WOMEN AND FILICIDEWHAT IS THE ROLE OF MENTAL ILLNESS?

JudithG.Edersheim,JD,MDCo-Director,TheCenterforLaw,Brain&Behavior

November17,2015

THE NEUROLOGY AND PSYCHIATRY OF WOMENHARVARD MEDICAL SCHOOL

March 30, 2017

GOALS FOR THIS PRESENTATION

1. The Scope of the Problem

2. Classifications and Characteristics

3. Case Studies in Maternal Filicide

4. Opportunities for Prevention

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GOALS FOR THIS PRESENTATION

1. The Scope of the Problem

2. Classifications and Characteristics

3. Case Studies in Maternal Filicide

4. Opportunities for Prevention

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Scope of the Problem• Childhomicideratesingeneraltripledbetween1950and2007

• FBIStatistics:Filicide– Atleast450childrenarekilledintentionallybytheirparentseachyear

– ¾ofthoseareundertheageoffive– Aroughly50/50splitbetweenmothersandfathersinthisdata

– Howeverfathersareperpetratorsin70%ofcasesinvolvingmultipleshootingvictims

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Definitions

Filicide:ChildrenUnder18

Infanticide:ChildrenUnder1Year

Neonaticide:Childrenunder1day

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ClassificationsofFilicide

q TheResnick Model(1969)–ØAltruisticØUnwantedChildØAccidentalØSpousalRevengeØAcutelyPsychotic

qSeealso(D’Orban,Guielyardo,BourgetandBradford,Scott)

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SomeCaveatstoModels

• Significantoverlapbetweencategories• Littleresearchonfatherswhokillchildren• Lessattentiontoperpetratormentalillness• Whilethereareoverallgenderequalitiesinthedata,theybreakdownwhenyouexaminefactorslikevictimage.

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PaternalFilicide

• Childvictimsareusuallyolder/multiplevictims

• Moreviolent(firearms,knives,headtrauma)

• Themotivationismostoften– Fatalabusewithunintentionalkilling– Significantfinancialstresswithoutsupports– Spousalrevengeordespairafterseparation

• WithahighpercentageofmaleperpetratorswithDepressionorPsychoticIllness(50-60%)

• Andahighincidenceofsuicideafterhomicide(40-60%)8

OverviewofFilicideBasedonPerpetratorCharacteristics(AdaptedfromWest,MD2007)

Perpetrator/Characteristics

MaternalFilicide Infanticide Neonaticide

AgeofParent 29YearsOld 23.8YearsOld 21.2YearsOld

Sex ofParent Female BothGenders Female

AgeofVictim 3.2Years Old 5Months Old Less than24Hours

PsychiatricIssues Common Common Uncommon

Suicide 36.4% Unknown Rare

MethodsofMurder HeadTraumaDrowningSuffocationStrangulation

HeadTraumaBatteryAssault

SuffocationDrowningExposure

OtherCharacteristics

SociallyIsolatedUnemployedPersonal HistoryofAbuse

LimitedEducationLackofPrenatalCare inmothers

UnmarriedPrimiparasConceal Pregnancy

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MaternalFilicide:Neonaticide

Neonaticide:vYoungunmarriedmothersvOftenconcealingpregnancyvNoprenatalcareofaftercarebabyplansvLessDepressionorpsychosisthanwitholderchildren

vMotiveprimarilyunwantedchild– uncertainpaternityorunwantedpregnancy

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MaternalFilicide:Infanticide• Mothersintheirearlytwenties• Withsevereeconomic/financialstress• Highpercentageoftheseunemployed• Highpercentagewithassociatedchildabuse• Somemothershadassociatedsuicideattempts

• Approximately40-70%withpreviouspsychiatricdisorders

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MaternalFilicideGenerally:OlderChildren

Forallchildrenolderthanayear,andingeneral• Marriedorseparatedwomen• Primarycaretakerofmorethanonechild• Unemployedorwithfinancialstress• Socialisolationandlackoffamilysupport• Ofteninanabusiveadultrelationship• Withachildhoodhistoryofphysicalabuse

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MothersWhoKillOlderChildren

• Generallyhighereducationallevel• Moreoftendivorcedorseparatedfrommate• Generallybutnotalwaysunemployed• Muchhigherprevalenceofmentalillness

– Previouspsychiatrichospitalizations– Previoussuicideattempts– Confoundingsubstanceuse– Ongoingpsychiatrictreatment

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Motherswhokillolderchildren• ExcludeFatalAbuseCases

– Themotherhasnointentionormotivationtocausechild’sdeath– Lowerprevalenceofmentalillnessotherthanpersonalitydisorderandor

substanceuse– Rarelyrelatedtopsychosisunlessoutoftouchmotherisunresponsiveto

child’sneeds– Frequentmaternalchildhoodabuseandparentalseparationorviolence– Veryhighincidenceofbeingvictimizedbycurrentabuse

• ExcludeRetaliatoryFilicide– Veryrareinmothers– Motiveistoretaliateagainstotherparent,usuallymale– Highincidenceofpersonalitydisorderandsubstanceuse– Oftenvictimgenderpreferenceismaletoretaliateagainstmaleparent

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SummaryBasedonMotiveorCause

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LikelyRelatedtoPostPartumpsychosisor

depression

Altruistic

AcutelyPsychotic

RarelyRelatedtoPostPartumPsychosisor

Depression

FatalMaltreatment

NotlikelyRelatedtoPostPartumPsychosis

orDepression

UnwantedChild

SpousalRevenge

Adapted from Friedman SH et al 2009

SevereMentalIllnessandMaternalFilicide

• Resnick’s AcutelyPsychoticCohort• Characteristics

– Psychosis– BipolarDisorder,MajorDepressionorSchizophrenia

– Ahistoryofpsychiatrictreatmentandsuicidality– WithAltruisticand/orPsychoticMotives– Predominating(over30%)inthepregnancyorpostpartumperiod

– Andthiscategoryoverlapssignificantlywithfilicide-suicidecases*

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SpecificCharacteristicsofAcutelyMentallyIllMothersatRiskforFilicide

–39MothersNGRIforFilicide• 72%hadpreviousmentalhealthtreatmenthistory

• 69%AuditoryHallucinations,primarilycommandAH

• 49%Depressedatthetimeoftheoffense• 38%Offenseswereduringpregnancyorpostpartum

FriedmanSHetal2005(JForensicSci)

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SevereMentalIllnessandMaternalFilicidectd…

• Asignificantoverlapwithfilicide-suicidecases– 16-30percentoffilicidesendinthesuicideofthemother

– Andmanyalsomakenonfatalsuicideattempts– Whenyoungmotherscommitsuicide5%ofthemalsokillatleastoneoftheirchildren

– Tendtokillolderchildren(meanage6)– Andkillalloftheiryoungchildren

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PostPartumDepression• Arangeofsymptomsfrombluestomildtoseveredepression

• Classicsymptomatologywithmorepronouncedanxiety• Developweekstomonthsafterdelivery• Insomnia,apathy,bondingdifficulty• Frequentpresenceofsuicidalandhomicidalthoughts• ConsiderinsteadPPPwith

– Depressedmoodwithrapidfluctuations– Cognitivedisturbanceanddisorganizedbehaviors– Unusualtypesofhallucinations(olfactory,visual)– Hypomaniaormixedmoodstates– Confusion*

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DepressionandFilicidalThoughts

• MaternalDepressionisapredictoroffilicidalandaggressivethoughts:

– 40%ofdepressedmotherswithkidsunder3havethoughtsofharmingtheirchildren(vs.7%controls)

– 70%ofmotherswithcolickyinfantsexpressaggressivethoughtstowardsthem

– 25%ofmotherswithcolickyinfantshadthoughtsofinfanticideduringcolickyepisodes

(Jenningsetal1999)21

PostPartumPsychosis• RelativelyRare:1-3casesper1000births• 70%ofwomenwithahistoryofpostpartumpsychosiswillexperienceanotherepisodefollowingasubsequentpregnancy

• Amedicalandpsychiatricemergencyrequiring– Hospitalization– Antipsychoticmedications– OftenECT

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RiskFactorsforPostPartumPsychosis

• Rapidhormonalshiftsthataccompanypregnancyanddelivery

• Sleepdeprivation• Psychosocialstressors(marital,SES,support)• BipolarDisorderorSchizoaffectiveDisorder• HistoryofPostPartumDepression• Previousperi orprenatalpsychiatrichospitalization

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Sit, D, Rothschild AJ, Wisner KL. A review of post partum psychosis, J Womens Health 2006

PostPartumPsychosis• Extremelyrapidonsetafterdelivery• Withapredominanceofbipolardisorderastheunderlyingdiagnosis:– 72%withbipolarorschizoaffectivedisorder– 12%withSchizophrenia

• Andsomedistinguishingclinicalfeatures:– Confusion,BizarreBehaviors– Tactile,Olfactory,VisualHallucinations(AHtoo)– Moodlability ratherthanfixeddepressedmood– Psychomotoragitation,insomnia,thoughtdisorganization– Bizarredelusionsoftenwithreligiousorsupernaturalthemes.

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Andrea Yates

FilicidePrevention

• AggressivelyScreenforandtreatpsychiatricdisordersduringpregnancyandperipartum

• Evenclosermonitoringforwomenwithahistoryofbipolardisorderandorpostpartumpsychosis

• Specialcounseling– Notifyfamilyandpatientoflikelyrapidonsetofdepressionorpsychosiswithindaysofdelivery

– Immediatetreatmentplaninplacebeforedelivery– Planforpostpartumresumptionofmedications/ECTorother

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ARiskv.RewardCalculusGuidesTreatment

• Balancetheriskoffetalexposuretopsychotropicmedicationsagainsttherisksofrecurrentpsychiatricillness:qMild– ModDepression:SupportivePsychotherapy,CBT,IPT

qNonResponsiveSevereMDD:qConsiderFluoxetine,Citalopram,Sertraline.ConsiderTCAs(desipramine,nortriptylene)andBupropion

qAllareCategoryCwithequivocalstudies

• RememberwomenwhodiscontinueADtherapyinpregnancyare5xmorelikelytorelapsearecomparedtowomenwhomaintainADtherapythroughoutpregnancy(Cohenetal2006Jama)

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ARiskv.RewardCalculusGuidesTreatment

• ForBipolarDisorder– Higherrisksassociatedwithanticonvulsantuse– LithiumandLamotrigine sometimes,ValproateandCarbamazepinehigherrisk

– Typicalantipsychoticspreferredbecauseofmoreoutcomesdata

• ForPsychosisduringpregnancy– TypicalAntipsychoticMedications(HaloperidolandThiothixene)

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LessonsinPrevention

• ForRiskofFatalMaltreatment:– UsuallydetectedbyChildProtectiveServices– Treatmentofmaternalsubstanceuse– Someinquiryaboutparentingandaffect

• Doyouloseyourtemperwhenthebabywontstopcrying?

• Whatareyoursupportsathome?Yourstressors?• Amaternalsafetyinquiryfordomesticabuse

– Parentingclasses– Emergencynumbers– EmotionalSupport

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LessonsinPrevention

• ASK…ASK…ASK!1. Considerthepossibilityofmaternalfilicide

(psychosis,depression,mania,delirium)2. EdinburghPostnatalDepressionScalein

pregnancyandpostpartum3. Foralltreaters

1. Askaboutchildrearingpracticesindepth2. Askaboutparentingproblemsorchallenges3. Askaboutfeelingsofbeingoverwhelmed4. Ifsuicidalideasareelicited:

-Whatwouldhappentothechildrenifyousuicide?-Doyoufearleavingyourchildrenbehindifyoudie?

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LessonsinPrevention:

• LowerThresholdsforHospitalization• Depressedmotherswithyoungchildren

– Maternalfearsofharmingthechild– Delusionsemergingaboutthesufferingofchild– Improbableconcernsaboutchild’shealth– Hostilitytowardsahatedpartnerwiththemesofthechildbeinginvolved

• Psychoticmotherswithyoungchildren– Persecutorydelusions(problem=hidden)– Childrenwillsufferafateworsethandeath– Excessivechecksonhealthandsafetyofchildren

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PostHospitalization:

• Familymeetingstodiscussadherencetomedicationandappropriatesocialsupports

• Considervisitingnursesordoulas• Increasefrequencyofoutpatientappointmentswithallproviders

• Monitorthepatientwithamultidisciplinaryteamifpossible(casemanagerwithhomevisits,perinatalpsychiatrist,therapists,nurses,pediatrician)

• Considermedicationeffectsonlactation• ConsidernotificationofChildProtectiveServiceswhenappropriate

• Consideroutpatientcommitmentwhenappropriateandavailable

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The Brain Matters, Science Matters, Justice Matters

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368,2006.3. BourgetD,GraceJ,WhitehurstL.AReviewofmaternalandpaternalfilicide.JAmAcad Psychiatry

Law35:74-82,2007.4. WestSG.AnOverviewofFilicide.Psychiatry;Feb;4(2):48-57,2007.5. AbramsN,MatthewsS,MartinLJ,LombardCetal.GenderDifferencesinHomicideofNeonates,

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7. Kauppi A,Kumpulainen K,Karkola K,Vanamo Tetal.Maternalandpaternalfilicides:AretrospectivereviewoffilicidesinFinland.JAmAcad PsychiatryLaw38:229-38,2010.

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9. FlynnSM,ShawJJ,AbelKM.Filicide:MentalIllnessinthosewhokilltheirchildren.Plos One8(4):e589812013.

10. LewisCF,Bunce SC.FilicidalMothersandtheImpactofPsychosisonMaternalFilicide.JAmAcadPsychiatryLaw31:459-70,2003.

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