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4.18 Fabricated or Induced Illness

This section of the procedures reflects the supplementary guidance to Working Together to Safeguard Children in whom illness is fabricated or induced (H.M. Government 2008).

AMENDMENT

This chapter was updated in June 2015. Minor amendments were made throughout, and the chapter should be re-read.


Contents

  1. Indicators of Fabricated or Induced Illness
  2. Emerging Concerns; Managing Uncertainty
  3. Response
  4. Chronology and Strategy Meetings
  5. Medical Evaluation
  6. Referral
  7. Effective Support and Supervision
  8. Allegations Against Staff
  9. References


1. Indicators of Fabricated or Induced Illness

The following are indicators that should alert any professional to concerns that a child is suffering, or at risk of suffering Significant Harm as a result of having Illness Fabricated or Induced (FII) by their carer:

  • A carer reporting symptoms and observed signs that are not explained by any known medical condition;
  • A carer reporting to professionals that a diagnosis has been made by another professional when this is not true, and giving conflicting information to different professionals;
  • Missed appointments especially if the appointments are not leading in the desired direction for the carer;
  • Physical examination and results of investigations that do not explain symptoms or signs reported by the carer;
  • The child having an inexplicably poor response to prescribed medication or other treatment, or intolerance of treatment;
  • Acute symptoms that are exclusively observed by/in the presence of the carer;
  • On resolution of the child's presenting problems, the carer reporting new symptoms or reporting symptoms in different children in sequence;
  • The child's daily life and activities being limited beyond what is expected due to any disorder from which the child is known to suffer, for example, partial or no school attendance and the use of seemingly unnecessary special aids;
  • Objective evidence of fabrication - for example, the history of events given by different observers appearing to be in conflict or being biologically implausible (such as small infants with a history of very large blood losses who do not become anaemic, or infants with large negative fluid balance who do not lose weight); test results such as toxicology studies or blood typing; evidence of fabrication or induction from covert video surveillance (CVS);
  • The carer expressing concern that they are under suspicion of FII, or relatives raising concerns about FII;
  • The carer seeking multiple opinions inappropriately.

There may be a number of explanations for these circumstances and each requires thorough and thoughtful review.

A characteristic of FII in the child is a discrepancy between the findings of the professional and signs and symptoms reported and/or observed. In diagnosed organic illness the professional may observe a lack of usual response to proven effective treatment (i.e. a child who suffers from asthma). It is this puzzling disparity that alerts the professional to the potential for harm to the child particularly where over time the child is repeatedly presented with a range of signs and symptoms or reported symptoms and found signs are not seen to begin in the absence of the carer:

  • FII may be manifest in a child in a number of ways. Fabrication of signs of illness may include false reporting of current symptoms or a fabrication of previous medical history. In addition to false reporting; falsification of letters, documentation and hospital charts and physical interference with specimens such as urine or stool samples may also be seen. Induction of illness can be achieved by a variety of means including, but not limited to, administration of household substances to induce vomiting, salt poisoning, withholding or over administration of medications, withholding of nutrition or intentional suffocation;
  • FII is relatively common in children who have an existing medical diagnosis including children with disabilities and developmental difficulties. This may be in the form of exaggeration of symptoms or unexpected responses to medications or treatment. Statistics show that disabled children are at increased risk of abuse *(Jones et al, 2012). FII can easily remain unappreciated in children who already have existing health care needs;
  • The needs of the child and the potential for significant harm must always be the first priority; however it is important to consider what secondary benefit the parent/carer may receive by presenting their child to services in this way. This can take many forms. It is important to note that the exaggeration or falsification of conditions, existing or otherwise, may be perpetrated in an attempt to retain or qualify for financial aid in the form of disability living allowance. 

The presenting signs and symptoms need careful evaluation for a range of possible causes. Professionals must remain open minded to all possible explanations. When dealing with their concerns for a child, a child may present for medical/health attention with unusual and puzzling symptoms that are not attributable to any organic disease and yet which do not involve deliberate fabrication or deception.

Concerns that a child's illness may be fabricated or induced are most likely to come from health professionals. However, any agency in contact with a child may become concerned, for example education staff where a child is frequently absent from school on questionable health grounds or nursery staff may not observe fits in a child who is described by a parent to be having frequent fits etc. It is essential that a paediatrician is involved in the assessment of FII. However the paediatrician will almost always need the help of social care and other agencies in gathering information needed to confirm or refute the diagnosis. The paediatrician will play a key role in the collation and interpretation of health information / evidence for non- health professionals.

*Jones, L. et al (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet 380(9845): 899-907.


2. Emerging Concerns; Managing Uncertainty

It must be acknowledged that parents may present to services with varying levels of anxiety and the initial actions for professionals may be in acknowledging and addressing these issues with the family without embarking on further invasive tests or investigations. Such early intervention may enable a clinician to identify causes of stress within a family unit which can then be signposted to appropriate services.

In the majority of cases of identifying FII, there will be uncertainty and insufficient evidence to confidently identify abuse or the nature of the risk (if any) to the child may be unclear.

NB Uncertainty can be reduced by establishing facts.

The following checklist can be used by any professional dealing with a possible case of FII:

  • Focusing on safeguarding and promoting the welfare of the child at all times;
  • Complete a chronology, listing what is evidence-based. This should be started before a referral to children’s social care unless the concerns are urgent or there is already evidence of significant harm (see exemplar Chronology Template below);
  • There is a need to cross reference the chronologies for different children in the family as illness behaviour can switch between different children in the family;
  • Listing inconsistencies and gathering more information from family members and other professionals to clarify inconsistencies;
  • Continuing to observe child and family - are patterns emerging?
  • Keeping detailed records: being specific about the evidence base/source of information - for example, observation, informed opinion, hearsay, etc;
  • Testing alternative explanations; review with a senior colleague or expert; complete medical tests and social work assessment; Paediatricians should discuss these cases with their named or designated doctor;
  • Continuing to re-assess the situation in light of new information;
  • It is usually not appropriate to share concerns about FII with parents at this stage, but plans need to be agreed between the lead paediatrician and the social worker manager regarding the appropriate response to managing concerns in order to protect the child. Also what it is or is not appropriate to discuss with the parents depending on circumstances but trying to be as open and transparent as possible needs to be agreed and documented between the different agencies /professionals involved;
  • Evaluating alternatives - as Sherlock Holmes said, 'Exclude the impossible and the solution lies in what remains, however unlikely';
  • Accessing information on the legal issues and national and local guidance.
Incredibly Caring. Department for Children, Schools and Families. 2008.


3. Response

All professionals who have concerns about a child's health should discuss these with their line manager or their agency's nominated safeguarding lead and the GP or paediatrician responsible for the child's health. If the child is receiving services from Children's Social Care, the concerns should be discussed with them immediately.

If the health professional has concerns about the mental health of the carer they should consider if a referral to the mental health access team would be appropriate. This assessment would then be available to inform the overall assessment. This referral would have to be made with the consent of the adult.

Joint working is essential, and all professionals should:

  • Be alert to potential indicators of illness being fabricated or induced in a child;
  • Be alert to the risk of harm which individual abusers may pose to children in whom illness is being fabricated or induced;
  • Share and help to analyse information so that an informed assessment can be made of children's needs and circumstances;
  • Contribute to whatever actions and services are required to safeguard and promote the child's welfare;
  • Assist in providing relevant evidence in any criminal or civil proceedings;
  • It is an expectation that a senior health professional leads for health and the same should apply for all other agencies as these cases are complex and difficult;
  • A Health Professionals meeting should be arranged by the lead Paediatric Consultant following the collation of chronologies. All professionals involved with the child and family who have produced chronologies will be invited to review and discuss the case and contribute to the decision making process around future management. The chair of the meeting should be determined for each case and is likely to be the Responsible Paediatric Consultant or Named Doctor in their absence. Minutes of the meeting will be recorded and agreed actions will be distributed to those in attendance. If there are any professional disagreements around the management of FII, staff will inform named health professionals. Staff should follow the escalation process if there are disagreements.
If any professional considers that their concerns are not taken seriously or responded to appropriately, they should discuss this as soon as possible with the designated doctor or designated nurse for child protection/safeguarding.

If any concerns relate to a member of staff, professionals should discuss this with their line manager and their agency's nominated safeguarding children lead. Where there are concerns or suspicions that a member of staff may be responsible for FII in a child, see the Managing Allegations of Abuse Made Against Adults Who Work with Children and Young People Procedure.

All concerns and discussions must be recorded contemporaneously in their agency records for the child, dated and signed.


4. Chronology and Strategy Meetings

Information gathered from the child's records and tabulated in the form of a chronology is key to confirming whether the situation is abusive. The documentation of facts and evidence in this format often reveals a startling picture. Getting the facts agreed and seeing the overall pattern is crucial and often very revealing.

The development of a chronology may be a staged process completed initially by the professional who has concerns. Depending on the emerging themes in this chronology, Children's Social Care may then be involved. The chronology plays an important role in any multi-agency assessment of risk. Your chronology may be one of several chronologies to identify an emerging theme of risk to the child. Chronologies will be needed if the case goes to a Strategy Meeting convened by Children's Social Care.

The preparation of the chronology should not delay intervention if this would put the child at increased risk of Significant Harm. If you believe a child is at immediate risk of Significant Harm you should immediately make a referral to Children's Social Care - see the Making Referrals to Children's Social Care Procedure.

Chronology template

This is a sample chronology template, which may be useful in the compilation of a chronology in possible FII cases. It is to be used in conjunction with:

Warning signs of Fabricated or Induced Illness Templates (the template summary and the template explained).

State on the chronology template which category the episode/event falls under. This enables analysis of the clinical presentation of that event, example below:

Click here to view Example Chronology.

Click here to view Chronology Template.

The Template - A Summary

Category Warning signs of Fabricated or Induced Illness
1. Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering.
2. Physical examination and results of medical investigations do not explain reported symptoms and signs.
3. There is an inexplicably poor response to prescribed medication and other treatment.
4. New symptoms are reported on resolution of previous ones.
5. Reported symptoms and found signs are not seen to begin in the absence of the carer.
6. The child's normal, daily life activities are being curtailed beyond that which might be expected for any medical disorder from which the child is known to suffer.
7. Over time the child is repeatedly presented with a range of signs and symptoms.
8. History of unexplained illnesses or deaths or multiple surgery in parents or siblings of the family.
9. Once the perpetrator's access to the child is restricted, signs and symptoms fade and eventually disappear (similar to category 5, above).
10. Exaggerated catastrophes or fabricated bereavements and other extended family problems are reported.
11. Incongruity between the seriousness of the story and the actions of the parents.
12. Erroneous or misleading information provided by parent.
0 No concerns about a contact.

Note: the order of numbering does not indicate the relative importance of each category.

A full explanation of the template is set out below in the Template - Explained.

The Template - Explained

Note: 'Symptoms' are subjective experiences reported by the carer or the patient. 'Signs' are observable events reported by the carer or observed or elicited by professionals. We set out below some examples of behaviour to look out for.

Category Warning signs of Fabricated or Induced Illness
1. Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering. Here the doctor is attempting to put all of the information together to make a diagnosis but the symptoms and signs do not correlate with any recognised disease or where there is a disease known to be present. A very simple example would be a skin rash, which did not correlate with any known skin disease and had, in fact, been produced by the perpetrator. An experienced doctor should be on their guard if something described is outside their previous experience, i.e. the symptoms and signs do not correlate with any recognisable disease or with a disease known to be present.
2. Physical examination and results of medical investigations do not explain reported symptoms and signs. Physical examination and appropriate investigations do not confirm the reported clinical story. For example, it is reported a child turns yellow (has jaundice) but no jaundice is confirmed when the child is examined and a test for jaundice, if appropriate, is negative. A child with frequent convulsions every day, has no abnormalities on a 24-hour videotelemetry (continuous video and EEG recording) even during a so-called 'convulsion'.
3. There is an inexplicably poor response to prescribed medication and other treatment. The practitioner should be alerted when treatment for the agreed condition does not produce the expected effect. This can result in escalating drugs with no apparent response, using multiple medications to control a routine problem and multiple changes in medication due to either poor response or frequent reports of side effects. On investigation, toxic drug levels commonly occur but may be interspersed with low drug levels suggesting extremely variable administration of medication fluctuating from over- medication to withdrawal of medication. Another feature may be the welcoming of intrusive investigations and treatments by the parent.
4. New symptoms are reported on resolution of previous ones. New symptoms often bear no likely relationship to the previous set of symptoms. For example, in a child where the focus has been on diarrhoea and vomiting, when appropriate assessments fail to confirm this, the story changes to one of convulsions. Sometimes this is manifest by the parents transferring consultation behaviour to another child in the family.
5. Reported symptoms and found signs are not seen to begin in the absence of the carer, i.e. the perpetrator is the only witness of the signs and symptoms. For example, reported symptoms and signs are not observed at school or during admission to hospital. This should particularly raise anxiety of FII where the severity and/or frequency of symptoms reported is such that the lack of independent observation is remarkable. Caution should be exercised when accepting statements from non-medically qualified people that symptoms have been observed. In the case under review there was evidence that the school described episodes as 'fits' because they were told that was the appropriate description of the behaviour they were seeing.
6. The child's normal, daily life activities are being curtailed beyond that which might be expected for any medical disorder from which the child is known to suffer. The carer limits the child's activities to an unreasonable degree and often either without knowledge of medical professionals or against their advice. For example, confining a child to a wheelchair when there is no reason for this, insisting on restrictions of physical activity when not necessary, adherence to extremely strict diets when there is no medical reason for this, restricting child's school attendance.
7 Over time the child is repeatedly presented with a range of signs and symptoms. At its most extreme this has been referred to as 'doctor shopping'. The extent and extraordinary nature of the additional consultations is orders of magnitude greater than any concerned parent would explore. Often consultations about the same or different problems are concealed in different medical facilities. Thus the patient might be being investigated in one hospital with one set of problems and the parent will initiate assessments elsewhere for a completely different set of problems (or even the same) without informing these various medical professionals about the other consultations.
8. History of unexplained illnesses or deaths or multiple surgery in parents or siblings of the family. The emphasis here is on the unexplained. Illness and deaths in parents or siblings can frequently be a clue to further investigation and hence a diagnosis in naturally occurring illness. In FII abuse, perpetrators frequently have had multiple unexplained medical problems themselves, ranging from frequent consultations with the general practitioner through to the extreme of Munchausen syndrome where there are multiple presentations with fabricated or induced illness resulting in multiple (unnecessary) operations. Self-harm, often multiple, and eating disorders are further common features in perpetrators. Additionally, other children either concurrently or sequentially might have been subject to FII abuse and their medical history should also be examined.
9. Once the perpetrator's access to the child is restricted, signs and symptoms fade and eventually disappear (similar to category 5 above). This is a planned separation of perpetrator and child which it has been agreed will have a high likelihood of proving (or disproving) FII abuse. It can be difficult in practice, and appear heartless, to separate perpetrator and child. The perpetrator frequently insists on remaining at the child's bedside, is unusually close to the medical team and thrives in a hospital environment.
10. Exaggerated catastrophes or fabricated bereavements and other extended family problems are reported. This is an extension of category 8. On exploring reported illnesses or deaths in other family members (often very dramatic stories) no evidence is found to confirm these stories. They were largely or wholly fictitious.
11. Incongruity between the seriousness of the story and the actions of the parents. Given a concerning story, parents by and large will cooperate with medical efforts to resolve the problem. They will attend outpatients, attend for investigations and bring the child for review urgently when requested. Perpetrators of FII abuse, apparently paradoxically, can be extremely creative at avoiding contacts which would resolve the problem. There is incongruity between their expressed concerns and the actions they take. They repeatedly fail to attend for crucial investigations. They go to hospitals that do not have the background information. They repeatedly produce the flimsiest of excuses for failing to attend for crucial assessments (somebody else's birthday, thought the hospital was closed, went to outpatients at one o'clock in the morning, etc). We have used a term, 'piloting care', for this behaviour.
12. Erroneous or misleading information provided by parent. These perpetrators are adept at spinning a web of misinformation which perpetuates and amplifies the illness story, increases access to interventions in the widest sense (more treatment, more investigations, more restrictions on the child or help, etc). An extreme example of this is spreading the idea that the child is going to die when in fact no-one in the medical profession has ever suggested this. Changing or inconsistent stories should be recognised and challenged.
0 This is included to encourage a thorough review of contacts into concerning and non concerning ones to give a balanced view.


5. Medical Evaluation

5.1 Where there are concerns about possible FII, the signs and symptoms require careful medical evaluation for a range of possible diagnoses by a paediatrician.
5.2 If no paediatrician is already involved, the child's GP should make a referral to a paediatrician.
5.3 Where, following a set of medical tests being completed, a reason cannot be found for the reported or observed signs and symptoms of illness, further specialist advice and tests may be required.
5.4 Normally the consultant paediatrician will tell the parent(s) that they do not have an explanation for the signs and symptoms.
5.5 Parents should be kept informed of further medical assessments / investigations/tests required and of the findings but at no time should concerns about the reasons for the child's signs and symptoms be shared with parents if this information would jeopardise the child's safety and compromise the child protection process and/or any criminal investigation.


6. Referral

6.1

Where there are suspicions of FII in a child, a referral must be made to Children's Social Care in accordance with the Making Referrals to Children's Social Care Procedure.

From the point of the referral, all professionals involved with the child should work together as follows:

  • Lead responsibility for action to safeguard and promote the child's welfare lies with Children's Social Care;
  • Any suspected case of FII may involve the commission of a crime and therefore the police should always be involved;
  • The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care.
6.2 In cases of suspected FII, discussing concerns with parents or carers prior to making a referral may place the child at increased risk of Significant Harm. It is in the child's interests that the parents/carers are not informed of the referral at this stage. The multi agency decision of when and how parents/carers will be informed of concerns will be made at a later stage.
6.3 Following the receipt of the referral, Children's Social Care has lead responsibility for undertaking an Assessment. This will include circumstances in which FII by the carer is suspected. Children's Social Care will conduct the assessment in conjunction with the doctor who has lead responsibility for the child's health care (usually a consultant paediatrician) and other relevant agencies.
6.4 Children's Social Care will coordinate the process of systematic information gathering to build up a medical, psychiatric and social history and an understanding of the child's needs and the parents' capacity to meet the child's developmental needs. Children's Social Care should ensure that a comprehensive chronology of the child's history is compiled.
6.5

Children's Social Care is responsible for convening Strategy Discussions/Meetings and, when appropriate, Initial and Review Child Protection Conferences, in order to review the child's situation and to decide and plan any further action that may be necessary. In cases of FII, the Strategy Discussion will always take the form of a face-to-face meeting, chaired by a manager from Children's Social Care - for further information, please see the Strategy Discussions Procedure. Any agency may request a Strategy Meeting or Child Protection Conference, if it has concerns that a child may be or is suffering Significant Harm.

At all stages it is important to discuss what information will be shared with parents and by whom. Clear decisions need to be made about who will monitor the child’s health and development.


7. Effective Support and Supervision

Working with children and families where it suspected or confirmed that illness is being fabricated or induced in a child requires sound professional judgments to be made. It is demanding work that can be distressing and stressful. Practitioners are likely to need support to enable them to deal with the feelings the suspicion or identification of this type of abuse engenders. It can be very distressing to a professional person, who has come to know a family well and trusted them, to have to deal with their feelings when they learn a child's illness has been caused by actions of that child's primary carer.

Possible known emotional responses to FII by staff are:

  • Self-doubt;
  • Fear leading to inaction;
  • Loss of self-respect, self-esteem;
  • Failure / didn't recognise the signs / symptoms;
  • Feelings of failing the child;
  • Anger at colleagues who disbelieve / believe;
  • Loss of trust;
  • Anger at parents / how could they have used me?
  • Feeling of being manipulated;
  • Feeling of being duped;
  • Fear of litigation / misdiagnosis;
  • Misdiagnosis;
  • Disbelief;
  • Denial;
  • Reluctance or unwillingness to pass on / share information;
  • Fear of being criticised;
  • Fear of challenging more senior colleagues / professionals and dealing with the power differential;
  • Helplessness;
  • Feeling unable to prepare a statement of evidence and / or giving evidence in court;
  • Fear of becoming frozen, unable to make decisions;
  • Becoming defensive;
  • Inability to treat the parents in a professional manner;
  • Knowing I was wrong / right.

This is not an exhaustive list.

Incredibly caring, Department of Children, Schools and Families 2008.


8. Allegations Against Staff

8.1 In this area of work, it is a possibility that complaints may be expressed by parents/carers about one or more members of staff and their handling of the case. During assessment parents may formally complain about any member of staff.
8.2 Any complaint should not detract from the seriousness of concerns for the child.
8.3 Staff will need good support systems from their organisation to help them deal with a complaint made against them.
8.4 Experience has shown that children can be subjected to abuse by those who work with them in any and all settings. Where there are concerns or suspicions that a member of staff may be responsible for FII in a child, see the Managing Allegations of Abuse Made Against Adults Who Work with Children and Young People Procedure.


9. References

Royal College of Paediatrics and Child Health (2009) Fabricated or Induced Illness by Carers (FII). RCPCH, London.

Department for children, schools and families (2008) Incredibly Caring. Radcliffe Medical Press. Abingdon.

Safeguarding children in whom illness is fabricated or induced (HM Government 2009).

*Jones, L. et al (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet 380(9845): 899-907.

End