Theoretical
basis of FII is unsound
In
2001, following continuing contention regarding the existence,
definition, and application of the term Munchausen Syndrome By
Proxy and many complaints by parents claiming to have been falsely
accused of child abuse, the UK Department of Health issued guidelines
to child protection workers in an attempt to give a form of credibility
and validity to Munchausen Syndrome By Proxy and introduced a
new title of Fabricated and/or Induced Illness in Children .[FII].
The
DoH Guidelines rely heavily on published articles by Professor
Sir Roy Meadow and by Professor David Southall and were drawn
up without the DoH conducting any independent and scientifically
based research or inquiry to substantiate their respective theories
and contentions. The guidelines merely regurgitated the unsubstantiated
opinions of Munchausen Syndrome By Proxy/FII proponents, in complete
disregard of conflicting opinions and without even an acknowledgement
that MSBP/FII had been the subject of immense dispute in the medical
and social work professions for over a decade and is not therefore
generally accepted by the child protection professional community.
The
term Fabricated and/or Induced Illness [FII] is therefore a variant
on what has variously been titled in Munchausen Syndrome by Proxy
[MSBP]; Meadow’s Syndrome; Polle’s Syndrome; Factitious
Disorder/Disease By Proxy, and several other titles. A general
definition of these titles and terms are that it is a form of
child abuse whereby a carer (usually the mother) fabricates or
induces an illness in a child in order to attract the attention
of a medical practitioner for him/herself.
The
original theoretical base for the term was contained in an article
by Professor Sir Roy Meadow which first appeared in the Lancet
medical journal in 1977. [Hinterlands of Child Abuse]. On examination
of the article, it can be found that no form of research methodology
was used and no research protocols are apparent. The contentions
of Meadow were anecdotally based on only two cases of children
under his medical care and he has never made available any records
of his `research’ for independent analysis and examination.
Nor has there been any peer review of his propositions. His findings
can therefore best be described as his personal conjectures and
speculations and the procedures he used show a lack of scientific
integrity and can at best be described as a set of beliefs and
suppositions.
Meadow
has stated in subsequent articles that MSBP is not a disease or
illness of either an adult or a child [BMJ – 1995], but
is a form of child abuse which can only be diagnosed by paediatricians,
and that it is not a form of mental illness. However, some psychiatrists
have entered the dispute regarding its definition, claiming it
is a psychiatric disorder, while there are recorded cases of psychotherapists,
physiotherapists, anaesthetists, nurses, social workers and teachers
all claiming to be able to make an MSBP diagnosis.
Munchausen
Syndrome By Proxy does not appear as a psychiatric illness in
DSM IV (U.S. Manual of Psychiatric Disorders) although it is referred
to in the appendix as Factitious Disorder By Proxy and requiring
further research.
The
problem of flawed and scientifically inadequate research regarding
MSBP/FII is not however confined to Meadow’s research but
can be found in the offerings of other MSBP/FII proponents. In
Pediatrics Vol. 113 No. 6. June 2004, Dr. Herbert Schreier, an
eminent psychiatrist in the U.S.A. and a stalwart MSBP/FII proponent,
admits regarding the best known works and oft-quoted research
by McClure RJ, Davis PM, Meadow SR, and Sibert JR, that, “…..not
all cases reported in the incidence findings were MBP cases. Some
were deliberate poisoning and suffocation outside of the dynamics
of MBP, and some of the MBP cases were not suffocation and poisoning.”
The McClure et al research also included a case where a father
had murdered his two children and committed suicide and did not
involve any allegation of MSBP/FII.
Schreier
admits of an article written by himself [Munchausen By Proxy Defined
– Pediatrics 2002. 110 985-988] that, “I quoted a
study of the epidemiology of MSBP from England and extrapolated
those results to the United States in an erroneous way. I compared
the incidence reported in the under-16 population in England to
the total population of the United States.” These studies
by McClure et al and by Schreier are often quoted in other articles
and research.
In a letter to the British Medical Journal in October 2004 concerning
child abuse research, Patrick E. Lantz, a forensic pathologist
at Wake Forest University Health Sciences in North Carolina, U.S.A,
and forty other physicians and scientists stated that,
“Evidence based medicine is the conscientious, explicit,
and judicious use of scientific evidence in making medical decisions
and cautions against unsystematic, untested reasoning and institution-based
clinical applications”.
It
may be reasonably contended therefore that there is a strong body
of opinion in the medical scientific community that is concerned
about the lack of scientific rigour in theories of child abuse.
Practice concerns
It
is claimed that FII/MSBP usually occurs in circumstances where
a child presents to a medical practitioner with symptoms of an
illness for which no medical explanation is apparent. However,
logic suggests that where no medical explanation is apparent,
an explanation would first be the limitations of medical science
and secondly in the individual level of knowledge of the medical
practitioner (See 2 below).
In
many cases of alleged FII/MSBP the following factors are notable
:
1.
The physician making the diagnosis has not carried out a thorough
and exhaustive investigation of the many possible causes of the
child’s illness e.g. for genetically inherited disorders,
birth injuries, surgical injuries, poisoning by toxic substances
in the environment, severe allergic reactions, vaccine damage,
reactions to prescribed medications (e.g. cisapride/propulsid
– this drug was withdrawn by the U.K. Government after at
least five recorded deaths of children and several hundred children
had been caused serious harm. The manufacturer, Jannsens, have
offered $US90m in damages to families worldwide) or a combination
of such medications, viral infections, or disorders such as chronic
fatigue syndrome, cystic fibrosis etc.
2.
There is a high proportion of allegations of FII/MSBP that seem
to follow a threat by the parent to report the physician for malpractice,
errors of diagnosis or treatment, negligence or incompetence.
The labelling of the complainant as FII/MSBP immediately prevents
more investigations of the child’s medical problems or legal
action by the carer, as the carer is labelled a liar and fabricator.
Bringing legal action or making a complaint against the physician
is therefore very effectively prevented.
It
has been claimed that ‘confessions’ have been made
by a few mothers to smothering or poisoning their children but
some mothers have claimed that such ‘confessions’
were made under the duress that if they did not confess and agree
to therapy, then they would never see their children again, or
that promises were made that their children would be returned
or they could have increased contact with the children in State
care.
It
has also been claimed that FII/MSBP has been shown by covert video
surveillance of mothers and children in hospital. However, such
video-taped evidence has been of very poor quality so that they
are of little value and at the most may arguably show parents
causing harm to a child, but there is no evidence in such tapes
that a parent is `fabricating’ or `inducing’ a child’s
illness in order to gain the attention of the physician for themselves.
In fact again, anecdotal evidence from parents suggests the opposite
applies in that they have often a deep animosity toward the physician
for being unable to diagnose and treat their seriously ill child.
In
a recent article in the British Medical Journal, Professor Alan
Craft and Professor D.M.B. Hall, who are both prominent paediatricians
in the U.K., state, “As there is no single psychological
profile of Munchausen Syndrome By Proxy [FII], and the label makes
unwarranted assumptions about the parent’s mental state
and motivation, many U.K paediatricians feel that the term should
be abandoned.”
MSBP/FII
has also been the subject of contentious debate in the U.K. Parliament
on several occasions and in a Parliamentary debate on 17 October
2001, Earl Frederick Howe said of MSBP/FII that, “(it is)
one of the most ill-founded and pernicious theories to have gained
currency in child care and social services over the past ten to
fifteen years.” In recent times calls have been made by
some Members of Parliament for a withdrawal of the DoH Guidelines.
Arguably,
an allegation of MSBP/FII usurps due legal process and the lawful
roles of the child protection agencies and the police by stating:
The
parent is in effect `convicted’ by doctors and child protection
agencies and this is frequently based solely on the opinion of
only one medical practitioner with no corroborative evidence.
There
is very rarely any evidence that full and independent investigation
and assessment of the allegation by the child protection workers
as required by U.K. child protection legislation, or a police
investigation.
There
is no government body in Australia, the U.K. or the U.S.A. which
records the numbers of MSBP/FII cases which are diagnosed each
year nor do they record cases of false positives. So the incidence
of MSBP/FII is statistically unknown and the accuracy rate is
indeterminate.
Inaccurate
Diagnoses
There
are several documented cases where the allegation of MSBP/FII
should not have been made and several have been reported in the
U.K. media.
A
classic illustration of a false positive allegation of MSBP/FII
was the case of an infant Megan Armstrong which occurred in Northumberland,
England in 2001. Since her birth in January 2000, Megan had been
receiving medical treatment in hospital and at home for failing
to thrive and was treated for an eating disorder. On 1 March 2001,
a Child Protection Conference was convened at which it was alleged
that Megan’s illness was fabricated and induced by one of
her parents and that this was a clear case of Munchausen Syndrome
By Proxy.
The
physicians present at this meeting stated that, "Megan's
needs have been thoroughly investigated by a paediatrician and
other consultants. All medics concerned are of the opinion that
there is no organic cause for Megan's faltering weight. Dr Quilliam
is clear that this child is gradually starving and will go into
organ failure before long as a result of lack of nutrition and
appropriate care with regard to her feeding routine."
On
the basis of these medical opinions, it was the decision of the
child protection meeting that Megan’s name be placed on
the children `At Risk’ register with a view to bringing
court proceedings for her removal from her parent’s care
into State care. On March 2, 2001, the day after the meeting,
Megan - then aged 14 months - was taken to Newcastle General Hospital
to be tested for suspected lead poisoning for which she was given
an MRI scan. The scan revealed that she had a large brain tumour
which was now pressing on the optic nerve in her right eye. The
tumour responded to chemotherapy treatment but the optic nerve
was permanently damaged and she has lost the sight in that eye.
Court
Decisions
In
2003 and 2004 there were landmark cases in the U.K. Criminal Appeal
Courts [Sally Clark/ Angela Cannings/Trupti Patel] regarding the
evidence presented by Professor Sir Roy Meadow and which have
resulted in his theories regarding Sudden Infant Death Syndrome
and MSBP/FII being totally discredited. Judicial comments at these
court hearings were that the medical evidence was “manifestly
wrong and grossly misleading” and such evidence “should
not have been put before a jury”.
As
a consequence of the criticism of his evidence in these hearings,
Professor Meadow is shortly to appear before the General Medical
Council on charges of serious professional misconduct. Professor
David Southall also became involved in the Clark case after seeing
a television documentary and solely on the basis of the information
in the TV documentary, alleged that the babies’ father,
Stephen Clark, had killed the children.
Southall
has already appeared before the GMC Professional Practice Committee
which determined that he was guilty of serious professional misconduct
and his behaviour was “Inappropriate, irresponsible, and
an abuse of his professional position”. Although he is to
be allowed to continue to practice as a paediatrician under constant
supervision, he is barred from engaging in any child protection
work for three years. A further eight complaints of professional
misconduct against Professor Southall by mothers he has accused
of MSBP are to be heard early in 2005. Some of these complaints
are from mothers in Australia and New Zealand.
New
rulings have been made by the U.K. courts in criminal and civil
cases involving the deaths of children which are that, (Lord Justice
Judge – Angela Cannings Appeal Hearing against conviction
2004), "in cases like the present, if the outcome of the
trial depends exclusively or almost exclusively on a serious disagreement
between distinguished and reputable experts, it will often be
unwise, and therefore unsafe, to proceed".
The
U.K Attorney General Lord Goldsmith has ordered a review of 258
cases of parents convicted in criminal courts in which Professor
Meadow gave evidence, such reviews utilising the ruling of Justice
Judge. The U.K. Minister for Children Margaret Hodge has ordered
local authorities to carry out a similar review of civil cases
where children have been placed in state care and adoption and
the Minister has informed Parliament that this involves over 35,000
child cases.
In
relating the ruling of Justice Judge to civil cases in Care Proceedings,
Justice Butler-Sloss has added further rulings that;
“i
) The cause of an injury or an episode that cannot be explained
scientifically remains equivocal;
ii) Recurrence is not in itself probative;
iii) Particular caution is necessary in any case where the medical
experts disagree, one opinion declining to exclude a reasonable
possibility of natural causes;
iv) The Court must always be on guard against the over-dogmatic
expert, the expert whose reputation or amour propre is at stake,
or the expert who has developed a scientific prejudice;
v) The judge in care proceedings must never forget that today's
medical certainty may be discarded by the next generation of experts
or that scientific research will throw light into corners that
are at present dark."
In
the U.S.A. the Supreme Court has ruled, (Daubert vs. Merrill Dow)
that medical evidence presented to a court must have been peer
reviewed, generally accepted by the relevant medical community,
and appropriately tested scientific evidence should be presented”.
Courts in both the U.S.A. and the U.K. have commented that courts
must not be the place for fanciful speculations to be offered
in evidence.
Most
recently in June 2004 in an Appeal Hearing, the Supreme Court
of Queensland, Australia have made the following findings in regard
to MSBP/FII. [R v LM [2004] QCA 192.], “As the term factitious
disorder (Munchausen Syndrome By Proxy) is merely descriptive
of a behaviour, not a psychiatrically identifiable illness or
condition, it does not relate to an organised or recognised reliable
body of knowledge or experience. “
The
Queensland Supreme Court further ruled that the determination
of whether or not a defendant had caused intentional harm to a
child was a matter for the jury to decide and not for the determination
by expert witnesses, i.e. “the diagnosis of Drs. Pincus,
Withers, and O’Loughlin that the appellant intentionally
caused her children to receive unnecessary treatment through her
own acts and the false reporting of symptoms of factitious disorder
(Munchausen Syndrome) by proxy is not a diagnosis of a recognised
medical condition, disorder, or syndrome. It is simply placing
her within the medical term used for the category of people exhibiting
such behaviour. In that sense, their opinions were not expert
evidence because they related to matters able to be decided on
the evidence by ordinary jurors. The essential issue as to whether
the appellant reported or fabricated false symptoms or did acts
to intentionally cause unnecessary medical procedures to injure
her children was a matter for the jury’s determination.
The evidence of Drs. Pincus, Withers, and O’Loughlin that
the appellant was exhibiting the behaviour of factitious disorder
(Munchausen Syndrome By Proxy) should have been excluded.”
Conclusions
Principles
of law and implications for legal processes which may be deduced
from these findings are that :-
1.
Any matters brought before a Court of Law should be determined
by the facts, not by suppositions attached to a label describing
a behaviour. i.e. MSBP/FII/FDBP.
2.
MSBP/FII/FDBP is not a mental disorder (not defined as such in
DSM IV) and the evidence of a psychiatrist should not therefore
be admissible.
3.
MSBPFII/FDBP has been stated to be a behaviour describing a form
of child abuse, and not a medical diagnosis of either a parent
or a child. A medical practitioner cannot therefore state that
a person `suffers’ from MSBPFII/FDBP and such evidence should
also therefore be inadmissible. The evidence of a medical practitioner
should be confined to what they observed and heard, and what forensic
information was found by recognised medical investigative procedures.
4.
A label used to describe a behaviour is not helpful in determining
guilt and is prejudicial. Applying an ambiguous label of MSBP/FII
to a person is implying guilt without factual supportive and corroborative
evidence.
5.
The assertion that other people may behave in this way i.e. fabricate
and/or induce illness in children to gain attention for themselves
(FII/MSBP/FDBY) contained within the label, is not factual evidence
that this individual has behaved in this way. Again, therefore,
the application of the label is prejudicial to fairness and a
finding based on fact.
In
the U.K. there is a long history of unproven medical and social
work theories being readily accepted and used by the child protection
services and which, when finally exposed as unsafe and unsound,
have led to national scandals, e.g. Cleveland 1987 involving the
anal dilatation test for child sexual abuse, the Orkneys/ Nottingham/
Rochdale 1990 involving the theory of Satanic Ritual Abuse, widespread
use of the Repressed Memory Syndrome which was subsequently discredited,
and the Shieldfield Day Care Centre, Newcastle involving the improper
manner of questioning of very young children by a paediatrician
regarding alleged sexual abuse.
It
is clear therefore that those professionals who believe in the
existence of FII/MSBP cannot agree on its title, how it is defined,
which profession can make a clear diagnosis of its occurrence,
and whether it has medical properties. Courts are now coming increasingly
to the view that the label of MSBP/FII should not be admissible
in evidence in criminal or civil cases.
AUTHOR
Charles
Pragnell
Expert Defence Witness – Child Protection and Social Care
Management Consultant
