involved in mounting defences. Generally, if a child is removed from its parents, it seems impossible for the parent to regain custody of the child. In my case studies, innocent parents who managed to keep their children had a much better chance of quashing the MSBP accusation. Sadly, my research indicates that compliant parents are more likely to lose their children than those who mount resistance.
Removal of a child from a parent leads to maternal and familial deprivation. This also occurs if the mother is imprisoned. Fear, anxiety, anger and distress are all common long-term inheritances of these painful experiences. Siblings demonstrated high levels of anxiety about being removed from the home. However, at the heart of false accusations is the family's very deep sense of betrayal. Their trust and belief in the medical and legal systems is completely destroyed. Even if proved innocent, the damage to the family's reputation remains.As stated above, some parents do harm their children, but this should be represented as suffocation or poisoning, so that the prejudice of MSBP is removed. There needs to be greatly increased accountability and transparency in purported MSBP cases so that innocent families are not harmed.