3.5 Fabricated or Induced Illness: Procedure and Guidance
- Impact on the child
- Identifying fabricated or induced illness
- Initial management of emerging concerns of possible fabricated or induced illness
- Strategy Meeting
- No further action relation to Section 47 enquiries or criminal investigations
- Section 47 / Criminal Investigation
- Allegations against professionals / volunteers
- Support and supervision for professionals
- Further Information
- Related Policies, Procedures, and Guidance
Fabricated or induced illness is a condition whereby a child has suffered, or is likely to suffer, significant harm through the deliberate action of their parent and which is attributed by the parent to another cause. Fabricated or induced illness is relatively uncommon but is a potentially dangerous form of abuse.
A parent/carer or professional fabricating or inducing illness in a child may do so in a variety of ways:
The above methods are not mutually exclusive. Existing diagnosed illness in a child does not exclude the possibility of induced illnesses. The very presence of an illness can act as a stimulus to the abnormal behaviour and also provide the parent with opportunities for inducing symptoms.
Impact on the child
Fabricated or induced illness is most commonly identified in younger children. Although some of these children die, there are many that do not die as a result of having their illness fabricated or induced, but who suffer significant long term physical or psychological health consequences.
Fabrication of illness may not necessarily result in a child experiencing physical harm, but there may be concerns about the child suffering emotional harm. They may suffer emotional harm as a result of an abnormal relationship with their parent and/or disturbed family relationships.
Significant harm is defined in the multi-agency Thresholds Guidance as a situation where a child is suffering, or is likely to suffer, a degree of physical, sexual and/or emotional harm (through abuse or neglect) which is so harmful there needs to be statutory intervention by child protection agencies in the life of the child and their family.
In working with cases of suspected fabricated or induced illness, the focus must be on the child’s physical and emotional health and welfare in the long and short term, and the likelihood of the child suffering significant harm.
Clinical evidence indicates that fabricated or induced illness is usually carried out by the child’s mother or a female carer, (Safeguarding children in whom illness is fabricated or induced, DCSF 2008). However, practitioners should also be aware of the possibility of other perpetrators including fathers, grandparents, siblings or other children, or practitioners (Fabricated or Induced Illness by Carers, Royal College of Paediatricians and Child Health, 2009).
Parents/carers may have the following history or exhibit a range of behaviours when they wish to convince others that their child is ill:
Identifying fabricated or induced illness
Identifying fabricated or induced illness is not an easy or quick process. Identifying the parent/carer/professional’s patterns of behaviour needs a multi-agency approach, expertise and observation.
Parents can display a range of behaviours in response to their child being ill / perceived to be ill with some showing more anxiety and symptoms of stress than others.
The spectrum of parental behaviours can include those who:
A key task for professionals working with children is to distinguish between an over-anxious parent/carer who may be responding in an understandable way to a very sick child, and parents/carers who exhibit abnormal behaviour or an unexpected response to diagnosis and care.
All professionals who come into contact with children and their families, or adults who are parents, may come into contact with a child or parent where there are suspicions of fabricated or induced illness. These suspicions are likely to centre on discrepancies between what a parent says and what the professional observes.
Concerns may arise when:
Harm to the child may occur in different ways:
Initial management of emerging concerns of possible fabricated or induced illness
Do NOT inform parents/carers of the concerns at this stage.
All professionals who have concerns about a child’s health should discuss these with their line manager, their agency's designated safeguarding children adviser and the GP or paediatrician responsible for the child's health. If the child is receiving services from local authority Children's Social Care, the concerns should also be discussed with them.
If any professional considers that their concerns are not taken seriously or responded to appropriately, they should escalate their concerns following the Multi-agency Escalation, Challenge and Conflict Resolution Procedure.
All concerns and discussions must be recorded contemporaneously by all parties in their agency records for the child, dated and signed.
Gather information and complete a chronology/timeline of key events.
Arrange a professionals meeting with agencies involved including GP/teacher/ nursery leader/paediatrician/social worker/police/mental health worker. Consider inviting named/designated professionals. Do not invite parents/carers to this meeting.
The purpose of any professionals meeting is to gather and share information from a number of sources where there is concern about a child’s welfare. When this level of concern regards the potential for fabricated/induced illness, consideration must be given that this may be the differential diagnosis.
The meeting should be minuted and actions agreed (see Aide memoire in Appendix 3). Due to the need for extreme care over confidentiality in these cases, each agency should follow their own local procedure for ensuring security of records.
During the initial professionals meeting, if immediate harm is deemed likely, formally refer family to Children’s Social Care urgently and request advice and/or a strategy meeting. Call 01296 383962 (0800 999 7677 out of hours). Follow up with a Multi-Agency Referral Form (MARF). Legal advice may also be required.
If no immediate harm is thought likely and fabricated illness is not suspected, ensure services are offered and/or provided as appropriate, including consideration of a referral seeking early help or child in need support from Children’s Social Care.
Further professionals meetings may be required before a final decision can be made. Although this should not impact on due and timely consideration to the potential or actual harm to the child and prompt referral to Children’s Social Care.
If there is reasonable cause to suspect the child is suffering, or likely to suffer, significant harm, Children's Social Care should convene and chair a strategy meeting involving all the key professionals. A meeting, rather than telephone discussion, is strongly advised when considering this complex form of abuse.
The strategy meeting should be convened in line with the agreed multi agency Section 47 Procedure. The meeting should be chaired by the local authority children's social care manager.
Participants must include Children's Social Care, the police, the paediatrician responsible for the child's health, and, as appropriate:
Consider the use of teleconferencing to ensure all professional information/opinion is available.
All practitioners must be advised that this is confidential and parents/carers are not to be informed.
The aim of the meeting is to consider the available information about the allegations and plan any necessary child protection investigation and/or any criminal investigation needed to protect the child. This may include an agreed intervention, e.g. removal of child from the home.
If at any point there is evidence to indicate the child’s life is at risk, or there is likelihood of serious immediate harm, child protection powers should be used to secure the immediate safety of the child.
The minutes of the strategy meeting must show clear, explicit evidence of the decision-making process and the reasons for the meeting outcomes.
No further action relation to Section 47 enquiries or criminal investigations
The outcome of ‘no further action’ relates only to the discussion not to carry out a Section 47 enquiry or undertake a criminal investigation; it is not intended to suggest that no further support or enquiry into the situation is required.
If the meeting agrees that the case does not appear to be one of fabricated or induced illness, consideration needs to be given to what further help and support is needed from professionals.
The meeting attendees must decide who the appropriate person is to inform the parents/carers and what support is appropriate.
Section 47 / Criminal Investigation
When it is decided there are grounds to initiate a child protection investigation (Section 47, Children Act 1989), decisions should be made about how the investigation, and the assessment, will be carried out, including:
All actions and timescales should be clearly recorded.
Allegations against professionals / volunteers
There have been instances where professionals working with children have been responsible for fabricating or inducing illness.
Where there are any concerns about the conduct of behaviour of processionals, volunteers or others who are working in a position of trust with children and young people, the BSCB policy for Managing Allegations Against Staff and Volunteers should be followed.
If the parent/carer responsible for fabricating or inducing illness is in a professional position of trust the Local Authority Designated Officer (LADO) should be informed following the strategy meeting.
Support and supervision for professionals
Working with children and families where it is suspected or confirmed that illness in a child is being fabricated or induced requires sound professional judgement to be made. It is demanding work that can be distressing and stressful.
Professionals are likely to need support. It can be very distressing for a professional who has come to know a family well and trusted them, to have to deal with learning that a child’s illness has been caused by actions of that child’s parent/carer.
Possible emotional responses of professionals to fabricated or induced illness in children include:
A debrief meeting should be considered to allow mutual support between professionals.
Individual agencies should consider how to support the needs of their staff through systems such as supervision etc.
- HM Government (2008) Safeguarding children in whom illness is fabricated or induced
- HM Government (2018) Working Together to Safeguard Children
- Royal College of Paediatricians (2009) Fabricated or Induced Illness by Carers: A Practical Guide for Paediatricians
- Ministry of Justice (2011) Achieving Best Evidence in Criminal Proceedings
- HM Government (2000) Freedom of Information Act
- Lazenbatt, A (2013) Fabricated or Induced Illness in Children: A Narrative Review of the Literature Child Care in Practice, Vol. 19, Iss. 1, 2013
Related Policies, Procedures, and Guidance
- Neglect Guidance
- Managing Allegations Against Staff and Volunteers
- Child Protection Section 47 Procedure
- Fabricated and Induced Illness Factsheet