2.6 Fabricated or Induced Illness
Previously known as Munchausens 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.
Concerns will be raised for a small number of children when it is considered that the health or development of a child is likely to be significantly impaired or further impaired by the actions of a carer or carers having fabricated or induced illness.
It is important that the focus is on the outcomes or impact on the child’s health and development and not initially on attempts to diagnose the parent or carer.
The range of symptoms and body systems involved in the spectrum of fabricated or induced illness are extremely wide.
Investigation of fabricated and induced illness and assessment of significant harm to a child falls under statutory framework provided by Working Together 2018 and Safeguarding Children in Whom Illness is Fabricated or Induced (Supplementary guidance to Working Together to Safeguard Children.
There are four main ways of the carer fabricating or inducing illness in a child:
- Fabrication of signs and symptoms, including fabrication of past medical history.
- Fabrication of signs and symptoms and falsification of hospital charts, records, letters and documents and specimens of bodily fluids.
- Exaggeration of symptoms/real problems. This may lead to unnecessary investigations, treatment and/or special equipment being provided.
- Induction of illness by a variety of means.
The above four methods are not mutually exclusive.
Harm to the child may be caused through unnecessary or invasive medical treatment, which may be harmful and possibly dangerous, based on symptoms that are falsely described or deliberately manufactured by the carer, and lack independent corroboration.
Concern may be raised at the possibility of a child suffering significant harm as a result of having illness fabricated or induced by their carer.
The following is a list of behaviours, exhibited by carers, which can be associated with fabricating or inducing illness in a child:
- Deliberately inducing symptoms in children by administering medication or other substances, or by means of intentional suffocation.
- Interfering with treatments by over dosing, not administering them 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, 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.
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.
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
- excessive use of any medical website or alternative opinions.
There may be a number of explanations for these circumstances and each requires careful consideration and review.
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
Fabricated and induced illness is a child protection issue and cannot be treated by the NHS alone but requires a truly multi-agency approach. However fabricated and induced illness should always be diagnosed by a senior, experienced paediatrician. Medical professionals who suspect fabricated and induced illness is taking place should liaise with social services and the police, and must follow local child protection procedures.
Where there is a suspicion of fabricated and induced illness, practitioners should consider this guidance carefully when fulfilling their role in assessing and investigating their concerns effectively.
Children who have had illness fabricated or induced require coordinated help from a range of agencies. Joint working is essential, and 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 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 children’s needs and circumstances including an up to date chronology
- contribute to whatever actions and services are required to safeguard and promote the child’s welfare
- assist in providing relevant evidence in any criminal or civil proceedings.
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.
Normally, the doctor would tell the parent/s that s/he has not found the explanation for the signs and symptoms and record the parental response.
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.
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 services or the police (see Referrals procedure):
- Lead responsibility for the coordination of action to safeguard and promote the child’s welfare lies with children’s social care.
- Any suspected case of fabricated or induced illness may involve the commission of a crime and therefore the police should always be involved.
- The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child’s healthcare.
In cases where the police obtain evidence that a criminal offence has been committed by the parent or carer, and a prosecution is contemplated, it is important that the suspect’s rights are protected by adherence to the Police and Criminal Evidence Act 1984.
The Strategy Discussion should include children’s social care, the police, the medical consultant responsible for the child’s health and, if the child is an in-patient, a senior ward nurse. It is also important to consider seeking advice from, or having present, a medical professional 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.
Professionals involved with the child such as the GP, health visitor and staff from education settings should also be involved as appropriate. The investigative team must ensure that all involved professionals are made aware of the importance of confidentiality in keeping the child safe. At no time should concerns about reasons for chil’'s signs and symptoms be shared with the parents if this information would jeopardise the child’s safety.
Decisions should 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
- further paediatric assessment
- any particular factors, such as the child and family's race, ethnicity and language which should be taken into account
- any particular factors that should be taken into account 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 convert video surveillance is being considered.
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.
Any decision to use covert video surveillance must be a multi-agency decision at a Strategy Discussion/Meeting.
Conventional methods of gathering evidence must first be tried or be deemed to be impractical before a decision is taken to use covert or technical equipment.
The use of covert video surveillance is governed by the Regulation of Investigatory Powers Act 2000. The use of covert video surveillance should be controlled by the police and accountability for it held by a police manager. The police should supply and install any equipment, and be responsible for the security of and archiving of the video tapes. Any such technical devices supplied and used by the police to gather evidence will require the authority of an Assistant Chief Constable. Police officers planning surveillance in cases of suspected fabricated or induced illness may seek advice from the National Crime Agency (0370 496 7622, firstname.lastname@example.org).
If covert video surveillance is considered to be appropriate, consideration will be given to where this surveillance should take place.
If significant episodes of harm to the child are documented, children’s social services will seek an Emergency Protection Order for the child and police will take any necessary action against the carer.
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 to deliberately inducing symptoms by administering drugs or other substances. At the extreme end it is fatal, or has life changing consequences for the child.
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.
- 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