Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub

Summary

Podcast Summary: Nobody Should Believe Me
Episode: Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Release Date: December 26, 2024

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Introduction

In the tenth episode of "Case Files" from the "Nobody Should Believe Me" podcast, host Andrea Dunlop engages in a profound conversation with Dr. Cathy Ayoub, an associate professor at Harvard Medical School. The episode delves deep into the intricate psychological landscapes of perpetrators of Munchausen by Proxy (now more accurately termed Factitious Disorder Imposed on Another), exploring their motivations, behaviors, and the devastating impacts on their victims and families.

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Dr. Cathy Ayoub's Background and Expertise

Dr. Ayoub begins by sharing her extensive background in child abuse and neglect. Her journey into this field was sparked by her early work as a nurse practitioner in Tulsa, Oklahoma, where she encountered her first case of medical child abuse in the late 1970s—a time when awareness of such disorders was nascent.

Dr. Ayoub [08:39]: "It was in the late 1970s, very long ago, around the time that Roy Meadows wrote the first paper on Munchausen by Proxy. I found the paper and even tried to say, I wonder if this is what's going on."

Her professional trajectory led her to Boston, where she further specialized in child forensics, working closely with the juvenile court system and pediatric hospitals to identify and address cases of child abuse, particularly those involving deception and fabricated illnesses.

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Understanding Munchausen by Proxy

Throughout the episode, Dr. Ayoub clarifies the complexities of Munchausen by Proxy, emphasizing its distinction from other forms of child abuse. She highlights that while parental anxiety for a child's well-being is natural, perpetrators of this disorder manipulate medical systems and professionals to fabricate or induce illnesses in their children.

Dr. Ayoub [16:00]: "What you see in Munchausen by Proxy is that there is always what I call a 'yes, but'—the child has a procedure, and then new symptoms arise, making the illness seem more pervasive and difficult to treat."

She outlines key behavioral patterns that differentiate genuine parental concern from deceptive abuse, such as incessant doctor shopping, pushing for unnecessary medical procedures, and the tendency to present as overly knowledgeable or victimized.

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Psychological Profiles of Perpetrators

A significant portion of the discussion centers on the varying psychological profiles of Munchausen by Proxy perpetrators. Dr. Ayoub references her prospective study involving 45 verified families, identifying distinct groups based on their interactions with their children:

1. Detached Perpetrators: These mothers show minimal interaction with their children outside of harming them, exhibiting no emotional bonds.

2. Engaged but Deceptive Mothers: They appear nurturing and involved but engage in suffocating or abusing their children covertly.

3. Aggressive Abusers: This group not only fabricates illnesses but also inflicts physical harm through actions like poisoning or inflicting injuries.

Dr. Ayoub [30:41]: "We found three distinct groups... One where mothers had no interaction except to suffocate, another where they engaged normally but harmed covertly, and a third where they inflicted multiple types of harm."

She emphasizes that these behaviors are often deeply ingrained and compulsive, making cessation and treatment exceedingly challenging.

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Family Dynamics and Impact on Survivors

Dr. Ayoub delves into the intricate family dynamics surrounding these cases. She notes that fathers are often either enablers of the perpetrator or become estranged due to the abuse, complicating the child's ability to seek safety and support.

Dr. Ayoub [48:00]: "Almost always the father was enabling the perpetrator... Another significant group of fathers are estranged or divorced and are fighting for their children."

The conversation highlights the long-term psychological effects on survivors, including attachment issues, PTSD, identity struggles, and difficulties in forming healthy relationships. Dr. Ayoub underscores the importance of understanding and acknowledging the abuse for healing to occur.

Dr. Ayoub [56:41]: "Understanding what happened to you breaks through the traumatic consequences and helps you build your own identity."

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Prevalence and Misconceptions

Addressing the common misconception that Munchausen by Proxy is exceedingly rare, Dr. Ayoub challenges outdated statistics and emphasizes its underreporting and misclassification.

Dr. Ayoub [83:36]: "The study that suggests it’s 2.8 out of a thousand only accounts for the most severe cases like suffocation and poisoning, explaining just about 15% of Munchausen by Proxy instances."

She asserts that the disorder is more prevalent than widely believed, advocating for heightened awareness and better diagnostic criteria to identify and support affected families.

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Conclusions and Recommendations

In wrapping up the discussion, Dr. Ayoub offers critical insights into supporting survivors and preventing future abuse. She advocates for:

1. Comprehensive Evaluations: Ensuring that forensic assessments consider the entire family dynamic rather than isolated aspects.

2. Continuous Support Systems: Providing long-term care and oversight for survivors to navigate their healing journeys effectively.

3. Enhanced Legal Protections: Implementing measures like restraining orders and permanent guardianship to safeguard children even after legal proceedings conclude.

Dr. Ayoub [73:16]: "We have to come together as a society to provide these supports. In successful cases, the entire system supports the family to ensure the child’s safety and well-being."

Andrea Dunlop concludes the episode by expressing profound gratitude for Dr. Ayoub's expertise, acknowledging the depth and complexity of the subject matter.

Andrea Dunlop [89:44]: "I learned a whole bunch of new things, and now I have 8 million more questions for you... there's so many layers to it you could never believe."

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Final Thoughts

"Case Files 10: The Psychology of Perpetrators" offers listeners an in-depth exploration of Munchausen by Proxy, illuminating the psychological intricacies of its perpetrators and the cascading effects on victims. Through Dr. Cathy Ayoub's expert insights, the episode fosters a greater understanding of this covert form of abuse, urging society to recognize, address, and support those affected by it.

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Notable Quotes:

• Dr. Cathy Ayoub [16:00]: "There is always what I call a 'yes, but'—the child has a procedure, and then new symptoms arise, making the illness seem more pervasive and difficult to treat."

• Dr. Cathy Ayoub [30:41]: "We found three distinct groups... One where mothers had no interaction except to suffocate, another where they engaged normally but harmed covertly, and a third where they inflicted multiple types of harm."

• Dr. Cathy Ayoub [56:41]: "Understanding what happened to you breaks through the traumatic consequences and helps you build your own identity."

• Dr. Cathy Ayoub [83:36]: "The study that suggests it’s 2.8 out of a thousand only accounts for the most severe cases like suffocation and poisoning, explaining just about 15% of Munchausen by Proxy instances."

• Andrea Dunlop [89:44]: "I learned a whole bunch of new things, and now I have 8 million more questions for you... there's so many layers to it you could never believe."

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This comprehensive summary encapsulates the critical discussions and insights shared by Dr. Cathy Ayoub in the episode, providing listeners with a clear understanding of the psychological underpinnings of Munchausen by Proxy and its profound implications.

Transcript

[Andrea Dunlop]

Foreign hello, it's Andrea. Today is our final Case Files episode of the year because next Thursday, January 2nd, we are launching season five of Nobody Should Believe Me. So for listeners on the main feed we will have it at its regular weekly cadence and for the first time ever for subscribers, we will have the entire season, season, all eight episodes ready to binge. I want to say a huge thank you to my incredible Season five team, Mariah Gossett, Erin Ajayi, Nicole Hill, Greta Stromquist, Robin Edgar and Nola Carmouche for making this all happen. You guys are the best. If you subscribe to the show, you will also get Nobody Should Believe Me After Hours, which is the subscriber exclusive show that I co host with Dr. Bex. Twice a month we talk about a variety of Nobody Should Believe Me adjacent things in crime, pop culture, the news, etc. This month we had a discussion about the Menendez brothers and their case which has been back in the news recently. And as always, if monetary support is not an option, rating, reviewing, commenting on Spotify, sharing the show on social media are all things that really, really help us stay on the air as an independent show. So today I'm talking to Dr. Kathy Ayoub from Harvard. Kathy is a colleague of mine from the American Professional Society on the Abuse of Children and we had a really fascinating conversation about survivors, perpetrators and just all of the complex psychological dynamics involved in these cases. I really appreciated Kathy coming on to.

[Dr. Bex]

Share all of her research and her insights.

[Andrea Dunlop]

Thank you for being with me this year and for your support of the show. I hope that you are getting some rest this holiday time and spending lots of time with those you love and getting a break from it all here at the end of this absolutely bonkers year, whatever is coming in 2025, I will be here with you every week and we'll get through it together. Now on with the show.

[Dr. Bex]

Well friends, it's 2025. It's here.

[Andrea Dunlop]

This year is going to be.

[Dr. Bex]

Well, one thing it won't be is boring. And that's about the only prediction I'm going to make right now. But one piece of news that I am excited to share is that the wait for my new book, the Mother Next Door is almost over. It is coming at you on February 4th from St. Martin's Press.

[Andrea Dunlop]

So soon.

[Dr. Bex]

I co authored this book with friend and beloved contributor of this show, Detective Mike Weber, about three of the most impactful cases of his career. Even if you are one of the OG est of OG listeners to this show, I promise you are going to learn so many new and shocking details about the three cases we cover. We just go into so much more depth on these stories. And you're also going to learn a ton about Mike's story. Now, I know y'all love Detective Mike because he gets his very own fan mail here at Nobody Should Believe Me. And if you've ever wondered how did Mike become the detective when it came to Munchausen by proxy cases, you are going to learn all about his origin story in this book. And I know we've got many audiobook listeners out there, so I am very excited to share with you. The audiobook is read by me, Andrea Dunlop, your humble narrator of this very show. I really loved getting to read this book and I'm so excited to share this with you.

[Andrea Dunlop]

If you are able to pre order.

[Dr. Bex]

The book, doing so will really help us out. It will signal to our publisher that there is excitement about the book and it will also give us a shot at that all important bestseller list. And of course, if that's simply not in the budget right now, we get it. Books are not cheap. Library sales are also extremely important for books. So putting in a request at your local library is another way that you can help. So you can pre order the book right now in all formats at the link in our show notes. And if you are in Seattle or Fort Worth, Mike and I are doing live events the week of launch, which you can also find more information about at the link in our show notes. These events will be free to attend, but please do RSVP so that we can plan accordingly. See you out there.

[Andrea Dunlop]

What was that? From the director of the Invisible Man. What's wrong with Daddy?

[Dr. Kathy Ayoub]

He got infected.

[Andrea Dunlop]

And Blumhouse, producers of the Black Phone.

[Dr. Kathy Ayoub]

Something's happening to me.

[Dr. Bex]

Can you hear me?

[Dr. Kathy Ayoub]

I can't understand you.

[Andrea Dunlop]

Mommy, we changing.

[Dr. Kathy Ayoub]

Wait. Daddy, is that you? Wolfman Directed by Lee Whannell.

[Narrator]

Rated R. Under 17 out of middle without parent.

[Dr. Kathy Ayoub]

Only in theaters Friday.

[Andrea Dunlop]

Well, hi, Kathy.

[Dr. Kathy Ayoub]

Hello.

[Andrea Dunlop]

Thank you so much for being with us. So, yeah, if you could just start off by telling us who you are and what you do.

[Dr. Kathy Ayoub]

My name is Catherine Ayou, usually called Kathy, and I'm an associate professor at Harvard Medical School. And I'm a counseling and consulting psychologist and a nurse practitioner. So I come at all the work that I do from my basic interest in work in. In working with children and their families.

[Andrea Dunlop]

Which of those several jobs that you just listed? Which of those was your first entry into this work? How did you get started in your career?

[Dr. Kathy Ayoub]

I Actually got started as a nurse practitioner, nurse clinical specialist, and I wanted to work in a hospital with young children and families. I actually wanted to work with children who were ill. So I wanted to work with chronically ill children. And we moved to Tulsa, Oklahoma, for my husband's job many years ago. And I convinced the director of nursing that I could be the mental health consultant to their pediatrics and obstetrical unit. And while I was there, I not only worked with chronically ill children, but the chief of pediatrics said to me, hey, there are these new things we've heard about, and they're called hospital child abuse teams. How about if you start one along with the other things you're doing? Because I think we probably see four or five cases a year. I said, well, okay, let me see what I can find out. And I had the tremendous luck in working with a couple of great pediatricians who had trained with Dr. Henry Kemp in Colorado. But he was one of the first people who really talked about child abuse and helped get the child abuse legislation through in all 50 states for mandated reporting. And he really wrote about child abuse first and foremost. And so I said, okay, very naively, I'll start this child protection team. And we saw 150 children in the first year and about 200 or more in the second year and realized the other hospitals in town didn't have teams and worked on building those teams. And so I saw my first case of medical child abuse in Tulsa when I was part of the child abuse team. And most, if not all of the pediatricians and the nurses were very, really very willing to have folks on the child abuse team go ahead and talk to the parents, understand what happened to the child, and really try to understand any forms of abuse or neglect we were seeing and whether we should report to child welfare, for example, except for one case. And the chief physician, who had really helped start the team and actually circulated, rotated through the team, said, I have a case and I'm not referring it. And there is a mother here and her baby almost died because the baby's bottle was full of salt. And I'm going to handle this case myself and I'm going to work with child protection. I'm going to work with, you know, referring it, and she's very sorry and you're not going to touch this case.

[Andrea Dunlop]

Wow.

[Dr. Kathy Ayoub]

And I was really curious, and I think my curiosity led me to. Then after I moved to Boston and went back and went back to school in my clinical work, both as a pre doctoral and postdoctoral, I was really interested in working through the courts and with child protection agencies and hospitals around child abuse, neglect. And I was always curious about this by then, this Munchausen by proxy.

[Andrea Dunlop]

So what year roughly was that case? What year did that come up, would you say?

[Dr. Kathy Ayoub]

It was in the late 1970s, very long ago, really around the time that Roy Meadows actually wrote the first paper on Munchausen by proxy. I found the paper and even tried to say, I wonder if this is what's going on. And it was just, again, our whole team was really shut out of the process.

[Andrea Dunlop]

I'm so curious about that dynamic because, yes, my first question, I was sort of doing some quick math in my head and I was like, I bet that was around the time that even term came into existence. And I wonder if that doctor who. So it sounds like the doctor in that case was really trying to protect that mother and was very much unwittingly, I'm sure, but sort of colluding with her. And so how did he frame what had happened? You know, like he was cutting out your part of the process, but like, he sounds like he did report it. Like, what was his conception of what was happening?

[Dr. Kathy Ayoub]

I believe his conception was really that this was a very remorseful mother who had made a big mistake and he was very connected to her. I mean, that was the other thing that really, really got my attention because he was so connected to her that he really needed to. He not only kept us out of the situation, but he really worked with the child protective workers to keep them out in a way too. I'm going to see her, I'm going to see this baby. I'm sure this isn't going to happen again. And he made a lot of assertions and was incredibly protective around the whole reporting system.

[Andrea Dunlop]

That's really fascinating. So that was your entry point then, sounds like into getting interested in Munchausen by proxy.

[Dr. Kathy Ayoub]

Exactly. That was my entry point. And then when I went back and got my doctorate in psychology, I was lucky enough to be both as a pre doctoral student and then to do a postdoctoral fellowship in child forensics. And I worked at the Boston Juvenile Court Clinic as part of that experience and also did a lot of work in family court. And I was handed a case. And they said, well, you're a nurse, you should understand these medical things. And you're a psychologist, so you, you should understand, you know, the mental health issues. Here's this really unusual case at the Boston Juvenile Court Clinic. This was a court clinic that sets within the juvenile courthouse and judges would refer to us directly around, you know, any kind of juvenile cases. But in particular, I was really interested in young children, and I was really interested in child abuse and neglect. So they used to give me those cases. And it was really there at the Boston Juvenile Court Clinic that I began to be the person who ended up seeing these cases. And we also. At the same time, I did work in family court, and this is through the law and psychiatry service at Massachusetts General Hospital, which is where I still practice my forensic work, but ended up seeing those cases once they got to court, and then at the same time, doing some work with a number of hospitals about how to set up child protection teams and hospitals. And these were always what a number of my colleagues called the black holes of child abuse and neglect, because there was so much information and it was so complicated and.

[Andrea Dunlop]

You mean medical child abuse cases, The.

[Dr. Kathy Ayoub]

Munchausen cases, Munchausen by proxy cases in particular? Yes.

[Andrea Dunlop]

Right. Are the black hole of. Yeah, I can see that. I mean, this is really fascinating because I think that sometimes people. And certainly even as I've been digging into this, I think many of us are surprised at how recent our recognition of child abuse period is. Right. Munchausen by proxy is its own thing, but even sort of this idea of like, the battered child syndrome and the need for protections for children from abuse is very recent.

[Dr. Kathy Ayoub]

Absolutely. And, you know, again, I'm old, so I've had the opportunity to really see this develop again. I remember talking to Dr. Henry Kemp at the University of Colorado, and he was saying, you know, you're a young thing. You don't remember when there were no protections for children. And he worked with Walter Mondale when he was in the Senate and actually got them to pass legislation that provided federal funds for states that would develop child protection laws.

[Andrea Dunlop]

And what year was that?

[Dr. Kathy Ayoub]

That was in the 1960s. Because by the time we got to the 1970s, all 50 states had passed child protection laws. And most states had child protection systems that were developed within their states. However, there were a few states that didn't. And Massachusetts was actually the last state to integrate into their state system child protection services, because those services had been provided since the late 1880s by the Centers for Prevention of Child Abuse, the Massachusetts Society for the Prevention of Child Abuse.

[Andrea Dunlop]

So it sounds like previous to this era, there were sort of patchwork, maybe efforts to protect children, but not this sort of overall understanding that this is something that needs to be taken really seriously.

[Dr. Kathy Ayoub]

Exactly. So, you know, we're really in a very different place now than people were in the 1960s, as this was really developing and even in the 70s. But we're still struggling with some of the same issues and some of the real backlash to protecting children.

[Andrea Dunlop]

Yeah. If you can just talk us through. And I always want to make sure in my work that I don't cast aspersions of any kind or sort of make parents of truly chronically ill children nervous. And of course, those parents do have bad experiences with the medical system plenty of the time. Right. I mean, there are those real problems also. Munchausen by proxy cases are very distinct from those, I think. But I wonder if you can kind of talk us through, like, what are some of the things that makes either parental behavior just the sort of expression of it? Like, what are some of those things of. Like, if you take a child that has a genuinely rare medical complexity and put it up against a Munchausen by proxy case, what are the differences between those things?

[Dr. Kathy Ayoub]

There are some very distinct differences, but oftentimes healthcare professionals get so wrapped up with, and I'm going to say mothers because 97% are moms or are women who are caretakers. But there are some real distinctions. Having worked with a lot of families with chronically ill children, it's incredibly anxiety producing. I mean, there's nothing worse than having your child be ill, particularly chronically ill. And so parents are anxious. But what you see by and large is that parents want action and then they're so relieved when the child gets better, or they're very anxious when the child is not getting better, or when they have a chronic life course that the parent often can't control, particularly if the child's quite ill. What you see in Munchausen by Proxy is that there is always what I call a yes, but it's like there's a procedure. The child has a procedure. Sometimes the parent will often push for a procedure that the doctor may not think is totally necessary. And the parent comes back and says, yes, but my child is still ill, or my child has another problem. If their GI problem was taken care of, now they have seizures. If they're also having seizures, then they have an immunological problem. So almost every body system gets tagged and it just gets worse. The other thing you see is if providers have time to go back and look at the records, you can almost track where different disorders appeared. So you also see Dr. Shopping not to try to find a way to have the child get better, but to have somebody validate that the child is ill. So you have to really look at all those patterns very carefully. I think I could say almost every parent that I've interviewed with factitious disorder has convinced me. At some point in time, I get taken in to the point where I often have a colleague when I'm doing these forensic interviews, where I can do six interviews, 10 interviews. I can spend much more time. I may have a colleague sit behind me to watch me be taken in, oftentimes because these are very, very convincing people. And some of these women present as victims and really want everybody to feel sorry for them. Some of them are more assertive and are more intellectual. I know more about this disease than the doctor. And that's also kind of another sign. It doesn't mean that parents of chronically ill kids aren't going to know a lot about their child's disease, but it almost comes across in a different way. They don't spend all their waking hours on the Internet looking at rare diseases.

[Andrea Dunlop]

Right.

[Dr. Kathy Ayoub]

So I hope that's given you, you know, a few characteristics that are really different, but it. You can see that it's not something that you might know instantaneously, and you have to dig. And that's one of the things I think that's always interested me is that it's very important to really start out thinking this is a chronically ill child and really peeling back the onion and then watching and spending some time with the child, really understanding, who is this child? What are they doing? You know, how do they appear when they're, you know, relaxed or will sit and, you know, be with you, play with you? Those kinds of things.

[Andrea Dunlop]

Right. I mean, I'm fascinated at the way you describe that because, you know, I've had Bjorker on the show a couple of times, and she described the exact same experience of just, oh, my God, I get roped in every time you'll be in a conversation with them and you'll just be like, oh, we've got it all wrong. And then you sort of like, come out of that trance when you look at these other factors. Right. When you look at the evidence.

[Dr. Kathy Ayoub]

Yes, exactly. And it's. It's what a lot of times we talk about it is as there are lots of what we call cognitive distortions with the parents. It's that you think you're following a logical train of thought, but it gets distorted. And what you see is that the events that most people would see one way are often described by these mothers in a way that actually moves to make them look like they're more nurturing, more competent, and that they're right about what they're saying. They also will take a piece of truth and distort it. So even when I have the opportunity to do psychological testing which I think is interested in understanding people's personalities, it certainly doesn't define or identify Munchausen. But to look at how oftentimes these women will actually start with the detail and build information like circle that detail to make it something that it isn't. Or they'll take an overall statement and add the details that then change the situation. So even looking and I also believe that these women are not all made in the same cloth, that there are at least three or more different, pretty clear groups of women with with different ways of being and that their prognosis for really being able to change their behavior has something to do with that as well.

[Andrea Dunlop]

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[Dr. Kathy Ayoub]

There are a number of different ways of talking about perpetrators. And we actually did what I think is still the largest prospective study, which is only 45 families of Munchausen by proxy cases. And they all were verified through one court. In other words, the judge found that this was true several cases with criminal courts, most often it was juvenile court or family court. And so we tried to understand what the mothers really looked like. I've got lots of different information. We first we looked at their IQs and they were all, you know, some were very high and then there were people whose IQs were not that high. So just want to say, I think, you know, these are, and these were people from multiple walks of life. So you can look at these moms in a number of different ways. The person who I think looked at the most carefully and I think this was so interesting is Dr. Southall, who was the pediatrician in the UK who actually did surreptitious video surveillance of children who had unexplained breathing episodes, or what we call apparent life threatening events where kids stop breathing. And what he found was that when they analyzed those tapes, all of these individuals were suffocating their children on videotape. Again, they didn't know they were being videotaped. But, but he found three distinct groups. So one of the ways to think about these moms is how do they act with their children. And what he found was that there was one group of mothers who had no interaction with their children except to reach into the crib and suffocate them. So no, no connection, no interaction. When the nurse came in, they would play with the child, they would change the child, but when they were alone, nothing. Second group of mothers who seem to engage with their kids in a pretty normal way, and then they'd reach out and suffocate them. And then a third group who would pinch their children, one mother even broke their child's arm. You know, they were really hurting the child in multiple ways. That third group of women, I think are probably in the acute situation, the most dangerous. Now these were all women who were suffocating their children. And that is the most likely form of medical child abuse to be fatal. And in our study we found of 45 families, we had a 7, 17% mortality rate that is so high when you think when you compare to other chronic diseases. For example, the most common cause of death in children is infectious disease in the child. One to four, there's a 10% mortality rate, and four to 14, there's a 5% mortality rate. If you're born with A congenital heart condition. You have a 2% mortality rate now. It used to be 77 in 1990 and now it's gone way down because we know how to treat these children. When you think of children with chronic illnesses or even with acute, the most common illnesses that actually lead to serious injury or death in children, Munchausen by proxy is way up there. And it's primarily because of the children who are being suffocated. Although there were also several children in this study who died of chronic intestinal problems because they were just so debilitated. And I've also seen, sadly, I've seen young adults, 21, 22 year olds. I get a call from their internist. What can you do? I think this mother's making this young woman sick or this young man. And at that point there are no protections. Anyway, they've gotten off the topic there.

[Andrea Dunlop]

No, no, no. All of this is on the topic. And I mean, that's really fascinating. And I'm sort of, as you're talking, I'm sort of triangulating my various, the various cases into like those three groups. So the 45 families that you studied, those were not all suffocation cases, right? Those were a variety of Munchausen by proxy cases. Okay.

[Dr. Kathy Ayoub]

They had a variety of different kinds of problems. GI disorders, asthma, mitochondrial disorder, seizures. I mean, I have a list, I could even read it off for you. I think we saw a little bit of everything. Poisoning, we did have some apnea or suffocation cases. And we also had 10% of the cases were cases in which the illnesses that were being fabricated, exaggerated or induced were psychological or psychoeducational. So it was either they were seen in schools or they were being seen by mental health professionals. So we were able to identify that as a form of victimization as well.

[Andrea Dunlop]

I think medical child abuse is a helpful terminology for some pieces of it. But I actually really have come to appreciate sort of just the descriptor of Munchausen by proxy abuse because of exactly what you said. We see in so many of these cases, even if there are those, you know, really the life threatening elements are more the poisoning, the suffocation, that kind of thing, the starvation in some cases, the, the, it also extends to this, you know, emotional abuse and psychological abuse and educational abuse. And it really, like in some cases, it's really only taking place in those, in those arenas and it's still extremely harmful and leaves lifelong wounds, whether they're physical or not.

[Dr. Kathy Ayoub]

Exactly. And that's my problem with the term medical child abuse. We tried to craft a term back in 2002 and I think, you know, it was too complicated, but it was child abuse by illness falsification and what we were. And we really said illness or condition falsification so that it wasn't just physical abuse. But I think this is still a struggle. And unfortunately, you know, the term medical child abuse is, is a great one for, for pediatricians, but it doesn't differentiate the dyadic nature of Munchausen by proxy, which, you know, there's a diagnosis for the parent, there's a diagnosis for the child and you put them together and that's Munchausen by proxy. And unfortunately, in our healthcare system you can't have a dyadic diagnosis.

[Andrea Dunlop]

Right, but what is a dyadic diagnosis? Even though we know that one.

[Dr. Kathy Ayoub]

I like that. Anyway, lots of Ds here. We also talk about Munchausen by proxy as being one of a number of disorders of deception. And you know, getting back to these three groups of women and some other things you can think about disorders of deception as a more global term are people who fabricate or exaggerate or change their reality or some of them are what we commonly know as pathological liars. Now with Munchausen by proxy perpetrators, some of them are very focused on their children, on their children's symptoms. And in a number of cases I've had some perpetrators say to me, my child has these physical symptoms, they would never have psychological problems, or my child has these psychoeducational problems and they would never have physical symptoms. And sometimes there are a combination of both. I think the child's symptomatology also tells you something about actually how many children in the family are going to be targeted. So that's kind of another issue we can come back to if you're interested. But then thinking about the perpetrators, they may also be evaluated or be identified based on their. Whatever is motivating them to keep this secret or to actually make an admission. I've been involved in long term treatment of a small number of cases, but significant cases and had the privilege of actually working with these families for seven or eight years from the time they were identified to the time that the children were completely reunified. And it was really quite extraordinary. And then I've seen several of the families when the children were adults and their siblings. So that's been very interesting. And in those cases, those mothers each said to me, I happen to be the forensic evaluators for each of them and in one case actually got a full confession which was just extraordinary because it just doesn't happen. But each of these mothers essentially said, I was waiting for someone to find me out. Why didn't. For example, there was a woman who was in a hospital here in Boston and her child was getting ready to 4 year old, was getting ready to have surgery to have part of, of his pancreas removed because he kept having excessive insulin production. And no one could figure this out in their hometown. So they came to Boston to, for evaluation. And he had these hypoglycemic, you know, low blood sugar episodes in the, which were life threatening in the hospital. And the doctor would immediately take blood and this is the chief of endocrinology and he looked at the findings and he said, this can't be. The lab is wrong. Then there was a second episode, then there was a third episode and he finally said, this has got to be right. And what he was doing is he could identify that this child was being injected with insulin because the breakdown products for insulin were not present in the child's blood if it had been insulin that had been created from the child's pancreas. So there was in some sense a smoking gun. And he went in and, you know, face the mother and said, this is what's going on with you? She came back to me and she said, I don't know why, you know, he came in and he told me I did this. The syringes were in my purse. I don't know why he didn't come find them. I don't know why. No one looked at me or examined me, you know, or looked for some evidence that I did this because I really wanted to stop and I couldn't stop and I really needed to stop. And as ashamed as she was, and I helped her walk through telling her husband, which was the hardest thing for her, she was desperate to stop. And the women that I've worked with, at least in treatment, and maybe this is just random, but are women who are almost compulsive about doing this. They've started to do it, they continue to do it, and then they can't stop. And so I think that's one group of mothers. And those were often the mothers that were actually able to interact with their children fairly normally in other ways.

[Narrator]

This episode is brought to you by Amazon. Sometimes the most painful part of getting sick is the getting better part. Waiting on hold for an appointment, sitting in crowded waiting rooms, standing in line at the far pharmacy. That's painful. Amazon One medical and Amazon pharmacy remove those painful parts of getting better with things like 247 virtual visits and prescriptions delivered to your door thanks to Amazon Pharmacy and Amazon 1. Medical Healthcare just got less painful.

[Andrea Dunlop]

If.

[Dr. Bex]

You'Ve been listening to this show for a while, you know that I have very strong feelings about what is and is not responsible true crime content. Maybe you've heard me make some pointed comments about the producers of a certain film. Or perhaps you've heard one of my dozen or so rants about a certain journalist whose name rhymes with Schmeich Schmixenbach. And if you've been with me for a while, you'll also know that getting Nobody Should Believe Me on the air was quite the rollercoaster. Podcasting is just the Wild west, y'all, and these experiences are what led me to launch my new network, True Story Media, where we are all about uplifting true crime creators doing the work and making thoughtful Survivor centric shows. And I could not be more thrilled to announce our very first creator partner. You probably think this story's about you the first season of this enthralling show from breakout creator Brittany Ard took podcasting by storm in 2024, zooming to the number one spot in the charts on Apple and Spotify as Brittany revealed the captivating story story of a romantic deception that upended her life and trace the roots of her own complicated personal history that led her there. Britney is back in 2025 with brand new episodes, this time helping others tell their own stories of betrayal, heartache and resilience. If you love, nobody should believe me. I think you will also love. You probably think this story's about you for its themes of deception, complex family intrigue, and its raw, vulnerable storytelling. You can binge the full first season and listen to brand new episodes each week by following the show on Spotify, Apple or wherever you get your podcasts. You can also find it at the link in our show notes.

[Andrea Dunlop]

You know when you're talking about the sort of three different styles of interacting with the kid and that's really interesting to think about this sort of idea that I've always wondered and I think one of the things that people are the why people are so disbelieving about this abuse is because if you have kids especially. But I think for anybody it's so hard to imagine, right?

[Dr. Kathy Ayoub]

It's like kids are here, right?

[Andrea Dunlop]

Like harming your child not even because you're having like you're in a rage or like because you're, you know, abusing substances and don't, you know, have lost your you know, sort of faculties or what have you, but like this deliberate, planned out, orchestrated harming of your children.

[Dr. Kathy Ayoub]

Exactly.

[Andrea Dunlop]

It's hard for me to believe that a person who's capable of doing that is really capable of empathy. And so when you describe someone just sort of going down that road, but also simultaneously having the empathy, sounds like to be able to sort of rebuild and get to a better place. I mean, I. I just like. I almost can't like reconcile that idea. So what do you think makes that difference where someone that. That very small, admittedly percentage of perpetrators that may be treatable?

[Dr. Kathy Ayoub]

I think that they really came from different backgrounds and that they had different genetic predispositions. In each of these cases, what I discovered fairly quickly was that these women had experienced significant and severe trauma of their own. Many of them have been sexually abused within their families. They had been physically ignored and really mistreated, although they were designated as the caregivers in their families. And they actually took care of their own parents, who oftentimes were abusive to them. Now, I don't think that's the case with all Munchausen perpetrators, but with this subgroup, I wonder if there is an extended family trauma that along with a very strong push to be the caregiver in the family. And then the third piece is that I believe that there is often a trigger for these perpetrators. Some of them really had triggers and adolescence and, you know, began with some issues in adolescence, but they're often often some triggers or some trigger that really pushes them into. Into this. Now, there are two other groups, and I think the biggest one are the mothers who really don't do a lot with their children unless they're on stage. And I think that's a different. Because the bond between the child and the parent is really not there from the parent's perspective. And those are the individuals who have recreated themselves. As my colleague Herb Shrier says, they are impostering as nurturing parents. And that takes up their whole time, their whole being. And those are the folks who I think are very, very difficult. I mean, that's where you're really not. You're not going to get admissions. And treatment isn't effective without some kind of an admission. Well, without a genuine, sustained admission, yeah.

[Andrea Dunlop]

There are many cases. Munchausen by proxy, many of the cases I've covered. In fact, almost all of them I can think of off the top of my head. There was no known history of abuse as a child. And I think that makes it even sort of more perplexing. And again, like Dr. Mark Feldman and the others sort of describe this as a maladaptive coping mechanism. And I think one of the things that I always try and, you know, remind folks to sort of bring the whole thing down to earth because it does seem so bizarre, is like most of us, I think, if we take a moment, can really understand that intrinsic reward that you get for being sick or having a sick child. Right. As you said, with this sort of first profile that you're talking about, if someone was heavily parentified in an abuse situation and put in that caretaker role, that that might sort of become this coping mechanism and this thing that they do and this thing that sort of becomes all twisted up for them. I mean, what's really fascinating is that it sounds like people who are perpetrating this abuse because of their own history of abuse are more treatable than the other variety who is not doing it for those same reasons. And I'm also assuming with that second group that doesn't have a history of abuse, that's probably where you're more likely to see that pathological lying that spills into other areas. So the really high rates of excessive infidelity, lying at work, fraudulent this, that, and just a million things, you know, because so many of these cases that I, that I look at, you scratch the surface and you're like, oh, this was not the only thing that this person was lying about. So I'm assuming that that's kind of more common in that second group too.

[Dr. Kathy Ayoub]

Yes, absolutely. And that you, you. You've got it. That. That those tend to be the people who oftentime have factitious disorder as well as they're involved in factitious disorder imposed on another, they make themselves sick. And those people, we may often see some of that develop in adolescence and they start the behavior of distorting situations. And some of them in the extreme, I think, then go over into the third group where they tend to really make all kinds of people ill. Their spouses, their friends, you know, they may. If they're upset with a partner, they may fabricate. Domestic violence is something that we see. You know, it's only limited by the perpetrator's imagination. Just like the forms of illness are.

[Andrea Dunlop]

Right. Just absolute chaos agent on all fronts.

[Dr. Kathy Ayoub]

Right. And it's more than that. What we found in our study was that about 60% of the. And these were all women in our study, 60% of them were also fabricating, exaggerating, reducing illness in themselves. We did find that a very large number of the women that we evaluated had mixed character disorders or personality disorders. In other words, they had long term dysfunctional ways of being and of acting that they had really, you know, kind of supported for. For a number of years. You know, again, on the extreme where. Where we had women that were really chronically violent with their children in a number of different ways and then they tended to be with other people as well, oftentimes in a very indirect or subtle way. But, you know, I'm going to put ipecac, which makes you vomit in your applesauce and you're not going to know it's there kind of thing.

[Andrea Dunlop]

Like we saw this with the hope you borrow case that we covered in the first season. You know, she poisoned a co worker, like that kind of thing. Yeah. What else did you learn in this study about. And just what have you observed about like the family dynamics surrounding perpetrators? So both in like the family of origin, as you said, that's a piece that you look at. And also their family as it is. So like their marriages, their dynamics with their, you know, extended family, that kind of thing.

[Dr. Kathy Ayoub]

Let me start with the current information because I'd love to talk about fathers as we evaluated mothers and fathers in or partners in both cases. And in terms of thinking about, again, I always did this from thinking about, so how can the child be safe, how can they be cared for and how can they have some permanent placement? There were really two groups of fathers, were really two family constellations. There was the two parent family. And in those situations, almost always the father was enabling the perpetrator. And there are often times where additional maternal family members in particular that were also supporting mom. In some cases there were other maternal family members who were really, really trying to get into the system. Grandparents, you know, aunts and uncles. And they couldn't kind of break this, this couple because dad really supported mom. That was really quite typical. Those fathers totally stayed out of the health care for their kids. That's mom's job. I don't know anything about it, but I totally support her way of thinking. And I think of the one case I was involved in a number of years ago where mother was tried criminally and was convicted. Dad was in the courtroom and he walked out and he said to the press, they've just convicted an angel. So he was firmly connected to her. There's another very fairly significant group of fathers that are estranged from their partners. Either were never married or oftentimes were quickly married and divorced and they're fighting for their children. And those situations show up most often in family Court. And I think there are a couple of us have probably done more work in family court than a lot of other folks. And it's almost the hardest to manage those cases in family court, because in family court, when you come in for a divorce, the assumption is that both parents are fit. And so it's often very hard to really demonstrate that. That this is going on. And I always think of the case I can talk about, which was a criminal case in Dallas back in 2019 with a. Trying to remember the little boy's name was. I probably even have it here, Christopher Bowen.

[Andrea Dunlop]

Oh, yeah, we spoke to Ryan Crawford on the show. Yeah.

[Dr. Kathy Ayoub]

Yes. And I actually testified in the sentencing portion of that criminal trial just about what Munchausen is, what the prognosis is, what the likelihood is that she would, you know, continue to do this. And. But that was such an interesting case. And I did. I did talk to Ryan afterwards and, you know, heard more of his story and how he really, you know, how he was really found in contempt of court and family court trying to present this information and. Not surprising.

[Andrea Dunlop]

Yeah. And I mean, for those fathers who find themselves in that situation, who. I mean, on the one hand, I can understand where this gets complicated in the arena of divorce, because something that people ask me about constantly, and we can address this a bit, is like, well, what about all these false accusations of Munchausen by proxy? Now, there aren't. There's not really any data that there are. Yeah, I know we're having the same reaction. There isn't any data to support that. There are a large number of false accusations of much thousand by proxy happening. But I think where you might see one is that a dad could throw that out in the context of contentious divorce, but there wouldn't be any evidence to back it up. Right. So I can see where it feels like a thing someone might throw out as a way to sort of get custody of kids. But I, number one, I don't know that that happens often. And obviously, if you were. If you discovered that your spouse was doing this and did not want to go along with them, did not want to enable them, this almost certainly would end in divorce. Right. Because you're not going to maintain your marriage with that person and watch them torture your children. So for dads who discover this abuse, I mean, is there any way, like, is it about reporting it sooner so that that's on record while you're still married? Or. I mean, is there any sort of practical advice? Because we hear from a lot of people on the show I know, it's.

[Dr. Kathy Ayoub]

Really so painful and so tragic. There are lots of fathers and what I always say is, you know, have you filed for divorce? If that's something you're going to do, you need to make sure that you get a guardian ad litem or an expert on Munchausen appointed by the judge to do an assessment. The guardian ad litem is really looking at the best interest of the child. It's the best way in family court to get someone to evaluate both parties. But it has to be somebody who knows something about Munchausen if that's what they're suspecting. And I have, you know, and I've done probably almost 100 cases in family court, maybe more. And you know, some of them have turned out not to be Munchausen. It's interesting that most of them have because I think by the time they get there, there's enough information. But judges need to be convinced. And unfortunately, I think it's going to take someone to put all the pieces together. And what they shouldn't do is have someone do one piece and another person do a second piece and another person do a third piece and try to put the information together. Because that's what these perpetrators want. They want to divide and conquer. So the kinds of assessments that often happen in family court. Well, we'll go have you do a psychological evaluation of both parents. Well, that's not that helpful. It is really hard when fathers haven't left and it's really hard to know what to say to them except to describe what the kids look like and what the perpetrators look like and have them make their own decisions. I do think that some of the groups that Bjorker is running are absolutely critical. These partners are so feel so lost and so alone. And the other thing that tends to happen, particularly in those divorce situations is these mothers never give up. And that's something I want to make sure I get to say is that in thinking about the long term, they do not give up. They do not give up. When the children turn 18, if they have been, if their rights have been terminated, they're on the doorstep on that child's birthday. They've seen it over and over and over again. So when I'm talking to fathers, I'll say, you know, when your child gets ready to turn 18, if they're willing, get a restraining order for your ex wife because there's no protection. And these women are just relentless. And they come back, they may come back into the situation when rights haven't been terminated five Six, seven years later and say, oh, here I am, I love my child. I want to do something. And if there aren't any legal, you know, legal protection for these children, adolescents and even young adults, they get pulled right back into the same kinds of behavior patterns.

[Andrea Dunlop]

I know in addition to studying perpetrators, and I know you don't necessarily have data to publish yet, but you are doing a long term study on adult survivors. And I wonder if you can just share with us, you know, even anecdotally, sort of what, what you've noticed about how this affects, you know, sort of maybe even starting with like, how how does this affect children when they're children and being victimized? And then what are those long term effects on adult survivors?

[Dr. Kathy Ayoub]

We're really hoping to reach out to more adult survivors. This study started 20 years ago when we had to wait. We published some current information on it, but not about the follow up. And so I think this is really important. First of all, when we look at what the children are like when they're in this situation, one of the things that's really critical is they are very unlikely to acknowledge their abuse until they're separated and safe. And Judy LeBeau did a study 20 years ago. She talked to adult survivors. She literally put an ad in the paper and said, you know, do you think this might have happened to you? And she talked to folks and what she found was that half of them said they didn't. They were unsure that they were being abused until they really heard about this as an adult. And some perpetrators are very overt and others are much more subtle. And so that's one thing about victims, is that they're very confused because they're being told that they're feeling things or particularly when illness is being induced, that they're feeling things that aren't really there. So, you know, we know, for example, that sexual abuse victims have a lot of difficulty. They, they often will not disclose. Munchausen by proxy victims are even more likely to not disclose. I had one case, the little girl was 7, and her mother was convicted five years after she was removed. She could not even think or say anything about her mother until she actually heard on the news that her mother was convicted. And then she finally could begin to say, you know, my mother did that to me. My mother did hurt me. So once these children are in a safe place, and, you know, part of this depends on their ages, but they often then begin to show some signs of behavioral difficulties. So the other problem is, particularly in a divorce situation, this child custody changes from mother to father. And all of a sudden, you know, three or four or five months later, father has a child who's got some attachment difficulties, is maybe some oppositionality, maybe is lying, maybe having some other issues. I do have one young man who I've followed. He was severely abused. I saw him at 7, I saw him at 12 and actually did some testing. He went to live with a paternal aunt and uncle, and he was very wary, you know, was superficially happy and, but. But you couldn't get under the surface. And when I tested him, he had some psychotic process going on that was traumatically related. And by the time he was 16 or 17, his paternal uncle and family had. It was a failed adoption. Now, I don't know what kind of issues this young man would have had otherwise, but a great deal. And he had a very sadistic mom. So one of the things that we've actually recommended is that these children have some follow up before they're 12 or 13, and that someone really worked with them during early adolescence to help them understand what happened to them. Because this not understanding what happened to you leave you with, with all of these struggles about what's real, what's not real, how, what do I need to do to get attention. Oftentimes these children are really seeking a lot of attention. They got attention for the wrong things from their biological parents, but they think that's the way they need to be. And so oftentimes they can. If they go to live with a relative or even go into foster care, they really struggle with building relationships. And we see this through adulthood too, that along a number of the survivors are just. They're very cautious about building long term relationships. You know, we saw a lot of kids with PTSD and a lot of kids with identity problems. The children who really were subjected to this form of abuse for a long time also did sometimes end up fabricating, exaggerating and inducing their own illness. And then those are the kids that we saw as adults that are crippled and die in their 20s. So yeah, and then there are people who have really struggled and been able to lead good lives and develop strong relationships. But I think it's something that you always overcome to think that you had a parent that really saw you as who you weren't. They're basic, basic issues around identification and also having some control. I've had a number of young adult Dixon say to me, I had to learn to take control of my own life because someone controlled everything that I did for so long. I have no identity because it was Just what someone else put on me.

[Andrea Dunlop]

Yeah. I mean, it really seems to me that one of the, you know, even if someone, Even if a parent isn't engaging in things that are as physically dangerous or as life threatening or surgeries and that kind of thing, that just this, like, you're really robbing a child of their opportunity to come of age. Right. Because they're not having normal childhood experiences. They're not learning to take care of themselves, which is what you're, you know, it's like your whole job as a parent is to prepare someone to go and live in the world, and then they're just like, really, in the deepest, most persistent way, not getting the opportunity to do those things.

[Dr. Kathy Ayoub]

Exactly. Yeah.

[Andrea Dunlop]

I'm hoping you can give us a little bit of hope or some direction in this arena that, you know, given that, I mean, unfortunately, as we both know, the likelihood of a victim being separated from their perpetrator in any meaningful way is low. It's low. Even if they are in the best case scenario where they have a father who is protective. Right. Even then, it's a huge challenge, as we know from cases like Ryan Crawford's and George Honeycutts and, you know, many of the other dads we've talked to on the show. So given the fact that many of many survivors of this abuse are going to end up only confronting it in adulthood, in their 20s, in their 30s, whenever it is that they sort of are able to have that revelation, what are some things that survivors can look to and what can we all do to make. Make this better, make this world better for survivors, essentially? I mean, what are some of the keys here to fixing this?

[Dr. Kathy Ayoub]

One of the things, at least that I've heard from survivors is the first thing is they need to understand what happened to them. So oftentimes, survivors take a journey, they go back and they talk to the doctor that saw them. I think of Mary Burke, who was one of the first survivors who came forward, and she tells a beautiful story about how she went back to the doctor who treated her and said, I want to see my medical records. You know, I need to tell you, Doctor, what happened to me. You know, my mother actually pulled a hammer out of her bedside table at the same time every day and pounded on my joints. And that's why they were the way they were. So in whatever way, that's certainly not the only way, but there are a number of ways. Some people, like Julie Gregory, write a beautiful book. Some people really decide they need to tell their stories in other ways. And they need to work with other adults who are victimized. I think there are probably many, many ways of doing this, but one is connecting and understanding what really happened because that really breaks through the whole traumatic consequence of building around, building relationships and around really being able to set your life on a pattern where you really firm your own identity. This is what happened to me. This is what occurred to me, and here's how I'm going to work through it and beyond it. So at least we believe fairly strongly that this needed to happen and that if children are out of an abusive situation, that this is something that they really might want to be offered the opportunity to do in adolescence, to really, here's what happened. Do you want to see your medical records? One of the things that I've really advocated for is if victims want to see their own records, I'll say I'd be glad to sit down and go through them with you. Let's figure out what they say. Some people may not want to do that. And then the second step is really understanding who is safe and who isn't safe. And it's very, very hard for adult victims. Their mothers are often very persistent about seeing them, connecting with them, being with them, and that is a lot of energy. And again, they have to decide what they want to do, how much contact they want to have. Many of the victims, again, I go back to Judy Lebo's study 20 years ago where she asked victims, well, what happens when you go see your mother? And most of them said, well, when I go there, she still tries to make me sick. So when we say this is a persistent disorder of the perpetrators, it is so to also help victims understand and come to some peace with the notion that this is who this important parent is. I mean, we usually only have one mother. And this is really problematic. The other thing that's really helpful for victims is to have people on their side, other family, other friends. But family, family is absolutely critical. We saw about 43% of the children in this study go into foster care and their long term outcomes. About 24% of them went to grandparents, and I believe something like 17% of them went to fathers. I hope there are more children going to fathers, but it's very hard because these women assault the families in which these children are living, even as they move on to be adults. And we've had some fathers who have essentially given the children. I have two who gave the child back to mom. He said, I just can't deal with this anymore. She is after me every day. You know, she's destroying my relationships at work. She's trying to get me fired. She's, you know, she's wanting this child, she's accusing me, she's filing, you know, child abuse reports, et cetera. So whoever the caregiver is of the child after they're out of the situation needs support and so does the child. The adult victims that have struggled the most have been those without family. And we had 43% of the children that we saw in this study that remained in temporary placements. So not having a permanent placement with people who care and love you is critical. And they were in long term limbo. And I think that just did irreparable damage.

[Andrea Dunlop]

Such a strong sort of splitting that the perpetrators do that. Like if you are that person who has, quote, taken their child. I think something that I've come to understand about perpetrators of this abuse is, listen, if someone will do this to their child, there are not limits on this person's behavior. And they are going to, you know, take everyone down with them. Like, they will keep fighting. I mean, I just. You see this all the time, right? They will bankrupt whatever family members are supporting them in court. They will. I mean, they will just sort of. I remember when I was talking to one of one of the dads who presented with us at the appsat conference conference, and he made a great. Brian is his name. And he made a great. I wish I could remember it word for word, but he made a great analogy where he's sort of like, you know, what people don't understand about dealing with someone like this is you're like, it's not like there's someone in your house and you need them to leave. It's like there's someone in your house and they're threatening to burn it down with you in it and then blame you when the police get there. Like, it's just this sort of like scorched earth thing that is very pervasive in these cases.

[Dr. Kathy Ayoub]

Yes, absolutely. And it's, it's really so destructive. So again, I think that for these children as they grow, you know, they need protection from that and it's very hard to deliver that if you're the adult caregiver for them and you're having to, you know, to try to protect them from all these assaults, so to speak, the more protection they can get, I think, you know, and really being able to be seen as well, you know, identified if they do have an illness, you know, for the real extent of that illness. And then. But again, mostly it's it's having family. And I think families need to be supported by the system. What I mean by that is in the situations where we saw successful reunification, and I have to say I was very skeptical, and I think that's the reason that the court kept me involved to provide oversight in these few cases for eight years. Because it was like, these kids can't go home unless this is a safe place and a healthy place. But in those situations, I really. The whole system came together to support this family. There were paternal grandparents who took the children. There was a father in each of the cases. These were two parent families, but the fathers kind of were like, oh, my gosh, I can't stay with you unless you get treatment. And I do need to protect my children, although that was hard for them. A lot of the fathers have what I call they have on blinders. The Mack truck is coming down the road, and they're standing in the middle of it, and they don't see it. So helping the father see what's going on is also a critical part of treatment, because they then have the tools to be able to then protect the child. But extended families, also critical, and oftentimes extended family is split, which is another real problem, and then having good caregivers. And I think these cases need to stay in the courts. That's the only way we had successful treatment. And I've had other cases that I've asked to stay in the juvenile court system because the mothers were so dangerous.

[Andrea Dunlop]

So you mean when you say stay.

[Dr. Kathy Ayoub]

In the court, I mean have an open court case.

[Andrea Dunlop]

Okay.

[Dr. Kathy Ayoub]

I mean, I know, but the young man that I mentioned at 17, who actually was in. In residential treatment because of his psychiatric problems, he had a guardian adolitem appointed by the court. And the juvenile court judge kept the case open so that he could make sure that this young man was fine 10 years after he was. Was abused and removed from his mother.

[Andrea Dunlop]

Wow.

[Dr. Kathy Ayoub]

And that guardian ad litem worked with him for 10 years, and he is now living outside of an, you know, a psychiatric institution. He's doing fairly well. He has a good job, and he still sees his guardian ad litem. He's now 27 or 28, but he literally. At 18, his mother was on the. And I'm talking very literally was on the doorstep. I'm here to see you. I love you. And thank goodness there was a restraining order, and he agreed to continue to have his guardian ad litem actually appointed to help him with guardianship through 21.

[Dr. Bex]

Wow.

[Dr. Kathy Ayoub]

So, I mean, that may Be an extreme, but we have to, as a society come and provide these supports for. And in other cases, it's been critical in divorce court for these fathers to have the ability to go back to court and say, she's doing it again. You know, I need some help.

[Andrea Dunlop]

Yeah, I think there's a real strong theme. There's a really strong theme in what you're saying here. And I've wrestled with, not in terms of family members so much, but in terms of survivors especially, is sort of like the importance of before you can do anything to help anyone, you have to see the truth. You have to really acknowledge what has happened here. Because there's so much denial in these cases. And I mean, I think certainly in like splitting the families, it's like you can't, you know, you can't protect a child if you're not acknowledging the fact that they're being abused in the first place. Like that is, then you are enabling the abuse, and that is what you are doing. I think with survivors, it's an interesting question for me because, like one, one I've thought of in particular, just as specific, just as a specific example, we covered in season three, the Kowalski case, which I'm continuing to follow up on. And you know that Survivor and I, I feel very strongly that she is a survivor of Munchausen by proxy abuse, although she does not currently acknowledge that, probably for a lot of obvious reasons. Reasons there's a pending case against the hospital, et cetera. But I've wondered just personally, for my own self with regards to Maya Kowalski or someone who's in that situation where she is 18 now. Her mother died, sadly by suicide in 2017. So her mom has been gone for a long time. And one of the reasons I felt a little bit conflicted, not enough to not cover it, because this is an extremely important case to many other people and for sort of outcomes overall for child abuse, I think. But, you know, is that I sort of wonder, like, with someone like Maya Kowalski, is it better for her to live the rest of her life and just believe that her mom was who she believed her to be and believe that her mom didn't do this and believe that her mom was a loving mom, or will she not be able to sort of move forward with her life if she doesn't know the truth? And I don't have an answer to that. But, I mean, I think it's a really interesting question because, of course, this is a horrible truth to have to confront.

[Dr. Kathy Ayoub]

Exactly. And I think that's a really Good question. You know, I think, I believe because of what I understand about trauma and what I've studied about trauma is that when you hold less than truths, it's very difficult to then take a look at the kind of dysfunctional ways you have adapted to everyday life. You can, you have to really acknowledge, this is who I am, this is why I feel this way. And my guess is that they're critical periods in our lives and you know, they vary for a lot of us, but some of them are, you know, when, when we decide to build a relationship with another adult, you know, when we have children, there, there are some critical periods where you really see people fall apart, they're coming in a new situation, they're transitioning, and all that old stuff just comes forward, it doesn't go away. And so again, at least it's my understanding that it's really going to be hard to lead a full life and to, in particular to build full relationships that are lasting if there's not some understanding.

[Dr. Bex]

Yeah.

[Dr. Kathy Ayoub]

Of what you've been through. I mean, for each of us around our own childhoods, you know, traumatic or not.

[Andrea Dunlop]

Right. That, I mean that, that so resonates with me and sort of understanding why you react to things that you do. And certainly in a much, you know, I'm not, not a childhood trauma survivor, but I, you know, the impetus for me getting into this work was having my first child because as you said, that tends to shake a lot of stuff loose. And for me, that was. I, yeah, I, you know, I suddenly found myself just overcome with sort of processing it in this new way what had happened in my family and really confronting some of the ways that that had burrowed itself itself in me that I did not previously recognize and sort of thought like, you know what? I'm doing pretty great, I'm doing all right, you know, and then it just kind of takes you down. And so I assume, and I'd imagine, especially if that's childhood trauma, which obviously sort of implants itself even deeper and then you can have all those levels of disassociation with it, that, that, that could just sort of be this monster under the bed for your whole life unless you sort of drag it out into the light.

[Dr. Kathy Ayoub]

And for some people, they can't bring it out into the light. It stays under the bed and it really changes some of the ways that they probably could build. In particular, it's about building long term relationships and attachments. And then you think of having your own children, some of the most important people out there for Us to be attached to and care for and support to be adults. And so I. I would have trouble thinking that she's going to have a very good life. I mean, my concern is that the same way with some of, again, the other victims, about 10% of the children in our study, and the number was so low because these were all cases involved in the court already, the children went back to their mothers without any oversight or treatment, and those are the children who did the worst.

[Andrea Dunlop]

Yeah, that's almost extraordinary. Well, not to me, but I think, you know, you sort of think, like, oh, how could someone have ended up back with their mother if it went all the way through the courts? And like you said, this study was very specific to families. And what I've come to understand is the least likely outcome. Right. Where there is, like, actually a decision against the mother. I mean, certainly from looking at the cases I've looked at, talking to adult survivors, most of them have more of this pattern of like, yeah, my mom was getting, you know, she was getting reported all the time. CPS was there all the time, or like this, that and the other thing happened, or this family member suspected and they got cut out. But it's like most of them were raised by their abuser. Right? Like, most. Most of the time, I think that's most survivors we're gonna talk to are not going to be placed elsewhere permanently. And then, as you said, when there is another placement, there's all kinds of other things that can come up there. So it's a difficult situation.

[Dr. Kathy Ayoub]

Exactly. This is, I think, so important. I just did, actually, several months ago, a piece at Boston Children's Hospital, where I now work with the child protection team, because they kind of wanted to say, what do we do when we get past the diagnosis? And I wanted to talk about setting up visitation and, you know, and access immediately, because if the child's in the hospital, that all gets negotiated with child protection while the child's in the hospital. And it's really important, you know, so part of the question for me, even with those children when they're diagnosed, is how much access are they going to continue to have and how is this going to be managed? And I, you know, having worked in the child abuse field for a long time, I never thought I would hear myself say parental rights need to be terminated. I mean, I saw lots of battered child syndrome cases, both juvenile and sometimes in criminal court. And, you know, there clearly are times when parents should not be parenting their children. But in these cases, I don't know what the Other alternative is if these perpetrators are not able to modify their behavior. And even those who were the most willing to be in treatment needed to have the court fence surround them, safeguards in order to follow through, particularly initially. Even though they made confessions, they never were full confessions at first. It took some time to hear more.

[Andrea Dunlop]

Well, and presumably, I mean, from what I understand, this is such a deeply compulsive behavior that even if someone really, even if in those cases where a parent is trying their best and fighting the good fight, they're still going to be fighting those compulsions. So they need a lot of help and support to be their best as a parent. I mean, I think we could say that probably across the board that all parents need help and support to be their best parents, but especially if you're. Yeah, especially if you really are struggling with, you know, your own sort of maladaptive tendencies. So, Kathy, I honestly could talk to you all day. I hope maybe you will come back on and talk about some of these cases with us, like the Jennifer Bush or I don't know if you're able to talk about the Justina Pelletier case that obviously happened in your backyard. But I want to be mindful of your time. So just one kind of final question, because this came up in a couple of your peers that I was reading. Do you think that Munchausen by proxy is extremely rare?

[Dr. Kathy Ayoub]

No. No, I don't.

[Andrea Dunlop]

I saw that you had referred to, and it's so funny because I feel like this is one of these sort of franken pieces of data that has made its way into people who are wishing to cast this as rare. And I think, you know, as we see this, some of these narratives playing out in Mike Hickson Bogg's work in sort of Take Care of Maya film and some of the press around, that there's this argument that's made in court, in the media, what have you, where Munchausen by proxy is so extraordinarily rare that if a child abuse pediatrician has had more than one case of it, then in their lifetime, then that is proof that that child abuse pediatrician is overzealous and they're making it up and they're looking for cases, et cetera, or if that some, you know, a place like Tarrant county that has this higher rate of conviction. Oh, there must be, you know, that must be because they are seeing something that's not there because we have this piece of data that it is so rare. And what it is, I finally realized, and Dr. Feldman had made A reference to this. And I sort of was like, oh my gosh, this is the smoking gun of the bad piece of data, which is this British study that was on 600 cases of suffocation and non accident accidental pointing only. And that there was.

[Dr. Kathy Ayoub]

Yeah, suffocation.

[Andrea Dunlop]

Right. And so that is this tiny percentage. And so that then has been applied to like, oh, this is the instance of Munchausen by proxy overall. So you looked at this very small, at this point, pretty old study that was just about these two specific, most severe, most, you know, life threatening and sort of expanded into this. Oh, it's this point, you know, you see, I see this statistic floating around of this 2.8 out of a thousand or what have you. And so can we just like debunk that statistic that people use kind of once and for all here?

[Dr. Kathy Ayoub]

Yeah, although I'll tell you, I've used that statistic to say, look, in our study, I believe it was something like 10%. It's less than that. 10% of the cases were suffocation cases and 5% were poisoning. So if those are the numbers you just got from suffocation and poisoning, you're only explaining 15% of Munchausen by proxy, if you want to think about it, by disorder. And so we know we must have a lot more out there.

[Andrea Dunlop]

Right.

[Dr. Kathy Ayoub]

Because this only accounts, I mean, it's misinterpretation of that study that I think we actually could use to further the cause.

[Andrea Dunlop]

Thank you. Yeah. So it's not that it's a bad study that needs to be debunked necessarily. It is that it is being used. It is being, I think, deliberately misinterpreted. Yeah, misused. Yeah, exactly.

[Dr. Kathy Ayoub]

It's been. And we really don't know. Yeah, I mean, that's the other thing. Even in our study, it's a small sample. So maybe I've got an overrepresentation of kids with GI problems or kids with apnea. We did, by the way, do a study just on life threatening events that I'd love to come back and talk about because it was really sobering.

[Andrea Dunlop]

I would love you to come back and talk about that as well. I'm making my little list to myself of things to have got you back on the talk. You mentioned GI issues. And I mean those are so common in these cases. And there was that study at Seattle Children's that a couple of our colleagues were involved with that looked at cases within that and I mean the prevalence pointed to much higher than what most people I think would Think so. I think there's all kinds of reasons, both data and anecdotal, to think this is way more common than most people believe.

[Dr. Kathy Ayoub]

I'm just absolutely convinced. And again, one of the other things that I'm trying to put this under this umbrella of disorders of deception, and when you kind of step back, for women, we see them impostering as nurturers. And for men, they often are either really con artists who are impostering, you know, really to meet their own needs, to get material goods and services. There's another group of people who are really. And they tend to be men rather than women, who imposter as doctors or lawyers or, you know, judges. And those. I've evaluated a couple of those folks. They're very interesting. Again, when you kind of look at the larger group of people who imposter, you kind of think about. And then you have the con artists, you know, who really are antisocial, which is what. There's a subgroup of these women who are really, really don't have conscience. I mean.

[Andrea Dunlop]

Right.

[Dr. Kathy Ayoub]

They're really out for themselves, and it's in a really powerful way. Then there are people in between.

[Andrea Dunlop]

Well, I would really love to have you back on, because I think, you know, what you're saying about sort of like the con artist thing. It's like I look at some of the spouses actually, like your Lou Pelletiers and your Jack Kowalski. Is that, like, when you dig into their history, I'm like, oh, then you get both. You get one of them each, and you get them in a couple.

[Dr. Kathy Ayoub]

Yes.

[Andrea Dunlop]

All right. Well, if you'll permit, we would love to have you back on, because these are all things I would really like to dive into.

[Dr. Kathy Ayoub]

One of my commitments is really to do whatever I can at this point in time to. To help people understand and to share what I know, what I don't know, you know, kind of what I think, and use it as you will. But thank you for asking me, Andrea.

[Andrea Dunlop]

Oh, my goodness. Well, thank you. Thank you for. Thank you for doing it with me. I really appreciate it. I think I just. I learned a whole bunch of new things, and Now I have 8 million more questions for you, which is why this whole thing has turned into a podcast, because there's so many layers to it you could never believe. Yeah.

[Dr. Kathy Ayoub]

I'm just so glad you're doing it, I can't tell you. It's. It's really just. It's so critical, and I don't know how you. You know, you can make a half an hour video. I mean, and that's, that's really important too. But I think this is something ongoing where you continue to tell the story. It's just, it's so important.

[Andrea Dunlop]

Yeah. Well, thank you so much, Kathy. I appreciate that. Nobody should believe me. Case Files is produced and hosted by me, Andrea Dunlop. Our editor is Greta Stromquist, and our senior producer is Mariah Gossett. Administrative support from Nola Carmouche Foreign if.

[Dr. Bex]

You'Ve been listening to this show for a while, you know that I have very strong feelings about what is and is not responsible true crime content. Maybe you've heard me make some pointed comments about the producers of a certain film. Or perhaps you've heard one of my dozen or so rants about a certain journalist whose name rhymes with Schmeik Schmixenbach. And if you've been with me for a while, you'll also know that getting Nobody Should Believe Me on the air was quite the rollercoaster. Podcasting is just the Wild west, y'all, and these experiences are what led me to launch my new network, True Story Media, where we are all about uplifting true crime creators doing the work and making thoughtful survivor centric shows. And I could not be more thrilled to announce our very first creator Partner. You probably think this story's about you the first season of this enthralling show from Breakout creator Brittany Ard took podcasting by storm in 2024, zooming to the number one spot in the charts on Apple and Spotify as Brittany revealed the captivating story of a romantic deception that upended her life and traced the roots of her own complex, complicated personal history that led her there. Brittany is back in 2025 with brand new episodes, this time helping others tell their own stories of betrayal, heartache and resilience. If you love, nobody should believe me. I think you will also love. You probably think this story's about you for its themes of deception, complex family intrigue, and its raw, vulnerable storytelling. You can binge the full first season and listen to brand new episodes each week by following the show on Spotify, Apple, or wherever you get your podcasts. You can also find it at the link in our show notes.