Soon afterward Kheematah had begun to cough and complain of a stomachache. While two nurses tended to the girl, a third quietly removed the liner from the wastebasket and fished out a syringe with white residue at its tip.

An emergency-room nurse, Ken Smith, provided another piece of the puzzle.

Smith had been on duty in the ER on October 10, 2004, when Judy Pickens was wheeled down after feeling faint. Smith asked Karl Pickens to list the medications his wife was currently taking, and he cited several as she lay silent and listless on the stretcher. But when Pickens mentioned clonidine hydrochloride, a medication prescribed to adults for hypertension, Judy suddenly came to life. She became argumentative, Smith would later testify, adding: "She denied being on clonidine, and she said she no longer took clonidine anymore, and she wanted it taken off of her chart."

Judy Pickens' booking photo, February 2006.
Judy Pickens' booking photo, February 2006.

Sixteen months into the inquiry — which included more than a hundred police interviews and several rounds of toxicology tests on DNA samples from both children — investigators finally reached a conclusion.

On February 7, 2006, St. Louis Medical Examiner Michael Graham signed Mikal Pickens' death certificate. The cause of death, Graham wrote, was clonidine poisoning.

Police arrested Judy Pickens the following day. Investigators concluded that she had pulverized her clonidine tablets and repeatedly injected the drug into her children's IV lines.

The St. Louis Circuit Attorney's Office charged Pickens with six felonies, including child abuse and murder.

Pickens denied the charges and proclaimed her innocence. Unable to raise the $3 million cash bond, she was jailed pending trial.

Friends from church rallied to Pickens' cause, raising thousands of dollars to cover the fee of noted local defense attorney Scott Rosenblum. (Rosenblum would later withdraw from the case; Pickens was represented at trial by John Tucci, an attorney in private practice who was retained through the St. Louis Public Defender's Office.)

"I stand behind my wife; it's that simple," Karl Pickens told the St. Louis Post-Dispatch in 2006. "I don't believe my wife harmed my kids."

Family and friends continue to protest that Judy Pickens is innocent and nothing like the murderer police and prosecutors have made her out to be.

"She was a good mother," says Samuel Armstrong, her first husband, with whom Pickens had a son.

"She supported those kids with all she had," adds Pinkie Porter, an ex-in-law, with whom Pickens has maintained amicable relations. "She gave them birthday parties at Chuck E. Cheese, took them to football games and movies. She was outstanding."

Flora Lee says her close friend was a long-time devoted member of Trinity Full Gospel, ministering to young adults, performing eulogies and leading readings at worship. Lee portrays Pickens as God-fearing in the extreme. "She was, like, peculiar. She didn't do a lot of stuff normal kids do. Never smoked, never drank," Lee says. "Even when she was eighteen, she'd say, 'I'ma pray for you.'"

In July 2008 Pickens submitted to a court-ordered psychiatric evaluation by Michael Armour, a psychologist and forensic examiner with Missouri's Department of Mental Health. Pickens told Armour that when her mother was eight and a half months pregnant with her, she had fallen out of a car. She admitted to being bullied somewhat in her youth, but she also said she had many friends and was always very "protective" of others.

According to Armour's report, Pickens stated that an elder male relative had sexually abused her from age three until she turned fourteen, and that the relative was never prosecuted even though some relatives were aware of the abuse. ("I don't know anything more than what is in the report," says John Tucci, Pickens' attorney.)

Pickens told Armour that before her children's illness, "everything had been right with the world." She professed to be "angry to no end" about the criminal charges against her. A plea bargain was out of the question: "I will never admit to something I did not do," she told Armour.

Pickens discussed her medical history at length. She told Armour she has had high blood pressure since she was ten and was diagnosed with congestive heart failure in her mid-twenties. She also has complained of edema and asthma and was transported to Barnes-Jewish Hospital various times during her incarceration.

Armour, however, noted that corrections personnel had deemed Pickens "not a reliable source of current information" when it comes to her health and that prior to her incarceration, medical staff at Barnes had diagnosed Pickens on more than one occasion with "factitious hypoglycemia" and "factitious diabetes" — meaning she fabricated the illnesses. Additionally, the psychologist wrote, jail records indicated that Pickens "had hidden pills in her medication cups and in her clothing" while in custody.

Armour diagnosed Pickens with a vague form of personality disorder characterized by "histrionic" traits, including "not being comfortable with situations in which he or she is not the center of attention, rapidly shifting but shallow expression of emotions, and self-dramatization and exaggerated expression of emotion."

In Armour's opinion, however, the disorder did not make Pickens unfit to proceed with a criminal trial.

Having examined her medical records and an investigative police report, Armour additionally concluded that Judy Pickens had exhibited the "key criteria" for Münchausen by proxy: She had little to gain from harming her children, and she was considered "a very devoted caretaker."

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