The Boy Who Was Raised as a Dog (31 page)

We began to look more closely at his records and at the different versions of the events contained there. That overdose, for example. With a little additional research we discovered that James had run away from home earlier the same day and had been returned to his mother by sheriff's deputies. Within an hour, according to Merle, he'd “taken an overdose” of an antidepressant. She called the poison control hotline and operators told her to get the child to the hospital immediately. Inexplicably, Merle hadn't driven to the hospital. Instead, she went to a nearby supermarket, and what should have been a ten-minute drive from her home to that shop somehow took her half an hour. After parking, she ran screaming into the store, seemingly hysterical about her unconscious child. EMS was called. Recognizing the urgency of the situation, paramedics rapidly called in a Life Flight helicopter to take him to the hospital.

Now we learned that medical staff had been suspicious of Merle almost every time she'd had contact with them. As EMS workers fought frantically to stabilize the boy at the market, she'd sat calmly, sipping a soda, her hysterics and worry about the child mysteriously ended, even though his survival was still far from assured. At the hospital, upon being given the good news that he would pull through, Merle shocked the doctor by asking that the boy be removed from life support. One ER
nurse suspected her of tampering with the medical equipment. As soon as he was conscious and his mother was not present, James told hospital staff, “Mom is lying. Mom is hurting me. Please call the police.”

Suddenly, James's behavior made sense to us. There had been numerous aspects of his story that didn't “fit,” that made no sense in the context of what I knew about child behavior. Over time one's sense of how certain kinds of youth are likely to behave in certain circumstances becomes intuitive and, when something doesn't “seem right,” it's a signal one should give close attention. That's how I knew, for example, that Stephanie and I weren't reacting the way we would if James had really had RAD. Such “trained intuition” is a large part of what distinguishes experts from amateurs in most fields. We don't always consciously know what it is that doesn't fit, but somewhere our brain recognizes that part of the puzzle is missing, and it sends up a signal that something's askew. (This “gut feeling” is actually a low-level activation of the stress response system, which is acutely attuned to combinations of incoming signals that are out of context or novel.)

It was clear to me that James had run away because his mother was harming him, not because he was defiantly misbehaving. Running away is uncommon among children his age, even those who are abused: even the most severely battered and neglected elementary school children tend to fear change and strangeness more than they fear losing the only parents they have ever known. They prefer the certainty of misery to the misery of uncertainty. The younger the child, the more important familiar people and situations usually are. Many such children have begged me to return them to violent and dangerous parents. But James was different. His behavior was that of someone seeking help, not of someone who had difficulty forming attachments and relationships.

From this new perspective I could see that the boy hadn't jumped off the second-floor balcony or tried to leap out of moving cars. He'd been pushed. James hadn't voluntarily swallowed a whole bottle of antidepressants: the “overdose” had been forced on him. He was not manipulative
nor was he “acting out,” he was simply trying to get help for himself and his siblings in the only ways he knew how. And he refused to give up, despite being disregarded, ignored, disbelieved and even punished for telling the truth.

Merle had almost succeeded in killing James at least twice: his helicopter ride following the “overdose” had not been his first experience with Life Flight transportation. He'd been helicoptered to the hospital following the “fall” from the second-story balcony as well. James was scheduled to return to her home after the “respite care” and, worse, his adoptive siblings were, as we sat around discussing the case, still in that dangerous household. I am ordinarily extremely cautious, but I knew once we figured out what had happened that those children were in imminent danger. I contacted the authorities and asked the judge to have CPS remove the other children immediately and seek permanent termination of parental rights.

James's case plunged me into the heart of one of the key conflicts in child psychiatry: although the patient is the child, he is not the one that gets to make most decisions about his care and treatment, and he is often not the person who provides the initial information about the case. We'd been told by Merle that James was sick, but James was sick only because Merle had been making him that way. James's case had been framed as that of a “difficult” child with “behavior problems.” But he was really a courageous, persistent and ethical child who'd been placed in an impossible situation—one in which his every attempt to help himself and his siblings was framed as evidence of his “bad behavior.”

Those of us who work with troubled children have to guard constantly against our preconceptions about a situation; one person's “troubled teen” may be another person's “victim of sexual abuse,” and the label given to the child often determines how he is treated. A child seen as “bad” will be treated differently from one viewed as “mad,” and both will have their behavior seen in a very different light depending on whether the clinician sees a “victim” or a “perpetrator.” Further, depending upon
one's point of view, the exact same behavior can be framed as “running away” or “seeking help” and the perspective will profoundly affect decisions about what to do for and to the child.

While most parents have their children's best interests at heart, it is also true that disturbed children often have disturbed parents who may be the direct cause of the children's problems. It is a serious challenge to engage the parents and to keep the child in therapy, but to avoid supporting them in ongoing actions that will do him harm. Many children are lost to treatment because the parents are either unwilling or unable to change harmful behavior patterns, and such parents often rapidly become suspicious of any treatment that doesn't place the blame for any difficulties squarely on the child.

In James's case, Merle continuously “doctor shopped,” seeking professionals who viewed him as a case of “Reactive Attachment Disorder” and dropping those who questioned her actions or judgment too closely. She was able to present the opinions of therapists and social workers in support of her case to child welfare authorities, leaving out the views of those who disagreed with the diagnosis.

However, to be fair, I should also point out that many parents also do have good reason to avoid stigmatizing, parent-blaming theories of mental illness: not long ago, schizophrenia was believed to be caused by “schizophrenogenic mothers” and autism was blamed on “refrigerator moms,” (mothers who are “cold” and uncaring). We now know that genetics and biology play the major role in the etiology of those conditions. But abuse and trauma can also produce similar symptoms. As we have seen, children like Connor and Justin, whose problems were solely due to abuse and neglect, are often labeled autistic, schizophrenic and/or brain damaged. Their problems, however, were the result of a damaging environment. It is an ongoing challenge for child psychiatry to distinguish between diseases like schizophrenia and autism and disorders caused by early abuse and neglect, and it is even more difficult to understand and take into account how early childhood trauma can express underlying
genetic vulnerabilities. For example, people with genuine schizophrenia are far more likely than others to have a history of childhood abuse or trauma; all complex human conditions, even those that involve a strong genetic component, can also be affected by the environment. The challenge of treating these children and dealing with their parents becomes even more daunting in cases like that of James, in which the parents are deliberately deceptive.

Merle would turn out to have a condition called Munchausen's syndrome by proxy. Munchausen's disorder is named after an eighteenth-century German Baron, Karl Friedrich von Munchausen, who was known for the exuberantly exaggerated tall tales he told. Patients with Munchausen's syndrome, usually women, deliberately make themselves ill in order to get medical attention and sympathy from others. They go from doctor to doctor, undergoing unnecessary painful and invasive tests and procedures. In order to produce convincing symptoms they go to great extremes—contaminating IV lines with feces to cause infection, for example. In Munchausen's by proxy syndrome (MBPS), the patient tries to make another person, usually a child, sick, in a similar ploy for attention and support. The cause is not known, but it clearly involves problems with dependency. People like Merle have a pathological need to be needed and their identities revolve around being seen as nurturers and helpers. Having a sick or injured child allows them to display this aspect of themselves; they live for the concerned glances, hugs of support and medical attention they get when the child is hospitalized. Often they attract partners who are extremely passive and whose own needs for care and direction are met by being with someone who has such a strong desire for control and utility. Merle's husband fit that description perfectly.

What people with MBPS cannot cope with is a child's maturation and the decreased neediness and increased independence that goes along with it. Often, they “solve” this problem by having or adopting additional, younger or sicker children, but in Merle's case, she seemed to have a specific need for James in particular to be ill. And, his resistance and
running away, which was not getting her the attention and support from professionals she thought she'd get, became increasingly threatening to her. Since a mother whose young child has died is the ultimate object of sympathy, and since James's behavior could expose her and lead to her losing custody of her other children, his life was increasingly in jeopardy.

Mothers with Munchausen's by proxy are extremely dangerous. They may succeed in killing several children before they are caught because the very idea of a mother killing a child is so monstrous. The sympathy for parents who have lost children is also so natural and automatic that the deaths are often not thoroughly investigated. In many cases the children are killed in infancy and their demise ascribed to Sudden Infant Death Syndrome (SIDS). In fact, the research paper originally used to claim that SIDS has a genetic origin was based primarily on the case of a mother who had supposedly lost five successive children to SIDS. It turned out that the mother had MBPS and had smothered the children to death. She was ultimately convicted of the murders.

One of the earliest studies of Munchausen's by proxy involved covertly videotaping mothers suspected of having the condition. Thirty-nine mothers with MBPS were caught on tape; some tampered with life support machines, some smothered their babies with pillows and one even forced her fingers down her infant's throat. Twelve siblings of these children were found to have died suddenly and, when confronted with the videotapes, four of the mothers confessed to having killed eight of the babies.

Unfortunately, increased attention to the disorder has also led to wrongful prosecutions of women whose children genuinely did die of SIDS. Because, thankfully, both multiple SIDS deaths in one family and Munchausen's by proxy are exceptionally rare, the limited data available has made distinguishing between the two causes of death tricky. The British pediatrician who originally named the syndrome, Roy Meadow, devised the basis of what became known as Meadow's law regarding infant deaths: “One sudden infant death is a tragedy, two is suspicious and
three is murder until proved otherwise.” Recently, however, he lost his medical license after his expert testimony on the foundations of his “law” turned out not to be supported by the data. The convictions of numerous women based on this “law” are being revisited, although Meadow's license has now been returned. At least three convictions have already been overturned.

The Meadow debacle has led some to doubt even the existence of Munchausen's as a specific form of child abuse, but there are clear cases like Merle's and like those of the parents in the videotapes who deliberately harm their children in order to get support and medical attention. Around 9 percent of children born to women with this disorder die at their hands, and many more suffer serious injuries and are subjected to hundreds of unneeded and painful medical procedures. Unfortunately, because so little is known about its cause, there are very few clues to diagnosing it. Few males have MBPS; and MBPS may be overrepresented in women who work in the health care field. Many seem to have suffered childhood trauma or abuse themselves—often severe neglect—but the overwhelming majority of women who work in health care or who were victims of childhood trauma never develop this condition. It may be on the pathological end of a spectrum of healthy behaviors stemming from a desire to nurture others and be valued for it—a case of too much of a good thing. The same dependency may drive other people to extreme acts of caring and altruism. How some slip from desperately wanting to help others into feeling compelled to hurt them so that help will always be needed, I cannot say.

Thankfully, the judge took our advice and, on an emergency basis, removed James and his siblings from the custody of Merle and her husband. A civil jury later agreed that James had been abused by his adoptive mother and that the father had not intervened to prevent it. Evidence was presented that proved how James's mother had twisted his words and actions to portray him as a troubled child and hide her own depravity. The couple's parental rights in relation to all five children—including their
one biological child—were terminated and criminal child abuse charges were also filed against them.