Wednesday, December 11, 2019
Infant Mental Health: When a Mother Takes the Baby to the ER Too Often
I have been neglecting this blog so badly, because a lot of my time in the last six months has been taken up by writing and talking about “parental alienation” (PA) and I don’t suppose anyone wants to read about that every day. But a few days ago someone asked me a question about a non-PA issue and I think it’s one that may be of interest to a number of people.
My correspondent is a lawyer who works with an anti-child-abuse non-profit organization. She wrote to me to ask if I could recommend a psychologist who could diagnose a type of factitious disorder or “Munchausen’s by proxy”. These terms are used to describe cases in which an adult, usually a parent and often the mother, asks for medical treatment for her child but secretly does things that would cause the child to seem to need treatment. For example, the adult might substitute something else for the child’s urine for a urinalysis, or more seriously-- and this has been videorecorded—partially suffocate the child and then call for help because the child has stopped breathing. These cases are obviously to be taken very seriously. What if the child actually is sick but no treatment is provided because it’s mistakenly thought that the parent is causing the symptoms? What if the parent is causing the symptoms, this is not recognized, and the child dies because of the parent’s actions? It’s no wonder that there is much concern when such a situation is suspected.
Here is the story my lawyer-correspondent gave me. (Readers with infant mental health background will quickly see why I am bringing this up.) A woman of 40, who had a 5-year-old child, began to make frequent emergency room visits when her second child was about 2 months old. When I say frequent: she took the baby in on 27 of 30 possible days. No medical problems were detected. A neighbor reported that she had come into the house to find the baby turning blue and had restored the airway; as far as I know, she did not see the mother causing this episode.
Medical personnel were worried about this situation and suspected factitious disorder. They moved to have the baby placed in foster care and the mother has for at least a month had only supervised visitation. A forensic psychologist, who may or may not have any infant mental health training is to evaluate the mother. My lawyer-correspondent was concerned about the extent of the evaluation, and that was why she asked me to recommend an evaluator.
My response was that everyone was ignoring the most obvious explanation of the mother’s behavior: a perinatal mood disorder (PMD). PMD, sometimes called post-partum depression, is a state of anxiety and depression that sometimes occurs during pregnancy and/or after childbirth. Mothers with PMD may feel incapable of caring for the children and sometimes focus on the idea that there is something terribly wrong with a baby. By far the largest number of comments and queries I have had on this blog have come from mothers who were tortured by their beliefs that their babies were somehow damaged; many of the mothers were convinced that a baby of a few weeks of age might be autistic. When I answered these queries I usually recommended that the mothers see their ob-gyns for PMD evaluation and receive the treatment they needed, because the problem was in their own conditions, not in the babies. Many of them subsequently wrote and said that they had done this and had been helped a great deal.
PMDs have been known for quite a long time to be identifiable and treatable. They are no one’s fault and although the mothers often blame themselves, the rest of us should not blame or punish them. About 15 years ago, several states had innovative programs to educate people about PMD. New Jersey, for example, had a program called “Speak Up When You’re Down” that was sponsored very effectively by the wife of the then-governor. (I was at that time part of the train-the-trainer program for that program.) Regrettably, political forces cancelled funding for these programs and it appears that we are back where we started on this issue.
Ob-gyn offices should be making regular use of a screening instrument for PMD, the Edinburgh Depression Scale. This is quick and easy to use and identifies women who may benefit from treatment for PMD. In addition, I would argue that its use with every new mother benefits everyone, not just those with mood problems, as it reminds everyone of the potential for PMD in themselves and others. This is especially important as PMD symptoms may not occur until later in the first year after childbirth, and women who were screened early may realize later that new symptoms they experience are related to what they were asked on the screening instrument. In the case brought up by my lawyer-correspondent, the mother had apparently not been assessed for PMD, and candidly I remain unsure whether this is happening at this point, although I suggested some possible resources in addition to her ob-gyn.
I want to take a moment to talk about the experience of the mother in this case. I’m basing my comments on the assumption that PMD is at work here—I do not have enough details to know this, of course. The mother’s anxiety about her baby, expressed by multiple ER visits, has not been understood as an expression of her disordered mood, but instead has been interpreted as highly abnormal maternal behavior that is a danger to the baby. The obvious solution from that viewpoint is to put the baby in foster care. But what if the mother’s behavior is symptomatic of PMD and is thus both identifiable and treatable, but neither identified nor treated? In that case, the mother’s experience is of validation of her abnormal mood. Yes, we say to her, you are right to be anxious and depressed and feel that something is wrong, and we are taking your baby away because something is so wrong with you that you cannot be helped.
The mother now sees the baby only under supervision, and it is no longer “her baby”. The constant tiny maturational changes of the early months go by between visits without the mother having any chance to learn from them, and the baby at each visit is a somewhat different person than the mother saw the last time. Her behavior toward the baby is bound to be out of synch for exactly that reason, so she will be observed on each visit to be awkward and uncertain with the baby and not to behave like a “normal mother”. This kind of experience adds to her sense of anxiety and sadness, which apparently is not being treated by appropriate medication and talk therapy. Who will step in to help this family? When will anyone do anything to support the mother in her fight with PMD and to facilitate her relationship with her baby? Or is the solution seen to be indefinite foster care, even termination of parental rights?
N.B. I should point out that there is a severe form of perinatal mood disorder, sometimes called post-partum psychosis, and some readers will recall the tragic case of Andrea Yates, who killed all her children after repeated post-partum problems that were ignored by the children’s father. But these horrible cases are very unusual, and most cases of PMD, when identified, can be treated quite effectively.