The Devil You Know

by Gwen Adshead

  After I left Broadmoor in 2013, I continued to work as a forensic psychiatrist, providing consultations for different mental health teams in female prisons and the probation service, as I’ve described, but I always tried to make space in my schedule to carry out psychiatric assessments for the family court, which deals with the care and protection of children, among other family disputes. I’d been asked to assess Sharon, and she’d clearly come reluctantly. Her moon-shaped face, curtained by lank orange-blonde hair, was distorted by a scowl, her voice low and sullen. ‘How long’s this gonna take?’ She gave an exaggerated sigh, but at least she set her mobile phone aside. I felt like sighing too.

  The situation was pretty serious. Thomas, her thirteen-month-old son, had developed a mystery illness during infancy which no one could explain. Sharon had been unwilling to work with health care professionals towards a resolution, complaining instead that they were somehow at fault. She had become increasingly aggressive and uncooperative, to the point where social services feared that she could not safely look after Thomas. They had applied for a care order, meaning that he was temporarily removed into foster care, and the family court had ordered a psychiatric assessment of Sharon in order to assess whether he could safely be returned to her care. Unlike criminal courts, if there is a risk of harm, family courts do not wait for proof of an offence; child safety is paramount, and the state moves quickly to protect its smallest citizens.

  I tried to frame our task for her, emphasising that I wasn’t there to decide anything or take a side. ‘My job is to be neutral, help the court see things from your perspec—’ But she cut across me. ‘I don’t want to be here, you know. I’m a good mum, no matter what they say. The social’s been in my face half my life, and what fucking good are they? I can look after Thomas just fine. It’s those doctors – they don’t listen, they don’t care, they don’t do anything!’ As her voice rose, I heard a note of fear. ‘Now they’re practically saying I’m a child abuser, aren’t they? Taking him away from me! I’m a good mum, nothing like my mum, that’s for fucking sure. The doctors are the guilty ones, not me.’ She sat back, and now I could see her eyes brimming. I pushed the box of tissues towards her, and I thought I heard a muffled ‘Thanks’ as she blew her nose.

  Her phone buzzed with a text, and she immediately went to reply. ‘Sharon?’ I resisted an impulse to grab the device and set it out of her reach. ‘Gotta keep it on in case it’s about Thomas, you know? I’ll put it on vibrate.’ She was offering me a truce of sorts, and I took it gratefully. ‘So how do we come to be meeting?’ I asked. She grunted, looking at the ceiling. When she’d arrived that morning, she’d flung herself into the chair and draped her legs over one arm, as if to signal her disdain for the process by not facing me – or not facing what we had to do together. I thought her aggressive presentation was a defence against feeling small and vulnerable. She was young David, confronting the evil Goliath of the family court and social services, a victim of the malignant overreach of the nanny state. ‘My little boy was sick. Really, really sick, for ages. I tried to help him, and the doctors were crap. When I complained, they wanted to get back at me, so they lied to the social. The end.’ I made some notes, then looked up at her. ‘Get you back? How do you mean?’

  ‘Duh. They didn’t like me – or Thomas – because I called them out, didn’t I? And you know the rest.’ She raised bitten fingernails to her mouth and gnawed at the raw edge of her thumb. I wasn’t discouraged; I thought she was showing some insight. She was probably right that the medical teams hadn’t warmed to her. I made another note, aware that she was craning her head to see. I turned the pad towards her. ‘You’re welcome to read it.’ She shuffled in her chair to sit normally and frowned, trying to decipher my scrawl. ‘I thought, with a shrink, isn’t everything I tell you meant to be totally private, just between you and me?’ I explained that the court needed to know what we had talked about so that they could better understand her point of view, which meant I had to get things down accurately. ‘Right,’ she said, sounding dubious. I took inspiration from her smartphone, balanced precariously on the arm of her chair. ‘I need to take a clear photograph of your story, without any filters or Photoshopping. Does that make sense?’ She rolled her eyes but nodded as if she understood.

  I knew the basic contours already from talking with her solicitor and reading through the legal files they had provided. Sharon was a single mum who lived in council housing on the outer fringe of west London. Her parents were both dead; her mother had been in a car accident when she was small, and her father had died of an illness a few years later. As a consequence, she was fostered from the age of thirteen, and five years later, soon after being discharged from the care system, she had become pregnant. There were no details about the father in the documentation I had seen, but some medical notes that were included indicated her pregnancy and labour were normal.

  Within a month of her son’s birth, Sharon started to appear at her local doctor’s surgery, expressing concerns about the baby’s health, as often as two or three times a week. It’s not unusual for first-time parents, especially those without family around them, to be peppering GPs and nurses with queries, but Thomas was found to be in good health every time. His height and weight were at the high end of the average range and none of the symptoms his mother described were evident upon examination. A health visitor had been to see her at home and given her helpful pamphlets about breast-feeding and such, with advice on how to join mother and baby groups. That hadn’t been enough for Sharon and she began taking her son to different hospitals’ emergency departments on a regular basis, looking for answers to her continuing concerns. She described some alarming symptoms with great urgency; one nurse noted that she wept and said she was ‘desperate’. But several different physicians at various hospitals were unable to detect anything – the baby always appeared to be in good health.

  Late one night, when Thomas was about twenty weeks old, Sharon brought him in to A&E, saying he had a high fever and ‘might have sepsis’. She described how other doctors had told her that he had ‘something wrong with his kidneys’ and gave the junior doctor on duty a urine sample she said was Thomas’s, claiming her health visitor had advised her to collect the sample if symptoms continued. It was bright red. Further tests were run on the baby. The senior paediatrician who was called to review the case found that the kidney scans were clear and the baby seemed comfortable. A new urine sample was taken and no blood was seen; the notes referred to ‘a perplexing presentation’.

  After making a call to Sharon’s GP, the paediatrician heard about the history of frequent visits and false alarms at the emergency room and took the view that the case needed a review by the child safeguarding lead. This is a hospital staffer who is specifically assigned to co-ordinate safeguarding procedures for vulnerable patients, including contacting social services, if necessary. The dominos fell, one after another: a child protection investigation was opened, the local authority got involved, care proceedings were opened in the family court, and Thomas was temporarily removed to foster care. A court-appointed guardian would represent his interests while a psychiatric assessment of his mother was set in motion.

  By this time, I had been providing reports for cases in the family court for more than a decade, including while I was still working at Broadmoor. The work drew on my increasing interest in early child development as it relates to risk, but my study of medical child abuse had begun many years earlier, not long after I became a forensic psychotherapist – partly prompted by my own experience of motherhood and what it did to my mind. Like many women, I found that maternal instincts did not switch on like a light, and I did not always find being a mother comfortable. I was used to being a competent carer at work, but sometimes I felt like an incompetent one at home, and this made me anxious.

  I was interested to discover more about the causes of the kind of maternal anxiety that led to extreme behaviours, and together with some colleagues I embarked on research whi
ch was as enlightening as it was difficult. In the course of our work, we gained access to some disturbing covert surveillance footage from a 1980s child protection investigation, featuring a group of mothers caught in the act of stopping their children’s breathing while in hospital. Those videos were not easy to watch, but they offered a rare chance for a forensic psychiatrist to see violent offenders in action. Most of the women had no ‘bicycle lock’ risk factors for violence and appeared to be the most caring of mothers, other than when they had their hands over their babies’ noses and mouths. We concluded that the common denominator between women like this and violent offenders was their early attachment patterns, with high incidences of childhood abuse, neglect and loss.1

  Since then, I’ve seen more mothers like them, such as Sharon. Each case I’ve worked on has been unique, humanly rich and always poignant. All of the women appeared to be making up stories about their children’s ill health or actively making them ill and lying about it. At the same time, they were baffled by the idea that they could harm the child, as if this were out of their psychological sightline. Nearly all of them used one phrase over and over: they ‘just felt something was wrong’. This unusual parental behaviour was commonly known as Munchausen’s syndrome by proxy (MSBP). The current official term is medical child abuse causing a child to have factitious or induced illness (FII). Munchausen’s is a name appropriated in the 1950s by British doctor Richard Asher from the fabled Baron von Munchausen, a character who went around telling fantastic stories about himself. Asher used it to describe patients who gave false or exaggerated accounts of their illness. Subsequently, it was recognised that people might also do this ‘by proxy’ with their children (or another vulnerable person in their care), giving rise to the term MSBP.

  What usually happens is that a caregiver, nine times out of ten a mother, tells health care professionals that her child is ill when they are not, lying about or magnifying their symptoms. The most severe cases tend to involve children younger than five, no doubt because they can’t protest or contradict their parent. GPs and paediatricians have to take such parental accounts at face value – and, indeed, are trained to do so – which means it can take some time before the truth emerges. Like Sharon, mothers may seek out many different doctors and different hospitals, reporting different symptoms. Eventually, when it becomes clear they are fabricating or even causing a child’s symptoms or injuries, social services will be alerted.

  Some of the mothers present themselves as anxious but brave, heroic carers who are just trying to advocate for their children. Others are demanding and accusatory, insisting that the doctors are wrong, that the child’s tests are not normal and that more must be done, always demanding new and better investigations. Some will use social media to depict themselves as gallant fighters against the medical system. Even if the child gets better, there are mothers who come back to report a whole new set of symptoms, and so the cycle begins again, until a professional becomes suspicious enough to investigate. With all the smoke and mirrors involved, that can take months or even years.

  Medical child abuse remains as controversial now as it was when the term was first coined, with critics variously questioning whether it can be conclusively proven, linking it to systemic misogyny or labelling the very idea preposterous, with all the fervour of those who question the American moon landings. It is hard for any culture to accept that mothers would harm their children, but there is enough good-quality data to show that it happens, even if it is rare. What the numbers actually are is another matter, since this kind of data is challenging to collect and verify, as we see with other kinds of abuse. One UK study conducted in the 1990s found an average of around fifty cases per year;2 more recent overviews in the US suggest a similarly low incidence relative to population size.3

  The biggest worry are those cases where someone actively induces illness in a child who may have an existing physical health condition. Every branch of paediatrics has a horror story to tell about this: the mother who put faeces in an intravenous line; the mother who withheld or tampered with life-saving medication or oxygen supplies; the mother who used a ball-peen hammer to create ‘inexplicable’ haematomas on the legs of her disabled son. Although this kind of behaviour is uncommon, child protection professionals are attuned and reactive to potential signs. They are also trained to know that it can be a progressive behaviour. A baby like Thomas might be in good health, with various tenuous symptoms, for a period of time, when the immediate danger to them is low, other than the risks posed by unnecessary medical interventions and highly anxious parenting. But if their mother or carer does not get the medical attention they feel is needed, this could escalate into them impulsively inducing more alarming symptoms. In view of Sharon’s history with Thomas, and the increasing frequency of her hospital visits, social services felt compelled to take action.

  Sharon did not respond well to their intervention and was difficult and obstructive, refusing to let social workers touch her son or see him alone, or cancelling appointments at the last minute. Social work is an invaluable but thankless job, among the most challenging of front-line services, and particularly so in child protection. Much as in the prison service, and in general health care, I’ve seen that people working in social services are functioning within an overwhelmed and underfunded bureaucracy, and mistakes can be made. If this leads to cases of child abuse being missed or misread, they will face an inevitable wave of media coverage and scapegoating. This is one reason why family courts have such a vital role: they are protecting parental interests as well as those of the children, and every case involves close scrutiny of all the evidence. In my experience, family courts are scrupulous about this and will seek out whatever independent opinions may be required; it is not unknown for a judge to hear from more than ten different experts in a given case.

  As my session with Sharon neared its end, I realised I had no information about her childhood, which meant I couldn’t explore any possible problems in her early attachment. As is often the case, the social services records were lists, not narratives, primarily data about her son and his health, with almost nothing about Sharon’s past. I asked about her deceased parents, but she was not forthcoming. ‘What’s this got to do with anything? Look, all I need is for you to tell the judge I’m a good mum!’ When she’d gone, I reflected that she had unconsciously said something important about her own need to be a good mum. I thought she was expressing another layer of need too: she seemed to need her son in order to be an adult; without him, she reverted to being a distressed and frustrated girl, one who was probably quite fearful.

  I submitted my report soon after that meeting. Under the UK’s Children and Families Act 2014, care proceedings have to be handled within twenty-six weeks; in the past, backlogs and delays had meant the average was at least a year, which was rightly seen as untenable. I concluded that Sharon suffered from extreme anxiety but had no other mental illness, and made a recommendation that she have therapy, if possible. If she were willing to accept that help, I thought there was a good chance her anxiety might improve. I was not being wildly optimistic when I gave that opinion: I’d seen cases where women like Sharon had changed their minds for the better.

  I doubted I would see her again and assumed that was the end of the story for me. But it was only the end of the beginning. Sixteen months later, Sharon’s legal aid solicitors emailed me, asking if I would see her again. Since our last encounter, she had attempted to remove her son from foster care without permission; meanwhile, her alcohol and drug use had escalated. Eventually, the family court had been persuaded that Thomas should be adopted; this is always a last resort, so the judge must have considered permanent separation from Sharon to be ‘in the child’s best interests’. Her solicitor told me that soon after this judgement, Sharon had really gone off the rails. She was homeless on and off and was thought to have a meth addiction, but was refusing any treatment or housing assistance. About a year ago, she had met a new partner, Jake, a young man
about her age who was well known to the police and the local addiction support team. She had become pregnant again, and the midwife who booked her in to the antenatal clinic contacted social services because of the history with Thomas, her substance abuse, and because she could see that Sharon had a recent black eye and bruises on her arms. I feared I knew where this story was headed. Sure enough, social workers made plans to remove the baby into foster care straight after the birth.

  This process is certainly not unique to the UK; most countries with organised legal systems have similar laws about the termination of parental rights, due to the reality of substance abuse, physical abuse and neglect.4 Striking a balance in terms of rights vs risk is not straightforward in the family realm, and advocates of maternal rights have increasingly protested about the infringement of civil liberties, particularly in the US. Removing a child from their parents in this way is not a common occurrence in the UK, but it is legally supported in the context of child protection legislation, and is done only when there are real safety concerns. The decision is usually taken months in advance, and the mother (and father, if around) will be fully aware and legally represented; there is no element of surprise. But the social work team in Sharon’s case guessed rightly that this removal would be difficult, and it was. While some parents manage to keep it together in these circumstances, generally because their lawyers have advised them to co-operate if they ever want to regain custody, Sharon and Jake had to be restrained as their son was taken from the delivery ward.