Susan Hatters Friedman, MD

Reviewed by Karen B. Rosenbaum, MD, and Susan Hatters Friedman, MD

 is a novel by Australian author Liane Moriarty,

, which was made into a 2-season HBO series. 

was recently adapted into an 8-episode Hulu miniseries, which premiered on August 18, 2021. Although there are many important plot changes between the novel and the miniseries, the miniseries is very well cast, making Moriarty’s characters come to life. Both the novel and the miniseries deal with 9 people who want to reinvent themselves through an exclusive (and expensive) 10-day “wellness” retreat led by a mysterious woman named Masha, played seemingly effortlessly by Nicole Kidman.

[Spoiler Alert] Masha’s backstory is that she was a ruthless, successful businesswoman who nearly died (the method is different between the novel and the miniseries) and was rescued by a mild-mannered, eager Yao (played by Manny Jacinto from 

, who was then a practicing EMT. She survived and changed her life, building “Tranquillum House,” an idyllic wellness retreat where the 9 perfect strangers meet. The novel is set in Australia, but the miniseries is set in the fictional town of Cabrillo, California, although it was filmed in New South Wales, Australia.

Psychiatric themes include suicide and experimental psychopharmacology. For example, the Marconi family are 3 of the Tranquillum House guests: They are the parents and twin sister of a deceased boy who each blame themselves and each other after the boy—17-year-old Zachary—died by suicide 3 years prior. In the book, Zachary’s mother, Heather Marconi, reveals that she did not pay attention to the side effects on the insert of a new asthma medication Zachary was taking, 1 of which was suicidal ideation. In the show, she only remembers reading this while under the influence of Masha’s LSD. In the book, the sister of another guest, Ben, dies by drug overdose after losing a long battle with addiction.

The miniseries takes many liberties with the plot of the novel, including changing characters’ professions, which ultimately shifts the tone of the story. For example, another character, Carmel, a mother of 4 whose husband left her for another woman, becomes violent in the show, but not in the novel. These plot and character changes do increase the suspense, but they also make the characters more 1-dimensional. The book feels less mysterious, but in both, the person responsible for the wellbeing of 9 people, Masha, has a dark past and a narcissistic side that drives her to do things that are self-serving and not in the best interest of others. In both the miniseries and the novel, when the guests eventually realize that they are being medicated, Masha calmly tells them, “It’s called ‘microdosing,’ and it’s perfectly safe.”

Microdosing usually implies taking very small amounts of a psychedelic such as LSD or psilocybin-containing mushrooms—not necessarily enough to cause an altered state of consciousness, but enough to experience an elevation in mood. Well-respected establishments such as the Depression Evaluation Service at Columbia University

 are currently researching the use of psychedelic medications, and several studies examine the risks and benefits of low-dose psychedelics. For example, in 2020, Lea et al“examined motivations, dosing practices, and perceived benefits and limitations of microdosing.” They found that reported benefits included “cognitive and creative enhancement, reduced depression and anxiety, enhanced self-insight and mindfulness, improved mood and attitude toward life, improved habits and health behaviors, and improved social interactions and interpersonal connections.” Some of the negative effects included that these drugs are still illegal, involve self-administration, bring only short-term benefits, and may result in more frequent “off” days.

One of the many problems with Masha microdosing her guests through smoothies is that there is no consent. The guests are unaware that this is happening, and some of them have possible contraindications to psychoactive medications such as other medical conditions and family histories of addiction. The microdosing also causes frank hallucinations. The Marconi family, for example, all see the deceased Zachary. There are also unpleasant side effects, as seen in a study by Anderson et al where 18% of people described physiological discomfort and 7% described increased anxiety.

In the 8th and final episode, Masha makes an ironic attempt to show some semblance of therapeutic integrity. When the Marconi family confronts Masha, saying she left out vital information indicating that she had ulterior motives for helping them hallucinate Zachary, Masha replies, “It’s not acceptable for a ‘therapist’ to be talking about her own life.”

Despite some interesting character development in terms of some of the backstories of the guests and of Masha and her staff, there are very few likeable characters. Although they are all human in terms of having flaws, weaknesses, and difficulties, it is difficult to relate to them at times. Wellness retreats are gaining in popularity, and the benefits of yoga, meditation, and other alternative medicines are widely known and accepted in our field. However, the experimental practices at the fictional Tranquillum House are off-putting and potentially harmful, and they may potentiate fears around the mental health and wellness communities. There are also frank references in the miniseries to Western psychiatric facilities not being as safe as Masha’s experimental “wellness” facility. It is important as psychiatrists to know what entertainment our patients are consuming so that we can dispel potential myths around mental health and experimental psychopharmacology.

is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. 

 serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of 

Family Murder: Pathologies of Love and Hate

 (Washington, DC: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and was awarded the 2020 Manfred Guttmacher Award by the American Psychiatric Association.

Inside the Tranquillum House from Hulu’s Nine Perfect Strangers

. August 25, 2021. Accessed September 5, 2021.

. Columbia University. 2021. Accessed September 13, 2021. 

Psychedelic microdosing: a Subreddit analysis.

5. Anderson T, Petranker R, Christopher A, et al. 

Psychedelic microdosing benefits and challenges: an empirical codebook

Articles

Microdosing at “Tranquillum House,” and its implications for real-world experimental psychopharmacology.

Nine Perfect Strangers

The bodies of several dead infants are discovered in a woman’s garage.

One mother drowns her young children after a divorce because they are a hindrance; another mother drowns her young children in the delusional belief that she is sending them to heaven to protect them from being forced into child pornography.

A father shoots his sons and wife before turning the gun on himself.

A child dies of a traumatic head injury; both parents initially disavow any knowledge of trauma and later say he accidentally fell from his changing table.

These cases demonstrate a wide range of behavior that ends in the death of children at the hands of their parents. For the very different motives in these cases, different prevention strategies are needed and different legal outcomes can be anticipated.

Filicide refers to the killing of a child by a parent. Neonaticide is defined as the killing of an infant in the first 24 hours after birth

; it has its own characteristics and is a different entity than other filicides. Infanticide is a less precise term that commonly denotes the murder of an infant in the first year of life.

[[{"type":"media","view_mode":"media_crop","fid":"42461","attributes":{"alt":"Â© ALEKSEI POTOV/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_7729834092617","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4603","media_crop_rotate":"0","media_crop_scale_h":"98","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© ALEKSEI POTOV/SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]Approximately 15% of all murders are filicides.

 Rates of child murder in the US are greater than the rates in other developed countries.

 About one-third of victims are infants (up to 12 months old), and more than two-thirds are younger than 6 years.

In 1969, 5 motives that explain why parents kill their children were described (

fatal maltreatment, partner revenge, unwanted child, altruistic, and acutely psychotic

. The most common reason a child is killed by a parent is 

, in which a parent kills the child in order to make the other parent suffer emotionally. An 

 is killed because that child is seen as a hindrance to the parent’s goals. Alternatively, in 

 child murder, the parent kills the child out of love. These parents may kill their child in association with their own suicide or to protect the child from a fate worse than death. Finally, in the case of 

 filicide, the parent in the throes of psychosis or mania kills the child for no comprehensible reason.

For a person to be found legally insane, mental illness must cause the individual not to know the wrongfulness of his or her act (crime). In approximately one-third of states, insanity may be the finding if the defendant was unable to control the (offending) behavior because of mental illness. Our study of those mothers found insane for the crime of child murder in Michigan and Ohio concluded that their motives were altruistic or acutely psychotic.

 Other motives are not likely to result in a successful insanity defense, even if the mother was mentally ill.

Andrea Yates’ drowning of her 5 children is an example of altruistic filicide. She had the delusional belief that if she did not take her children’s lives before the age of accountability, all her children (age 6 months to 7 years) would go to hell because of her defective mothering. She killed them out of love so that they could be with God for all of eternity. She qualified for an insanity defense because she had the delusional belief that she was doing what was right for her children.

Neonaticide is almost always committed by the mother acting on her own. The true rates of neonaticide are difficult to ascertain because when the pregnancy is hidden and the newborn baby disposed of, no one knows of the crime. Of the 5 motives described by Resnick, the most common motive for neonaticide is because the infant is unwanted.

Neonaticide perpetrators almost always deny or conceal their pregnancies and rarely seek prenatal care. Although they may develop psychiatric symptoms after the murder, they rarely have preexisting psychosis or major depression.

 Some women may experience dissociation around the time of the birth and murder.

 Suicide after neonaticide is extremely rare.

Depending on the type of sample, researchers’ findings vary across filicide studies. In samples of administrative records (such as those from coroners’ offices or law enforcement departments), the mother often was the primary caregiver and had social stressors, such as financial problems, and a personal history of abuse.

 Mothers from psychiatric populations (such as those found in psychiatric hospitals) unsurprisingly had high rates of mental illness, especially psychosis and depression. They often had financial stressors and a history of earlier traumatic events. Mothers in samples from incarcerated populations were often undereducated, single, unemployed, and previously victimized, and had little social support. Some had a history of mental illness or substance abuse.

Fathers and mothers kill their children at similar rates; however, mothers’ victims are younger on average.

 Fathers are more likely to kill impulsively, to be intoxicated, and to use violent methods.

Mothers who kill their children are much more likely than fathers to pursue an insanity defense successfully. Therefore, after a filicide, fathers are more often incarcerated than mothers, while mothers are more frequently hospitalized in a psychiatric facility. In addition, fathers are more likely to kill themselves after murdering their children than mothers are.

 Furthermore, fathers are more likely than mothers to kill the entire family, an act known as familicide.

Strategies for prevention vary with the motive for the child homicide. Women who commit neonaticide are unlikely to have previously come to psychiatric attention. However, several efforts may be helpful in neonaticide prevention.

 First, improved contraceptive education can reduce rates of unintentional pregnancy. Second, women and teenagers who become pregnant should be urged to seek prenatal care. Teachers, parents, and physicians should ask teenage girls whether there is any likelihood that they are pregnant. If there is any suspicion, physicians should test for pregnancy.

Third, Safe Haven laws have been passed in every state in the US. These laws seek to reduce the number of abandoned babies and neonaticides. The specifics of these laws vary depending on the state, but in general women can leave their unwanted infants at a hospital or fire station within the first few days of life, with no questions asked. However, one problem is the lack of public awareness of these laws, especially among young women.

The murders of older infants and children are difficult to prevent because many parents-who would never kill their child-possess the same factors, such as mental illness and social stressors, found among those who do kill. In addition, one must keep in mind that most child murders stem from child abuse, rather than from mental illness in the parents.

Some parents with a severe mental illness, personality disorder, or substance abuse do abuse their children. Psychiatrists should inquire whether their patients are parents, and assess their parenting capacity and the risk of harm toward their child. All physicians have a duty to report a suspicion of child abuse or neglect to child protective services.

Even among parents without mental illness, aggressive thoughts and fantasies toward infants may occur. In fact, one study found that more than one-quarter of mothers with colicky infants experienced infanticidal thoughts.

Psychiatrists should not be afraid to inquire about thoughts of harming a child. More than 40% of depressed mothers of infants and toddlers admitted to having such thoughts.

 Obviously, most do not go on to harm their child. However, psychiatrists often underestimate how often these thoughts occur.

 Psychiatric hospitalization should be considered when there is an elevated risk of child harm. In addition, psychiatrists should search for unrealistic concerns about a child’s health and delusions about the child.

Parents who are suicidal should be asked about their plans for the children if they were to take their own life. A loving father who plans to kill himself because of his depression may have thoughts about taking the whole family with him.

During the postpartum period, women should be routinely screened for both postpartum depression and psychosis. Untreated postpartum psychosis significantly increases the risk of both suicide and child murder. Keep in mind that fathers also can experience exacerbations of mental illness during the stressful postpartum period. Finally, care must be taken not to mistake postpartum obsessive-compulsive disorder (OCD) symptoms for postpartum psychosis. Parents with OCD sometimes experience obsessive thoughts about harm to their baby; however, there is no evidence that these ego-dystonic obsessions in OCD (without depression) raise the risk of child murder.

In summary, parents have various motives for killing their children. Fathers and mothers kill at similar rates; however, mothers are the perpetrator in almost all cases of neonaticide. Psychiatrists should assess parenting issues and other stressors when treating depressed or psychotic parents of young children.

Dr Friedman is Associate Professor in Psychiatry at Case Western Reserve University School of Medicine in Cleveland; she is also Associate Professor of Psychological Medicine at the University of Auckland in New Zealand. Dr Resnick is Professor of Psychiatry and Director of the Division of Forensic Psychiatry at Case Western Reserve University School of Medicine. He has performed research on child murder for 50 years. The authors report no conflicts of interest concerning the subject matter of this article.

 Resnick PJ. Murder of the newborn: a psychiatric review of neonaticide. 

 Friedman SH, Resnick PJ. Neonaticide: phenomenology and considerations for prevention. 

 Mariano TY, Chan HC, Myers WC. Toward a more holistic understanding of filicide: a multidisciplinary analysis of 32 years of U.S. arrest data. 

 Friedman SH, Horwitz SM, Resnick PJ. Child murder by mothers: a critical analysis of the current state of knowledge and a research agenda. 

 Resnick PJ. Child murder by parents: a psychiatric review of filicide. 

 Friedman SH, Resnick PJ. Child murder by mothers: patterns and prevention. 

 Friedman SH, Hrouda DR, Holden CE, et al. Child murder committed by severely mentally ill mothers: an examination of mothers found not guilty by reason of insanity. 

 Friedman SH, Cavney J, Resnick PJ. Child murder by parents and evolutionary psychology: a framework for approaching forensic assessment. 

 Spinelli MG. A systematic investigation of 16 cases of neonaticide. 

 Putkonen H, Amon S, Eronen M, et al. Gender differences in filicide offense characteristics-a comprehensive register-based study of child murder in two European countries. 

 West SG, Friedman SH, Resnick PJ. Fathers who kill their children: an analysis of the literature. 

 Friedman SH, Hrouda DR, Holden CE, et al. Filicide-suicide: common factors in parents who kill their children and themselves. 

 Levitzky S, Cooper R. Infant colic syndrome-maternal fantasies of aggression and infanticide. 

 Jennings KD, Ross S, Popper S, Elmore M. Thoughts of harming infants in depressed and nondepressed mothers. 

 Friedman SH, Sorrentino RM, Stankowski JE, et al. Psychiatrists’ knowledge about maternal filicidal thoughts. 

 Booth BD, Friedman SH, Curry S, et al. Obsessions of child murder: underrecognized manifestations of obsessive-compulsive disorder. 

Psychiatrists should not be afraid to assess parenting issues and other stressors when treating depressed or psychotic parents of young children.

Parents Who Kill: Clinical and Legal Perspectives

To our readers: We appreciate the feedback you've given thus far. The authors offer a wrap-up of key teaching points based on your input. 

See the next page for the latest teaching points

The following vignette is an amalgamation of several different cases described by the media.

 It highlights several characteristics common among women who sexually abuse their students.

Questions to consider when reading the case

1. In treating a female who sexually abuses a minor, what should the clinician keep in mind?

2. Is the treatment plan different for a female offender than a male?

3. How might you counsel Joe's upset mother? 

4. If Joe were to inform you that he believes he and Mrs Smith are "truly in love" - how might you counsel him?

Mrs Smith was a 28-year-old, high school biology teacher in a small town. She was well liked by students, parents, and colleagues. Students easily identified with her because of her youthful appearance. Soon after she started teaching, rumors surfaced that photos of her wearing seductive attire were available on the Internet. Although this caused a stir within the school, the administration did not become involved. Mrs Smith admitted that these pictures were of her, appeared contrite, and explained that they were taken some time ago; the incident was forgotten relatively quickly.

During the fall of the next school year, Mrs Smith began attending many high school football games. Unbeknownst to others, she started paying close attention to one of the players, who was also one of her students. Joe was a 14-year-old varsity linebacker who was unusually tall for his age. He did not often socialize with his teammates and was considered a loner.

Mrs Smith initially contacted Joe by e-mail, offering to assist him with his homework after school in her classroom. He accepted, flattered by the attention from an attractive, young female teacher. These tutorial sessions then moved to her home on Thursday evenings. Mrs Smith began asking him increasingly personal questions during these sessions. Initially, she inquired how he felt about various female classmates, and then eventually about his past sexual activities.

After 6 months, she encouraged him to take an overnight trip with her to a museum located a few hours away. She told him that his parents might be uncomfortable with the idea, so she encouraged him to tell them that he was spending the night at a friend’s house. It was during this trip that Mrs Smith and Joe first engaged in sexual activity, which both later described as consensual. Following the initial encounter, their meetings took place with increasing frequency: at first limited to hotels, then in her car, and finally in her classroom during her free period.

Joe’s parents noticed that his school performance was slipping and his few friends denied any recent contact with him. Concerned, his parents searched his room. Under his bed, they found a number of love letters from Mrs Smith, and they discovered on his computer a file containing photos of Mrs Smith and their son engaging in sexual activity. Joe’s parents approached the school board and the police with their findings.

We invite your comments below. The authors will review your responses and give their feedback in coming weeks. 

See the next page for key teaching points

For further reading, see the earlier published article, “

Lessons to Learn: Female Educators Who Sexually Abuse Their Students

FROM THE AUTHORS: Key Teaching Points Based on Reader Comments

"One can clearly see in the vignette how she groomed him. She knew he was a loner and used that to her advantage, she was very predatory in her actions."

 This is an excellent point.  In my experience consulting with school administrators and attorneys in the wake of these incidents, the grooming pattern was invariably present and almost painfully obvious. How is it that parents miss the signs? Very often, they have been groomed as well.  The offender purposely gains their trust, puts them at ease, and "assures" them that they have nothing but the child's best interests at heart. To busy parents with a struggling child, this can seem like a Godsend. However, it is this phenomenon that can cause parents to overlook the inappropriate boundary crossings that become more frequent and progressive.

For example, in the case of Joe, the tutorial sessions after school would not raise any suspicions.  But once the sessions moved to the teacher's home, and then progressed to an overnight trip, parental concern should pique.  

“Keeping in mind that sexually acting out is a sign of bipolar, if I were her psychiatrist, I would be sure to screen her for bipolar disorder and treat her accordingly.”

 It is astute to consider the possibility of mania where uncharacteristic sexual behavior is concerned. In fact, in one notable case, teacher Debra Lafave claimed that she suffered from bipolar disorder at the time she engaged in sexual misconduct with a 14 year old student.

 However, she was unable to raise any type of mental health defense, and pleaded guilty in 2005 to Lewd or Lascivious Battery. Of course, the majority of teacher sexual abusers will demonstrate little in the way of serious mental illness.

"The important aspect to note in this case is whether it is a case of sexual abuse or some sort of 'counter-transference'? Had it been a case of sexual abuse, it would have happened with more than one student by the offending teacher. Transference is fairly common in students towards their teachers belonging to opposite sex."

 Indeed, transference and counter-transference, as described in the psychoanalytic and psychotherapy literature, are constantly occurring regardless of the nature of the relationship.   As opposed to a pathological process, these phenomena are meant to generally describe how we relate to one another via evoked past experiences and relationships, and we psychiatrists try to stay attuned to this so as to make use of it in psychotherapy in a way that is helpful to the patient.  The teacher-student relationship does share some similarities with the therapist-patient relationship in that both involve a power imbalance, the need for trust, and the over-arching goal of the former placing the latter's best interests first.   Research has shown that teachers, by and large, are acutely aware of this special relationship and the heavy ethical burden it comes with.  In a study of teachers’ opinions on ethical standards, teachers rated boundary violations as the single most serious ethical violation.

 http://edition.cnn.com/2005/LAW/11/22/teacher.sex/index.html

 Moulden H, Firestone P, Kingston D, Wexler A. A description of sexual offending committed by Canadian teachers. 

 Barrett DE, Headly KN, Stovall B, Witte JC. Teachers’ perceptions of the frequency and seriousness of violations of ethical standards.


The big list: female teachers with students. WorldNetDaily Web site.

 http://www.worldnetdaily.com/news/article.asp?ARTICLE_ID=53859

In treating a female who sexually abuses a minor, what should the clinician keep in mind? Is the treatment plan different for a female offender than a male? 

The Case of a Female Teacher Who Sexually Abuses Her Student

Education is a noble profession, and society places a great deal of trust in those who dedicate their lives to teaching children. Unfortunately, a small percentage of those educators use their position of power to sexually exploit their students. While it is assumed that men are often responsible for this type of behavior, in recent years, a number of high-profile cases of female educator sexual misconduct have been covered by the media.

“Educator sexual misconduct” is a term used to describe “behavior by an educator that is directed at a student and intended to sexually arouse or titillate the educator or the child.”

 The word “educator” not only includes classroom teachers but also coaches, counselors, administrators, tutors, and aides. Victims include students up through 12th grade. This misconduct pertains to any physical, verbal, or visual (such as showing pornography) sexual behavior between educator and student.

Following a federal mandate to investigate this topic, the US Department of Education published a literature review of educator sexual misconduct synthesized by Charol Shakeshaft in 2004. According to her analysis, 9.6% of high school students have experienced some form of educator sexual misconduct during their school career. The offenders were most commonly teachers or coaches, whose positions allowed them to spend increased individual time with particular students.

 Across 7 studies, the sex of the offender varied significantly; although the majority were men, 4% to 43% were women.

 The offenders ranged in age from 21 to 75 years, with a mean age of 28.8

The sex of the victim was somewhat less variable than that of the offender: 54% to 77% of the victims were female and 23% to 46% were male.

 Same-sex abuse was in the minority. In 13% of cases, female teachers abused female students.

 Within samples of victims, overrepresented minorities included black, Hispanic, and Native American children.

Children with disabilities were at increased risk for sexual abuse because of greater individualized attention and because of their possible difficulties with communication.

What  the teacher is, is more important than what [s]he teaches.

“Grooming” describes the process in which the offender lures the victim into the sexual abuse. Given their level of interaction with students, educators are in a unique position to do this. Grooming can also serve to make the student feel complicit in the behavior.

 A teacher may provide the student with increased attention while slowly initiating sexual behavior, including asking questions about the student’s sexuality or increasing general physical contact. The rewards and extra attention are meant to aid in the attachment of the child (and potentially the child’s parents) to the teacher, while the behavior tests the student’s ability to keep a secret and be compliant with the wishes of the abuser.

Borderline inappropriate acts may also desensitize the child to the commencement of more overt sexual activity. To maintain the relationship, the educator may resort to manipulation, exploitation, or intimidation-including the loss of the contact with the educator (which the child may value) or threatening academic or other consequences for revealing the nature of their contact.

A number of features may distinguish students who fall victim to educator sexual misconduct. These youths are often isolated from their peers and their families, which makes the abuse less likely to be detected. They may be shy and quiet, which makes them easier to control and less likely to disclose the abuse to an adult. On the opposite end of the spectrum, the victims may be troublemakers who, on the basis of their past behavior, are not likely to be believed by authorities even if they do report the abuse.

Women account for fewer than 10% of all arrests made for sexual offenses.

 It is strongly suspected that this figure represents an underestimate of the actual number of crimes that occur. For example, 60% to 80% of men sexually abused during their childhood identified a female perpetrator.

 Female sex offenders are often white, have a history of substance use, and have been victims of sexual abuse themselves. They often commit the crimes in their 20s and 30s.

Several typologies assist in understanding these offenders. One of the categories, the “teacher/lover,” describes women who assert that they are educating their victims about sex as part of a consensual relationship. They often claim that their behavior does not constitute abuse.

“Heterosexual nurturers” are women who develop sexual relationships with children and adolescents on the basis of feelings of love or a desire for intimacy. These women also often mistakenly assert that their behavior is not abusive.

Educators working in primary education (K-12) who engage in sexual activity with their students can be categorized by the age of their victims.

 The first group consists of those who sexually abuse elementary schoolchildren. These individuals are frequently considered high achievers in their profession. They may have won awards highlighting their outstanding teaching abilities and are frequently well liked by both students and parents. The educators may use this positive standing to become close to students (and their families) and increase their ability to surreptitiously engage in sexual relationships with the children. These traits make the revelation of their aberrant behavior all the more shocking to the community, and allegations may be initially overlooked on the basis of the teachers’ reputations. In addition, these educators also have the potential to serially reoffend when they move to another location if they are relieved of their present teaching position.

The second group includes educators who sexually abuse older students. Their abuse tends to be unplanned and the result of immaturity and bad judgment rather than the premeditated behavior repeated with multiple victims that typifies the former group.

The idea of a teacher engaging in sexual activity with a young student is disturbing and may lead to the consideration that mental illness fuels this behavior. In 2004, Debra Lafave, a 23-year-old teacher, was arrested for having sex with a 14-year-old male student. Her attorney, on the basis of his client’s history of extremes of mood and other symptoms of bipolar illness, prepared an insanity defense. He stated, “Here we have a woman that, by every societal standard, can get a date, can get a man. Yet, she destroyed her career, destroyed her marriage. I believe the only logical reason why Debra Lafave did what she did was because of her mental illness.” According to 3 psychiatrists for the defense, she suffered from bipolar disorder. Ultimately, Lafave accepted a plea bargain.

Currently, there is little empirical evidence related to the presence of mental illness in female sexual offenders overall. In a study of 15 women charged with a sexual offense who were referred to a psychiatric facility for forensic evaluation, one-half (n = 7) had mild mental retardation or borderline intellectual function, one-third (n = 5) were depressed, and one-fifth (n = 3) were psychotic. None had posttraumatic stress disorder (PTSD), and substance use was rarely associated with the crimes.

 Another study showed that female sex offenders had a personal history of more severe sexual abuse, were more likely to have attempted suicide, and were more likely to have received a diagnosis of PTSD than their male counterparts.

 It high-lights several characteristics common among women who sexually abuse their students.

During the fall of the next school year, Mrs Smith began attending many high school football games. Unbeknownst to others, she started paying close attention to one of the players, who was also one of her students. Joe was a 14-year-old varsity linebacker who was unusually tall for his age. He did not often socialize with his teammates and was considered a loner. 

Allegations of sexual misconduct by an educator are often made to the school board rather than to the police. These reports almost always concern inappropriate physical contact, not verbal or visual abuse,

 The consequences of the abuse reported by students often include negative ef-fects on academic achievement, fear of repercussion, and health problems.

 As for the educators, many go on to teach again. For those women who are prosecuted, there is some debate concerning whether they are less severely punished than male sex offenders.

Psychiatrists may find themselves treating either victims or perpetrators of educator sexual misconduct. Similar to other forms of abuse of minors, a physician is legally obligated to inform the appropriate authorities-regardless of the perpetrator. This may include a call to local law enforcement, depending on the urgency of the situation. Some experts who have studied mandatory reporting laws for sexual abuse of children suggest that other alternatives, such as the construction of a clinical treatment plan for the minor and the offender in lieu of obligatory reporting, may lead to better protection for minors and improved treatment for offenders.

Little literature exists specifically on the effects of educator sexual misconduct on children. Clinicians should be aware that any child who has been abused is more likely to develop suicidal ideation,

Victims may suffer from a sense of betrayal, given that the abuse was perpetrated by someone whom they were encouraged to trust.

 Clinicians may also need to address the victim’s mistaken assumption that the abuse is socially acceptable, since it was perpetrated by someone who should serve as a role model.

It is important to realize that the abuse extends to the child’s family, so family therapy and individual therapy for the parents may be warranted. Parents may require intensive therapy for feelings of guilt, self-blame, depression, and denial, especially if they are the primary care providers for their abused child in the period immediately following the abuse.

In treating the perpetrators of educator sexual misconduct, be aware that a serious violation of the teacher’s professional boundaries has occurred and work on better delineating those boundaries and highlighting to the offenders the ways in which they abused their power.

Different treatment approaches may be required for offenders who victimize young children (pedophiles) than for those who target high school–aged children (the teacher/lover or heterosexual nurturer category). If the crimes are prosecuted, these potentially high-profile offenders may have limited housing and employment options secondary to a requirement to register as a sex offender. It is unclear whether standard sex offender treatment and relapse prevention treatment are effective in this population.

Educator Sexual Misconduct: A Synthesis of Existing Literature.

 Washington, DC: US Dept of Education; 2004. Doc 2004-09.


 American Association of University Women. 

Hostile Hallways: The AAUW Survey on Sexual Harassment in America’s Schools.

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 Colorado Springs, CO: Family Research Institute; 1993.


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 Gallagher B. The extent and nature of known cases of institutional child sexual abuse. 

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 Jennings D, Tharp R. Betrayal of trust. 

 Shakeshaft C, Cohan A. In loco parentis: sexual abuse of students in schools: what administrators should know. Administration and Policy Studies, Hofstra University. 1994;(1):1-40.


 Robins SL. Protecting our students: a review to identify and prevent sexual misconduct in Ontario schools. Toronto. Ontario Ministry of the Attorney General; 1998.


Uniform Crime Reports: Crime in the United States, 2005.

A small percentage of educators use their position of power to sexually exploit their students. While it is assumed that men are often responsible for this type of behavior, in recent years, a number of high-profile cases of female educator sexual misconduct have been covered by the media.

Child murder by parents is an upsetting topic for both the public and clinicians. It is even more distressing when a mother kills her child than when a father does because we expect mothers to love and protect their children at all costs.

The term filicide refers to the homicide of a child by a biological parent. Stepfathers kill their stepchildren at much higher rates than do bio­logical fathers.

 Infanticide commonly denotes the murder of an infant during the first 12 months of life but is a less precise term. Infanticide laws exist that reduce the penalty for a mother who kills her child in the first year of life in more than 2 dozen countries (not including the United States).

 The Table presents the 5 parental motives for child homicide.

The 2 most famous cases of maternal filicide in the United States are those of Susan Smith and Andrea Yates. On October 25, 1994, Susan Smith reported that her 2 sons (aged 14 months and 3 years) had been kidnapped by a black carjacker.

 After 9 days of searching by law enforcement, she revealed that she had rolled her car into a lake with her sons strapped into their car seats. She said that she had planned to drown herself with them, but she changed her mind at the last moment.

If her account is taken at face value, her act would be considered an altruistic extended suicide. During her trial, her turbulent life came to light, which included the suicide of her father, prolonged molestation by her stepfather, and her depression and suicide attempts.

 According to the prosecution theory, her motive was that of un­wanted child; she wished to rid herself of her children to increase her chances of having a relationship with a man who did not want to marry a woman burdened with children. The jury spared her life but sentenced her to life in prison.

Andrea Yates called 911 to request police assistance on June 20, 2001.8 She told police that she had killed her 5 children and she led them to their bodies. Ms Yates experienced both depression and psychosis. She believed that her house was bugged, tele­vi­sion cameras were monitoring her home, and that Satan was literally within her. She became convinced that her children were not righteous and would ultimately burn in hell. She believed that she needed to kill her children before the age of accountability to save their souls. Her motive was clearly altruistic. She was eventually found not guilty by reason of insanity.


 Similar numbers of filicides are committed by mothers and fathers. Research findings vary based on the sample studied. Samples from admini­strative records consist of cases with information from coroners’ reports or law enforcement data. These are the most accurate because they include all cases of filicide within a jurisdiction. However, certain information may be unavailable; for example, perpetrators may not have been psychiatrically evaluated. The filicidal mother in these samples often served as her child’s primary caregiver and experienced financial difficulties. Some had a personal history of abuse. Although some of these mothers were primarily abusive or neglectful of their children, others suffered from mental illness.

Mothers studied in psychiatric populations (who were psychiatrically evaluated and/or had psychiatric dispositions) often were unemployed and had a personal history of physical abuse. As expected, mental illness was pervasive, including psychosis, depression, and suicidal ideation.

 Mothers from correctional population studies were often unemployed, under-educated, and unmarried victims of abuse with little social support; some had a history of substance use or mental illness.

Fathers and mothers kill their chil­dren for similar reasons.

 How­-ever, fathers are approximately twice as likely as mothers to commit suicide after filicide (40% to 60% vs 16% to 29%).

Thus, mothers are more like­ly to stand trial, which may partially account for why we more frequently hear about mothers who kill. Fathers are much more likely than mothers to commit familicide (killing the entire family).

 After filicides, fathers are more often in­carcerated, whereas moth­­ers more frequently receive a psychiatric disposition.


 Neonaticide is the murder of an infant in the first 24 hours of life.

 Neonaticide is distinct from other filicides.

 Almost always, this crime is com­mitted by the mother, acting alone. Suicide in conjunction with neonaticide is extremely rare. True neonaticide rates are hard to ascertain because no one knows how many new­­born babies are disposed of without discovery.

Melissa Drexler (known in the popular press as the Prom Mom) disposed of her newborn in a bathroom trash can at her high school prom on June 6, 1997.

 She had kept the pregnancy secret from her family and boyfriends. After giving birth and disposing of the baby, she returned to dance at the prom. Her motive was “unwanted child,” the most common motive in neonaticides. She was sentenced to 15 years in pris­on but was released after serving 3 years.

Perpetrators of neonaticide are  usually unmarried women in their  late teens or early 20s.

 They rarely  obtain prenatal care for their preg­nancies, which are usually denied or concealed. They rarely have premorbid Axis I diagnoses. Spinelli

 found that some mothers experienced dis­sociative symptoms around the time  of childbirth. A small minority have psychoses.


 Because of the low base rate of child murder and the frequency of characteristics of filicidal parents that occur among parents who would never harm their children, filicide prevention is difficult. Fewer than half the cases of filicide are associated with parental mental illness; the majority of deaths actually stem from child abuse. Some parents in psychiatric treatment for personality disorder, substance use problems, or severe mental illness, for example, do neglect or abuse their children. Parents with altruistic or acutely psychotic motives are usually manic, depressed, or delirious.

When filicidal thoughts are elic­ited, the clinician must consider why the parent has these thoughts. This helps guide both treatment and risk management.

Parenting capacity should be considered in evaluating patients. Certainly, when children are present for a portion of a psychiatric visit, the psychiatrist can observe the appropriateness of the parent-child interaction. Parents should be routinely assessed for their potential to harm their children. Clinicians have a duty to report suspicion of child abuse and endangered children in all 50 states.

Most psychiatrists underestimate the percentage of depressed mothers who have thoughts of harming their young children.