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MSBP/FDBP 1995-2008; Two Roads Diverge in a Not-so-Yellow Wood [Fifth Essay]
This section proposes to describe how MSPB/FDBP has been handled in the psychological and legal literature from the publication of the DSM-IV in 1994 until the present. It also surveys the unfortunate professional history of the Urvater of MSBP, Dr. Roy Meadow, whose professional reputation, primarily because of his false statistical inferences as an expert witness, has been irreparably tarnished. To this end I will divide this part into three sub-parts: 1. The growing and insistent questions within a portion of the mental health profession regarding the diagnostic label MSPB/FDBP; 2. The attempt to rehabilitate the syndrome through narrower definitions, continued studies of purported cases and legal articles; and 3. The discrediting of the founder/namer of the phenomenon and its questionable status today in England and other English-speaking countries.
1. Doubts in the Mental Health Profession
In a series of articles from 1995 to 2008, significant voices within either the medical or mental health field pointed out some of the persistent problems with a MSBP/FDBP diagnosis. I have already mentioned many of these problems, since they were so evident to anyone who would have done a careful literature review before 1995. But hindsight frequently provides a better vantage point than contemporary sight. This section will show that significant questions were raised by professionals in these fields regarding the breadth of the diagnosis, the naming of it as a syndrome, who should diagnose the problem, the skewed numbers of the phenomenon, and the definitional confusion created by the variety, conflicting nature and application of the two definitions (Rosenberg’s 1987 attempt and the DSM-IV in 1994).
We begin with the strong statement of skepticism raised by none other than the namer of the syndrome in 1977, Dr. Roy Meadow. In a 1995 article he raised a number of “red flags” regarding the diagnosis of MSBP/FDBP. (48) His primary concern was that the imprecision in definition of the phenomenon between 1977-94 had led to dangerous levels of over-diagnosis. In his own words:
“While the introduction of the new term, in 1977, achieved its aim in lending to the recognition of many under recognized, ill described, and new forms of child abuse; its over use has led to confusion for the medical, social work, and legal professions.” (49)
(48) "What is, and what is not, 'Munchausen syndrome by proxy'?" Archives of Disease in Childhood 72 (1995), pp. 534-538.
(49) Ibid., p. 534.
What is the nature of the problem? It is several-fold, according to Meadow. First, Rosenberg’s four-fold 1987 definition is unhelpful. In his words, “As a diagnostic aid, these criteria lack specificity: many different occurrences fulfil them.” That is, it is common for children suffering physical or other forms of abuse to be presented repeatedly for medical assessment, and for the perpetrating parent to deny that they have injured the child. Yet, as he says, “most of that abuse should not be classified as MSBP.” (50) The problem with the definition is not simply that it provides no clarity or guidance for researchers, but it also causes havoc among care providers. As he says:
“Currently the term Munchausen syndrome by proxy seems to cause great insecurity and panic among some of those who work with abused children." (51)
(51) Ibid., 535.
This “panic” will be described later in the section—it is the need for case workers to make what they believe is an instantaneous diagnosis in order to keep the child from going home to face a probable death. Of course, this supposition was fueled by erroneous statistics, but it didn’t displace the “panic” of which Dr. Meadow speaks.
A second problem he isolates is that the term is imprecisely used regarding the person to whom it applies. At first the term was used to describe a form of child abuse, rather than to describe the parent’s behavior. Nevertheless, as time has gone on, he notes, colleagues in other professions have begun to talk about mothers who “suffer from MSBP.” But, for Meadow, MSBP is a term describing the abuse rather than the abuser. This was also Rosenberg’s approach, but is almost completely rejected in the legal literature. In that literature it is the abuser who has MSBP. In a fit of pique he gives the following example:
“In the past I have resented being asked in court whether someone is ‘suffering from MSBP’: it has seemed no more appropriate than being asked if a man who has buggered his stepson is ‘suffering from sex abuse.’” (52)
Third, Meadow’s dissatisfaction with Rosenberg’s definition leads him to adopt, in large measure, the DSM-IV definition, despite the fact that he is a medical, and not mental health, provider. In Meadow’s understanding, the problem is not simply the result of physical injury. He says:
“However, although it often involves physical abuse, a more important and pervasive aspect is the associated and continuing emotional abuse. The DSM-IV criteria would reinforce that." (53)
In other words, he wants to inject a “mental state of the mother” into the diagnosis of MSBP/FDBP. Indeed, by so doing, he hoped to limit the use of the diagnosis. By making maternal motivation (to assume the sick role) an essential aspect of the definition, Meadow hoped to curtail its wild application. In his words, the limitation suggested by the DSM-IV definition will “prevent the term being used for many forms of child abuse for which it is currently used inappropriately.” To illustrate his point, he lists eight prevalent forms of child abuse which, by themselves, really ought not to be described as MSBP: (1) unrecognized child abuse; (2) failure to thrive/neglect; (3) overanxious parents; (4) mothers with delusional disorder; (5) masquerade syndrome; (6) hysteria by proxy; (7) doctor shopping; and (8) mothering to death. (54) Meadow’s timely observations not only indicated the problem of over-diagnosis circa 1995 but provided a means, by following the DSM-IV criteria, of limiting these “panic” allegations of MSBP.
(54) Ibid., pp. 536-537.
The barrage continued in the same issue of Archives of Disease in Childhood, as two clinicians argued that MSBP was not a “syndrome” after all. (55) If Meadow was bothered by the over-diagnosis of MSBP, Fisher and Mitchell were plagued by the imprecision in language surrounding its description as a syndrome, which they felt eventuated in unhelpful “leaping to conclusions” by a variety of diagnosing professionals. They noted that it was pediatricians, in their experience, who raised a suspicion that fabrication occurred when discrepancies were noted between the perpetrator’s history, physical findings or course of the illness. Then, the pediatrician tended to make the “diagnosis.” They go on to say:
“It is clear that a ‘diagnosis of MSBP/FIBP [the “I” stands for “illness”] only describes a single or series of observed anomalies and discrepancies. The word diagnosis is usually understood as the identification or inferring of the presence of a disease by means of a patient’s symptoms. MSBP/FIBP is not a diagnosis in a traditional sense but an observational description with implications regarding cause.” (56)
(55) GC Fisher and I Mitchell, "Is MSBP really a syndrome?" Archives of Disease in Childhood 72 (1995), pp. 530-534.
(56) Ibid., p. 532.
Thus, when making such a series of observations, an “observational description,” pediatricians ought not to opine about mother’s mental condition. Nevertheless, in their experience:
“at the point the observation is made or the label MSBP/FIBP applied there appears to be an almost automatic reaction by many medical and adjunct staff to assume an illness called MSBP/FIBP is present in a parent." (57)
(57) Ibid., pp. 532-533.
Thus, breathless social workers and lawyers ask, “Does the mother have MSBP as if it were a diagnosable disease entity with specific psychopathology that is the same in all cases.” In fact, as Fisher and Mitchell argue, it is not simply an imprecise use of diagnosis but also of syndrome that is at fault. A syndrome, they say, is “a grouping of symptoms and signs that recurrently appear temporally together in many persons.” But here the victims present with a wide variety of symptoms (Rosenberg lists nearly 100) and the perpetrators demonstrate “an extensive assortment of psychopathological dysfunctions, syndromes, and illnesses.”
The upshot is that “these observations have far reaching implications.” (58) We cannot rightly call MSBP/FIBP a disease or a syndrome. If it exists at all, we must realize that the perpetrators have various psychological “pathways” that lead to a behavior of fabricating or inducing illness in a child. Such pathways could include personality disorder, depressive illness or severe family and social stressors. In their opinion, the term MSBP/FIBP should be reserved only for parents who themselves have Munchausen syndrome or factitious illness and for various unique reasons, manifest these symptoms through their children.
(58) Ibid., p. 533.
One doesn’t have to agree with the last sentence to realize that they are doing substantially the same thing as suggested by Dr. Meadow—sharply limiting the diagnosis or identification. While Meadow emphasizes his interest in avoiding a rush to judgment and an imprecise category, Fisher and Mitchell seem to wonder whether the imprecise words surrounding MSBP/FIBP have completely eviscerated all meaning from the term. Instead of going along with Meadow’s suggestion to follow the DSM-IV definition, Fisher and Mitchell are content to emphasize that the primary focus of pediatricians ought to be on close description of the observed situation, without any hypothesis regarding MSBP as a cause. It is for the consulting mental health professional to speculate on the perpetrator psychopathological “pathways” leading to the parent’s behavior.
If these authors have severely damaged the continuing vitality of MSBP/FIBP as a common diagnosis (both of them refer to it as a “rare” condition), psychologist Eric Mart has argued, from statistical theory, that the danger of over-diagnosis and, consequently, misdiagnosis is so great that the label is all but useless. (59) While he makes many points in his article and book, only one will concern me here—the so-called “base rate” problem. The concept of “base rate” is important in statistics, and it requires that the smaller the incidence of a phenomenon, the greater precision in definition of the phenomenon is required or else one will end up with too many “false positives,” (i.e., incorrect identifications). That is, Mart attempts to illustrate from statistical theory the same problem that doctors and mental health professionals refer to by observation—that the diagnosis is used excessively, irresponsibly and harmfully.
(59) "Problems with the Diagnosis of Factitious Disorder by Proxy in Forensic Settings," American Journal of Forensic Psychology 17 (1999), pp. 69-82. Munchausen Syndrome by Proxy Reconsidered (Bally Vaughn 2002).
To illustrate the “base-rate” problem, Mart gives the following example. Let’s suppose, he says, that a test has been developed which accurately identifies 100% of serial killers, but misidentifies only one percent of non-serial killers as serial killers. That is, it, like most tests, isn’t 100% infallible; it is only 99% so. Let us also assume that the base rate of serial killers in the general population is 1 in 100,000 individuals. Let us further administer the test to 100,000 individuals. We will identify that one bona fide serial killer, to be sure, but since there is a 1% error rate, we will also identify 999 people whom the test says are serial killers but, in fact, are not. In ferreting out the one genuine serial killer, we would have misidentified 999 people and, if we got carried away with it, we might actually destroy their lives and reputations as they tried to extricate themselves from allegations that they were serial killers.
Let’s now move this over to the field of MSBP. Almost all researchers stress how “rare” this phenomenon is. The legal articles which talk about its being vastly underreported cannot be accepted as good “data” on this question. Mart points to one study that found that out of 20,000 children identified as having sleep apnea, 54 cases (.27%) were suspected of being related to MSPB/FDBP. (60) Another study looked at babies with serious episodic health problems and found that five cases (1.5%) might be related to MSBP/FDBP. So, it is a “rare” phenomenon.
(60) Munchausen Syndrome by Proxy Reconsidered, pp. 33-34.
Let us take the MSBP/FDBP “profile” given in the description of the Jessica Z case above, and say that the typical MSBP/FDBP mother is overly attentive to the sick child, solicitous of the medical staff, and has a medical background. If we hypothesize that the base rate of MSBP/FDBP mothers among mothers of chronically ill children is 1% (that is, one percent of mothers of chronically ill children are MSBP--probably a high estimate), and if we further assume that the rate of all mothers who are attentive to their seriously ill children, solicitous of medical staff and have a medical background of some sort is 10% (which is probably low), we would have the following calculations. In looking at 100 mothers which present with these three issues, as well as a seriously ill child, only 1 of the mothers would, in fact, be a MSBP/FDBP mom. But, since 10% of mothers fit the profile, our test would identify 10 mothers in this potential MSBP/FDBP category. Thus, the error rate would be 9:1; nine errors for each correct identification, based on these three factors. We would have identified nine “false positives” for every correct identification.
It ought now to be clear that when you have a suspected rare disease or medical condition, you need very tight criteria in order not simply to identify the true sufferers of the disease but also not to include in your number many that don’t suffer from it. But that is precisely what we don’t have in the definition. The results have been devastating. Instead of displaying caution in diagnosing MSBP/FDBP, social workers and prosecutors, fueled by the aforementioned problems of child abuse in our society, have used the label as a broad brush to paint large numbers of “false positives” as people who “have” MSBP/FDBP. Countless family lives have thus been shattered from the “false positive” problem. And, writing as a person who was a litigation attorney, I can testify that the amount of money it costs a person to extricate him/herself from a false allegation can frequently run into the six figures.
An attempt to bring some reason or calm rationality to the aforementioned problems and hasty/false diagnoses lies behind the work of Oregon psychologist Dr. Loren Pankratz. In two articles, dealing with persistent problems with the identification of MSPB/FDBP, he not only agrees with the analysis of the three articles/books just reviewed but wants to develop a more collaborative and non-confrontational model of dealing with mothers who may, in fact, be having difficulty managing the medical problems of their children. (61) Make no mistake about it. Dr. Pankratz believes that allegations of MSBP are usually irresponsibly made. He says:
“My clinincal experience with MSBP has convinced me that the problems with this diagnosis are far more extensive than the concerns I raised in my earlier writings [referring to some of his work in 1998/1999]. The medical literature on MSBP often mentions false accusations, or the possibility of false accusations, but does not convey the prevalence of these misunderstandings or the devastating consequences of a wrong diagnosis.” (62)
(61) One article is "Persistent Problems with the Munchausen Syndrome by Proxy Label," Journal of the American Academy of Psychiatry and Law 34 (2006), pp. 90-95; his latest, in press, is entitled, "Persistent Problems with the 'Separation Test' in Munchausen Syndrome by Proxy." I am grateful to Dr Pankratz for making the latter article available to me and for a one-hour conversation on his experience of more than 20 years in diagnosing MSBP and testifying as an expert witness around the country in such cases.
(62) Pankratz (2006), p. 90
He understands that the development of an MSBP “profile” was a response to Meadow’s distress about the excessive time it took him and other pediatricians to consider the parent as a source of the child’s problems. Yet, the profiling of mothers leads to false positives, leaping to judgment and allegations that often end, rather than begin, the diagnostic process. In other words, because the profile data is so vague (a problem Mart mentioned through his statistical example), extreme care must be taken to determine if these generic profile features really eventuate in actual cases of MSBP. The DSM-IV makes it “impossible to confirm the diagnosis without an evaluation of the intentions and motivations of the mother.” Thus, if a responsible diagnosis of MSBP is to be given, it must only happen after extensive interview and observation. Unless you have “smoking gun evidence,” such as video surveillance (and even that kind of evidence has been brought into question on ethical and clarity grounds), the circumstantial evidence has to be teased out carefully by professionals before a diagnosis is made.
But that is precisely what doesn’t happen. Instead of doing the patient work of analysis, people leap to conclusions, sometimes without interviewing the mother. Dr. Pankratz tells of several “horror stories” in which psychiatrists jumped to conclusions about MSBP without even examining the mother, where mothers are accused of MSBP simply because physicians disagreed about the medical management of their child or because spouses are trying to “get back” at each other in divorce proceedings. Dr. Pankratz’s approach is that MSBP, if it continues to be used as a diagnosis, be done in a way that tries to enhance the well-being of the family, rather than as an accusatory tool to allow prosecutors an advantage in trials. MSBP, therefore, should be an adjunct to treatment, rather than a label, like “sexual abuser,” that leads to panic, disruption of families and huge legal and psychological bills. Finally, the irresponsible use of morbidity statistics, which he illustrates and I have mentioned, is a problem. It is meant, purely and simply, to whip up fears about MSBP mothers. Tales of children quietly going to their death after being returned to suspected MSBP mothers/parents are almost always sufficient for a judge to order a child into protective custody, even without an assessment of the mother. (63)
(63) Ibid., p. 94.
With these damning indictments of an MSBP diagnosis used as a club with which to beat often unsuspecting parents into submission, as well as with the persistent problems in defining the phenomenon, in who can diagnose it, in what its leading features are, in what its incidence is and in how to treat it (most literature in the 1980s-1990s said that if a mother “had” MSBP, it was a nearly untreatable condition), we might wonder how anyone could credibly plow ahead and ignore the cogent and well-reasoned objections I have related. Indeed, the attacks I have mentioned, if not shaking the foundations of those who trusted the diagnosis implicitly, caused a three-fold response. On one hand, there was an attempt to narrow the definition of MSBP so as not to run aground of all the definitional problems I have described. On another hand was an effort to minimize use of the term by inventing yet a third term. Finally, law, which fully bought into the phenomenon by the early 1990s, continued to accept it as a legitimate psychological diagnosis with almost no objection. Let’s turn to that response now.