What makes mothers kill?
Women like Angela Cannings are able to maltreat and murder their babies because doctors are blinded by romantic notions about maternal instinctYvonne Roberts
Sunday April 21, 2002
Angela Cannings began a life sentence last week for killing her two baby sons, Jason and Matthew. Each was smothered within weeks of his birth. A third child, Gemma, born in 1989, had also died within weeks. Cannings had claimed all three had been victims of sudden infant death syndrome, otherwise known as cot death.
Both Jason and Matthew had suffered an acute life-threatening experience before their deaths, struggling for breath while being smothered by Cannings. Paul Dunkels QC, prosecuting, said: 'For a mother to attack a child in this way is against nature and instinct.'
Cannings had police baffled as to her motive. She refused to undergo a psychiatric examination and investigations revealed no sign of post-natal depression. She was described as 'a loving mother'. So what propelled a woman coldly and calculatedly to kill her own offspring? Why was the pattern of behaviour not recognised and halted earlier? And what more have we learnt of this 'perversion of motherhood' since it was first identified 25 years ago?
In 1977 the paediatrician Professor Sir Roy Meadow had a six-year-old girl as his patient whose urine was flecked with blood. Sixteen consultants were involved in her case but it was Meadow who came to the correct conclusion - that her mother, a nurse, had tampered with the child's urine sample, adding menstrual blood. Meadow labelled this behaviour Münchhausen syndrome by proxy.
A woman with the syndrome - usually a mother, co-operative, outgoing, the consummate actress - maintains a medical drama in which she exercises considerable power over doctors, turning them from healers into harmers. She (it is rarely a man) may engage in a range of activities, from encouraging doctors to conduct invasive procedures to administering poison or salt or blinding with bleach, to using temporary suffocation.
Relabelled last month by the Royal College of Paediatricians and Child Health as fabricated or induced illness by carers (FII), the syndrome recasts traditional roles. The doctor, trained to act in partnership, is required to exercise deception and turn detective, treating the parent, who is often the stereotypical 'good' mother, as the potential saboteur of all cures.
'Some professionals believe only what they can bear to believe,' said Gretchen Precey, a social worker and organiser of a major conference on FII next month. 'That's one of the reasons why we're failing to pick up on a great deal of this behaviour - to the detriment of children.'
It is now recognised that FII covers a wide spectrum. At the mild end is the mother who, for instance, grossly exaggerates her child's symptoms, either for gain (disability benefits) or as a cry for help.
At the other extreme are mothers who kill by accident or design - like Cannings and solicitor Sally Clark, who was jailed in 1999 for suffocating her two babies - or who repeatedly present a child who they say has symptoms such as seizures, epilepsy or respiratory problems.
In 1996, Jennifer Bush, aged seven, was taken from her mother, Kathy. She had had 40 operations. Her gall bladder, her appendix and a portion of her intestines had been removed. Florida child-abuse investigators alleged that at the root of Jennifer's 'illness' was her mother's state of mind. Kathy Bush had contaminated the surgical tubes implanted in her child's stomach with faeces.
The potential link between FII and cot deaths inevitably causes distress to parents who have inexplicably lost children, but the statistics suggest that a thorough inquiry is urgently needed. According to Sarah Kenyon of the Foundation for the Study of Infant Deaths, one baby a day dies a cot death. Ten per cent of these deaths are due to maltreatment.
The foundation runs a programme, Care of the Next Infant, which supports families who have already suffered a cot death. Of the first 5,000 babies enrolled, 44 subsequently died. Seven of those arose from maltreatment, 19 were due to 'true' cot deaths or natural causes, and information on the remaining 18 was 'inadequate'.
Only a third of postmortem examinations on babies who die suddenly are conducted by paediatric specialists - in the rest, essential tests are not carried out. Over a six-year period until the early Nineties, 39 cases of FII were detected, using covert video surveillance in hospitals. That group also had 41 siblings, 11 of whom died of cot deaths. Four parents subsequently admitted suffocating eight babies. But a handful of cases does not prove a pattern.
The foundation would like a clearer picture. It wants a paediatrician to visit a family within 24 hours of death, all postmortems to be con ducted by paediatric pathologists and a case conference called.
Is there a difference between women who kill and women who injure? Judith Libow, a Californian psychologist who is co-author of one of the seminal books on FII, Hurting for Love , believes there is, but that has yet to be established by research. 'We need to classify more and understand better,' she said.
She points out that both groups often share certain traits. 'Often we see an absent father in their own childhood and some early, prolonged experience with the healthcare system.'
What drives an outwardly 'normal' woman to kill? Some professionals argue that the child becomes a fetish. Pain inflicted on the infant is a way of deflecting memories from the mother's own childhood trauma. Libow also believes that FII is linked to an inversion of society's idealisation of motherhood. A 'perfect' mother will express 'a kind of gleeful excitement just when her child's life hangs in the balance'.
What are the long-term consequences of being mothered to near-death? One study followed 54 children for five years after they were reunited with their families. Half displayed severe behavioural problems and poor development.
Libow recently conducted a study of children, aged between eight and their teens, who inflicted symptoms on themselves - cutting the insides of their mouths with razor blades, injecting themselves with faeces. For many this is learnt behaviour: mummy loves a sick child.
The difficulty is that, since many abusers refuse to admit their guilt, if jailed they receive no help. If they are classified as suffering from a personality disorder, they are deemed untreatable. If sufficient evidence can be gathered against them (not an easy task), they may still reject support. 'Do they have more children after one child at risk is taken from them?' asked Precey rhetorically. 'Yes, they do.'
Critics dismiss FII as a 'a dustbin diagnosis' that ensnares the innocent. One parent, who alleges she was falsely accused, said: 'Of course a mother isn't herself when she has a sick child; that doesn't make her an abuser.'
How frequently are mistaken diagnoses made? Paediatrician Dr Nigel Speight has acted as an expert witness in 14 cases of young people with ME in which, he said, the spectre of FII has haunted the parents. One teenage boy was placed in a secure psychiatric ward for seven months, five years ago, and now in addition to ME, according to Speight, he also suffers from post-traumatic stress disorder. 'In all the cases, the doctor who pulled the trigger failed to take a proper medical history,' said Speight.
FII has become a fraught and bloody battlefield. Paediatricians complain of constant harassment from families who claim innocence. So much so that professionals are reluctant to take on cases. For those engaged in FII, pursuit is part of the game. 'They are litigious, persistent and without compassion,' said Harvey Marcovitch of the Royal College of Paediatricians and Child Health.
What adds to the difficulties is the ambivalence of the public and media towards child abuse in general, often championing the parent against the social worker, and the complexity of the cases, pitting the power of the parent against the often impoverished rights of the child.
A working party headed by Dr Richard Wilson on behalf of the Royal College produced a meticulously researched report last month that suggested a range of measures, including more professional collaboration, monitoring a child's health once removed from the parent, improved paediatric training, reviewing the legal and ethical obligations of doctors often torn between patient confidentiality and the needs of the child, and improving parental access to a second opinion.
The Department of Health is to publish its own guidelines in the summer. What may also help to detect women like Cannings sooner is jettisoning romantic notions about the maternal instinct, which can blind even the most expert, and providing professionals with the tool they lack most - time.
'Every clinic I do, I have a parent where I think, "What lies beyond the immediate presentation of symptoms? Why is this person bringing this child to me now?" ' said Wilson.
'In most cases it's not FII, but what we desperately require is time to consult properly. Professionals will still get fooled but, on some occasions, we may be able to detect what's really wrong - and help to rescue a child.'
Guardian Unlimited © Guardian Newspapers Limited 2002