1.4.8 Fabricated or Induced Illness
SCOPE OF THIS CHAPTER
This policy applies to all staff working in Milton Keynes agencies whose work brings them into contact with children and families, and should be used as a means of bringing about better outcomes for children and young people. It 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 having fabricated or induced illness in the child.
- 1. Introduction
- 2. Recognition of FII
- 3. Indicators Which Should Alert Professionals to Possible FII
- 4. How is the Child Harmed?
- 5. Perpetrator
- 6. Barriers to the Identification of FII
- 7. Managing an Individual Case
- 8. Medical Evaluation
- 9. Referral to Children's Social Care
- 10. Strategy Meeting
- 11. Section 47 Enquiries (as part of Child and Family Single Assessment)
- 12. Initial Child Protection Conference
- 13. Police Investigation
- 14. Roles and Responsibilities
- 15. Record Keeping
- 16. Supervision and Support
- 17. References
- Appendix 1: Preparing a FII Chronology
- Appendix 2: FII Chronology Template
This document is based on 'Safeguarding Children in Whom Illness is Fabricated or Induced' DoH 2008.
The objective of this document is to provide clarity to professionals on how to safeguard and promote the welfare of children and young people in who fabricated or induced illness (FII) is suspected.
What is FII
Fabricated and Induced Illness (FII) was first described as Munchausen Syndrome by Proxy (MSbP) in 1977. The term FII was introduced in the UK by the Royal College of Paediatrics and Child Health (RCPCH) in 2001 and subsequently adopted by the Department of Health.
FII involves a well child being presented by a carer as ill or disabled, or an ill or disabled child being presented with a more significant problem than he or she has in reality, and suffering harm as a consequence. The carer actively promotes the sick role by exaggeration, fabrication (lying) or falsification of signs and in severe cases inducing illness.
There is no universal agreement on the definition of FII.
The defining characteristics of FII are:
Acute symptoms and signs cease when the child is separated from the perpetrator.
A Shared Responsibility
Promoting children's well being and safeguarding them from significant harm depends crucially upon effective information sharing, collaboration and understanding between agencies and professionals. Joint working is essential and all agencies and professionals should:
2. Recognition of FII
Cases of FII may present in an acute situation in hospital or more commonly there may be a chronic evolution with frequent presentations of exaggeration or fabrication in a range of settings.
Health professionals such as doctors (particularly General Practitioners or Paediatricians), health visitors, nursing staff during an acute admission, dieticians and allied health professionals working with the child, may observe discrepancies between reported and observed symptoms and signs.
FII does not only present with physical problems. Child and Adolescent Mental Health Services professionals may identify that a fabricated or induced illness is being presented to them in the form of fabricated or induced emotional or behavioural symptoms.
Frequent or unexplained school absence to keep a doctor’s or hospital appointment or repeated claims by the carer that a child is unwell though appears otherwise to the teacher, may cause concern in the school setting.
Social workers may note excessive demands for support which raises their concern.
Mental health professionals working with the child or child’s parent/ carer may identify a child being drawn into the parent’s illness.
3. Indicators Which Should Alert Professionals to Possible FII
4. How is the Child Harmed?
In fabricated illness the perpetrator does not directly harm the child. The carer actively promotes the sick role by exaggeration or fabrication (lying) of symptoms. The harm caused to the child can be significant and may include:
In fabricated illness falsified specimens may support the clinical story. For example substances containing glucose added to urine to mimic diabetes. The specimens are obtained not by injuring the child but by other means.
In induced illness, the perpetrator inflicts direct harm to the child. This can range from trivial injuries or pricking the child to obtain blood to add to urine, poisoning with a range of prescribed and non prescribed medication through to suffocation to induce apnoea (child stops breathing as a result of suffocation and goes blue).
There is no such thing as a typical perpetrator. Various studies have highlighted the following characteristics:
6. Barriers to the Identification of FII
The following approaches and attitudes can be a barrier to the identification of FII:
7. Managing an Individual Case
Acting on emerging concerns
Concerns could arise as a result from your own professional judgement, talking to colleagues or professionals from other agencies. As soon as concerns about FII arise, concerns should be documented in an accurate and factual manner differentiating between opinion, judgement and hypothesis to build a bigger picture and gather evidence. Documentation must include the name and agency of the person who provided or reported the information. Record all telephone conversations fully. Any professional who suspects FII should compile a chronology (Appendix 1: Preparing a FII Chronology and Appendix 2: FII Chronology Template).
MKSCB has adopted and modified the Cumbria Safeguarding Children Board chronology template (Appendix 3: The FII Template Explained) for use in cases of FII. The template lists fifteen categories of warning signs that may indicate the presence of FII and is used in conjunction with the chronology.
Evidence collated must be discussed with the named person for child protection within their own organisation to help decide whether to arrange an ‘emerging concerns professionals meeting’ or to conclude that FII is unlikely.
Emerging concerns professionals meeting
The purpose of this meeting is to:
The meeting is usually convened by a health professional but can be called by any professional involved with the child. When the meeting is convened by Health, the Named Nurse for Child Protection must be informed. Parents/ carer should not be informed of the meeting or concerns at this stage in order to ensure the child’s safety. Although in general it is good practice to share information with parents/ carers in cases of FII it could place the child at further risk and hamper subsequent criminal investigations.
At this multi agency meeting all staff that has had significant contact or involvement with the family should be invited to ensure that all views can be expressed and shared.
The staff who usually attend are:
The meeting could conclude:
If any professional considers their concerns about FII are not being taken seriously or responded to appropriately then they should discuss these with their lead professional for child protection.
8. Medical Evaluation
When the child is acutely ill and significant harm has occurred or there are concerns that the child is at risk of such harm and safety is an issue the child should be admitted for close observation until medical evaluation is complete.
Where the child’s health and safety is more secure the priority is to obtain as much information about the clinical events as possible. Careful history taking and examination is central to this process. For children who are not already under the care of a paediatrician the child’s GP should make a referral to a paediatrician.
The consultant who is responsible for the child’s health is the key clinical lead for the case and should take lead responsibility for all decisions about the child’s healthcare. This role is known as theresponsible paediatric consultant and it is important that timely agreement is made of who takes on this responsibility.
The use of a treatment diary for those families for who there are FII concerns should be considered. This will be held by the family and document the prescribed medication and the responsible paediatric consultant contact details. Other information may include appointment details, symptoms and duration. It would be expected for the family to carry this diary to all appointments, and this may prevent the family taking their child to different hospitals / doctors for treatment and medication. There is no set format for this diary as it is more appropriate to work out what information is required for each individual case.
Discussion with the Designated Doctor or MKHFT Named Doctor for Child Protection can help guide the process.
Informal discussions with experienced social workers and the police may prove of benefit. If noxious substances or assault injuries have caused harm to a child, a crime will have occurred that needs to be investigated by police and CSC.
Nurseries and schools may also have an important contribution but care needs to be exercised in the way enquiries are made.
If concerns persist and FII is a definite possibility then a wider assessment by Children’s Social Care should take place.
9. Referral to Children's Social Care
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 Children’s Social Care.
A referral may follow:
Whilst professionals should in general discuss any concerns with the family and where possible seek agreement this should only be done where such discussion and agreement seeking will not place the child at increased risk of harm or lead to interference with any potential investigation.
The referral should be made to the Multi Agency Safeguarding Hub (MASH using the Multi Agency Referral Form (MARF). The referrer will need to follow this up with a telephone call to ensure that the referral has been received. The referral must include exactly what the concerns are and include the professional meeting notes summary.
Following referral Children’s Social Care will organise a strategy meeting involving health, social care and police. The timing of the meeting depends on the urgency of the situation and the perceived risk. Forensic and medical evidence will need to be taken into consideration.
In order to safeguard the child’s welfare it is important that all three agencies work closely together in making and taking forward decisions about future action, recognising each others roles and responsibilities.
10. Strategy Meeting
At a minimum the meeting requires the involvement of:
The following professionals should be invited if appropriate:
Attendance must be restricted to those who need to be aware of the concerns in the best interests of the child. All participants need to be appraised of the utmost need for confidentiality.
The first task of the strategy team is to share concerns about the possibility of FII and what steps should be taken to safeguard the child.
It is crucial that the responsible paediatric consultant explains the medical issues as clearly as possible to the other agencies and plays a central role in the process. If there is any doubt about the medical evidence appropriate opinions need to be sought. It may be that a small panel consisting of a general paediatrician, specialist paediatrician and Designated Doctor for Child Protection is brought together to review the case if there is significant doubt about the diagnosis.
As a result of the strategy meeting three conclusions are possible:
Depending on the conclusion reached decisions need to be made about:
More than one strategy meeting may be necessary particularly when the circumstances are very complex and a number of discussions are required to consider whether and if so when to initiate section 47 enquiries.
11. Section 47 Enquiries (as part of Child and Family Single Assessment)
Children’s Social Care will undertake the Child and Family Single Assessment, which will include the gathering of information about the history of the child and each family member. Emphasis should be given to both physical and mental health of family members, education and employment as well as receipt of state benefits and charitable donations relating to a disabled child, social and family functioning and any history of criminal involvement.
It is important to assess the child’s understanding of their symptoms and the nature of their relationship with each significant family member including care givers.
Specialist assessments must be considered. For example, physiotherapists, occupational therapists, speech therapists, education services, child psychologists and child and adolescent and adult mental health services may be involved in the assessment of individuals or of families.
Careful and detailed record keeping by all staff is very important for any subsequent police investigation or court proceedings. Notes should be kept in a secure place so that unauthorised persons cannot access them.
12. Initial Child Protection Conference
If it is deemed necessary that a child protection conference is required the timing of the conference will depend on the urgency of the case and time needed to obtain relevant information.
It is essential that the responsible paediatric consultant and the GP attend this conference and thought needs to be given to facilitate this.
13. Police Investigation
Any evidence gathered by the police should be available to other relevant professionals to inform discussions and decisions about the child’s welfare and contribute to the section 47 enquiry and Child and Family Single Assessment unless this is likely to prejudice criminal proceedings.
It is important that suspects’ rights are protected by adherence to the Police and Criminal Evidence Act 1984 and European Convention on Human Rights 1984. In a criminal investigation no other agency other than the police should be confronting any suspect(s) under investigation.
14. Roles and Responsibilities
A clear understanding of the roles and responsibilities of others is essential for effective collaboration. Joint working is essential.
Health professionals may feel a conflict of loyalty, especially when their primary patient is not the child. However the primary concern should always be to safeguard and promote the child's welfare.
Once a health practitioner has suspicions that fabricated or induced illness is being presented, he or she should consult the named or designated doctor or nurse for child protection keeping detailed notes of the discussions.
Health practitioners should not discuss their concerns with the parents at this stage.
Contemporaneous notes should be maintained at all times and close multidisciplinary and interagency working is essential.
Health professionals can seek advice and support from the named or designated professionals for child protection.
All members of the Primary Health Care Team are well placed to recognise the early symptoms of fabricated or induced illness in a child. In families where FII is encountered parental concern is inappropriately increased. Abnormal illness behaviour needs to be recognised early and contained.
The common warning signs in the primary care setting are:
Abnormal illness behaviour can sometimes be contained by:
The parent/ carer is offered planned appointments with one or two senior doctors who are aware of the background and history.
“Active Listening” generally recommended for negotiation is a helpful (if time consuming) process for these families. It is important to listen, show you have listened by paraphrasing/ summarising what they have said. This is conducive to getting agreement on the concerns raised.
This can be followed by an emphasis on the normal objective findings. Ensure the positive aspects of the child’s health are accentuated.
Ensure the parent/ carer is made aware of your concern about the emphasis on ill-health. A management plan can then be hopefully worked out. The following tools are useful.
Any concerns that other primary care staff have should be discussed with the child's GP, with a view to referring to a Paediatrician, unless already known to them.
Second opinions can be useful to settle the usual professional worry that the parents may be right, the anxiety is well founded and that a serious medical problem has been missed. This needs to be negotiated so that only one is requested. The referral letter needs to be skilfully written acknowledging the discrepancy in the level of concern but without undue efforts to prejudice the outcome. The local paediatrician is well placed to provide advice on tertiary specialists. It is essential that invasive tests and procedures are not duplicated.
The responsible GP should consult the Designated or Named Doctor/Nurse for Child Protection about the child and keep him/her informed in the process. This applies particularly when the threshold between abnormal illness behaviour and FII is approached.
Nurses, Midwives and Health Visitors
Because of their contact with children and their families in community and hospital settings, these staff groups play an important role in not only providing services but are also an important part of the multi disciplinary team and should contribute to the assessment and planning process.
Where a nurse, midwife or health visitor has concerns that a carer is impairing a child's health and development by fabricating or inducing illness, the practitioner should explore the presenting information to see where it is on the continuum from parental concern, over-anxiety, through to suspected significant harm. In cases where fabricated or induced illness is suspected, the process suggested in the management of an individual case should be followed.
Advice and support should be sought from the named nurses/midwife for child protection. It is also available from Children's Social Care.
Midwives should be alert to the information given by the mother during pregnancy especially in relation to strange illnesses; unusual complications of pregnancy, unexpected deaths in the family; family members with untreatable illnesses; or her children having complicated medical histories; histories of failure to thrive or non accidental injuries; and if signs and symptoms reported by the mother are not observed by the midwife.
Nurses may be responsible for collecting specimens such as urine or faeces. These should be collected and sent off in such a way that they cannot be interfered with.
Junior medical and nursing staff
A common scenario is for a child to be presented repeatedly, usually out of hours with a history of symptoms incongruous with the clinical findings. You may be asked to review a child who has stopped breathing or had a seizure and find the child appears unusually well given the history.
When faced with a child in whom you suspect some or all of the signs and symptoms of illness are being fabricated or induced by the carer, the consultant responsible for the child's health care should assume role of ‘responsible paediatric consultant’ as per the RCPCH document and take lead responsibility for all decisions about the child's health care.
It is important for the Consultant to:
Allied Health Professionals
Range of professionals, e.g. speech therapists, physiotherapists, dieticians, working in health settings may play a role in identifying and managing fabricated and induced illness in children. When concerns arise they should be discussed with the line manager, seek advice from the named nurse or doctor and referring to GP or Paediatrician as appropriate.
Specialist Child and Adolescent Mental Health Services (SpCAMHS)
SpCAMHS professionals may be the first to identify that a fabricated or induced illness is being presented to them in the form of fabricated or induced emotional or behavioural symptoms.
Requests for advice may be received from other professionals when fabricated or induced illness is considered a possibility. SpCAMHS professionals should provide an opportunity for other professionals to clarify their thinking, and consider possible reasons for parental behaviours and anxieties.
In the course of an assessment of a child and family where fabricated or induced illness is an issue, the service should, if requested, contribute with other professionals to the provision of an assessment. The most important areas will be an assessment of the child's psychological functioning, in particular the child's beliefs and possible anxieties, about their state of health, ways to support and to improve this family's functioning and an assessment of the parents capacity to meet the child's needs.
SpCAMHS professionals may also make a contribution to an assessment of the mental health functioning of a parent. Here it will be important to liaise with colleagues in adult mental health services.
If a child has suffered significant harm as a result of fabricated or induce illness, SpCAMHS professionals may need to provide interventions and services as part of the overall plan for the child.
Adult Mental Health Services
The full range of adult mental health professionals, including nurses, social workers, occupational therapists, clinical psychologists and psychiatrists, may need to be involved in an assessment and the treatment of a carer of a potentially abused child. This involvement may follow the raising of concerns in relation to fabricated or induced illness in a child during the course of section 47 enquiries and subsequent actions, or following the identification of the carer's involvement in the abuse or likely abuse of a child.
Through their involvement with a patient, adult mental health professionals may become concerned about the welfare of a child. This may be if a carer has a somatising disorder or is known to fabricate or induce illness in themselves. If concerns about a child become apparent they should discuss these concerns with a named or designated doctor/nurse or with Children's Social Care Duty Social Worker.
Children's Social Care
Under the 1989 Children Act Milton Keynes Children's Social Care have lead responsibility for the protection of children. These responsibilities fall into four main areas:
This will be conducted in conjunction with the doctor who is medically responsible for the child's health and other relevant agencies. It will include a full chronology of the information gathered about the medical, psychiatric and social history, and an understanding of the child's needs and the parents' capacities to ensure the child's health and developmental progress.
Children's Social Care is responsible for convening strategy discussions and s47 investigations and where appropriate, initial and review Child Protection Conferences. The police will decide whether to instigate a criminal investigation.
If concerns are substantiated but the child is not judged to be at continuing risk of harm, a child in need plan will be developed setting out what services are to be provided by whom, and what agency has the lead responsibility for reviewing the plan at regular intervals.
Children's Social Care will have responsibility for coordinating the multi agency child protection plan to safeguard the child, so must ensure that their staff are sufficiently senior to be able to commit the department to following through any recommendations regarding action to be taken.
If it is found that the child's welfare cannot be safeguarded if she/he remains at home, Children's Social Care may seek parents' agreement for voluntary accommodation or may apply to the courts for an Emergency Protection Order or Care Order (involving the local authority's solicitor)
Provision of Services
Children's Social Care has a duty to safeguard and promote the welfare of children in need in their area, through the provision of services appropriate to the needs of the children.
Children's Social Care has lead responsibility for reviewing any child protection plan.
Through their day-to-day contact with children, early year's staff, teachers and other school staff are particularly well-placed to notice outward signs of harm, and have an important role to play in the identification and management of suspected cases of fabricated or induced illness.
School staff should refer any child welfare concerns they have to the teacher with designated responsibility for child protection. The designated teacher can seek advice from the Multi Agency Safeguarding Hub (MASH). Early year's staff should refer any child welfare concerns they have to their designated child protection officer, who will report any concerns to the designated child protection representative in the Local Authority, Children's Social Care.
The following are factors that teachers and other school staff should be aware of that can indicate that a pupil may be at risk:
The designated teacher for child protection or the early years designated child protection officer is responsible for making the referral to Children's Social Care. School staff/early years staff should not carry out their own enquiries but maintain a chronology of events/concerns (using Appendix 2), including a record of absences and the reasons for absence given by the parent. The designated teacher is normally invited to attend any strategy meeting or case conference.
The Child Abuse Investigation Unit (CAIU) should be made aware of cases of suspected criminal offences at an early stage.
The priority for the police will be to protect the child or young person, and to assist the Paediatrician in reaching an understanding of the child's health status. Once a crime is alleged to have been committed the police will need to ensure the rights of the suspect are upheld and that evidence is gathered in a fair and appropriate way.
Police should carry out any work within a hospital sensitively and delicately, with any disruption to normal ward life being kept to a minimum e.g. using plain-clothes officers.
Voluntary, Independent and Private Social Care Sectors
Voluntary organisations and independent and private sector providers play a significant role in the provision of services to children in need. They provide a wide range of supportive services and may be involved in providing services after fabricated or induced illness has been identified.
Staff and volunteers should be aware of this guidance and the procedures in place to ensure that when they are concerned a child is suffering or likely to suffer Significant Harm appropriate referrals are made in accordance with MKSCB procedures. This applies in instances where a concern arises that a child may be subject to maltreatment due to fabricated or induced illness.
15. Record Keeping
Good record keeping is paramount to good practice and is an important part of accountability of professionals. Clear and accurate records ensure that there is a documented account of an agency, or professional's involvement with a child and/or family. Records are an essential source of evidence for section 47 enquiries and investigations
The recording of a detailed chronology which includes medical, psychiatric and social histories of the child, parents, siblings and other significant family members is important when identifying fabricated or induced illness in a child, as it enables patterns of presentation to be recognised.
Requests for access to the child's records should be actioned in accordance with each agency's Access to Records policy. Where there is any doubt about the retention or disclosure of information, legal advice should be sought.
Documentation should be recorded in a separate section in the child's file.
16. Supervision and Support
It is acknowledged that working with families where it is suspected that illness is fabricated or induced is demanding, and can be distressing and stressful.
Agencies should have a supervision policy, which identifies how, where and when staff can access supervision about such cases. Everyone should have access to advice and support from peers and managers.
Children Act 1989
Safeguarding Children in Whom Illness is Fabricated or Induced. (2009, RCPCH)
Every Child and Young Person in Milton Keynes Matters (2006). Milton Keynes: Learning and Development Directorate
Royal College of Paediatrics and Child Health, October 2009, Fabricated or Induced Illness by Carers
Appendix 1: Preparing a FII Chronology
The information available to a meeting about a possible case of Fabricated or Induced Illness (FII) is enormous and can be difficult to organise. As complete a picture of the concerns is essential. All information will need examining, and the integrating of all reports will be necessary. If freehand chronologies are provided by all the agencies and individual professionals concerned, this task becomes impossible.
Appendix 2 is the chronology template to be used in possible cases of FII. It can then be merged and sorted.
What to include in the chronology
The template should be used to organise the information, to include any event that comes under any one of the categories of warning sign so that it can be discussed.
If every single contact with any professional is included, the chronology loses its value. On the other hand, any selection has the risk of excluding a vital detail. It is advised to include all relevant information, including relatively trivial injuries, which in fact may be accidents as there is an increasing recognition of the links between all other forms of abuse and Fabricated or Induced Illness.
It is worth noting the number of signs or symptoms in the children and the number of medications and details. Reported side effects of medication are also important. The number of invasive tests and/or operations should be included and the number of different medical teams involved. Missed appointments, unexplained absences from school/early years should be recorded.
Appendix 2: FII Chronology Template