Mentally ill mothers who have killed: three cases addressing the issue of future parenting capability

Ethical Considerations for Assessing Parent Mental Health during Child Assessment Services

Parents play an integral role in the mental health service provision of children and adolescents, and they can have significant effects on the outcomes of youth. A growing body of research has linked parents' own mental health status to numerous outcomes for their children, and recent guidelines have emerged recommending the assessment of parent psychopathology when treating child patients. However, these recommendations present a range of ethical considerations. Mental health professionals must determine if the assessment of a parent is empirically supported and that an assessment procedure appropriate for parents can be feasibly implemented. They must also respect the autonomy and confidentiality of parents while ensuring that assessment findings can be translated to meaningful benefits for child patients. This article details and discusses each of these concerns within the context of the relevant principles and standards of the 2016 American Psychological Association's Code of Ethics. Further, it provides guidelines, relevant clinical examples, and an applied model for mental health professionals to consider the ethical implications of assessing parent mental health when serving child patients.

Violence by Parents Against Their Children: Reporting of Maltreatment Suspicions, Child Protection, and Risk in Mental Illness

Psychiatrists are mandated to report suspicions of child abuse in America. Potential for harm to children should be considered when one is treating parents who are at risk. Although it is the commonly held wisdom that mental illness itself is a major risk factor for child abuse, there are methodologic issues with studies purporting to demonstrate this. Rather, the risk from an individual parent must be considered. Substance abuse and personality disorder pose a separate risk than serious mental illness. Violence risk from mental illness is dynamic, rather than static. When severe mental illness is well-treated, the risk is decreased. However, these families are in need of social support.

Factors associated with two types of child custody loss among a sample of African American mothers: A novel approach

African American families are overrepresented in the Child Welfare System; however, extant research on this phenomenon has (1) focused mostly on Caucasian or mixed-race samples and (2) has not examined informal custody arrangements alongside official child custody loss. This research addresses these gaps in the literature by examining factors associated with both official and informal child custody loss among a sample of African American mothers. Multinomial regression results show that having ever been incarcerated following a conviction increases the odds of experiencing both types of custody loss relative to no loss. Additionally, mother's experiences of childhood victimization increase the likelihood of informal custody loss relative to no loss, while being older, past year homelessness, number of minor children, being lesbian or bisexual, crack/cocaine use, and more family social support increase the odds of official loss versus no loss. Finally, increases in social support from friends decrease the odds of official loss. Implications are discussed.

New challenges in family interventions for schizophrenia

This review first outlines the rationale and research base supporting the development of family interventions for schizophrenia. The over-riding principles guiding effective family interventions for schizophrenia are then presented, along with the key components (engagement, assessment, education, communication skills training and problem-solving) shared by most family programs in schizophrenia. Meta-analyses demonstrating the efficacy of family interventions in reducing relapse and rehospitalization in schizophrenia are then discussed, along with issues regarding minimal duration of effective treatment, differential benefits of single and multiple family modalities and mixed evidence for the maintenance of treatment effects after termination. The benefits of participation in family-organized, nonprofessional support and education programs are then described. Finally, three issues meriting further study are outlined.

Distressed fathers and their children: a review of the literature

BACKGROUND

Many men diagnosed with mental health problems are also fathers. This literature review addresses issues relating to both the fathering role taken on by men who have mental health problems as well as the impact of their mental health on their children.

MATERIAL

An integrative review of the literature was conducted from studies originating in four countries, resulting in an analysis of 31 journal articles.

DISCUSSION AND CONCLUSIONS

Most of the quantitative literature focuses on the many risks and negative outcomes for children. However, qualitative studies suggest positive outcomes such as strong parent-child relationships, which demand further attention both in research and in practice.

Denial of pregnancy: a psychodynamic paradigm

This article discusses denial of pregnancy. It includes clinical material from 17 women who not only denied pregnancy but committed neonaticide and were evaluated for forensic reasons. The forensic issues have been discussed elsewhere and are not considered here. The literature on denial of pregnancy taken in conjunction with the clinical profiles presented here indicates that women who deny pregnancy tend to experience dissociative psychopathology. Not all pregnant women who dissociate deny pregnancy, however. This article discusses why some women who dissociate but not all develop the dramatic symptom-denial of pregnancy.

Parental divorce, parental depression, and gender differences in adult offspring suicide attempt

Research suggests parental divorce during childhood increases risk of suicide attempt for male but not female offspring. The negative impact on offspring associated with parental divorce may be better explained by parental psychopathology, such as depression. We examined whether adult offspring of parental divorce experience elevated risk of suicide attempt, controlling for parental history of depression, and whether the risk varies by the gender of the offspring. Using the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the sample consists of respondents who experienced parental divorce (N = 4895). Multivariable regressions controlled for age, race/ethnicity, income, marital status, and parental history of depression. Females living with their fathers were significantly more likely to report lifetime suicide attempts than females living with their mothers, even after controlling for parental depression. Findings suggest that childhood/adolescent parental divorce may have a stronger impact on suicide attempt risk in female offspring than previously recognized.

WHEN PARENTS WITH SEVERE MENTAL ILLNESS LOSE CONTACT WITH THEIR CHILDREN: ARE PSYCHIATRIC SYMPTOMS OR SUBSTANCE USE TO BLAME?

This study compared parental psychiatric symptom severity, and the absence or presence of severe substance abuse, as predictors of contact with minor children for a representative sample of adults with diagnoses of serious mental illness (N = 45). Child contact and psychiatric symptom severity were measured during regularly scheduled 6-month research interviews over a total 30-month period following each participant's entry into the project. Severe substance abuse was documented as present or absent for the 6-month interval preceding each interview. Results revealed that incidence of severe substance abuse was repeatedly associated with less frequent parent-child contact, even after controlling for psychiatric symptoms, diagnosis, gender, age, ethnicity, and socioeconomic status. Neither psychiatric diagnosis nor symptom severity predicted frequency of child contact when substance abuse was taken into account. Mental health agencies offering parenting classes for adults with serious mental illness should incorporate substance use interventions to reduce loss of child custody and strengthen parent-child relationships.

[Infanticide in the postpartum period: about a clinical case]

BACKGROUND

Infanticide is an extremely traumatic criminal act, which has psychopathologic repercussions and severe sociofamilial consequences. It is marked by its plurality of forms, the variety of its aspects and the frequency of its hidden cases. Circumstances and modes of completion of the infanticide act are variable according to the nature of the author and the sociocultural context. Infanticide is often situated within the framework of an acute and a chronic structured psychiatric pathology (puerperal psychosis, maniacodepressive psychosis, schizophrenia, epilepsy, substance abuse, etc.). Sometimes, it is connected to sociocultural constraints and confusions of adaptation of the postpartum stage. The psychopathologic justifications evoke a profound dysfunction of the mother-child interactions, fears of division and the infantile and regressive characteristics of the mother. The medicolegal issue of responsibility of the author of infanticide is complex. Treatment depends on the mental pathology of the author; psychotherapeutic efforts are required in parallel with pharmacological treatment. The role of psychiatrists in preventing the act of infanticide is crucial. This consists in detecting the populations at risk, identifying the psychiatric complications of the postpartum stage and ensuring an adequate coordination of the maternity team and the social services.

CASE-REPORT

The infanticide acts reported in the literature are situated in diverse contexts and are motivated by various circumstances. We report a case of a young woman without any personal or family psychiatric history; she is married and has a stable matrimonial life. She was hospitalised following a suicide attempt and subsequently killed her child by strangulation; this occurred ten days after giving birth. The murder took place during a first psychotic episode that arose brutally one week after delivery and essentially included persecution mania, inconsistent comments, auditive hallucinations, indifference and emotional coolness. This symptomatology lasted four months and totally regressed with antipsychotics. The diagnosis of a puerperal psychosis was evoked at first, having eliminated major melancholic depression and any organic affection.

CONCLUSION

The illustration of our clinical case shows to what extent the role of the psychiatrist is essential in preventing and ensuring the therapeutic stage of such psychiatric disorders arising during the postpartum stage, which would complicate infanticide acts at any time.

Workforce capacity to respond to children whose parents have a mental illness

OBJECTIVE

The first of the three objectives of this study was to identify the core barriers that impede adult mental health and other clinicians from working with patients about parenting and child-related issues. The second and third objectives were to rate the importance of these barriers and to compare barriers for adult mental health workers with other workers.

METHOD

There were two data collection phases; the first, qualitative phase involved collecting verbatim responses from 60 mental health and welfare workers, regarding barriers about working with mentally ill patients about their parenting role as well as with their children. The second involved 32 participants, including 20 adult mental health workers and 12 other workers, responding to the scaled questionnaire items based on the qualitative barriers identified at phase one.

RESULTS

The most important barriers highlighted by workers were patients not identifying their illness as a problem for their children and patients denying that they had a mental health problem. All workers reported that it was part of their role to get involved with issues regarding their patient's children. In comparison to other workers, adult mental health workers reported time and resource limitations, as well as skill and knowledge deficits regarding parenting and working with children.

CONCLUSIONS

The findings are discussed in relation to adult mental health policy and ongoing professional development, particularly for adult mental health workers.

The potential impact of the recovery movement on family interventions for schizophrenia: opportunities and obstacles

Many types of family interventions have been found to be effective in reducing exacerbations in schizophrenia; some also improve consumer social functioning and reduce family burden. Regardless of their origins, these interventions share a number of common features, such as showing empathy for all participants, providing knowledge about the illness, assuming a nonpathologizing stance, and teaching communication and problem-solving skills. Importantly, these family interventions have many characteristics that are consistent with the growing recovery movement in mental health in that they are community-based, emphasize achieving personally relevant goals, work on instilling hope, and focus on improving natural supports. Nevertheless, these interventions are generally reflective of older models of serious and persisting psychiatric illnesses that are grounded in a "patient being treated for a chronic illness" rather than a "consumer assuming as much responsibility as possible for his/her recovery" stance. These interventions could be made more consistent with recovery principles by (1) expanding the definition of family to include marital, parenting, and sibling relationships, (2) identifying better ways to match consumers with treatments, (3) broadening the research focus to include systems change that promotes making family members a part of the treatment team (with the consumer's consent), and (4) overcoming implementation obstacles that preclude access to effective family interventions for most consumers and their relatives.

The aftermath: aspects of recovery described by perpetrators of maternal filicide committed in the context of severe mental illness

Mentally abnormal maternal filicide is a rare and horrifying event. Clinicians are unlikely to develop broad experience with this and there is little information available about recovery. This paper presents a range of descriptions of recovery experiences derived from a qualitative study of mentally abnormal maternal filicide perpetrators. Transcripts from a qualitative, semi-structured interview study of six women who committed filicide in the context of major mental illness were reviewed. Descriptions related to rehabilitation issues were grouped and themes extracted. The women described patchy but horrific memories they avoided thinking and talking about. They described intense self-judgement and self-hate. They valued ongoing relationships with surviving children and were distressed by perceptions that they might be a danger to other children. Managing illness was not described as a major challenge. Acknowledgement of illness was described as important in coming to terms with what they had done. Surviving children and relationships with family and other support networks were described as important in their rehabilitation. We conclude that optimizing treatment and rehabilitation for mental illness, supporting the woman to acknowledge the role of illness in the offence, maximizing support from personal networks, and enabling her to regain some aspect of the mother role may be more efficacious than debriefing with respect to the offence.

Ethical challenges of decision making with pregnant patients who have schizophrenia

OBJECTIVE

Because there is a dearth of literature, we developed an ethical framework to guide decision making about the management of pregnancy of patients with schizophrenia.

STUDY DESIGN

We review pertinent literature on schizophrenia and pregnancy, including information on maternal and fetal risks and outcomes, and relate this information to ethical concepts.

RESULTS

The ethical framework has five components: the concept of chronically and variably impaired autonomy, assisted decision making, surrogate decision making, strategies for dealing with the physician's feelings in response to these patients, and the concept of the fetus as a patient. We apply this ethical framework to clinical challenges of decision making during pregnancy with this patient population.

CONCLUSIONS

The preventive ethics strategies of assisted and surrogate decision making can be used to prevent ethical conflicts in decision making about the management of pregnancy of patients with schizophrenia. These preventive ethics strategies should contribute significantly to reducing the vulnerability of these patients and therefore to enhancing their autonomy in the physician-patient relationship.

Community mental health care for women with severe mental illness who are parents

Women with SMI are involved in childbearing and childrearing, but may have problems with parenting related to symptoms, lack of knowledge and skills, or lack of environmental supports. They may need intensive services to manage their mental illness and to parent to the best of their abilities. Preliminary research suggests that mental health interventions can improve family functioning, but that these services are not widely available in community mental health systems. This paper describes services to help clients who are parents, which includes integration of adult's and children's services, long-term, home-based parent training, and linkage with community supports.

The evaluation of maternal competency

There is limited discussion of maternal competency in the consultation-liaison psychiatry literature. As awareness and reporting of child abuse is increasing, maternal ability to care for newborns is more often called into question. Maternal risk factors for harm and neglect have been identified, and positive signs of maternal ability have also been recognized as important to appraise. Specific domains in the maternal competency exam should be assessed by the psychiatrist, nursing staff, social work staff and pediatrician. The competency exam by the psychiatrist requires a sensitive and nonjudgmental inquiry into maternal behavior and thoughts. The authors present a case study of an inpatient maternal competency consultation that illustrates some of the dilemmas encountered. Future directions should include more involvement by psychiatrists in preventive efforts and interventions that focus on pregnant women at risk in prenatal clinics and in the community.

Child abuse: current problems and key public health challenges

Child abuse has recently been recognized by the World Health Organization as a major worldwide health problem impairing the health and welfare of children and adolescents. This paper attempts to look at child abuse from a public health perspective taking into account the vast cultural diversity in which children and adolescents live focusing on the issue of abuse and violence in a broad public health perspective, and trying to highlight the need for greater attention to be given to possible country-specific interventions.