East Asian Arch Psychiatry 2015;25:79-87

ORIGINAL ARTICLE

Dr Salmi Razali, MD, MMedPsych, Psychological and Behavioural Medicine Discipline, Faculty of Medicine, Universiti Teknologi MARA, Malaysia.
Dr Raba’iah Mohd Salleh, MBBS, MMed (Psych), Dip (Forensic Psych), Forensic Psychiatry Unit, Hospital Bahagia Ulu Kinta, Perak, Malaysia.
Dr Badiah Yahya, MD, MMed (Psych), Dip (Forensic Psych), Forensic Psychiatry Unit, Hospital Permai, Tampoi, Johore, Malaysia.
Dr S. Hassan Ahmad, MBBS, DPM, Dip. Psych, MRCPsych, Psychological and Behavioural Medicine Discipline, Faculty of Medicine, Universiti Teknologi MARA, Malaysia.

Address for correspondence: Dr Salmi Razali, Psychological and Behavioural Medicine Discipline, Faculty of Medicine, Universiti Teknologi MARA, Malaysia.
Tel: (614) 5180 0435; Emails: drsalmi@gmail.com / drsalmi@salam.uitm.edu.my

Submitted: 4 February 2015; Accepted: 5 March 2015

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Introduction

‘Filicide’ is a general term used when a parent (biological, step-, or adoptive parent) kills his / her own child.^1-3 When the victim is aged less than a day, the term ‘neonaticide’ is used. ‘Infanticide’ is commonly used when the victim is aged less than a year.⁴ When the victims of killing are the child/ren and the spouse of the offender, the act is called ‘familicide’.⁵ Filicide includes a spectrum of behaviour that ranges from non-intentional to an intentional act of killing, from death related to maltreatment (such as abandonment, neglect, or exposure) to fatal assault (such as suffocation, strangulation, and stabbing) and from covert to overt child homicide.⁶ Many scholars have used ‘maternal filicide’ or ‘paternal filicide’ when the perpetrator is the mother or the father of the victim, respectively.^3,7

Interest in filicide among women with psychiatric disorders has increased considerably in recent years and is reflected by the substantial literature that has been published on this subject. While emergent research has refined our understanding of maternal filicide, a major limitation of current global knowledge of literature is the scarcity of empirical data as well as scholarly published studies from developing and poorly resourced countries. Thus, it hinders a broader understanding of this predicament.

The surge in research in filicide has begun since the review of filicide by Resnick in 1969.² Derived from the world literature of 13 languages from 1751 to 1967, a total of 155 filicide cases were reviewed. In this landmark study, Resnick² proposed a classification of filicide into 5 groups according to motive: (i) ‘altruistic’ — filicide occurred together with suicide of the parent or it was believed that by committing filicide, the parent could relieve his / her child’s suffering; (ii) ‘acutely psychotic’ — the parent killed his / her child under the influence of psychosis (such as hallucination or delusion) due to mental illness or organic psychosis; (iii) ‘unwanted child’ — the child was killed because s/he was not wanted or desired (such as illegitimate child, severe poverty); (iv) ‘accidental’ or fatal child maltreatment — the death of a child following battering or child abuse; and (v) ‘spouse revenge’ — the parent killed the child in the attempt to make his / her partner suffer. Later, in 1970, Resnick⁴ introduced ‘neonaticide’ to indicate killing of a newborn aged less than 1 day. Since the review by Resnick, various other proposed classifications with slight adjustments and modifications have been suggested.^8-12

There is no consensus on the prevalence of women with mental illness who commit filicide. The major limitation to the study of maternal filicide is inadequate numbers and inconsistent methodologies. The rates of major mental illness such as psychosis or depression in people who commit filicide are likewise inconsistent. In reported studies, the proportion with psychosis has ranged from 27% to 73%,^4,13-16 whereas the proportion with depression has been reported to be as low as 6% or as high as 82%.^2,17,18 Such variation may be due to differences in study location and the nature of the samples. Studies that have been carried out in a psychiatric setting^13,19 tend to report a higher percentage of mental illness.^14,15 Nonetheless the presence of minor mental illness in filicidal offenders was relatively low: only about 2% to 4% of studied offenders had an anxiety disorder^20,21 and a small proportion, in particular those who committed neonaticide, manifested dissociative phenomenon or symptoms of post-traumatic stress.^22,23

Most researchers agree that mental illness is an important mediating factor in filicide, especially in those who kill older infants or children. Opinion, however, is divided on the presence of profound mental illness in women who commit neonaticide. Some believe that such women have no frank mental disorders,^24-27 while others report a significant proportion with remarkable symptoms of mental illness.^13,20 The women have often been described as single, young, immature, with low self-esteem and dependent. They have often manifested with denial of pregnancy, received no perinatal care, delivered the baby alone, and killed the baby as soon as possible following delivery.^20,24,28

For filicide of infants and older children, substantial studies have implicated the presence of mental illness either before, during, or after the act. The characteristics of women who have severe mental illness and who commit filicide have been described by several studies. They were often older and had killed an older child, were married and more intelligent, but unemployed, divorced or separated and came from low socioeconomic status compared with those without mental illness. Women who committed filicide and had mental illness were more likely to have received outpatient psychiatric treatment, had a history of attempted suicide, and had previous substance abuse. They often confessed to the act and were acquitted on the grounds of insanity.^19,21,29,30

Objective of Study

Current knowledge and understanding of maternal filicide in women with mental illness published in scholarly journals are devoid of information from developing countries such as Malaysia. There are knowledge gaps in various socioeconomic backgrounds, motives for killing, stress, and various other life events experienced by the women who have mental illness and have attempted or committed filicide from this side of the world. The main objective of this study was therefore to gain more insight into the nature of this phenomenon with reference to Malaysia. We illustrate descriptively the background socio-demographics of women who attempted or committed the act of filicide and their victims, the various life events experienced by these women, and a summary of the history of the alleged offence.

Methods

Data Source

Data were derived from the clinical records of women who were admitted to 2 main forensic psychiatric institutions in Malaysia: Hospital Bahagia Ulu Kinta, Perak and Hospital Permai, Johore from 2000 until 2012. Both hospitals provide medicolegal or forensic admissions via referrals through the courts, prisons, and other relevant detention centres, mostly from peninsular Malaysia. The records contained a daily clinical evaluation of each patient and summary reports of the case from the police and courts.

The clinical records included patient demographic information, comprehensive history of the present illness, current and previous psychiatric history, history of the alleged offence, medical and surgical history, obstetric and gynaecological history, family history, social history, childhood history, and personal history. This routine individual history clerking was supported by information from family members, as well as routine physical examinations, mental state examinations, and relevant laboratory tests (such as urine or blood test for drugs), tests for general health — liver or kidney function test, etc., and psychological tests (such as the Minnesota Multiphasic Personality Inventory-2 for personality test³¹).

Data Management and Analysis

The research was led by a senior consultant forensic psychiatrist. Research members in each forensic psychiatric institution included a team comprising a consultant forensic psychiatrist and a medical officer in psychiatry. At each institution, the respective team reviewed the registration records from 2000 to 2012. The inclusion criteria included cases of women (biological, adoptive, or stepmother of the victim) who killed or attempted to kill her child aged 18 years and below. The clinical records together with the summary of related police and court records were reviewed. Brief characteristics of the women (age, ethnicity, marital status, level of education, and cohabiting family members) and the characteristics of the victim (age, sex, and relationship with the parent), as well as method of killing and diagnosis were reviewed and evaluated by both team members and later discussed with the senior consultant psychiatrist. All psychiatric diagnoses including Axis I and Axis II disorders were based on the diagnosis reported in the clinical records and usually followed the Diagnostic and Statistical Manual of Mental Disorders, Text Revision.³² The records were thoroughly discussed among the team and the stressors deemed crucial to the women’s life were summarised. Discussions also included the process of grouping each case. In keeping with other types of classification, overlapping occurred. Thus each case was grouped according to Resnick’s classification^2,4 only after each team member agreed that the chosen manifestation of the illness had the strongest influence on the women to commit filicide.

Ethics Approval

This study was approved by the Institute for Health Behavioural Research, Malaysia, National Institutes of Health Malaysia, Medical and Health Research Ethics Committee of Ministry of Health Malaysia, as well as Research and Ethics Committee of University Teknologi MARA.

Results

Table 1 illustrates brief characteristics of all the women in the study. There were 18 cases of women who had committed filicide with consequent death of 24 children. All women in our forensic psychiatric wards were either admitted under a court order for observation because of suspected mental illness or had committed filicide for reasons of insanity. The mean age of women without Axis 1 psychiatric diagnosis was 26 years (range, 17-42 years) and that of those with Axis 1 diagnosis was 33 years (range, 23-41 years). Six (33%) of the women were Malays, 5 (28%) Chinese, 3 (17%) Indians, 3 (17%) immigrants, and 1 (5%) Punjabi (an ethnic group originating from Punjab, India). Those 24 victims (9 girls and 15 boys) aged from newborn to 16 years. There were 3 (13%) cases of neonaticide. Three (13%) of the victims were stepchildren. There were a variety of methods used to kill the child: suffocation by smothering or strangulation in 6 (33%) cases; slashing or stabbing of child with a sharp object in 4 (22%) cases; beating, hitting and stepping on child in 3 (17%) cases, and 1 case each of poisoning, throwing into the bush, dropping, burning, and drowning (Table 2).

Overall, 13 (72%) women were within the 12-month postpartum period. Major depression was present in 8 (44%) women, schizophrenia in 3 (17%), and 1 for each had personality disorder and adjustment disorder. The remaining women (n = 5; 28%) had no obvious psychiatric diagnosis. Their marital status varied from either the women or their spouse had had previous marriage, had first or second divorce, had polygamous marriage, or both had first marriage.

In terms of stress, the clinical records in 7 (39%) cases showed evidence of marital discord; of these cases, 2 showed evidence of physical, psychological, or sexual abuse within the family (domestic violence). Other important stressors were financial constraint (n = 6; 33%), a husband with alcohol or substance dependence (n = 4; 22%), an overprotective husband (the woman perceived that her husband was overcontrolling or limiting her activity) [n = 2; 11%], felt burdened looking after children (the women complained about looking after their children) [n = 2; 11%], and 1 case of a child with physical illness (heart problem).

Resnick’s classification was used to group the cases. The most common groups were ‘acute psychosis’ (n = 5; 28%) and ‘altruistic or attempted suicide’ (n = 5; 28%) followed by ‘battering or fatal child maltreatment’ (n = 3; 17%) and ‘unwanted child’ (n = 3; 17%). The least common was ‘retaliation or spouse revenge’ (n = 2; 11%). In group 1, i.e. women with acute psychosis, the acts of filicide were mostly influenced by auditory hallucinations (4 women in this group). One woman (case 3) committed filicide during an episode of chronic and poorly controlled refractory psychosis because of cognitive deficit and poor judgement. This was also evidenced by a history of quarrelling with her husband about simple matters, for example, the child’s birth certificate. In group 2, all women who attempted suicide and committed filicide were either Chinese or Indian. Three of the women (cases 6, 8, and 10) had altruistic thoughts that the children should die because they did not want them to undergo the same suffering they had experienced before. The behaviour of another woman (case 6) was also influenced by her belief that she had passed her ‘bad karma’ to her child.

One case of familicide occurred following a serious financial difficulty. The woman had severe anxiety and fear about threats from illegal loan sharks. In group 3, all the women who killed their child by battering were in their middle 20s. It was the second marriage for either the women or their spouse. In group 4, 2 of the women (cases 15 and 16) were the victim of rape although they had not reported the crime. Case 15, an immigrant who was working as a maid, was raped by her employer’s relative. She was too afraid of being blamed and punished by her employer, and killed the unwanted baby immediately after the birth. In case 16, a female adolescent who lived with her parents, was the victim of date-and-drug rape. She had true denial of pregnancy. Both parents were unaware of the pregnancy until she killed the newborn. In group 5, cases 17 and 18 killed their child/ren as a result of anger and hatred about the husband’s infidelity.

Discussion

Only a limited number of cases from forensic clinical records are described so this study does not represent the true incidence of filicide in Malaysia. Despite this, we have managed to capture and add to the understanding of the variety of cases of maternal filicide. The characteristics of and motive to commit filicide by women in Malaysia are similar to those that have been described by many researchers before.^2,4,7-10

Socio-demographics

In terms of background socio-demographics, women with Axis I psychiatric disorders who had committed filicide in our study were generally older than those without psychiatric disorder. The majority of them came from a low socioeconomic background and had a low level of education. This is consistent with the findings of previous studies of women with psychiatric disorders who committed filicide.^19,21,30,33

Marital Stress

In this study, a variety of psychosocial factors were explored. Here, we would like to highlight the importance of marital discord or domestic violence. In the majority of cases, filicide occurred in a family where either the mother or father had a history of or current marital discord. Parents of our filicide victims had limited skills to maintain their interpersonal relationship with their spouse as evidenced by divorce in the current or a previous marriage. Some mothers who became perpetrators were in their early years of marriage. They were young women in their late 20s or early 30s who might not have been able to cope with becoming a mother, to nurture and look after many children; not only their own children but also stepchildren. The maltreatment of stepchildren compared with genetic children or the “Cinderella effect” as proposed by evolutionary psychologist, Daly and Wilson,³⁴ and investigated further by other researchers,^15,34-38 occurred in 2 of the 3 accidental or battering cases in our study. The burden of marital discord was obvious in this group of mothers.

Marital discord has been documented by other researchers to precipitate the act of filicide.^15,39-41 In a Hong Kong study of homicide-suicide in which about a third of the victims were children, termination of a marital or sexual relationship and other domestic disputes constituted approximately 20% to 39% of factors that contributed to the act of killing.⁴² In Japan, severe marital discord was also documented as an important stressor for maternal filicide involving a child older than 1 year.⁴³ In contrast, in Finland, only 10% to 20% women who committed filicide were described as having difficulties in marriage or subject to domestic violence.⁴⁰ This low percentage may have been due to the small number of cases that were also confined to women with postpartum depression.

Spousal Attitude and Behaviour

Another crucial stressor was the attitude of a husband who was dependent on alcohol or illegal substances, and wives who generally remained loyal. In Malaysia, substance abuse is a serious problem. By 2004, approximately 234,000 heroin abusers were officially registered, and hundreds of thousands more heroin or other substance abusers were unreported or unregistered.⁴⁴ According to the National Anti-Drug Agency,⁴⁵ about 655 drug abusers are detected monthly in Malaysia. Drug misuse has had a significant adverse impact on the life of women in Malaysia. According to Women’s Aid Organisation,⁴⁶ drugs such as rohypnol have been misused to hypnotise women or female youths in cases of date-rape or rape by an acquaintance. Drug misuse is also associated with child maltreatment. About 12% of the detected child abuse cases recorded by Suspected Child Abuse and Neglect team (a multidisciplinary medical, social, police, and legal team) in this country involve an abusive father who is an alcoholic or drug abuser.⁴⁷ Following drug abuse, some children, such as in this study, might become the victim of filicide.

Another crucial attitude of the spouse, which was present in this study, was being disloyal. Spousal infidelity has also been described by Resnick^2,4 in his classification of filicide. Such behaviour invites revenge and hatred leading to filicide as illustrated in Medea complex — wherein filicide occurred as a result of spousal infidelity.⁴⁸

Mental Illness

The influence of psychosis as a motive for committing filicide among patients with schizophrenia or depressive disorder has been well recognised. The presence of this psychopathology such as auditory hallucinations that influence the act of killing has been documented by many researchers.^1,49 We found a smaller proportion of 21% compared with another study wherein approximately 69% of the severely mentally ill mothers who committed filicide experienced auditory hallucinations at the time of the offence.⁴⁹

The active psychotic symptoms were present in this group of women in our study in part because they were either not receiving proper treatment or were noncompliant with medication. Locally, an important factor that contributes to a delay in seeking treatment for major psychiatric disorders or increases noncompliance with treatment is a preference for traditional remedies.^50,51 A study of postnatal depression in one state in Malaysia indicated that more than half of women were adhering to traditional remedies and the influence of traditional birth assistants (“Mak Bidan”) in providing advice on physical and emotional care was still prominent.⁵² More distressing is the fact that mothers with postnatal depression who attend a conventional medical consultation may not receive appropriate intervention. In a study in Malaysia, more than 50% of midwives who were the primary carers in a position to screen for postnatal depression had no clear understanding of the differences between postnatal blues and postnatal depression.⁵³

Postnatal blues is a benign condition that manifests with sadness, anxiety, irritability, and changes in appetite and sleep. It occurs in 50% to 90% of new mothers and the symptoms reduce spontaneously about 2 weeks postpartum. Postnatal depression is more severe and occurs in about 10% to 20% of new mothers. The onset of depressive symptoms occurs within 4 weeks postpartum or sometimes during pregnancy and peaks at 2 to 6 months. Such women may continue to feel depressed a year following delivery. Postnatal depression may be complicated by psychosis and must be differentiated from depressive symptoms that occur in bipolar disorder or schizophrenia.⁵⁴ In order to curb the act of filicide among women with psychiatric disorders in this country, a comprehensive goal to raise awareness and understanding of postpartum psychiatric disorders by the public and all health care workers is warranted.

Attempted Suicide and Financial Stress

Another important group of maternal filicide in our study was those with an altruistic motive or suicide attempt. Half of the women in our study who committed filicide-attempted suicide were Chinese who experienced devastating financial difficulties. Interestingly, local phenomenon of the financial crisis as a result of multiple debts from illegal creditors (or local term — ‘ah-long’ or ‘loan shark’) has been widely reported by local media. A financial crisis has also been described as one of the important factors that precipitates filicide-suicide among Chinese in other countries such as Hong Kong.³⁹

The pattern of this dichotomous act is in keeping with the pattern of suicide and attempted suicide cases in Malaysia with a high prevalence among Indians and Chinese and a low prevalence among Malays who are predominantly Muslim. Our study found no Malay women who committed filicide-attempted suicide. It has been argued that this difference arises because of differences between Islam and Hinduism and Buddhism. Islam is widely embraced by Malays and prohibits suicide. Hinduism and Buddhism are embraced by the majority of Indians and Chinese respectively, and may condone suicide in certain circumstances, such as maintenance of honour, integrity, and for spiritual purposes.⁵⁵

Marginalised Woman

In our study of neonaticide cases, we demonstrated 2 important social scenarios that may contribute to the act of killing and that occur among marginalised groups of women in Malaysia; adolescents and immigrant workers. They experienced date-rape or rape by an acquaintance. According to Women’s Aid Organisation, the number of reported rape cases in Malaysia has increased, from 1431 cases in 2002 to 2998 cases in 2012.⁵⁶ The actual number of cases is likely to be even higher since most cases, in particular acquaintance rape, often go unreported. Sexual violence among migrant workers is another serious problem that needs urgent attention. It occurs among women who are employed as legal or illegal domestic workers and who experience serious neglect and ill treatment, not only from their employers but also from other relevant authorities.

This study is limited by its nature of being descriptive and using a very small sample size of women incarcerated in a forensic psychiatric institution. Hence, the study did not represent all cases of filicide in Malaysia. It is a descriptive review of series of cases with no specific questionnaire to provide consistent evaluation of the variables. It also did not evaluate the records in-depth as in qualitative research.

Conclusion

Illustrating the various stressors experienced by women, such as financial constraint, marital disharmony, having a husband with alcohol or substance dependence, infidelity, and those who become victims of domestic violence and rape, may help inform and prepare mental health professionals. Although filicide is rare, exploring the thought of committing this act should be emphasised in every routine assessment and management of women with psychiatric disorders.

Declaration

This work was supported by the Fundamental Research Grant Scheme (FRGS), Universiti Teknologi MARA, Ministry of Higher Education, Malaysia under Grant No.: 600-RMI/Ssp/FRGS/5/3Fsp(68/2010).

Acknowledgements

The authors would like to thank Hospital Bahagia Ulu Kinta, Perak and Hospital Permai, Johore, Malaysia, together with their dedicated staff for having rendered this research possible.

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