On his fourth birthday, Mikal Pickens slipped into semi-consciousness in a bed at St. Louis Children's Hospital. His sister Kheematah Pickens, a year older, lay in the bed beside his, alert but unwell. It was October 8, 2004. The siblings had been sick for more than a week.
Doctors were stumped as to the cause. Mikal (pronounced like "Michael") and Kheematah (pronounced kah-mah-tah), who had no history of health problems, had arrived at the hospital on October 4, exhausted and severely dehydrated. They exhibited similar symptoms: incessant vomiting and diarrhea. So constant were their expulsions that nurses were keeping the children diapered. Colorful buckets for vomit were swapped out regularly.
Judy Pickens, the children's mother, told doctors that the children had fallen ill a week earlier. A bug was going around, she said, and several of the children's classmates were sick. Suspecting stomach flu, doctors initially prescribed IV fluid replenishment and figured the children would soon recover.
But they didn't. Several days into the hospital stay, their mother mentioned a chicken sandwich she'd purchased for the kids from a north-county street vendor.
Aha, thought Dr. Jamie Sutherell, the hospital's then-chief medical resident: Perhaps they'd fallen prey to food poisoning.
The revelation sent Sutherell's staff down a new path of inquiry. Nurses began to poke and prod their little patients, extracting vials of blood, urine and stool to submit for a battery of tests. But nothing conclusive emerged. Mikal and Kheematah continued to vomit, and vomit, and vomit.
Sutherell consulted specialists, including pediatric infectious-disease experts, who asked numerous questions of Judy Pickens and her husband, Karl: Had the family taken any unusual trips recently? Where did the Pickenses store things such as household cleaners? Was there any rat poison within reach? Any strange insects in the house? Were the parents' medications stored up high in a medicine cabinet?
Nothing out of the ordinary.
The hospital alerted the city and state public-health departments, which dispatched their own sleuths to look for clues of a possible outbreak at the daycare center Mikal attended.
Meanwhile, nurses were having trouble keeping Mikal's IV lines in. Sutherell inserted a feeding tube into his stomach, but that didn't work, so a surgeon implanted a catheter into a vein in the boy's leg. For a day the source of nourishment seemed to quell the mysterious invader. But on his birthday, the new arrangement appeared to malfunction, and Mikal's condition took another turn for the worse. Only a firm turn of the fist into his breastbone — a maneuver doctors call a "sternal rub" — could induce the boy to open his eyes.
Something appeared to be blocking the IV lines into the catheter, so the medical staff inquired with the hospital pharmacy: Were there problems with the saline bags? Was any of the saline crystallizing in the tubing? A hospital pharmacist checked for product recalls and spent several hours experimenting with the bags. All kosher, he reported.
Mikal's condition seesawed all evening. Concerned that a blood clot might be interfering with the feeding apparatus, Sutherell prescribed an anticoagulant, and, for a time around midnight, his patient was stable.
Soon afterward, though, Mikal began to wheeze. Sutherell ordered a chest X-ray. It came back normal. By 4:30 a.m., when Sutherell was again summoned to Mikal's room, the boy was unable to breathe. "He was using all the muscles of his body, struggling to breathe," Sutherell would subsequently recall during court testimony. "He had a fearful look in his eyes. You could tell he was afraid."
Abruptly, Mikal lapsed into unconsciousness. Sutherell and several nurses performed CPR as a crisis-response team was summoned to rush the boy to intensive care.
"I stayed with the family, because at that point I wasn't their doctor anymore," Sutherell would later testify. "I wouldn't necessarily say [I was their] friend, but there was so much emotion in the rapidity — the suddenness — of how this evolved, that at that point I was right there in tears with them when the doctor came in with the bad news."
Mikal was dead.
Later that morning Mikal's sister Kheematah awoke and told family members, "I don't want to die," and, "I want my brother back."
A day afterward she fell unconscious, just as her brother had, and was rushed to the ICU. Complaining of dizziness and feeling faint, a stricken Judy Pickens was conveyed to the hospital's emergency room on a stretcher. She told doctors her heart was breaking.
Sixteen months later, after an extensive investigation, the St. Louis Medical Examiner's Office concluded that Mikal Pickens had been fatally poisoned. On February 8, 2006, a day after the medical examiner signed Mikal's death certificate, St. Louis police arrested Judy Pickens and charged her with six felonies, including child abuse and the murder of her son.
Why would a mother harm her own children?
In 1977 a British pediatrician thought he'd found an answer: She'd do it to look like a hero.
Roy Meadow had been studying the cases of two unrelated children. Six-year-old Kay suffered from an apparent urinary-tract infection; fourteen-month-old Charles experienced sudden spells of drowsiness and vomiting. In both cases doctors could find no cause for the children's mysteriously recurring illnesses.
Then they discovered that Kay's mother had been doctoring the girl's urine samples; in fact, Kay was never sick at all. Charles' mother, meanwhile, had been force-feeding her baby excessive doses of salt to make him sick.
In a 1977 article in the international medical journal The Lancet, Meadow dubbed this peculiar form of child abuse "Münchausen syndrome by proxy." Münchausen syndrome — also coined in The Lancet, in 1951 — is a psychiatric condition in which a patient concocts illnesses or injures himself solely to draw attention or sympathy. (The condition is named after an eighteenth-century German baron notorious for his exaggerated storytelling.) A mother who maimed her children for no tangible gain, Meadow theorized, would be looking to earn sympathy and to portray herself as an indefatigable caregiver in the face of adversity.
In 1979 California prosecutors brought Münchausen by proxy into the courtroom, citing it as the motive in a murder case against Priscilla Phillips, who had steadfastly cared for her ailing adopted daughter until the girl died of unexplained causes. Suspicions were raised when a second daughter came down with similar symptoms, and a doctor discovered that Phillips was spiking the child's infant formula with toxic quantities of baking soda. Found guilty of second-degree murder and child endangerment, Phillips served four years in prison.
Prosecutors in Texas, Florida, Delaware and at least three other states subsequently used the Münchausen-by-proxy motive to win guilty verdicts, and law enforcement officials have suggested the condition as a possible explanation in hundreds, if not thousands, of unsolved cases in which mothers were deemed potential suspects.
But many in the medical community remain unconvinced.
The abuse can be hard for doctors to discern, notes Dr. Marc Feldman, a clinical professor of psychiatry at the University of Alabama at Tuscaloosa who serves as an expert witness in Münchausen cases — and who believes the condition is a valid diagnosis. Warning signs: more than one child in the same family who falls ill with similar, unexplained symptoms; no overt signs of abuse (such as cuts or bruises); a mother who appears to be an ideal parent; symptoms that only appear when the mother is present.
"Suffocation is very common," Feldman elaborates. "There's also bleeding by creating the illusion of bleeding: A mother may bloody the child's diaper in some way, such as using her own tampon, which forces a wide array of intrusive medical procedures on the child. We see a lot of vomiting induced by ipecac. There's diarrhea due to surreptitious use of laxatives. Alternatively, some mothers give the child constipating products."
Feldman says he's aware of cases in which mothers injected feces into a child's IV line. "Every time I think I've heard the last possible variant of Münchausen by proxy, I hear about something new," he says. "It really boggles the imagination."
According to Feldman, most Münchausen-by-proxy victims may continue to be subjected to the abuse — and the medical consequences — for a long time, "but 90 percent of them don't die as a result."
Eric Mart, a forensic psychologist in Manchester, New Hampshire, serves as an expert witness in debunking Münchausen-by-proxy cases.
"Look, I'm not somebody who doesn't believe people hurt their kids," says Mart, who in 2002 authored Münchausen's Syndrome by Proxy Reconsidered, a critique of the diagnosis. "But they do it for a million reasons: because they're drunk, because they're angry, because they have mental problems, because the kid is causing trouble. Do we say that all rapists are exactly the same? No. Are all murderers exactly the same? No. I think it's misleading to a jury to say there's a scientific profile that differentiates these mothers from anybody else."
Mart adds that the logic law-enforcement officials and psychologists apply to their argument is disconcertingly circular: "They say, 'OK, why would she do such a thing? Because she has Münchausen by proxy.' You ask, 'How do you know she has Münchausen by proxy?' They say, 'Because she did it.' You have to differentiate between clinical lore and things that have been empirically proven. A lot of this hasn't been proven."
Indeed, few studies have been conducted worldwide. In the American Psychiatric Association's clinical manual — considered by most psychiatrists to be the diagnostic bible — the syndrome is mentioned only in the appendix, as a condition "that requires further research and study."
Ten years ago it looked as though a group of forensic examiners from across the nation, including Marc Feldman, might have had the opportunity to perform a unique study on a woman convicted of what has been called the largest maternal infanticide in American history. Marie Noe of Philadelphia confessed in 1998 to murdering eight of her ten children between 1949 and 1968. (The other two died of natural causes as infants.) As part of her criminal sentencing, a judge ordered Noe to submit to an extensive psychological examination.
One court-appointed psychiatrist subsequently ruled out Münchausen by proxy in Noe's case, but the judge called off the more thorough study. Feldman says he personally appealed to the judge to reconsider, "and he never responded."
In Great Britain, meanwhile, Münchausen-by-proxy prosecutions — and Roy Meadow's reputation — took a hit after three high-profile convictions achieved with the aid of his testimony were overturned during the past decade.
The Pickenses are a devoutly religious family. "Kheematah used to say, 'Come on, Mikal, fall and shout now! Let me bring you back from the Spirit! Let me put my hands on you!'" recalls Flora Lee, a close friend of the family who visited the children during their hospital stay. "And when they would play, they would pray for you," Lee adds. "They were real happy. Mikal and Kheematah loved each other, baby."
When Mikal died, donations from members of at Karl and Judy Pickens' church, Trinity Full Gospel Church in the Baden neighborhood of north St. Louis, helped the family lay out the boy in a small wooden casket. He wore a white suit.
The Pickens entourage had maintained a rotating vigil at the hospital throughout the children's stay, with some family members so reluctant to leave that they slept in the parents' lounge. Of particular note was Judy Pickens, a constant presence who slept in the children's room, bathed them and changed their bed linens.
The staff was impressed by Pickens' devotion.
"It was exciting for us to have a parent who wanted to clean up after their child and be so involved," Becky Stolle, a registered nurse who helped care for Mikal and Kheematah, would recount in court testimony.
But opinion of Pickens among the personnel began to change in the hours after Mikal's death. The first sign of something amiss came when Dr. Margaret Schmandt, the family's pediatrician, got word of Mikal's death and rushed to Children's Hospital to check on Kheematah. She found Stephanie Finch, Judy Pickens' cousin, at the girl's bedside.
"[Finch] went and pulled some IV tubing out of Ms. Pickens' bag," Schmandt would later testify. "She told me Ms. Pickens had told her that the previous day, Mikal's IV wasn't working, she had called the nurses to look at it and they had seen a white substance in it."
Finch told Schmandt that after watching the nurses throw away the faulty tubing, Pickens had fished the apparatus from the trash and stashed it in her bag. Finch gave the tubing to Schmandt, and it was sent along with Mikal's body for an autopsy.
When the medical examiner's office was unable immediately to determine the cause of death, hospital and police officials were alerted that toxicology tests would be necessary, and after Kheematah Pickens was transferred back to a regular room from the ICU, a nurse's assistant was assigned to her bedside 24/7.
On October 16, 2004, Children's Hospital barred Judy Pickens from her daughter's room. A week later, the little girl, healthy again, was discharged into the care of her paternal grandmother.
Meanwhile, police and forensic examiners had initiated an extensive inquiry.
Detectives interviewed personnel at the children's schools and learned that, contrary to what Judy Pickens had told doctors, no flu bug had been going around.
At Pickens' workplace, colleagues told police that Pickens said she'd earned graduate degrees and a CPA's license from Saint Louis University and Washington University. The claims proved untrue; police learned that Pickens had not attended either school. Detectives also learned that Pickens was arrested in 1997 for making a bomb threat at Bank of America, where she worked at the time. (Prosecutors had not pursued charges.)
But it was the dozens of medical personnel involved in the Pickens case whose testimony would shed the most light on the children's poisoning.
On October 13 the nursing assistant on duty at Kheematah's bedside, Natalie Sommers, had reported two curious events that evening. According to Sommers' subsequent court testimony, Judy Pickens had insisted that Kheematah needed a drink and, over the assistant's objections, had tried to make her daughter swallow Sprite from a blue paper cafeteria cup.
Kheematah recoiled at the flavor. As Sommers put it: "She said, 'It tastes gross.'"
After Kheematah accepted a drink offered by a different visitor, Sommers said, Pickens became more insistent about making the girl drink from the blue cup.
Later Pickens asked Sommers to help her remove a glass angel hanging from Kheematah's IV stand. As Pickens reached for the ornament, Sommers saw a syringe drop to the floor. Testified Sommers: "She quickly covered it with her foot."
The women's eyes met, but neither mentioned the syringe. "I didn't want to let her know that I saw it drop, because I didn't want her to do anything to Kheematah or me," Sommers later stated. Instead, after Pickens left the room, Sommers summoned several nurses and showed them the blue cup, which contained a small mound of white sediment.
Pickens later returned to the room frantic, asking for the tray on which she'd left the cup of Sprite, according to Sommers.
The medical staff had already confiscated it.
The following night, October 14, another assistant, Tara Owens, was on duty in Kheematah's room when Pickens pulled the privacy curtain in order to change the girl's diaper. Owens would later testify that after muttering that Kheematah's IV line was tangled, Pickens had stooped at the bedside as if to straighten it out. "She got up and said, 'I can't fix them, so they're just gonna stay like that'...[then] walked to the trash can and dropped something in there," Owens stated.
Soon afterward Kheematah had begun to cough and complain of a stomachache. While two nurses tended to the girl, a third quietly removed the liner from the wastebasket and fished out a syringe with white residue at its tip.
An emergency-room nurse, Ken Smith, provided another piece of the puzzle.
Smith had been on duty in the ER on October 10, 2004, when Judy Pickens was wheeled down after feeling faint. Smith asked Karl Pickens to list the medications his wife was currently taking, and he cited several as she lay silent and listless on the stretcher. But when Pickens mentioned clonidine hydrochloride, a medication prescribed to adults for hypertension, Judy suddenly came to life. She became argumentative, Smith would later testify, adding: "She denied being on clonidine, and she said she no longer took clonidine anymore, and she wanted it taken off of her chart."
Sixteen months into the inquiry — which included more than a hundred police interviews and several rounds of toxicology tests on DNA samples from both children — investigators finally reached a conclusion.
On February 7, 2006, St. Louis Medical Examiner Michael Graham signed Mikal Pickens' death certificate. The cause of death, Graham wrote, was clonidine poisoning.
Police arrested Judy Pickens the following day. Investigators concluded that she had pulverized her clonidine tablets and repeatedly injected the drug into her children's IV lines.
The St. Louis Circuit Attorney's Office charged Pickens with six felonies, including child abuse and murder.
Pickens denied the charges and proclaimed her innocence. Unable to raise the $3 million cash bond, she was jailed pending trial.
Friends from church rallied to Pickens' cause, raising thousands of dollars to cover the fee of noted local defense attorney Scott Rosenblum. (Rosenblum would later withdraw from the case; Pickens was represented at trial by John Tucci, an attorney in private practice who was retained through the St. Louis Public Defender's Office.)
"I stand behind my wife; it's that simple," Karl Pickens told the St. Louis Post-Dispatch in 2006. "I don't believe my wife harmed my kids."
Family and friends continue to protest that Judy Pickens is innocent and nothing like the murderer police and prosecutors have made her out to be.
"She was a good mother," says Samuel Armstrong, her first husband, with whom Pickens had a son.
"She supported those kids with all she had," adds Pinkie Porter, an ex-in-law, with whom Pickens has maintained amicable relations. "She gave them birthday parties at Chuck E. Cheese, took them to football games and movies. She was outstanding."
Flora Lee says her close friend was a long-time devoted member of Trinity Full Gospel, ministering to young adults, performing eulogies and leading readings at worship. Lee portrays Pickens as God-fearing in the extreme. "She was, like, peculiar. She didn't do a lot of stuff normal kids do. Never smoked, never drank," Lee says. "Even when she was eighteen, she'd say, 'I'ma pray for you.'"
In July 2008 Pickens submitted to a court-ordered psychiatric evaluation by Michael Armour, a psychologist and forensic examiner with Missouri's Department of Mental Health. Pickens told Armour that when her mother was eight and a half months pregnant with her, she had fallen out of a car. She admitted to being bullied somewhat in her youth, but she also said she had many friends and was always very "protective" of others.
According to Armour's report, Pickens stated that an elder male relative had sexually abused her from age three until she turned fourteen, and that the relative was never prosecuted even though some relatives were aware of the abuse. ("I don't know anything more than what is in the report," says John Tucci, Pickens' attorney.)
Pickens told Armour that before her children's illness, "everything had been right with the world." She professed to be "angry to no end" about the criminal charges against her. A plea bargain was out of the question: "I will never admit to something I did not do," she told Armour.
Pickens discussed her medical history at length. She told Armour she has had high blood pressure since she was ten and was diagnosed with congestive heart failure in her mid-twenties. She also has complained of edema and asthma and was transported to Barnes-Jewish Hospital various times during her incarceration.
Armour, however, noted that corrections personnel had deemed Pickens "not a reliable source of current information" when it comes to her health and that prior to her incarceration, medical staff at Barnes had diagnosed Pickens on more than one occasion with "factitious hypoglycemia" and "factitious diabetes" — meaning she fabricated the illnesses. Additionally, the psychologist wrote, jail records indicated that Pickens "had hidden pills in her medication cups and in her clothing" while in custody.
Armour diagnosed Pickens with a vague form of personality disorder characterized by "histrionic" traits, including "not being comfortable with situations in which he or she is not the center of attention, rapidly shifting but shallow expression of emotions, and self-dramatization and exaggerated expression of emotion."
In Armour's opinion, however, the disorder did not make Pickens unfit to proceed with a criminal trial.
Having examined her medical records and an investigative police report, Armour additionally concluded that Judy Pickens had exhibited the "key criteria" for Münchausen by proxy: She had little to gain from harming her children, and she was considered "a very devoted caretaker."
At a five-day trial in June, Judy Pickens became the first alleged Münchausen mom prosecuted for murder in Missouri. She arrived at the St. Louis Circuit Court hooked up to an oxygen tank and sitting in a wheelchair, swollen in the face and considerably heavier than when she was arrested in 2006.
In a courtroom packed with the defendant's family and friends, as well as prosecutors and social workers, Shirley Rogers, chief trial assistant for the city's Circuit Attorney's Office, called 47 witnesses to testify for the state. It marked the first time in twelve years that Rogers had tried a case before a judge.
Rogers traced the course of Mikal's and Kheematah's illnesses in painstaking detail. Witnesses revealed that neither child had ever been prescribed clonidine hydrochloride, and that records showed their mother had taken the medication since 2000. Rogers homed in on the fact that Judy Pickens picked up her clonidine prescription six days before Mikal and Kheematah fell ill and that she obtained a refill of the 0.3 milligram tablets on Mikal's birthday, October 8: the day before he died.
Donning a latex glove, Rogers exhibited the blue paper cup Pickens allegedly admonished her daughter to drink from. According to a toxicologist, the cup contained residue from clonidine, as did blood samples taken from Kheematah Pickens on two different days.
Dr. Kamal Sabharwal, a forensic pathologist at the St. Louis Medical Examiner's Office, told the jury he detected clonidine hydrochloride in Mikal's blood and liver tissue. While that alone could have killed the boy, the insoluble binder material used in the tablets was equally lethal, said Sabharwal. "This material went into the blood vessels, and the lungs, and clogged them so no blood or air could get pushed through," Sabharwal testified. "This is the same type of thing we see in drug abusers who crush up pills and inject [them] into their veins."
Rogers offered two possible motives. Cash poor, Pickens enlisted an attorney days after Mikal died in order to sue Children's Hospital for medical malpractice and wrongful death. She may have been poisoning the children in the hope of a financial windfall, Rogers said.
Or perhaps psychologist Michael Armour, who had taken the stand, had been correct when he ticked off the telltale signs of Münchausen by proxy. "[Perpetrators] can be quite accomplished liars or manipulators," he had said. "They may seek attention from a wide variety of people. They deny all or part of their involvement when questioned. They don't stop their behavior when they're caught; they keep going when they're discovered."
Rogers concluded her closing argument by saying, "One of the last things Mikal Pickens saw was the face of a killer, and it was his mother. I think it's a pretty horrible accusation to say a mother killed her child. That's why you get proof. And we did."
Judy Pickens did not take the stand in her own defense. In fact, Tucci, her lawyer, called no witnesses. In his closing argument, he suggested the hospital was to blame, and that the staff had set out to frame his client in order to avoid a lawsuit.
"This hospital is staffed by human beings. Staffed by people. And people make mistakes. It's one of the few constants in life," the defense attorney argued.
As the jury deliberated Pickens' fate on June 19, a family member paced alone outside the courtroom. "Man, I don't know what to think," he said, shaking his head. "They all got her clothes and stuff here," he said of the Pickenses' optimistic entourage. "They're ready to take her home!"
Karl Pickens and other family members declined to be interviewed for this story. Through her attorney, Pickens also refused to comment.
After four hours, the twelve-member jury returned to deliver its verdict to a standing room-only courtroom. Gasps and quiet cries escaped from the crowd behind Pickens as St. Louis Circuit Court Judge Jack Garvey read aloud: guilty on all six charges.
Karl Pickens bowed his head on the bench in front of him and cried.
Judy Pickens faces life in prison when Garvey sentences her on August 13.
Tucci says his client intends to appeal. "Judy continues to mourn and grieve for her children, and she ultimately believes she'll be exonerated," he says.
Pickens' ex-husband Samuel Armstrong says his son, now a teenager, has not visited his mother in jail. "That's not the way he'd want to see her," Armstrong explains.
Kheematah Pickens, who has been healthy ever since her 2004 hospitalization, remains a part of her mother's life. According to family friend Flora Lee, Kheematah visits her mother in jail every Sunday after church.