2.2.26 Fabricated or Induced Illness

Caption: main heading

2.2.26 Fabricated or Induced Illness

Introduction
Definition
Recognition of Emerging Concerns
Involvement of Children and Young People’s Mental Health Services (CYPMHS) and Adult Mental Health Services
Response
Medical Evaluation
Referral to Children Social Work Services (Kent)/Children’s Social Care Services (Medway) and/or Police Public Protection Unit
Initial Consideration of Referral
Child and Family Assessment
Strategy Discussion
The Enquiry and Child and Family Assessment
Police Investigation
Outcome of Enquiries
Initial Child Protection Conference
Covert Video Surveillance

1. Introduction

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.

For further information see HM Government March 2008 document ‘Safeguarding Children in Whom Illness is Fabricated’ and The Royal College of Paediatrics and Child Health ‘Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children Guidance’.

2. Definition

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 duplicitously attributed by the adult to another cause.

The DfE describes 3 main (and 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 documents / specimens e.g. hospital charts, records, letters, specimens of bodily fluids;
Induction of illness by a variety of means.

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.

The child may additionally suffer emotional harm through limitations placed on her/his development and social interaction e.g. overprotection, limitation of exploration and learning, prevention from participation in normal social interaction.

3. Recognition of Emerging Concerns

Concerns that a child is suffering Significant Harm as a result of having illness fabricated or induced by their carer may be raised by any professional, or more rarely, by family members or members of the public. 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 / correlated with any disease;
Physical examination and results of investigations do not explain reported symptoms and signs;
There is an inexplicably poor response to prescribed medication and treatment;
New symptoms are reported on resolution of previous ones;
Reported symptoms and found signs are not observed to commence, in the absence of the carer;
Over time the child repeatedly presents with a range of symptoms to different professionals in a variety of settings;
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.

There may be a number of explanations for these circumstances and each requires careful consideration and review. A full developmental history and an appropriate developmental assessment should be carried out.

Consultation with peers, named or designated professionals or colleagues in other agencies, will be an important part of the process of making sense of the underlying reason for these signs and symptoms.

Concerns may be raised by professionals e.g. nurses, teachers or social workers working with the child noting discrepancies between reported and observed medical conditions, such as the incidence of fits. GPs or mental health professionals, may identify a child being ‘drawn into’ the parent’s illness.

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

Early commencement of 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 unexplained death, illness or multiple surgery in parents and/or siblings of the family;
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.

Generally, some indicators of abuse mentioned in Recognition of Significant Harm Procedure of this manual (often in the context of wider parenting difficulties), may (or may not) be associated with this form of abuse, such as:

Faltering growth;
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;
Child’s carers history of abuse and/or psychiatric illness.

4. Involvement of Children and Young People’s Mental Health Services (CYPMHS) and Adult Mental Health Services

Adult Mental Health Services may be involved in the assessment, planning management or treatment of a carer and practitioners may recognise a risk to children. In these circumstances liaison should take place between the adult psychiatrist and those responsible for the child’s health or assessment.

An adult psychiatrist should be involved at the point at which there is concern / suspicion that a parent has been inducing symptoms or a court has made a finding of fact that such behaviour has occurred.

CYPMHS may identify fabricated or induced emotional or behavioural symptoms in children with whom they work and must refer to Children Social Work Services (Kent)/Children’s Social Care Services (Medway). They may also be asked for urgent advice by other practitioners working with families where FII is a possibility.

5. Response

All professionals should routinely keep records relating to the child. Whenever unusual features are noted, as described above, detailed records must be maintained of events, reported illnesses, parent / carer explanations of illness and absences from school and child’s symptoms when carer present and in her/his absence.

When a child is undergoing significant ongoing medical treatment, liaison must always take place with the GP to assist in the confirmation of diagnosis and subsequent treatment.

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.

If any professional considers her/his concerns are not responded to appropriately, the concerns should be discussed with the designated doctor or nurse and/or the professional’s own designated or named professional.

If any concerns relate to a member of staff, they should be discussed with the designated or named professional and must be reported to the LADO (see also Allegations Against Persons Who Work with Children Procedure of this manual).

6. Medical Evaluation

Signs and symptoms require careful medical evaluation for a range of possible diagnoses. All tests and results should be fully and accurately recorded. It is important the child’s record is not altered in any way, e.g. through tampering with results. The name of the person reporting observations should be legibly recorded and dated.

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 (see Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children Guidance).

Ensuring medical evaluation takes into account what children are saying is what is important. In the case of suspected fabricated induced illness it is equally important, but can be complicated by some parents reluctance to leave their child. This reluctance to allow their child to be talked to by a clinician has to be balanced against the need to see the child on their own in order to ensure the child’s welfare.

Every effort should be made to see the child without the parent being present. Some children may be competent to make their own decisions on this matter.

A chronology of health involvement, using the agreed template including access to all health facilities, should be prepared so as to provide comprehensive information within 6 weeks of the suspicion arising or the first strategy discussion.

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.

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 (see Flowcharts of Key Processes - medical evaluation flowchart).

7. Referral to Children Social Work Services (Kent)/Children’s Social Care Services (Medway) and/or Police Public Protection Unit

Following consultation with the designated doctor / consultant a referral should be made to Children Social Work Services (Kent)/Children’s Social Care Services (Medway). A Strategy Discussion should be held if a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer. The referral may follow a medical evaluation or be the result of concern by professionals or members of the public. The Strategy Discussion will decide when and how the parents are informed.

The Royal College of Paediatrics and Child Health 2009 ‘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.’

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.

Whilst professionals should in general, discuss any concerns with the family and, where possible, seek agreement to making referrals to Children Social Work Services (Kent)/Children’s Social Care Services (Medway), this should only be done where such discussion and agreement-seeking will not place a child at increased risk of Significant Harm.

The Police Public Protection Unit must be informed of any referral where FII is suspected as this may also involve the commission of a crime.

If intervention is required immediately to avoid immediate harm to the child e.g. observed that medication / feeds tampered with in hospital, medical staff should call the Police via ‘999’ service.

8. Initial Consideration of Referral

From the point of the referral, all professionals involved with the child should work together as follows:

Lead responsibility for action to safeguard and promote the child’s welfare lies with Children Social Work Services (Kent)/Children’s Social Care Services (Medway);
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 health care.

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.

As with all other referrals, Children Social Work Services (Kent)/Children’s Social Care Services (Medway) 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 Police Public Protection Unit. This decision making process must agree the action to be taken, by whom and within what timeframe.

All decisions about what information is shared with parents should be agreed between the Police Public Protection Unit, Children Social Work Services (Kent)/Children’s Social Care Services (Medway), the consultant paediatrician and the 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 referral.

If emergency action is required e.g. if 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 Social Work Services (Kent)/Children’s Social Care Services (Medway), Police Public Protection Unit, health and other agencies as appropriate. However this should not delay the use of immediate protection if required.

9. Child and Family Assessment

A Child and Family Assessment should usually be completed, as with all referrals (see Child and Family Assessment Procedure) following the guidance set out in the local Assessment Framework

This should be undertaken in collaboration with the consultant paediatrician responsible for the child’s health care.

The Royal College of Paediatricians and Child Health 2009 ‘Fabricated or Induced Illness by Carers’ (p.23) suggests that second opinions should usually only be requested in specific issues

Outcomes of the Child and Family Assessment are as described in Child and Family Assessment Procedure. The decision should be made in consultation with the paediatric consultant and Police Public Protection Unit, with agreement reached about what parent/s 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’ paragraph 4.22).

10. Strategy Discussion

If there is reasonable cause to suspect the child is suffering, or likely to suffer Significant Harm, Children Social Work Services (Kent)/Children’s Social Care Services (Medway) should convene and chair a Strategy Discussion involving all the key professionals. Unless there is an emergency this should take the form of a Strategy Meeting chaired by a Children Social Work Services (Kent)/Children’s Social Care Services (Medway) Manager.

A strategy meeting must be chaired by, at a minimum level, the Team Leader (Kent) / Operational Safeguarding Lead (Medway). If other operational managers chair the discussion a child protection adviser / manager should be informed and consulted.

This meeting requires involvement of key senior professionals responsible for the child’s welfare. At a minimum this must include Local Authority Children’s Services, Police Public Protection Unit 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;
Designated Nurse/Named Nurse.

If it is decided there are grounds to initiate a Section 47 Enquiry, decisions should be made about how, as part of the Child and Family Assessment, it will be carried out. The decisions usually taken at a Strategy Discussion (see Strategy Discussion/Meetings Procedure) apply here and additional factors to address are:

What further information is required about the child and family and how should it 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 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 covert surveillance (Police led and co-ordinated);
The need for extreme care over confidentiality, including careful security regarding supplementary records;
The 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;
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 Video Surveillance;
How information will be shared with parents and at what stage;
Obtaining legal advice over evaluation of the available information (if legal adviser not present at meeting);
The timescales for any further Strategy Discussions, and if previous treating physicians should be invited to a meeting.

Investigating this specific circumstance is complex and disturbing for practitioners and one 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.

If at any point there is medical evidence the child’s symptoms are being fabricated or induced, action may be required to ensure her/his life is not put at risk.

There will usually be 1 or more further strategy meetings to evaluate information collected and agree next steps: ‘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.’ (‘Safeguarding Children in Whom Illness is Fabricated or Induced’ paragraph 4.32).

11. The Enquiry and Child and Family Assessment

During the enquiry practitioners should be aware that:

The carer may present as very plausible and well informed as to the nature of the child’s medical problems;
There is a need to keep a focus on the impact of the carer’s behaviour on the child when assessing levels of risk;
Children under 5, especially those who are pre-verbal or who have an existing bone fide illness, disability and/or communication difficulty are at greatest risk because of their inherent vulnerability.

Early confrontation with the suspected abuser should be avoided until all information is available, thoroughly documented and provisions made for protection of child. This action should be planned with the Police Public Protection Unit.

Before placing a child with members of either extended family, a thorough assessment of them should 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.

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.

12. Police Investigation

Any evidence gathered by Police must 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 Assessment, unless this would be likely to prejudice criminal proceedings.

In cases where a criminal offence is suspected It is important that suspects’ rights are protected by adherence to the Police and Criminal Evidence Act 1984, which would normally rule out any agency other than the Police confronting any suspect persons.

Covert video surveillance is a legitimate investigative tool, but its use should only be considered when a multi-agency Strategy Discussion has agreed there is no other available way of obtaining information to explain the child’s signs and symptoms. For further details see Section 15, Covert Video Surveillance

13. Outcome of Enquiries

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.

It may be that no protective action is required and the family should be provided with the opportunity to discuss further help it may require and consideration should be given to the use of a child and young person’s plan.

Concerns may be substantiated, but an assessment made that the child is not judged to be at continuing risk of harm. A decision not to proceed to a Child Protection Conference must be endorsed by the relevant manager within Childrens Services.

Where concerns are substantiated and the child judged to be suffering or likely to suffer Significant Harm, a conference must be convened unless the decision is taken to initiate legal proceedings to protect the child(ren), in which case a conference may not be required in addition to the safeguards put in place via the court. All evidence should be thoroughly documented by this stage and the protection plan for the child already in place.

14. Initial Child Protection Conference

The Initial Child Protection Conference should be held within15 working days from the last strategy discussion.

Attendance at this conference should be as for other initial conferences, with the additional experts invited as appropriate:

A professional with expertise in working with children in whom illness is fabricated or induced and their families;
A paediatrician with expertise in the branch of paediatric medicine concerned, able to present the medical findings.

Each agency should contribute a written report to the conference which sets out the nature of its involvement with the child and the family. This information should be precise and where possible validated at its source.

The child may have been seen by a number of professionals over a period of time: Children Social Work Services (Kent)/Children’s Social Care Services (Medway) have responsibility for ensuring that, as far as is possible, this chronology (with special emphasis on the child’s medical history) has been systematically brought together for the conference. Where the medical history is complex, this should be done in close collaboration with the paediatric consultant responsible for the child’s health care. The health history of any siblings should also be considered. The Conference Chair has responsibility for ensuring that additional or contradictory information is presented, discussed and recorded at the conference.

Careful consideration should be given to when agency reports will be shared with the child’s parents. This decision will be made by the Conference Chair, in consultation with the professional responsible for the each report.

If the family has recently moved, contact should be made and information obtained from the paediatric services in the area where the family previously lived.

The conference should decide whether the child is at continuing risk of Significant Harm, and therefore in need of a Child Protection Plan. If this is the case, an outline Child Protection Plan should be developed stating clearly what action will be taken to safeguard the child immediately after the conference, as well as in the longer term.

The conference should also consider what action if any is required to protect siblings in the family

Subsequent management of the case is the same as described in Child Protection (Section 47) Enquiries Procedure and Initial Child Protection Conferences Procedure

15. Covert Video Surveillance

The use of covert video surveillance (CVS) is governed by the Regulation of Investigatory Powers Act 2000.

After a decision has been made at a Strategy Discussion to use CVS in a case of suspected fabricated or induced illness, the surveillance should be undertaken by the Police. The operation 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 video tapes.

The decision will only be made if there is no alternative way of obtaining information to explain the child’s signs and symptoms and its use is justified on the medical information available.

The primary aim of the surveillance is to identify whether a child is having an illness induced; and the obtaining of criminal evidence is of secondary importance. The safety of the child is the overriding factor.

Police officers planning 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.

All personnel including nursing staff who will be involved in its use should have received specialist training.

Children Social Work Services (Kent)/Children’s Social Care Services (Medway) should have a contingency plan in place, which can be implemented immediately if covert video surveillance provides evidence of the child suffering Significant Harm.

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