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.
