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                                  I. The Rise of MSBP  [Second Essay]

 

                                                                                                A.  Meadow’s Article

 

The honor of naming the phenomenon goes to an English pediatrician, Dr. Roy Meadow (2). In the mid-1970s he recognized something in two, yes only two, cases which puzzled him and whose symptoms previously had received little documentation in medical literature.  A case was reported in which, over a period of six years, the parents systematically provided fictitious information about their child’s symptoms to medical personnel, tampered with the child’s urine specimens to produce false results and interfered with hospital observations. This caused the child innumerable investigations and many anesthetic, surgical, and radiological procedures in three different medical centers.  A second case was where a child was intermittently given toxic doses of salt which, after extensive medical investigation, ended in the child’s death.  

(2) Meadow, Roy, "Munchausen Syndrome by Proxy:  the Hinterlands of Child Abuse," Lancet II (1977), 353-345.

 

Meadow noted that the two cases shared common features. The mothers’ stories about their children, told to medical personnel, were false, deliberately and consistently false. The mothers’ actions caused unpleasant and serious consequences for the children.  Both mothers skillfully altered specimens and evaded close and experienced supervision. Yet, seemingly ironically, through the course of the investigation Dr. Meadow and others grew to know the mothers well.  In his words, they were “very pleasant people to deal with, cooperative, and appreciative of good medical care, which encouraged us to try all the harder.” (3)  Some mothers who stay in the hospital with children become uneasy or bored, he said.  But these two mothers “flourished there, as if they belonged, and thrived on the attention the staff gave to them.”  Both mothers had a history of falsifying their own medical records, and it seemed as if they were doing the same for their children in these instances.  Even though Meadow recognized that parents many times exaggerate their children’s symptoms in order to obtain more thorough medical care, in these instances the motivations of the mothers appeared to be different.  In his words, “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.”  Why?  Well, perhaps to project on the child her own worries about medical problems she faced. (4)

(3) Ibid., p. 344.

(4) Ibid., p. 345.

 

Meadow suggested that this sort of fabricated story was reminiscent of Munchausen syndrome.  Named after an 18th century German soldier-of-fortune, who fought in several battles on behalf of the Russians and then retired to his German estate, only to regale others with his fantastic exploits of military prowess or physical skill (such as pulling himself out of a quicksand swamp by his own hair), Munchausen syndrome was named in 1951 and attributed to people whose fantastic and fabricated stories about their own medical conditions led them to seek frequent treatment in widely-scattered clinics.  But here there was the added factor of the parent, the mother in these cases, telling fantastic stories and inducing illness (and death in one case) in another person. Thus, the name “Munchausen Syndrome by Proxy” was suggested.  Meadow’s first case, he says, seems to be the “first example” of “Munchausen syndrome by proxy.”  Even though a 1976 article describing poisoning of children by parents seemed to be similar, Meadow suggested that the poisoning was an “extended form of child abuse,” while he suggested that the acts of abuse suffered in MSBP cases were “so different in quality, periodicity, and planning from the more usual non-accidental injury of childhood that I am uneasy about classifying these sad cases as variants of non-accidental injury.” (5)  Later writers would have no such reluctance.

(5) Ibid. 

 

Thus, from 1977, we have two cases anecdotally described, where the induction of false symptoms was combined with maternal officiousness to such an extent that the medical community was baffled for a long time before concluding that the children’s injuries were actually caused by the mothers. These two cases, and I continue to emphasize the small number two, became the template, then, for others to use to try to “flesh out” this “syndrome.”  But already at this point we have the problematic character of MSBP illustrated.  It would be described as a “syndrome” where there was not only injury but where the mother’s mental state and actions deceived medical personnel and hindered the medical process.  To what extent all these things were to become necessary or sufficient characteristics of this “syndrome” would unfold in the ensuing decade.

 

 

                                                     B. The Phillips Case (1981)

 

Surprisingly, the next forum which took up the MSBP diagnosis was not the medical literature but was a legal case in one of the appellate courts of California. This relatively rapid adoption of expert witness testimony on MSBP by a trial court in 1979 and an appellate body in 1981 shows that law was already inclined to lend a helping hand to any new psychological theory that might claim to protect children. The facts of that case, and the discussion in court regarding accepting the testimony of a psychologist, perhaps appropriately named Dr. Blinder, are important to note. (6) For those familiar with MSBP cases, the court’s recitation of preliminary facts is ominous:

 

     “By nearly all accounts, Priscilla Phillips was a kind, helpful and loving person, a dutiful        wife to her husband and a devoted mother to their two sons, who at the time of trial            were nine and six years of age. Highly educated, with a master's degree in social work,      she was employed in the Marin County Health and Human Services Department. After        the birth of her sons, she turned her attention increasingly to religious and civil                    volunteer work, and became active in a variety of community organizations. Among the      many organizations to which she volunteered time and energy was the Child Protective      Services Unit of the Marin County Child Abuse Agency.” (7)

(6) People v Phillips, 122 Cal App. 3d 69 (1981).

(7) Ibid, p. 73.

 

She had a hysterectomy in 1975 but later regretted her decision and decided, with her husband, to adopt Tia, a Korean child.  Shortly after Tia arrived in the Phillips family, Mrs. Phillips began to take Tia to doctors with a variety of symptoms, from vomiting to ear infections to diaper rash.  Numerous doctors were called in to deal with her symptoms, which seemed to improve when Tia was in the hospital.  Upon return to home, however, her conditions returned.  Later tests revealed she was suffering from extreme levels of sodium in the blood.  The doctors had no explanation for this phenomenon.  Repeated releases and returns to the hospital with extreme levels of sodium eventuated in Tia’s death in Feb. 1977.  


The Phillips’ then adopted another Korean girl, and two years from the day of Tia’s death she began to develop symptoms identical to Tia.  A doctor finally decided that since there was no biological connection between the sisters that poisoning might be at work.  After the child improved when isolated from the mother in the hospital, the hospital staff contacted Child Protective Services. Mrs. Phillips was then charged with the murder of Tia and abuse of the second child, Mindy.  

 

At her trial in 1979, the prosecution called psychologist Dr. Martin Binder as an expert witness so that he might opine about a motive for a poisoning that seemed so unexpected.  Dr. Binder had read Dr. Meadow’s three-page article described above, and testified, over defense objections, on Munchausen Syndrome by Proxy. (8)  Note the way that information gathered from the three-page article is already “exploding” into a “profile” of a suspected MSBP mother.

(8) The Court noted that Dr Blinder actually cited six authorities on which he relied, one of which was Dr Meadow's study and one a summary of his work in an American journal. The four other articles reported cases of apparent parental poisoning of their children. None of the other articles used the terms MSBP to describe these cases of non-accidental poisoning.

 

Dr. Blinder said that a mother who repeatedly and surreptitiously administered a sodium compound to her adopted children in facts such as related displayed symptoms consistent with MSBP.  MSBP, he said, is a syndrome in which an individual either directly or through the vehicle of a child feigns, simulates or actually fabricates a physical illness, usually a serious one.  The mother is outwardly devoted to the child; invariably (!) the child is less than two years of age (despite one of Dr. Meadow’s patients being six).  The key to MSBP, according to Dr. Blinder, was that the mother typically transfers her own unmet parental needs to pediatricians, nurses and other caregivers.  He further testified that mothers who do this normally “flourish on the ward.”  She seems almost to blossom in the medical drama of the hospital.  She is concerned, competent and intelligent, and this fact makes it hard for doctors to suspect them as the possible cause for their child’s illness.  When confronted with evidence she is in fact responsible for her child’s condition, she cannot accept responsibility. (9)

(9) Ibid., p. 78.

 

Mrs. Phillips was convicted of murdering Tia and endangering the health of Mindy.  On appeal the court had to deal with the admissibility of Dr. Blinder’s testimony.  Even though the testimony concerned a phenomenon not attested in the recently-published DSM-III (1980), the court failed to strike the testimony.  The testimony was relevant, the court opined:

 

     “While a prosecutor ordinarily need not prove motive as an element of a crime, the              absence of apparent motive may make proof of the essential elements less persuasive.      Clearly this was the principal problem confronting the prosecution here.  In the absence      of a motivational hypothesis, and in the light of other information which the jury had            concerning her personality and character, the conduct ascribed to appellant was                incongruous and apparently inexplicable.  As both parties recognize, Dr. Blinder’s                testimony was designed to fill that gap.” (10)

(10) Ibid., p. 84.

Since information about MSBP was beyond the knowledge of jury members, and because it was attested in “the literature,” the court decided that the trial court didn’t err in admitting Dr. Blinder’s testimony.  One qualification has to be added here.  When an appellate court reviews a trial court’s admission of an expert witness to testify, it does so with what is known as an “abuse of discretion” standard.  Such a standard asks, ‘did the court clearly err or was there no justification for allowing such testimony?’ It is not a de novo review of the trial court’s decision, which would allow the appellate court to exercise its independent judgment on admissibility of Dr. Blinder’s testimony.  An “abuse of discretion” standard is much more deferential to the trial court’s decisions.  

Thus by 1979, the time of Mrs. Phillips’ trial, we have a surprisingly robust picture of MSBP.  The factors of induced illness, maternal denial, her unmet psychological needs while apparently showing dramatic concern for the child and medical personnel, seem to be at the heart of this developing “syndrome.” But the court’s clear desire to help the prosecution, by allowing testimony of MSBP to fill the evidentiary gap, is striking.   In something as important as child abuse prosecutions apparently the prosecution needs all the help it can get.  Striking also is the fact that such expert testimony was accepted, and was so crucial, when the “identified” cases of MSBP in the literature up to this time were two in number.

 

                                           3.  Rosenberg’s “Classic” Study of 1987

 

As if aware that the paucity of MSBP cases might be a problem, Prof. Diane Rosenberg wrote an article, published in Child Abuse and Neglect in 1987, which claimed to identify 117 cases of MSBP in the medical literature from the preceding 22 years. (11) After describing a generally emerging profile of MSBP, without footnote, she presented her definition of MSBP, which remained fairly standard until the 1994 DSM-IV definition and until Rosenberg herself considerably revamped her own definition in 2003.  The resultant confusion, of having three definitions of this so-called syndrome, has not been remarked upon to date in the legal literature. Definitions two and three will emerge in due course of this paper.

(11) "Web of Deceit:  A Literature Review of Munchausen by Proxy," Child Abuse and Neglect 11 (1987), pp. 547-563.

 

In short, she declared, “in Munchausen syndrome by proxy the following constitute the syndrome cluster:”

 

     “1.  Illness in a child which is simulated (faked) and/or produced by a parent
     or someone who is in loco parentis;

     2. Presentation of the child for medical assessment and care, usually persistently, often      resulting in multiple medical procedures;
     3.  Denial of knowledge by the perpetrator as to the etiology of the child’s illness; and

     4.  Acute symptoms and signs of the child abate when the child is separated from the          perpetrator." (12)

(12) Ibid., at pp. 548-549.

 

After reciting the facts of one case, where she strikingly said that the child, rather than the mother, suffered from MSBP, and after stressing that the condition was “uncommon,” she emphasized that a limitation in her study was that inferences of MSBP had to be made in many instances from the literature because not enough information about each case was presented in the source.  Without wondering, then, whether her method in fact manufactured more cases than it discovered, and without giving us the particulars or even citations to any of the cases from which she culled the data, she gave us the following relevant facts:  (1) Information on simulation or production of illness was available in 72 cases, of which 25% of these were simulation cases.  Most (72%) of the simulation cases took place while the child was in the hospital.  In 95% of the production cases, however, production took place in the hospital.  (2) An enormous range of symptoms, signs and laboratory findings were presented. Children suffered everything from abdominal pain (“a”) to weight loss (“z”).  (3) Most striking to here were the “morbidity” rates of children after they were released to their parents.  She said that of these 117 children, 10 died, and of the 107 survivors, at least 8% had long-term morbidity. (13) Thus, the mortality rate of the MSBP children released back home was 9%.  In language that seems chillingly “non-scientific,” she continues:  “All the children died at the hands of their mothers….Four of the mothers had some nursing training, and one mother was  a social worker..In 20% of the cases, the parents had been confronted with the diagnosis of MSBP and the children had been sent home to them, subsequently to die.” (14) (5) In 15% of the 117 cases the mother completely admitted to the deception, and in an additional 7% of the cases there was partial admission.  Mother’s statements regarding denial were unknown in 60% of the cases.  (6) An overwhelming number of mothers were described as having an affable and friendly demeanor and being social adept. (15)

(13) Ibid., p. 552

(14) Ibid., p. 553.

(15) Ibid., p. 555.

 

In the face of these statistics, Rosenberg had a number of recommendations, a few of which are noteworthy because they entered into the legal and medical lore of how to handle these cases.  First, she suggested that despite the paucity of cases of MSBP, pediatricians ought to consider MSBP in their “differential diagnosis” (a process of elimination in getting to the actual diagnosis of illness). (16) Thus, from the beginning a suspicion of parents ought to be incorporated into diagnosis.  Second, because the rate of subsequent death of children in MSBP families  was so high (9%), doctors ought to be encouraged to “take steps to protect the child immediately.” (17) Finally, psychiatric care should be offered to the mother and father immediately after diagnosis of MSBP. (18) Thus, the model envisioned is that the pediatrician and other attending physicians should come up with the diagnosis, spring it on the mother, quickly move to isolate and protect the child and then get the mother/father into counseling.  After all, since nearly 10% of the kids die when they are left in the hands of their mothers, the medical profession was morally obliged to intervene.

(16) Ibid., p. 556.

(17) Ibid., p. 558

(18) Ibid., p. 559.

 

Many things can be said in analyzing Rosenberg’s article and numbers, but let’s first begin with the reaction of none other than Dr. Meadow himself.  He would, you would think, be most interested in supporting research such as Rosenberg’s, especially since she seemingly wanted to be cautious in her discovery of the syndrome (117 cases in 22 years—or only about 5.1 per year in the medical literature).   One can tell, however, that instead of being delighted he was quite disturbed.  In a letter to the editor of Child Abuse and Neglect, he said that Rosenberg’s numbers, which of course was the whole purpose of her study, were faulty.  “Extreme caution should be applied to its quantitative aspects…”  (19) This was especially true on two figures quoted above—the 9% mortality rate and the notion that 20% of those who died were “sent home subsequently to die.”  He felt competent to deal with the 9% mortality figure because he had gathered the data and she had misquoted him.  As he tried to say gently, “Most of these reports do not mention that the same child is reported elsewhere in another series.”  That is, she has not just “double-counted,” but she has perhaps multiplied the original number so much that her numbers are meaningless.  As Meadow says, “Adding up these cases gives false information,” and in the end, “the overall picture in relation to morbidity and mortality becomes even more false.” Then, taking off the gloves, he continued, “The statement that in 20% of the deaths the parents had been confronted and the child sent home ‘subsequently to die’ is particularly misleading.” (20) In fact, he said that he knew of only one case, yes one, in which a child had been returned to a mother who had been subject to full confrontation and had directly harmed that child or a subsequent child.  Thus, he was particularly offended that in legal cases in the British Courts lawyers and psychologists were blithely quoting the 20% mortality figure as gospel. It simply wasn’t true.

(19) Child Abuse and Neglect 14 (1990), p. 289.

(20) Ibid. 

 

To Dr. Meadow’s frosty assessment of the two linchpin statistics of Dr. Rosenberg’s article, I add the following.  First, as noted above, one has no reason simply to accept her number of 117 cases of MSBP in the literature, especially when 12 of the 22 years she surveyed were before the first cases cited by Dr. Meadow.  Second, though “simulation” or “production” is essential to the definition of MSBP, Rosenberg said that information on this was only available in 72 cases, about 65% of the total.  Thus she includes, in her 117 cases, 45 cases where the essential element of the definition of the syndrome is absent.  This brings “math-challenge” to new dimensions.  Third, she notes that in 60% of the cases, about 72 cases, there is no information about whether the mother admitted or denied the allegations of simulation/production.  Then, in about 15% of the cases the mother “admitted completely” the deception and in another 7% there was “partial admission.” (21)  So, in more than 80% of the cases the mother either admitted her culpability or we have no information about admission of culpability. This directly contradicts the third part of her definition—that the mother denies responsibility for the simulation/production.  Fourth, she mentions that in most cases the symptoms seemingly got worse in a hospital setting. Or, using her language, she mentioned that of the 72/117 cases for which there was information, simulation took place in 25%, production in 50% and both simulation and production in 25%.  In 72% of the “simulation-only” cases, simulation happened in the hospital; in 95% production took place in the hospital; in 84% simulation and production took place in the hospital.  Without more, these statistics mean nothing or, possibly more ominously, they mean that the child got worse when medical care was administered.  She gives no reason to believe that the mother in all these cases is standing by the bedside inserting her own urine into her daughter’s sample or otherwise tinkering with the catheters or other medical devices.  Thus, without more, it looks as if things get worse when the child is in the hospital—out of the mother’s care.  This would contradict the fourth prong of her definition.

(21) Rosenberg, Op. Cit., p 555.

 

Finally, we need further reflection on the fourth part of her definition, because mental health professionals often point to the abatement of symptoms when the child is separated from the perpetrator as evidence of production or fabrication of MSBP in the child. We can look at this issue from three angles: (a) the data which Rosenberg brings forward to support her point; (b) the expected result when a child is separated from a perpetrator; and (c) the way that the proposed definition of “Factitious Disorder by Proxy” in the 1994 DSM-IV (and 2000 DSM-IV-TR) deals with the issue.  

 

With respect to the data, I only need to reformulate the argument made previously by focusing on the specific kind of evidence Rosenberg brings forth.  She says there is only data on the issue of symptoms for 72 of the 117 cases, or about 60% of them.  In 25% of the cases (or 18 cases), the illness was simulated; in 50% of the cases (36 cases) there was production of the illness; in 25% (18 cases) there was both production and simulation. (22) Rosenberg further says that the vast majority of these cases were simulated or produced in the hospital (about 85%).  (23) Thus, we have the curious phenomenon, if we take her at her word,  that in 85% of the cases where she has data (and this is only in 65% of the cases), there apparently wasn’t any production/simulation of symptoms until the child got to the hospital/medical facility.   Thus, MSBP, according to her numbers, is primarily a phenomenon induced in the medical setting.  This is strange indeed, but there is no language in her presentation or analysis of data which suggests that the illness was re-presented or re-induced in the medical context.  Thus, by reading her data as she presents it, one would think that it is the medical personnel, rather than the mother or other caretaker, who are responsible for appearance or exacerbation of symptoms.  Of course, that is exactly the opposite of what she claims, but her data lead us to that point.

(22) Ibid., p. 552.

(23) Ibid.

 

Her data thus show an increase in symptoms of the child when in medical care.  But the fourth part of her definition is that when the child is removed from the caregiver’s oversight, symptoms recede.  We have a contradiction here. She can’t have it both ways.  In any case, if the symptoms actually got worse under medical care, wouldn’t a better hypothesis be to examine the nature of the medical experience than to blame the caregiver? Or, on the contrary, if the symptoms improved when the child was in medical care and was removed from the caregiver (which she wants to argue—for which she has no data), wouldn’t that sort of be expected?  Generally, do we find it surprising if medical symptoms abate when the doctors/nurses are able to attend to a situation?  Isn’t that  the job of medical staff—to try to get symptoms to abate?  

 

In fact, Rosenberg has not shown anything.  She simply asserts a fourth criteria or prong of a definition, but her data point the opposite direction of her point.  But even if her data seemed to support her assertion (abatement of symptoms when caretakers are removed from the equation), isn’t that just about what we would expect?  If mothers/caregivers have some kind of shadowy disease/syndrome called MSBP because their loved ones get better when doctors attend to them, maybe the incidence of this syndrome exists in about 95% of the population.  

 

Perhaps because of some of these difficulties, the 1994 (repeated in 2000) definition of “Factitious Disorder by Proxy” (discussed below) in the DSM-IV has no reference to the child’s medical condition once removed from caregiver oversight.  One can’t necessarily say that the abandonment of this prong of the definition is because there is no evidence for this amelioration, but one can’t really say that Rosenberg’s data (or any other that I know) support the fourth part of Rosenberg’s definition.

Thus, in conclusion, one can say that Rosenberg’s study, which has been quoted affirmatively by every subsequent study in the MSBP literature, has deep methodological and quantitative flaws relating to every aspect of the definition for MSBP she proffers.  In the end, those not adept at statistics might simply skip over her inconsistencies and focus on her recommendations—of early intervention, of including a dimension of suspicion in differential diagnosis, of springing diagnosis on the mother before she even sees a mental health professional.  But her numbers, which is the whole purpose of her article, simply won’t support the definition she advances.  And her effort is the “solid rock” on which all subsequent MSBP research is based.

                                      4. A New York Legal Case From 1987

Early in 1987, before Rosenberg’s study was published, a New York family court, informed by the Phillips case in CA and the growing body of medical literature on MSBP, invoked the legal doctrine of res ipsa loquitur (“the thing speaks for itself”) to conclude that MSBP testimony adequately explained how Mrs. “Z” systematically injected large doses of laxatives into her daughter Jessica’s food for a four month period, causing her intense pain and diarrhea. (24) The crucial thing to notice about this case, however, is not that expert testimony was allowed but the way that MSBP was, in the court’s mind, already taking on such a solid scientific validity that a rather full “profile” of an MSBP perpetrator was emerging.  The court listed the following factors which were “commonly found in the case histories of MSP” and which were reported in the medical literature:

“1. The child’s prolonged illness which presents confusing symptoms defying diagnosis, and is unresponsive to medical treatment.
2.  The child’s recurring hospitalizations, surgery and other invasive procedures.
3.  The child’s dramatic improvement after removal from mother’s access and care.
4.  The mother’s training as a nurse or in medically related fields.
5.  The mother’s unusual degree of attentiveness to child’s needs in hospital.
6.  The mother’s unusually supportive and cooperative attitude towards doctors and hospital staff.
7.  The mother’s symbiotic relationship to the child.” (25) 

(24) Matter of Jessica Z, 515 NYS 2d 370 (NY Family Ct, 1987).

(25) Ibid., p. 371.

Even though Rosenberg’s four-pronged definition wouldn’t be published until later in the year, we note an overlap of only two factors—hospitalizations and improvement after removal from mother’s care.  Of course, you wouldn’t have any kind of a problem if you had no hospitalizations, so that leaves the only substantive overlap in the two definitions to be the child’s improvement after removal from mother’s care.  Rosenberg’s data don’t show this, as mentioned.  They show the opposite. Factors 4-7 of the NY family court are based on observations by Meadow in his two cases and by other researchers, but their problematic nature should be noted here.  Normally one thinks of a supportive mother or a “symbiotic” relationship of mother and child to be a good thing, both in hospital and family living. Indeed, parents who are attentive to their children’s medical condition are normally praised. But the “insidious” nature of this syndrome, according to the court, is that this is being done in a deceptive manner that leads the medical people down many false roads of diagnosis and hinders care for the child.  

 

Yet, as the court says, quoting a 1986 study, the mortality rate for 23 poisoned children released back to parental care was 22% (more than doubling the figure that Meadow showed was unreliable in the Rosenberg literature review).  Thus, with so much at stake and with children literally dying in their parents’ care, there was no reasonable alternative other than to try to intervene rapidly and early in cases of suspected MSBP.  But note the problematic nature of the assumptions here.  Since the so-called syndrome is based on deception, and the mother manifests signs of concern that normally would be applauded by the medical community, the pediatricians and other medical professionals confronting the child’s illness must now also be experts in deception.  As one leading psychologist on deception explained to me, medical personnel get no training in medical school on how to identify deception, its nature and course, its warning signs and how it should be handled. (26)

(26) Telephone conversation with Dr. Loren Pancratz, psychologist and frequent expert witness in MSBP cases, May 5, 2008.

The court quoted with approval the following two statements:  “The roles played by the parents and doctors have been examined in hopes of alerting other physicians to the possibility of MSBP when a baffling pediatric problem is being considered.  The swift recognition of this condition may prevent irreparable harm to a child…” (27) And, again, “The act of abuse in these cases is a continuous seemingly unconscious act, motivated by the parents psychopathology.  Mental health professionals need to be alerted to the warning signs of MSBP and be prepared to face the often difficult job of managing the treatment of these complex and often life threatening cases.” (28)

(27) Jessica Z, at p. 372 (quoting Vincent Guandolo MD, "MSBP:  An Outpatient Challenge," Pediatrics 75 (1985), p. 530). 

(28) Ibid. (quoting Chan et al., "MSBP:  A Review and Case Study," Journal of Pediatric Psychology 11 (1986), p. 80).

Four observations in the wake of the Jessica Z case are appropriate.  First, we see that law has now lost whatever original skepticism it first might have had about MSBP.  Now that CA and NY courts have accepted expert witnesses on the phenomenon and recognized its existence and danger, other states would quickly follow suit.  After all, the courts are our ultimate societal guardians of the most helpless in our midst (children); if they don’t respond to a clear “crisis” out there, no one else will.  And, when you think that there might be a morbidity rate in excess of 20% (though no one combed or critically evaluated these figures), well, the court simply has to act.  Second, the court recognizes “extensive difficulties” in identifying MSBP because of the confusing behavior of the mother.  Third, even though physicians and pediatricians are not trained in deception, they must intervene early with their suspicions in order to save children.  Finally, a profile is emerging of the “MSBP mom,” a most dangerous person.  She presents herself as ‘one of us’—a concerned and responsible parent.  But underneath she is a deceptive person, who will manifest her Jekyll and Hyde (my terms) character and, if she isn’t stopped, probably will kill her child.  

 

With legal “findings” or implications like this, what can one do?  Or, better said, if you are a parent accused of MSBP you really can’t do very much.  The concern with child abuse, which fueled the MSBP diagnosis, was such an overriding concern of courts in the 1980 and 1990s that any credible psychological diagnosis that would help us win this kind of  ‘war on terror’ would be used by the courts.  

But any ideological movement (i.e., a movement motivated by largely by philosophy rather than one grounded primarily in science or statistics) is going to run into difficulties when it begins to face some of the complexities of life.  The next portion of the paper deals with a few complications that emerged in the early 1990s.  In the end, however, by 1995, the “faith” in MSBP had been largely reaffirmed.

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