Fabricated or induced illness is the term used to describe parental behaviour previously labelled Munchausen’s Syndrome by Proxy. Fabricated or induced illness is a complex issue and individual suspected cases typically require a lot of consideration and discussion before they are to be regarded in child protection terms.
The characteristics of fabricated or induced illness are a lack of the usual corroboration of findings with symptoms or signs, or – in circumstances of proven organic illness – lack of the usual response to proven effective treatments.
There are three main ways of fabricating or inducing illness in a child. More than one may be evident in individual cases:
- Fabrication of signs and symptoms, including fabrication of past medical history
- Fabrication of signs and symptoms and falsification of hospital charts and records, and specimens of bodily fluids. This may also include falsification of letters and documents
- Induction of illness by a variety of means
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; or new symptoms are reported on resolution of previous ones;
- Reported symptoms and found signs are not seen to begin in the absence of the carer;
- Over time the child is repeatedly presented with a range of signs and symptoms;
- The child’s normal, daily life activities are being curtailed, e.g. school attendance, beyond that which might be expected for any medical disorder from which the child is known to suffer.
- Physical or laboratory findings are highly unusual, discrepant with history, or physically or clinically impossible
There may be a number of explanations for these circumstances. An in depth assessment of the child’s development and developmental history, medical evaluation and an assessment of the child and family will be required to make sense of the underlying reasons for the signs and symptoms. Parents should be kept informed of findings from the assessments, but at no time should concerns about reasons for child’s signs and symptoms be shared with the parents if this information would jeopardise the child’s safety.
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.
However concerns may be raised by professionals other than medical clinicians, such as nurses, teachers or social workers who are working with the child e.g. in a school setting the staff may not observe any fits in a child who is described by a parent to be having frequent fits during the day whilst in their care.
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.
When a possible explanation for the symptoms suffered by a child 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.
Parents should not initially be informed of a referral to Children’s Social Care in these circumstances. Decisions about what the parents will be told, by whom and when must be made in agreement with the agencies involved following a Strategy Discussion/Meeting.
The Strategy Discussion/Meeting 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.
- 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.
- GP, Health Visitor, staff from education settings as appropriate.
The investigative team must ensure that all involved professionals are made aware of the importance of confidentiality in keeping the child safe.
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.
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. Good practice guidance for police officers in the use of covert surveillance is available from the National Crime Faculty. Any such technical devices supplied and used by the police to gather evidence will require the authority of an Assistant Chief Constable.
Ref:
DCSF Safeguarding Children in whom Illness is Fabricated or Induced
Working Together 2010 Chapter 6 Para 6.6 – 6.9
GOOD PRACTICE GUIDANCE:-
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 or altering records charts
- 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.
- Welcoming medical tests of the child even when they are painful and distressing,
- Appears to be medically knowledgeable and /or fascinated with medical details.
- Enjoys the hospital environment, relates well to hospital staff and expresses interest in details of other people’s problems.
- Highly attentive and is reluctant to leave the child but, paradoxically, is less concerned about the child’s illness than the professionals caring for the child
- Devalues staff and demands further investigation, more procedures, second opinions and transfers to other more sophisticated facilities
- Has symptoms similar to child’s own medical problems or an illness history that itself is puzzling and unusual
- Is emotionally distant with spouse; the spouse often fails to visit the child and has little contact with physicians even when the child is hospitalised with serious illness
- Reports dramatic events, such as house fires, burglaries, car accidents affecting family while the child is undergoing treatment
