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Termination of Parental Rights
LETTERS TO THE EDITOR Letters to the Editor will be considered for publication. Such letters must be signed by all authors. Letters should, in general, not exceed 500 words. All letters are subject to editing and shortening. The Editor reserves the right to publish replies and solicit responses. Letters should be typed double-spaced, and submitted in duplicate to Melvin Lewis, M.D., Editor, Journal of the American Academy of Child Psychiatry, 333 Cedar Street, New Haven, CT 06510.
of rubbish had been thrown away for a number of years, such that only a narrow track ran from the back door through the dining room to the kitchen sink. The rubbish was 6-9 inches deep on the floor of the track, and sloped up to about 3 feet high against the walls. The kitchen table had several feet of rubbish precariously piled onto it, and all other surfaces were likewise unavailable for food production. The house was infested with cockroaches and other vermin, and spiders' webs extended from floor to ceiling. Two unusual features in this case were the fact that the children did appear actually to be given the vitamins that the mother claimed were helpful, and that two negative ion generators hung from ceilings in the house. This "care" may have been genuine, but was more likely to be experimental, to give the mother more importance at meetings with other mothers. The hospital pediatrician supplied drugs appropriate for hyperactivity although there was no evidence that either of the children were hyperactive. The family doctor "suspected that there was something going on" but never visited the family at home. Social welfare has been called in to deal with the case. While this form of Munchausen's is not typical of the acute presentations as cited by Palmer and Yoshimura, its presence may be more widespread. It may also be more insidious, with a more normal presentation of the parent making it harder to identify. P. L. Holborow, M.Sc. University of Queensland St. Lucia Brisbane Australia
A Variant of Munchausen's Syndrome by Proxy To the Editor: The Munchausen's syndrome by proxy, as described by Palmer and Yoshimura (984) may be extended to the form of child abuse that results in growth failure, IQ deficit and learning disability (Money, 1982). Since 1958, Money has seen 50 such cases and after followup of a number of these reported improvement on removal of the children from the parents and regression on subsequent return. While Money does not explain how the parents produce abuse dwarfism in the child, he does comment on the "mask of parental sanity and concern." This can occur by means of claims of hyperactivity and allergy, and the use of elimination diets to cover the deliberate underfeeding that results in the abuse dwarfism. One such case in Brisbane is a mother whose husband left when the two children were still at preschool age. A visit to a hospital pediatrician and an allergy-oriented dietician resulted in recommendation for a strict diet in which all grains, milk and sugar were to be eliminated, and at the same time the Feingold diet (Feingold, 1974) was to be implemented. This restricted fresh fruits to three varieties and also restricted some vegetables, while all foods with artificial coloring and flavoring were absolutely forbidden. No specific allergy tests had been conducted. The mother regularly attended meetings of foodsensitive people, always brought food along and offered suggestions on vitamin, mineral or other supplements which supposedly alleviated the problem. However, after several years, the children were small, very thin and pale, and were beginning to show learning difficulties. The younger child was still taken around in a small, folding push chair when she was 6 years of age. At 8 years of age, she was carried around a park by a 9 year-old, who said "she was too weak and tired to walk." The home showed another aspect of abuse. No item
References FEINGOLD, B. F. (1974), Why Your Child i.~ Hyperactive. New York: Random House. MONEY, .J. (1982), Child abuse: growth failure, IQ deficit, and learning disability. J. Learn. Disabil., 15:597-582. PALMER, A. J. & YOSHIMURA, G. J. (1984), Munchausen syndrome by proxy. This Journal, 23:503-508.
Termination of Parental Rights To the Editor: It was good to read Dr. Schoettle's paper on termination of parental rights in the September issue (23:5), and I agree with him on almost all the points he made. However, I feel that his last two sentences are a bit unrealistic. I felt he said that ultimately psychiatry should find ways to treat inadequate parents so that termination of parental rights should become a phenomenon of the past. 2~8
LEITERS TO EDITOR
To expect that all human beings have the potential to responsibly care for children is idealistic, in my opinion. And until our nation develops a national policy for children's care which would require cabinet level-a Department of Child Health and Development-authority and funding, I feel child psychiatrists must continue to be child advocates, attempting to educate and collaborate with other disciplines involved in the care of children and their families which includes the courts and the legal profession. I believe that many child psychiatrists, like Dr. Schetky and Dr. Schoettle, particularly in the last 10 years, have acted responsibly in these matters, but I believe that termination of parental rights is a realistic step forward rather than a failure on psychiatry's part. John B. Reinhart, M.D. Child Psychiatrist Hendersonville, N.C.
Author's Reply To the Editor:
Dr. Reinhart's comments that my closing sentences were "a bit unrealistic" is unfortunately accurate for the state of affairs in 1984. However, if the mandate to psychiatry is not to evaluate and treat the inadequate parent and his or her effect upon a child, what is it? I would hope, as Dr. Reinhart suggests, that we view this mandate as a challenge to the national policy, to the professional psychiatric organizations, and to the individual psychiatrist. In recognizing our own treatment limitations, we must continue to appropriately suggest termination of parental rights as one alternative to a profoundly dysfunctional parentchild dyad. Dr. Schetky's (1979) study strongly suggests and documents that termination of parental rights with a subsequent permanent placement or adoption is preferable to the continued state of abuse and uncertainty for the child. Likewise, Kempe and Kempe (1978) found that approximately 10% of abusive parents are "too seriously mentally ill," thus requiring the termination of parental responsibility. One to two percent of these are delusional psychotic patients who repeatedly abuse their child as part of the symptom complex. Another 2-3% are aggressive sociopaths who essentially lack impulse control and repeatedly assail their child victims. A further 1-2% are frankly "cruel" and torture their children for minor infractions. The final 2-3% are "fanatics" whose religious beliefs often justify abusing children. In my opinion, for a minority of all abusing, neglectful, or otherwise deficient parents, the termination of parental rights is the most humane and viable alternative both for the parents and their children. Nevertheless, it is my belief that we as a professional com-
239
munity should not accept a 10% failure rate. However, I would rather see this as a mandate to appropriately intervene at whatever level necessary to ultimately lessen the dire consequence to grossly inadequate or inappropriate parent-child relationships. If we have abdicated in this responsibility, we have colluded with parental failure. It is in this sense that I suggest the termination of parental rights should ultimately become past history rather than a present reality. Ulrich C. Schoettle, M.D. Seattle, Washington
References KEMPE, R. S. & KEMPE, C. H. (1978), Child Abu.~e-The Developing Child. Cambridge, Mass.: Harvard University Press, pp. 68-69. SCHETKY, D. H., ANGELL, R., MORRISON, C. V. & SACK, W. H. (1979), Parents who fail: a study of 51 cases of termination of
parental rights. This Journal, 18:366-383.
Autism or Fragile X Syndrome? To the Editor: I read with interest "A Study of Three Brothers with Infantile Autism: A Case Report with Follow-up" by Shell et al. (1984). This report describes three brothers with developmental delays and unusual behavior consistent with the DSM-III definition of Infantile Autism. They concluded that the cognitive and behavioral dysfunction reported seemed to be a function of the pre- and perinatal stresses suffered by each child although genetic factors may also be implicated. In reviewing the pre- and perinatal courses of the two children who were delivered full-term with appropriate birth weights and adequate Apgar scores, only one pregnancy was complicated by pyelitis, vaginal bleeding, and progesterone treatment. The third child was delivered prematurely after similar complications but the birth weight was appropriate for gestational age and there was no evidence of hypoxia in the history reported. Minor pregnancy or birth complications are usually not associated with severe cognitive and behavioral dysfunction (Sameroff and Chandler, 1975). Since there are three siblings with similar cognitive and behavioral problems and one of these children did not have pregnancy and birth difficulties, genetic problems are highly likely. With three males involved in one family, X-linked forms of mental retardation are suggested. The "fragile X" syndrome is responsible for approximately 50% of cases with X-linked mental retardation (Herbst and Miller, 1980). Autism or autistic characteristics have also been documented in 60% of male patients with the fragile X syndrome (Levitas et al., 1983a, 1983b). Behaviors such as hand flapping, hyperactivity, poor eye contact, echolalic speech, and ritualistic posturing behavior are common in the fragile X syndrome, and were also present in
of rubbish had been thrown away for a number of years, such that only a narrow track ran from the back door through the dining room to the kitchen sink. The rubbish was 6-9 inches deep on the floor of the track, and sloped up to about 3 feet high against the walls. The kitchen table had several feet of rubbish precariously piled onto it, and all other surfaces were likewise unavailable for food production. The house was infested with cockroaches and other vermin, and spiders' webs extended from floor to ceiling. Two unusual features in this case were the fact that the children did appear actually to be given the vitamins that the mother claimed were helpful, and that two negative ion generators hung from ceilings in the house. This "care" may have been genuine, but was more likely to be experimental, to give the mother more importance at meetings with other mothers. The hospital pediatrician supplied drugs appropriate for hyperactivity although there was no evidence that either of the children were hyperactive. The family doctor "suspected that there was something going on" but never visited the family at home. Social welfare has been called in to deal with the case. While this form of Munchausen's is not typical of the acute presentations as cited by Palmer and Yoshimura, its presence may be more widespread. It may also be more insidious, with a more normal presentation of the parent making it harder to identify. P. L. Holborow, M.Sc. University of Queensland St. Lucia Brisbane Australia
A Variant of Munchausen's Syndrome by Proxy To the Editor: The Munchausen's syndrome by proxy, as described by Palmer and Yoshimura (984) may be extended to the form of child abuse that results in growth failure, IQ deficit and learning disability (Money, 1982). Since 1958, Money has seen 50 such cases and after followup of a number of these reported improvement on removal of the children from the parents and regression on subsequent return. While Money does not explain how the parents produce abuse dwarfism in the child, he does comment on the "mask of parental sanity and concern." This can occur by means of claims of hyperactivity and allergy, and the use of elimination diets to cover the deliberate underfeeding that results in the abuse dwarfism. One such case in Brisbane is a mother whose husband left when the two children were still at preschool age. A visit to a hospital pediatrician and an allergy-oriented dietician resulted in recommendation for a strict diet in which all grains, milk and sugar were to be eliminated, and at the same time the Feingold diet (Feingold, 1974) was to be implemented. This restricted fresh fruits to three varieties and also restricted some vegetables, while all foods with artificial coloring and flavoring were absolutely forbidden. No specific allergy tests had been conducted. The mother regularly attended meetings of foodsensitive people, always brought food along and offered suggestions on vitamin, mineral or other supplements which supposedly alleviated the problem. However, after several years, the children were small, very thin and pale, and were beginning to show learning difficulties. The younger child was still taken around in a small, folding push chair when she was 6 years of age. At 8 years of age, she was carried around a park by a 9 year-old, who said "she was too weak and tired to walk." The home showed another aspect of abuse. No item
References FEINGOLD, B. F. (1974), Why Your Child i.~ Hyperactive. New York: Random House. MONEY, .J. (1982), Child abuse: growth failure, IQ deficit, and learning disability. J. Learn. Disabil., 15:597-582. PALMER, A. J. & YOSHIMURA, G. J. (1984), Munchausen syndrome by proxy. This Journal, 23:503-508.
Termination of Parental Rights To the Editor: It was good to read Dr. Schoettle's paper on termination of parental rights in the September issue (23:5), and I agree with him on almost all the points he made. However, I feel that his last two sentences are a bit unrealistic. I felt he said that ultimately psychiatry should find ways to treat inadequate parents so that termination of parental rights should become a phenomenon of the past. 2~8
LEITERS TO EDITOR
To expect that all human beings have the potential to responsibly care for children is idealistic, in my opinion. And until our nation develops a national policy for children's care which would require cabinet level-a Department of Child Health and Development-authority and funding, I feel child psychiatrists must continue to be child advocates, attempting to educate and collaborate with other disciplines involved in the care of children and their families which includes the courts and the legal profession. I believe that many child psychiatrists, like Dr. Schetky and Dr. Schoettle, particularly in the last 10 years, have acted responsibly in these matters, but I believe that termination of parental rights is a realistic step forward rather than a failure on psychiatry's part. John B. Reinhart, M.D. Child Psychiatrist Hendersonville, N.C.
Author's Reply To the Editor:
Dr. Reinhart's comments that my closing sentences were "a bit unrealistic" is unfortunately accurate for the state of affairs in 1984. However, if the mandate to psychiatry is not to evaluate and treat the inadequate parent and his or her effect upon a child, what is it? I would hope, as Dr. Reinhart suggests, that we view this mandate as a challenge to the national policy, to the professional psychiatric organizations, and to the individual psychiatrist. In recognizing our own treatment limitations, we must continue to appropriately suggest termination of parental rights as one alternative to a profoundly dysfunctional parentchild dyad. Dr. Schetky's (1979) study strongly suggests and documents that termination of parental rights with a subsequent permanent placement or adoption is preferable to the continued state of abuse and uncertainty for the child. Likewise, Kempe and Kempe (1978) found that approximately 10% of abusive parents are "too seriously mentally ill," thus requiring the termination of parental responsibility. One to two percent of these are delusional psychotic patients who repeatedly abuse their child as part of the symptom complex. Another 2-3% are aggressive sociopaths who essentially lack impulse control and repeatedly assail their child victims. A further 1-2% are frankly "cruel" and torture their children for minor infractions. The final 2-3% are "fanatics" whose religious beliefs often justify abusing children. In my opinion, for a minority of all abusing, neglectful, or otherwise deficient parents, the termination of parental rights is the most humane and viable alternative both for the parents and their children. Nevertheless, it is my belief that we as a professional com-
239
munity should not accept a 10% failure rate. However, I would rather see this as a mandate to appropriately intervene at whatever level necessary to ultimately lessen the dire consequence to grossly inadequate or inappropriate parent-child relationships. If we have abdicated in this responsibility, we have colluded with parental failure. It is in this sense that I suggest the termination of parental rights should ultimately become past history rather than a present reality. Ulrich C. Schoettle, M.D. Seattle, Washington
References KEMPE, R. S. & KEMPE, C. H. (1978), Child Abu.~e-The Developing Child. Cambridge, Mass.: Harvard University Press, pp. 68-69. SCHETKY, D. H., ANGELL, R., MORRISON, C. V. & SACK, W. H. (1979), Parents who fail: a study of 51 cases of termination of
parental rights. This Journal, 18:366-383.
Autism or Fragile X Syndrome? To the Editor: I read with interest "A Study of Three Brothers with Infantile Autism: A Case Report with Follow-up" by Shell et al. (1984). This report describes three brothers with developmental delays and unusual behavior consistent with the DSM-III definition of Infantile Autism. They concluded that the cognitive and behavioral dysfunction reported seemed to be a function of the pre- and perinatal stresses suffered by each child although genetic factors may also be implicated. In reviewing the pre- and perinatal courses of the two children who were delivered full-term with appropriate birth weights and adequate Apgar scores, only one pregnancy was complicated by pyelitis, vaginal bleeding, and progesterone treatment. The third child was delivered prematurely after similar complications but the birth weight was appropriate for gestational age and there was no evidence of hypoxia in the history reported. Minor pregnancy or birth complications are usually not associated with severe cognitive and behavioral dysfunction (Sameroff and Chandler, 1975). Since there are three siblings with similar cognitive and behavioral problems and one of these children did not have pregnancy and birth difficulties, genetic problems are highly likely. With three males involved in one family, X-linked forms of mental retardation are suggested. The "fragile X" syndrome is responsible for approximately 50% of cases with X-linked mental retardation (Herbst and Miller, 1980). Autism or autistic characteristics have also been documented in 60% of male patients with the fragile X syndrome (Levitas et al., 1983a, 1983b). Behaviors such as hand flapping, hyperactivity, poor eye contact, echolalic speech, and ritualistic posturing behavior are common in the fragile X syndrome, and were also present in