View Working Together View Working Together
View Oxfordshire Childrens Service Procedures Manual View Oxfordshire Childrens Service Procedures Manual

3.19 Fabricated or Induced Illness

This procedure was written by Dr Claire Burns (who was then the Designated Doctor for Oxfordshire) in November 2008 and first included in the manual in February 2009. It was updated in July 2009 to take account of the change of Designated Doctor and Named Doctor.

Throughout this chapter Fabricated or Induced illness is referred to as FII.


Contents

  1. Background
  2. Management of Suspected Fabricated or Induced Illness(FII)
  3. Support for Parents
  4. Advice When Dealing with Possible FII


1. Background

Children with FII typically present to health professionals.

Identifying FII can be challenging and distinguishing some of these cases from children with abnormally anxious parents can also be difficult.

FII is not common; incidence ~ 0.5-1.2/ 100,000 <16y; 2.8/ 100,000 <1y.

FII is associated with significant morbidity and occasional mortality.

Parents demonstrate a range of behaviours in response to their child being ill / perceived to be ill. Some become more stressed and anxious than others.

The spectrum of parental behaviours includes - those who present as anxious about minor symptoms in their child - those who tend to exaggerate symptoms - those who invent symptoms and - those who induce them.

A key task for health professionals is to distinguish the anxious parent who responds in an unusual way to a child's health problem from the parent who exhibits behaviour suggestive of FII.

Managing an anxious parent who repeatedly presents a child with minor or possibly exaggerated symptoms is different from the situation where a parent fabricates or induces a child's illness but in all cases the welfare/safety of the child and support for the family require careful consideration.

Parents who fabricate/ induce illness in their child may do so in a variety of ways:

  • Claiming a child has symptoms which result in unnecessary investigations/ treatment/use of unnecessary equipment (e.g. crutches, wheelchairs);
  • Fabricating a child's past medical history;
  • Alleging psychological illness in a child;
  • Deliberately inducing symptoms in a child by administering medication/other substances;
  • Interfering with treatment by overdosing/ omitting medication/ tampering with medical equipment/ charts etc.

Harm to the child may occur in different ways:

  • Directly through induction of ill health;
  • Indirectly through unnecessary hospitalisation, investigation and treatment;
  • Psychologically in association with:
    • Confusion of affection with sickness;
    • Being used by their carer;
    • Development of 'illness behaviour';
    • Other parenting problems and forms of maltreatment.

Suspicion of FII may be raised in primary care, by mental health professionals or by teachers initially but sometimes is first considered when the child is seen in paediatric outpatients or as an inpatient.

FII cases are suspected/confirmed in hospital when:

  • Symptoms and signs are not explained;
  • Investigation results don't tally with the history/ findings;
  • There is a poor response to treatment;
  • New symptoms appear on resolution of previous ones;
  • Evidence of falsification/tampering is found.

The approach to managing FII may have to be less open than that employed in other areas of child protection. Parents should be informed about investigation results but concerns about possible FII should not be shared with parents if this would jeopardise the child's safety, until a clear plan of action has been agreed by professionals.


2.  Management of Suspected Fabricated or Induced Illness(FII)

2.1 Initial Management of suspected FII

See Initial Management of Suspected FII (fabricated or induced illness) in Children Flowchart.

Child with Unusual Medical History / Symptoms Which Don't Tally with the Clinical Findings - in Surgery/Outpatient Clinic/School

The child appears well but exaggerated or fabricated symptoms are suspected.

Careful notes should be made in the child's records and the welfare of the child and support for the parent considered.

Consultation with the named or designated professional for safeguarding/child protection in the Trust or agency about the case is advised.

If the child is already known to a paediatrician, discuss the case with her/him.

Assessment by a paediatrician can be helpful, even when physical ill health in the child is felt unlikely.

A paediatric consultation can provide reassurance to an anxious parent as well as an opinion for professionals about the possibility of FII.

Prior to the appointment the referrer should discuss the concerns about possible FII with the paediatrician.

Outcome of Paediatric Consultation

  1. The paediatrician feels the case does not represent FII but there is a high level of parental anxiety: Support for the parent and follow up for the child should be arranged;
  2. The paediatrician agrees with possible FII but the child is judged to be safe and well cared for: Further information should be obtained and discussion with a senior social worker arranged. The presentation may indicate hospital admission is required to confirm or refute FII;
  3. The paediatrician feels FII is likely and the child is suffering/ at risk of harm. Urgent referral to Social Care services is required for a strategy meeting. The safety of the child needs addressing and in some circumstances hospital admission may be required.

Information Gathering

Information to consider obtaining:

  • Information from those other than the carer who are reported to have witnessed the child's symptoms/ behaviours (with parental permission) e.g. when fits are said to have occurred at nursery/school;
  • Information about the child's school/ nursery progress (with parental permission);
  • Information from professionals who have previously been involved in the child's medical care;
  • Information about the parent's pattern of dealing with health problems and, if the parent has a history of mental health problems, details of this too. GP's and psychiatrists may be reluctant to share information about adult's health/mental health without permission. In this situation the importance of sharing information 'in the child's best interest' should be highlighted. Professionals can only work together to safeguard children if there is an exchange of relevant information between them (DOH 2006).

Discussion with a Senior Social Worker and the Trust's Named Professional.

This may result in a judgement that FII is unlikely and the child is not at risk of harm but that there is significant parental anxiety which needs addressing.

Alternatively the discussion may result in an opinion that FII is likely. A formal referral to Children, Education and Families should be made - see Referrals (including Referral Pathway) Procedure. The welfare of the child - whether s/he is considered to be suffering harm/at risk of harm or not at immediate risk of harm - would determine the action necessary.

2.2 Hospitalised Child with Unusual Symptoms/Signs Which Don't Tally with Clinical Findings/Evidence that Illness is Being Induced - FII Suspected or Confirmed

Information gathering and discussion with named professionals as above.

Careful record keeping; note what was said, by whom, about the child's symptoms and history. Record what the child communicates about events (if appropriate).

If after observation, information gathering and discussion FII is considered likely, a referral to Children, Education and Families should be made - see Referrals (including Referrals Pathway) Procedure.


3.  Support for Parents

  • When a child is not felt to be at risk of harm but there are concerns about an anxious parent with a tendency to exaggerate symptoms the most appropriate way to help and support the family should be considered at the conference or discussion meeting;
  • The parental tendency to exaggerate symptoms needs to be shared within the primary care team (consider using Reed code 13WB-1 for maternal anxiety);
  • Specialist CAMHS and adult mental health psychiatric advice can be helpful in this situation. Named professionals within CAMHS (see Section 4, Advice When Dealing with Possible FII) can advise on this;
  • Teachers and nursery workers can also be supportive to families and should be included in support plans where relevant.


4.  Advice When Dealing with Possible FII

Few professionals have great experience of FII.

All Health Trusts have named/ designated professionals for child protection/ safeguarding who can be consulted when FII is suspected.

Children, Education and Families have also identified experienced staff take a lead in early case discussion.

The Schools Safeguarding Team can also be consulted.

The contact details of the various leads are set out in Local Contacts.

For detailed guidance see the DSCF 2008 document 'Safeguarding Children in Whom Illness is Fabricated or Induced'.

End