3.5 Fabricated or Induced Illness: Procedure 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:

• claiming a child has symptoms which result in unnecessary investigations/ treatment/ use of unnecessary equipment (e.g. crutches, wheelchairs).
• fabricating a child’s past medical history
• alleging that their child has a psychological illness
• deliberately inducing symptoms in a child by administering medication/other substances
• interfering with treatment by overdosing/omitting medication/ tampering with medical equipment/ charts etc.

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.

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 Continuum of Need Incorporating Threshold 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:

• The parent/carer may have a history of childhood abuse. There may also be false or known allegations of physical or sexual abuse, self-harm and/or psychiatric disorder, especially personality disorder or psychotic illness (Lazenbatt, 2013).
• A history of any previous mental ill heath in the parent/carer.
• The parent/carer may have some medical knowledge and may try to intimidate health/educational professionals.
• Erroneous or misleading information provided by the parent/carer.
• The parent/carer refuses to allow professionals to share information regarding the child’s presentation/illness.
• The parent/carer may threaten law suits too readily or complain to professional bodies (e.g. Nursing and Midwifery Council, General Medical Council).
• The parent/carer tends to be over friendly with health/educational staff, but may become abusive if practitioners do not comply with their wishes.
• The parent/carer shows inappropriate behaviour, e.g. being over-anxious or even less attentive than you would expect.
• The parent/carer is not always present when the child has alleged or real symptoms or signs of illness, as presentation of symptoms may be deliberately delayed.
• The parent/carer may be motivated by financial gain; this can be through the receipt of benefits or the provision of a placement within an educational setting (e.g. residential school for special educational needs).
• One parent may be more vocal or dominant than the other.

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:

• present as anxious about minor symptoms in their child
• tend to exaggerate symptoms
• invent symptoms
• induce them.

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:

• reported symptoms and signs found on examination are not explained by any 'normal' medical condition
• physical examination and results of investigations do not explain reported symptoms and signs
• new symptoms are reported on resolution of previous ones
• reported symptoms and identified signs are not observed in the absence of the parent
• the child's normal daily life activities are being curtailed beyond that which may be expected from any known medical disorder from which the child is known to suffer
• treatment for an agreed condition does not produce the expected effects
• there are repeated presentations to a variety of doctors and with a variety of problems
• the child denies parental reports of symptoms
• there are specific problems (e.g. apnoea, fits, choking or collapse)
• the child is becoming drawn into the parent's illness
• there is a history of unexplained illnesses or deaths or multiple surgery in parents or siblings of the family.

Harm to the child may occur in different ways:

• directly through induction of ill health
• indirectly through unnecessary admission to hospital, investigation and treatment
• psychologically in association with:
  • confusion of affection with sickness
  • being used by their carer
  • development of ‘illness behaviour’.
• other parenting problems and forms of maltreatment including poor attachment.

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.

Where fabricated/induced illness is likely or confirmed at the professionals meeting a referral should be made to Children’s Social Care using a Multi-Agency Referral Form (MARF).

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 (Early Help in Buckinghamshire is now provided by the Family Support Service) 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:

• GP
• All other medical professionals involved with the child’s care (including mental health workers /paediatricians from tertiary units/private practice)
• Health visitor or school nurse
• Staff from education settings
• Local authority legal adviser.

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.

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.

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:

• whether the child requires constant professional observation and, if so, whether the carer should be present
• 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
• 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 nature and timing of any police investigations
• the need for extreme care over confidentiality, including careful security regarding the recording and storage of supplementary records
• the need for expert consultation
• any particular factors, such as the child's and family's race, ethnicity, language and special needs, which should be taken into account
• the needs of the siblings and other children with whom the alleged abuser has contact
• the needs of parents
• obtaining legal advice over evaluation of the available information (if a legal adviser is not present at the meeting)
• when and how parents/carers are to be informed of the decision.

All actions and timescales should be clearly recorded.

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 BSCP 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.

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:

• self-doubt and helplessness
• fear leading to inaction or defensiveness
• loss of self-respect or self-esteem
• feelings of failure as they didn’t recognise the signs/symptoms
• feeling to have failed the child
• anger at colleagues who disbelieve/believe
• anger at the parents/carers (how could they have used me?)
• feeling of being manipulated and loss of trust
• disbelief/denial
• reluctance or unwillingness to pass on/share information
• fear of being criticised and fear of litigation/misdiagnosis
• fear of challenging more senior colleagues/professionals and dealing with the power differential
• feeling unable to prepare a statement of evidence and/or giving evidence incourt
• fear of becoming frozen and unable to make decisions
• inability to treat parents/carers in a professional manner.

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.

Appendix 1: Management of Suspected Fabricated or Induced Illness in Children

Appendix 2: Chronology of Significant Events Template

Appendix 3: Professional Meeting for Fabricated / Induced Illness - Aide Memoire