The documentary shows how much harm child protection can do. | #childsafety | #kids | #chldern | #parents | #schoolsafey

The Netflix documentary Take Care of Maya, currently in the service’s Top 10, follows the plight of a family facing an accusation of child abuse. At age 10, Maya, who lives in Florida, was admitted to the local children’s hospital. Suffering from an uncommon and poorly understood chronic illness, complex regional pain syndrome, Maya had been sick for a number of years. Her parents, desperate to alleviate her symptoms, took her to see unconventional experts, who prescribed treatments that departed quite starkly from mainstream standards of care. When Maya’s medical team encountered her history of experimental treatment, including a trip to Mexico for a dangerous and unregulated “ketamine coma” therapy, they were understandably concerned. This resulted in the hospital making a referral to child protective services for “medical child abuse,” previously known as Munchausen by proxy.

Maya and her family were now ensnared within what I, and other advocates, call a system of family policing. Maya was hospitalized and kept away from her family, loved ones, and community for nearly three months. Due to a perverse ideal of “child protection,” Maya was alone, vulnerable, and felt unheard by the medical staff. Outside the hospital, her family fell apart, culminating in her mother’s tragic death by suicide.

This case has drawn much attention—first from New York magazine and now from Netflix—yet it speaks to a larger problem. The documentary’s dystopian depiction of child protection is not an anomaly. Children are regularly removed from their loving parents and placed in unsafe situations—from sleeping on couches in office buildings to foster homes where they are often abused—all in the name of child protection. An estimated one-third of all children in the United States will undergo a child protection investigation before their 18^th birthday. For Black children, the numbers are even higher—more than half will experience such an investigation. Yet this overpolicing of families and children is not a necessity and does not keep kids safe. Rather, the specter of child abuse has created a system that is harmful and even abusive. Perhaps Take Care of Maya, because of the unusual details of its case, will bring attention to the harmful impact of an overreaching family policing system.

The term Munchausen by proxy was first coined by British pediatrician Roy Meadow in 1977. The term “Munchausen syndrome” had been used since the 1950s to describe adults who fabricated or induced illness in themselves in order to access unnecessary care and even invasive interventions; the name is borrowed from the 18^th-century Baron von Munchausen, who told fantastic stories of his adventures. Meadow described Munchausen by proxy based on a series of two cases. In the first, the mother contaminated the child’s urine samples; in the second, the mother repeatedly poisoned her toddler with large amounts of salt, ultimately resulting in his death. In both cases, the mothers either induced illness or produced false evidence of illness and then sought care.

As often is the case with new medical syndromes, new attention to Munchausen by proxy, alongside a growing emphasis on the reporting and investigation of child abuse in the 1980s and 1990s, led to increased volume of allegations. The syndrome was soon invoked in a rising number of cases, often when there was conflict between a mother and the child’s health care team. This sometimes resulted in disaster. In 1997, California mother Debra Reid was accused by physicians of exaggerating the severity of her son’s asthma, taking him too often to the emergency room, and not following her physician’s plan. Her son was subsequently placed in foster care and died two weeks later of an asthma attack.

Still, in other cases, children did suffer as their parents poisoned them in order to seek unnecessary medical intervention. In the well-known case of Gypsy Blanchard, a Florida mother feigned her daughter’s illness for years, resulting in countless harmful interventions. Had Gypsy’s plight been recognized earlier, she would have been spared the abuse that ultimately led her to arrange for her mother’s murder. As Blanchard’s story illustrates, medical child abuse is a real phenomenon, but the data we do have on the subject shows that Munchausen by proxy is rare, and the boundaries of this diagnosis remain controversial.

In Maya’s case, the unorthodox treatment the family sought was alarming to her physicians at the children’s hospital. Yet parents have a right to determine appropriate medical care for their child. If the state does not want physicians to prescribe high-dose ketamine for young children, it would be wise to regulate this practice, or to have the state Board of Medicine examine physicians’ prescribing habits. Punishing a family for seeking care from a credentialed, though perhaps unscrupulous, physician is  counterproductive. This is tricky, of course, as Maya’s family sought care in Mexico, as a workaround to circumvent regulation, but also as a result of frustration with standard care. The cavalier descriptions used by Maya’s physicians—as the documentary notes, they referred to her as “ketamine girl” and accused her of fabricating her illness—show that Maya and her family had many reasons to distrust the conventional medical system.

Individuals with chronic pain and poorly understood symptoms often are met with disbelief and suspicion. While the treatment Maya’s family chose for her was unorthodox, she had a debilitating medical condition and required care. In an alternative reality, the treating team would have worked with the family and the child to try to agree on a care plan or discharged Maya to allow her family to pursue their favored treatment plan, even if it was one that the hospital was under no obligation to provide. It was not inevitable to pursue a route that pitted the family against the hospital and separated the child from her support system.

The movie depicts Dr. Sally Smith, a child abuse pediatrician—a professional trained and certified in the diagnosis and treatment of children suspected to be victims of abuse—in a very harsh light. Smith did not agree to be interviewed for the documentary, and this portrayal is one-sided. Physicians who specialize in the care of abused children perform a difficult and important societal role. Yet Smith was not a specialist in the syndrome Maya suffered from and seemed determined to prove that Maya was “faking” her illness, describing Maya’s symptoms in texts with colleagues as a “charade.” The fact that children were removed from their homes for allegations of child abuse in the county where Smith worked at much higher rates than neighboring counties also raises concern.

But this is a problem much greater than whether Smith herself made a mistake in this case, and it’s a question that’s difficult to resolve fairly. Child abuse physicians have enormous power and responsibility in adjudicating difficult cases such as medical child abuse. Case workers defer to the specialist physician in assessing whether abuse had occurred. Yet the reality, when it comes to cases in which parents’ choices around medical treatment are questioned by the state, is often more complex. Parents are given conflicting medical diagnoses and advice, and they are doing their best to navigate a child’s chronic illness. Medical child abuse as a syndrome should be narrowed to those parents who sicken their children or tamper with their medical testing to make them appear ill—neither of which applies to Maya’s family. Invoking this syndrome to describe parents of chronically ill children who may experience conflict with medical staff about their treatment is harmful and can be in itself abusive to children and families.

From the moment Smith walked into Maya’s room, her family should have been made aware of her role. Child abuse physicians are often employed by or funded by agencies of the state, and their assessments can be used in an adversarial manner against the child’s family. Parents speak openly to a physician, only to discover that the physician is not providing care for the child but rather amassing evidence to accuse the parent of wrongdoing. Child abuse pediatricians should clearly state at the start of their assessment both their role and the fact that they may share their opinion with child protection services.

Parents seek care for their own drug use during pregnancy, for a child’s broken bone, or for a burn injury, only to find themselves the target of an investigation. Women who desire solace from domestic abuse, who need assistance providing for their children, or who struggle to find transportation to a medical appointment often find themselves investigated for child neglect. Research has shown that parents who have experienced such an investigation are less likely to seek vital services, like prenatal care, in the future. And more reporting does not lead to better identification of children in need for urgent intervention for protection. Most policy changes designed to protect children result in more investigations and more interventions but not in better identification of children at risk of harm.

Children who are removed in their homes and placed in foster care, or in Maya’s case, under state custody, experience trauma. Parents are saddled with debt; lose their jobs, their reputations, and sometimes their homes as they struggle to battle charges; or agree to “safety plans” that have not been proved to keep children safer. Parents are not granted grace to err and learn. When Christopher Ratté took his child to a Detroit Tigers game in 2008 and accidently bought him a hard lemonade, his son Leo was removed from his care and placed in a foster home. Ratté, a professor at the University of Michigan, had resources and the ability to fight this removal. Subsequently, the Michigan Legislature passed Leo’s Law designed to limit unnecessary emergency removals. Yet other families without these resources remain powerless.

Take Care of Maya reminds us of the perils of policing families in the name of “child protection.” Many of these interventions serve to make children, families, and communities less safe. Parents should know how common these coercive interventions are. Often parents who experience such investigations are reticent to speak of their mistakes or ashamed of the allegations brought against them. Parents should know that there are community advocacy groups and support available to them.

Policymakers should listen to affected families and hear how the broad reach of the family policing system has harmed them. Texas recently passed a law, House Bill 730, requiring families to be notified of their rights within a child welfare investigation. New York missed the opportunity to do so this past legislative session. Let us work to narrow the front door to the system and to protect families from being ensnared in a coercive system that devalues families and often endangers children.