Remember the kids when parents are ill
When evaluating and treating adults, keep in mind that mental disorders may cause functional impairment that hinders parents’ ability to care for dependent children. Certain disorders—such as schizophrenia, bipolar disorder, and major depressive disorder—are often associated with substantial functional impairment.1 Failure to consider the impact of the functional impairment on a parent’s caretaking responsibilities can place dependent children at risk.
Don’t forget the kids. Ask adult patients with psychiatric conditions if they have dependent children in their care. If they do, determine if any functional impairment resulting from the mental disorder is impacting the patient’s ability to care for the children or places children at imminent risk of harm.
Keep in mind that parents who are experiencing delusions or suicidal ideation may harbor thoughts of filicide.2 Maintain a high degree of suspicion when evaluating and managing such patients, and inquire directly about filicidal thoughts.
Use techniques similar to those for assessing suicidal thoughts. Begin with a normalizing statement such as, “Sometimes, when people have symptoms like those you are describing, they have thoughts of harming their children.” Then follow up with a direct question using unambiguous language: “Have you had any thoughts of hurting or killing your children?” When patients endorse such thoughts, explore whether they have formulated a plan and assess whether they intend to follow through with it.3
When a patient with dependent children requires hospital admission or admits to caretaking inability, ensure that proper arrangements are made for his or her children’s care. Contact the spouse, grandparent, guardian, or social services agency.
Remember that not all dependents are children. An increasing number of elderly persons are being cared for by their adult children. Caretaking can be a major psychosocial stressor that triggers the onset or exacerbation of a psychiatric disorder—such as a major depressive episode—that leads to functional impairment.4
1. Hales RE, Yudofsky SC, eds. Textbook of clinical psychiatry (4th ed). Washington, DC: American Psychiatric Publishing; 2003.
2. Jennings KD, Ross S, Popper S, Elmore M. Thoughts of harming infants in depressed and nondepressed mothers. J Affect Disord 1999;54:21-8.
3. Shea SC. Psychiatric interviewing: the art of understanding (2nd ed). Philadelphia: WB Saunders; 1998.
4. Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s comprehensive textbook of psychiatry (8th ed). New York: Lippincott Williams & Wilkins; 2004.
Dr. Campbell is assistant professor, department of psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, and is residency program director and director of clinical services, department of psychiatry, University Hospitals of Cleveland.