Published Oct. 10, 2019

This article, the second in a series, was published in partnership with NBC News.

Just after 9 p.m. on a Sunday two years ago, with Hurricane Harvey’s flood waters filling her Houston home and more rain falling, Ajshay James climbed into a rescue boat, holding her daughter, Harper.

“I need to get her to Texas Children’s Hospital,” James told the firefighters.

The story so far A Houston Chronicle and NBC News investigation found that doctors trained to spot child abuse had in some instances overstated their ability to determine when a child had been harmed, triggering traumatic family separations. In response, some Texas lawmakers have begun calling for additional safeguards to protect families.

Harper, not yet 2, had been in and out of hospitals her entire life. Born nearly four months early, she spent her first 16 weeks in an incubator, connected to a machine that pumped oxygen in and out of her still-developing lungs. Her skin was thin and fragile, like plastic wrap. Each time Harper’s breathing slowed dangerously in those early months, James cried and prayed as nurses rushed to revive her.

When Harper finally left the hospital at five months, doctors sent her with a device to monitor her heart rate and breathing. After its alarm sounded a few weeks later, Harper underwent surgery at Texas Children’s, one of the nation’s top-ranked pediatric hospitals, to correct an airway defect.

In the months that followed, doctors there wrote orders for continuous oxygen support, physical therapy and around-the-clock home nursing care. A neurologist recommended anti-seizure medication after James raised concerns about shaking spells.

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As a single mom, James built her life around Harper’s medical needs, always on guard for signs of distress. When forecasters warned of a massive hurricane heading for Texas in August 2017, James worried she might lose power or run out of Harper’s oxygen.

Murky water was still rising as they climbed off the rescue boat and into a fire truck. The road to Texas Children’s main campus was impassable, a voice on the radio said, but an ambulance could take them to one of the hospital’s facilities in the suburbs.

James felt relief hours later as they pulled up to Texas Children’s Hospital West Campus. Harper was safe now, she thought.

Doctors there, however, soon identified what they believed was another threat to the girl’s safety.

It wasn’t the hurricane they wanted to protect her from. It was her mom.

A new type of abuse

Mothers accused of faking their children’s illnesses often make for salacious headlines.

Fort Worth: “Mom said her baby stopped breathing and turned blue. She was the cause, officials say”

Milwaukee: “Nurse mom accused of subjecting 10-year-old daughter to unnecessary medical procedures”

Portland, Ore. : “Woman doped breast milk for attention, police say”

British pediatrician Roy Meadow was the first to document the bizarre phenomenon in 1977, when he published a case study of a woman who’d apparently been contaminating her child’s urine samples, leading to false diagnoses, and another who kept her child sick through repeated salt poisoning. Based on those examples, Meadow dubbed the disorder Munchausen Syndrome by proxy, a nod to the already established psychiatric ailment in which patients seek medical care for imagined diseases.

The name stuck, and soon doctors across the globe were reporting cases of disturbed mothers — it is almost never fathers — and over-medicalized children.

In more recent years, after a string of overturned convictions abroad raised doubts about the reliability of the Munchausen diagnosis and the doctors making it, child abuse specialists in the U.S. proposed a new, simpler way of categorizing mothers who seek unnecessary treatments for children.

Physicians diagnosing what’s now known as “medical child abuse” are not required to assess the mental health of the parent or their intent. Instead, doctors must show only that a child received unnecessary or excessive medical care and that a caregiver instigated it.

With this vastly widened net, critics say doctors have wrongly accused some mothers who expressed genuine concerns about their children’s health, leading to painful family separations and threats of criminal charges.

Often, the doctors making these accusations are child abuse pediatricians, a small but growing medical subspecialty trained to assess suspicious injuries and report their findings to child welfare agencies. Only a small fraction of the cases handled by these doctors involve concerns of medical abuse. Texas Children’s handles about two dozen a year, according to one of its doctors, and one expert estimates about 1,600 mothers nationally are reported to authorities annually.

As part of a broader investigation into the work of child abuse pediatricians in Texas, reporters for the Houston Chronicle and NBC News scrutinized seven cases of mothers from across the state who were accused of medical child abuse. They reviewed thousands of pages of medical records and court documents and interviewed dozens of physicians, lawyers and social workers, as well as the accused parents.

These cases often begin with a child abuse pediatrician or another physician second-guessing years of treatments for complex or rare medical conditions. In some instances, the child’s treating physicians disagree with accusing doctors, leaving child welfare workers, who often have little medical training, to determine what’s best for the child.

The evidence is rarely straightforward, but reporters identified problems with the ways doctors handled some of these cases.

In one from 2017, a Child Protective Services worker told parents that the medical team that flagged potential child abuse did not believe their daughter really suffered from a bleeding disorder. The family recorded the conversation and shared the audio with reporters. Records later showed, however, that the bleeding disorder had been verified via medical testing.

In another case from that same year, a child abuse pediatrician ordered covert video surveillance of a mother whom she suspected of exaggerating her teenage daughter’s chronic pain and digestive issues, symptoms that the doctor believed were mental, not physical. The doctor wrote that she was concerned the mother might tamper with the girl’s medical equipment, records show. The secret hospital-room recording did not reveal anything unusual, however, and months later, another doctor identified the cause of the girl’s digestive problems and repaired it with surgery.

Few experts question that some mothers, in rare instances, intentionally harm their children through medical treatment, perhaps for sympathy or financial gain, experts believe. But critics say the medical child abuse diagnosis is too broad, poorly defined and, therefore, easy to get wrong.

“The process for diagnosing what they call medical child abuse is subjective, it’s vague, it doesn’t have a clearly tested error rate,” said Maxine Eichner, a professor at the University of North Carolina School of Law who has studied the way medical child abuse allegations play out in court. “This is a process of belief. This is not a process of scientific testing.”

Among the warning signs that child abuse pediatricians are taught to look for: A mother who frequently describes symptoms that are not verified by medical testing. A mother who insists on second or third opinions after a normal test result. A highly attentive parent who is unwilling to leave her child’s side. A mother who is fluent in complex medical terminology. A mother who solicits online donations to cover the costs of a child’s medical treatment.

“The problem is that many of the warning signs describe many parents I know, particularly those whose children suffer from complex and hard-to-diagnose medical problems,” said Eichner, who added that she has observed an increase in accusations against mothers whose children are believed to suffer from mitochondrial disease and other rare genetic disorders.

In two of the cases reviewed by reporters, the alleged victims were born premature and suffered developmental delays as a result. One 2011 paper by child abuse specialists in Ohio even identified premature birth as a possible risk factor for medical child abuse, hypothesizing that some mothers of preemies come to enjoy “the positive attention” from doctors during the initial stay in the neonatal intensive care unit, triggering a desire to keep their child sick as they grow older.

Dr. Eli Newberger, who founded the child protection team at Boston Children’s Hospital in 1970, said that theory ignores a far more likely explanation: Research shows that mothers who give birth prematurely and who have watched their babies nearly die often suffer from post-traumatic stress disorder and, as a result, remain on high-alert for medical problems, even as their babies grow healthier.

Doctors who suspect these mothers of overstating their child’s symptoms should initially offer “a compassionate response,” Newberger said, but too often pediatricians intent on protecting children “seek to label and to punish.”

“So the answer is to remove the child, rather than help the mom,” Newberger said, criticizing that approach.

These trial separations, either through a voluntary agreement or a court order, aim to show whether a suspected mother is guilty. If the child’s condition improves or if doctors are able to wean the child from medical treatments while away from the mom, some child abuse pediatricians consider that to be proof of abusive parenting.

But that doesn’t necessarily prove a mother has attempted to harm her child, said Loren Pankratz, a psychologist in Oregon who has testified on behalf of dozens of parents accused of medical child abuse.

“Maybe the child’s health improved over time,” Pankratz said. “Maybe a doctor misdiagnosed the child. Maybe mom was overly anxious, or maybe she misstated or simply misinterpreted her child’s symptoms. Those are all far more likely explanations, and none justify tearing a mother from her child.”

Dr. Christopher Greeley, the top child abuse pediatrician at Texas Children’s Hospital, said his team does not make these allegations lightly.

“These kids often do have medical issues, and they often do have complex medical needs, and to separate that is often a challenge,” Greeley said. “This is not a decision that’s made without everybody who’s caring for the child being brought to the table and talking through that specific concern.”

To distinguish abusive parents from those who are merely hyper-vigilant or anxious, Greeley said it’s important that doctors sit parents down and explain their concerns, giving them an opportunity to agree to less-invasive medical care, before involving Child Protective Services.

Hospital officials insist that’s what happened in the case of Ajshay James. But that’s not how she remembers it.

‘We prayed for this’

James, now 38, thought it was strange when, a day after arriving at Texas Children’s Hospital West Campus in August 2017, doctors started talking about weaning Harper from her oxygen support.

They had just survived a disaster, James thought. Her home was flooded, and she had no idea where she was going to live. Plus these weren’t Harper’s normal doctors. But after initially resisting, James signed off on a plan to reduce Harper’s breathing treatments while they remained in the hospital, medical records show.

An overnight sleep study a few days later delivered good news. It showed that Harper still suffered from mild apnea, but her breathing had improved since the last time a specialist performed the test more than a year earlier. Doctors told James that, based on the new results, Harper did not need breathing support.

James, a business and marketing consultant, says she called a friend to celebrate. Without the bulky oxygen tank tethered to Harper, James could finally make plans for the Disney trip they’d long discussed, both she and the friend recalled in interviews.

A Texas Children’s doctor noted James’ reaction in Harper’s medical record: “After telling mother results of sleep study she stated, ‘We prayed for this. ... Very happy to hear the good news.’”

James didn’t know that, behind the scenes, a different Texas Children’s doctor was quietly building a case against her. Dr. Jeanine Graf, the chief medical officer at Texas Children’s Hospital West Campus, would later testify that she became concerned about the possibility of medical child abuse the moment she met Harper. The girl appeared too healthy for the long list of health problems listed in her medical chart, she would say later.

Graf is not a child abuse pediatrician or psychiatrist, but she has testified as an expert in identifying signs of Munchausen Syndrome by proxy — a label some doctors use interchangeably with medical child abuse — and has co-authored a paper on the subject.

A review of medical records revealed that this was not the first time a Texas Children’s doctor had raised a concern about the way James described her daughter’s symptoms. A doctor wrote in the spring of 2016, when Harper was just 8 months old, that possible seizures described by James could not be verified through medical testing. The doctor floated the possibility that she was exaggerating, noting that James “appeared to be excited to be at [the] hospital.” And Harper’s primary physician later reported that she believed James tended to overstate her daughter's health problems.

James said nobody at Texas Children’s ever raised the earlier concerns with her and insists she always did her best to describe Harper’s symptoms accurately. At no point has anyone accused her of giving her daughter medications or treatments that weren’t ordered by a doctor.

Despite Graf’s concerns, a different Texas Children’s physician signed papers discharging Harper from the hospital on Sept. 5, eight days after she arrived during the hurricane, with instructions for James to continue giving her daughter all the same medications.

A day later, two Child Protective Services investigators showed up at the friend’s house where James and Harper were staying. One of them explained that the agency had received a report from Texas Children’s alleging that James had left against medical advice — though that’s not what medical records show — and that she had been giving her daughter unneeded medication, according to James and one of the investigators’ notes.

The initial report to Child Protective Services from Texas Children’s also claimed that James had arrived at the hospital “completely dry and dressed in designer wear,” according to agency records, seeming to question her story about escaping her flooded home during the hurricane.

James said she denied the allegations and, after showing the agents her discharge papers and prescription orders, agreed to return to the hospital.

“I thought we were just going to run a test to clear things up,” James said. “They told me if I didn’t come voluntarily, they would come back with a court order and that things would be worse for me.”

In interviews, James described what happened next.

At the hospital, they were met by a Texas Children’s social worker, James said. The woman asked the child welfare workers if they’d explained everything.

“I have some questions,” James remembers saying.

“I don’t have answers,” she remembers the social worker responding.

After a short conversation, James said, the hospital worker lifted Harper into her arms.

“Now I’m going to go this way,” James remembers the social worker saying, “and you’re going to go that way.”

James began to panic. She hadn’t signed anything agreeing to medical care for her daughter, although the hospital social worker wrote that she verbally consented. The social worker also wrote in medical records that Child Protective Services had taken custody of Harper and that James was barred from seeing the girl. But records show the agency didn’t ask James to sign a voluntary agreement granting the hospital authority to perform a separation trial until a day later, and James said she didn’t realize she had no legal obligation to agree to the plan.

She was in a trance, she said, as the investigators ushered her out of the hospital. When they reached one of the workers’ vehicles, James said she glanced down at Harper’s empty car seat, and the reality of what had just happened began to set in.

She and Harper had rarely been apart. James remembers holding her on her bare chest for hours at a time in the neonatal intensive care unit, when Harper was still tiny and frail, listening to her breathe. Now who was going to keep her safe?

She looked up from the car seat and pleaded with the investigators.

“When am I going to see my baby?”

Doctors share ‘grave concerns’

Two days later, Texas Children’s doctors were convinced that Harper was the victim of medical child abuse. Dr. Marcella Donaruma, a child abuse pediatrician who’d never met James nor treated Harper, but who had reviewed the child’s medical records, wrote a letter to Child Protective Services.

“A trial separation has diagnosed Harper as a victim of her mother’s abusive parenting,” she wrote on Sept. 8, 2017, a day before Harper turned 2. “I recommend that Harper remain separated from her mother for Harper’s own safety.”

A week later, as the state was contemplating whether to seek an emergency order to take custody of Harper, another Texas Children’s doctor added a note to the girl’s medical record warning that Harper would be in “imminent danger and at risk of death” if allowed to go home with her mother.

A hospital social worker reported sharing a copy of that note with Child Protective Services, records show, and the agency took custody of the child that afternoon.

The following morning, doctors laid out their case before a Harris County family law judge. James had not been allowed to see her daughter since the separation. She learned about the hearing from her lawyer a few hours before it started and rushed downtown to attend. Harper’s father, who had split up with James soon after Harper was born, and his mother were also there.

Graf was called to testify first. The doctor explained that over the course of a few days, the hospital had weaned Harper off nearly all of her medications and treatments, according to a transcript. The girl did not need anti-seizure medicine, the doctor said. She did not need medicine to regulate her urine output. She did not need breathing support, other than an inhaler.

James’ lawyer asked Graf how she knew James was to blame and not the doctors who’d prescribed all those medications. How did she know Harper’s health hadn’t simply improved gradually, over the course of several months leading up to the separation? And instead of filing a child abuse report, why didn’t the doctor sit James down first and suggest dialing back Harper’s treatments?

“Why not have that conversation with her?”

“Because, in cases of medical abuse or fabricated illness, it is really contraindicated to bring this up to the perpetrator,” Graf said, indicating that trying to work with James to wean treatments before filing a report could have put Harper in danger.

Graf and Donaruma, both professors at Baylor College of Medicine, declined through a medical school spokeswoman to be interviewed for this story.

James said she squirmed in her seat as the doctors testified. Donaruma acknowledged in court that Harper was born with serious health problems that required medical treatment. But after Harper left the hospital as an infant, Donaruma said, her medical records revealed a pattern of James describing symptoms that were never verified by objective medical testing or observed by others.

However, a Chronicle and NBC News review of more than 9,000 pages of Harper’s medical records — which were later entered as an exhibit during a 2017 hearing in Harris County District Court — uncovered evidence contradicting some of the doctors' testimony at the initial court hearing.

For example, Donaruma testified that a former Texas Children’s endocrinologist misdiagnosed Harper with diabetes insipidus, a condition that leads to excessive urination and extreme thirst, based only on James’ reports that Harper was having as many as 20 wet diapers a day, suggesting that she pushed for the diagnosis.

Ajshay James fixes her daughter's hair during one of her scheduled visits. Ajshay James fixes her daughter's hair during one of her scheduled visits. Photo: Elizabeth Conley/Staff Photographer Photo: Elizabeth Conley/Staff Photographer Image 1 of / 9 Caption Close Doctors accused moms of abusing their children. Our investigation raised questions about that 1 / 9 Back to Gallery

But according to a note in Harper’s medical records from February 2017, it was a Texas Children’s neurologist who made the initial referral after an MRI showed a potential problem with Harper’s pituitary gland. The endocrinologist cited the MRI, along with the diaper count, in his decision to prescribe medication, writing, “Her imaging findings as well as her clinical picture ... are consistent with central diabetes insipidus.”

Donaruma also testified that children cannot outgrow diabetes insipidus, and since Harper didn’t have symptoms after being removed from medication, that meant James hadn’t told the truth about her daughter’s wet diapers and excessive thirst.

But according to endocrinologists, diabetes insipidus isn’t the only cause of frequent urination. It’s possible that the symptoms James described were real, experts told reporters, even if the doctor’s diagnosis was wrong.

Donaruma testified that Harper previously wore a special helmet because James “asked for it,” and that in her opinion, there was no evidence that the girl needed it, although the doctor added later that the treatment was not a central focus of her analysis.

But medical records later entered as evidence in the case show that multiple Texas Children’s doctors diagnosed Harper with a condition commonly known as flat head syndrome, which is typical in children born prematurely. A neurosurgeon digitally scanned her head and recommended that she wear the cranial orthotic to correct the problem.

Donaruma testified that Harper had been receiving anti-seizure medication based only on James’ reports of shaking spells and that no medical professional had ever witnessed them.

But medical records show that, following a reported seizure in July 2016, one of the nurses who cared for Harper at home told doctors she “witnessed this episode as well and attests to mom’s description.” The home nurse said that she “noticed some twitching movements of all extremities,” according to a note by another Texas Children’s doctor. The nurse also “noticed desats into the 40’s,” the note said, indicating that the girl was suffering a serious breathing episode.

Credit: Robin Muccari / NBC News

James’ lawyer, who hadn’t been given access to any of Harper’s records prior to the hearing, didn’t have an opportunity to question doctors about these passages at the initial hearing. And the court did not hear from two in-home nurses who later signed affidavits stating that they witnessed Harper suffer breathing problems or seizures while caring for her.

Reporters presented these findings, along with source documents, to Eichner, the North Carolina law professor who has reviewed dozens of medical child abuse cases on behalf of accused mothers. She said James’ case followed a familiar pattern.

“In these cases, doctors repeatedly present the evidence in the light least favorable to the mother, emphasizing records that support the case for medical child abuse and minimizing evidence that raises doubts about it,” Eichner said.

“The question isn’t whether the child was truly having seizures; the question is whether Mom was intentionally lying to doctors,” Eichner added, noting that if nurses witnessed what they believed were seizures and breathing troubles, it stands to reason that a mother with no medical training would draw the same conclusions.

In response to questions from NBC News and the Chronicle, Texas Children’s officials, who were authorized by family members other than James to disclose facts about Harper’s medical care, released a statement defending the hospital’s handling of the case.

“While at Texas Children’s, Harper underwent extensive observation and treatment to address symptoms described by her mother that indicated diabetes insipidus, sleep apnea, seizures, feeding difficulty, and insufficient oxygen,” the statement said. “Once Harper began her therapeutic separation as an inpatient at Texas Children’s, she improved at a rapid rate as she was weaned from unnecessary medications and treatments.”

RELATED: Read Texas Children's Hospital's complete statement and responses

Hospital officials said the doctors’ testimony at the initial court hearing was accurate, and pointed out that physicians gave more complete testimony at a subsequent hearing. At that hearing a month later, the child’s primary care physician testified that she initially suggested weaning Harper from oxygen support six months before the hurricane, but James continued to report breathing problems and the doctor continued to sign off on her plan of care. Overwhelmingly, the hospital said, Harper’s treatments were primarily driven by James’ reports of serious health problems, which the hospital said turned out to be unsubstantiated.

Texas Children’s also provided a statement from Dr. Marc Feldman, an Alabama psychiatrist and expert consultant whom the hospital hired to review James’ case in response to a defamation lawsuit she filed last year, which was dismissed in August. Feldman, considered an expert in cases of Munchausen Syndrome by proxy, said he reviewed Harper’s medical records and agreed with the conclusions of doctors who reported her to Child Protective Services.

In response to emailed questions from reporters, Feldman said the “overwhelming evidence from the thousands of pages” of medical records demonstrated that James “constantly provided information that was almost never replicated in a hospital or other clinical setting.” He said home health nurses “do not have the same specialized training as pediatric physicians” and that he wouldn’t give as much weight to their observations.

“I have found no evidence that Texas Children’s or its staff acted with malice or negligence,” Feldman wrote. “The separation from Ms. James was clearly in Harper’s best interests.”

Toward the end of Graf’s testimony during that initial hearing in September 2017, an attorney representing Child Protective Services asked the doctor if she thought it would be appropriate to allow Harper to go home now that she’d been weaned from most of her medical treatments.

“I have grave concerns that this child will not be safe with her mother,” Graf said. “All of the literature to date suggests that reunification is never in the best interest of the child.”

James gasped.

Never?

Afterward, the judge signed an order placing Harper in the custody of the state and into the care of her paternal grandparents.

A ‘Disneyland for Munchausen’

In her three decades as a child abuse social worker at Texas Children’s Hospital, Jennifer Stansbury says that she became such an expert in spotting the subtle signs of medical child abuse that she could sometimes see it in a mother’s mannerisms.

“There’s a little smile, and it’s like, ‘I’m fooling you,’” Stansbury told reporters. “It’s a very sick sort of dynamic.”

Lisa Creamer, a nurse who spent a decade as the assistant director of child abuse pediatrics at Texas Children’s until her retirement in 2017, said she came to view these cases as “the most evil form of child abuse.”

“In some ways, with physical abuse, you know the parent or the perpetrator loses their temper, they slap the kid, they throw them, whatever,” Creamer said. “In medical child abuse, these perpetrators have to plan, they have to research, and then they have to implement their abuse. And then they have to watch it. They watch it and they get satisfaction out of seeing their child go through these horrible medical procedures.”

In interviews with the Chronicle and NBC News, Stansbury and Creamer said the controversies surrounding medical child abuse have been overblown. Having each recently retired from Texas Children’s, they said they felt empowered to speak up for physicians and hospital staff who face criticism for their work to protect children.

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During their years at the hospital, they said their team evaluated more than 200 of these cases. Without fail, Stansbury said, once the children were separated from the caregiver, they recovered.

They described children who’d undergone unneeded surgeries and tests at the urging of cunning mothers.

Stansbury and Creamer said people who question the plausibility of these cases are in denial because they don’t want to believe mothers can be so heinous. That includes physicians, who they say struggle to accept the fact that they’ve been used as an instrument of abuse.

“What everybody’s supposed to do is love their children,” said Stansbury, who spent 20 years at Child Protective Services before going to work for Texas Children’s. “The medical child abuse mothers, I can say unequivocally, do not love their children.”

In nearly 30 years at Texas Children’s — which she referred to as “a Disneyland for Munchausen,” given the hospital’s size and reputation for treating medically complex children — Stansbury said she doesn’t believe she or her colleagues were ever wrong about a case.

Once these children were placed into the care of the hospital, Stansbury said, they “actually really don’t even miss their mothers,” which she views as a sign that something has broken down in the parent-child relationship.

“You would think the kid would be crying and screaming, ‘Mommy, Mommy, Mommy,’ like our kids would be,” she said. “They never do.”

Federal patient privacy rules prevented Creamer and Stansbury from commenting on specific cases that they may have been involved in.

But records show it was Stansbury who made the initial call reporting James to Child Protective Services following the hurricane.

Ajshay James puts her daughter's tiara on an artificial Christmas tree as she decorates a Kingwood hotel room to celebrate the Christmas during a supervised visit. Ajshay James puts her daughter's tiara on an artificial Christmas tree as she decorates a Kingwood hotel room to celebrate the Christmas during a supervised visit. Photo: Elizabeth Conley/Staff Photographer Photo: Elizabeth Conley/Staff Photographer Image 1 of / 9 Caption Close Do No Harm part 2 - Christmas 1 / 9 Back to Gallery

Years later, still separated

In the months that followed, James could see Harper for only a few hours at a time, always with Child Protective Services supervising. Social workers documented each tear-filled goodbye.

“Child became quiet and requested to be carried by mom,” one worker wrote after a visit at an agency office in April 2018. “Child rested her head on mom’s shoulder, tucked her hand in between their chests and sucked her thumb. Mother rocks her and hums some songs until the end of visit.”

For James, the medical child abuse allegation was dropped into the middle of a legal dispute with Harper’s father, Jason Wyatt. The two were never married, and he had left the country for work about a year after Harper’s birth. James had been petitioning for Wyatt to pay child support when Child Protective Services intervened to take the child from her in September 2017, records show.

James began attending court-mandated parenting classes and met with a psychiatrist, who concluded in March 2018 that she was “mentally and physically fit to be a good mother to her child.” That same month, a separate psychological evaluation ordered by Child Protective Services found no evidence to support the state’s concern that James might have a personality disorder that would have led her to fabricate her daughter’s symptoms. The counselor instead concluded that James suffered from post-traumatic stress disorder, tied in part to the trauma of Harper’s premature birth.

Yet two years after the separation, Harper is still primarily in the care of her grandparents, with James limited to twice-monthly visits.

Wyatt and his parents declined to be interviewed. In a joint statement released through a Texas Children’s spokeswoman, they praised the work of the hospital’s child abuse team, which they said “gave Harper her life back.”

“Today, Harper is not receiving any specialized medical care and she is a healthy, happy little girl,” the family wrote. “She is in a speech therapy program at school and is thriving. We believe in the doctors’ assessment and diagnosis of her as a victim of medical child abuse and look forward to watching Harper grow and blossom.”

James grew emotional after a reporter read the family’s statement to her: “One day,” she said, “my daughter is going to read that and know that her father and grandparents believed that her mother was a child abuser.”

She said she’s thrilled that Harper hasn’t needed significant medical care since being taken from her and never would have done anything to hurt her. She has the backing of family and friends, many of whom wrote letters of support urging the state to return the child.

“Shay is the type of mother that is truly invested in their child, totally engaged,” wrote Jaime Paige, a close friend who said she once witnessed a Texas Children’s nurse assist Harper after she suffered a breathing problem. “Shay would never do anything to stunt Harper’s growth or progress. Shay lives and breathes for Harper.”

In the Texas Children’s statement defending its handling of this case, hospital officials emphasized that once Harper was taken from her mother, they were able to wean her from most of her medical treatments.

But was that proof that James had been abusing her?

Donaruma, the child abuse pediatrician who based her opinion on a review of Harper’s medical records, said it was. “She’s been abused by her mother,” she testified at one hearing, “using the doctors to abuse her.”

But James was never charged with a crime. And after more than a year, Child Protective Services agreed to walk away, permitting James to maintain her parental rights and allowing her to negotiate a custody arrangement with Wyatt.

The medical abuse allegation still looms over that legal process, which so far has dragged on for eight months. Harper’s father and paternal grandparents are insisting that James undergo an additional psychiatric evaluation to rule out the possibility that she suffers from Munchausen Syndrome by proxy. A lawyer representing James told reporters that a new evaluation isn’t necessary, given the earlier examinations ordered by Child Protective Services.

Until they can settle the dispute, James is permitted to see Harper for only six hours, two Saturdays a month, unsupervised.

In November 2018, after one year apart, James put up a live Christmas tree at her home and decorated it with lights and ornaments. Her therapist had suggested that she continue marking special occasions.

“I’m not taking it down,” James said at the time, “until Harper is home.”

Eleven months later, the tree is still there. Its needles have turned brown, and it has started to droop toward the wall.

During a recent visit, James and Harper rushed from one activity to the next, trying to make the most of their short time together. James chased Harper through the backyard. They worked on a puzzle and had a princess tea party. They baked cookies and played at the park.

And soon, before either of them was ready, it was over. Harper said she didn’t want to go.

James buckled her into her car seat and began the drive back to the grandparents’ home, a round-trip that takes almost two hours.

Harper drifted to sleep in the backseat while James cried.

After dropping Harper off, James returned to her home, restored since the hurricane, but painfully quiet. She stepped over a half-completed puzzle. Ignored the Play-Doh left out on a table. Avoided looking at the tiny silver shoes discarded in her entryway.

She couldn’t bring herself to clean any of it up. Not for a few days, at least.

Once she did, she said, it would feel like Harper was really gone.

The series so far:

Part 1: A Devastating Diagnosis

Part 3: Burned by ‘bad science’

Part 4: Short falls, serious injuries

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Mike Hixenbaugh is a national investigative reporter for NBC News, based in Houston. Prior to joining NBC earlier this year, he spent three years at the Houston Chronicle, where his reporting about a troubled heart transplant program led to changes to improve patient safety. Follow him on Twitter at @Mike_Hixenbaugh. Contact him at mike.hixenbaugh@nbcuni.com.

Keri Blakinger is a Houston Chronicle reporter specializing in criminal justice. Her reporting has prompted improvements in Texas’ prisons, including a recent change to provide dentures to inmates. She joined the Chronicle after covering breaking news for the New York Daily News. She has a popular podcast, Behind the Walls. Follow her on Twitter at @keribla. Contact her at keri.blakinger@chron.com

Elizabeth Conley is a an award-winning staff photographer for the Houston Chronicle. Before moving to Houston in 2015, she was a photographer for 12 years at The Detroit News, specializing in sports photography and multimedia projects. A professional photojournalist for more than 20 years, she still feels she has the best job in the world every time people let her share their stories. Follow her on Twitter and Instagram, or reach out to her by email at elizabeth.conley@chron.com.

Design by Jasmine Goldband and Jordan Rubio

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