Psychosomatics 41:523-530, December 2000
© 2000 The Academy of Psychosomatic Medicine
The Evaluation of Maternal Competency
Sudha Nair, M.D., M.P.H., and
Mary F. Morrison, M.D.
Received October 13, 1999; revised February 14, 2000; accepted May 31, 2000. From Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. Address reprint requests to Dr. Morrison, Department of Psychiatry, University of Pennsylvania School of Medicine, 3600 Market Street, Room 704, Philadelphia, PA 19104; e-mail mmorriso{at}mail.med.upenn.edu
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ABSTRACT
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There is limited discussion of maternal competency in the consultation-liaison psychiatry literature. As awareness and reporting of child abuse is increasing, maternal ability to care for newborns is more often called into question. Maternal risk factors for harm and neglect have been identified, and positive signs of maternal ability have also been recognized as important to appraise. Specific domains in the maternal competency exam should be assessed by the psychiatrist, nursing staff, social work staff, and pediatrician. The competency exam by the psychiatrist requires a sensitive and nonjudgmental inquiry into maternal behavior and thoughts. The authors present a case study of an inpatient maternal competency consultation that illustrates some of the dilemmas encountered. Future directions should include more involvement by psychiatrists in preventive efforts and interventions that focus on pregnant women at risk in prenatal clinics and in the community.
Key Words: Child Abuse • Mother-Child Relations • Mental Compentency
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INTRODUCTION
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Patient competency assessments are an integral and increasingly important function of the consultation-liaison (C-L) psychiatrist.1 Psychiatrists cannot legally declare a patient incompetent; however, they can clinically evaluate the functional capacity of a patient.2 Most competency evaluations focus on the four following areas: 1) giving informed consent, 2) refusing medical care,3 3) discharge decisions (e.g., signing out against medical advice), and 4) disposition decisions (e.g., ability to care for self and to manage finances for independent living).1 An important and understudied area of competency evaluations is maternal competency.
Maternal competency is the capacity to care adequately for a vulnerable newborn without assistance. Maternal competency assessments are extremely challenging, and the impact of an error in evaluation can be devastating.4 Serious injury or death of the child can occur if the child is sent home with an incompetent (i.e., abusive or negligent) mother. On the other hand, separating the child from competent parents results in unnecessary emotional distress to both the child and the parents. Maternal inability to care for infants is receiving increasing public attention. The number of child abuse cases in the United States increased by 50% between 1985 and 1993.5 Some of the increase in maternal inability to care for a child is thought to be the result of social factors such as the increasing prevalence of substance abuse, deinstitutionalization of the chronically mentally ill,4,6 and homelessness. This could also be explained in part by improved reporting but it is likely that child abuse is still underreported.
In 1996, child protective services agencies in the United States conducted investigations, revealing that more than 970,000 children had been victims of abuse or neglect.7 At least half of the children entering the child protection system are believed to have been neglected.8 According to data from the National Child Abuse and Neglect Data System (NCANDS), 1,077 children died in the United States because of maltreatment. Seventy-six percent of the children were under 4 years old.7 The data for neonaticide, or the murder of a baby during the first 24 hours of life, accounted for 45% of children killed during their first year of life.5 Parents were 77% of the perpetrators of all child abuse. In addition, two-thirds of the perpetrators were women, and 80% were under the age of 40 years.7 One explanation for the high rate of abuse by women is that mothers use violence against children more often than fathers because they spend more time with the children.9
Assessment of maternal competency can be an elaborate and time-consuming process consisting of gathering data from parents and collateral sources, home visits, evaluation of the mother-child interaction,10 and involvement of the legal system. We will briefly touch upon the legal issues, but this paper focuses primarily on the role of the psychiatrist.
Legal Issues
Incompetent is a legal term applied to individuals who are considered by law not to be mentally capable of performing a particular act or assuming a particular role.11 In the legal system, a number of conditions allow a termination of parental rights or an incompetency finding: 1) conditions constituting abandonment of the child; 2) conditions of neglect or abuse; 3) conditions of behavior or lifestyle that can endanger the child's life, health, or development; 4) conditions of mental deficiency or mental illness of parents; and 5) conditions of loss of civil rights of parents because they cannot meet the needs of the child. More recently, the courts interpret the mere presence of any of these conditions as insufficient grounds for a finding of incompetency; it is necessary to demonstrate that the parents' condition significantly affects the welfare of the child. Though legal standards vary in different states, in most states intervention in cases of child abuse or neglect occurs when the child has suffered or is at a substantial risk of suffering serious harm, and intervention is necessary to protect the child from being endangered in the future.12 For instance, in Pennsylvania, the Child Protective Services laws provide that a child may be taken into protective custody by a treating or examining physician or a director of a hospital or medical institution if such custody is immediately necessary to protect the child from further serious physical injury, sexual abuse, or serious physical neglect.13 Child Protective Services must be immediately contacted. Once child abuse or neglect is reported to the state, an investigation is initiated. The state attorney or child protection agency will then file a petition, stating that abuse or neglect has occurred. The next phase is the determination of disposition, including the decision regarding termination of parental rights.8
The Evaluation
We will delineate the sources of information and unique elements of the history included in the assessment of maternal competency.
Patient competency evaluations focus on a person's cognitive capacity to make decisions about personal medical care—the ability to communicate, understand information, rationally use information to reach conclusions, and cognitively and effectively appreciate the consequences of medical decisions.14,15 Maternal competency differs because it deals with the life of another person and focuses on the capacity of the parent to care for the needs of a vulnerable, incompetent, and usually newborn, child. According to Stewart and Gangbar,16 new mothers referred for psychiatric evaluations of maternal competency were more often single, primiparous, unprepared for the pregnancy, had poor prenatal care, had premature or ill babies, and had psychiatric problems in the past. Using past and present history, we attempt to predict the likelihood of abuse or neglect of the neonate. The law establishes the child's needs for growth and development as the context in which to consider the functional lability of the parent, but there is no definite set of characteristics that distinguishes a competent parent from an incompetent one.12
The parenting that children receive has a significant effect on their emotional, physical, and social well-being;17 poor parenting has been linked to developmental psychopathology.7,18 The job of the psychiatrist is to assess whether sending the neonate home with the mother after delivery would result in significant harm to the child. This requires weighing the mother's strengths and supports against her limitations.17 Although evaluations may look for optimal parenting ability, minimal parenting competence is probably the appropriate standard. When the mother is coping with a severe mental illness, the most likely support for her is her partner or her parents and other relatives.5 The child needs, at minimum, one adult to meet the child's physical, emotional, and social needs. The father, grandparent, or another relative may assume the primary caretaking role.18 This may make it possible for the neonate to return home with the family and, thus, maintain the integrity of the family.19 Therefore, in any maternal competency assessment, it is important to evaluate the ability of other family members to care for the newborn. A case study is presented to illustrate the elements of the maternal competency evaluation and how the information is used to assess maternal ability to care for her infant.
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Case Report
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Ms. B. is a 38-year-old woman who was admitted to the hospital in labor and gave birth to a female infant. Two days postpartum, Ms. B. exhibited disruptive behavior. A crisis situation ensued and an emergency psychiatric consultation was obtained. Ms. B. was reportedly hostile, illogical, demonstrated affective ability, and refused care for herself and her child. She accused the Department of Human Services (DHS) and the social workers of a conspiracy to make her children "victims" of a DHS agenda to take children away from their parents. She refused to answer questions regarding her involvement with her other children but admitted that she had lost custody of them. Ms. B. noted that one of her sons had been burned by a hotplate, and she had been criminally charged.
According to the nursing staff, Ms. B. had left her newborn baby face down on the hospital bed with covers over it and left the room for over 15 minutes. She had also refused to allow the pediatrician to evaluate the baby for jaundice and refused to comply with simple instructions from the staff. She was reluctant to be seen by a psychiatrist but did agree to a brief interview. Ms. B. was noted to have a labile affect, circumstantial and rapid speech, and paranoid ideation about the hospital staff. Her insight and judgment were impaired. Ms. B. demanded to leave the hospital and was discharged without her infant after being offered psychiatric evaluation and treatment, which she refused.
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DISCUSSION
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Analysis of Case
A complete assessment was not performed at the time of the emergency consultation because Ms. B. was uncooperative in answering questions and demanded to leave the hospital. Women with a history of abusing their children are often difficult to assess because of a lack of cooperation, thus a full psychiatric evaluation is often not possible.16 Because of Ms. B.'s lack of cooperation with an evaluation, the substantial evidence of impairment based on observation of her behavior that had been carefully documented by the nursing staff, coupled with her prior history of maternal incompetence, the psychiatric consultant concluded that Ms. B. did not have the capacity to care for her newborn daughter. Ms. B. had not been able to assess potentially harmful situations for her son in the past nor for her newborn daughter during the time of the evaluation. She was also unable to control her emotions and behavior and permit the evaluation of her newborn who had jaundice, suggesting a significant potential risk for neglect and harm to her daughter. She was unable to appreciate the seriousness of her situation, her behavior alarmed the hospital staff, and the consequences of her refusal to comply with an adequate psychiatric and medical evaluation could have gravely affected her and her child.
Ms. B. may have benefited from treatment of her paranoid symptoms, but her decision to leave the hospital precluded such treatment. In view of the potential for harm to her child, the DHS Child Protection Services was brought in on the case, and the infant was retained in the hospital. Because of the involvement of the legal system, DHS began a full inquiry into Ms. B.'s parenting abilities. Six months later, the father tried to obtain custody of the child, prompting Ms. B. to try to have her daughter placed back in her care.
Maternal Risk Factors (Table 1)
Psychiatric Problems. Child abuse or neglect occurs in the setting of external stressors with an impaired caretaker and a vulnerable child.17 The presence of active mood or psychotic symptoms is a maternal factor that increases the risk of difficulty with parenting. In a study of 56 women referred to the psychiatric C-L service for maternal competency assessment, 50% had mental illnesses, including postpartum disorders, schizophrenia, bipolar disorder, severe personality disorders with poor impulse control, and severe substance abuse.16 About 60% of mothers with severe mental illness do not care for their own children.10 Presence of delusional symptoms involving the child is of concern, as in the case of Ms. B. who, because of her paranoia, was unable to recognize the need for her sick child to be evaluated by the pediatrician. Denial of mental illness or denial of the need for treatment in a mother with active psychiatric symptoms predicts poor maternal skills.4 Substance dependence (involved in at least 50% of substantiated child abuse and neglect reports of the Child Welfare League of America)7 and severe personality disorders20 (particularly those associated with excessive anger, impulsivity, or poor coping skills)7 that interfere with impulse control, judgment, and empathy predispose a mother to child abuse or neglect. Alcohol dependence has been shown to correlate with occurrence of child abuse and neglect even when analysis of data controls for sociodemographic and other psychiatric variables.20 The comorbidity of Axis I and Axis II disorders increases the risk further. Nevertheless, it is important to remember that in many cases brought to court where the mother has a mental illness, if the mother is otherwise a fit parent, the custody of minor children is awarded to her. The decision is made with little regard to the mental illness and risk of relapse.12
Cognitive Problems. Moderate to severe mental retardation and other forms of cognitive impairment can make adequate parenting difficult. In addition, medications or medical illnesses that impair the mother's cognitive capacity or cause psychiatric illnesses will diminish the mother's capacity to care for her child.
Medical and Neurological Problems. Debilitating illnesses, such as heart failure or AIDS, may physically and emotionally impair the mother. Motor deficits from stroke, spinal cord injury, or demyelinating disease can interfere with a mother's capability to care for her newborn. Severe sensory deficits such as blindness or deafness, in the absence of adequate compensation, can interfere with the mother's ability to care for her child effectively. It is important to remember that a majority of mothers with medical or neurological problems are very capable of caring for their newborns and only some mothers are unable to cope effectively.
Problems With Maternal-Infant Relationship. It is important to assess current maternal caregiving ability. Misperceptions about the child and child rearing, including a lack of understanding of normal childhood behavior, can lead to abuse.2,10 After education about infant behavior, parents who continue to have unrealistic expectations of their child's behavior may be punitive and regard the child as worthless, thereby leading to neglect.17 If the pregnancy was unplanned and unwanted, or if the mother shows obvious disinterest in the child, the hospital staff should be alerted to the possibility of maternal incompetence. Verbal threats to harm the infant must be taken very seriously. Past DHS referrals for child abuse or neglect, spouse abuse, or history of children having been voluntarily or involuntarily placed in foster care are poor prognostic features.
Lack of Support. If the mother has difficulty taking care of her own health and hygiene, it is unlikely that she will be able to meet the demands and needs of an infant. The lack of a social support system, adequate financial resources, or adequate shelter can make parenting difficult, though these factors alone are unlikely predictors of maternal incompetence.
Past Problems in Social/Family Relationships. Mothers who have been abused in childhood,4 or experienced psychological deprivation or maltreatment,17 are at an increased risk of abusing or neglecting their own children. Early separation from one or both parents predicts mothering difficulties.21 A history of chaotic social and family relationships and violence are often predictors of a poor mother-infant relationship. Teenage parenting is an important social and health problem. However, this is not an independent risk factor for child abuse.22 Teenage parenting is often associated with other psychosocial risk factors that can increase the risk of maternal parenting difficulties.
Infant Risk Factors (Table 2)
Characteristics that make the newborn difficult to care for increase the risk of child abuse or neglect (Table 2). Parenting of infants with major medical illnesses that result in physical or intellectual defects or require constant medical attention (e.g., cardiopulmonary monitoring, tube feeding, or oxygen administration at home) can be extremely stressful. Neonates who are difficult to soothe or who cry constantly5 are also a strain on parents. Deformed or handicapped children and unwanted children5 are more likely to be abused or neglected.23 When these factors are coupled with a parent who is already compromised because of psychosocial problems, there is an increased incidence of maternal incompetence.
Predictors of Good Outcome
It is equally important in the assessment to look for factors that predict a good outcome (Table 3). This assessment should include the ability of the mother to both appreciate and respond to the essential needs of the child. A positive attitude towards the pregnancy and making adequate preparations for the arrival of the child are predictors of good parenting. Mothers who have good parental role models are likely to emulate their own parents with their newborns.2,4,18
Women with psychiatric illnesses who have insight into their illness and recognize the need for treatment are more likely to get treatment for their psychiatric illness or be in drug or alcohol rehabilitation programs.4 They are more likely to recognize the effects of mental illness on the child and the benefits to the child of seeking treatment.4 Fathers or other family members who are able to support an impaired mother or take over parenting responsibilities can protect the child from an otherwise untenable situation.19
Objectivity in the Evaluation of Maternal Competency
An issue that is often present with many competency evaluations, including maternal competency evaluations, is the expectation on the part of the treating team that the patient will be found incompetent. Fear of making the wrong choice or fear of being at odds with one's colleagues may influence the psychiatrist's evaluation.14 Therefore, it is reassuring that the assessment of maternal competency is seldom sought in the absence of severe mental illness, serious difficulty in caring for the newborn in the hospital,16 or other valid concerns. Competence is usually presumed by both the hospital staff and the law, unless there are extenuating circumstances.15
The hospital is an artificial setting in which the mother is at a disadvantage because of the following: 1) the unequal relationship between the doctor and the patient; 2) a recent major life event, namely delivery; 3) being evaluated outside of her usual environment, frequently without the presence or support of family; and 4) the knowledge of being under scrutiny. Some mothers respond with greater anxiety than others to being scrutinized and their behavior during the interview process in itself may be nonrepresentative of their parenting ability.12 In these cases, observation of her behavior by the nursing staff in the noninterview setting is extremely helpful.
Mothers who have serious difficulties in the hospital have much greater difficulty in the absence of the structure and support of the inpatient setting.16 Psychiatrists have to keep in mind that there is an intrinsic conflict between two important societal values: the mother's right to keep and care for her child according to her own value system and the moral imperative of caring for others (parens patriae),24,25 in this case, the concern for the welfare of the child. Appelbaum and Grisso15 have suggested conducting several examinations over time to guard against temporary mental status changes because of psychiatric illness, fatigue, or the effect of medications. They also suggest doing the assessment in the presence of family or friends to optimize the competency evaluation.
Clear standards of caretaking do not exist. The standards that do exist are not uniform across all cultures nor are they static. Cultural and social values affect the child- rearing beliefs and practices of each society. In dissimilar societies, standards of optimal child care and child maltreatment may be diverse.23 Psychiatrists have to guard against injecting their own values and personal bias into the evaluation. As with any competency evaluation, special care has to be taken with patients of lower socioeconomic or educational backgrounds or those from a different cultural or ethnic background. Examiners of similar ethnic or cultural backgrounds may help to make the assessment more comfortable for the mother.15
Protocol for Maternal Competency Assessment
Psychiatric consultation for maternal competency assessment should include examination of the mother, direct observation of mother with the child, and verbal and written report of the staff directly involved with the mother's or child's care.16 Information should be gathered from the following: 1) nursery staff, 2) obstetric nurse, 3) obstetrician, 4) neonatologist, 5) father of the baby and other relatives, 6) Child Protective Services (DHS)—to check if there has been a change in the mother's situation since prior involvement, and 7) the mother. Psychiatrists are ethically obliged to tell the mother the nature and purpose of the assessment and advise the mother of the lack of confidentiality before assessment.26 In addition to doing a psychiatric evaluation, psychiatrists should ask the mother about her plans to care for herself and her baby. As always, factual information should be documented and sources of information should be clearly identified.9
Domains of Maternal Competency Assessment (Table 4)
Psychiatric Assessment—Setting. The psychiatrist is often called into a crisis situation. Interviewing the mother in a calm, private setting in a nonjudgmental fashion is important.
History. The history includes the standard elements of a psychiatric evaluation, which includes asking about the presence of active psychiatric symptoms such as depressive or psychotic symptoms, drug or alcohol use, and eliciting sufficient developmental, relationship, and work history to arrive at an Axis II diagnosis. Past history of psychiatric problems, hospitalizations, or violence must be explored. A medical history and an understanding of the effect of cognitive and physical disabilities on the mother are essential.
The psychiatrist should also inquire about the mother's childhood, specifically whether she experienced abuse or deprivation in her childhood. Information about her other children is critical; in particular, whether any of her children are in foster care and the reasons for child placement. Does she understand her other children and their needs? With regards to the current pregnancy, her thoughts about her pregnancy and history of prenatal care can help with the assessment of whether the mother can cope with an infant. For instance, has she made any preparations for her newborn? Current social supports, including relationship with the newborn's father, should be assessed.
Mental Status Exam. The mental status examination focuses on an assessment of the patient's mood, thought, and perception. Special attention is paid to symptoms directly involving the child, such as delusions about the child. The intellectual capacity of the mother can be estimated from the interview and, if required, formal testing. The mother's insight into her illness, its impact on her life and that of her child, and the need for treatment must be evaluated. Good judgment, as evidenced by ability to make decisions related to the welfare of the child based on logic and reasoning, should be noted.
The psychiatrist may request testing as appropriate, including urine toxicology and neuropsychological testing. Documentation should be complete as the psychiatrist may be called to testify in court regarding the mother's mental status exam and behavior.
Nursing. The obstetrics and the nursery nursing staff are critical in their assessment of the maternal-child interaction. They can observe the mother's response to the child's needs and demands, her ability to care for the child, and her expectations of the child. Specifically the nurse must assess the mother with regard to the following: 1) mother-infant bonding, 2) ability to feed/nurse the child, 3) safety issues (the mother's knowledge of and response to dangerous situations for infants), and 4) ability to diaper the baby.
Neonatologist. The doctor can evaluate the medical needs of the infant and provide information about the medical care required after discharge.
Social Worker. The social worker can assess the social situation of the mother: the availability of home and finances and the suitability of living quarters, the availability of a support system, and the local resources available for the mother. They are also instrumental in the liaison with the Child Protective Services, DHS.
Future Directions
Although individual risk factors for harm and neglect of the child are being identified, only the most obvious have been explored. We do not yet know how to weigh each factor when it occurs in combination with others and with counterbalancing positive factors. We also need to evaluate the potential benefit of the systematic involvement of mental health professionals with either the victims or perpetrators of child abuse and neglect. Psychiatrists may have an important role to play in the early detection and remediation of maternal incompetency. For example, the National Research Council reported in 1993 that parents with reported histories of abuse who do not abuse their own children are more likely to have had a positive relationship with a significant adult in childhood or a positive experience with therapy as an adolescent or adult, especially when able to appropriately direct their anger at the perpetrator rather than themselves.7
More data on the role of rehabilitation and treatment in reuniting the parent and child and the outcome of such efforts are important in improving the evaluation process and outcome. Another area that needs to be explored is the role that the health system can play to better prepare women at risk so that this issue is not addressed in a crisis situation with very little information. Primary prevention should focus on the early identification of mothers at risk in prenatal clinics.21 In a prospective study, the Family Stress Checklist demonstrated a sensitivity of 80% and a specificity of 89% in detecting likelihood of future child abuse/neglect.27 Psychological tests such as the Parent Attitude Survey,28 Parental Attitude Research Instrument,29 Child Abuse Potential Inventory,30 and the Michigan Screening Profile of Parenting31 can be used to determine parenting attitudes and screen for the risk of child abuse.12
Widespread use of screening instruments could enable physicians to address this issue proactively. Psychiatrists can increase awareness of the risk factors and management strategies particularly related to mental illness and substance abuse among primary care physicians, obstetricians, and neonatologists. In the household survey by the National Institutes of Mental Health Epidemiological Catchment Area study, Egami et al.20 discovered that over one- third of people with mental illnesses who reported physically abusing or neglecting children had never seen or received treatment from a mental health professional. Encouraging collaboration between medical and mental health professionals increases the probability that the affected families will receive comprehensive care.32 The United States Advisory Board on Child Abuse and Neglect (ABCAN) has recommended a neighborhood-based child protection strategy. Instead of a punitive child abuse reporting and response process, the Child Protection Services's intervention could be designed to get immediate help to families based on voluntary requests for assistance.8 Mobilizing fathers, family, social support, physicians and community resources in the first years of the child's life is important in order to keep the mother-child dyad safe and intact.
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ACKNOWLEDGMENTS
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The authors are grateful for the valuable assistance of James L. Stinnett, M.D. This study was supported in part by National Institute of Mental Health Grant KO7 MH01350 (Morrison, PI).
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ABSTRACT
INTRODUCTION
