Do experts know best?

‘Parents are most likely perpetrators’
Gwen Adshead, consultant forensic psychotherapist, West London
Mental Health Trust 

“Munchausen’s syndrome by proxy (MSBP) has come to be replaced
by the term factitious disorder by proxy. Although most cases cause
little serious harm, a small proportion might be fatal.

“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; they
were right in 80 per cent of their suspicions. I have watched
videotapes of mothers smothering their babies, and talked with
mothers who admit having done so.

“This 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 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 no scientific evidence. We do, however,
have hard evidence that mothers smother their children and call it
cot death. 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.”

‘The fault is with the judiciary’
Donna Kinnair, director of nursing at Southwark Primary Care Trust
and a member of the Department of Health’s MSBP methods of
identification steering group

“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.

“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. 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.”

‘Many doctors now feel frightened’
Richard Wilson, consultant paediatrician, Kingston
Hospital

 “Children who die because of cot deaths and homicides should be
considered as a separate issue from children who are alive but the
victims of fabricated or induced illnesses (FII). The Royal College
of Paediatrics does not use the term Munchausen’s syndrome 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.

“FII is difficult territory. I had a case where a child had a
congenital condition that gave her a number of problems. But 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 unnecessary major surgery. 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 in foster
care all the things her mother had 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.

“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 too much treatment, or are forever taking them to see
doctors. Those parents may not be nasty people but they are harming
that child. Where do you make a judgement about what is in that
child’s best interests? Would they be better off in foster care?
The trouble is that when you make a decision which is solely about
the child, it may have adverse consequences for parents. But this
is not about parents’ rights, it’s about the interests of the
child.

“Family courts are the right place 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. Probably most family court
decisions in FII cases are right.

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

“On the other hand, I’ve never felt 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 strong evidence, children shouldn’t be taken away at birth, or
at least not permanently. But you can argue that if a child is
going to be removed and adopted it’s better for it to happen
straight away.

“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 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
always saying was true. But there is no doubt that children are
being harmed by carers who fabricate or induce illness, and that
children have a right to be protected.”

‘Paediatricians shy away  from courts’  
Tink Palmer is Barnardo’s policy officer   on sexual
exploitation

“Fabricated or induced illnesses may result in the death of a
child if there is not timely intervention. However, carers showing
FIIoften have unmet psychological and emotional needs and are in
need of support from adult psychiatric services. I believe throwing
the full weight of the law at them may not be the correct way of
helping.

“There are concerns that children may be removed from their parents
unnecessarily. It is impossible to comment on this without knowing
each individual case.

“When FII is suspected the matter is managed by a group of
experienced child protection professionals. No decisions regarding
a child’s removal are 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. It is my
experience that paediatricians are cautious, caring and shy away
from presenting evidence in court unless it’s crucial.

“With the current highly charged state of affairs, one can envisage
that our paediatric colleagues will be reluctant to give expert
evidence on this topic. Yet it is this evidence that forms part of
the jigsaw that needs to be put together to form a clear picture of
what has happened to the child.”

‘We need to be much more sceptical’   
John Simmonds, director of policy, research and development at
Baaf Adoption and Fostering

“There is a lot of controversy about how evidence is collected
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
– 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. We assume that when somebody says something it is 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.”

Munchausen’s syndrome by proxy came to wider  public notice in
1993, when Beverly Allitt was convicted of killing four children
and injuring nine others. Her actions were linked to the condition.
Allitt carried out the crimes while working as a nurse on the
maternity ward at Lincolnshire’s Grantham Hospital between 1991 and
1993. She is serving 13 life sentences at Rampton secure
hospital.

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