Safeguarding Children in Whom Illness is Fabricated or Induced (supplementary guidance to Working Together to Safeguard Children, HM Government 2008) recognises that the use of terminology to describe the fabrication or induction of illness in a child has been the subject of considerable debate between professionals. That guidance states that: Show There are three main ways of the carer fabricating or inducing illness in a child. These are not mutually exclusive and include:
Royal College of Paediatrics and Child Health guidance Perplexing Presentations (PP)/Fabricated or Induced Illness in Children (2021) uses the following definitions: The child complains of symptoms which are genuinely experienced but not fully explained medically. The symptoms are likely to be based on underlying factors in the child (usually of a psychosomatic or psychosocial nature), and can represent the expression of psychological illness through physical symptoms. This is acknowledged by both clinicians and parents, who work collaboratively to achieve therapeutic work in the best interests of the child. The presence of alerting signs of possible Fabricated or Induced Illness but when the actual state of the child’s physical/mental health is not yet clear and there is no perceived risk of immediate serious harm to the child’s physical health or life. The actual state of the health of the child will need to be established. The essence of alerting sings is the presence of discrepancies between reports, presentation of the child and independent observations of the child, implausible descriptions and unexplained findings or parental behaviour. A clinical situation in which a child is, or is very likely to be, harmed due to parental behaviour and action, carried out in order to convince doctors that the child’s state of physical and/or mental health or neurodevelopment is impaired or more impaired than is actually the case. FII can result in emotional and physical abuse and neglect as a result of parental actions, behaviours or beliefs and from doctors’ responses to these. This can include inadvertent harm caused by medical professionals such as unnecessary invasive investigations/procedures. The parent does not necessarily intend to deceive, and their motivations may not be initially evident. Previously known as Munchausen Syndrome by Proxy. 2. Alerting Signs of Possible Fabricated or Induced IllnessThe 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:
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:
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. 3. Harm to the ChildHarm to the child takes several forms. Some of these are caused directly by the parent, intentionally or unintentionally, but may be supported by the doctor; others are brought about by the doctor’s actions, the harm being caused inadvertently. The following three aspects need to be considered when assessing potential harm to the child. As FII is not a category of maltreatment in itself, these forms of harm may be expressed as emotional abuse, medical or other neglect, or physical abuse. There is also often a confirmed co-existing physical or mental health condition.
4. Emerging Concerns; Managing UncertaintyIt 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. N.B. Uncertainty can be reduced by establishing facts. The following checklist can be used by any professional dealing with a possible case of FII:
5. ResponseAll 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:
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.6. Chronology and Strategy MeetingsInformation 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. 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.
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.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.
7. Medical Evaluation
8. Referral
9. Effective Support and SupervisionWorking 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:
This is not an exhaustive list. Incredibly caring, Department of Children, Schools and Families 2008. 10. Allegations Against Staff
ReferencesRoyal College of Paediatrics and Child Health (2021) Perplexing Presentations (PP)/Fabricated or Induced Illness by Carers (FII) in Children. 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 |