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CHAPTER 16: Fabricated or Induced Illness (LAST REVISED AUGUST 2011)

AMENDMENTS

Section 5 of this chapter was revised in August 2011 with updated references to the Achieving Best Evidence guidance 2011 (in 5.4) and the Specialist Operations Centre, Covert Advice Team (in 5.5).


Contents

  1. Introduction
  2. Definition
  3. Recognition of Emerging Concerns
  4. Response
  5. Criminal Investigation (REVISED AUGUST 2011)


1. INTRODUCTION

1.1 This section outlines the procedures to follow when professionals are concerned that the health or development of a child may be significantly impaired by the actions of a carer having fabricated or induced illness.
1.2 Further guidance is provided in Government Guidance document Safeguarding Children in Whom Illness is Fabricated or Induced 2008.
1.3 The Royal College of Paediatricians and Child Health 2002 Fabricated or Induced Illness by Carers provides further guidance for medical clinicians.


2. DEFINITION

2.1 Fabricated or induced illness (FII in a child is a condition whereby a child suffers harm through the deliberate action of her/his main carer and which is duplicitously attributed by the adult to another cause.
2.2

There are 3 main (not mutually exclusive) 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
  • Induction of illness by a variety of means
2.3 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.
2.4 The child may additionally suffer emotional harm through limitations placed on their development and social interaction e.g. overprotection, limitation of exploration and learning, prevention from participation in normal social interaction


3. RECOGNITION OF EMERGING CONCERNS

3.1

Doctors / paediatricians may be concerned at the possibility of a child suffering significant harm as a result of having illness fabricated or induced by her/his carer. These 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 / correlate with any disease or;
  • Physical examination and results of investigations do not explain reported symptoms and signs or;
  • There is an inexplicably poor response to prescribed medication and treatment or;
  • New symptoms are reported on resolution of previous ones or;
  • Reported symptoms and found signs are not observed to commence, in the absence of the carer or;
  • Over time the child repeatedly presents with a range of symptoms or;
  • The child's normal, daily life activities are being curtailed beyond that which might be expected from any known medical disorder from which the child is known to suffer
3.2 There may be a number of explanations for these circumstances and each requires careful consideration and review.
3.3 Concerns may be raised by other professionals e.g. nurses, teachers or social workers who are working with the child and who may notice discrepancies between reported and observed medical conditions, such as the incidence of fits.
3.4 Professionals working with the child's parents may also note relevant concerns e.g. mental health professionals, may identify a child being drawn into the parents illness.
3.5

Features that may be associated with this form of abuse, though none of which are themselves indicative, are:

  • Early commencement of child's medical, especially hospital, treatment
  • Attendance at various hospitals, in different geographical areas
  • Development of feeding disorders, as a result of unpleasant feeding interactions
  • The child may develop abnormal attitudes to her/his own health
  • History of unexpected death, illness or multiple surgery in parents and/or siblings of the family
  • Past history in the carer of childhood abuse, self harm, somatising disorder or false allegations of physical or sexual assault
  • Carers may be over involved in participating in medical tests, taking temperatures and measuring bodily fluids
  • Carer/s are observed to be intensely involved with their children, never taking a much needed break nor allowing anyone else to undertake their child's care.
  • Carer/s may appear unusually concerned about the results of investigations which may indicate physical illness in the child
3.6

Generally, some indicators of abuse (often in a context of wider parenting difficulties), may (or may not) be associated with this form of abuse e.g.:

  • Non organic failure to thrive
  • Speech, language or motor developmental delays
  • Dislike of close physical contact
  • Attachment disorders
  • Low self esteem.
  • Poor quality or no relationships with peers because social interactions are restricted.
  • Poor attendance at school and under-achievement
  • Carers' history of abuse and / or psychiatric illness


4. RESPONSE

4.1 Concerns about a child's health should be discussed as early as possible with the appropriate health professional responsible for the child's health e.g. GP, paediatrician.
4.2 If any professional considers her/his concerns are not responded to appropriately, s/he should discuss the concerns with the designated doctor or nurse and / or the professional's own designated professional.
4.3 If any concerns relate to a member of staff, the concerns should be discussed with the designated or named professional. See also Allegations Against Staff, Carers and Volunteers Procedure.


MEDICAL EVALUATION
4.4 The signs and symptoms require careful medical evaluation for a range of possible diagnoses.
4.5 All tests and their results should be fully and accurately recorded. It is important that the child's record is not altered in any way, e.g. through tampering with test results.
4.6 The name of the person reporting any observations should be legibly recorded and dated.
4.7 When suspicion of fabricated or induced illness first arises, the paediatrician has a duty to consult widely in an attempt to confirm or refute the suspicions.
4.8 All secondary and tertiary health services should ensure that discharge reports clearly identify to whom they should be sent and that they are despatched without delay.
4.9 A chronology of health involvement, including access to all health facilities, should be prepared so as to provide comprehensive information.
4.10 Parents should be kept informed of further assessments / investigations / tests required and of the findings. Normally, the doctor would tell the parent/s that s/he has not found the explanation and record the parental response.
4.11 Concerns about the reasons for the child's signs and symptoms should not be shared with parents, if this information is likely to jeopardise the child's safety.


REFERRAL TO CHILDREN'S SOCIAL CARE
4.12 A referral should be made to Children's Social Care for an initial assessment if a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer.
4.13 The referral may follow a medical evaluation or be the result of concern by professionals or members of the public.
4.14 The Royal College of Paediatrics and Child Health 2002 Fabricated or Induced Illness by Carers recommends 'when there are persisting concerns there should be a wider assessment by the social services department. The criterion for referral is that the paediatrician has continuing concerns about the child's welfare and not that fabrication or illness induction or harm has been proved.'
4.15 This guidance makes it clear that paediatricians should undertake consultation with other agencies, as part of the process of confirming (or disproving) the possibility of FII.
4.16 Whilst professionals should in general, discuss any concerns with the family and, where possible, seek agreement to making referrals to Children's Social Care, this should only be done where such discussion and agreement-seeking will not place a child at increased risk of Significant Harm.
4.17 The police CAIU must be informed of any referral where FII is suspected as this may also involve the commission of a crime.


INITIAL CONSIDERATION OF REFERRAL
4.18 As with all other referrals, Children's Social Care should decide, within 1 working day, the response required. The decision must be taken in consultation with the consultant paediatrician responsible for the child's health care and the CAIU. This decision making process must agree the action to be taken, by whom and within what time frame.
4.19 All decisions about what information is shared with parents should be agreed between CAIU, Children's Social Care, consultant paediatrician and referring professional, bearing in mind the safety of the child and the conduct of any police investigations. Possible outcomes of referrals are the same as any other.
4.20 If emergency action is required e.g. a child's life is in danger through toxic substances being introduced into the blood stream, an immediate Strategy Discussion should take place, where possible, between Children's Social Care, CAIU, health and other agencies as appropriate. This should not delay the use of immediate protection if required.


INITIAL ASSESSMENT
4.21 An Initial Assessment should usually be completed, as with all referrals following the guidance set out in the Assessment Framework (paragraphs 3.9 - 3.10).
4.22 This should be undertaken in collaboration with the consultant paediatrician responsible for the child's health care.
4.23 If a 2nd medical opinion has not previously been obtained The Royal College of Paediatricians and Child Health 2002 Fabricated or Induced Illness by Carers (p.35) suggests that this is the point when it is sought.
4.24 The decision should be made in consultation with the paediatrician consultant and CAIU, with agreement reached regarding what the parents should be told. 'Concerns should not be raised with a parent if it is judged that this action will jeopardise the child's safety.' (Safeguarding Children in Whom Illness is Fabricated or Induced 2008).


STRATEGY DISCUSSION
4.25 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 Discussion involving all the key professionals. A meeting is advisable when considering this complex form of abuse.
4.26 The Strategy Meeting must be chaired by, at a minimum level, the first line manager or child protection adviser. If operational managers chair the discussion a child protection adviser or safeguarding manager should be informed and consulted.
4.27

This meeting requires the involvement of key senior professionals responsible for the child's welfare. At a minimum this must include Children's Social Care, CAIU and the paediatric consultant responsible for the child's health. Additionally the following should be invited as appropriate:

  • A senior ward nurse if the child is an in-patient
  • A medical professional with relevant expertise
  • GP, health visitor
  • Staff from education settings
  • Local authority's legal adviser
4.28

When it is decided there are grounds to initiate a Section 47 Enquiry decisions should be made about how the enquiry, as part of the Core Assessment, will be carried out. In addition to the decisions usually taken at a Strategy Discussion (see Section 5, Strategy Discussion, of the Section 47 Enquiries Procedure) additional factors to address are:

  • Whether the child requires constant professional observation, and is 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
  • Nature and timing of any police investigations, including analysis of samples and police led and co-ordinated covert surveillance
  • Need for extreme care over confidentiality, including careful security regarding supplementary records
  • Need for expert consultation
  • Any particular factors, such as the child and family's race, ethnicity, language and special needs which should be taken into account
  • Needs of siblings and other children with whom the alleged abuser has contact
  • Needs of parents or carers
  • Obtaining legal advice over evaluation of the available information (where legal adviser not present at meeting)
4.29 Investigating this specific circumstance is complex and disturbing for practitioners and 1 worker should not undertake the enquiry in isolation. The strategy discussion should recognise the need to ensure multi-agency co-ordinated working and good supervision.
4.30 If at any point there is medical evidence that the child's symptoms are being fabricated or induced, action may be required to ensure her/his life is not put at risk .
4.31 'It may be necessary to have more than 1 strategy meeting. This is likely where the child's circumstances are complex and a number of discussions are required to consider whether and, if relevant, when to initiate Section 47 enquiries.See Safeguarding Children in Whom Illness is Fabricated or Induced guidance.


THE ENQUIRY
4.32 Staff must be prepared for the carer to present as very plausible and well informed as to the nature of the child's medical problems and keep a focus on the impact of the carer's behaviour on the child when assessing levels of risk.
4.33 Children under the age of 5, especially pre-verbal children and children with an existing bone fide illness, disability and/or communication difficulties are at greatest risk because of their inherent vulnerability.
4.34 Early confrontation with the suspected abuser should be avoided until all information is available and thoroughly documented and provisions made for the protection of the children. This action should be planned with CAIU.
4.35 Before placing children with members of either extended family, thorough assessment of them must have taken place. FII may (or may not) be a feature of the family behaviour in previous generations. Any alternative carer should demonstrate an ability to believe that the suspected abuser may have posed a risk to the child.
4.36 A psychiatrist should be involved at the point at which there is moderate to high suspicion that a parent has been inducing symptoms or a court has made a finding of fact that such behaviour has occurred.


5. CRIMINAL INVESTIGATION (REVISED AUGUST 2011)

5.1 The police have a key role in assisting health and children's social care staff to understand the reasons for the child's signs and symptoms of illness. Whereas the police investigations may produce conclusive evidence of maltreatment, they may also confirm that the carer is not responsible for causing the child's condition. In this later situation, the police may be involved in investigating who is responsible or, if there is not evidence of a crime being committed healthcare staff can continue looking for a medical problem which arises from an intrinsic illness within the child rather than from externally induced or invented causes.
5.2 The nature and timing of any criminal investigations will depend on the medical evidence. Whether or not police investigations reveal grounds for instigating criminal proceedings, any evidence gathered by the police should be available to other relevant professionals to inform discussions about the child's welfare.
5.3 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. This would normally rule out, for example, the suspect being confronted with the evidence by a paediatrician or any other personnel from the statutory agencies, except for the police, which is the lead investigative agency.
5.4

Many of the children who have had illness fabricated or induced will be too young to be interviewed as part of any criminal investigation. If a decision is made to undertake an interview the guidance set out in Achieving Best Evidence in Criminal Proceedings: Guidance on Interviewing Victims and Witnesses and Guidance on Using Special Measures (2011) should be followed.

5.5

Police officers are able to obtain good practice advice on the use of appropriate investigative methods, including Surveillance, in cases of suspected fabricated or induced illness may seek advice from the Specialist Operations Centre, Covert Advice Team, Telephone 0845 000 5463, soc@npia.pnn.police.uk.

For further information see Safeguarding Children in Whom Illness is Fabricated or Induced: Supplementary Guidance to Working Together To Safeguard Children (Department of Health).


OUTCOME OF ENQUIRIES
5.6 As with all Section 47 enquiries, the outcome may be that concerns are not substantiated e.g. tests may identify a medical condition, which explains the signs and symptoms.
5.7 It may be that no protective action is required, but the family should be provided with the opportunity to discuss what further help it may require.
5.8 Concerns may be substantiated, but an assessment made that the child is not judged to be at continuing risk of harm.
5.9 Where concerns are substantiated and the child judged to be suffering or at risk of suffering significant harm, a conference must be convened. All evidence should be thoroughly documented by this stage and the protection plan for the child already in place.


INITIAL CHILD PROTECTION CONFERENCE
5.10 The conference should be held within 15 working days from the last strategy discussion.
5.11

Attendance at this conference should be as for other Initial Child Protection Conferences, with the additional experts invited as appropriate:

  • Professional with expertise in working with children in whom illness is fabricated or induced and their families
  • Paediatrician with expertise in the branch of paediatric medicine concerned, able to present the medical findings
5.12 The Royal College of Paediatricians and Child Health 2002 Fabricated or Induced Illness by Carers states 'that it is absolutely essential that the consultant paediatrician and GP attend ...and provide a chronology and a full report.'
5.13 Subsequent management of the case is the same as described in Child Protection Conferences Procedure and Planning & Implementation Procedure.

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