Mental health professionals have a legal, ethical, and moral duty to warn when they suspect a client may be a danger to themselves or others. An individual’s risk of violence is based on a synergistic combination of certain historical experiences and behaviors, environmental and situational conditions, as well as personality traits and trends. It is a determination that is difficult to make, and is especially challenging when attempting to identify the propensity of a parent for filicide-suicide (F-S).

Assessing for F-S is not merely a matter of determining the propensity for fatal violence and the likelihood of suicide. This is due to the fact that some of the most reliable risk and protective factors of violence and of suicide are not indicative of F-S (Stroud & Pritchard, 2001; Beck & Weishaar, 1990; Blumenthal, 1990). For example, a few of the most reliable risk factors for general, serious violence include being a young adult, substance abuse, and impulsivity. With F-S, the parents are comparatively older and typically do not have past or present problems with substance abuse or impulsivity. Two of the most notable protective factors for suicide—being married and parenting—are actually characteristic of perpetrators of F-S (Marzuk, Tardiff, & Hirsch, 1992). Of note, it appears that maternal F-S does parallel the suicide rate in any given country (World Health Organization, 2008).

Characteristics of the Crime
Over the past four decades, approximately 50% of parents who murdered their children also made a nonfatal or fatal attempt at suicide (Bourget & Gagne, 2002; Alder & Polk, 2001; Haapasalo & Petaejae, 1999; Alder & Baker, 1997; Adelson, 1961, 1991). When filicide occurs without the subsequent parental suicide, the victims are typically younger than victims of filicide followed by suicide (Bourget, Grace, & Whitehurst, 2007; Christoffel, Liu, & Stamler, 1981). Most acts of infanticide (and filicide without parental suicide) occur during the first 12 months of the child’s life. By definition, victims of neonaticide are less than 25 hours old, while victims of post-partum filicide are younger than 12 months. According to the most recently available data, victims of fatal child abuse in the United States are under the age of 2; this average varies between countries and across time (Child Welfare Information Gateway, 2008; McClain, Sacks, Froehlke, & Ewigman, 1993; Christoffel et al.). In contrast with these figures, approximately 60% of the child victims of F-S are between 1 and 6 years old and, unlike fatal child abuse, this figure tends to be stable across time and countries (Byard, Knight, James, & Gilbert, 1999; McKee & Shea, 1998).

Not only is there a difference in the age of the child victim of fatal abuse and F-S, there is also a difference in the average age of the parent perpetrator. Fatally abusive mothers tend to be in their late teens or early 20s, whereas mothers who commit F-S are generally between 27 and 35 years old. Beyond demographic characteristics, there is a significant difference in the mental state of the perpetrator. While death from child abuse is accidental, a child’s death from F-S is the result of deliberately executed acts that were pre-planned and in no way impulsive (Bourget et al., 2007; Bourget & Gagne, 2002; Alder & Polk, 2001; Meszaros & Fisher-Danzinger, 2000; Okumura & Kraus, 1996).

Research suggests that most mothers who committed F-S had one or two children, with the eldest child generally not older than 7 (Bourget et al., 2007; McKee & Shea, 1998). Daughters with no male siblings appear to be at a higher risk than those with male siblings or with sons alone. When committing filicide, mothers tended to use those methods they believed were “painless,” such as suffocation, drowning, or asphyxiation by gas. The vast majority of mothers used the same method employed in the filicide for their suicide. When that was not feasible, they tended to use a more violent method.

By definition, F-S includes the suicide—post-filicide—of the perpetrating parent. It seems, however, that the small group of F-S mothers whose pathology included psychotic features were the least likely to follow through on their intention, making no attempt or a nonfatal attempt (Lewis & Bunce, 2003; Adler & Polk, 2001; Marzuk, Tardiff, Leon, & Portera, 1997). It has been posited that the filicide alone may have provided sufficient release of tension to drain the physical and emotional energy required for successful suicide. In general, nonfatal F-S tends to be the result of some unanticipated or unforeseen problem with the chosen method. Parents who commit F-S virtually never utilize an “accomplice” or make any effort to disguise their behavior or shift responsibility to another party.

Indicators of Vulnerability
Common sense would suggest that parents who intentionally kill their child(ren) and themselves must suffer from severe mental illness. This is, however, a misconception based in part on an incomplete analysis of the research. Those studies finding significant mental illness used samples of F-S parents whose suicide attempt was nonfatal. These subject pools fall into two narrow groups: those who were assessed immediately after the incident while still hospitalized, and those who were assessed in the context of raising an “insanity” defense during criminal proceedings on charges of filicide. As previously mentioned, failed suicide attempts are most frequently seen in the small group of F-S parents with psychotic features, thereby limiting the generalization of the findings. The myth or misconception of mental illness has been further reinforced by the psychosis often associated with post-partum filicides, a distinctly different event from F-S.

More reliable findings come from studies utilizing psychological autopsies on those F-S parents whose suicide attempt was fatal. This research demonstrates that most F-S parents were functioning well in all social roles prior to the incident. These parents were not abusive and did not have a diagnosable problem with substance abuse. While not manifesting more obvious psychiatric illness, F-S parents generally do suffer from depression and anxiety that is exclusive of a thought disorder.

Fathers who commit F-S tend to be the sole earner in the family who are also given to chronic depression. Around the time of the incident, these men are likely to have suffered some work-related loss, such as a decrease in salary or hours, a demotion, being laid off or fired, or a disabling work-related injury. On average, the child victims of F-S fathers are older than those of F-S mothers.
Some of the most extensive retrospective research has been conducted on F-S mothers. This body of work reveals certain personality traits and trends that can serve as risk factors or indicators of vulnerability for F-S (Alder & Polk, 2001; Meszaros & Fisher-Danzinger, 2000; Haapasalo & Petaejae, 1999; Alder & Baker, 1997; Okumura & Kraus, 1996). Specifically, these women tend to suffer from an overwhelming sensitivity to real and perceived rejection, resulting in chronic symptoms of both anxiety and depression. They live with paralyzing performance anxiety, unrealistically afraid of not being able to meet the perceived standards of others. F-S mothers dread that what they believe to be personal shortcomings will be exposed, and they will be rejected and stigmatized as a result. In an effort to avoid being “found out,” they tend to be overly responsible, very orderly, and given to following the rules.

Mothers who commit F-S often had difficult childhoods that may have included emotional and/or sexual abuse. Their own mothers may have been incapable of providing nurturance or unconditional acceptance. The fear of rejection that is so characteristic of F-S mothers dates back to early age and may have made their adolescence especially painful. Over the years, these women developed a profound sense of guilt over essentially “normal” behaviors that they perceive as shameful. They live with the fear that these “secrets” will be discovered and bring disgrace to their family.

Mothers who commit F-S are given to over-identifying with others, especially with their children. They see their children as extensions of themselves, rather than as independent, separate individuals. As such, they are convinced their children will have the same problems and pains they did throughout their life. They are mortified at what they consider to be the inevitable humiliation and rejection their children will suffer. Excessively concerned with their children’s future well being, their grief and anxiety is compounded by their self-perception of being inadequate mothers, unable to change themselves or to have any meaningful impact on their children’s future.

Believing themselves to be “damaged goods,” these mothers fear their weaknesses and limitations will be passed on to their children by nature or nurture. The guilt this provokes is exacerbated if their child is in any way disabled. Such a disability highlights the mother’s feelings of helplessness and increases the fear that her child (and, therefore, she) will be rejected. The additional demands of parenting a child with special needs may tax the mother’s drive for perfection and order to the breaking point.
These are women who, despite appearances, find every aspect of life hard. They have a limited ability to cope with stress and change, a tendency also seen in women who commit suicide without filicide (Shneidman, 1999). With periods of heightened stress, their fear of impending doom and disaster can become absolutely overwhelming. Events that should be happy and filled with positive anticipation (like a child’s birthday party, soccer game, or first day of school) can be agonizing for these mothers.
To survive this unbearable degree of mental and emotional turmoil, F-S mothers essentially “shut off” their thinking and awareness, keeping their focus limited to the behavioral task at hand. Although emotionally numb and detached, they are able to maintain a presentation of normalcy that does not belie their fragility. When the F-S mother is no longer able to suppress her fear and anxiety, she may see no way to protect herself and her children from current and future misery but through filicide-suicide.

Identifying the Risk
Research suggests that maternal F-S is committed primarily by high-functioning, white, middle-class women who were employed prior to becoming “stay-at-home moms” (Bourget et al., 2007; Bourget & Gagne, 2002; Alder & Polk, 2001; Meszaros & Fisher-Danzinger, 2000; Okumura & Kraus, 1996). Perhaps most sobering is the fact that over the last 15 to 20 years, 70%–100% of F-S mothers had received psychotherapy at some time in the year preceding the murder-suicide. For a significant number, their last contact with a mental health professional was just weeks or days before. For virtually all, the presenting problem was depression. Approximately 20% had been hospitalized previously for severe depression.

Unfortunately, the very pathology that leads to F-S makes these women rather difficult clients. Ambivalent about the therapeutic process, they may have a history of frequent interruptions in their treatment, premature terminations, or show a pattern of moving from therapist to therapist. They tend to be disillusioned by therapy, perhaps due, in part, to their inability to disclose the full scope of the issues with which they struggle.

The F-S-vulnerable client fears being “revealed” and rejected by others, which includes the mental health professional. They worry about being negatively evaluated by others for being in therapy, being seen as “crazy” by their therapist, and being ostracized by family should they be hospitalized. Beyond the stigmatization, these women cannot bear the thought of having to openly face their perceived failings. As a result, it is unlikely these mothers will disclose F-S ideation, let alone a prior aborted attempt. While this information may not be volunteered to therapists, virtually all F-S mothers have made reference to their ideation to a family member or friend. Often the thought is expressed very clearly, but in a manner the listener is apt not to take seriously.

Ideation itself poses a huge problem for the mother’s self-image, reinforcing her self-perception of being a “bad mother.” This, in turn, increases the mother’s depression, leads to further emotional isolation, and perpetuates the ideation. Ideation may escalate sharply when the F-S mother is facing some type of real or perceived loss or abandonment, such as a child starting school or a divorce. An increase in ideation is especially likely when the F-S mother is facing an upcoming event (something as seemingly innocuous as a medical appointment), which she fears will lead to the exposure of her “secrets” (or past behaviors she perceived as shameful), which she then believes will lead to subsequent rejection and isolation. As with suicide, ideation increases the probability of the behavior occurring, and those mothers who have made an aborted attempt at F-S may be more likely to try again.

The role of fear of abandonment as an escalator of F-S ideation is especially significant as many F-S mothers have poor, emotionally distant marriages that leave them feeling further isolated. Many of these women have simultaneous problems with their own parents, either or both of which may have taken them to counseling. Problems in these domains are especially salient risk factors for these mothers, whose acute social anxiety leaves them uniquely dependent on their family for their sense of security. The fear of losing this perceived support tends to be exacerbated by these mothers’ self-perception of being unattractive on any level.

There is a clear association between generalized or social anxiety disorder and suicidality (Lecrubier et al., 2000). Of all those diagnosed with social anxiety disorder, approximately 75% will experience suicidal ideation and 45% will make a nonfatal suicide attempt during their lifetime. For all women under 40 (regardless the diagnosis), the first attempt at suicide proves fatal for 50%. These are statistics that appear to extend to F-S mothers. Of note, 50% of F-S mothers who made a fatal or nonfatal suicide attempt after filicide had made a previous attempt without associated attempted filicide (Bourget & Gagne, 2002; Alder & Polk, 2001). With maternal F-S, a suicide attempt prior to motherhood escalates the risk of eventual, successful F-S.

With all clients who are depressed mothers of young children—regardless of whether they have either directly or indirectly raised the issue of suicidal ideation—mental health professionals should assess the bond between the mother and child(ren). This is especially important when the mother does not work and suffers from severe social anxiety. Beyond the enmeshed relationship, child victims of F-S are often “too loved” by their mother. These mothers may compensate for their filicidal thoughts by being overly concerned (even preoccupied) about the child being harmed by others, and over protective as a result (Jennings, Ross, Popper, & Elmore, 1999).

When a depressed mother (or father who is the primary caretaker) has acknowledged suicidal ideation, it may prove beneficial to ask directly what they believe will happen to their child(ren) after their death. This is not specifically to ground them to a reason for living, but to assess if filicide is part of the parent’s suicidal plan. Mothers who are focused on planning for F-S may not have an immediate or well-thought-out answer.

Similar to a suicidal patient, with F-S mothers, be certain to assess the feasibility of their plan and the extent of their preparation. Check for such things as the availability of the chosen method and whether (and why) they intend to use the same method for both the filicide and the suicide. Probe not only for when and where they intend to commit the offense, but also if they plan to include all of their children in the filicide (and in what order). Perhaps most importantly, determine if the F-S mother has a “Plan B” in case some aspect of her chosen plan fails.

Final Thoughts
In the time leading up to the incident, the F-S client may have been experiencing prolonged periods of heightened sensitivity to rejection and foreboding that they are unable to contain. Therapists may see a qualitative change in how and what the client discusses in therapy; she or he may “pull back,” minimize any problems, and/or credit the therapist with reported “progress.” Since F-S is carefully planned in advance, and 70%–100% of F-S perpetrators are in therapy during the year before the crime, there is a tremendous opportunity for mental health professionals to intervene.

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