5.13 Fabricated or Induced Illness
See also the SSCB Guidance on Fabricated or Induced Illness, which can be accessed via the ‘SSCB website’ button in the menu on the left hand side of the page.
This chapter was reviewed and revised for the October 2011 edition of the manual.
- 1. Introduction
- 2. Definition
- 3. Recognition
- 4. Response
- 5. Medical Evaluation
- 6. Referral
- 7. Initial Consideration of Referral
- 8. Assessment, Outcomes and Immediate Protection
- 9. Strategy Meeting
- 10. Outcome of Section 47 Enquiries
- 11. Initial Child Protection Conference
- 12. Pre-birth Child Protection Conference
- Appendix - Template for Warning Signs of Fabricated or Induced Illness
Fabricated or Induced Illness is a rare, potentially lethal form of abuse. It has previously been referred to as
- Fabricated illness by proxy;
- Factitious illness by proxy;
- Munchausen Syndrome by proxy;
- Illness Induction Syndrome.
In order to keep the child's safety and welfare as the primary focus of all professional activity the government guidance: 'Safeguarding Children in Whom Illness is Fabricated or Induced' (2008) refers to "fabrication or induction of illness in a child by a carer" rather than using a particular term.
This section outlines the procedures to follow when professionals are concerned that the health or development of a child is likely to be significantly impaired by the actions of a parent/carer/s having fabricated or induced illness.
The procedures are derived from the government guidance issued in 2008 document Safeguarding Children in Whom Illness is Fabricated or Induced which provides further essential guidance.
The Royal College of Paediatricians and Child Health 2009 guidance Fabricated or Induced Illness by Carers provides further guidance for medical clinicians.
Professionals should also refer to the Appendix: Template for Warning signs of Fabricated or Induced Illness.
A condition whereby a child suffers harm through the deliberate action of her/his main carer and which is attributed by the adult to another cause.
There are three main ways of the carer fabricating or inducing illness in a child:
- Fabrication of signs and symptoms, including fabrication of past medical history;
- Fabrication of signs and symptoms and falsification of hospital charts, records, letters and documents and specimens of bodily fluids;
- Induction of illness by a variety of means.
The above three methods are not mutually exclusive.
Harm to the child may be caused through unnecessary or invasive medical treatment, which may be harmful and possibly dangerous, based on symptoms that are falsely described or deliberately manufactured by the carer, and lack independent corroboration.
Doctors/paediatricians may be concerned at the possibility of a child suffering Significant Harm as a result of having illness fabricated or induced by their carer. These concerns may arise when:
- Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering; or
- Physical examination and results of investigations do not explain reported symptoms and signs; or
- There is an inexplicably poor response to prescribed medication and treatment; or
- New symptoms are reported on resolution of previous ones; or
- Reported symptoms and found signs are not observed in the absence of the carer; or
- The child’s normal, daily life activities are being curtailed beyond that which might be expected from any known medical disorder from which the child is known to suffer;
- Over time the child is repeatedly presented with a range of signs and symptoms;
- History of unexplained illness or deaths or multiple surgery in parents or siblings of the family;
- Once the perpetrator's access to the child is restricted, signs and symptoms fade and eventually disappear;
- Exaggerated catastrophes or fabricated bereavements and other extended family problems are reported;
- Incongruity between the seriousness of the story and the actions of the parents;
- Erroneous or misleading information provided by parent.
Concerns may be raised by other professionals who are working with the child and/or parents/carers who may notice discrepancies between reported and observed medical conditions, such as the incidence of fits.
Professionals working with the child’s parents may also note these concerns e.g. mental health professionals may identify a child being drawn into the parent’s illness.
Further details regarding the warning signs given above are provided in Appendix: Template for Warning Signs of Fabricated or Induced Illness.
Concerns about a child’s health should be discussed with a health professional who is involved with the child such as the school nurse, GP or paediatrician.
If any professional considers their concerns are not taken seriously or responded to appropriately, these should be discussed with the Designated Doctor or Designated Nurse (see also Surrey Health Service Contacts).
If any concerns relate to a member of staff, these should be discussed with the relevant Named or Designated Professional and the Allegations Against Staff, Carers and Volunteers Procedureshould be followed.
5. Medical Evaluation
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 any Section 47 Enquiry and or criminal investigation.
The signs and symptoms require careful medical evaluation for a range of possible diagnoses.
Where a reason cannot be found for the signs and symptoms, specialist advice and tests may be required.
Normally, the doctor would tell the parent(s) that s/he has not found the explanation for the signs and symptoms and record the parental response.
Parents should be kept informed of further medical assessments/ investigations/tests required and of the findings.
Health professionals should consider using the Appendix: Template for Warning Signs of Fabricated or Induced Illness which can help to analyse any suspicions by categorising events and other available facts. However, the categories should be used as indicators and even if a case encompasses all the categories in the template it does not necessarily mean that the child is being abused.
When a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer and as a consequence the child’s health or development is or is likely to be impaired, a referral should be made to the Surrey Children's Services in accordance with theContacts and Referrals Procedure.
The referral may follow a medical evaluation or be the result of concern by professionals or members of the public.
Whilst professionals should in general, discuss any concerns with the family and, where possible, seek agreement to making referrals to Surrey Children's Services, this should only be done where such discussion and agreement-seeking will not place a child at increased risk of significant harm.
The Police Public Protection Investigation Unit (PPIU) must be informed at the earliest opportunity. Any suspected case of fabricated or induced illness may also involve the commission of a crime and the Police will take responsibility for deciding whether or not to initiate a criminal investigation.
The referrer, Surrey Children's Services and PPIU should agree what the parents will be told, by whom and when.
7. Initial Consideration of Referral
As with all other referrals, Surrey Children's Services should decide within one working day what response is necessary.
Whilst Surrey Children's Services has lead responsibility for action to safeguard and promote the child’s welfare, the decision should be taken in consultation with the Consultant Paediatrician responsible for the child’s health care and the PPIU.
This decision-making process must agree what action needs to be taken by whom and within what time-frame.
All decisions about what information is shared with parents should be taken jointly, bearing in mind the safety of the child.
The possible outcome of referrals is the same as for any other referrals (see the Contacts and Referrals Procedure).
If emergency action is the required response, e.g. if a child’s life is in danger through poisoning or toxic substances being introduced into the child’s blood stream, an immediate Strategy Meetingshould take place, where possible, between Surrey Children's Services, Police, health and other agencies as appropriate. Decisions about possible immediate action to protect the child should be kept under constant review.
8. Assessment, Outcomes and Immediate Protection
The decision on the outcome should be made in consultation with the Paediatric Consultant and the police, with agreement reached regarding what the parents should be told. ‘Concerns should not be raised with a parent if it is judged that this action will jeopardise the child’s safety.’ (Safeguarding Children in Whom Illness is Fabricated or Induced paragraph 3.18).
9. Strategy Meeting
If there is reasonable cause to suspect the child is suffering, or likely to suffer significant harm, Surrey Children's Services should convene and chair a Strategy Meeting involving all the key professionals.
The Strategy Meeting requires the involvement of key senior professionals responsible for the child’s welfare. At a minimum this must include Surrey Children's Services, the Police and the Paediatric Consultant responsible for the child’s health. Additionally the following should be invited as appropriate:
- A senior ward nurse if the child is an in-patient;
- A medical professional with expertise in the relevant branch of medicine;
- GP, health visitor;
- Staff from education settings;
- Local authority’s legal adviser;
- Designated Nurse and Named Nurse.
Wherever possible, prior to the Strategy Meeting, each agency should provide a written chronology of the contacts they have had with the child and family, to include all aspects of the family’s life, and a lead person should be identified to collate the chronologies in order to provide the best possible information for the decision-making process.
- The need for extreme care over confidentiality, including careful security regarding supplementary records;
- The need for expert consultation;
- Whether the child requires constant professional observation, and if so, whether the carer should be present;
- Arrangements for a collated chronology to be prepared if not already done;
- Arrangements for the medical records of all family members, including children who may have died or no longer live with the family, to be collated by the Consultant Paediatrician or other suitable medical clinician;
- The designation of a medical clinician to oversee and co-ordinate the medical treatment of the child to control the number of specialists and hospital staff the child may be seeing;
- Any particular factors, such as the child and family’s race, ethnicity, language and special needs which should be taken into account;
- The needs of siblings and other children with whom the alleged abuser has contact;
- The needs of parents;
- The nature and timing of any police investigations, including analysis of samples and covert surveillance (this will be police led and co-ordinated, with advice available from the National Crime Faculty);
- Obtaining legal advice over the evaluation of the available information (where a legal adviser is not present at the meeting).
It may be necessary to have more than one Strategy Meeting. This is likely where the child’s circumstances are very complex and a number of discussions are required to consider whether and, if relevant, when to initiate a Section 47 Enquiry and/or a Police investigation.
Any evidence gathered by the Police should be available to other relevant professionals, to inform discussions about the child’s welfare and contribute to the Section 47 Enquiry and Assessment.
10. Outcome of Section 47 Enquiries
As with all Section 47 Enquiries, the outcome may be that concerns are not substantiated - e.g. tests may identify a medical condition, which explains the signs and symptoms.
It may be that no protective action is required, but the family should be provided with the opportunity to discuss what further help it may require.
Concerns may be substantiated, but an assessment made that the child is not judged to be at continuing risk of harm. In this case, the decision not to proceed to a Child Protection Conferencemust be endorsed by a Surrey Children's Services Manager.
11. Initial Child Protection Conference
The Initial Child Protection Conference should be held within 15 working days from the last Strategy Meeting.
Attendance at this conference should be as for other Initial Child Protection Conferences, with the additional experts invited as appropriate.
12. Pre-birth Child Protection Conference
Evidence of illness having been fabricated in an older sibling or another child should be carefully considered during the pregnancy of a woman who is known to have abused a child in this way. A pregnant woman may have a history of fabricating illness in herself during a previous pregnancy. This could include the fabrication of medical problems while the baby is in the womb.
A pre-birth child protection conference should be convened if, following a Section 47 Enquiry, either the unborn child’s health is considered to be at risk or the baby is likely to be at risk of harm following his or her birth.
Appendix - Template for Warning Signs of Fabricated or Induced Illness
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 video telemetry (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 Fabricated or Induced Illness 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 abuse through Fabricated or Induced Illness, 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 abuse through Fabricated or Induced Illness 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) abuse through Fabricated or Induced Illness. 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 abuse through Fabricated or Induced Illness, 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.|
Permission given by Cumbria ACPC to replicate this template as developed following their Serious Case Review, March 2004.