In recent years, several mothers in the autism community have been accused of Munchausen Syndrome By Proxy (MSBP), in which the mother is thought to be imagining the medical problems in her son/daughter. Former law professor, Dr. Bill Long, wrote a review paper for lawyers and judges on MSBP. Dr. Long’s Executive Summary is below.
MUNCHAUSEN SYNDROME BY PROXY (“MSBP”)/FACTITIOUS DISORDER BY PROXY (“FDBP”):
A Guide for Judges, Lawyer and Parents
Dr. Bill Long; firstname.lastname@example.org
For more than 30 years prosecutors, social workers and many mental health professionals have used a diagnosis of MSBP/FDBP as a means of taking children from their caregivers and then, often, bringing charges against the caregiver for abusing the children. At the heart of MSBP/FDBP is the allegation that the caregiver (usually the mother) is either lying about the medical symptoms experienced by the child or has induced real symptoms through poisoning or other injurious actions against the child. Why would the mother/caregiver do such a thing? Those who “believe in” the diagnosis argue that she does so in order to get attention from the medical community, often for unmet needs in her own life, and become the center of attention in a complex medical drama that she is inducing. Thus, the heart of a MSBP/FDBP allegation is that the mother or child’s caregiver is secretly “working the system” and trying to deceive multiple levels of medical staff as she goes about her nefarious design of injuring and perhaps even killing her child. Because the allegation of MSBP/FDBP relates to child endangerment, it has been a “hot button” sub-issue in the larger world of child abuse that has been at the fore of American social services and law in the past generation.
It is often difficult for prosecutors to “prove” that a mother has actually injured her child, especially since so many of the mothers alleged to be “MSBP/FDBP” “moms” themselves have medical training, personal charm, apparent solicitude for the child’s well-being and the well-being of the medical staff attending the child. Direct evidence (e.g., eyewitness testimony of induced poisons) is hard to come by; circumstantial evidence, too, is often scanty. Thus, the allegation of MSBP/FDPB—that the mother suffers from this “syndrome”–can be a sort of evidentiary boost for the prosecution when its case might otherwise be weak. By arguing that it is consistent for the sufferer of the “syndrome” to be an outwardly caring mother, one who eagerly seeks medical advice and affirms the medical staff, prosecutors can leap over a sometimes yawning evidentiary gap and help the state pry the child away from the parents. Then, as is argued in the paper, prosecutors need only refer to vague “studies” that show that children returned to MSBP/FDBP mothers face a significant likelihood of physical danger and even death at the hands of the caregiver, and courts almost always deprive parents of their child/children. Though child abuse is a significant problem and one that ought to be seriously addressed at all levels of society, the allegation of MSBP/FDBP can function as a evidentiary “short cut” to help make a prosecutor’s case for him/her when direct or circumstantial evidence is lacking.
One of the criteria for MSBP identified in a classic study is that the child’s symptoms abate when separated from the perpetrator. This is taken to be a sign that the caregiver induced or fabricated the symptoms. Yet, when the classic article using this definition is examined, one finds that the statistics she provides not only don’t support her point but actually lead to the opposite conclusion. Indeed, her evidence points to most cases of worsening of symptoms happening in the hospital. Of course, one could argue that these symptoms were induced by the caregiver in that context, but she does not so argue. In addition, if one thinks about this point for a moment, one would normally expect the child’s symptoms to abate when give over to the medical professionals. Perhaps as a result of the flimsiness of this criterion, later papers and definitions of MSBP don’t include it as a feature of MSBP.
I argue in the paper that the result of this kind of thinking and action has led to dramatically bad consequences for parents and their children, children who may have medical conditions that are difficult to diagnose and treat. If the mother, for example, denies that she has induced the physical ailment in her child, the state can say, “Ah, a denial is a sure sign that the mother is guilty of being an MSBP/FDBP mother. Thus, we recommend the child be taken away.” If, on the other hand, the mother “confesses” to having induced the illness in the child, the child will be taken away because a confession serves as direct evidence of the mother’s abuse of the child. Thus, mothers accused of being an “MSBP/FDBP mom” are in a Catch-22 type-of-situation. Shadowy allegations often are enough to take a child away from parents; and denials of abuse protect them no more than a confession.
With this the problem before us, I do two things in the paper: (1) describe the history of the diagnosis of MSBP/FDBP since its inception in 1977 and divide that history into four “sub-periods,” so that we can see the nature of the syndrome as it emerged in psychology and was developed in law; and (2) point out a number of vulnerabilities in the diagnosis that my historical discussion has uncovered. Four major difficulties with the diagnosis are: (a) its definition; (b) who is able to diagnose it; (c) who suffers from it (mother or child); and (d) what statistical evidence we have of the phenomenon. I argue that the cumulative effect of these problems is that that courts ought to stop accepting a diagnosis of MSBP/FDBP until they are satisfactorily cleared up. The remainder of this summary states my conclusions on (a)-(d).
First, with respect to definition, I show how the “classic” definition of MSBP in a 1987 article and the psychological definition of FDBP (the “successor” name for it), which appeared in the 1994 DSM-IV, differ in crucial ways. The 1987 article makes the mother’s intent and denial crucial to the definition of MSBP, while the 1994 definition focuses more on the induction of symptoms in the child than on caregiver intent. Indeed, in my article, I point to four ways in which the definitions aren’t consistent. On top of this is the fact that a new definition was introduced in 2000 as a significant professional group dealing with abused children created yet a third parallel syndrome—“Pediatric Condition Falsification.”
Second, the issue of who can diagnose MSBP/FDBP is a subtle one with wide-ranging ramifications. If it is only diagnosable by a mental health professional, then it will be done after suspicions are raised and tests are administered to the one suspected of MSBP. If, however, it is more of a “hypothesis” than a “conclusion,” social workers, educators, police, or anyone who might come in contact with a child whom they “suspect” might be a victim of MSBP can “diagnose.” But this difference of opinion on who can diagnose goes right to the heart of what MSBP is—a “syndrome” or a “suspicion.” The literature, as well as court cases, are confused on this point. A subsidiary point is when such a diagnosis may be made—at the beginning of the relationship between caregiver and professional or only after a process of examination has concluded?
Third, there is the issue of who suffers from MSBP. Most literature today says that it is the caregiver who does, but the classic 1987 article talks about the children being afflicted by MSBP.
Finally, there is disagreement on the statistics for MSBP. How prevalent is it? The early studies talked about its comparative rarity. Indeed, the 1987 study only found 117 cases of it in the previous 22 years of literature review—about 5.3 cases per year. But by the mid-1990s, some articles were claiming that the condition was not rare at all, and that courts, prosecutors, social workers and doctors must be on their guard to “smoke out” some of the hidden ways that this “syndrome” goes unnoticed. Along with great differences on the number of cases of MSBP is the related issue of the treatment of children if they are released back to their “Munchausen home.” With almost no foundation, some of the literature claimed that there was about a 20% chance that a child who goes home to Munchausen caregivers is going home to die. But when the 1987 study suggested a much smaller number, even the inventor of the “syndrome,” Dr. Roy Meadow, wrote to the publication saying that the 1987 numbers were highly inflated. Thus, we have a major statistical problem on our hands that needs to be resolved before such a diagnosis should be allowed in court.
Finally, it should be noted, the “godfather” of the diagnosis, Dr. Roy Meadow, has now been discredited in his native England for giving expert witness testimony in more than one case where he opined on statistical matters where he was later shown to have no competence, and his opinion contributed to separate jury’s finding that two mothers had murdered their children.
Therefore, until these four problems are addressed by those who still support a diagnosis of MSBP/FDBP, I recommend that it should be interred alongside its eponymous ancestor, Karl Friedrich Hieronymus, Freiherr von Munchausen.