2.6 Fabricated or Induced Illness
Also known as Munchausen’s Syndrome by Proxy, fabricated or induced illness is 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. It is a relatively rare but potentially lethal form of abuse.
There are four main ways of the carer fabricating or inducing illness in a child. These are not mutually exclusive and include:
- fabrication of signs and symptoms, this may include fabrication of past medical history;
- falsification of hospital charts and records, letters and documents, and specimens of bodily fluids;
- exaggeration of symptoms/real problems;
- induction of illness by a variety of means.
Risks and indicators
The following list is of behaviours exhibited by carers that can be associated with fabricating or inducing illness in a child. This list is not exhaustive and should be interpreted with an awareness of cultural behaviours and practices which can be mistakenly construed as abnormal behaviours:
- deliberately inducing symptoms in children by administering medication or other substances, by intentional transient airways obstruction or by interfering with the child’s body to cause physical signs;
- interfering with treatments by overdosing with medication, not administering medication or interfering with medical equipment such as infusion lines;
- claiming the child has symptoms which are unverifiable unless observed directly, such as pain, frequency of passing urine, vomiting or fits. These claims result in unnecessary investigations and treatments which may cause secondary physical problems;
- exaggerating symptoms which are unverifiable unless observed directly, causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and, therefore, are harmful and possibly dangerous;
- obtaining specialist treatments or equipment for children who do not require them;
- alleging psychological illness in a child.
Child welfare 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;
- physical examination and results of medical investigations do not explain reported symptoms and signs;
- there is an inexplicably poor response to prescribed medication and other treatment;
- new symptoms are reported on resolution of previous ones;
- reported symptoms and found signs are not observed in the absence of the carer;
- over time the child is repeatedly presented with a range of symptoms to different professionals in a variety of settings;
- the child’s normal, daily life activities, such as attending school, are being curtailed beyond that which might be expected from any known medical disorder from which the child is known to suffer;
- missed appointments especially if the appointments are not leading in the desired direction for the carer;
- excessive use of any medical website or a pattern of seeking alternative opinions from professionals.
The majority of cases of fabricated or induced illness in children are confirmed in a hospital setting because either medical findings or their absence provide evidence of this type of abuse. Objective evidence of fabrication may include:
- The history of events given by different observers appearing to be in conflict
- The history of events is biologically implausible (such as small infants with a history of very large blood losses who do not become anaemic, or infants with large negative fluid balance who do not lose weight);
- Test results such as toxicology studies or blood typing;
- Evidence of fabrication or induction from covert video surveillance (CVS).
Concerns may also 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.
In addition, professionals working with the child's parents may be being given information by the parent about the child or observe the child directly and note discrepancies between what they are told about the child's health and development and what they see themselves.
Protection and action to be taken
In using this guidance all agencies and professionals should:
- be alert to potential indicators of illness being fabricated or induced in a child;
- be alert to the risk of harm which individual abusers, or potential abusers, may pose to children in whom illness is being fabricated or induced;
- share and help to analyse information so that an informed assessment can be made of the child’s needs and circumstances;
- contribute to whatever actions (including the cessation of unnecessary medical tests and treatments) and services are required to safeguard and promote the child’s welfare and regularly review the outcomes for the child against specific planned outcomes work co-operatively with parents unless to do so would place the child at increased risk of harm;
- assist in providing relevant evidence in any criminal or civil proceedings, should this course of action be deemed necessary.
In the first instance, the GP or 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. However, once a paediatric consultant is involved the paediatrician will take the lead responsibility for all decisions pertaining to the child’s healthcare.
When a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer and therefore the child's health or development is or is likely to be impaired, a referral should be made to Children's Social Care Services or the Police in accordance with the Referrals Procedure. If there is reasonable cause to suspect the child is suffering, or is likely to suffer significant harm, children’s social care must convene and chair a strategy discussion that involves all the key professionals responsible for the child’s welfare. It should, at a minimum, include children’s social care, the police, the GP and/or paediatric consultant responsible for the child’s health and the community paediatric nursing service or if the child is an in-patient, a senior ward nurse. It is also important to consider seeking advice from the designated safeguarding doctor and/, or having present, a paediatrician who has expertise in the branch of medicine, for example respiratory, gastroenterology, neurology or renal which deals with the symptoms and illness processes caused by the suspected abuse. This would enable the medical information to be presented and evaluated from a sound evidence base. Other professionals involved with the child such as the GP, health visitor and staff from education settings should be involved also as appropriate. It may be appropriate to involve the local authority’s solicitor at this meeting. Staff should be sufficiently senior to be able to contribute to the discussion of often complex information, and to make decisions on behalf of their agencies.
Children who have had illness fabricated or induced require coordinated help from a range of agencies.
Consultation with peers or colleagues in other agencies is an important part of the process of making sense of the underlying reasons for these signs and symptoms. The characteristics of fabricated or induced illness are that there is a lack of the usual corroboration of findings with signs or symptoms or, in circumstances of diagnosed illness, lack of the usual response to effective treatment. It is this puzzling discrepancy which alerts the medical staff to possible harm being caused to the child
Where there are concerns about possible fabricated or induced illness, the signs and symptoms require careful medical evaluation for a range of possible diagnoses by a paediatrician.
If no paediatrician is already involved, the child's GP should make a referral to a paediatrician.
Where, following a set of medical tests being completed, a reason cannot be found for the reported or observed signs and symptoms of illness, further specialist advice and tests may be required.
Normally the consultant paediatrician will tell the parent(s) that they do not have an explanation for the signs and symptoms.
Parents should be kept informed of further medical assessments/ investigations/tests required and of the findings but 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 the child protection process and/or any criminal investigation. As with all strategy discussions, the meeting should be used to:
- share available information; to collate a multi-agency chronology. All agencies should prepare and bring their own chronology to the strategy meeting.
- agree the conduct and timing of any criminal investigation; and
- decide whether enquiries under section 47 of the Children Act 1989 should be undertaken, or assessment under section 17 Children Act 1989.
NB. Strategy Discussions may be independently chaired.
In cases of suspected FII decisions should also be made at the strategy discussion about:
- whether the child requires constant professional observation and, if so, whether or when the carer(s) should be present;
- whether it is necessary for records to be kept in a secure manner to safeguard the child’s welfare, and how this will be ensured;
- what immediate and short-term action is required to support the child, and who will do what by when;
- further paediatric assessment;
- any factors such as the child and family's culture, ethnicity and language which should be taken into account;
- factors that should be considered if the child is disabled;
- the needs of siblings and other children with whom the alleged perpetrator has contact;
- the nature and timing of any police investigations, including the analysis of samples. This is particularly pertinent if covert video surveillance is being considered.
If at any point there is medical evidence to indicate the child's life is at risk or there is a likelihood of serious immediate harm, child protection powers should be used to act secure the immediate safety of the child.
More than one strategy discussion may be necessary. This is likely where the child’s circumstances are very complex, and a number of discussions are required to consider whether and, if so, when to initiate section 47 enquiries.
Legal advice about how to proceed should always be sought and made directly available to doctors who are responsible for making clinical decisions in these cases. Such advice should be documented in medical and children’s social care records.
When it is decided that there are grounds to initiate a Section 47 Enquiry as part of a Social Work Assessment, decisions should be made at the Strategy Discussion about how the Section 47 enquiry will be carried out including:
- What further information is required about the child and family and how it should be obtained and recorded;
- Whether it is necessary for records to be kept in a secure manner and how this will be ensured;
- Whether the child requires constant professional observation and if so, whether or when carer(s) should be present;
- Who will carry out what actions, by when and for what purpose, in particular planning further paediatric assessment(s);
- Any factors, such as the child and family's culture, religion, ethnicity and language which should be taken into account;
- Effective communication between colleagues is essential if to ensure a good outcome for the child is to be achieved. Concerns about FII should be mentioned in all communications about the case, and the responsible social worker and paediatric consultant should be the main conduit for communications.
- The needs of siblings and other children with whom the alleged abuser has contact;
- The needs of parents or carers;
- The nature and timing of any police investigations, including analysis of samples and covert Surveillance. The use of covert video surveillance (CVS) is governed by the Regulation of Investigatory Powers Act 2000
- All personnel including nursing staff who will be involved surveillance use should have received specialist training.
- Children's Social Care Services team should have a contingency plan in place, which can be implemented immediately if covert video surveillance provides evidence of the child suffering Significant Harm.
- How information will be shared with parents and at what stage.
This section should be read in conjunction with paragraphs 2.97 – 2.105 of Working Together which set out the principles applying to the police role in child protection investigations.
Safeguarding children in whom illness is fabricated or induced
Any suspected case of fabricated or induced illness may also involve the commission of a crime, and therefore the police should always be involved in accordance with paragraphs 5.17-5.22 of Working Together. Events such as intentional smothering or poisoning are clearly criminal assaults, but more subtle forms of child abuse, such as wilfully interfering with feeding lines or causing unnecessary medical intervention to be undertaken, may also be criminal acts.
The police should be alerted to suspected cases of fabricated and especially induced illness as early as possible. It may be crucial for any ongoing criminal investigation that the carer is not made aware of the child protection concerns. There are many low-key enquiries which can be made by the police before any proactive investigation is launched. At this stage, i.e. before suspicions are confirmed, the responsible consultant for the child’s health (usually a paediatrician) should retain the lead role for the child’s health, and the priority of police officers should be to assist the paediatrician, where relevant and appropriate in reaching an understanding of the child’s health status. The balance may change when it becomes clear whether or that a crime appears to have been committed. In such circumstances, the police will need to ensure the rights of the suspect are upheld and that evidence is gathered in a fair and appropriate way.
The Police Service is the prime agency for gathering evidence in connection with criminal cases. There is sometimes reluctance on the part of doctors to involve the police, but it must be remembered that all professionals should be working towards the same goal, i.e. securing the safety of the child. It may well be that enquiries made by the police assist in identifying that the underlying explanation for the child’s symptoms is not related to harm caused by a carer. In any case, the police should work within the multi-agency framework, and all relevant information should be shared with those professionals treating the child. Any evidence of child abuse gathered by the police will normally be available for use by the local authority in any care proceedings.
The police use technical means to gather evidence in many types of criminal enquiry, and it may be appropriate to use such methods, for example covert video surveillance, in cases of suspected fabricated or induced illness. In a case, where this is indicated as appropriate by the multi-agency strategy discussion, the police will supply any equipment required and be responsible for monitoring and managing the process. The police, like other public authorities, are bound by the Human Rights Act 1998 and the Regulation of Investigatory Powers Act 2000. Any operations within this context therefore will be carefully controlled and police managers will be fully accountable. Doctors or other professionals should not independently carry out covert video surveillance. If the suspicion of child abuse is high enough to consider the use of such a technique, the threshold must have been passed to involve the police and children’s social care services. The National Crime Faculty provides confidential good practice advice for police officers.
The police should carry out any work within a hospital sensitively and delicately, with any disruption to normal ward life being kept to a minimum. Any arrest or interview in a hospital setting should be carried out as sensitively as possible, ideally using plain clothes officers, to:
- safeguard children in whom illness is fabricated or induced
- avoid disruption to patients and staff. The inter-agency management team should, if possible, consider the arrest strategy well in advance of it being carried out.
Irrespective of what evidence is likely to be used in the Civil Court or the Criminal Court or both, it must be gathered to the highest standards. When the police are involved in a situation where induced or fabricated illness is suspected, even greater care should be taken to ensure that the investigation is thorough and professional, and led by an experienced senior investigating officer.
Outcome of Section 47 Enquiries:
- Concerns not substantiated - determine and agree ongoing help and support of the child and family and the best means of meeting these
- Concerns substantiated, but child not judged to be at continuing risk of significant harm – children’s social care, in consultation with other agencies, should take carefully any decision not to proceed to an Initial Child Protection Conference where it is known that a child has suffered significant harm as a result of fabricated or induced illness
- Concerns substantiated, and child judged to be at continuing risk of harm - initiate an Initial Child Protection Conference
Whilst cases of fabricated or induced illness are relatively rare, the term encompasses a spectrum of behaviour ranging from a genuine belief that the child is ill through deliberately inducing symptoms by administering drugs or other substances to significant surgery. At the extreme end, it may have life changing consequences for the child and can be fatal.
Contrary to normal professional relationships with parents, being open and challenging about suspicions from the start may scare off a parent thus making it more difficult to gain evidence. There may be an unintended consequence in increasing the harmful behaviour in an attempt to be convincing.
Parents who harm their children this way may appear to be plausible, convincing and have developed a friendly relationship with practitioners before suspicions arise. They may also demonstrate a seemingly advanced and sophisticated medical knowledge which can make them difficult to challenge. Practitioners should demonstrate professional curiosity and challenge in an appropriate way and with coordination between the agencies.
Where illness is being fabricated or induced, extensive and unnecessary medical investigations may be carried out to establish the underlying causes for the reported signs and symptoms. The child may also have treatments prescribed or operations which are unnecessary. These investigations can result in children spending long periods of time in hospital and some, by their nature, may also place the child at risk of suffering harm or even death.
Nearly all affected children undergo unpleasant investigations and/or treatments but many children, especially young children, who have had illness fabricated or induced may not be fully aware of the nature of their abuse. Few studies have sought children’s views on this matter, but Neale et al (1991), through their interviews with children, found that many had not been able to disclose the nature of their abuse, in part because of the skill of their mothers (the perpetrators) in teaching the children to present a rosy picture to the external world whilst they were being subjected to extensive physical and emotional abuse at home. Even after disclosure of the abuse and placement with alternative carers, some still wanted continued contact with them.
Some children are confused about their state of health. Many are preoccupied with anxieties about their health and survival and may express suicidal thoughts as a result of their despair. Older children and adults who have been abused in this way may come to feel anger at their betrayal by their parent(s), and a lack of trust in those caring for them including medical professionals.
In summary, following identification of fabricated or induced illness in a child by a carer, the way in which the case is managed will have a major impact on the developmental outcomes for the child. The extent to which the parents have acknowledged some responsibility for fabricating or inducing illness in their child will also affect these outcomes for the child.
- Fabricated or Induced Illness (NHS Choices)
- Safeguarding Children in Whom Illness is Fabricated or Induced (supplementary guidance to Working Together to Safeguard Children), HM Government, 2008
- Fabricated or Induced Illness by Carers: A Practical Guide for Paediatricians, Royal College of Paediatricians and Child Health, 2009
https://www.youtube.com/watch?v=b17PqLRInBQ Incredibly Caring (DVD 2009)