The three girls sat in a room, bandaging their dolls' arms and pretending to call 911. Nearby, a therapist watched as they re-created the physical and emotional abuse their mother inflicted on them over several years.
Child advocates call it a heartbreaking display that leaves them wondering why Susan Hyde hasn't faced criminal charges for harming her girls, ages 8, 6, and 4.
In June, a jury terminated Hyde's parental rights in an Ellis County civil case. Doctors testified that the 31-year-old mother medically abused her kids in what's known as Munchausen syndrome by proxy, in which people exaggerate or create false symptoms of illness in others. After the investigation began, the Texas Board of Health stripped Hyde of her paramedic certification.
But no criminal charges have been filed. District attorneys in Ellis, Dallas and Tarrant counties are grappling over jurisdictional boundaries. Meanwhile, medical professionals continue to debate whether Munchausen syndrome by proxy, also called factitious disorder by proxy, is a clinical disorder at all.
It's been nearly five months since a district judge affirmed the jury's order and permanently separated Hyde from her three daughters.
Court records show more than 150 emergency room visits over four years. Doctors treated the girls for cerebral palsy, cystic fibrosis, headaches and seizures. Hyde convinced doctors that one of her daughters needed a feeding tube. Another used a wheelchair and wore leg braces and a safety helmet. A pediatrician testified during the monthlong trial that the girls needed none of the treatments.
The 6-year-old now lives with her biological father in Iowa. The other two girls, who have a different father, live together in foster care.
Hyde's attorney, who declined an interview request, has filed an appeal in the civil case. Attorneys for Hyde's parents have also filed paperwork on their intent to appeal and get custody of the two grandchildren in foster care.
Criminal charges?
Last summer's civil case addressed only the girls' custody. But with thousands of pages citing medical abuse, criminal charges against Hyde should be easy to come by, said former Harris County Assistant District Attorney Mike Trent.
"By the time you have that evidence in family court, a lot of what you have to do to support probable cause for charges is already done," said Trent, an experienced prosecutor in Munchausen by proxy cases.
But the Ellis County case is complicated because Hyde is accused of doctor shopping. Her daughters saw several different doctors in North Texas counties and in Nebraska and Iowa. Hyde would change doctors before anyone could trace a pattern of abuse. Each time, the new doctors accepted Hyde's word that the children suffered from a variety of illnesses.
Officials in the Dallas, Tarrant and Ellis county district attorney's offices said it would be difficult to prove that felony child abuse occurred within their boundaries. Jurisdiction has become the primary issue, so much so that one Tarrant County prosecutor questions whether the laws need to change to make Munchausen by proxy, or factitious disorder by proxy, easier to prove.
"Our laws are not written to prosecute cases such as these," said Alana Minton, an assistant district attorney in the crimes against children unit. "It is a problem, and there should be some way to incorporate these cases in our laws to be able to protect children from situations such as this."
Ellis County District Attorney Joe Grubbs said his office is working with other counties to possibly pursue criminal prosecution. But he, too, says it's out of his jurisdiction because the girls' serious injuries occurred elsewhere.
The bureaucratic hand-wringing is nothing new in cases alleging Munchausen syndrome by proxy. Among medical professionals, there's no clear definition. Is it psychologically based? Or is it a medical condition that can be diagnosed by pediatricians and doctors? Reports show the mothers tend to deny they have a problem and are vocal about their innocence.
'Planning, deception'
"It's infrequent that these cases get to the criminal system ... which is very frustrating to me," said Dr. Marc D. Feldman, clinical professor of psychiatry at the University of Alabama at Tuscaloosa who has studied Munchausen.
He said these women know what they're doing when they make their children sick or allow them to undergo medical procedures they don't need.
"In some cases [there is] significant planning and deception in carrying out the ruses," Feldman said. "That's evidence that they're not psychotic."
"It's child mistreatment, undeniably," he said. "It may be the single most lethal form of child abuse there is."
But prosecutors typically have a difficult time gathering the evidence and proving that abuse took place. And doctors in such cases don't usually testify that they performed procedures that were unnecessary, experts said.
Munchausen by proxy is generally attributed to women more often than men. The person usually has a medical background and is overly attentive to the sick child, solicitous of medical staff and craves the attention.
But even those characteristics are challenged, said Dr. Eric Mart, a forensic psychologist in New Hampshire who said he believes much of the literature out there on profiling Munchausen is "folklore."
Mart said he realizes there are mothers out there who medically abuse their children. But he questions the court's overzealous use of Munchausen by proxy when medical professionals are still debating it.
"There's not a lot of hard science on this," he said. "How can somebody have something when we don't know what it is?"
Regardless of the debate, it doesn't lessen a mother's culpability, said another psychologist.
"It's not considered a psychological disorder," said Larry Bramlette, a Houston-area doctor who has testified in Munchausen cases. "In my view it's just child abuse."
