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Parents Who Kill Their Children

2010; American Academy of Pediatrics; Volume: 31; Issue: 2 Linguagem: Inglês

10.1542/pir.31.2.e10

1529-7233

Susan Hatters Friedman, Joshua B. Friedman,

Suicide and Self-Harm Studies

After completing this article, readers should be able to: Child homicide is a significant public health problem in America. In 2005, homicide was the fourth leading cause of death in both the 1- to 4-year-old and 5- to 14-year-old age groups. (1) Most young children who are homicide victims are killed by a parent. Of American children younger than 5 years of age who were murdered over the 30-year period from 1976 to 2005, 31% were killed by their fathers or stepfathers, and 29% were killed by their mothers or stepmothers. (2) Of the 40% not killed by a parent, most were killed by male acquaintances. The average number of children up to 5 years of age known to be murdered by their parents in the United States was 344 per year (range, 246 to 426). (2) Underestimations of death rates, however, pervade the literature. There are hidden pregnancies and hidden corpses, medical examiner misjudgments of homicide as being accidental or natural (eg, sudden infant death syndrome) or undetermined, and unwillingness to place responsibility on a grieving parent. (3) In addition, estimates of the frequency of maltreatment and death vary, depending on the data source.Filicide is defined as the homicide of a child by his or her parent. Inspection of the psychiatric literature about parents who kill their children suggests patterns among parents and in family dynamics. Examination of the common parental motives can help to understand why individual parents kill. Causative factors include either fatal maltreatment, birth of an unwanted child, altruistic motives, an acutely psychotic parent, or spouse revenge. (4)Most commonly in filicide cases, the child's death results from fatal maltreatment, also known as "accidental filicide," because the death was an unintended endpoint of intentional chronic abuse, neglect, or fabrication of illness. (4) Most of these deaths occur after severe head trauma. (3) Many current articles focus on the prevention of maltreatment; (5)(6) this article focuses primarily on preventing the killing of children due to other motives."Unwanted" children may be killed when they are newborns or later in life, when they may become undesirable or are seen as a hindrance to a new relationship. An evolutionary view suggests that the parent has distorted his or her perspective of personal reproductive fitness to an immoral extreme. (7) For example, the woman has a new boyfriend with whom she wants to start a new family, and the existing child is not considered worth additional investment and will not contribute to the success of the new family."Altruistic" filicide, or murder "out of love," occurs when parents kill their child out of a belief that they are doing what genuinely is best for the child. This ranges from a euthanasia-type killing of a severely chronically ill child to a suicidal parent who, in his or her severely depressed thinking, wouldn't leave the child alone in the "awful" world that the parent is departing to a parent who (possibly delusionally) believes that severe harm will befall the child should he or she live. One example is a suicidal parent who has lost a job, is in economic crisis, has no support, and is patently against the children going into foster care.Alternatively, "acutely psychotic" filicide occurs when the parent, in the throes of psychosis or mania, kills the child for no rational reason, as in response to a commanding auditory hallucination. This type of killing may be the culmination of multiple hallucinations over days."Spousal revenge" filicide, also known as the Medea syndrome, occurs with the least frequency and is associated with the souring of the parental relationship. The parent kills the favored child of the other parent, or all of the children, to punish the other parent.A child's risk of being a victim of parental homicide varies with age. Children younger than age 5 years who are not yet in school and have limited contacts outside of their families are less able to report their abuse to others. School-age children spend much of their day in the presence of others but also may be at risk from their parents. By the teen years, the risk of homicide is similar to risk in early adulthood and more related to gangs and the outside world than to violence in the home.Neonaticide refers to infant homicide by a parent on the first day after birth. (8) In North Carolina, 2.1 per 100,000 newborns annually were killed or left to die. (9) Neonaticide has occurred through the ages, as in the sacrificing of weak infants or twins in primitive societies due to scare resources. The patterns of neonaticide, however, are different in modern societies. Women and teenage girls who kill their infants at birth predominantly either have denied or concealed their pregnancies (10) and do not deliver in hospitals.The types of denial of pregnancy are pervasive denial, affective denial, and psychotic denial. (11) Those who experience pervasive denial are surprised at the infant's birth and have no emotional or physical awareness of the pregnancy. (11) They may continue to experience menstrual-like bleeding, may continue to wear their regular clothes, and often do not experience physical changes of pregnancy such as "morning sickness." (11)(12) Others experience affective denial; they are cognitively aware that they must be pregnant, yet they make no preparations and do not emotionally acknowledge the pregnancy. (11)(13)Rarer still is psychotic denial, which may occur in women who have schizophrenia. (11)(14) Psychotic denial has been correlated with prior custody loss and anticipation of future custody loss. (14) Women experiencing psychotic denial may acknowledge and deny their pregnancies intermittently or may attribute their weight gain and physical changes to another (perhaps bizarre) cause. For example, one such patient, on seeing her reflection, would assert that supernatural causes had caused her weight gain. Identified women who have psychotic denial should be treated in a setting that includes both psychiatric and obstetric support. (14)Alternatively, concealment of pregnancy occurs when the woman is aware that she is pregnant but actively hides her pregnancy from others. Denial may occur early; the woman may move along a continuum; and later she may recognize, accept, and acknowledge her pregnancy or she may conceal it from others at a later stage. (13)Without adequate support, many young women who have these characteristics do not seek or attend prenatal care. (10) When the reality of contractions and labor occurs, the women no longer can deny or conceal. Some present to the hospital for delivery or, in partial recognition, complaining of abdominal pain (contractions); others deliver at home, oblivious to labor or to avoid detection. (13) Risks to the infant include not only neonaticide but other morbidity from lack of prenatal care, such as higher rates of prematurity, (15) or the consequences of unattended delivery.The neonaticide may or may not be planned. Passivity and denial may have characterized the pregnancy, and the young woman may be surprised at the birth. Alternatively, she may have planned to maintain concealment of the pregnancy and birth. Common methods of neonaticide include suffocation, drowning, strangulation, head trauma, and exposure. (8) Suffocation may be related to stifling the cries to avoid detection. In many cases, the corpse is concealed.An analysis of world literature reveals that in addition to manifesting denial or concealment of pregnancy, perpetrators commonly are in their late teenage years to early 20s, of lower socioeconomic status, living with their parents, and unmarried. (10) The pregnancy may have been the result of an illicit relationship of which the woman's parents are unaware or unsupportive or it may be the result of incest; some may fear reprisal. Many perpetrators have psychological issues.An interview study (n=16) reported that despite a mean age in the early 20s, perpetrators often had "a childlike demeanour and la belle indifference." (12) As well as denial, experiences of dissociation, amnesia, abuse, and family dysfunction were reported. More reported affective denial than pervasive denial. This study cited much higher rates of amnesia than anticipated, in the context of legal charges, and did not use specific tests for malingering. Other authors have noted: "It is conceivable that presenting the accused with an extensive checklist of mental symptoms may inadvertently educate them about psychiatric symptoms that might provide an alibi or justification for their actions." (16)In some cases, family and friends appear complicit in the denial. Some clinicians also may fail to consider the diagnosis of pregnancy. Some studies of women and girls who gave birth after denial of pregnancy find that when they visited their physicians, their pregnancy was missed. (13)(17) Pregnancy is not included in the differential diagnosis, they are considered "good girls," they deny sexual activity, or they are seen with their parents present. To minimize chances of family discord reinforcing denial or concealment, a vital portion of the evaluation of postmenarchal young women should be conducted without parents present, during which time the teen may speak more freely.Young women may present to their pediatricians with a seemingly innocuous complaint, at some level recognizing that they might be pregnant. Pediatricians should create a safe environment, take a history, and maintain a low threshold for seeking consent and screening for pregnancy.For those who are pregnant, a discussion in support of the young woman could include education about her options, including adoption and abortion; the importance of prenatal care; how she might approach the topic with her parents; and the availability of parenting classes. Some may wish to pursue abortions, and physicians play an important role in educating them about their rights and referring them to appropriate agencies. If the teen does not wish to tell her parents of her pregnancy and desire for abortion, judicial over-ride of the requirement for parental consent may be considered. (18) The juvenile courts can supply information about the legal procedure for obtaining judicial over-ride (and the so-called Jane Doe anonymity laws), which varies by jurisdiction. Some young women who deny their pregnancies are unable to go through with plans for abortion yet still do not obtain prenatal care. (13)For those who wish to continue with their pregnancies, obstetric referral and follow-up to confirm compliance with prenatal care are critical. Ultrasonography of the developing fetus has been suggested to help break through denial of pregnancy by providing a convincing concrete visual aid.A legal framework for safely and anonymously relinquishing responsibilities and parental rights has been established, in recognition that some mothers who have maintained denial or concealment remain unsupported and deliver unprepared. Known as Safe Haven laws, all 50 American states have passed such legislation since 1999 that allows mothers to leave their babies at a hospital or fire station, some within the first days and others up to 1 month or 1 year of birth, without prosecution for abandonment. (10) Public awareness is key to allowing these laws to save infant lives. Over the first 7 years of the Safe Haven law in Texas, although some infants were legally surrendered, many still were abandoned illegally. (19) An estimated 85 lives per year could be saved with these laws. (3)(9) Other countries offer anonymous free delivery or relinquishment. (10)Infanticide often is defined as child homicide by parents within the first postnatal year. (20) The risk of homicide victimization is highest in this first year. (20) One quarter of infant homicides occur in the first 2 months after birth and half within the first 4 months. (3)(21) The time of highest risk for being murdered in any child's life is the first day after birth. (8)American infants killed in the first postnatal year were more likely to have a mother younger than age 19 years who had more than one child and had received no prenatal care. (21) Infanticide laws exist in 24 countries outside the United States, often variations of the British Infanticide Act of 1922 and 1938. This act reduced punishment for infanticide from that of murder to that of manslaughter if the perpetrator was a mother who was suffering mental instability. (20) Mothers who commit infanticide in the developed world may have experienced economic stress, infant anomalies, mental illness, or a combination of these factors. (22)Pediatricians play an important role in screening for postpartum depression and recognizing postpartum psychosis at health supervision visits. (23) Good clinical acumen involves evaluating the health of the maternal-infant interaction. Bonding that is problematic may be indicated by a mother who is distant and disengaged, a mother who expects to receive comfort without providing comfort, or a mother who appears overly protective and reacts to minor issues with great anxiety. Pediatricians can provide education about symptoms of mental illness and available treatments. This interaction is particularly opportune for mothers who comply with their children's health supervision appointments but dismiss the importance of their own postpartum obstetric appointments.Postpartum depression occurs in approximately 10% to 25% of mothers within the first year after giving birth. Symptoms are of gradual onset. Mothers may experience depressed mood or lack of enjoying activities, which often leads to difficulty bonding with the baby. (24) The mother may have difficulty sleeping when her baby sleeps. She also may experience weight and appetite changes, decreased energy, suicidal thoughts, and anxiety. Some mentally ill mothers may neglect their children because of the deficits caused by their mental illness. Some mothers do not acknowledge symptoms because of fears of stigma or loss of child custody. Fathers also may experience depression when their children are infants and have similar symptomatic presentations.A milder condition that can affect mothers is "baby blues," which usually resolves within 2 weeks. (24) Symptoms are self-limited and include crying, lability, irritability, and tiredness. Baby Blues actually are considered to be a normative experience because 50% to 80% of women experience them. Educating the mother and her partner about both postpartum depression and baby blues and stressing the importance of sleep (possibly with breaks from baby care by supportive family) are appropriate measures.The Edinburgh postnatal depression scale, (25) readily available on the Internet, is a quick 10-question screening tool that mothers complete themselves, perhaps in the waiting room. Those who are illiterate or who speak another language may need help with completion. The scale is simple to score, with a range of 0 to 30 and a threshold of 10 to 13 for depression. The scale has been validated in both the postpartum period and during pregnancy. In particular, the mother's answer to the final question on the Edinburgh scale should be reviewed because it inquires about thoughts of suicide.A parent who is suicidal should be seen promptly by a mental health professional in an emergency department if same-day evaluations or crisis teams are not available. Remember that many parents in the "altruistic filicide" group kill their children as part of an "extended suicide" plan. All threats of harm against children should be taken seriously and child protective services and emergency psychiatric services engaged. (Many areas have mobile crisis teams or suicide hotline services that can be accessed.) Also, parents who appear to be excessively concerned about their children's health (ie, delusional) should be evaluated. In a sample of mothers who killed their children and had psychiatric dispositions, many were depressed or experienced auditory hallucinations, and several delusional mothers had presented repeatedly with their well children, asserting that the children were ill. (26)One recent study (27) found that 41% of depressed mothers who had children younger than age 3 years had experienced thoughts of harming their children. Although mothers may be unlikely to disclose these thoughts, they often realize that they need help and may mention thoughts of suicide. (28) Depressed parents should be asked if they have thoughts of harming themselves or the child and about their supports. They should be referred to their internists or directly to psychiatry or counseling. Postpartum depression is treatable with both medication and counseling. Multiple antidepressants are compatible with breastfeeding. Depending on the level of concern, contacting the parent prior to the follow-up visit may be justified. In cases presenting immediate danger, a parent may require an emergency department evaluation and a child protection referral. Threats to the child should be taken seriously. (20)Postpartum psychosis is rarer, occurring in mothers after 1 to 3 per 1,000 deliveries. Postpartum psychosis has a much swifter onset and rapid evolution, usually in the first weeks after delivery. (29) Mothers may experience an astonishing range of psychiatric symptoms, including psychosis, mania, depression, and confusion. They may hear voices or see visions and experience rapid mood swings. Bizarre behaviors, agitation, disorganized thinking, insomnia, delusions, and decreased judgment also may occur. (29) If a mother presents with depression, rapid mood swings, and confusion or hallucinations, postpartum psychosis should be considered. (29)Included in the differential diagnosis of postpartum psychosis is postpartum obsessive-compulsive disorder (OCD), an anxiety disorder rather than a psychotic disorder. (29) In postpartum OCD, mothers are not out of touch with reality; rather, they may experience thoughts or serious fears or preoccupying worries about harming their children. Such women should be referred to psychiatry because although their risk profile is different from that of postpartum psychosis, their symptoms are distressing, and psychiatric treatment can lead to improvement. In many cases, the input of a psychiatrist is needed to make the diagnosis.Women experiencing postpartum psychosis have elevated rates of both suicide and infanticide, with up to 4% of mothers who have untreated postpartum psychosis killing their infants. (20) It is of particular concern when delusional beliefs become focused on the infant. (29) For example, the mother may hear voices saying that she should sacrifice her baby to God or that she has a baby who is half-human and half-alien. Postpartum psychosis generally is considered a psychiatric emergency (as is suicidal depression), and the mother should undergo immediate psychiatric evaluation if it is suspected (ie, in the emergency department). She is likely to require psychiatric hospitalization and medication after a medical evaluation has been completed.Depending on state and practice facilities, family, staff, or police may escort the mother to the emergency department. It is critical to communicate concerns and symptoms to the receiving emergency department because once there, some mothers may attempt to persuade staff that there are no problems. The decision to contact child protective services can be made collaboratively with psychiatry. Long-term psychiatric management optimally includes collaboration among the disciplines.Clearly, most parents who have mental illness do not kill or assault their children. However, acute symptoms of mental illness may elevate risk. Stigma is an important concern for many; it is important that parents feel that they are in an environment where it is safe to disclose their symptoms and that help is available. Both postpartum depression and postpartum psychosis are treatable, and most mothers retain custody of their infants. Providing written information in the office about depression and treatment services is helpful. (30) Pediatricians should be aware of clinics where identified mothers can be referred for treatment, and pediatricians and psychiatrists should communicate to facilitate best practices.Analysis of published studies indicates that mothers who commit filicide are often poor; are primary caregivers who are socially isolated; and have suffered victimization (such as from domestic violence), substance abuse, or mental illness. (20)(22) Much less research evidence exists regarding fathers who kill. Common factors among fathers who commit filicide include a history of physical abuse, with some cases related to mental illness; on average, fathers are in their mid-30s, and the mean age of the child is 5 years. (31) Studies also consistently show that children of stepparents are at an elevated risk of being the victims of child homicide. Most commonly, when mental illness is involved, depression, suicidality, or psychosis is found. Suicide occurs frequently in cases of both maternal and paternal filicide. In conjunction with filicide, 16% to 29% of mothers and 40% to 60% of fathers commit suicide. (32) Many other suicide attempts are unsuccessful. The parents may be delusional about the child whom they are killing, experiencing acute hallucinations, trying to "save" the child, (22)(26) or they might be in a rage (spousal revenge). As children age, imperatives remain for observing relationships, screening for mental illness and parental stress, and making referrals.In addition to maternal factors, infant features may elevate risk. For example, a study of nonmentally ill mothers of colicky infants (33) found that mothers experienced both psychological and physical symptoms in response to their infant's colic as well as marital and social tension. Seventy percent of the mothers had "explicit aggressive thoughts and fantasies," and 26% had infanticidal thoughts during the colic episodes. With impaired judgment, decreased impulse control, sleep deprivation, and desperation to get the baby quiet, the mother may have pervasive thoughts of silencing the crying baby, even by violent means. Most mothers who have colicky infants do not attempt to hurt or kill their children, but these figures suggest that they consider such violent actions. Thus, sensitive interviewing about the impact of colic on the mother is imperative. Furthermore, strategies focusing on what to do with a crying child, rather than what not to do, have been suggested. A strengths-based approach that normalizes crying and promotes planning in advance is suggested, as is family support for respite.Factors inherent in the child, such as autism, may increase the risk of filicide. (34) A child who has a developmental disability is known to have an increased overall risk of being maltreated. (5) Regarding a euthanasia-type killing, preventive efforts might include the pediatrician discussing palliative care, comfort care, and hospice care with the parent.Recognizing acute financial, relationship, and social stressors can be vital in helping parents take stock and gain perspective and can lead to the provision of coping skills and plans. The pediatrician should ask about parenting problems and feelings of being overwhelmed with the children. Mandatory reporting laws and procedures, which vary by jurisdiction, are important to know. Also, clinicians should consider whether a referral to social work or a specific social program or parenting classes would be useful.