Sitting and squirming on the witness stand, the little girl clutched a stuffed frog as a Tarrant County prosecutor coaxed her back in time.
Back when she still lived with “Mama Brittany.” Back when she had a tube in her tummy. Back when she visited doctors all the time.
“Were you sick?” prosecutor Dawn Ferguson asked the girl, now 7.
“No, I don’t think I was sick. I don’t really know,” said the little girl, dressed in polka dots.
“If you don’t think you were sick, why did your mommy take you to the doctors?” Ferguson asked.
“I think she liked to,” the girl replied.
Her mother, Brittany Phillips, stood accused of injuring her child through medical child abuse, better known as Munchausen syndrome by proxy, and hers was the first such case in Tarrant County to go to trial.
Prosecutors say Phillips, 31, liked the attention she received from having a sick child so much that she lied about her daughter’s medical history and symptoms, withheld food from the girl and ultimately put feces into her IV line or feeding tube.
The case not only illustrates the bizarre nature of Munchausen syndrome by proxy, but also demonstrates the lengths that Tarrant County will go to treat the accused caregiver as a criminal, as opposed to someone who is claiming to be an overprotective parent or to suffer from a mental illness.
“Except maybe in Tarrant County, these cases are rarely prosecuted criminally, even when they’re identified,” said Dr. Marc Feldman, an Alabama psychiatrist who is a national expert and author on the topic. “They tend to get handled in family court. The mother will have a termination of parental rights and that’s as far as it goes.”
Behind the efforts of Tarrant County investigator Michael Weber and others, from social workers to pediatricians, more caregivers — mostly mothers — are getting caught and punished for the pain they inflicted upon their children.
Tarrant County prosecutors have filed criminal charges in six cases since 2009.
In comparison, Harris County, the state’s largest, has prosecuted one case in the past three years. Though a San Antonio mother was prosecuted federally in 1999, long-time prosecutors in the child abuse division of the Bexar County district attorney’s office can’t recall a single such case.
Weber calls such abusers “grifters” and “con men and women” who know that their child is not really sick.
“Attention is a huge motivating factor,” Weber said. “They want the attention that comes with being the parent of a sick child. They want to be reinforced of what good parents they are and they basically use the child as a means to an end.”
Such children are left with physical and emotional scars. They can suffer developmental delays and miss great amounts of school and are sometimes put at risk of death.
“We’ve had children come in who really thought they were dying and their siblings thought they were dying because that’s what the mom presented them as,” said Dr. Jamye Coffman, medical director at the Center for Prevention of Child Maltreatment at Cook Children’s Medical Center.
“I can’t even imagine the emotional abuse that those children and their siblings and family members have suffered from in thinking that they were sick, thinking they needed these hospitalizations.”
Weber said, “While they may not be trying to kill the child, they are not doctors and they make mistakes.”
Weber was a new investigator with the Tarrant County district attorney’s crimes against children unit when he got his first medical child abuse case in 2008.
“I didn’t know what I was doing,” Weber readily admits today. “I was really flying blind.”
He scoured the Internet for information on Munchausen’s syndrome by proxy. He picked the brains of experts and a Houston prosecutor who had tried such a case.
Although the Tarrant County case was ultimately referred to another state because of jurisdictional issues, the few months he spent learning about the syndrome led Weber to pay a visit to Alana Minton, then supervisor of the crimes against children unit.
“I went to her after that and told her if we get any more of these, why don’t you give them to me because there’s no way detectives with 30 cases on their caseload are going to be able to do this amount of work,” Weber said. “She’s like, ‘Mike, that’s fine, but we haven’t had another one in the eight years I’ve been here.’ ”
Two months later, a second case came in.
Six years later, Weber has investigated 16 such cases.
Research on medical child abuse is limited. Studies estimate the number of new cases per year in the United States to be anywhere from 200 to 1,200.
Feldman, the psychiatrist, suspects that far more cases go undetected.
“We identify the ones that are really florid, where there’s actual induction of illness into a child. The child is injected with bacteria or suffocated to induce arrest,” Feldman said. “We don't identify the case where there’s just false reporting or exaggerating false symptoms. Those milder forms, I think, occur much more frequently.”
Because such reports are relatively rare, most law enforcement and social service agencies receive little or no training in investigating and identifying medical child abuse.
“CPS, in particular, they seem not to know enough about medical child abuse,” Feldman said. “They may know that the investigations are extraordinarily time-consuming and the records they have to accumulate may fill many banker boxes. I think consciously, or unconsciously, they turn a blind eye to what needs to be done.”
In Tarrant County, law enforcement, Child Protective Services and Cook Children’s often work together on investigations because of the complexity and multitude of medical records involved.
CPS investigator Ashley Rader acknowledges that she had received no training in medical child abuse when she was handed her first case a few years ago. She now has five such investigations under her belt and has become the agency’s unofficial go-to investigator for medical child abuse.
Last year, she and Weber taught a half-day class on the subject to CPS and law enforcement investigators.
She said she hopes such training will become routine for CPS investigators statewide.
“When we do get them, you really have to be aware of how to handle the case,” Rader said. “It is very sensitive. You have to take different steps than you would on a normal investigation.”
Coffman is one of two child abuse pediatricians at Cook Children’s who review medical records when medical child abuse suspicions arise in Tarrant County.
“Not in all the records that we review do we say it’s medical child abuse,” Coffman said. “There has to be harm to the child first and then discrepancy to where we think it may warrant a full investigation.”
‘When does it become criminal?’
Phillips’ attorney, Micheal Schneider, applauds Tarrant County for having investigators and doctors who specialize in medical child abuse, but also notes that the special focus brings with it concern.
“It’s like the old saying, if you’re a hammer, everything is a nail. If you’re a detective who specializes in this, you’re going to start seeing it even when it may or may not be there,” Schneider said. “That is a real problem.”
He worries that overly vigilant caregivers could be falsely accused.
“How do we balance the right of a parent to seek different treatments or second opinions or third opinions versus this idea that if you switch doctors, you’re doctor shopping?” Schneider asks.
“There are mothers out there who traditionally we’ve all just kind of snickered at and say, ‘Boy she just overreacts on every little thing.’ Well, when does that become just an overprotective mother and when does it become criminal?”
In the case against his client, he called the state’s “smoking gun” a two-minute website view.
“It’s a little scary that the government can prove up a criminal case based on what you read on the Internet,” Schneider said.
Weber said that before going forward with a case, investigators and the doctors who provided the unnecessary and potentially harmful treatment must agree that medical child abuse was at play.
“It isn’t just CPS, myself and Dr. Coffman,” Weber said. “None of these other doctors are experts in medical child abuse. And none of them are going to be easily influenced to see something that isn’t there.”
And doctors aren’t the only ones filing reports.
In Tarrant County, speech pathologists, school employees, family members and friends have filed reports about suspicions that eventually led to criminal charges.
Bridget Sexton did not know that investigations were already underway when she emailed CPS, using the fake name Sarah Jonesy, about concerns involving her best friend, Cecilia Ransbottom.
Sexton said she decided to alert CPS after visiting Ransbottom in May 2014, shortly after Ransbottom’s 3-year-old daughter underwent surgery for the insertion of a feeding tube.
During that visit of several days, Sexton said, she rarely saw her friend feed her daughter. Even during a trip to McDonald’s, Sexton said, she watched as the little girl sat down with a stranger and began eating his fries after her own parents didn’t buy her food.
The girl “was supposed to be on a strict feeding schedule,” Sexton said. “The only time I actually saw them feed [her] was the one time they cooked like enchiladas, and I was there a week.”
Sexton said Ransbottom called and confronted her a few days after she made the report. Their friendship ended, but Sexton says she has no regrets.
“It’s not really about me. It’s about the kids,” Sexton told the Star-Telegram. “I’ve known these kids since they were babies. For me to turn my head, I would have been just as much at fault as she.”
‘A badge of honor’
In the Tarrant County cases, mothers were accused of exposing their children needlessly to brain surgeries and painful biopsies and other procedures.
In what is true with the majority of medical child abuse cases, all six of the children underwent surgery to be fitted with a feeding tube, also known as a gastronomy tube or G-tube.
“To some degree, a mother getting a G-tube for her child seems to be kind of a badge of honor,” Feldman said. “It convinces everyone else that something must be seriously wrong if the doctor inserted it.”
Coffman said feeding issues can be the easiest to fake to a physician.
“We’re not watching the child eat in our clinic. We’re not watching if they’re having vomiting issues because we only have a limited amount of time,” Coffman said. “So a parent can fabricate these symptoms and then, say, just not feed their child, so they lose weight.
“Because we trust the parent to give us the accurate information, they end up with a procedure.”
And it’s not only young, nonverbal children, experts say. In the Tarrant County cases, victims ranged in age from 1 to 11.
“Medical child abuse can happen at any age in a child’s life and it’s oftentimes sequential,” Coffman said. “It may be one child and then maybe that child gets old enough to where either [the caregivers] can’t do it or they don’t get the same benefits, so they’ll move to the next child.”
Mary Welch’s son was 11 when she was indicted in Tarrant County in December 2014 on accusations that she obtained and gave medications to the boy by misrepresenting his medical history. She was also accused of trying to persuade doctors at Cook Children’s to perform invasive surgery on the boy.
Mike Heiskell, Welch’s defense attorney, said she is simply an overprotective mother and points out that her son was old enough to verbalize issues to doctors in Texas and Minnesota, where the brain surgeries took place.
“He was talking about his aches and pains and the other matters that manifested his illness,” Heiskell said. “It did not come strictly from the mother.”
Coffman said victims of medical child abuse may be brainwashed into believing they’re sick.
“It’s usually been a process that’s been going on their whole lives,” she said. “Many times these children are convinced they’re sick because their moms have always told them they’re sick or whomever the caregiver is that is causing the problem.
“Also, these children are dependent on that parent for attention. Maybe their whole relationship is they have to play the sick child in order to get that attention from their parent.”
‘It’s a type of abuse’
Only two years ago did the American Psychiatric Association officially recognize Munchausen syndrome by proxy as a mental diagnosis, albeit by a new name, factitious disorder imposed on another.
Feldman, for one, opposed its inclusion, saying it allows abusive parents to claim a mental illness when they’re actually committing a crime.
“These women have planned what they’re going to do. It’s willful. It’s deliberate,” Feldman said.
Dr. Mark Blotcky, a Dallas psychiatrist who has dealt with medical child abusers, said that though such abusers may be mentally ill, most are mentally capable “and therefore they should have to answer to the criminal justice system.”
“Most of the people know what they're doing and are doing it on purpose,” Blotcky said. “They may not understand all that goes into why they're doing it but I think because they're so secretively deceitful, that indicates that they realize what they're doing is wrong.”
In Tarrant County, investigators and prosecutors have quit using the term “Munchausen syndrome by proxy” to further distance the crime from being blamed on mental illness.
“You don’t have to have a mental illness to sexually assault a kid, or beat a kid, or shake a baby or any of those,” Ferguson said. “It’s just like that. We don’t know why you do it, but you do it, and it’s a type of abuse just like anything else.”
But getting police to recognize it as abuse — and then seek criminal charges against these caregivers — can be an uphill challenge, said Minton, formerly with the Tarrant County DA’s office.
“Some other jurisdictions that haven’t encountered these types of cases have difficulty comprehending the nature of the crime or even that a crime had been committed,” Minton said.
In her years leading the crimes against children unit, Minton recalls some other agencies declining to take a case after an investigation revealed that the surgeries in question occurred in their jurisdiction.
“Some states outside of Texas may not have laws that allow for prosecution of this type of crime at a level of offense that makes prosecution worthwhile based upon the amount of work involved,” Minton said.
Texas has no laws aimed at medical child abuse, but prosecutors can usually apply the offense of injury to a child.
In Welch’s case in Tarrant County, the charge was dismissed last month after the state filed a motion indicating that prosecution would be more appropriately sought in Ramsey County, Minn., where Welch’s son underwent repeated surgeries.
A spokesman for the Ramsey County attorney’s office said they are in discussions with Tarrant County to determine whether charges will be filed there.
“I don’t think, quite frankly, that Minnesota is going to pick this up and run with it,” said Heiskell, Welch’s attorney. “I think it’s a dead issue. I would be shocked and surprised if they did so.”
Four of the other Tarrant County cases ended in plea deals.
In one, the mother, Hope Ybarra, pleaded guilty to injuring her youngest daughter in exchange for a 10-year prison sentence.
In the three others, the mothers received deferred adjudication probation sentences, ranging from five to 10 years.
Under such a sentence, if the mother completes the terms of her probation, a conviction will not appear on her record. If she cannot, she could be sentenced by the judge to the full range of punishment.
“If the kid has already been removed and placed in a good home, I’m more OK with probation,” Ferguson said. “If the kid is still up in the air and has access to the mother, then probation is going to really hurt. You don’t want the kid to get in more danger.”
Shopping for doctors
Detecting medical child abuse cases can take years.
Doctors are trained to build relationships with their patients and can be reluctant to report suspicions.
“The first step is doubting what the parent is telling you before you can even entertain the notion that this is child abuse going on, and that’s a big leap,” Coffman said.
To avoid suspicion, the abuser often “doctor shops,” crossing city, county or even state lines to seek treatment for the child.
Convincing doctors that a child is sick is not hard, experts say.
“We are dependent on the parent to give us the history of what’s going on with their child, and we count on them to be honest,” Coffman said.
If the history is made up, doctors are led down the wrong path.
“Anything we do in medicine starts with the history, and that is key to our diagnosis and treatment plan,” Coffman said. “So if we get a false history, you’re going to get a false diagnosis.”
In many of the Tarrant County cases, mothers took their children to different doctors, and the same tests and procedures were performed within days of each other at different clinics or hospitals.
But Coffman said different institutions, even hospitals in the same city, can’t share records because of federal privacy laws established in the Health Insurance Portability and Accountability Act.
“I don’t have access to that information, so unless the caregiver chooses to tell us that they’re getting care at another institution, we’re not even going to know that,” Coffman said.
The caregivers who are committing medical child abuse are overwhelmingly mothers, and they sometimes have familiarity with the medical field, working as secretaries in a hospital or as lab techs.
Other times, they glean their medical knowledge from the Internet.
“The Internet is the bane of doctors’ existence. ‘Dr. Google,’ ” Coffman said.
She said that though well-intentioned parents can be led astray with inaccurate medical information online, “it’s also enabled parents who want to do bad things to their children to find all kinds of sources and news events and things where they can see what other people have done and they can replicate it.”
During the hospitalization of Phillips’ daughter, investigators later discovered, Phillips pulled up a news article on her laptop about an Austin woman caught on camera placing feces in her daughter’s IV line.
Phillips also did several suspicious searches on her computer, including one for “poop in feeding tube” two minutes after reading about the Austin case, according to testimony at her trial.
Within 24 to 48 hours of Phillips’ online search, three blood cultures taken from her daughter — at the mother’s insistence — tested positive for a multiple-organism blood infection, including E. coli.
Phillips’ defense attorneys, Schneider and Emily LaChance, suggested to jurors that the blood infection could have resulted from contamination by medical staffers.
“There’s really no direct evidence she did it,” Schneider said in an interview after Phillips’ trial. “There’s a lot of circumstantial evidence.”
Social media networks and blogs also give abusers an avenue for attention by allowing them to post updates on their child’s maladies. Seeking sympathy through online comments has become so prevalent that Feldman referred to it as “Munchausen by Internet.”
In another Tarrant County case, Elisabeth Hunnicutt used the couple’s home computer to post updates on a support group page about her 1-year-old son’s potentially fatal brain diseases.
In truth, court documents say, doctors had already ruled out those diseases after the boy underwent various procedures, including having a hole drilled in his skull and a monitor placed on his brain.
“You have so much more going on though, and you handle it so gracefully. … I really do look up to you!” one woman told Hunnicutt in an exchange later obtained by investigators.
Hunnicutt then joked that margaritas have helped see her through.
“But they are great boys i wouldn’t have it any other way, but we are having no more kids haha,” Hunnicutt responded. “I couldn’t do all this again most days im at the verge of tears. I am positive because I have to be.”
The Fort Worth mother was arrested in 2012, charged with causing bodily injury to a child and eventually sentenced to 10 years’ deferred adjudication probation. This year, she agreed to terminate her parental rights to her two sons.
Tarrant’s first trial case
The Phillips case is the first, and so far only, to make it to trial in Tarrant County.
Over two weeks in August and September, prosecutors Ferguson and Paige McCormick presented evidence of the countless doctor visits and medical procedures Phillips’ daughter was subjected to within the first three years of her life.
In the Cook Children’s system alone, the girl visited the emergency room or urgent care clinics 30 times, saw specialists 23 times, and underwent 17 radiography exams, including MRIs and X-rays.
Doctors testified they they were duped into conducting tests and procedures on the girl after Phillips continually reported that the child struggled to eat and gain weight — even after a feeding tube had been placed.
A Dallas doctor and a speech pathologist who treated the girl testified that they contacted CPS in 2010 over concerns that Phillips might be subjecting the girl to medical child abuse.
Their reports, and those made by two others, were investigated by CPS and initially closed out as “unable to determine.”
The allegation resurfaced again — this time leading to a criminal investigation — after Phillips’ daughter contracted a potentially deadly blood infection while hospitalized at Cook Children’s for dehydration in August 2011.
“Dr. [Peter] Lazarus describes this as highly unusual and a ‘hallmark of Muchausen by Proxy,’ ” Weber wrote in a search warrant affidavit.
Defense attorneys told jurors that the case sent a frightening message that parents could be prosecuted for what they post on Facebook about their kids or for seeking second or third opinions regarding their child’s health.
“Apparently that’s enough to land you in criminal court,” LaChance told jurors. “… We should all be terrified of that.”
After 18 hours of deliberation, the trial ended with a hung jury. A male dentist was the only juror who declined to find Phillips guilty.
On Nov. 13, in lieu of going to trial again, Phillips accepted a plea deal and pleaded guilty to injury to a child with serious bodily injury in exchange for a five-year prison sentence.
On Dec. 2, she pleaded guilty to the same charge in Dallas County for causing her daughter, then 17 months old, to undergo surgery for a feeding tube. She received a five-year prison sentence, which will run concurrently with the Tarrant County sentence.
Ferguson said that while she and investigators were prepared to take the case back to trial, knowing that Phillips would receive at least a minimum prison sentence won out.
“You could have gone again and gotten 12 jurors that are better,” Ferguson said. “You could get 12 jurors that are worse and question it even more. She still would have been probation-eligible if she would have gone through a trial. So they could have convicted her and then felt sorry for her and thought she was crazy and felt pity for her.”
Phillips, who terminated her parental rights before the trial, declined a jail interview.
Schneider said that he and his client also had mixed feelings about taking the plea agreement.
“Up until the time she stood before the judge and actually said ‘Guilty,’ she still professed her innocence,” Schneider said. “I just think the pressure of the entire situation bearing down upon her and the risk that she could get up to 99 years or life just finally came to a head and she cut her losses, honestly.”
A disorder in which a person with a great need for attention intentionally acts as if he or she is ill, physically or mentally, when he or she is not sick. It is considered a mental illness and is associated with severe emotional difficulties. Those with Munchausen syndrome generally suffer from borderline personality disorder.
It is considered a rare condition, and adults from 20 to 40 years old are most likely to develop the disorder.
Munchausen syndrome by proxy
A caregiver, usually a mother, who exaggerates or fakes illnesses for or deliberately sickens or injures an individual he or she is caring for, often a child.
Signs of Munchausen by proxy
- A caregiver describes symptoms that do not exist in the child.
- Caregiver appears overattentive of the child.
- Symptoms are often described as worse than observed by a doctor.
- Symptoms described do not match test results.
- Symptoms seem to go away when the caregiver is not present.
- Chemicals or drugs are found in the child’s blood or urine.
- Caregiver exhibits knowledge of healthcare field.
Source: Star-Telegram research