“The Preventionist” Erases Munchausen by Proxy with Dr. Jim Hamilton

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Speaker 1 Making Nobody Should Believe Me has really changed my life. And I've often felt like I was clinging to a runaway train, mostly in a good way.

Speaker 1 But the truth is, even though I've always really believed in this show, I didn't expect it to take off the way it did.

Speaker 1 I didn't get into this as some kind of planned out career pivot into podcasting, though I'm really glad that it's happened.

Speaker 1 I started this show because I'd been through something that no one in my life really understood or related to.

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Speaker 1 I knew when I set out to cover Munchhausen by proxy how misunderstood it was.

Speaker 1 But what I didn't expect, naively I guess, is that there would be such a strong push to just deny its existence at all and to dismantle what little progress had been made in protecting kids and helping survivors.

Speaker 1 However, years into this project, I can see that we're in a moment where decades of progress on child abuse awareness, prevention, and treatment are under threat from an increasingly vocal and politically mobile parents' rights movement.

Speaker 1 And misunderstood as it is, Munchausen by proxy abuse makes a relatively easy target. I found the preventionists' coverage of Munchausen by proxy to be both misleading and harmful.

Speaker 1 And this was one of several concerns I brought up to the team at Serial.

Speaker 1 In response, they said that Munchausen by proxy is, quote, not the primary focus of our series, and we believe we've characterized it fairly and accurately.

Speaker 1 Downplaying the importance of Munchausen by proxy in this series is interesting, given that the preventionist devotes a full episode of the three-part series to Mark Pinsley's report on the alleged overdiagnosis of Munchausen by proxy, and the lead claimant in the Lehigh lawsuit involves allegations of a false Munchausen by proxy diagnosis.

Speaker 1 Munchausen by proxy is the match that lit the fire in Lehigh, and the series goes out of its way to include an additional Munchausen by proxy-related anecdote in the second episode.

Speaker 1 Now, naturally, I disagree that calling Munchausen by proxy a rare psychological disorder that's just, quote, a popular storyline in movies is a fair and accurate portrayal.

Speaker 1 I mean, it's only been in like four movies, but I digress.

Speaker 1 To dig into all of this and why it matters, I called up my friend and colleague, Dr. Jim Hamilton.

Speaker 1 Jim is an associate professor in the general pediatrics section of the Department of Pediatrics at Yale School of Medicine.

Speaker 1 He has served on APSAC's Munchausen biproxy committee and the Board of Munchausen Support, and is one of the most well-regarded experts in the country on Munchausen biproxy abuse.

Speaker 1 We spoke at the end of October on the eve of the Preventionist publication.

Speaker 1 So, Jim, you've listened to the series, is that correct?

Speaker 4 Yes, yes, I have.

Speaker 1 Yeah, like what are your, what are your high-level thoughts on what this piece of coverage is?

Speaker 4 Well, my,

Speaker 4 you know, what the story is, is, is one thing. What the coverage is, is another.
And

Speaker 4 it just feels so solidly part of this relentless

Speaker 4 PR campaign to

Speaker 4 deny child abuse,

Speaker 4 to support in a very uncritical way.

Speaker 4 the people who are accused of perpetrating child abuse. And I always come back to when I see these media things, and

Speaker 4 I think media things and podcasts are great, including yours, and we're so thankful for it. But

Speaker 4 as an academic,

Speaker 4 as a clinician, as a scientist,

Speaker 4 I hate that this is being litigated on podcasts. But we live in a world where

Speaker 4 careful, patient, thoughtful, scientific and scholarly work gets just run over, you know, like a bug on the road by sensationalist media and so on and so forth.

Speaker 4 I thought as we're going through this, listening to yet another one of these things

Speaker 4 is like,

Speaker 4 where's the kid?

Speaker 1 Where's even a description of what happened to the kid, right?

Speaker 4 It's the perpetrator. It's the perpetrator's troubled boyfriend, the fathers of the children.
It's people standing up at some microphone.

Speaker 4 Where's the kid standing up at the microphone saying what happened to them? My frustration that these things always end up being an asymmetrical

Speaker 4 warfare, the information space is entirely controlled by people who can withhold their medical records, withhold the police records.

Speaker 4 Family courts

Speaker 4 protect all of these records in terms of what the judicial proceedings are around removing children and so forth. And these people are free to go out and stand at a microphone and castigate

Speaker 4 and impugn the child abuse pediatricians and others who are trying to help the children.

Speaker 4 And, you know, even if we have the information, we're not allowed to fight back with it because of our professional responsibilities.

Speaker 4 It's a very frustrating situation.

Speaker 1 Yeah, I think what I, you know, what frustrates me about this kind of reporting, and I will say like, it's my opinion as a journalist that some of this is,

Speaker 1 some of this happens because journalists are out of their depth and they don't understand the issues and they are being, you know, co-opted by these very emotional stories and they're sort of who they're seeing as the underdog, right?

Speaker 1 They're seeing the parents as the underdog against the system. So I will not say that I think all of this reporting is happening in bad faith.

Speaker 1 You know, yes, there's a built-in asymmetry that should be acknowledged if you are reporting on one of these cases.

Speaker 1 For example, you know, did the parents sign a HIPAA release so that you could not only see the medical records that they were wanting to share with you, but all of them, and so that you could speak to the doctors about the case?

Speaker 1 You know, did you do

Speaker 1 public records requests so that you could see what was said in the police reports and all the sort of complicated pieces that go into one of these cases? It's not impossible to figure out.

Speaker 1 You know, it's like the genuine lack of curiosity about what happened to the children in these cases is,

Speaker 1 I think, morally repugnant.

Speaker 4 It's an awful and regrettable thing.

Speaker 4 What I was struck by is

Speaker 4 the

Speaker 4 sort of something about the format, something about the sort of

Speaker 4 conversational

Speaker 4 human interest sort of

Speaker 4 vibe of the show

Speaker 4 kind of makes it sound like I'm just, you know, I, the interviewer, is just sort of innocently letting this person tell their story.

Speaker 4 But there is a lot of editorializing in it.

Speaker 4 You know, there's an interesting sort of technique, a sleight-of-hand technique of making it clear they're just talking about this one person, Dr. Jensen,

Speaker 4 whether or not one agrees with their portrayal of her or their conclusions,

Speaker 4 but sort of then sort of seamlessly shifting to talking about caps in general.

Speaker 1 This all begs the question, if Munchausen by Proxy is, quote, not the primary focus of the series, then what is exactly?

Speaker 1 It sure feels like another entry in the newly popular child abuse pediatricians are destroying families genre, but Ceriel says this isn't the case.

Speaker 1 They wrote me, quote, our show is about an individual physician and her particular form of diagnostic practice.

Speaker 1 It is not meant to serve as a condemnation of the field of child abuse pediatrics at large.

Speaker 1 Many of the criticisms included in the show were actually formed through a process of speaking in depth with other CAPs about what differentiates their practice from Dr. Jensen's.

Speaker 1 To the degree that the host Diane Neary does differentiate Dr. Jensen's practice from other CAPs, there are few direct quotes and little insight into how Neary framed any of the questions she asked.

Speaker 1 For example, she cites CAPS' criticism of their colleagues who are, quote, exceedingly dogmatic in their approach and in their opinion, too quick to diagnose abuse, but it's unclear whether they're in any way referring to anything Dr.

Speaker 1 Jensen did. In another example, Neary presents two CAPs who disagreed with Dr.
Jensen and her team's assessment on a particular case, the Amanda Sarnofsky case featured in episode three.

Speaker 1 But it's unclear how this case was presented to them. Nearly says in the show that these caps were given anonymized medical records.

Speaker 1 I asked Serial if any of the parents they featured signed HIPAA releases so that Serial could see complete medical records, but in their most recent email to me, they didn't answer this question or comment on whether the professionals asked to weigh in on Dr.

Speaker 1 Jensen's work were given any additional context such as police or CPS records.

Speaker 1 The one cap whose voice is featured on the show, Dr. Jensen's former boss, Dr.

Speaker 1 Randy Alexander, had only glowing things to say about her and reported that he'd never received any official complaints about her and would have acted on them if he had.

Speaker 1 As to the idea of this not being an overall criticism of CAPS, well, here are Neri's exact words at the end of the series. She says, quote, here's my diagnosis.

Speaker 1 It seems to me that everyone involved in child welfare cases that include a child abuse pediatrician, I mean caseworkers, doctors, hospital administrators, cops, prosecutors, judges, should take into account the real possibility that the CAP might be mistaken.

Speaker 1 So I definitely read that as a comment on CAPS as a whole. And I'm left wondering, what is the point of this series?

Speaker 1 I have my takeaways, of course, but what do the people making this thing think they're doing with it?

Speaker 1 I spend a lot of time on this show defending doctors who I believe have done the right thing to protect children, often at great cost to themselves.

Speaker 1 However, I I don't think doctors are perfect or above criticism.

Speaker 1 There are also many doctors we've spoken about who've contributed to the harm of child abuse victims, and a few who've been culpable for child deaths.

Speaker 1 Pediatric doctors bear a heavy weight of responsibility because of the trust we place in them to care for our most vulnerable citizens.

Speaker 1 And saying that there's room for change in the medical system and the child welfare system is an understatement.

Speaker 1 It's just that none of the reporting in The Preventionist actually points to a real problem.

Speaker 1 Diane Neary's argument, as far as I can tell, is that child abuse pediatricians have too much power and influence.

Speaker 1 And she offers the idea of second opinion laws as a solution. But I think this problem is contrived.
Nearly doesn't present any evidence that the checks and balances on Dr.

Speaker 1 Jensen weren't working, or that any of these parents were denied due process. And in the one case she speaks about in depth, that of Amanda Sarnofsky in episode 3, Dr.

Speaker 1 Jensen Jensen was the second opinion. She confirmed a diagnosis made by another doctor.
The point Niri appears to be making is that doctors shouldn't be acting alone or absent from oversight.

Speaker 1 And they're not.

Speaker 4 I'm all for peer review. I think peer review is good in setting up peer review relationships and so on and so forth.

Speaker 4 You know, there's transparency there. There's

Speaker 4 you know, having more eyes on the situation is always the case.

Speaker 4 But keep in mind that, you know, know the cap isn't sitting in the emergency room watching every case that comes in the cap is called by a concerned physician

Speaker 4 typically it could be a concerned somebody else but somebody all has already looked at the facts of the case and said this is something that should be looked at by somebody else so it's not like the people that the caps are introduced to to assess are randomly selected children from the population.

Speaker 4 They're people who are suspected of child abuse. And it's not every kid that goes to the emergency room with an injury.
It's only a very small number of them.

Speaker 4 And so the idea that caps are quick to find for abuse.

Speaker 4 I think in some of the materials that you showed me, and others I've read, discussions with my colleagues on the

Speaker 4 safety, advocacy, and health section of the Department of Pediatrics at Yale. It's often the CAP who says, thanks for bringing the case to our attention, but I don't think this is abuse.

Speaker 4 And given that the people they say, see, are suspected,

Speaker 4 I mean, you know, something like a 50%,

Speaker 4 you know,

Speaker 4 CPS reporting incidence,

Speaker 4 is not a statistic that suggests that, you know, these are madmen and women out for, you know, to take a piece of flesh out of poor beleaguered parents.

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Speaker 1 In Serial's initial response to my comments, that I felt they were mishandling munchausen by proxy abuse, they pointed me to a commonly cited statistic from the American Academy of Pediatrics that puts the number of children under 16 affected by munchausen by proxy at fewer than two per 100,000.

Speaker 1 And like many statistics on an underrecognized phenomenon, this only tells a piece of the story.

Speaker 4 Prevalent studies, unfortunately, in the sort of landmark paper that the American Association of Pediatrics published,

Speaker 4 If you read it carefully, they talk about several different studies that deal with the prevalence of medical child abuse and Munchausen by proxy abuse.

Speaker 4 These studies, the larger studies, the population studies came from England.

Speaker 4 They used

Speaker 4 as their sort of denominator, so how many kids were reported by the pediatricians, and they divided that by all of the children in that age group in the entire country.

Speaker 4 That's a flawed flawed approach for a number of reasons. One is it's perfectly possible that children are being medically abused in ways that don't come before doctors in ways that are

Speaker 4 obvious. In many cases of medical child abuse, the primary audience is the school, is the family.

Speaker 4 People who are perpetrating that abuse do just as much medical contact as they need to preserve the narrative that the child's sick. Again, you know, and we've talked about this in the past,

Speaker 4 as much as the high-profile cases like the Kowalsey case and the Blanchard case have raised the profile of medical child abuse, they've also given terrible misimpressions about what the average case is like.

Speaker 4 They're not all ravenous for attention. Some of these are parents who are afraid of losing connection with their child and and want to keep them dependent.
Those are sort of low-boil kinds of cases.

Speaker 4 They don't present like, you know, with a lot of smothering and poisoning and trips to the emergency room every other week.

Speaker 1 So you might see something more like this, you know.

Speaker 1 fabricated autism or ADHD diagnosis and an IEP and a bunch of sort of like messaging to the child that they're not normal and like that kind of thing, educationally.

Speaker 4 Exactly right. And that wouldn't be be caught by

Speaker 4 these larger studies. So for, you know,

Speaker 4 to put it more simply, they can't be sure all the people that they counted as non-cases of medical child abuse are really non-cases of medical child abuse.

Speaker 4 But suffice it to say, look, I don't believe that medical child abuse is highly prevalent in the general population.

Speaker 4 But I think it's more prevalent in clinical populations and in populations of special needs children, for example, than anybody is fully aware of.

Speaker 4 So in that seminal paper published by the American Association of Pediatrics, there are studies of smaller populations.

Speaker 4 Populations, for example, of

Speaker 4 kids who had apnea that

Speaker 4 needed to be explained.

Speaker 1 And well, I was also thinking of, you know, the children's, the paper out of Seattle Children's that was studying instances of munchhousen biproxy in

Speaker 1 children that were given

Speaker 1 gastric feeding tubes. And that was, you know, that was like much higher.
So yeah, looking at some of those sort of

Speaker 1 things.

Speaker 4 There are studies out there that are smaller studies. They're generally less scientifically rigorous.
They're usually done out of a particular practice.

Speaker 4 And the papers are written with those limitations

Speaker 4 clearly addressed. But they show that the percentage in some of these things can be as high as 10, 12, 13, 14, 15%

Speaker 4 among medically complex, difficult to explain, difficult to manage

Speaker 4 pediatric medical cases. And so I just published a paper on prevalence and am disappointed at how little empirical evidence there is on it and how many people sort of

Speaker 4 just reflexively cite those larger studies that that published a kind of vanishingly small prevalence.

Speaker 1 Yeah, and it's it's really, you know, it's an issue because that's to say that like there are many things that were once believed to be vanishingly rare that turned out not to be vanishingly rare once we had better data.

Speaker 1 That's sort of how it works.

Speaker 1 And yes, I think there's the, there's the, you know, she makes this

Speaker 1 what I found to be quite a glib comment in the first episode you know where she says basically well this is a popular storyline in movies but you know it's incredibly rare rare in real life um which i felt was like pretty dismissive and and then you know what she's doing in this case and i'll we'll talk a little bit about this this particular family that curiously she does not choose to name even though their names are very much public um Kimberly and Stephen Steltz, who are the lead plaintiffs in the lawsuit against Deborah Jensen and the hospital.

Speaker 1 And, you know,

Speaker 1 she

Speaker 1 puts this emphasis on it being a rare psychological disorder, which, you know, the actual name for the psychological disorder is factor disorder imposed on another, but I don't think this is just a terminology debate.

Speaker 1 She's classifying it that way because the argument that the steltses are making is that they were diagnosed as having Munchausen by proxy, and that if it's a rare psychological disorder, well, what are the chances that both of them would have it?

Speaker 1 So it must be wrong.

Speaker 1 So can we sort of talk through the, you know, the faults in that whole idea of this being a psychological disorder that you would diagnose in parents in the way they're presenting it?

Speaker 4 It's understandable and predictable that a

Speaker 4 situation that arises in the medical context is dealt with by everybody in a medical framework. And the medical framework is disorders and diagnosing them.

Speaker 4 My personal view, we could talk about it more,

Speaker 4 I won't belabor it now, is that we should throw away those diagnoses.

Speaker 4 Those diagnoses, you know, like most diagnoses, require that you sort of collect information from the person you're trying to diagnose.

Speaker 4 There's a premise that they're trying to get help and would like to improve their well-being. And so being truthful in those interviews and those evaluations, those tests

Speaker 4 is assumed. But those things are not true of people who have engaged in medical child abuse.
And so

Speaker 4 we've seen too many cases where the abuse baby is thrown out with the diagnosis bathwater.

Speaker 4 The legal representation for the state tries to say, okay, this person has factitious disorder.

Speaker 4 The other side says, well, what are the data? What are the tests that we use to diagnose this? Where's the empirical evidence? Does this meet the Daubert standard, etc.?

Speaker 4 It just opens up the door to having a losing argument, a losing conversation.

Speaker 4 about something that misses the point entirely. The point is that the person who is being accused of medical child abuse has done things, has engaged in behaviors, has said things, has failed to

Speaker 4 say things, has done things that she hasn't admitted to, has said she's done things that she hasn't done,

Speaker 4 all for,

Speaker 4 and it's different in any case, some psychological need that she maintains

Speaker 4 or feeds by having her child be sick. There's a thousand reasons why people would knock off a 7-Eleven.

Speaker 4 And kleptomania is probably that reason in like one in a million cases. That doesn't mean that the stores weren't robbed.

Speaker 1 Right. Or that you need to test, do psychological testing on the person that you have on video robbing the store to determine whether or not they're kleptomaniac.

Speaker 4 Right, right.

Speaker 4 So, you know, my view of how we should handle these cases,

Speaker 4 first of all, all, is that we should stop thinking about a diagnosis.

Speaker 4 These are medical problems, but they're not that kind of medical problem. I think they're things like infection control.
In a hospital, you do a number of things for infection control.

Speaker 4 You encourage the use of masks, you encourage frequent hand washing, you have procedures for what you can use and reuse, and wiping down the equipment with alcohol swabs, et cetera.

Speaker 4 There's no diagnosis that we need for infection control.

Speaker 4 It's an integral part of medical care, but it doesn't fit in that diagnosis thing. It's a thing we care about.
It's a thing we look into. It's a thing we keep track of.

Speaker 4 It's a thing we involve ourselves with in order to protect patients.

Speaker 4 And I think we should treat the healthcare seeking behavior, the healthcare seeking strategies, the healthcare related attitudes of all patients, but particularly for our purposes today,

Speaker 4 in the parents of pediatric patients, to consider it almost like the seventh vital sign.

Speaker 4 Like we consider pain management in all cases now, and we think about it before it becomes a problem so it won't become a problem.

Speaker 4 We have a completely different view of pain in medicine

Speaker 4 than we had 40 years ago, where it was, oh, well,

Speaker 4 stuff hurts.

Speaker 4 Suck it up, mothercut.

Speaker 4 But now,

Speaker 4 there are a zillion reasons why being fastidious about pain management and pain prevention

Speaker 4 in all sorts of aspects of medical care is considered the sixth vital sign. I think we should consider illness behavior, healthcare behavior, the seventh vital sign.

Speaker 4 We should think about this in every patient that comes into the hospital. And if we do that, I think there are a number of extremely positive consequences for that.

Speaker 4 One is if we do it for everybody, if we look at every parent's, you know,

Speaker 4 their involvement, are they doing too much? Are they doing too little?

Speaker 4 As one of my colleagues at Yale here puts it, I think it's beautiful. She says, are they too into it? Okay.

Speaker 4 If we we do that for everybody, then it isn't

Speaker 4 accusatory. It isn't offensive to anybody because it's just what we do now to make sure that we make sure that the family is as focused on quality of life as an end goal as anything else.

Speaker 4 That should be the end goal.

Speaker 4 So if we if we see patienthood and over-medicalization of the case consuming the family's lives. We have to say, do you really want to spend your life like this? You know, this is natural.

Speaker 4 We need to understand the developmental course of

Speaker 4 these situations. So a parent, for example,

Speaker 4 who has their kid for perfectly good reasons go on a feeding tube.

Speaker 4 Let's say that that person isn't a wealthy person.

Speaker 4 And their child is on a feeding tube. They have other kids in the house to feed.

Speaker 4 They're barely getting by. And they're getting their prescription, they're getting prescription formula for this feeding tube.

Speaker 4 Essentially, Medicaid or their health insurance is paying for their kid to eat. And now it looks like the kid is getting better.

Speaker 4 And the parent realizes that, gosh, some of the things that we're getting from, you know, direct medical equipment companies like special formula and diapers, et cetera, I've got to pay for all of those things.

Speaker 4 So what if that parent panics and says, I can't, this kid can't get off those tubes? That is an extremely sympathetic way of thinking about people who are technically engaged in medical child abuse.

Speaker 4 Okay.

Speaker 4 But if we, if we allowed ourselves to think about these scenarios and ask patients questions and understood like, you know, what dilemmas that somebody might be in, like the adult cancer patient spends, you know, three years being a cancer patient.

Speaker 4 And you know, the doctors tell them, well, you know, you're in remission here, so go back to your life. But maybe they had to quit their job.

Speaker 4 Maybe the people who are caring for them had to quit their job. Maybe the whole family system now relies on this person being a patient.
And the patient doesn't even know what to do.

Speaker 4 They don't have an identity. So that person is at risk for getting sucked into the patient role.

Speaker 4 And just as we know that people we put on pain medicines may become addicted,

Speaker 4 but you have to do it because otherwise it would be awful for them.

Speaker 4 We'll cross that bridge when we come to it. We will get them unaddicted.
You know, what if we thought that way about patients and how involvement in the medical

Speaker 4 system

Speaker 4 can, in fact, become addictive, understand

Speaker 4 that,

Speaker 4 deal with that compassionately,

Speaker 4 openly,

Speaker 4 so that people can't kind of start doing these things in secret and walking down a road of deception

Speaker 4 that

Speaker 4 brings them past the point of no return, and then they've literally got to be all in. That's the way I would like to see this dealt with.

Speaker 4 And if I think if we did, we would have many fewer situations like the ones that are talked about, like in this podcast, where it's just basically a war, a war between parents and doctors, a war between

Speaker 4 the state and the parents. The results speak for themselves.
We need a new paradigm for understanding these things.

Speaker 1 The utter lack of curiosity with which the preventionist approaches not only munchausen by proxy abuse, but this overdiagnosis report made by Mark Pinsley, a county controller with no experience in any relevant field, is really galling.

Speaker 1 Because why not go deeper if you're going to devote a third of the series to it? If you're going to just skim the surface of this whole thing, why spend two years reporting it?

Speaker 1 Serial is supposed to be investigative journalism. The claims Pinsley and these families are making are pretty incendiary.
So maybe, I don't know, investigate the actual claims?

Speaker 4 A wild idea, I know.

Speaker 1 Another thing that I challenged Serial on was letting the claims of Kimberly and Stephen Steltz that they had been diagnosed with the psychological condition of Munchausen by proxy stand without context, as it's very clear that this is an abuse diagnosis made by a doctor, not a diagnosis made by a mental health care professional.

Speaker 1 Serial told me that they reported it this way because that was the claim the Steltses, who again they don't name, made in their lawsuit.

Speaker 1 But Serial describing it as a rare psychological diagnosis rather than an abuse diagnosis shores up the Steltses' claim that this diagnosis couldn't be correct because the doctors hadn't met them.

Speaker 1 And a reminder that the Steltz's older son came forward about the abuse he and his brother were suffering. So reinforcing the Steltz's framing of Munchausen by proxy is hardly benign.

Speaker 1 This would be like dismissing a teenage victim's outcry about being sexually abused because the parents hadn't been psychologically evaluated for pedophilic disorder.

Speaker 1 And couching Munchausen by proxy as a DSM diagnosis rather than a form of abuse that is detected through a record review and separation test is often handy to perpetrators who can hire a psychologist to say that they just don't have it.

Speaker 1 This is what both Lisa McDaniel and Biata Kowalski, among others, have done. Framing Munchausen by proxy abuse this way isn't just incorrect.
It can be dangerous.

Speaker 4 There's no value added.

Speaker 4 There's no value added. And

Speaker 4 there's opportunity lost. if we sit around and wait for people's behavior to rise to the level of a diagnosable psychological problem.

Speaker 1 The Munchausen by Proxy cases I cover on this show are necessarily the dramatic ones, because this abuse generally goes to an extreme before there's any intervention, especially from the criminal justice system.

Speaker 1 The perpetrators I talk about have subjected their children to invasive surgeries, poisoned, suffocated, or starved them. crossing a Rubicon where there should be no conversation about reunification.

Speaker 1 But as Jim reminded me, this isn't most cases, and not every perpetrator will take it this far. And the earlier we can catch harmful behavior, the easier it might be to deter it.

Speaker 4 So we have to like, we have to think about this

Speaker 4 before

Speaker 4 these people become despicable. Yeah.

Speaker 4 So that we can think about them with like, think about them as people, not as... as stereotypes.
Think about them as people like us with needs and

Speaker 4 help keep the guardrails up and help prevent them from going down these paths.

Speaker 1 I really appreciate where you're coming from. And I think that what is helpful about what you're talking about is, yeah, it remains focused on the child, right?

Speaker 1 And the harm to the child and the health of the family, right?

Speaker 1 Because it's not, I think what I get perennially frustrated with, to kind of bring us back to the preventionist, is this idea of being positioned as like

Speaker 1 Diane Neary at, you know, and all at all, whatever the terminology is, you know, are for parents, right? They're for families. They're for keeping families together.

Speaker 1 And, you know, you and I are for ripping them apart, just willy-nilly, you know, the minute that there's any suspicion of abuse. And that's how these doctors in particular are being portrayed, right?

Speaker 1 Is well, they're just hammers looking for a nail and kind of this idea. And I think,

Speaker 1 you know, I think there are some, I had a wonderful interview yesterday with Dr. Boose, who's a child abuse pediatrician for the upcoming season.
You know, he was talking about,

Speaker 1 you know, just this idea of like the value system underlying all of this, right? Which is that

Speaker 1 presumably, and this is obviously where you and I fall, right? That we have a value that children have an inherent right. to be safe in their homes.

Speaker 1 And that if their parents cannot provide that right, then they shouldn't be left in those homes to suffer.

Speaker 1 And that is not a value that everyone shares. Most people will not openly say that they don't share that value.
But I struggle to see how something like the preventionist is speaking from

Speaker 1 that set of values.

Speaker 4 You know, again,

Speaker 4 I think that

Speaker 4 this often comes to be as it's evolved because the children are invisible. It doesn't seem like you're picking sides.

Speaker 4 It seems like there's a family and you're breaking the family up and the parents are sticking up for their family.

Speaker 4 But the whole concept of family assumes that the parents are fulfilling their roles as protectors of the children.

Speaker 4 It's also the case the things that we wish to have people pay attention to

Speaker 4 are things that people would like to believe don't happen.

Speaker 4 You know, it's as simple as that. Like, no one wants to believe, like, if we can't trust mothers to love their children, what on earth can we trust?

Speaker 4 And there are a lot of people who simply don't want to believe that a mother would poison their child or that a mother would

Speaker 4 sort of advocate to have a kid treated like a person with physical disabilities and kept from

Speaker 4 the activities of typically developing children

Speaker 4 just so that she could

Speaker 4 have something to do with her time or feel loved and supported by people in her community or to

Speaker 4 be the vice president of the cerebral, you know, the cerebral palsy

Speaker 4 advocacy committee in her town or what have you.

Speaker 4 We don't want to believe that that could be.

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Speaker 1 And the Stelts family, who are the lead plaintiffs, are a Munchausen by proxy case.

Speaker 1 But there are now a dozen families who've joined this lawsuit, and more than half of them are physical physical abuse cases.

Speaker 4 But one of the things that concerns me about the series, I listened to the three, first three episodes,

Speaker 4 is

Speaker 4 the danger of seeing medical child abuse

Speaker 4 in the same framework or using the same template of understanding that's used for physical abuse.

Speaker 4 Take the case of head trauma,

Speaker 4 shaken baby, if you will.

Speaker 4 any kind of violence perpetrated against a child to

Speaker 4 cause physical abuse.

Speaker 4 It is

Speaker 4 reasonable to think about that case, or those cases, as a parent who is overwhelmed

Speaker 4 and, you know, maybe they need anger management, maybe they have a substance abuse problem, maybe they have an untreated sleep disorder and

Speaker 4 they are always dysregulated, maybe they have an untreated

Speaker 4 bipolar disorder, whatever. It's much easier to, and much more correct, to think about like

Speaker 4 remediation, think about having the parent

Speaker 4 in the presence of the child under certain circumstances or meeting certain

Speaker 4 goals, et cetera. You can see some incrementalism in reunification that might be appropriate for that kind of case.
But that's rarely the case for medical child abuse. People really don't understand

Speaker 4 that, unlike the father who spouts off and, you know, shakes a kid

Speaker 4 out of frustration, the father's not intending to do it. If there's any misdirection or deception involved, it's to cover up because they know they did something wrong.
But when the jig's up, then

Speaker 4 it's not unusual, I don't think, for people who have abused their children in that way to want to not, you know, they want to not hurt their children again in the future, so on and so forth.

Speaker 4 Medical child abuse is much more in the cases that reach this level where CPS has to be contacted, are much more like child exploitation

Speaker 4 than physical abuse. It's not an event.

Speaker 4 oriented kind of abuse. You're not looking for like the sexual penetration event or the shaken baby event that has has its, you know, correlated medical findings.

Speaker 4 And, you know, what CAPs do very well is they understand those things and can make fine distinctions between things that

Speaker 4 non-abuse-trained pediatricians have a harder time doing.

Speaker 4 The intentional use of the child as a prop

Speaker 4 and sort of this theatrical narrative of the sick child and the

Speaker 4 sacrificing mother who is remaining loving and cheery in the face of scary illnesses in their child, et cetera. That is a long-running play,

Speaker 4 and it has to be understood

Speaker 4 as a narrative. The medical records are essentially sort of

Speaker 4 the screenplay, the text of the narrative. how we got here, how things, how this illusion that the child is sick is being maintained.

Speaker 4 And in that case, where what the parent parent is trying to do is intentionally protect a narrative, they can't be trusted. They can't be trusted with their other children.

Speaker 4 They can't be trusted until they see what they've done, admit what they've done, and make like psychologically,

Speaker 4 accurately targeted therapy efforts to fix whatever need.

Speaker 4 put them in this position in the first place. People,

Speaker 4 you want to link the abuse together. There's a natural tendency to want to link medical child abuse, which is less accepted, together with things that are more accepted.

Speaker 4 It's understandable to think about these things together, but they're really important, like qualitative

Speaker 4 differences in the the nature of the abuse, the course of the abuse, etc.

Speaker 4 And you know, here's where it comes in in handy to think of them differently.

Speaker 4 I've been involved in a lot of cases where the doctors have been suspicious that something was going on and they caught the mother on tape

Speaker 4 suffocating the child or putting something in the child's IV.

Speaker 4 And

Speaker 4 they and

Speaker 4 CPS basically said, case closed.

Speaker 4 They said, we've got all the evidence we need. We saw it happening right here.

Speaker 4 And then, As a defense,

Speaker 4 the mother and her attorney claim that, yes, she did that. It's on tape.
There's no denying it. The doctors have not paid attention to the child's real needs.

Speaker 4 They haven't diagnosed the child's real medical problems.

Speaker 4 And you go into court with your videotape, and the mother comes into court with the story saying that everything that I've done up to this point, the doctors said to do, it's all in the medical records.

Speaker 4 And the prosecution is caught completely off guard and they lose. And so, medical child abuse is not an event-related form of abuse.
It's a narrative related type of child exploitation.

Speaker 1 As we spoke about previously, the Steltz case is particularly interesting because it has an element I've never seen before.

Speaker 1 A teenage victim coming forward to disclose his own abuse and that of his younger brother. The Steltz's son then became emancipated from his parents and remains estranged from them.

Speaker 1 I asked Jim what he made of this remarkable detail.

Speaker 4 That's an unusual event. I have not had any personal cases where that is true, but I've had plenty of personal cases where the older child

Speaker 4 was so co-opted into the narrative that they were ill that they didn't fight it. I mean, it's not just being whether you're aware of it or not.

Speaker 4 Some people say, how could an older kid be convinced that,

Speaker 4 you know, convinced that they're sick when they're really not.

Speaker 4 That's not what they're convinced of. They're convinced that they can't support themselves.
They have nowhere to go.

Speaker 4 And they have two options. One, to make their mother furious with them or to go along.

Speaker 4 And so they go along to get along.

Speaker 4 This is an extraordinary young man who extricated himself at that age.

Speaker 4 sort of was aware of what was going on and did something for himself.

Speaker 4 But very often they don't, and not because they don't know, it's because

Speaker 4 they really don't have a choice.

Speaker 1 Yeah, I mean, and you know, we've heard,

Speaker 1 you know, you and I have both talked to many survivors of this abuse. And, you know, we have heard from them about their experiences of sort of how their mother would co-opt them into this, right?

Speaker 1 And they would say things to them like, you really are sick, so you need to do X, Y, Z in front of the doctor or they won't believe you and you'll die. I think this young man is extraordinary.

Speaker 1 And also also like sort of that shouldn't be the expectation that there would be an outcry from the child for all those reasons you mentioned. And it's extraordinary to me.

Speaker 1 I think the fact that Niri doesn't give us any context for the steltzes,

Speaker 1 to me, that shows an ill intent.

Speaker 1 Because as a journalist, if you are just approaching this the way that she frames it, You know, two years ago, I got a call about this situation and I went down there to investigate.

Speaker 1 And you find out the details of the steltses. How are you not intrigued by that?

Speaker 1 I mean, that is, that's, how does, and how does that not give you pause when you think like this young man is trying to live his life and you're doing PR for this lawsuit?

Speaker 1 I mean, it's so, yeah, I mean, that, that part is just so striking to me.

Speaker 4 I don't know if this young man is old enough to listen to podcasts about the problem that he was

Speaker 4 victimized by, but how must it feel to adult survivors and to people like him,

Speaker 4 who essentially, you know, we talked in the beginning of our discussion today about like who's speaking for the child? Where's the voice of the child?

Speaker 4 Well, we now have adult survivors that, thanks to you and the efforts of the professionals associated with Munchausen Support,

Speaker 4 are coming forward and telling their stories. Like they're telling their stories to us and they're telling the stories to each other, But what do you think they think and feel

Speaker 4 when

Speaker 4 so-called respected journalists are uncritically siding with the kind of people who abuse them?

Speaker 4 You know, I think our society, the medical community, especially, the legal community, really needs to hear from these people and

Speaker 4 put a face on this abuse.

Speaker 4 Yeah. Put a name on this abuse.
And

Speaker 4 a media climate like this,

Speaker 4 like, you know,

Speaker 4 they would just be getting abused again if they came out and started telling their stories.

Speaker 4 The media is making doing that require too much courage.

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Speaker 1 It was a bit surreal listening to Niri describe her experience of getting wind of this story and not mentioning the existence of the viral and similarly misleading story she wrote about Maya Kowalski for New York magazine, dragging Dr.

Speaker 1 Sally Smith through the mud. I just thought, of course the parents in Lehigh wanted to talk to Niri.
They know a mark when they see one.

Speaker 1 I do think there are journalists who get swept up in these stories out of genuine naivete.

Speaker 1 But if you're going to cover child abuse cases, you need to understand the systems that you're reporting on, because otherwise, you can end up not only spreading misinformation, but actually contributing to the abuse.

Speaker 4 The irony, at least as it applies to medical child abuse,

Speaker 4 is

Speaker 4 that these people have successfully convinced doctors and other medical professionals to believe their stories and to go along with them, et cetera,

Speaker 4 and to be essentially the victim by proxy, the poor beleaguered mom, da da da da da da da.

Speaker 4 And

Speaker 4 then

Speaker 4 they turn around and they do the same thing with the reporters. I mean, sort of the gall,

Speaker 4 the

Speaker 4 con artist skills of these perpetrators, you know,

Speaker 4 it's easy. It's easy to find people

Speaker 4 these journalists who

Speaker 4 want to be the champion. The doctors often are the ones who want to be the champion.
They want to be important. The patient, the parents say things like, no one else has listened to me.

Speaker 4 Thank God for you.

Speaker 1 You're the only person who understands my complex snowflake child.

Speaker 4 Yeah.

Speaker 4 You're my angel. And they get back all the love and appreciation

Speaker 4 and so forth that they're looking for. And then when they get caught, they're the victim of the justice system.

Speaker 4 They play the victim again and they find

Speaker 4 people that they can co-opt into their narrative and on it goes. Yeah.
It's, you know, this behavior is really sort of

Speaker 4 as much as anything, an extension of what they were doing with their kids.

Speaker 1 Yeah, absolutely.

Speaker 1 And I think, you know, we've talked at some length, certainly in Mental Sport board and on the committee, about how, you know, and I think, sorry, we will not rehash the endless terminology debates that we've had.

Speaker 1 But, you know, a lot of us have sort of settled on this descriptor rather than just medical child abuse of saying Munch House and biproxy abuse, exactly because it encompasses things that are not medical.

Speaker 1 Like, yes, there is often a focus on the medical, but it is also educational abuse, it's emotional abuse, it's psychological abuse, it's neglect.

Speaker 1 And I think like this is part of that, right? It's like, this is like the journalists are participating in the abuse. They are participating in the exploitation of these children.
And I do not,

Speaker 1 I am no longer sort of shying away from that framing

Speaker 1 because you are, you are feeding the beast, you know, it's like you are, you know, in terms of like.

Speaker 1 what we do know right about this sort of psychology of this is that it is this thing where like it escalates and you know it becomes it's like a drug right they have that just compulsive nature to it um and you are feeding that if you are a journalist who is just giving them a space to get what they want right which is that attention sympathy um feeling of control right feeling of fooling people um

Speaker 1 and i i think that like that is how we need to frame these you know not to say like there are certainly journalists i want want to make space for this, there are journalists that get caught up in these that do a feel-good story about a family raising money, you know, and like we have this nightmarish healthcare system where people do have to like go and perform their child's illness to get money.

Speaker 1 They need to cover it. Like that's, that's not a not real thing, right?

Speaker 1 And there are certainly journalists who, you know, are covering kids.

Speaker 1 cancer, but a telethon, you know, that kind of thing, like that certainly have gotten caught up into it that are not culpable, much like there are doctors that that get caught up in this that are not culpable.

Speaker 1 And then there's ones that are. And so I think,

Speaker 1 I think Diane Yeary, much like Mike Hicksenbog, is one that is just actively participating in the exploitation of the children, especially, you know,

Speaker 1 in those stories where, you know, and this is not relevant for the preventionist, but like where they're including just this horrific medical porn, you know, of the children.

Speaker 1 Like, do you know how many pictures I've had to look at of my niece hooked up to this, that, and the other thing? I mean,

Speaker 1 that's horrible that those photos are out there. There's an absolute lack of concern for the children.

Speaker 4 Well,

Speaker 4 it might be sobering for these journalists to think that because of what they're doing, somewhere out there,

Speaker 4 there's a parent who's somewhere along this developmental path I've spoken about, who's thinking, how do I get on a podcast?

Speaker 4 How do I get a feature in the New York Times?

Speaker 1 How do I get a movie on Netflix?

Speaker 4 Yep, how do I get a movie on Netflix?

Speaker 1 I think a lot about the possible unintended consequences of my reporting, because while I don't think that most perpetrators want the kind of attention I offer, and I'm certainly not offering them an uncritical platform, I'm still giving them attention and another reason to be a victim.

Speaker 1 And while there are stories we've told alongside the victims and survivors of the abuse, that isn't always possible.

Speaker 1 I feel that every story I've covered on this show was one that needed to be told, but my team and I are always scrutinizing our reporting, asking hard questions.

Speaker 1 Could anything we say inadvertently make things worse for any of these kids? Will it make it harder for parents of legitimately sick children in some way that we don't anticipate?

Speaker 1 We do our very best, but it's high stakes.

Speaker 1 And I simply don't see evidence of Niri or anyone else on the serial team grappling with this.

Speaker 1 They seem unconcerned with what Kimberly and Stephen Seltz's son might have endured at the hands of his parents. They don't even mention him.

Speaker 1 And they don't appear to have grappled at all with what it might mean for all of the children in this story if Serial is, unintentionally, just giving a sympathetic platform to their abusers.

Speaker 1 I wonder sometimes if they just don't think we really exist. If they suspect that maybe we're the ones who are fabricating things.
We've certainly all been accused of that at one point or another.

Speaker 1 Or maybe they don't think about us at all. Maybe they just don't care.
It's not like they didn't have the opportunity to get things right.

Speaker 4 It's a little bit disappointing that

Speaker 4 our colleague Dr. Randy Alexander was actually interviewed for the piece.
So he was apparently accessible to her to ask for background, to get some clarification,

Speaker 4 present that

Speaker 4 example to him and for him to comment on it. And

Speaker 4 he's pretty much famous for his work in medical child abuse. He's right there.
I worry that we're not too far away from

Speaker 4 this segment of the of the media, this segment of

Speaker 4 whoever, however we want to describe the parents who are involved, of saying it's pointless to talk about to search for experts on this thing because this thing doesn't exist.

Speaker 4 Anybody who claims to be an expert on it has been fooled

Speaker 4 or they're sort of complicit in the child kidnapping, the medical kidnapping business.

Speaker 1 Well, and we see that in the legal cases, right, where a lot of times they will try and use the dober motions or however that's pronounced to just say, Munchausen my proxy is junk science, throw it out.

Speaker 1 This is not a credible expert because it's not a credible field.

Speaker 4 They tried that in Kowalski. But I mean,

Speaker 4 and, you know, from the standpoint of,

Speaker 4 you know, medical or psychological diagnoses, et cetera, you know, they've got a great case to make, and that's why we should stop relying on it.

Speaker 4 But I'm talking about,

Speaker 4 you know, discrediting the whole idea of medical child abuse in any of its forms ever, anywhere.

Speaker 4 Like, just leave us alone to take care of our kids

Speaker 4 the way we want.

Speaker 4 And,

Speaker 4 you know, we know the victims, you know, we know their stories and we know what's happened to them. And that'll be a terrible thing if they achieve that.
And so

Speaker 4 one of the things I do specifically is focus on prevention because

Speaker 4 I don't want to be mistaken as some sort of child kidnapper. I would much rather your child didn't have to be kidnapped.

Speaker 4 And we can do that through prevention. Yeah, the other, I think another missing ingredient here,

Speaker 4 it's missing in court cases where

Speaker 4 defense attorneys try to represent the

Speaker 4 accused perpetrator. It's missing from these discussions in the media, is

Speaker 4 sort of a lack of any consideration of what motive a physician

Speaker 4 would have to want to find themselves in the middle of this kind of of chaos and legal jeopardy and you know being abraded in the media.

Speaker 4 It just doesn't make any sense at all. And in fact, the thing we worry about is that people are so,

Speaker 4 even independent of all of this media stuff,

Speaker 4 we are programmed to be disgusted by people who question whether sick people are really sick.

Speaker 4 Sometimes when I give talks,

Speaker 4 I say, you know, imagine somebody you know who's,

Speaker 4 they've told you they have cancer, that a relative has cancer, and saying to them, you know,

Speaker 4 I'm not buying it. You know, I ask them to actually think about saying those words to the face of somebody.

Speaker 4 And they can't imagine doing it. It makes you sick to your stomach just to think about it.

Speaker 4 And so this

Speaker 4 social contract we live in that a guy named Talcott Parsons, way back

Speaker 4 only slightly before I was born,

Speaker 4 described as the sick role.

Speaker 4 Like identified what it means to be the sick person and what are the obligations and entitlements involved in being sick, but what are also the obligations of people in your social orbit? And

Speaker 4 a fundamental one is to accept the person's illness at face value.

Speaker 4 and afford them, you know, the forbearance, the kindness, the compassion, et cetera, uh that will contribute to them getting better and getting back into the into their roles in society and the sick role is supposed to be a temporary thing

Speaker 4 but you know but because of that sort of exemplified by that is this idea that no one wants to accuse somebody of faking no one wants to see it

Speaker 4 and you know part of my part of my my

Speaker 4 um

Speaker 4 sort of

Speaker 4 mission is just to get people to open their minds and look for it.

Speaker 4 That being suspicious, having a slightly suspicious mind early and often

Speaker 4 will save you from the kind of sinking feeling you have that makes you wait.

Speaker 4 You kind of smell smoke in your house, but it's really embarrassing if you call the fire department and there's really, it's really nothing.

Speaker 4 And so you wait and you wait and you wait and you wait and you wait. And next thing you know, your house is half on fire and the fire department is still 10 minutes away.

Speaker 4 The worse it gets, the more awful it is to criticize the parent and the less likely they are to do it. So that's the reality.

Speaker 4 But the portrayal in the media is a bunch of child abuse pediatricians and other doctors who are sitting around waiting to kidnap your child.

Speaker 4 I mean, it's absurd. It's absurd.
It's offensive.

Speaker 4 And, you know,

Speaker 4 it's disappointing that people consuming this media don't think critically about this and ask those sorts of questions.

Speaker 1 I'm really waiting on someone to answer the question that you just posed of like, what would motivate anyone to

Speaker 1 falsely accuse parents of abuse?

Speaker 4 Larger minds than

Speaker 4 mine will have to think about why in general we've become a culture of people who need an enemy.

Speaker 4 Scapegoating? It's like we're

Speaker 1 to keep us from marching on the billionaires. I mean, that's just my

Speaker 1 keep us all at each other's throats so that we don't look at who's really ruining everything.

Speaker 4 Why do we need enemies? Why do we have to make

Speaker 4 and we're going to make enemies out of teachers and we're going to make enemies out of doctors and we're going to make enemies out of scientists and we're going to make enemies out of professors.

Speaker 1 Like the people on whom our continued progress as a society utterly depend, basically. The only people who benefit from this this kind of media coverage are child abusers and their defense attorneys.

Speaker 1 I'm not saying no one has ever been falsely accused of child abuse. I'm not saying no one has been badly treated by the system, but this critique does not lead us to anything helpful, right?

Speaker 1 They've identified the wrong point of failure.

Speaker 1 There is no evidence that child abuse pediatricians are kidnapping children, separating families unnecessarily, etc.

Speaker 1 So I do think that most people in this country share the value that children deserve to be safe in their homes and that they should not be subjected to abuse by their parents if that is happening.

Speaker 1 I think there is a small, unfortunately very active minority that believes that whatever happens between parents and children should not be the purview of doctors or the state or anyone else.

Speaker 1 There is that faction.

Speaker 1 And they are unfortunately like the Project 2025 of it all. But I think that most people agree that children should be safe in their homes.

Speaker 1 And that's why I think we just need to to keep confronting them with

Speaker 1 the person they should actually be sympathizing with, which is the child and which is the adult abuse survivor and the people who have suffered because of these actions and the inaction

Speaker 1 of systems to protect those children.

Speaker 4 Couldn't agree more.

Speaker 1 Well, Jim, thank you so much.

Speaker 1 Thank you so much to Dr. Jim Hamilton for joining us this week.
As always, if you want to learn more about Munchausen by proxy or you need help, you can find that at munchhausensupport.com.

Speaker 1 And if you'd like to support that work, you can also donate there. And just to note that The Preventionist does not have their Spotify comments enabled.

Speaker 1 So if you'd like to let them know your thoughts, the place to do that is in their Apple reviews or by sending them an email at serialshows at nytimes.com.

Speaker 1 And we'll be back next week, continuing our conversation on The Preventionist with a very special guest.

Speaker 7 Frankly, I've been accused of the same thing by some of these same people.

Speaker 7 I don't apologize for being fairly zealous in trying to protect children who I think are in serious danger.

Speaker 1 That's next time on Nobody Should Believe Me.

Speaker 1 Nobody Should Believe Me is produced and hosted by me, Andrea Dunlop. Our editor is Greta Stromquist, and our senior producer is Mariah Gossett.

Speaker 1 Research and fact-checking by Erin Ajayi, administrative support from Nola Carmouche.

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