Mothers Thinking of Murder: Considerations for Prevention

Edited by Rober I. Simon, MD

Recent high-profile cases, such as those of Andrea Yates and Susan Smith, have drawn national attention to the crime of maternal filicide. Yet mothers have killed their children for thousands of years. While many parents fear that strangers might kill their children, a parent is actually more likely to be the perpetrator. In the United States, from 1976 to 2004, 30% of children younger than 5 years who were murdered were killed by their mothers, and 31% were killed by their fathers.¹ Having a mother kill her children while under your psychiatric care is likely to be traumatic. Furthermore, malpractice suits may result, as in the Yates case. This column will focus on the prevention of these tragedies, in addition to forensic issues.

Maternal filicide has various motives.²

• Altruistic filicide, in which a mother kills her child out of "love," occurs because she believes death to be in the child's best interest. Altruistic filicides can occur, for example, when a psychotic mother believes that she is saving her child from a fate worse than death or when a suicidal mother does not want to leave her child to face the uncaring world that she sees through her depressed eyes.
• Acutely psychotic filicide occurs when a psychotic or delirious mother kills her child with no rational motive. For example, she may experience command hallucinations to kill.
• Fatal maltreatment occurs when death is not the anticipated outcome but rather the result of cumulative child abuse, neglect, or Munchausen syndrome by proxy.
• Unwanted-child filicide occurs because the mother thinks of her child as a hindrance.
• Spouse-revenge filicide--the most rare--occurs when a mother kills her child specifically to emotionally wound the child's father. A classic example from mythology is Medea, who killed her children in order to seek revenge on her husband, Jason.

Neonaticide is the killing of a newborn in the first day of life.³ This column will focus on filicide rather than neonaticide, since mothers who commit neonaticide usually have not come to psychiatric attention before their crimes.

Child murder by mothers is a public health concern. Psychiatrists are most likely to be able to intervene in cases associated with maternal mental illness. Mothers with altruistic or acutely psychotic motives for filicide may be depressed, psychotic, manic, or delirious. However, the majority of filicides are related to fatal maltreatment rather than maternal psychiatric illness. Some mothers with severe mental illnesses, substance use disorders, or personality disorders may abuse or neglect their children, and psychiatrists are in a unique position to inquire about child-rearing practices.

Research studies have examined different populations of filicidal mothers. General population studies indicate that mothers who committed filicide were often socially isolated full-time caregivers of lower socio-economic status who experienced substance abuse and were victims of domestic violence. Studies of women in psychiatric populations who killed their children documented high incidences of psychosis, depression, suicidality, substance use, and difficulties in their own childhood.⁴ A small New Zealand interview study found that psychotic mothers who had committed filicide often acted suddenly and without much planning, whereas depressed mothers had been contemplating killing their children for days to weeks before their crimes.⁵

Most psychiatrists underestimate the percentage of depressed mothers with young children who experience filicidal thoughts.⁶ More than 40% of a sample of mothers with depression who had children under the age of 3 admitted to having filicidal thoughts.⁷ A study of mothers with colicky infants found that 70% experienced "explicit aggressive fantasies," and 26% admitted to filicidal thoughts during colic episodes.⁸ However, mothers are often reluctant to share these thoughts for fear that their children will be removed from the home.

Filicide with maternal suicide

Maternal filicide may occur in the context of maternal suicide. Five percent of mothers who kill themselves take at least 1 of their children with them into death.⁹ Sixteen percent to 29% of mothers commit suicide subsequent to filicide, and many mothers make nonfatal suicide attempts.¹⁰ Just as some of our medical colleagues feel discomfort inquiring about suicidal thoughts, some psychiatrists are uncomfortable asking patients about thoughts of harming their children. American Psychiatric Association guidelines for the treatment of suicidal patients¹¹ suggest helpful questions to ask in assessing suicidality, which can be modified to inquire about filicide-suicide. Specifically, mothers can be asked whether their children would be able to go on without them. Mothers with suicide risk factors can be asked about their plans for their children if they were to take their own lives.

Raising the issue

While some psychiatrists inquire about filicidal thoughts in both psychotic mothers and suicidal mothers, others only vaguely ask about homicidal thoughts in general.⁶ One patient with postpartum psychosis came to psychiatric attention after calling the operator to ask whom she should call about having thoughts of harming her baby. Unfortunately, this mother is the exception rather than the rule. While psychotic mothers may have less forewarning about filicidal impulses, they should still be asked about hallucinations regarding their children. They can also be asked about thoughts or fears of harming their children. Threats should always be taken seriously. Mothers who express delusions regarding their children should be asked about filicidal thoughts. In our recent experience, some mothers with depression have brought up the case of Andrea Yates. Mentioning this or other similar cases can serve as a vehicle to begin the inquiry.

Detailed information about a mother's motive for her filicidal thoughts should be elicited. For example, a mother who is depressed and suicidal who speaks of removing her children from this "awful world" would be treated differently pharmacologically and psychotherapeutically than a mother who reports hearing the voice of God telling her to kill her children.

Psychiatrists have a good opportunity to inquire about child discipline and to evaluate parenting skills.¹² Increased awareness of parenting problems could help attenuate the risk of fatal maltreatment filicide. Levels of subjective stress can also be assessed to determine whether a mentally ill mother feels overwhelmed.

Because of the potential for the loss of more than one life, a lesser threshold for hospitalization should be considered for mentally ill mothers with young children. Symptoms that may merit hospitalization include a mother's fears of harming her children, delusions regarding a child's suffering, unrealistic concerns about a child's health, and hostility toward the favorite child of a despised husband or partner.¹³ Familiarity with child abuse reporting laws in your state is necessary.

Screening postpartum women for mental illness is important in the context of filicide. It is estimated that as many as 4% of mothers with untreated postpartum psychosis will commit filicide.^14-16 A prompt response from the mental health system is warranted. Although filicide victims may be of any age, the greatest risk of filicide is in the child's first year of life.¹

Filicide and the insanity defense

States employ diverse insanity statutes, with a few offering no insanity defense. The reader is referred to Noffsinger and Resnick¹⁷ for an in-depth discussion of insanity law and evaluations. In brief, insanity requires the element of mental illness; in addition, a defendant may need to not understand the wrongfulness of her acts or be unable to conform her actions to the law. Further consideration, applicable in some states, is the distinction between whether the mother understood the legal or moral wrongfulness. For example, while Andrea Yates was aware that the killing of her children was wrong in the eyes of the law, she believed that what she was doing was right, in order to save her children from eternal damnation in hell.

One recent study characterizing women found not guilty by reason of insanity (NGRI) for filicide in 2 states established that most mothers had previous mental health treatment.¹⁸ Maternal motives in the sample were predominantly altruistic or acutely psychotic. Most were experiencing auditory hallucinations, often of a commanding nature. Half were depressed. Most had experienced considerable developmental stressors themselves, such as incest or the death of their own mother. Holden and colleagues¹⁹ studied mothers referred for forensic evaluation after filicide, comparing those found NGRI with those adjudicated criminally responsible (CR). When compared with women found CR, mothers found NGRI were significantly more likely to have made suicide attempts and to have experienced hallucinations or delusions, while they were significantly less likely to have other children who were not victims.

In summary, the motives for maternal filicide provide a framework for understanding the phenomenon as well as considerations for prevention. No single profile of the filicidal mother exists. Each mother that the psychiatrist is concerned about merits careful evaluation. Finally, we must become more comfortable inquiring about filicidal thoughts and considering filicidal risk.

Dr Simon is clinical professor and director of the program in psychiatry and law at Georgetown University School of Medicine, Washington, DC. He is co-editor, with Robert E. Hales, MD, of The American Psychiatric Press Textbook of Suicide Assessment and Management, published this year, and co-editor, with Lisa H. Gold, MD, of The American Psychiatric Press Textbook of Forensic Psychiatry, published in 2004.

Dr Friedman is a senior instructor in the department of psychiatry at the Case Western Reserve University School of Medicine, Cleveland. She is employed by Northcoast Behavioral Healthcare, the Court Psychiatric Clinic of Cuyahoga County, and the Perinatal Clinic of Northeast Ohio Health Services.

Dr Resnick is the director of forensic psychiatry at University Hospitals of Cleveland, the director of the Court Psychiatric Clinic of Cuyahoga County, and a professor in the department of psychiatry at the Case Western Reserve University School of Medicine, Cleveland.

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