Expert view

Here our panel of professionals analyse the recent
controversy over the theories of Sir Roy Meadow on Munchausen’s
syndrome by proxy and the principle of experts giving evidence in
court cases.

Richard Wilson, consultant paediatrician, Kingston
Hospital:

“Dead children – ie cot deaths and homicides –
should be considered as a separate issue from live children who are
the victims of fabricated and induced illnesses (FII). The Royal
College of Paediatrics doesn’t use the term
“Munchausen’s by proxy” because it implies that
you can diagnose something in the parent. You can’t.
You’re deciding about the child – whether the
child’s story has been fabricated or the illness has been
induced, and you’re making a decision about whether this
child is coming to harm as a result of it.

“FII is really difficult territory. I had a case where a
child had a congenital condition which gave her a number of
problems. Her mother fabricated stories about the severity of the
girl’s condition, took her all over the world seeking help,
to the point that the girl had major surgery which was completely
unnecessary. People noted that the mother’s behaviour towards
the child wasn’t what it should have been, and eventually she
was taken into foster care. While she was in foster care all the
things her mother reported didn’t seem to happen. The child
was happy and didn’t want to go back to her mother, and the
courts decided she shouldn’t go back. That’s relatively
straightforward.

“Where it gets complicated is when you’ve got a
child who has either no illness or something relatively mild like
asthma, and the parents make up stories that the asthma is far
worse, and give the child far too much treatment, or are forever
taking them to see doctors so the child never gets to school.

“Now those parents may not be nasty people – they
might simply be very obsessional, protective people – but
they are harming that child. Where do you make a judgement about
what is in that child’s best interests? In one case a child
with asthma was made to sleep in the garden, in a wardrobe lined
with silver paper. That child loved his mum, he knew she was mad,
he put up with it. Would he be better off in foster care? The
trouble is that when you make a decision which is solely about the
child, that may have adverse consequences for parents. But this is
not about parents and parents’ rights, it’s about the
interests of the child.

“Family courts are the right places to decide these issues
because it is an investigation rather than a win/lose situation.
Judges can ask experts to sit down together and come up with some
sort of agreement. It can get a bit adversarial, but it’s not
like the legal process in criminal cases. I do think that probably
most family court decisions in FII cases are right.

“There are some caveats to that. I think it’s
unfortunate that courts are reluctant to take children away for
short periods, because it can be incredibly helpful. If all the
symptoms disappear then you’ve got some good evidence of what
is really happening.

“On the other hand, I’ve never felt very comfortable
about babies being taken away at birth, even when in extreme cases
a mother has admitted she’d killed the previous baby. In some
cases the mother’s thought processes were disturbed, in
others there have proved to be natural causes that weren’t
originally identified. So unless there is really very strong
evidence, children shouldn’t be taken away at birth, or at
least not permanently. You can argue, on the other hand, that if a
child is going to be removed and adopted it’s better for it
to happen straight away.

“I do believe that the recent cases will make it more
difficult to get doctors to work in child protection cases. It is
difficult and stressful at the best of times, and being attacked by
parents and the press – physically as well as verbally
– means many feel very frightened. Roy Meadow was seen as
someone who was working to support doctors in this field.
There’s a separate issue about whether what he was saying was
always true. But there is no doubt that children are being harmed
by carers who fabricate or induce illness and children have a right
to be protected.”

John Simmonds, Baaf’s director of policy, research
and development:

“There is an issue about calling it a syndrome and giving
it a dramatic title. It’s important to get underneath what we
mean by MSBP. That is the possibility that some parents have a
mental health problem that leads them to induce illness in their
children, be it by poisoning or holding a pillow over their face
for example, and there’s no doubt that this does exist.

“MSBP is about gaining attention and the excitement of
having doctors and nurses around and undertaking emergency
procedures. It often doesn’t lead to death but if a small
child is harmed often enough that’s a risk. But MSBP and
killing your child shouldn’t be muddled up.

“There is a lot of controversy about how we collect
evidence on MSBP and if you have suspicions how you provide support
and help when the needs of the adult have to be weighed against the
needs of the child.

“There’s an issue of relying on too much secondary
evidence. There needs to be more work on protocols for experts in
care proceedings – whether it’s done by the Lord
Chancellor’s Department, the Department of Health or the
Department for Education and Skills. Experts’ credentials are
explored at the beginning of giving evidence, but what makes
someone an expert and how they go about their work is something
that could be given further thought.

“The cases involving Roy Meadow open up whether we are
relying too much on experts rather than the evidence on which they
base their opinion. The distinction I make is that there’s
one set of evidence that relies on hard facts and there’s
soft evidence, for example, things people say, things that
don’t add up, things that require us to construct a
hypothesis of what might happen. These two distinctions between
hard and soft evidence often become blurred where you have an
expert saying ‘this must be the case because I say it
is’ rather than ‘this is my view’.

We assume that when somebody says something it’s based on
hard evidence – particularly when it’s statistical evidence.
We need to be much more sceptical. We are dealing with
probabilities rather than certainties. This is the case for lots of
syndromes in the medical profession. It’s important that we
recognise that when we make judgements the degree of certainty we
can have is never 100 per cent.”

Donna Kinnair, director of nursing at Southwark primary
care trust and a member of the DoH’s MSBP methods of
identification panel:

“I have come across MSBP as a health visitor and a child
protection adviser. I have seen cases in hospital where parents
have interfered with feeding tubes for their child even when we
were investigating their child’s weight loss, so I know it
exists.

“Decisions should be based on a thorough risk assessment.
I don’t believe you can have expert opinion alone, you have
to take all the factors into consideration. It is incumbent on all
of us to take account of the factual evidence before us.

“We use experts for many things throughout the whole of
our judicial system. If you are going to rest so much on medical
opinion then that should be tested. For me, the fault is with the
judiciary. The courts should test on what evidence experts base
their opinion. We are encouraging people to become bigger than they
are. If the only factor that a decision has been based on is the
opinion of one expert, even though a whole host of other things
should have happened, it would mean there’s something wrong
with the whole process.”

Tink Palmer, policy officer for sexual exploitation at
Barnardo’s:

“In 2001 the government issued national guidance regarding
the management of cases of children in whom illness is fabricated
or induced. This is a comprehensive document outlining the
background to this concerning behaviour. It is an official
acknowledgement that this condition does exist.

“We know that carers who try to harm their children often
have unmet psychological and emotional needs which frequently have
their roots in their own childhoods. They are generally in need of
support from adult psychiatric services but because of the very
nature of their condition, do not always appear
“needy”.

“FII may result in the death of a child if there is not
timely intervention. The fact that a carer can kill the child in
their charge is an emotive issue which brings out a high degree of
anger and condemnation by some members of the public. However, such
carers are suffering from a recognised “condition”, and
it has been my view that to throw the full weight of the law at
them may not be the correct way of helping them.

“There are concerns regarding the fact that children may
be removed from their parents unnecessarily. It is impossible to
comment on this without knowing each individual case. However, when
FII is suspected the matter is managed by a group of experienced
child protection professionals. No decisions regarding the removal
of children would be taken by a single person and the ultimate
decision should be put before the judiciary.

“The concern that individual expert opinion has been given
too much weight in specific cases has led to the announcement that
there will be a review of some cases. In the interests of justice,
it is inevitable that these reviews should take place. However, one
needs to be mindful of the fact that in many such cases there are
often a number of concerns regarding the child’s care which
precipitate an application for care proceedings – it is
rarely as simple as the one diagnostic factor.

“It is my experience that paediatricians are, on the
whole, cautious and caring and shy away from having to present
evidence in court unless it is absolutely crucial. Whilst the
current highly charged state of affairs is in place, one could
envisage the possibility that our paediatric colleagues will be
very reticent to give expert evidence on the topic of FII and yet
it is this very evidence which forms part of the jigsaw which needs
to be put together to form a clear picture of what has happened to
the child for whom there is concern.”

Gwen Adshead is a consultant forensic psychotherapist,
West London Mental Health Trust:

“The term Munchausen’s syndrome by proxy was coined
in 1977 to describe some highly unusual behaviour by parents
(usually mothers). Mothers took their children to doctors, saying
that they were ill; but when the child’s condition was
investigated, nothing was found.

It was later found that these mothers had either made up
accounts of symptoms that had never happened, or sometimes produced
fake ‘signs’ of illness, such as putting menstrual
blood in their child’s urine to suggest urinary disease. In
the original description of three cases, all the mothers denied the
behaviour, even when they were caught red-handed. It was also noted
that these mothers seemed very caring; that they used up a lot of
medical resources, and that harm could be done to the children as a
result of excessive or unnecessary investigations.

“Over the last 25 years, more information has come to
light about this puzzling behaviour by mothers. There are numerous
case studies describing different types of symptom or sign made up
by the parent. The MSBP term has come to be replaced by the term
‘Factitious Disorder by proxy’, factitious disorders
being those, which are made up or fabricated. Almost every sign or
symptom of disease can be used in this behaviour; there are case
reports of factitious brain tumours, chest disease, and
neurological disorders. This behaviour does not just occur in
hospitals; GPs may often be the first place where a mother
demonstrates this behaviour, sometimes just by presenting
repeatedly and excessively.

“Although probably most cases of this behaviour causes
very little serious harm, a small proportion (probably no more than
10-20 per cent of cases) may be fatal. There are numerous case
reports of mothers who have poisoned their children with salt or
prescribed medication. In one study of babies admitted to hospital
with breathing difficulties, deliberate suffocation by the mother
was the cause in several cases. This was established after police
investigation and based on the physicians excluding any other
possible cause; interestingly, they were right in 80 per cent of
their suspicions.

“In my own practice as a researcher and clinician, I have
watched videotapes of mothers smothering their babies, and also
talked with mothers who admit having done so. I have also talked to
mothers who admit smothering their babies and subsequently claiming
this as cot death.

“This sort of data is why all doctors involved in child
protection have to be suspicious of parents who present with
injured or unusually ill children. It goes against the grain to be
suspicious, but in cases of child abuse of any sort, the parents
are the most likely perpetrators.

The other real scientific problem is that we do not know what
causes sudden infant death syndrome. There is talk about a genetic
or infectious cause, but actually no scientific evidence that this
is so, only theory. We do, however, have hard evidence that mothers
smother their children and call it cot death: evidence that comes
from the mothers themselves or from video evidence. For this reason
alone, paediatricians will always have to consider factitious
disorder by proxy in cases of multiple cot deaths – not to do so
would be to ignore good medical evidence.