Sick Kids: Parental illness or child abuse?
First of Two Articles

Some say a psychiatric disorder known as Munchausen Syndrome by Proxy is used against parents.

By Steve Levin
Post-Gazette Staff Writer

For first time in her life, Beth Hane was separated from her parents this May. Several police officers and an employee of the Allegheny County Children, Youth and Families agency came to her family's South Hills home, forcibly removed the severely disabled 11-year-old from her parents’ care and placed her in a foster home.

Beth has a chromosomal disorder called Trisomy 15, and suffers from epilepsy, weighs just 32 pounds, and has only half a large intestine, and failing hearing and eyesight. She was taken away 90 minutes after her new pediatrician called CYF and told officials that the child was in imminent danger.

Beth's mother, the pediatrician claimed, was purposely hurting her daughter because the mother suffered from a psychiatric disorder known as Munchausen Syndrome by Proxy.

The Hanes' crisis was eerily similar to one that occurred with another family in Nashville, Tenn., in September 1996.

In that case, authorities took away Mark and Julie Patrick's 11 month old son Philip. From birth, Philip had suffered from multiple defects including a bowel disorder, fusion of his skull bones and gastrointestinal problems, which had been treated with little success at various hospitals. But at Vanderbilt Children's Hospital in Nashville, doctors reported the Patricks to police, accusing Julie Patrick of intentionally harming her son.

Julie Patrick was accused of having Munchausen Syndrome By Proxy. MSBP is a little-understood and highly controversial condition. Doctors and others who believe in it say it's a disorder in which a parent -usually the mother - intentionally harms her child in order to gain attention for herself.

Detractors say that MSBP is either vastly overdiagnosed or doesn’t exist at all. More and more, they say, it is being improperly used as the basis for taking children away from their parents.

The Hane and Patrick cases had very different outcomes. Beth was returned to her parents after 11 weeks in foster care. Philip died in the hospital a month after being separated from his parents.

A controversial condition

There is no consensus among doctors, child care professionals, lawyers and others about Munchausen, even on what to call it. Also, referred to as Factitious Disorder by Proxy and Pediatric Condition Falsification, it is not classified as a disorder in the DSM-IV, the American Psychiatric Association’s "bible" of mental conditions, because of "insufficient information." The American Academy of Pediatrics also has no policy on it.

But MSBP is included in the child-abuse guidelines published by the U.S. Department of Justice's Office of Juvenile Justice and Delinquency Prevention. Many Pediatricians, child protective services workers and even some FBI officials believe that MSBP is an illness that not only is under-reported, but is increasing.

Arrayed against them is a growing number of attorneys, physicians and child advocacy experts who claim that MSBP is a "disease dujour" that is not backed up by any credible medical evidence.

Caught in the middle are scores of families whose lives have been irreparably damaged by prison, the seizure of children and, in some cases, the children's deaths, all based on the assertion of this mysterious malady.

MSBP has existed in medical literature only since 1977. The first reference to "Munchausen" by name occurred in 1951, when a British doctor used the term to describe obstreperous patients in postwar England who wandered from hospital to hospital, exaggerating or falsifying their symptoms. He named the behavior after the 18th century Baron Karl Friedrich Hieronymus von Munchausen, a German soldier and adventurer known for his hyperbolic tales.

In 1977, British Professor Roy Meadow wrote a brief article in the Lancet medical journal about two cases of child abuse. He used the phrase "Munchausen syndrome by Proxy" in his discussion of the cases to try to explain the behavior of the mothers of the abused children. As Meadow described it, the mothers had created symptoms of illness in their children and lied about the children’s medical histories, all in an effort to discredit doctors treating the children, even though they were outwardly full of praise for the physicians and their staffs.

Like the postwar patients, Meadow said, the mothers were trying to attract sympathetic attention from doctors, but in this case were inducing or falsifying medical problems in their children to get that attention.

"In these cases," he wrote in his 1977 article, "it was as if the parents were using the children to get themselves into the sheltered environment of a children’s ward surrounded by friendly staff."

Shocking videos

Although Meadow identified MSBP, its touchstone over the years has been a series of abusive incidents involving parents and their children, secretly recorded on videotape in two British hospitals.

The videos, taken by professor David Southall between 1986 and 1994, showed 33 parents apparently harming their children through suffocation, poisoning with disinfectant or anticonvulsant drugs, and other types of physical and emotional abuse. Southall used the videos as the basis for an article in "Pediatrics" magazine, which concluded that "many parents appeared caring and kind in the presence of professionals, yet within seconds of being alone with the child became cruel and sadistic."

Although criminal charges were brought against many of the, parents, several of the charges subsequently were dropped by prosecutors for lack of evidence and because some of the video footage was inconclusive.

Even if everyone agreed that MSBP is real, it would involve only a fraction of all child abuse cases, according to figures used by its proponents. According to the U.S. Department of Health and Human Services, there were more than 465,000 substantiated cases of child abuse in 1996, the last year for which figures are available. Dr. Randall Alexander, a child-abuse expert and one of the foremost proponents of MSBP, estimates that nationally between 500 and 1,000 cases of the syndrome occur each year. That means that MSBP would account for between 0.1 and 0.2 percent. of the country's annual child abuse incidence.

In Allegheny County, there are no firm estimates of MSBP cases from pediatricians, hospitals or CYF, the agency responsible for removing children from parents' custody. But Dr. Basil Zitelli, a professor of pediatrics at Children’s Hospital and someone who has testified as an expert witness in MSBP trials, said that "I do believe it's out there to a much greater extent than we would like to believe."

No one disputes the fact that there are parents who intentionally harm their children. The problem arises from trying to prove that the abuse occurs because of the psychological motivations described by MSBP theorists.

Critics of the syndrome argue that it has been literally defined into existence by virtue of the overwhelming amount of material written about it - more than 300 articles - and not by any scientific studies that prove its existence.

Adolf Grunbaum, the Andrew W Mellon professor of philosophy at the University of Pittsburgh and a research professor in the department of psychiatry at the university's medical school, said the Munchausen trend reminds him of the claims made about hysteria by French physician Jean-Martin Charcot in the 1890s.

After Charcot's patients at a Paris mental hospital had been hypnotized, they would exhibit dramatic symptoms that didn’t appear to have any medical cause - blindness and paralysis for instance. Charcot called these patients "hysterics," and concluded that hysteria was a proven medical disorder.

But later experts cast doubt on Charcot's work. Some said he had either made up the patients' symptoms in his reports, or the patients had fabricated them. Even if some patients showed the symptoms, Grunbaum said, "one has to be very careful in inferring that a certain symptom set constitutes a genuine clinical entity."

In the same way, he said, just because some mothers may harm their children and claim it's the result of the children being ill, that doesn’t mean that their behavior constitutes a medical syndrome.

Syndrome's new uses

Despite the relatively small number of cases, detractors of MSBP say the Munchausen allegations are inflicting a growing amount of damage. They argue that the diagnosis is being used to separate families by professionals who don't have to fear the consequences of their accusations, because they are protected from legal liability under the federal Good Faith Immunity Law, passed in 1977 to encourage teachers, doctors and others to report suspected cases of child abuse.

In addition, health insurance fraud investigators now consider MSBP when investigating potentially fraudulent medical disability claims. At least one company, Forensic Intelligence Display and Analysis, Inc., describes symptoms Of MSBP parents for its clients, which include law enforcement agencies, U.S. attorneys' offices, insurance company claims managers and managed care physicians.

Some fathers' rights advocates have pushed the idea that making an MSBP allegation against an ex-wife in a child custody case is an "instant win" tool. "I have heard many men say, ‘Turnabout is fair play. I'm going to knock her off with that before she hits me with sexual abuse of the kids,’" said Kenneth R. Pangbom, a Florida trial consultant. In other words, Pangborn said men who fear they will be accused of abusing their children charge the mother with the syndrome first, putting the burden on her to prove that she is not the abuser.

Munchausen also has been mentioned in connection with a recent trend in which county coroners have reopened old cases of infant deaths that had no official cause or were blamed on Sudden Infant Death Syndrome. Prosecutors have brought charges against several women after these re-investigations, including a New York woman who was then convicted of killing her five children.

But critics of MSBP say that while these mothers may have killed their children, there often is no evidence that it had anything to do with the psychological motivations claimed for Munchausen’s. Allegheny County Coroner Cyril H. Wecht said he has no plans to reinvestigate any infant death cases here.

‘That’s not science’

One of the most vocal opponents of the Munchausen trend is Thomas M. Ryan, a medical malpractice attorney in private practice in Chandler, Ariz. "There are no scientific studies that prove [MSBP’s] existence," he said. "You have people saying, 'Gee, I've heard other people say mothers do suspicious things, so I'll call it Munchausen Syndrome by Proxy.’"

"That's not science. That's merely reporting anecdotes."

Ryan is one of the leading defense attorneys for people accused of MSBP Often working for free, he has persuaded the courts to overturn two guilty verdicts and has won dismissals of allegations in four other cases. He said he consults with 30 to 40 women annually who are accused of the syndrome and has volunteered more than 4,000 hours of his time defending women. He estimates the cost of defending someone accused of MSBP can range from $25,000 to $1 million.

"If a mother puts an inappropriate substance in a child, call it what it is: child abuse," he said. "If a doctor suspects a mother is doing something to her child, find out what she's doing, find out what to do to get her to stop and if you can’t, then report her."

In other words, Ryan said, most MSBP cases that involve real harm to children can be handled as straight forward child abuse. But if MSBP is being alleged, Ryan said, there often are ulterior motives for using the terminology.

In his experience the four leading situations in which the syndrome is cited are: (1) When mothers have seriously disagreed with their children’s physicians; (2) When mothers who use managed care organizations have children with difficult medical problems who incur steep medical bills; (3) When there are custody disputes, where fathers allege abuse by the mother. (4) When physicians raise the issue after they have been accused by a family of malpractice.

Once in court, Ryan said, "the cases are difficult to win [for those accused of the syndrome] because most juvenile court judges are afraid to rule against the state. It is safer for them to separate the families than to run the risk of ending up on the front page of the paper [if the child later is hurt or dies]."The question is, does the medical evidence support the allegations? If it doesn’t ... I guarantee the mother will win [the case]. I've yet to be proven wrong."

One of Ryan's cases involved a 9-year-old California boy who was taken to the University of California at Los Angeles Medical Center in early 1992 for treatment of the chronic diarrhea he'd suffered since birth. Based on a single stool sample that showed the presence of a laxative, plus the hospital's judgment that the boy's parents had "doctor shopped" and neglected their son’s educational, physical and developmental growth, the parents were charged with MSBP. Based on that, child protective workers declared the boy had been abused, and he was placed with an Illinois foster family.

Not until 1995 was the family reunited, when an Illinois circuit court found that there was insufficient evidence of abuse or neglect and that UCLA’s use of a single stool sample was specious, especially considering that 15 other stool samples showed no laxatives.

Not all women nurture

On the opposite side of the fence from Ryan is Dr. Herbert A. Schreier, chief of psychiatry at the Children’s Hospital of Oakland, Calif. and co-author of "Hurting for Love," a 1993 book that's considered by many to be the MSBP encyclopedia.

Schreier, who has testified as an expert witness in about 30 MSBP cases and consulted on another 70 to 80, said Ryan and others outspoken against MSBP have unfairly labeled him as "antifeminist" because of his extensive work with MSBP and the fact that 95 percent of MSBP cases are brought against women.

But Schreier does think that many women afflicted by MSBP are unable to nurture their children effectively. "The interesting part about [MSBP] is what this is telling us about women," Schreier said. "We can’t bring ourselves to see that all women aren’t natural-born mothers. When you look at the history of most of these women, either they felt undervalued in their family as little girls or they perceived themselves as being abused."

These women then manipulate doctors as a kind of revenge for past humiliations at the hands of adults, Schreier said. By making it appear that doctors are unable to help their sick children, he said, the women "turn the tables." Schreier played a large role in the development Of a "Profile" of MSBP offenders that many doctors and child protection officials use.

The FBI's version of the profile cites these factors:

* The parent ("most often biological mothers of the victims") appears to be very knowledgeable about the victim's illness.

* She has some medical education either through study or experience.

* She has an unusually close relationship with the hospital's medical staff, and praises them excessively.

* She maintains a high degree of attentiveness to the victim.

Critics of the MSBP profile say that these factors could very well describe any highly motivated mother who has a seriously ill child who requires a lot of medical treatment.

But Schreier said that even if a mother doesn’t exhibit a single aspect of the profile, she could still suffer from MSBP "There are many reasons for fabricating an illness in a child," he said, including a lonely parent wanting to keep the child at home, or one spouse "seeking revenge" on another.

Children’s Hospital's Zitelli admits there is no way to "test" for MSBP. But he has his own profile that he says physicians and child protective services workers can use to form an "index of suspicion' about a case.

Foremost, he said, is that the child's illness is factitious, or not genuine, as evidenced by either reported or actual symptoms. Second is that the perpetrator offers no information to physicians about how the child's illness occurred. The third clue is repeated medical evaluations. The fourth is that the symptoms subside when the mother and child are separated.

Yet Zitelli also urged caution in applying these criteria. I think any accusation of child abuse has to be very carefully investigated," Zitelli said. "It's incumbent upon [child protective workers] to investigate thoroughly those situations in which someone has been accused of Munchausen [Syndrome] by Proxy."

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