Dr. Cathy Ayoub
Appearances
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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. So I hope that's given you a few characteristics that are really different, but you can see that it's not something that you might know
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Yes, exactly. And it's what a lot of times we talk about it 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,
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
that there are at least three or more different pretty clear groups of women 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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 were criminal courts. Most often it was juvenile court or family court.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And so we tried to understand what the mothers really looked like. I've got lots of different information. 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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. He found three distinct groups. So one of the ways to think about these moms is how do they act with their children?
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 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
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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. 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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, of 45 families, we had a 17% mortality rate. That is so high 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
In 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 seven in 1990, and now it's gone way down because we know how to treat these children.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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, I haven't gotten off the topic there.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
They had a variety of different kinds of problems, GI disorders, asthma. myocondrial disorders, 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
We tried to craft a term back in 2002. And I think it was too complicated, but it was child abuse by illness falsification. 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, the term medical child abuse is
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
is a great one for pediatricians, but it doesn't differentiate the dyadic nature of Munchausen by proxy, which 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Anyway, lots of Ds here. We also talk about Munchausen by proxy as being one of a number of disorders of deception. And 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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 and work in working with children and their families.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 happened 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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, her four-year-old was getting ready to have surgery to have part of his pancreas removed. because he kept having excessive insulin production.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And no one could figure this out in their hometown, so they came to Boston for evaluation. And he had these hypoglycemic low blood sugar episodes, 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Then there was a third episode. And he finally said, this has gotta 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And he went in and faced 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. 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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,
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
but are women who are almost compulsive about doing this. They 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
It's like kids are here.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And then the third piece is that I believe that there is often a trigger. for these perpetrators. Some of them really had triggers in adolescence and began with some issues in adolescence, but they're offering often some triggers or some trigger that really pushes them into this. Now, there are two other groups.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 Schreier, says, they are impostering as nurturing parents.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Yes, absolutely. And that you've got it, that those tend to be the people who oftentimes have factitious disorder as well as they're involved in factitious disorder, you know, 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, you know, distorting situations.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
how about if you start one along with the other things you're doing? Cause I think we probably see four or five cases a year. And I said, well, okay, let me see what I can find out. And I had the tremendous, um, luck in working with a couple of great pediatricians who had trained with Dr. Henry Kemp in Colorado. And, but, uh,
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
In other words, they had long-term dysfunctional ways of being and of acting that they had really kind of supported for a number of years. Again, on the extreme 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
But, you know, I'm going to put Ipecac, which makes you vomit in your applesauce and you're not going to know what's there kind of thing.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Let me start with the current information because I'd love to talk about fathers. We evaluated mothers and fathers 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?
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 often times were additional maternal family members in particular that were also supporting the perpetrator. mom.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
In some cases, there were other maternal family members who were really, really trying to get into the system, grandparents, aunts and uncles, and they couldn't kind of break this couple because dad really supported mom. That was really quite typical. Those father's totally stayed out of the healthcare for their kids. That's mom's job.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
There's another 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 who've probably done more work in family court than a lot of other folks.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 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...
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
trying to remember the little boy's name was, I probably even have it here, Christopher Bowen.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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. But that was such an interesting case.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And 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 surprisingly,
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
It's 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. A guardian ad litem is really looking at the best interest of the child.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 work 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 a hundred cases in family court, maybe more. And, you know, some of them have turned out not to be Munchausen.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 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 Be Yorker is running are absolutely critical. These partners feel so lost and so alone.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 their rights have been terminated, they're on the doorstep on that child's birthday.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
I'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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And these women are just relentless and 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 protection for these children, adolescents, and even young adults, they get pulled right back into the same kinds of behavior patterns.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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, you know, when they're in this situation,
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And most of that, all of the pediatricians and the nurses were 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.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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've happened to you? And she talked to folks.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 we know, for example, that sexual abuse victims have a lot of difficulty. They often will not disclose. Munchausen by proxy victims are even more likely to not disclose.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
I had one case. The little girl was seven. 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,
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
maybe some oppositionality, maybe is lying, maybe having some other issues. I do have one young man in who I've followed. He was severely abused. I saw him at seven. 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, was superficially happy, but you couldn't get under the surface.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 work with them during early adolescence to help them understand what happened to them. Because this not understanding what happened to you leave you with all of these struggles about what's real, what's not real, what do I need to do to get attention?
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 gonna work with child protection.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And we see this through adulthood too, that a number of the survivors are just, they're very cautious about building long-term relationships. We saw a lot of kids with PTSD and a lot of kids with identity problems, the children who really were were subjected to this form of abuse for a long time, also did sometimes end up fabricating, exaggerating and inducing their own illness.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And then those are the kids that we saw as adults that are crippled and die in their twenties. 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. There are
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Basics, basic issues around identification and also having some control. I've had a number of young adult victims 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.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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.
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Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And she tells a beautiful story about how she went back to the doctor who treated her and said, you know, 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
So in whatever way, that's certainly not the only way. But there are a number of ways, you know, 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 were victimized. I think there are probably many, many ways of doing this.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
I'm gonna work with referring it and she's very sorry and you're not gonna touch this case. And I was really curious. And I think my curiosity led me to then after I moved to Boston and went back to school, In my clinical work, both as a pre-doctoral and post-doctoral, I was really interested in working through the courts and with child protection agencies and hospitals around child abuse neglect.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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?
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
adult victims, their mothers are often very persistent about seeing them, connecting with them, being with them. And that is a lot of energy. Um, and again, they have to decide what they want to do, how much contact they want to have, um, Many of the victims, again, I go back to Judy Lebow's study 20 years ago, where she asked victims, well, what happens when you go see your mother?
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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, you know, 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
The other thing that's really helpful for victims is to have people on their side, other family, other friends. But 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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. She said, I just can't deal with this anymore. She is after me every day.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
She's destroying my relationships at work. She's trying to get me fired. She's wanting this child. She's accusing me. She's 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And I was always curious about this, by then this Munchausen by proxy.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Yes, absolutely. And it's really so destructive. So again, I think that for these children as they grow, 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 try to protect them from all these assaults, so to speak.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
The more protection they can get, I think, and really being able to be seen as well, identified if they do have an illness for the real extent of that illness, And then, but again, mostly 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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. And 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
You know, 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 family is also critical. And oftentimes extended family is split, which is another real problem.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
I mean, the young man that I mentioned at 17, who actually was in residential treatment because of his psychiatric problems, he had a guardian ad litem 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 abused and removed from his mother. And that guardian ad litem worked with him for 10 years.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And he is now living outside of 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And he agreed to continue to have his guardian ad litem actually appointed to help him with guardianship through 21. Wow. 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 have to really acknowledge this is who I am. This is why I feel this way.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And my guess is that there are critical periods in our lives. And they vary for a lot of us, but some of them are. When we decide to build a relationship with another adult, when we have children, 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And so, again, at least it's my understanding that it's really going to be hard to lead a full life. And in particular, to build full relationships that are lasting, if there's not some understanding of life. of what you've been through for each of us around our own childhoods, you know, traumatic or not.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And for some people, they they can't bring it out into the light. It stays under the bed and it really changes everything. you know, some of the ways that they probably could, you know, build, in particular, it's about building long-term relationships and attachments.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And then, you know, then you think of having your own children, you know, some of the most important people out there for us to be attached to and care for and
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And support to be adults. And so 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 support. oversight or treatment.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And those are the children who did the worst.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Exactly. It, You know, it's this is, I think, so important that I just did 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
visitation and access immediately because if the child's in the hospital, that all gets negotiated with child protection where the child's in the hospital and it's really important. 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?
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And, 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Although I'll tell you, I've used that statistic to say, look, in our study, I believe it was something like 10% less than that. 10% of the cases were suffocation cases and 5% were poisoning cases. So if those are the numbers you just got from suffocation and poisoning, you're only explaining 15% of Munchausen by proxy, if you wanna think about it by disorder.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
And so we know we must have a lot more out there. Because this only accounts, I mean, it's misinterpretation of that study that I think we actually could use to further the cause.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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 over-representation 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
I, 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, you know, impostering as nurturers and, and, For men, they often are either really con artists who are impostering really to meet their own needs to get material goods and services.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
I'm gonna see her, I'm gonna see this baby, I'm sure this isn't gonna happen again. And he made a lot of assertions and was incredibly protective around the whole reporting system.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 judges. And those, I've evaluated a couple of those folks. They're very interesting.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 who really are antisocial, which is what there's a subgroup of these women who are really, really don't have conscience. I mean, they're really out for themselves in a really powerful way.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
One of my commitments is really to do whatever I can at this point in time 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
I'm just so glad you're doing it. I can't tell you. 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
You should understand these medical things. And you're a psychologist, so you should understand the mental health issues. Here's this really unusual case. At the Boston Juvenile Court Clinic, this was a court clinic that sits within the juvenile courthouse. And judges would refer to us directly around any kind of juvenile cases, but in particular cases I was really interested in young children.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 in hospitals.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
Daily Munchausen by proxy cases in particular, yes.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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. And what year was that? That was in the 1960s, because by the time we got to the 1970s, all 50 states had passed child protection laws.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 today.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy 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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 much husband by proxy is that there's always what I call a yes, but. It's like there's a procedure, the child has a procedure.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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 doctor shopping, not to try to find a way to have the child get better, but to have somebody validate that the child is ill.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
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, you know, I can spend much more time.
Nobody Should Believe Me
Case Files 10: The Psychology of Perpetrators with Dr. Cathy Ayoub
I may have a colleague sit behind me to watch me be taken in oftentimes because these are very, very convincing people. Now, 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. You know, I know more about this disease than the doctor. And that's also kind of another sign.