Ms. A, a 16-year-old mother with chronic dysthymia and posttraumatic stress disorder, came to the attention of the state child protective agency after she killed her newborn infant. Unaware that she was pregnant, Ms. A delivered her infant in a toilet. She subsequently placed the infant in a plastic bag in the basement and notified a relative. She was charged with manslaughter and spent several months in a juvenile detention home. During that time, Ms. A's mother raised Ms. A's first child, then age one.
Ms. A subsequently developed additional psychiatric problems. She suffered from vivid flashbacks of the baby's birth. She developed insomnia, crying spells, and intermittent depressed mood. She withdrew from friends. She became pregnant with a third child. This time she was fully aware of the pregnancy but concealed it from others. Because she deliberately concealed the pregnancy, she lost custody of this baby at birth.
A Parenting Risk Assessment was requested three years after the neonaticide to determine whether Ms. A should regain custody of her children, who were then one and four years old. The Parenting Risk Assessment revealed that Ms. A had maintained regular contact with her children since her loss of custody. In both a home and a clinical setting, she showed positive parenting skills and responded readily and sensitively to her children's cues (25). Her children directly sought her out for comfort when needed and were able to freely explore their surroundings in her presence (4,33). Ms. A had positive internal representations of her children and clearly valued her relationship with them (26). She could separate her own needs from those of her children. She had appropriate expectations about what could be expected of children of different ages (28).
A psychiatric interview and record review found that Ms. A had no current psychiatric symptoms. She had no history of violence or suicide attempts. After the neonaticide, Ms. A had occasional thoughts of wishing she were dead but did not act on these thoughts. Since the neonaticide, she had become involved in individual psychotherapy. She had developed a trusting relationship with her therapist and was directly discussing the neonaticide, her role in the death of her infant, and family problems.
Ms. A's complete suppression of her second pregnancy and her concealment of her third pregnancy were conditioned by substantial psychological and family problems already evidenced at the time of her first pregnancy at age 13. Her parents made it clear at that time that abortion was never an option. Her father blamed her mother for allowing the pregnancy to happen. He began drinking and often beat her mother after this incident. Family members repeatedly admonished Ms. A for the pregnancy and asked her how she could have done this to her mother.
Denial of pregnancy followed by neonaticide is a well-known phenomenon (35). In these cases, the mother is typically an unmarried, immature teenager who experiences the pregnancy as an overwhelming stress. This phenomenon usually occurs in a family context where the girl fears that revealing a pregnancy to her parents would have dire consequences.
Sometimes the girl is aware she is pregnant and deliberately conceals the pregnancy from others. The more dangerous situation involves the girl who under intense psychological pressure suppresses awareness of the pregnancy even from herself. She reinterprets or ignores physical changes. In these cases, the baby is typically delivered without preparation, often in a toilet. The sudden appearance of the baby triggers overwhelming panic in the mother, who either actively kills the baby or leaves the baby in the toilet to drown. After that, the mother may develop posttraumatic stress disorder, characterized by flashbacks, insomnia, and social withdrawal.
Ms. A's case belonged to the more dangerous scenarios for neonaticide because she fully denied her pregnancy and had reinterpreted major physical symptoms of the pregnancy. For example, she believed that the baby's kicking was due to gas and interpreted labor pains as signaling a need for a bowel movement.
The psychological and family problems that led Ms. A to conceal two pregnancies and kill her second baby were substantial. An evaluation of Ms. A's social support network, undertaken as part of the larger Parenting Risk Assessment, revealed that since the neonaticide, Ms. A had been living separately from her parents and had become less emotionally and financially dependent on them. She had established a small, but viable, support network for parenting. The assessment produced no evidence that her children were at risk of abuse from her. It also seemed highly likely that Ms. A's growing maturity and independence would lead her to approach a future pregnancy in a different manner.
The Risk of Violence Assessment revealed that Ms. A had no history of violent behavior. Several measures, including self-report, criminal record review, school reports, and interviews with collateral historians, supported this assessment. The one exception was the instance when she placed her newborn infant in a plastic bag and left it in the basement. This behavior had occurred in the context of a complete denial of pregnancy and considerable family pressure. Although Ms. A denied her next pregnancy, it seemed highly unlikely that she would deny any subsequent pregnancy or that she would kill a newborn. She had matured considerably since the neonaticide, had become independent of her family of origin, and was no longer influenced by pressures regarding pregnancy.
Ms. A's behavior with the newborn did not appear to be linked to dysthymia. When she was depressed, she had thought of suicide occasionally, but she had no history of suicide attempts. Her posttraumatic stress disorder appeared to be largely conditioned by the neonaticide. Nonetheless, when she was in individual therapy, Ms. A began to recall memories of early sexual abuse and talked openly about violence she witnessed between her stepfather and mother as a child. Although these factors could contribute to her experiencing anger and responding with violence, this explanation also seemed unlikely as she had been openly addressing these issues in therapy and was seeking out relationships and friends who had more healthy patterns of interaction. Finally, Ms. A had no history of other risk factors, such as alcohol or drug use.
Based on these recommendations, Ms. A regained custody of her children. She had provided safe parenting for about one year at the time this report was prepared.
Ms. B, a 17-year-old single mother with recurrent major depression, was convicted of involuntary manslaughter of her second child, Mary. Ms. B's repeated hitting of her daughter over a period of several months had contributed substantially to her death at age one. The autopsy revealed multiple bruises on the small body and head.
Ms. B lost custody of her first child at the time of her conviction. During her jail term, she delivered a third child. Subsequently, after her release from jail, she regained custody of her children. She again lost custody of her children ten years later, when she told her therapist that she was feeling the way she did when she killed Mary. At that time she was experiencing an episode of major depression. Two years later a Parenting Risk Assessment was requested to determine whether Ms. B could safely raise her children or whether parental rights should be terminated.
The Parenting Risk Assessment revealed that many parenting stresses were present when Ms. B killed Mary. At that time, she had been a teenage mother caring for two small children under age five (John, age three, and Mary, age one). When John was born, Ms. B had lived with her mother, who had helped care for John. At the time of Mary's birth, Ms. B had moved in with the father of her children. He was addicted to drugs and alcohol and was beating Ms. B regularly and severely. He would not allow her to leave their apartment or to socialize with anyone.
Ms. B no longer had support from her family of origin because they disapproved of her partner. Mary began to have feeding problems and often cried inconsolably. Ms. B became depressed and began hitting Mary in the head when she would not stop crying, or after she herself was hit by the children's father.
Ms. B's second custody loss and depressive episode also occurred in the context of overwhelming stress: pregnancy complications, birth of a new child, abandonment by her partner, poverty, and use of medroxyprogesterone acetate (Depo-Provera), a birth-control hormone that can cause depression as a side effect. At this time, Ms. B had four children who were younger than age 12.
Several current protective factors emerged in the Parenting Risk Assessment. On various cognitive, affective, and behavioral measures, Ms. B was found to have adequate caregiving abilities. She had appropriate ideas about what could be realistically expected of children of different ages (28). She had a balanced and realistic internal representation of her children and her relationship to them (26), and her interactions with her children were positive. She was able to read their cues and was sensitive to their needs. She showed no signs of hostile or intrusive behaviors, which are more prevalent in parents who physically abuse a child (25).
As for her mental illness, Ms. B could readily recognize the circumstances that triggered her depressive episodes and had previously sought and accepted help when she needed it. Although she herself had experienced an abusive and insecure childhood, she showed good insight into the effects of childhood experiences on her current parenting. She also acknowledged responsibility and remorse for Mary's killing and stated that this experience had forced her to mature and to try to be a better parent. Ownership of problems is a critical prerequisite for changes to occur in parenting (36).
Some risk factors were also present. Ms. B had four children to care for. Two had major developmental delays, and two were under age five. Her partner had frequently abandoned her in the past. Her continued reliance on his inconsistent support for parenting prevented her from identifying and maintaining other supports. Ms. B's depression was also a major risk factor. Record review revealed that when Ms. B had a major depressive episode, her parenting became impaired. She was less responsive to her children's cues, less able to meet their needs, and less apt to stimulate them. However, when Ms. B was not depressed, observations showed that her children enjoyed her presence and could use her as a secure base from which to explore their surroundings (4).
Several key issues needed to be considered in determining Ms. B's level of risk for future child maltreatment. They included the likelihood of relapse into depression, the likelihood that Ms. B would seek and accept help if she became depressed again, and the likelihood that Ms. B would abuse or grossly neglect her children if she became depressed.
Although there were no certain answers to these questions, there were probable answers. Ms. B's past depressions had all occurred under conditions of overwhelming stress. Her depression remitted when the stresses were no longer so acute. If overwhelming stress recurred in Ms. B's life and if she had inadequate support, her depression would probably recur.
As for her likelihood of seeking help when she became overwhelmed, the prognosis was good. When she was a teenager and killed her baby, she was socially isolated and was being abused herself. Since then, she had generally sought, accepted, and received help when she became depressed. Her recent custody loss was triggered by her acknowledging that she felt depressed and overwhelmed and needed help. Therapists working with her had uniformly found her to be responsive to therapy.
The likelihood of future abuse or neglect was also closely linked to Ms. B's relationship with her partner. At times he was supportive, showing a long-standing pattern of sporadic efforts to improve, followed by reneging on family responsibility. Unless this relationship could change, the risk of future maltreatment of the children was viewed as high. When Ms. B received feedback about the evaluation, she completely broke off her relationship with her partner and began to build a solid support network with family members and neighbors. Although Ms. B had killed an infant, the findings from the evaluation indicated that if she could build and maintain a solid support network for parenting, she would be at low risk for future maltreatment.
The Risk of Violence Assessment revealed that except for her repeated hitting of Mary, Ms. B had no history of violence toward anyone else. She denied ever having suicidal thoughts or attempting suicide, and there was little evidence that she was an angry, impulsive person. Ms. B also had no history of drug or alcohol abuse. These findings were corroborated by criminal background checks, by her therapist, and by interviews with collateral historians. Her beating of Mary was not an isolated instance of violence, however, and had occurred repeatedly over the course of several months.
Although this history should not be minimized, it is significant that it occurred in the context of depression, extreme stress, and social isolation, when Ms. B was young and was herself being beaten. Substantial evidence existed that she had matured considerably since that time. She had left her abusive partner. She had become engaged in and had responded well to therapy. In therapy, she had also explored her own sexual abuse by a relative in childhood and her witnessing of domestic violence between her mother and stepfather. When her depression recurred ten years after the first episode, she immediately told her counselor, as she was concerned that she could potentially place her children in danger again.
Ms. B had also developed a solid, though small, support network for parenting. Moreover, after Mary's death, Ms. B had been able to safely care for her four children for ten years. If Ms. B could maintain her support network, she appeared to be at low risk for future depression and violence. Ms. B is still in the process of regaining custody of her children.
Case 3: killing of an adult
Ms. C, a 22-year-old woman, killed a friend by beating her repeatedly in the face. The killing occurred during a psychotic break. Ms. C called the police after the event and stated that although she could not recall killing her friend, she must have done so because she had found her friend dead, the door was locked, and no one else was present. She was found not guilty of homicide by reason of insanity and was admitted to a psychiatric unit, where she remained for three years. During that time, she delivered a daughter and voluntarily relinquished her care to a relative. She was discharged on haloperidol, asymptomatic, with a diagnosis of schizoaffective disorder.
Ms. C took her medication regularly and remained asymptomatic until she became pregnant again. At that time her medication was discontinued due to the pregnancy. In her seventh month of pregnancy, she had hallucinations and paranoia. She decided to "wait it out" until she delivered, because then she would be able to resume her medication. During this time, she missed a probation appointment and was psychotic when the judge saw her in court. She was subsequently admitted involuntarily to a psychiatric unit. She voluntarily relinquished custody of her second child to a close relative.
After delivery she resumed taking haloperidol, this time in the form of long-acting decanoate injections. Her psychotic symptoms remitted within a few weeks. She remained asymptomatic until her next pregnancy, when her physician discontinued her haloperidol. Psychosis again recurred in the seventh month of pregnancy.
This time Ms. C asked her doctor for haloperidol. He prescribed a small dose but not her regular amount. Although this regimen kept her out of the hospital during pregnancy, she became psychotic the day she delivered her third child. At that time she was paranoid and made threats to "kill myself, kill my child, kill everyone." The state child protective agency took custody of her newborn. She was subsequently placed back on her usual dose of haloperidol; she quickly became asymptomatic and remained so.
A Parenting Risk Assessment was requested two years later to determine the anticipated level of risk if Ms. C's youngest child, then a two-year-old boy, was returned to her care. An examination of her parenting abilities and of factors that are known to directly influence parenting revealed a mixed picture. Ms. C had good cognitive understanding of different childrearing practices and disciplinary techniques (28), and she had a large social support network (32). The viability of this network was confirmed through interviews with collateral historians.
At the same time, several risk factors were present. Ms. C had a tendency to minimize the stresses of parenting (29). In interacting with her son, she tended to strongly direct and correct his behavior, rather than allowing him to initiate activities on his own (25). She also had somewhat negative perceptions of what her son was like and described him as "noncompliant and difficult." In observations with his mother both in the clinic and at home, Ms. C's son seemed apathetic and passive in her presence. His performance on a standard developmental test (37) showed that he had several delays in cognitive and linguistic development.
A mental status examination, undertaken as part of the larger Parenting Risk Assessment, revealed that Ms. C had coherent thought processes, with no loose associations, hallucinations, delusions, or suicidal or homicidal ideation. Her past symptoms were consistent with the diagnosis of schizophrenia (38). Ms. C had been highly responsive to pharmacotherapy with antipsychotic medication and was asymptomatic whenever she had taken medication regularly. She had demonstrated an excellent ability to manage her own self-care and function on a high level. Whenever she was without medication, however, her psychosis had recurred, sometimes with highly dangerous behaviors.
Thus while she was psychotic, Ms. C would be at high risk of neglecting and abusing a child due to behaviors that could be highly influenced by delusional beliefs, as had happened in her past episodes. When she was not psychotic, she did not exhibit violent behavior.
Some parents with schizophrenia have difficulty reading and responding to subtle nonverbal cues, which are essential for parenting (39). The Parenting Risk Assessment suggested that Ms. C had difficulties in this area, but because she had never had the opportunity to parent her children, it was not fully clear whether her difficulties were due to residual symptoms of schizophrenia, lack of experience, or both. There were some indications that she would benefit from interventions designed to improve her parenting. She was highly motivated and was taking medication regularly. She was also regularly attending group therapy.
Parenting rehabilitation efforts, such as coaching in the context of a therapeutic nursery, have successfully improved the parenting capability of many patients with schizophrenia (40). Thus a trial of intensive parenting rehabilitation could demonstrate whether Ms. C could respond to such intervention. If she could respond, the risk to her parenting would be considerably less.
After the Parenting Risk Assessment, Ms. C became involved in an intensive parenting rehabilitation program that included daily participation with her son for several hours at a time. A follow-up evaluation six months later showed marked progress. Her interactions with her son were more positive, as were her internal representations of him and of their relationship. Ms. C's son's developmental quotient had also improved.
A central remaining question concerned the likelihood of a relapse of her illness, given that she could become violent if she became psychotic again. However, once a person is responsive to a medication, the response generally persists over time. The major issue, then, was the likelihood that Ms. C would continue to take her medication. Ever since beginning a regimen of decanoate injections, she had adhered successfully to her medication regimen and had remained asymptomatic. There was no absolute assurance, however, that she would never relapse. As a back-up safety plan, it was suggested that she could arrange a standby guardianship in which legal custody of her children would automatically, but temporarily, revert to someone else in the event of relapse and revert back to her when she was well.
The Risk of Violence Assessment revealed that Ms. C could engage in dangerous and violent behaviors when she became psychotic. She also had violent fantasies of killing herself and others when she was paranoid. However, she had never exhibited violent behavior when she was not psychotic, and she had no history of arrests or incarcerations. When she was not psychotic, Ms. C was not an angry or impulsive person. She also had no problems with substance abuse. Her husband did have a long history of addiction problems, however, which could potentially influence Ms. C's ability to parent. Nonetheless, by all accounts, Ms. C's husband had taken his addiction treatment seriously and was maintaining sobriety. Overall, Ms. C appeared to be at low risk for future violence. Ms. C has not yet regained custody of her child, so it is not known whether the assessment's prediction of low risk for child maltreatment was accurate.
Recent proposals to "fast-track" cases in the foster care system are important, as many children may spend prolonged periods in foster care before decisions are made about custody. Prolonged separations, especially when a child is young, can have a powerful and negative impact on long-term development and functioning (4,5). At the same time, careful consideration needs to be given to criteria that are used to determine how to fast-track foster care cases.
The three cases described in this paper all involved mentally ill mothers who had lost custody of their children because they had killed a person in the past. Using recently proposed categories of abuse (3), these cases would be fast-tracked by automatically terminating parental rights. On the other hand, when these cases were examined individually with standard risk assessment methodologies, the mothers were deemed to be at low risk for future child maltreatment and violence.
It should be underscored that long-term outcome data on the parenting capabilities of the mothers are not yet available. The decisions in the cases reviewed here should not be generalized to other cases, as each case presents its own dynamics and constellation of issues to be addressed.
Cases like these, however, call into question the assumption that all mentally ill individuals who have killed in the past are permanently incapable of caring safely for children and that parental rights should, therefore, be terminated automatically (3). The cases also illustrate the fact that decisions about the parenting competency of mentally ill individuals are rarely clear-cut.
Careful consideration needs to be given to how to fast-track cases that involve individuals with chronic and severe mental disorders. Assessments that are performed when an individual first enters the mental health system would allow a thorough evaluation and speed up any future decisions about child custody. At present, many individuals with severe and chronic mental disorders are evaluated several times over a long period using unsound methodologies that do not directly assess parenting competency or potential for violence (41). Use of comprehensive, sound assessments when a case first enters the system could help considerably in shortening the length of time that children of mentally ill parents remain in foster care.