Procedure for Assessing and Responding to Fabrication and Induction of Illness in Children

The aim of this procedure is to support effective recognition and response when there are concerns that a child may be the subject of fabrication or induction of illness. It should be used in conjunction with relevant national guidance.

 

 

Introduction

Fabricated or Induced Illness by parents or carers (FII) can cause significant harm to children.  FII involves a well child being presented by a parent/carer as ill, or a disabled or ill child being presented with more significant problems than he or she has in reality.  This may result in extensive, unnecessary medical investigations being carried out in order to establish the underlying causes for the reported signs and symptoms.  The child may also have treatments prescribed or investigations, procedures or operations which are unnecessary.  These interventions 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 from harm or even death.

There are particular challenges for all professionals in terms of recognising and responding to possible FII. This procedure aims to support professionals from all agencies to recognise and respond in order to effectively safeguard the child.

 

Definition of FII

FII is a spectrum of disorders rather than a single entity. At one end of the spectrum less extreme behaviours may include a genuine belief that the child is ill or an exaggeration of existing symptoms. At the other end of the spectrum the behaviour of carers includes them deliberately inducing symptoms in the child.  For the purpose of this Procedure the behaviours can be broadly divided into the following areas, whilst recognising they are not mutually exclusive:

  • Exaggeration of existing symptoms to an extent which leads to potential harm to the child or significantly impacts on their day to day life.  
  • Fabrication of signs and symptoms.  
  • Falsification of hospital charts and records, and specimens of bodily fluids. 
  • Induction of illness by a variety of means.

 

Examples of behaviours associated with FII

  • Exaggerating symptoms, which may cause professionals to undertake investigations and treatments. 
  • Claiming the child has symptoms which are unverifiable unless observed directly, such as observing signs of pain, frequency of passing urine, vomiting or fits.
  • Fabrication of past medical history.
  • Falsification of letters and documents.
  • Providing specimens reported to be from the child which have been tampered with or other substances added or are from another person.
  • Interfering with treatments by overdosing, not administering them or interfering with medical equipment such as infusion lines.
  • Obtaining specialist treatments or equipment for children who do not require them.
  • Alleging psychological, emotional or behavioural disorders.
  • Deliberately inducing symptoms in children by administering medication or other substances or by means of intentional suffocation

FII can cause death, disability and physical illness. It can also lead to emotional difficulties for the child and confusion over their own health status.  Professionals must remain focused on the impact of FII on the child’s health and development, this is crucial to ensure an appropriate safeguarding response.

 

Recognition and Barriers to Recognition

Parents / Carers exhibit a range of behaviours when they believe that their child is ill.  A key task for professionals is to distinguish between the over anxious parent / carer and those who exhibit excessive health seeking behaviour.

 In addition, recognising FII can be especially difficult because often the reported signs and symptoms cannot be confirmed (when they are being exaggerated or imagined) or they may be inconsistent (when they are induced or fabricated).

The Table 1 identifies some of the ‘warning signs’ which should alert professionals to the possibility of FII (numbers 1-9) and some of the potential barriers to recognition (numbers 10-12).  The order of numbering in the table does not indicate the relative importance of each indicator.  Professionals should keep in mind the limits of the table; it is intended to give an indication of whether fabricated or induced illness is a possibility.  (Please note this is not an exhaustive list).

‘Symptoms’ are subjective experiences reported by the parent / carer or the patient.  ‘Signs’ are observable events reported by the carer or observed or elicited by professionals.

 

Table 1:

Number  Possible Warning Signs
 1.

Reported signs and symptoms found on examination are not explained by any medical condition from which the child may be suffering.  Here the health professional is attempting to put all the information together to make a diagnosis but the signs and symptoms do not correlate with any recognised disease or where there is a disease known to be present.

 2.

Physical examination and results of medical investigations do not explain reported symptoms and signs.  Physical examination and appropriate investigations do not confirm the reported clinical story e.g. a child with frequent convulsions every day has no abnormalities on a 24-hour video-telemetry (continuous video and EEG recording) even during a so-called ‘convulsion’.

 3.

There is an inexplicably poor response to prescribed medication and other treatment.  The practitioner should be alerted when treatment for the agreed condition does not produce the expected effect.  This can result in escalating medications with no apparent response, using multiple medications to control a routine problem and multiple changes in medication due to either poor response or frequent reports of side effects. Disguised compliance with medication regimes can occur with prescriptions not being requested/collected despite history to the contrary.

 4.

New symptoms are reported on resolution of previous ones.  New symptoms often bear no likely relationship to the previous set of symptoms.  For example, in a child where the focus has been on diarrhoea and vomiting, when appropriate assessments fail to confirm this, the story changes to one of convulsions.  Sometimes this is manifest by the parents transferring consultation behaviour to another child in the family.

 5.

Reported symptoms and found signs are not seen to begin in the absence of the parent / carer, i.e. a parent/carer is the only witness of the signs and symptoms.  For example, reported symptoms and signs are not observed at school or during admission to hospital.  This should particularly raise anxiety of FII where the severity and/or frequency of symptoms reported are such that the lack of independent observation is remarkable.  Caution should be exercised when accepting statements from non-medically qualified people that symptoms have been observed.  For example an education professional may describe an episode as ‘fits’ because they were told by the child’s parent/carer that was the appropriate description of the behaviour they were seeing.

 6.

The child’s normal, daily life activities are being curtailed beyond that which might be expected for any medical disorder from which the child is known to suffer.  The parent/carer limits the child’s activities to an unreasonable degree and often without knowledge of health professionals or against their advice.  For example, confining a child to a wheelchair when there is no reason for this, insisting on restrictions of physical activity when not necessary, adherence to extremely strict diets when there is no medical reason for this, restricting child’s school attendance.  In addition to the above there may be evidence of financial gain from the reported illness (e.g. receipt of benefits such as Disability Living Allowance).  It is essential professionals remain focused on the impact in the child and respond accordingly.

 7.

Over time the child is repeatedly presented to different health care settings with a range of signs and symptoms.  At its most extreme this has been referred to as ‘doctor shopping’.  The extent and extraordinary nature of the additional consultations is greater than what one would expect concerned parent would explore.  Often consultations about the same or different problems are concealed in different health facilities.  Thus the child might be being investigated in one hospital with one set of problems and the parent will initiate assessments elsewhere for a completely different set of problems (or even the same) without informing, or deliberately misleading these various health professionals about the other consultations.

 8.

History of unexplained illnesses or deaths or multiple surgeries in parent/carer or siblings of the family.  The emphasis here is on the unexplained.  Illness and deaths in parents or siblings can frequently be a clue to further investigations and hence a diagnosis in naturally occurring illness. In FII abuse, perpetrators frequently have had multiple unexplained medical problems themselves which may include obstetric history, ranging from frequent consultations with the general practitioner through to the extreme of Somatising and Somatoform disorder (previously referred to as Munchausen’s Syndrome) where there are multiple presentations with fabricated or induced illness resulting in multiple unnecessary interventions. Self-harm, often multiple, and eating disorders are further common features in perpetrators.  Additionally, other children either concurrently or sequentially might have been subject to FII abuse and their medical history should also be examined.

 9.

Incongruity between the seriousness of the story and the actions of the parents.  Given a concerning story, parents/carers by and large will cooperate with medical efforts to resolve the problem.  They will attend outpatients, attend for investigations and bring the child for review urgently when requested.  Perpetrators of FII abuse, apparently paradoxically, can be extremely creative at avoiding contacts which would resolve the problem.  There is incongruity between their expressed concerns and the actions they take.  They repeatedly fail to attend for crucial investigations.  They go to hospitals that do not have the background information.  They repeatedly produce the flimsiest of excuses for failing to attend for crucial assessments (e.g. somebody else’s birthday, thought the hospital was closed, went to outpatients on the wrong day etc.).  This has been described as the perpetrator ‘piloting care’.

  Possible Barriers to Recognition
 10.

Exaggerated catastrophes or fabricated bereavements and other extended family problems are reported.  This is an extension of category 8.  On exploring reported illnesses or deaths in other family members (often very dramatic stories) no evidence is found to confirm these stories.  They are largely or wholly fictitious and may be used to distract away from abusive behaviour.

 11.

Erroneous or misleading information provided by parent.  These perpetrators are adept at spinning a web of misinformation which perpetuates and amplifies the illness story, increases access to interventions in the widest sense (more treatment, more investigations, more restrictions on the child or help, etc).  An extreme example of this is that the parent may tell people that the child is going to die when in fact no one in the medical profession has ever suggested this.

 12.

Perpetrators behaviour/manipulation of professionals: Perpetrators of FII will often try to develop over familiar relationships with professionals.  However, when challenged they may threaten complaint or litigation. This can result in professionals’ further pursuing investigations or treatment for the child. Professionals may be inhibited by the perceived threat and stall in their response to their suspicions.

Roles and responsibilities in recognising and responding to possible signs of FII

Professionals not from a Health setting including Education/Early years


Professionals may have concerns because parents are describing a child’s illness or health needs which are not witnessed by the professionals. In such situations professionals should consider the other warning signs in Table 1. If they remain concerned or have heightened concerns they should discuss the child with the Safeguarding Lead within their organisation.  If concerns remain, then the child should be discussed with the School Nurse or Health Visitor. Consent from the parents to do this should be sought on the grounds that that this is usual practice where a child has an illness which is impacting on their health or development. At this stage the concern about possible FII should not be disclosed to the parent/carer. If parents refuse consent for a discussion with the School Nurse or Health Visitor then this should be discussed with the Safeguarding Lead to consider whether refusal increases the level of concern. When a parent/carer reports restrictions/limitations for normal school activities it is important this is verified with the reported source of the advice.

Professionals should keep careful and secure records of absences and reasons given by parents for absences so that these can be corroborated. The professionals should listen to the child and document what they are saying.

All discussions, including those with parents/carers, must be documented and kept in a secure record.

Professionals from a Health setting


All health professionals must seek advice and support on concerns about FII from the safeguarding team within their organisation throughout the process.

School Nurses/Health Visitors


If practitioners have concerns that a parent / carer is impairing a child’s health or development by fabricated or induced illness they should explore the presenting information with the parent / carer. The practitioner should meet with parents/carers or discuss the child’s illness, parental concerns and ascertain which other health professionals are involved.

After discussion it may be that some parents may have misunderstood information, are anxious about their child or have concerns that their child’s needs are not being met. This may lead to health seeking behaviours or exaggeration of symptoms. The practitioner should seek parents/carers consent to discuss the child with those professionals involved including the consultant. This may allow the case to be managed through early intervention i.e. Common Assessment Framework (CAF).

Where the practitioner has on-going concerns about FII or parents decline CAF and the child is already known to a Paediatrician/Consultant then information should be sought from that Paediatrician/Consultant regarding the medical illness/diagnosis and advice or an appropriate care plan should be provided, at this point consent is not required. Concerns about possible FII must be shared with the Paediatrician/Consultant. If the child does not have a Paediatrician/Consultant the case should be discussed with the GP.

If after speaking to medical professional the practitioner is still concerned about FII then a discussion with the Trust Safeguarding Team must take place.

Midwives


Midwives may be alerted to possible FII by mothers own health seeking behaviour, history of unusual illness; unusual complications of pregnancy; unexplained deaths; history of family members with untreatable disease. If concerns are raised then previous pregnancy notes should be obtained and the Midwife must discuss concerns with the Trust Safeguarding Team.

General Practitioners (GPs)


GPs are also well placed to recognise early symptoms and signs of FII in a child. This may evoke a conflict of loyalty if the parent or carer is also the GPs patient. However if there are concerns about the welfare of a child either with their health or development and FII is a consideration the child’s needs are paramount and the GP has a duty to share that information.

If the child is not known to a Consultant they should be referred to a Paediatric or CAMHS Consultant (dependent upon the presenting issues) with expertise in symptoms and signs that are being presented.

The GP should make it clear about their concerns re FII in the referral letter. Timeliness of the referral will depend on presentation. For example  if there are signs or symptoms of induced illness such as  suffocation or poisoning then same day referral is needed with a concurrent urgent referral to Children’s Social Care (CSC).

If concerns are more regarding fabrication or exaggeration of symptoms, then an urgent referral to a Paediatric Consultant or CAMHS Consultant should be made with a request that the child is seen within 2 weeks.

GPs should also discuss concerns with the Named or Designated Health Professionals for Safeguarding Children in their locality.

Child and Adolescent Mental Health Workers


Staff within CAMHS may also be alerted to concerns about FII in the process of evaluating children for mental health and behavioural difficulties.

Initial concerns about a child’s presentation should be shared with the Paediatrician or GP that referred the patient or other health professionals. If concerns continue then advice from the Trust Safeguarding Children Team should be sought. If concerns continue a meeting with all health staff involved with the child’s care should be held to:

  • discuss the concerns
  • consider other reasons for child and parents behaviour
  • discuss possibility of what early direct intervention, if any, should take place

If after the meeting or discussion concerns persist about FII then a referral to Children’s Social Care should be made. Notes of meetings and discussions should be made and action plans should be documented. Follow up meetings should be arranged if FII is not an on-going concern at this time, the child and their response to treatment should continue to be closely monitored.  If no concerns about the welfare of the child are present then feedback to parents regarding the plan for intervention should take place.

Adult Mental Health Services


Adult mental health staff may become concerned about the welfare of a child in relation to FII. These concerns may be increased if patient is a parent/carer is known to fabricate or induce illness themselves, although this can exist within the parent’s presentation and not the child’s. If an adult mental health worker has any concerns of this nature about a child’s welfare they should be discussed with the Trust Safeguarding Children Team. It is a duty to protect children from harm and therefore confidentiality may need to be broken without consent in order to protect the child.

Allied Health Professionals


If staff have concerns about FII in children they are providing therapy and care for they should discuss with the Safeguarding Children Team within their Trust and GP or the practitioner who referred to their service. They should also discuss with their clinical manager.

Consultant Paediatricians / CAMHS Consultants    


All cases of suspected FII should be led by a Consultant Paediatrician or a CAMHS Consultant (dependent upon concerns). This Consultant should take a lead role in all decisions about the child’s healthcare However, certain tasks can be delegated in the Consultant’s absence. In order to avoid unnecessary investigations and harm by further consultation, testing or treatment a management plan for when the child presents to hospital or primary care should be decided in the early stages of the investigation. This is usually decided at the strategy meeting. This management plan should be devised by the lead Consultant with support from the Named Doctor for Safeguarding.

During the thorough medical evaluation the lead Consultant should obtain information from the GP and other Consultants who have been involved in the child’s care. The Consultant should discuss any cases with the Safeguarding Children Team and Named Doctor for Safeguarding.

It is important that all discussions with parent / carers and other professionals are carefully recorded in the patient’s notes, which should be kept securely.

The Lead Consultant, with guidance and assistance from the Named Doctor and Safeguarding Team, should collate a chronology of the child’s medical care. A standard chronology template should be used.  It is important that attendances at emergency departments in the local trust and neighbouring trusts are included in the chronology.

A chronology is a complex and time consuming task and adequate resources and time should be allocated. The preparation of the chronology should not delay a referral to Children’s Social Care (CSC) or any other interventions if this would put the child at risk of harm.

Other Consultant Specialists


If another consultant, other than Paediatricians or CAMHS Consultant, has concerns about FII in a child in their care they should refer to a suitable Paediatrician with expertise in the symptoms and signs being presented. They must also discuss with the Named Doctor for Safeguarding in the Trust. The case should also be discussed with safeguarding team. If there are immediate concerns for the child’s safety an immediate referral should be to CSC.

Information sharing, consent and confidentiality

In all cases the overriding consideration in making decisions about information sharing in cases of FII must be the child’s safety and wellbeing.

Where possible gain consent from the parents to discuss the child’s case with other professionals and obtain medical notes/information unless in doing so would put the child at increased risk. Parents should be advised that the information is needed to help manage the child’s illness; the possibility of FII should not be discussed at this stage. If the Parent refuses consent to share information this may further increase suspicions of FII. In this situation the case should always be discussed with the Safeguarding Lead in your organisation.

If a decision is made to share confidential information without consent, the professional should explain to the parent that they intend to share the information for the wellbeing of the child, unless consulting the Parent would put an unjustified delay in making enquires or potentially put the child at further risk of harm.

 It is important when obtaining and sharing information that consideration is given to what information is shared i.e. relevant and proportionate to the concern. For example only relevant health and social information about parents should be shared in order to protect the children. Further advice can be obtained from your organisations Safeguarding Lead and it may be necessary to consult with your organisations legal advisor.

Any decision on whether or not to share information must be clearly documented.

Record keeping

Records should use clear and straightforward language, should be concise and accurate not only in fact, but in differentiating between opinion, judgements and hypothesis.  It should be clearly recorded what is reported by the parents/carers and what has been directly observed by the practitioners. Where it is considered that illness may be fabricated or induced, the records relating to the child’s symptoms, illness, diagnosis and treatments should always include the name (and agency) or the person who gave or reported the information. This should be dated and signed legibly.

The recording and retention of information, including information about covert video surveillance should be made in accordance with the Data Protection Act 1998.

Chronologies

The purpose of a chronology is to help professionals get a clear picture of what is happening in a child’s life and to help them form a judgement on the nature and level of risk to the child. However, where there are concerns about FII children often have complex histories of reported illness and subsequent medical care, sometimes going back many years. Chronologies should not be the complete replication of a child’s record in table format. If a chronology is to be helpful it is important that it is well constructed. For those agencies that do not have a chronology template a recommended format is included.

Good chronologies

  • Pay particular attention to the specific concerns that have been raised about the child
  • Clearly state what has been said, by whom and to whom. 
  • What has been reported or observed and whether this was observed by professionals
  • Record where information is from e.g. ‘History taken from Mother’
  • Are written in a way that can be understood by colleagues from other non-medical professional backgrounds.  
  • ummarise large amounts of information where this appropriate. E.g. John was on the ward between 1 June and 4 June there are no recorded incidents of diarrhoea. There is a stool chart which shows …’
  • The comments section of the  chronology can be used to highlight where there are particular  ‘warning signs’ as identified in Table 1 

FII_Chronology_Format.doc 

Timescales


Chronologies should go back far enough to include relevant information but not so far back to as make the chronology so large it is unwieldy. How far this is will be a judgement to be made for each individual case. Remember the purpose is to help make a judgement on risk to the child.

In some instances a child may be said to have had a condition for many years. In this case whilst it may not be necessary to go back over all information from this period it is important where possible to confirm or refute specific information e.g. where a child is said to have a been given a specific diagnosis evidence of that diagnosis should be sought, where evidence is not found the chronology should show that evidence has not been located.

Making a referral to Children’s Social Care (CSC)

At the point of referral to CSC careful consideration should be given as to whether or not the Parents should be made aware of the concerns about FII and if consent is required. Advice must be sought from the Safeguarding Lead within your organisation.  Parents should not be informed of the referral if it is considered that by doing so this may lead to increased risk to the Child.

There will be situations where an urgent referral to CSC is required, for example induction of illness, poisoning or suffocation.  If a Professional is concerned about the immediate safety of a child then an urgent referral must be made to CSC, the referrer must be very clear regarding the significance and immediacy of the concerns

All referrals to CSC must identify the exact nature of the concerns and explicitly state with FII is suspected.

Response by Children’s Social Care and Multi Agency Strategy Meeting

CSC will decide and record within 1 working day what action is required in response to the referral. Lead responsibility for action taken to safeguard and promote the children’s welfare lies with CSC.  The police must be involved throughout the safeguarding investigation.

In all cases where it is believed the information indicates suspected FII there must be a Multiagency Strategy Meeting which considers all children within the family.

Wherever possible the Multiagency Strategy meeting should be chaired by an appropriate experienced Manager. The Strategy must be a ‘face to face’ meeting and it is essential that the appropriate professionals attend. However, non-attendance of one or two key professionals should not delay the meeting if it is indicated the child may be at risk of significant harm.  Any professionals who are unable to attend the meeting must send a brief summary of their involvement and whether they have any concerns re FII. Key professionals will include:

  • Senior Social Work Manager
  • Named/Designated Doctor
  • Specialist/Named Nurse Safeguarding from relevant organisation
  • Lead Paediatric Consultant/CAMHS Consultant (as applicable)
  • Police Officer from Child Vulnerability Unit
  • The referrer
  • Other allied health professionals involved in child’s care
  • Other Consultants involved in child’s care.
  • General Practitioner
  • School or early years setting representative
  • Legal advisor to local authority

During the strategy meeting specific consideration must be given to what information is to be shared with the parents and when. In addition decisions about involving the child in discussions must also take place and consideration must be given to any relevant therapeutic work. 

The Paediatric Consultant or relevant senior clinician, for example CAMHS Consultant, is the lead health professional pertaining to the child’s health    care. If the child is only known to a GP but not a paediatrician, it is important that the GP refers to a Paediatrician or CAMHS Consultant, if not already done so, who will then take on this responsibility. It is critical that all agencies work together in making and taking forward decisions about the future action recognising individual roles.

Police response

During the process of information sharing and assessment it may become apparent that there are indicators that a crime has been committed.  This should be taken into due consideration during all stages of assessment and interventions and the police will provide direction regarding professional intervention in order to avoid disrupting any possible criminal investigation/process.

Emergency action

Circumstances of the child can change at any point during the investigation, for example if parents or carers become aware of concerns they may escalate the abuse. Decisions about need for immediate action to safeguard the child/ren should be kept under constant review and appropriate legal advice sought where required.

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