Hatters Friedman and Landess are forensic psychiatry experts.
The so-called “Take Care of Maya” trial ended last month with a $261 million verdict for compensatory and punitive damages for the Kowalski family. The jury found Johns Hopkins All Children’s Hospital of Florida liable for multiple claims, including the wrongful death of Beata Kowalski by suicide, infliction of emotional distress, and false imprisonment and battery. In part, the Kowalskis alleged that the hospital improperly reported that Maya Kowalski, Beata’s daughter, was the victim of Medical Child Abuse (MCA) and that Beata was the perpetrator with Munchausen’s syndrome by proxy.
In 2015, 10-year-old Maya Kowalski experienced mysterious symptoms. Her mother, Beata, a nurse, scoured the internet for answers, eventually finding a Florida doctor who diagnosed Maya with complex regional pain syndrome (CRPS) and began treating her with ketamine. At one point, the Kowalskis even traveled to Mexico so that Maya could undergo a 5-day experimental ketamine-induced coma. The next year, staff at All Children’s Hospital, where she was taken after a sudden relapse of symptoms, became suspicious about MCA perpetrated by Beata. The hospital then contacted child protective services for the county.
A child abuse pediatrician interviewed Maya and her family, and after extensive investigation, filed a report with the diagnosis of Munchausen’s by proxy. The court ordered that Maya be sheltered at the hospital, and Beata was only allowed to speak to Maya via phone under staff supervision. Beata communicated her distress about the separation from Maya, and also believed that Maya’s condition was not improving while in the hospital because they were not treating the CRPS. After 87 days of hospitalization, the Kowalskis’ attorney asked the court to allow Maya and Beata to hug, but this request was denied. Beata collapsed in court, and shortly after, died by suicide.
The Maya Kowalski case has drawn public and professional attention, fueled in part by the Netflix documentary and the large jury award to the Kowalskis. The case incited emotional reactions online and in the media. Some believed this case represented an outrageous invasion and breach of parental rights. Others staunchly stood by hospital staff, pointing out that healthcare professionals have a legal and ethical duty to report their suspicions of child abuse.
The Complexity of Assessing Medical Child Abuse
MCA involves the purposeful feigning of medical symptoms in a child, which leads to inappropriate and potentially harmful medical interventions (delivered by doctors for what they believed was the benefit of the child). In Munchausen’s syndrome by proxy (also known as factitious disorder imposed on another), the caregiver fakes symptoms of illness in the child in order to receive attention themselves. In 95% of Munchausen’s by proxy cases, that caregiver is the child’s mother, and in 45% of cases, the caregiver is a healthcare professional themselves.
Munchausen’s by proxy and MCA are terms that tend to be used interchangeably. However, what is most critical is the harm to the child, and understanding that a parent may have various reasons to engage in such dangerous behavior. Believing that the mother must be diagnosable with Munchausen’s by proxy in order for MCA to exist could lead to both false positives (when hospital staff suspect mental health issues) and false negatives (when staff have difficulty believing that the mother could be harming her child for unsavory reasons). The very ideas of MCA and Munchausen’s by proxy go against our image of the nurturing and loving mother. Yet although MCA is rare, physicians must keep it in mind in the differential diagnosis.
Much of the Maya Kowalski case focused on the hospital’s reporting of their suspicion of child abuse and the subsequent actions, many of them ordered by the court. Mandated reporting laws evolved in the 1960s and are now present in every state.
Just as with other types of child maltreatment, physicians must report reasonable suspicions or beliefs of medical child abuse. Yet, how physicians conceptualize this “reasonable suspicion or belief” shows wide variation in practice, and the exact definition or threshold of “reasonable suspicion” remains elusive. It is a somewhat subjective threshold, and may present a dilemma in “close to call” cases such as when a child presents with unusual diagnoses, symptoms, or patterns of behavior. No doubt, a doctor’s individual philosophies, experiences, and training play a role in their decision to report or not, as do institutional policies.
States do provide immunity for reports of child abuse made in good faith, but physicians may be reticent to report concerns. “Good faith” means the reporter is guided by moral, ethical, and medical professional guidelines. The standard of a “reasonable suspicion” rather than absolute certainty that abuse has occurred in order to make a report to child protection means that there is a risk of false positives in reporting that should then be proven negative in investigations. Said differently, the large sensitivity of a lower standard of evidence in reporting means that as a society, we are more likely to capture all the cases of children who have been abused, and then investigations can help with the specificity. This is critical for child safety, since studies of adults indicate that only one-tenth of child abuse cases are detected in official rates.
The Potential Impact of the Kowalski Case on Reporting
This case will likely compound physician concerns about reporting child abuse, even if done in “good faith.” But, this case is a reminder of the importance of differential diagnosis, ethics consultation, and managing our own biases and counter-transferences in complex medical cases. It highlights the importance of repeatedly examining the diagnosis, assessment, and plan throughout the course of treatment, and to avoid anchoring on initial impressions or counter-transference reactions. Also, physicians should not hesitate to seek second or third opinions in complex cases.
Today, pediatricians consulting on child abuse cases consider much more than the child abuse mimic of osteogenesis imperfecta that many of us memorized for the board exams years ago. Rare genetic syndromes and medical conditions abound, which can be confused for child abuse.
Appropriate suspicion and differential diagnosis of any type of child abuse should be considered separately from determining parental mental health issues; for example, the diagnosis of sexual abuse in a child does not require the parental abuser be diagnosed with pedophilia. Demanding or “difficult” parents may not represent an abuser but a frustrated, scared, and helpless caregiver who is seeking diagnostic answers and help. Medical professionals are in a bind in these cases as they strive to build rapport with parents and withhold judgment while also considering the potential for, and ruling out, child abuse.
Ultimately, this verdict reminds us all of the importance of careful diagnosis, collaborative consultation, attention to all perspectives, attention to consensus, family meetings as informing sessions, and appropriate documentation.
Susan Hatters Friedman, MD, is the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland, Ohio, where she is also professor of psychiatry, reproductive biology, pediatrics, and law (adj). Jacqueline Landess, MD, JD, is the training director of the Forensic Psychiatry Fellowship at the Medical College of Wisconsin and adjunct faculty at the University of Wisconsin.