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Psychiatric Times
In some cases of child murder by the mother, psychiatrists may have a critical role in prevention. Learn more here.
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SPECIAL REPORT: FORENSIC PSYCHIATRY PART 2
Maternal filicide, the term for a mother killing her child, usually refers to mothers killing children while they are still living at home and younger than 18 years. (This article will not focus on neonaticide—murder of the newborn at birth or in the first 24 hours of life1—because it is a very different phenomenon than other maternal filicides.2 In some cases of child murder by the mother, psychiatrists may have a critical role in prevention.
In 1969, after reviewing the world literature, Phillip J. Resnick, MD, described the 5 most common motives behind parents killing their children.3 Subsequent research has shed further light on these motives, which are used in forensic reports around the world.4-6 These motives are not only helpful to courts in understanding a parent’s criminal responsibility after a homicide but also helpful for all psychiatrists to understand and help prevent filicides. The 5 motives are (1) fatal maltreatment, (2) unwanted child, (3) partner revenge, (4) altruism, and (5) acute psychosis.7 Only sometimes is serious mental illness implicated.
The 5 Motives
Fatal maltreatment occurs as the outcome of what is often chronic abuse or neglect. This is the most common type of child homicide by parents. There are likely many child deaths by fatal maltreatment that go undetected or remain unconfirmed, but the annual rate of confirmed child maltreatment deaths is 1 to 2 per 100,000 children in the US.8 Of those children, three-quarters are younger than 4 years.8 Children with prior reports to child protective services were almost 6 times more likely to die from subsequent fatal maltreatment than children without prior reports.9 Infants and children have presented to medical settings with non–life-threatening injuries such as unexplained bruises, with a lack of recognition that the injuries were likely from maltreatment, and have gone on to present later with signs of escalating abuse, including death. Such injuries have been termed sentinel injuries, as they are clinical indicators of potentially adverse outcomes that warrant further inquiry.10
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Fatal maltreatment incidents may begin with a caregiver poorly coping with their crying infant, becoming angry with their young child in the midst of feeding or toilet training issues, providing excessive corporal punishment for general disobedience, or becoming frustrated with their child with medical complexity or disability. Parents in fatal maltreatment cases may have mental illnesses, personality disorders, substance use disorders, or coping difficulties.
In unwanted child cases, mothers kill a child who is seen as a hindrance or is in the way of the mother’s goals. In partner revenge cases, the mother kills a child to emotionally wound the other parent. She may kill all her children or only the child perceived as the favorite of the other parent. This may occur in the context of a volatile breakup or custody battle. In both these motive categories, one may note personality disorders or attachment issues. These 2 types may seem the most difficult for others to grasp, but in these cases, the child is often seen as akin to property or a pawn rather than a person in their own right.
In altruistic maternal filicide cases, the mother kills the child out of love, often related to severe depression or psychosis. Some mothers with suicidal ideation believe they should kill their child as part of an extended suicide rather than leaving them motherless6; others believe their child is otherwise facing a fate worse than death—such as being sold to a human trafficking organization—and believe a loving death is better for their child. Finally, in maternal filicide cases of rare acute psychosis, a mother experiencing psychosis may, for example, follow a command hallucination that she believes is God telling her to kill.
Diagnosis
Diagnostically, it is also important to discern the difference between an obsession in postpartum obsessive-compulsive disorder (ppOCD) and the delusions of postpartum psychosis. This can be tricky, as obsessions of child murder may be a presentation of ppOCD.11 ppOCD is much more common than postpartum psychosis, often presenting with worries or fears about the infant and attempts to neutralize the intrusive, unwanted, and distressing thoughts (such as accidentally putting the baby in a microwave or dropping the baby over a balcony) with compulsions or avoidance of the infant.12
In contrast with ppOCD, postpartum psychosis is generally considered a medical emergency, necessitating hospitalization related to its rapid evolution, severe symptoms, and elevated risk of both infanticide and suicide.13 Mothers may have delusions about the infant and may experience commanding auditory hallucinations. It can be critical to determine whether a mother has developed delusions about her baby (such as those occurring in postpartum psychosis or severe depression), as these may significantly increase the risk, such as if they are delusions that the baby is evil.14
However, recent evidence indicates that when mental illness is treated, the risk of parents harming their child decreases.15,16 This is similar to how mental illness symptoms are considered dynamic risk factors for other types of violence.
Prevention
In considering prevention, psychiatrists should feel comfortable inquiring about maternal filicidal thoughts, though many do not.17 One way to begin asking about such thoughts is as they relate to suicide. For example, one may ask a mother expressing suicidal thoughts what she thinks would happen to her child should she die by suicide. This can yield useful information. Another avenue of inquiry is to ask a mother about her thoughts of frustration with the child and how she copes with these.
Mothers who have filicidal thoughts may feel more comfortable disclosing suicidal thoughts to mental health clinicians in order to get help.18 Mothers with depression or psychosis may experience filicidal thoughts,19 but mothers who are stressed may also experience them—for example, those with a colicky infant.20
Child Fatality Review Teams
On a public health level, psychiatrists can be valuable members of their local county child fatality review teams (CFRs).21 CFRs are local-level public health teams that include multidisciplinary membership (social services, law enforcement, health personnel, and medical examiners, among others). CFRs examine each unexpected child fatality in each jurisdiction, giving dignity to each child’s life and ensuring that prevention lessons might be learned when possible. New community support programs may be enacted. For example, American safe-haven laws, which allow parents to safely relinquish custody of unwanted unharmed infants, were borne out of CFRs.21 There are additional initiatives put into place in medical settings to help prevent child maltreatment fatalities, including shaken baby prevention programs, no-hit zones and no-hit homes, sentinel injury detection training, and pediatric medical practice safety training modules and parent informational brochures, which help parents prepare to manage infant crying and toilet training safely.10,22
Reporting
Mental health professionals are required to report reasonable suspicions of child abuse and neglect to their local authorities.20 When making a report of suspected abuse and neglect, the medical professional should discuss they are making the report with the child’s family, starting with a neutral topic such as the patient’s status, and should do this in a private setting, maintaining their caring demeanor. Clinicians should ensure that the child’s family knows that medical professionals are required by law to make such reports but that their focus is on safety and they are not responsible for assessing blame. Clinicians can help prepare a family for the next steps, such as letting the family know to make themselves available to and cooperate with child welfare and law enforcement investigators. Lastly, one should reinforce that involved medical systems and providers should continue to have roles in the child’s ongoing physical and mental health and safety.
Concluding Thoughts
In summary, understanding the potential motives for child murder by mothers can help in the prevention of child deaths, saving lives. In some but not all cases, mental illness is present in the mothers. Psychiatrists should be mindful of the risk and inquire about thoughts of suicide and filicide, keeping in mind the difference between ppOCD and postpartum psychosis. Psychiatrists have a valuable role in individual-level prevention as well as a potential public health role with CFRs.
Dr Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry; professor of psychiatry, reproductive biology, and pediatrics; and adjunct professor of law at Case Western Reserve University in Cleveland, Ohio. She served as editor of the Group for the Advancement of Psychiatry volume Family Murder: Pathologies of Love and Hate, which won the Manfred S. Guttmacher Award. She is a pediatrician. Dr Friedman is an assistant professor at Case Western Reserve University in Cleveland, Ohio.
References
1. Resnick PJ. Murder of the newborn: a psychiatric review of neonaticide. Am J Psychiatry. 1970;126(10):1414-1420.
2. Neonaticide. In: Friedman SH, ed. Family Murder: Pathologies of Love and Hate. American Psychiatric Association Press; 2018.
3. Resnick PJ. Child murder by parents: a psychiatric review of filicide. Am J Psychiatry. 1969;126(3):325-334.
4. Friedman SH, Hrouda DR, Holden CE, et al. Filicide-suicide: common factors in parents who kill their children and themselves. J Am Acad Psychiatry Law. 2005;33(4):496-504.
5. Friedman SH, Hrouda DR, Holden CE, et al. Child murder committed by severely mentally ill mothers: an examination of mothers found not guilty by reason of insanity. J Forensic Sci. 2005;50(6):1466-1471.
6. Friedman SH, Resnick PJ. Child murder by mothers: patterns and prevention. World Psychiatry. 2007;6(3):137-141.
7. Friedman SH. Child murder by parents: toward prevention. Current Psychiatry. 2023;22(6):12-21.
8. Palusci VJ, Covington TM. Child maltreatment deaths in the US National Child Death Review Case Reporting System. Child Abuse Negl. 2014;38(1):25-36.
9. Putnam-Hornstein E. Report of maltreatment as a risk factor for injury death: a prospective birth cohort study. Child Maltreat. 2011;16(3):163-174.
10. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707.
11. Booth BD, Friedman SH, Curry S, et al. Obsessions of child murder: underrecognized manifestations of obsessive-compulsive disorder. J Am Acad Psychiatry Law. 2014;42(1):66-74.
12. Fairbrother N, Woody SR. New mothers’ thoughts of harm related to the newborn. Arch Womens Ment Health. 2008;11(3):221-229.
13. Friedman SH, Prakash C, Nagle-Yang S. Postpartum psychosis: protecting mother and infant. Current Psychiatry. 2019;18(4):12-21.
14. Chandra PS, Bhargavaraman RP, Raghunandan VNGP, Shaligram D. Delusions related to infant and their association with mother–infant interactions in postpartum psychotic disorders. Arch Womens Ment Health. 2006;9(5):285-288.
15. Friedman SH, McEwan MV. Treated mental illness and the risk of child abuse perpetration. Psychiatr Serv. 2018;69(2):211-216.
16. McEwan M, Friedman SH. Violence by parents against their children: reporting of maltreatment suspicions, child protection, and risk in mental illness. Psychiatr Clin North Am. 2016;39(4):691-700.
17. Friedman SH, Sorrentino RM, Stankowski JE, et al. Psychiatrists’ knowledge about maternal filicidal thoughts. Compr Psychiatry. 2008;49(1):106-110.
18. Barr JA, Beck CT. Infanticide secrets: qualitative study on postpartum depression. Can Fam Physician. 2008;54(12):1716-1717.e5.
19. Jennings KD, Ross S, Popper S, Elmore M. Thoughts of harming infants in depressed and nondepressed mothers. J Affect Disord. 1999;54(1-2):21-28.
20. Levitzky S, Cooper R. Infant colic syndrome—maternal fantasies of aggression and infanticide. Clin Pediatr (Phila). 2000;39(7):395-400.
21. Friedman SH, Beaman JW, Friedman JB. Fatality review and the role of the forensic psychiatrist. J Am Acad Psychiatry Law. 2021;49(3):396-405.
22. Abatemarco DJ, Gubernick RS, LaNoue MD, et al. Practicing safety: a quality improvement intervention to test tools to enhance pediatric psychosocial care for children 0–3 years. Prim Health Care Res Dev. 2018;19(4):365-377.
