In the field of Women's Reproductive Mental Health
Severe maternal depression carries with it the characteristic features of impaired judgment, thought distortions and emotional detachment that increases a woman’s risk for child neglect, child abuse, and even fatal injury to her child. 5% of women with postpartum psychosis will complete a suicide and 4% will take the life of their child through either infanticide or neonaticide. Dr. Barnes is also the author of the entry on Infanticde in the Encyclopedia of Motherhood, published by Sage Publications in April 2010.
Expert Appointments for Legal Cases Involving Women’s Reproductive Mental Health
By Diana Lynn Barnes, Psy.D, LMFT (President, Postpartum Support International 2002-2004)
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As the legal community becomes increasingly aware of the impact of a postpartum mood disorder on a new mother’s state of mind with respect to her infant, the question of when to utilize the expertise of a woman’s reproductive mental health specialist becomes particularly salient. There are a wide range of perinatal mood illnesses (those disorders relating to the period surrounding pregnancy and childbirth) that can affect a woman’s behavior in relation to her baby. Although postpartum psychosis, in which there is a dramatic break with reality, is the illness most closely associated with neonaticide and infanticide, severe maternal depression carries with it a high risk of impaired judgment, distortions in thinking, and emotional detachment that increases the potential for child neglect and abuse that can have criminal implications. Among the many symptoms that the DSM IV identifies as criteria for a Major Depressive Episode are a “diminished ability to think or concentrate, and indecisiveness as well as recurrent thoughts of death which may include recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.” A diagnosis of Major Depression is confirmed when symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.
In many cases, the origins of a woman’s depression or psychosis are tied to reproductive events that occurred long before the actual legal offense that brings her to trial. Reproductive events include not only live births, but miscarriages, abortions, stillbirths, and ectopic pregnancies. Those of us familiar with the mental health history of Andrea Yates know that her psychotic thoughts began years before she drowned her five children in the bathtub of her Houston home; in fact, the seeds of her psychosis were already apparent after the birth of her first child. The research informs that with each untreated depression following childbirth, the risk of recurrence increases by 50-75% and the severity of the mood illness and its accompanying symptoms escalates.
When trying to ascertain a direct connection between a perinatal mood disorder and injury to a child, there are a number of factors for the defense to consider. How many pregnancies has this particular woman had over what period of time? Was her pregnancy planned or unplanned, and if it was an unexpected pregnancy, what kind of emotional support, if any, has she received from her partner and other family members? It’s not uncommon in cases of neonticide (the killing of an infant within 24 hours of birth) for a woman to be threatened with parental abandonment if at some future time she should become pregnant. Terrified of being isolated from family members, some of these women, upon discovering they are pregnant, are thrown into a state of dissociation and become immersed in a psychological denial, concealing the existence of the pregnancy not only to family and friends, but to themselves as well.
Questions about her mental state and behavior during the pregnancy in question should be asked of involved family members as well as the woman herself. Were there noticeable changes in mood or did she demonstrate a diminished sense of the emotional significance of the pregnancy? The blunting of affect during pregnancy in which the expectant mother acts as though she is not pregnant, – there is no change in lifestyle, no interactions with the fetus, no preparations made for the infant’s birth, no apparent connection to the pregnancy – all of these actions can have unfavorable consequences for both maternal mental health and fetal outcome. Sometimes, women with psychotic disorders have delusional beliefs about the pregnancy. They may acknowledge that something is growing inside of them, but don’t experience it as a fetus. For example, a woman may perceive it as a blood clot or a cancer, or in the case of one woman, an alien that needed to be cut out for her own survival.
In considering whether the death of a child has been precipitated by a psychotic episode, the psychosocial stresses that are known to contribute to a woman’s vulnerability to depression and psychosis need to be evaluated by a woman’s reproductive mental health expert who understands the relationship between those stresses and changes in brain chemistry that can disrupt normal thought processes and affect a woman’s ability to cope with reality. Some of these stressors include a history of sexual, physical and/or emotional abuse, domestic violence, childhood traumas, previous losses (for example, a pregnancy loss or the death of a loved one) and a familial history of alcohol or drug abuse. Among women who commit neonaticide, a pervasive denial of the pregnancy through dissociation often becomes a way for them to manage the terror and undue stress that accompanies an unwanted pregnancy.
Upon questioning, these women may attribute fetal movement to intestinal problems like gas, labor pains are frequently misinterpreted as food poisoning or flu-like symptoms. The physical indications of pregnancy like weight gain or missed periods are either absent or misread. Many of these women have quiet, unassisted deliveries at home, while family members are sitting in an adjacent room. There are even characteristic ways in which they deliver. A state of depersonalization in which a woman may feel psychologically separated from her own body, seems to account for her ability to tolerate the intensity of labor, describing labor pains as mild and sometimes even non-existent. Some women even experience amnesia during certain aspects of the birthing process and upon return to conscious awareness are totally unable to account for the dead or abandoned infant.
Sometimes, as was the case with Andrea Yates, all of the children are put at risk by the harsh changes in mental health that occur with the birth of the last child; in other situations, only one of the children is targeted, and not necessarily the newborn, as in the case of a woman with psychosis who took the life of her middle child, a 2-year-old with special needs. However, it is the birth of the last child that becomes “the straw that broke the camel’s back,” particularly when a woman’s health and even her sanity, has been repeatedly compromised by previous pregnancies and untreated depression.
The appointment of an expert specifically trained in woman’s reproductive mental health is essential to the defense in terms of fitting together the relevant pieces of a woman’s reproductive and mental health history in order to determine any connections between her state of mind and the events surrounding the harm to her child. A clinician knowledgeable in the diagnosis and assessment of postpartum mood disorders is in the best position to ascertain whether the circumstances surrounding a particular case were driven by symptoms that would indicate a postpartum depression or psychosis.
American Psychiatric Association (1994). Diagnostic and statistical manual of Mental disorders (4th ed). Washington, DC.
Rosenberg, R., Greening, D., & Windell, J. (2003).Conquering postpartum depression: A proven plan for recovery. New York: De Capo Press.
Spinelli, M (2003). Infanticide: Psychosocial and legal perspectives on mothers who kill. New York: American Psychiatric Publishing