Munchausen Syndrome By Proxy: A Critical Assessment
for Judges and Lawyers, First Essay
William R Long, M Div, Ph D, J D; July 12, 2008
[Note: I penned this 21,000 word essay in 2008 while I was a consultant for the Autism Research Institute of San Diego, CA. At the time, and since then, the charge of "MSBP" made against parents usually by state departments of children's services, was often a means of trying to remove a child from the home. In this paper I reviewed the origin and development of this legal device. Several attorneys over the years have contacted me about this paper; I put it here so that it would be readily available to any who might find it useful. I have not updated or kept it current since it was first written; perhaps some enterprising graduate student or professor can do that. . .]
For more than 30 years the diagnosis of Munchausen Syndrome By Proxy (“MSBP”)/Factitious Disorder by Proxy (“FDBP”) has been used as a tool to enable the state and its prosecutors to accuse caregivers, usually mothers, of harming and abusing their children. When such a diagnosis is made, or even surmised by a state’s expert, the child can summarily be taken away from parents, and parents are put in the position of having to defend themselves against often shadowy, imprecise and almost irrebuttable charges of deceptively “working” the medical system, surreptitiously faking abuse or actually harming their children. Since caregiver deception is at the heart of MSBP, a denial of abuse by a caregiver of a child functions almost the same as a confession of abuse, i.e., both likely make the caregiver “guilty” of neglecting or abusing the child. Thus, in legal proceedings, the allegation of MSBP acts as a “boost” to prosecutors, a sort of evidentiary steroid to fill gaps in cases that often lack direct or even convincing circumstantial evidence. MSBP is the prosecutor’s friend, the means by which suspicions of abuse and parental unfitness can be “confirmed” without having actually to show that any abuse occurred. Like the broomstick in the Sorcerer’s Apprentice, which under the spell of the inexperienced magician at first served a useful function of bringing water but then took over the magician’s life and began to dump far more water than needed, causing a general disaster, so MSBP may have served a useful, if adjuvant, function at one time but has over the years taken on a sinister and dangerous role, harming far more people than it helps. This latter impression is not simply the complaint of disgruntled losers in the legal system; it is the considered conclusion of career psychologists who have worked with MSBP allegations for two decades. (1)
(1) Phone and email communication with Loren Pancratz, Ph. D., psychologist and frequent expert witness in cases involving MSBP.
With such a powerful tool at prosecutorial disposal, and so much at stake for parents, one would naturally think that MSBP rests on solid observational and scientific proof or, if proof is too strong a word, on almost universal consent that such a condition is readily identifiable. Yet, as this paper will show, there not only is no clear definition of what MSBP is, but there is no consensus on the type of person who should diagnose it. For example, the definition of the phenomenon given in the 1994 DSM-IV differs significantly from the “classic” definition given of the “Syndrome” in a 1987 article. So different are the definitions that the pediatrician who first named MSBP in a 1977 article actually agreed, in a 1995 article, that the DSM-IV definition (the psychological definition) was to be preferred over the medical definition in the 1987 article. Thus, even those who are supposedly most “in tune” with the phenomenon disagree in fundamental ways regarding its definition. So serious has this problem become that the primary professional body that deals with child abuse quietly dropped the label MSBP in 2000, or significantly curtailed its use, in favor of the more limited “Pediatric Condition Falsification.” There is no agreement, then, on what constitutes MSBP or even what it should be called.
Then, there is considerable confusion regarding who should diagnose it. Is it, for example, primarily a psychological problem, to be divined by people in that trade, or is it a medical condition to be ascertained by pediatricians and treating physicians? To what extent is it a diagnosis, a conclusion reached after intensive examination of the mother/caregiver, or a suspicion, a sort of a hypothesis that should set in motion the wheels of the judicial system by taking the child away from parents and putting the burden of proof on parents that they are not abusers of their children? Then, there is confusion in the literature regarding who suffers from the “Syndrome.” Most of the legal cases and many articles written by psychologists say that MSBP is a disorder or syndrome suffered by the caregiver, yet the classic 1987 article suggests that it is the child who suffers the disorder.
Then, there is the problem with statistics. We don’t know, for example, if the condition is rare or common. Most of the literature tends to emphasize the relative rarity of the syndrome, but then, in the mid-1990s, an increasing number of articles, without citing any confirmatory statistics, began alleging that MSBP is far more widespread than ever thought. Like ghouls supposedly hiding behind every bush in a bosky wood, so MSBP became the “bogey man,” especially of legal literature in the 1990s. MSBP was supposed not to be rare at all, but was hypothesized to be a drastically under-reported phenomenon and, as such, something that had to be “smoked out” if society was really to stamp out the spectre of child abuse.
Make no mistake about it. Abuse of children by caregivers is a most heinous and reprehensible activity, which can sometimes rise to the level of criminal behavior. Inducing illness or injury in children, which is at the heart of the traditional definition of MSBP, no doubt exists and should be ferreted out. But what the “statistical revolution” of the 1990s in MSBP did was to hypothesize that the number of cases of MSBP was much larger than reported, which led to more vigorous prosecutorial activity against parents who supposedly had this “syndrome.” Wild numbers were suggested without foundation. Whereas the classic 1987 article found 117 cases of MSBP by combing 22 years of psychological literature, by the 1990s there were unsubstantiated and scattered references to that many cases per year.
It is a common phenomenon when you want to get recognition of your phenomenon that you inflate the numbers or argue for its widespread rather than rare occurrence. The Americans with Disabilities Act of 1990, for example, would never have so easily passed without the rather fantastic numbers suggested in the “Congressional Findings” of how many disabled people there were in America. Incidentally, the reason you see all those empty “handicapped parking” spaces everywhere you go is that the over-inflated projections of the number of disabled people in America in 1990 led to calculations about how many of these parking spaces we needed all over the place. The 1990s saw a like exaggeration in the number of MSBP people “out there.” Then, when this hyper-inflated, and unsubstantiated, number was linked with the theory of early detection, a movement in medicine and psychology in the 1990s, you had established all the conditions for a veritable witch-hunt to find the perpetrators/sufferers of MSBP. For if you supposed that the number of MSBP perpetrators was much larger than ever suspected, and if you further believed that early detection was required in order to “save the children,” the state would redouble its effort to try to intervene as early as possible into the lives of families where there may have been an MSBP person and remove the child from the home. When this philosophy of action is combined with the fundamental notion that MSBP is a disorder which manifests itself in deception, you have the conditions set for suspicion, uninformed intervention, ideological prosecution, and unwarranted conclusion that anything a caregiver says in his/her defense is further proof of MSBP.
The problem with numbers goes beyond this, if it can be imagined. What I am calling the “classic” study of 1987 was the first which tried to put a numerical face on this condition. But Dr. Roy Meadow, the author of the 1977 article naming the syndrome, vigorously contended that crucial numbers in this 1987 article were over-inflated and, in fact, he tried to warn the profession about rampant over-diagnosis of the condition in a 1995 article. What makes this attempt of Dr. Meadow so poignant is that he was objecting to the overstatement of numbers in what later would be considered the most conservative article (the “classic” 1987 piece). Thus, as time went on, the conservative numbers, especially relating to mortality rates of children in MSBP families who were returned to their families, of the 1987 article, numbers which were discredited by Dr. Meadow himself (because he gathered the statistics originally), became the number on the low end of potential mortality rates of children returned to home after a MSBP diagnosis. Expert prosecution witnesses in legal cases in the 1990s and 2000s used the discredited 1987 numbers as the low end of abuse numbers. We were then working in such a world of smoke and mirrors that almost no “statistical truth” could be established. The Sorcerer’s Apprentice broomstick was flooding the house with water, multiplying the amount even as the stick was cut in two, then four, then eight pieces.
The final irony in the sad history of MSBP is that the one who named the syndrome, Dr. Roy Meadow, who argued for a more conservative use of the diagnosis and a much smaller number of deaths/injuries of children returned to their MSBP homes, has himself now been fully discredited precisely for inflating numbers as an expert witness in several English cases of infant crib death. The upshot of these cases is that Dr. Meadow relied more on philosophy or ideology in diagnosing than on good statistics.
With such a multi-form problematic facing the diagnosis of MSBP, I argue that it is time for the legal, as well as the psychological/medical, community to inter this syndrome next to its eponymous ancestor, the Baron Munchausen (1720-1797). If abuse is happening in the home, name the abuse and have that abuse be the reason either for terminating parental rights or prosecuting caregivers under state child abuse statutes. Have the pediatricians or other doctors testify to the supposed abuse, but have them testify as fact rather than as expert witnesses. Use psychologists/psychiatrists only sparingly, if at all, in cases of supposed induced or fabricated illness, and then only to opine on the mental state of caregivers, rather than whether a caregiver suffers from a “syndrome” that has ever-shifting boundaries and no clear and agreed-upon definition. Discard the term MSBP and the corresponding DSM-IV (and DSM-IV-TR, from 2000) term FDBP, and focus on the facts that are observable rather than a theoretical construct that might help explain the facts in a few instances but probably misleads much more frequently than it informs.
The following paper is, like Caesar’s Gaul, divided into three parts. Part I explores the rise of the diagnosis from 1977 until its early “high water mark” after an important 1987 article and court case. If one were to “plot the curve” of MSBP in these years, one would have a line similar to the rise of Starbucks’ stock until the last few years, i.e., a steep-upward line or curve. Part II explores the reception of MSBP through the inclusion of it in the DSM-IV as a topic to be further studied in 1994. Part III then shows the bifurcated path of MSBP from 1995-2008. This part will show two things: (a) how large pockets of the psychological community gradually became disenchanted with the diagnosis, even as the “true believers” in that community wanted to “ramp up” the frequency, and (b) how the legal community swallowed, hook, line and sinker, the diagnosis and its supposed growing frequency, and called for even more use of the syndrome. Finally, a brief conclusion summarizes my findings and argues that all professional communities would be well-served by dropping reference to this “disorder” at this time.