We thank the Hong Kong Medical Journal for publishing our letter in March 2023 regarding filicide.1 On 5 June 2023, another tragic case of filicide occurred, involving three Pakistani children who were smothered by their mother.2 The three girls, aged 2, 4, and 5 years, were unresponsive when officers arrived at their apartment after receiving a call from the woman, who initially claimed the children had been killed by her husband.2 The previous year, in September 2022, a case drew widespread publicity and prompted some government action concerning mandatory reporting.3 In that case, a mother was suspected of murdering her 5-year-old son, whose body showed more than 30 bruises and scars.4 These cases represent the loss of precious, healthy young lives amid a shrinking Hong Kong population, characterised by low birth rates and high emigration rates. Sadly, there have been no substantial policy advances despite the transient publicity that emerges year after year.

Filicide is the intentional act of murdering one’s own child.1 5 6 There are no accurate local statistics on filicide, and limited information has been reported about the physical and psychosocial well-being of the children involved—despite its frequent recurrence. The June 2023 case involved the highest number of paediatric deaths ever in Hong Kong in a single episode and featured individuals of non-Chinese ethnicity.2

Internationally, the systematic collection of nationwide filicide data has provided new insights into the problem. Depression may be one of the psychological conditions affecting parents or caregivers who commit filicide.5 6 7

Mothers are more often responsible for filicides during infancy, while fathers are more often responsible for the murders of children aged ≥8 years.7 8 Parents caused 61% of child murders involving victims under 5 years of age.8 Sometimes, filicide cases involve both murder and suicide. The comprehensive longitudinal study of convicted cases of filicide and filicide-suicide in the United Kingdom revealed that over one-third of perpetrators had a recorded mental illness, with mood and personality disorders being the most common diagnoses, and psychosis was present in 15% of cases.8 Nevertheless, the majority had no prior contact with mental health services.8 Mothers were more likely to have a history of teenage pregnancy, while fathers were more likely to have prior convictions for violent offences, exhibit a history of substance abuse, and kill multiple victims.8 Infants were more likely to be victims than older children, potentially due to postnatal depression.8 Children murdered by their parents were often victims of physical abuse prior to death. The first known infanticide-suicide case during the coronavirus disease 2019 (COVID-19) pandemic has been reported, with financial distress and fear of infection identified as contributing factors.9

In Hong Kong, a few incidents have attracted considerable publicity but were soon forgotten amid the COVID-19 crisis over the past 2 years. Another local case of filicide occurred in early 2021, during the COVID-19 pandemic. Tragically, a naked businesswoman and her 5-month-old daughter fell to their deaths from their penthouse within an upscale residential complex, in an apparent murder-suicide.10 Initial investigations indicated the mother had postnatal depression.10 In September 2020, the press reported the case of a 21-year-old intellectually disabled man who was strangled to death by his 46-year-old mother.11 In May 2023, a 30-year-old woman and her 5-year-old son fell to their deaths from a residential building in Hong Kong in a suspected murder-suicide.12

In our densely populated city, mental health and social support networks remain limited.13 The incidence of maternal filicide is likely underestimated.7 Based on personal observations, however, the incidence of filicide is probably not low.7 13 In our previous review of filicide cases and possible risk factors in Hong Kong,13 we found that the cases mostly involved children aged under 12 years. Psychosocial risk factors offer clues for potential interventions and may include adverse life situations such as marital discord, single parenthood, unwanted pregnancy, financial strain, parental psychiatric morbidity, and postnatal depression in Hong Kong.5 6 13 The most common modes of filicide include jumping from height, poisoning, charcoal burning, and discarding the baby’s body in rubbish bins. Based on our recent observations, poverty does not appear to be the primary precipitating factor—rather, psychosocial distress and jumping from high-rise buildings are key patterns.

The use of a stepped care model or framework is a highly valuable approach for safeguarding children and preventing various forms of child abuse, including the tragic act of filicide. By adopting this framework, professionals in healthcare, social services, and child protection can tailor interventions to the specific circumstances and risk levels faced by individuals and families.14 15 16 This structured model acknowledges that not all cases require the same level of intervention, thereby ensuring that prevention efforts, early intervention, and treatment services are appropriately matched to each case. It begins with broad prevention efforts and community education initiatives, progressing to targeted screening, early intervention strategies, and the development of comprehensive support systems. In more serious cases, secondary interventions involve collaboration with specialised services to provide appropriate assistance.

In collaboration with community organisations, schools, and healthcare providers, social workers can effectively raise awareness about the signs and risk factors of filicide, such as a history of domestic violence or abuse; mental health issues affecting parents or caregivers (eg, depression, anxiety disorders, postnatal depression, or psychosis); parental stress and isolation (eg, financial difficulties, relationship problems, or major life stressors); previous threats or expressions of harm towards children; substance abuse; family conflict or relationship breakdown; social isolation; and lack of support. Conducting workshops, seminars, and public campaigns is instrumental in disseminating vital information and promoting early identification and intervention.

To identify individuals or families at high risk, it is essential to develop and implement updated screening tools and protocols. An interdisciplinary team comprising health and mental health practitioners, social workers, psychologists, teachers, and child protection agencies should conduct comprehensive assessments, particularly when concerns arise about a parent’s mental health or general well-being.

Social service agencies play a crucial role in providing counselling and support services to individuals or families identified as high risk for family abuse. One way to achieve this is by providing crisis hotlines and helplines to those in need. The hotline number should be easy to memorise and widely publicised, eg, 1111 or 9999, or the like. Particular emphasis should be placed on creating and facilitating support groups or peer networks for parents experiencing stress, isolation, or mental health challenges. Additionally, access to emergency shelter services is essential for individuals or families seeking safety from violence or abuse.

Mental health professionals can offer counselling and support to individuals or families identified as high risk for child abuse. This intervention involves addressing underlying mental health issues, providing parenting skills training, and facilitating access to appropriate resources such as psychotherapy, support groups, or respite care.

In addition, social workers play a pivotal role in facilitating access to specialised mental health services, therapy, support groups, or respite care for individuals or families requiring more intensive interventions. When signs of complex psychological distress, risk of harm, or sustained caregiving stress are identified, social workers should make timely referrals to appropriate specialised services, such as psychiatric care, trauma-informed counselling, or family protection services to ensure individuals receive the level of support best suited to their needs. The referral process must be streamlined and prompt.

In Hong Kong, there remains a general lack of awareness regarding the importance of mental health and its profound impact on individuals and families. Moreover, the prevailing social stigma associated with seeking help during times of emotional distress often dissuades individuals from accessing support. In collaboration with community organisations, schools, and healthcare providers, helping professionals—including general practitioners, mental health professionals, social workers, educators, and childcare workers—can effectively raise awareness about the signs and risk factors of filicide.

There have been several cases of filicide each year. We cannot afford to allow our healthy babies to perish in such horrific circumstances on a recurring basis. As paediatricians, we urge the government to establish a registry or task force to examine and implement preventive measures related to filicide. An official registry could help track changing patterns of filicide and support the development of targeted interventions. A systematic screening tool for filicide risk should be developed to characterise cases for preventive purposes. Healthcare providers should remain vigilant regarding the emotional state and psychosocial needs of caregivers. Hong Kong urgently requires a robust community nursing system to oversee child healthcare, psychiatric and mental health services, and the early detection of problems. Despite accumulating statistics, we are already substantially behind in terms of awareness and preparedness; there is no room for complacency or procrastination. Mandatory reporting might be one solution, but a dedicated registry and a special task force including social work experts and physicians would provide a far more comprehensive and effective response.

The COVID-19 pandemic has resulted in numerous associations under the umbrella of long-COVID syndrome in children. Meanwhile, we have witnessed the conflation of novel syndromes associated with COVID-19.17 18 We believe the term ‘COVID filicide syndrome’ could have been coined to raise public awareness. With the pandemic now behind us, filicide has returned in a drastic manner. On 29 December 2023, just before the year ended, an attempted—albeit unsuccessful—filicide occurred involving a 17-year-old teenager attacked by his mother, who later jumped to her death at a public housing estate.19 In March 2024, a 7-year-old boy was riding on his debt-ridden father’s shoulders when the father flung him from the rooftop of a six-storey shopping centre in Hong Kong before jumping to his own death in an attempted murder-suicide.20 To conclude, physicians and child health workers must be prepared to address this horrific non-communicable disease that continues to claim precious young lives in Hong Kong.21

All authors contributed to the concept or design, acquisition of the data, analysis or interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

As an editor of the journal, KL Hon was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Hon KL, Leung KK, Chan CH. Time to take action on filicides in Hong Kong. Hong Kong Med J 2023;29:87. Crossref

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18. Hon KL, Leung KK. Pediatric COVID-19: what disease is this? World J Pediatr 2020;16:323-5. Crossref

19. Lo HY. Hong Kong teenager, 17, said to have been attacked by mother who later jumped to her death at public housing estate. South China Morning Post [newspaper on the Internet]. 2023 Dec 29: Crime in Hong Kong. Available from: https://www.scmp.com/news/hong-kong/law-and-crime/article/3246614/hong-kong-teenager-17-allegedly-attacked-mother-who-then-jumped-her-death-public-housing-estate?campaign=3246614&module=perpetual_scroll_0&pgtype=article. Accessed 1 May 2024.

20. Mok D, Lo C. ‘Debt-ridden’ father throws son, 7, off Hong Kong shopping centre rooftop before jumping to his death. South China Morning Post [newspaper on the Internet]. 2024 Mar 5: Hong Kong Police. Available from: https://www.scmp.com/news/hong-kong/society/article/3254155/hong-kong-police-launch-attempted-murder-suicide-probe-after-father-and-son-7-plunge-city-shopping. Accessed 1 May 2024.

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