FABRICATED or INDUCED ILLNESS by CARERS
These guidelines must be read in conjunction with the Derby and Derbyshire Safeguarding Children Procedures (Tri-x), Section 6 (Children in whom Illness is Fabricated or Induced)
Introduction
The terminology of this condition has been the subject of considerable debate. Fabricated or induced illness has been accepted in guidance from the Department of Health and the Royal College of Paediatrics and Child Health.
Professor Roy Meadows has outlined 4 features which are common to this condition, which may be better thought of as a behaviour:
i)Illness in a child which is fabricated or induced by a parent or someone in loco parentis
ii)A child is presented for medical assessment and care, usually persistently, often resulting in multiple medical procedures
iii)The perpetrator denies the aetiology of the child’s illness
iv)Acute signs and symptoms cease when the child is separated from the perpetrator
The incidence and prevalence depends on the inclusion criteria and methods of ascertainment of studies and there is wide variation between different regions of the country. Children giving rise to “concern” in the minds of paediatricians far outweigh those who are subject to a child protection conference.
It is also important to recognise that FII is not the only reason that parents may exaggerate or fabricate symptoms. Other reasons include
Over anxious parents
Limited cognitive ability in carers
Strong or unusual beliefs
Less than ideal treatment previously
Carers who are deluded
Unrecognised physical abuse
Failure to thrive / neglect
Custody / access disputes
Many of these situations are successfully managed within health.
There are 2 intertwined problems to be determined in addressing the issue in practice:
- Is the child suffering from fabricated or induced illness by the carer?
- Has the child suffered or is he/she likely to suffer significant harm in the future as a result?
This may be difficult to determine. It is not known what is mild or severe in the long-term effects on children, particularly in terms of emotional health, or what factors are protective in those children who come through relatively unscathed. “Emotional robustness” is probably an important factor.
We do not know the risk of escalation of the behaviour from “milder” to more “severe” forms.
Health Professionals who may recognise FII include
Obstetricians and midwives – harm may be caused by a pregnant mother to her unborn child
Neonatologists
Adult psychiatrists caring for mothers or mothers to be
Child psychiatrists may encounter fabrication of emotional or behavioural symptoms
Surgeons dealing with children – insertion of gastrostomies and fundoplication seem particularly common in FII
Paediatricians
Children’s nurses – hospital and community
Allied health professionals
Emergency department staff
General practitioners
Health visitors
The Process
1. Emerging concerns of FII
- Health practitioners who suspect the presentation of FII should consult their clinical manager.
- The concerns should be discussed with the child’s paediatrician, general practitioner or with the Named or Designated Doctor or Nurse in Child Protection.
- If any professional feels their concerns are not being taken seriously or responded to appropriately, the matter should be discussed with the named or designated doctor or nurse.
- If concerns relate to a member of staff (either in their work role or in their capacity as a parent), these should be discussed with the relevant named or designated professional, who should ensure the safety of the child. The procedures for allegations against staff must be followed.
- Health professionals should not normally discuss concerns with the parents at this stage – reasons for not doing so should be recorded
2. Medical evaluation (Variable time period).
- Normally, following appropriate assessment and investigation, the doctor would tell the carer that they do not have an explanation for the signs and symptoms. The carer’s response should be documented. The next steps, including further investigation should be set out, but at no point should concerns about the reason for the child’s signs or symptoms be shared with the carer if this would jeopardise the child’s safety.
- The child should be referred to a paediatrician if this has not already happened.
3. Persisting concerns of FII.
- If the child’s immediate safety is a concern, admit for close observation.
- For all children where concerns persist, the paediatrician should take a careful and complete, detailed history and clinical and developmental examination should be undertaken, together with a review of all other documentation or information from other sources, including that from primary care (including any prescribed drugs), the community, ED, other hospitals. For ALTE (apparent life threatening event) – ask about bleeding from the nose or mouth and look for petechial haemorrhages around the neck or on the face.
- Try to corroborate as much information as possible, from different family members, carers, witnesses – this may include other health professionals, education etc.
- A chronology of health information should be compiled. Information should also be collated regarding other family members where possible, and charted in parallel. Information sharing guidance should be followed when considering obtaining information from health records of other individuals. All tests and their results should be fully recorded, including those with negative results.
- Referral to Children’s Social Care
- If there are persistent concerns that signs or symptoms may have been fabricated or induced, a referral to Children’s Social Care under child protection should be made, usually by telephone, with written confirmation within 48 hours.
- In circumstances where the paediatrician is uncertain whether or not to refer a case, they should discuss the situation with the Safeguarding Children Manager / Child Protection Manager in Children’s Social Care.
- The parent should only be informed about the concerns if this would not place the child at increased risk of significant harm. Reasons for not informing the parent should be carefully documented.
Please consult Derby and Derbyshire Safeguarding Children Procedures, Section 6 (Children in whom Illness is Fabricated or Induced), available on the Intranet for details of the interagency process.
General Principles of Management
1Overall management of the child should be by the consultant, although some roles / tasks may be delegated to a junior doctor.
2Consultants must attend and take a key role in any multi agency strategy discussion.
3Consultation with peers or colleagues in other agencies may be an important part of the process of making sense of the underlying reason for the signs and symptoms. It may be helpful to invite a consultant colleague to review the notes.
4It is important at all stages to consider seeking advice from or having present a medical professional with expertise in the appropriate branch of medicine, to enable the medical information to be presented from a sound evidence base.
5 An expert may be involved, either at the strategy review stage or later. Alternatively, a panel of a general paediatrician, a named or forensic paediatrician and a paediatrician from the relative subspecialty may be considered.
6The consultant should consult the named doctor about child safety concerns and keep him or her informed in the process. (if the consultant is the named doctor, they should consult with the designated doctor)
7When FII is suspected or confirmed in a child, all decisions about what and when to tell the parents and children should be taken by senior staff within the multi agency team. Information sharing with carers should not place a child at risk of significant harm.
8All record entries must be timed, dated and signed legibly. They should be kept securely. All events must be carefully documented. All telephone conversations must be fully recorded.
9In inpatient observation, the person recording observations and taking samples must be stipulated. Samples that may be needed forensically later must be delivered to the lab by hand after discussion, so that handling can be accurately documented. Presence or absence of the carers during any event and interaction with the child should be noted, trying where possible, not to alert the carers to the concerns– Steps should be taken to ensure that records, charts or results are not tampered with by any one.
10Parents who apply to access their child’s notes should not have access without reference to the Consultant Paediatrician responsible.(See Access to Health Care Records Policy Organisational policies 1.6) If FII is thought to be a likely diagnosis or there is any risk to the child’s welfare as a consequence of parental access to the records, then a discussion with social care must take place – it may be necessary to hold a strategy meeting to assess and manage any risk to the child prior to the parent accessing the child’s records.
Consideration should be given as to how the concerns will be shared with the parent, at the strategy meeting if appropriate. This may include the paediatrician explaining the concerns or going through the notes with the parents.
11There is debate over whether or not separation from the parent is justifiable as a diagnostic test. It may be achieved voluntarily. If legal proceedings are contemplated by social services, a court will need clear evidence to make a no contact order. The parameters to be recorded, the length of separation and the significance of findings must be agreed before separation. It is important that the parents, social services and the court understand that this is a diagnostic manoeuvre, not a judgement
12Supervision and support
All involved in this work should have access to advice and support from peers, managers, named and designated professionals and external professional with experience of fabricated or induced illness where appropriate. The named doctor or nurse will advise within the Trust
Surveillance
Overt surveillance
As an inpatient if the presentation may be life threatening.
Carefully documented observations, clear accurate recording of events, including what was reported as opposed to witnessed, timing of events and drugs, who administered drugs, collected them and handled them.
All primary, secondary and tertiary care records, including community notes, should be obtained and charted chronologically.
Overt video monitoring
Either incidentally on hospital security cameras, on any cameras in use to monitor children on the ward, or the specific use of personal cameras by parents to record events.
Physiological monitoring
Useful in children suffering from recurrent ALTE or other unexplained episodes – in Chesterfield, this would require referral to a specialist centre.
Covert video surveillance
CVS should be undertaken if there is no other way of obtaining the information. The decision to undertake covert video surveillance should be undertaken at a strategy discussion. The use should be proportionate to the aim to be achieved.
CVS is the responsibility of the police, who can be authorised to undertake surveillance of possible criminal activities. The police will supply any equipment required and be responsible for monitoring and managing the process.
Role of CAMHS
CAMHS professionals may identify fabricated or induced emotional or behavioural symptoms in children. They may also be asked for advice by other professionals working with families where FII is a possibility. The service may be asked to:
i)help other professionals clarify their own thinking
ii)help in the identifying the risk of harm
iii)consider possible reasons for parental behaviours and anxieties
iv)consider ways to explain and engage parents with professional concerns
v)provide psychiatric expertise in considering the child’s welfare and responses, including evidence of significant emotional harm
vi)help other professional who are assisting parents with difficulties in the parenting role or the management of chronic illness
vii)become directly involved with some families
viii)contribute to the assessment of families where FII is an issue – particularly in assessment of the child’s psychological functioning, supporting and improving the family functioning and assessment of parenting capacity
ix)assess adult mental health, liaise with adult mental health services and arrange joint assessment if appropriate
x)provide therapeutic services as appropriate
Role of Adult Mental Health Services
Adult mental health services may be involved in the assessment, planning, management or treatment of a carer. Adult mental health professionals may recognise the risk to children of FII, particularly those in contact with adults with a somatising disorder. Liaison should take place between the adult psychiatrist and those responsible for the child’s health or assessment, certainly at the point where there is suspicion that a parent has been inducing symptoms, or a court has made a finding of fact that such behaviour has occurred.
References / further information from
- Fabricated or Induced Illness by Carers: Report of the Working Party of the Royal College of Paediatrics and Child Health, February 2002
- Safeguarding children in whom illness is Fabricated or Induced: Supplementary Guidance to Working Together to Safeguard Children. DfCSF 2008.
- Derby and Derbyshire Safeguarding Children Procedures 2013, Section 6 Specific Circumstances, 6.10 Children in whom Illness is Fabricated or Induced.
- Fabricated or Induced Illness by Carers. Royal College of Paediatrics and Child Health, 2009.
Cross Reference
Organisational Policy 1.6 - Access to Health Care Records Policy
DateJuly 2013
Review DateJuly 2015
Review byNDP
………………………………………………………
Original Lead Author Dr P Field
Amended by Dr A. Ramsbottom
Consultant Paediatrician/Named Doctor Safeguarding Children
Policy Review