Fabricated or Induced Illness (FII) is a condition whereby a child suffers harm through the deliberate action of her/his main carer and which is attributed by the adult to another cause.
It is a relatively uncommon with a reported incidence with strict criteria of 0.5-1.2/100,1000 in under 16y, and 2.8/100,000 in <1y. Another study with wider criteria has shown an incidence of 89 per 100,000 over 2 years. It is associated with significant morbidity and occasional mortality.
FII can involve children of all ages, but the most severe cases are usually in children under the age of 5 years. Older children may actually collude in their sick role with the parent or carer.
In more than 90% of reported cases of FII, the child's mother is responsible for the abuse. However, there have been cases where the father, foster parent, grandparent, guardian or healthcare or childcare professional was responsible. It is perpetrated by parents/carers from all social backgrounds, and is not associated with other types of family violence or crime.
There are many children who present with medically unexplained symptoms and perplexing presentations. Most of these children are not subjects of fabricated or induced illness by a carer. Health professionals need to assess and evaluate, and consider FII when there are additional factors known to be associated with FII, or when there is evidence to suggest FII. Concerns will be raised for a minority of children when it is considered that the health or development of a child is likely to be significantly impaired or further impaired, by the actions of a carer or carers having fabricated or induced illness.
There are four main ways of the carer fabricating or inducing illness in a child:
- Exaggeration of symptoms/real problems. This may lead to unnecessary investigations, treatment and/or special equipment being provided;
- Fabrication of signs and symptoms, including fabrication of past medical history;
- Falsification of hospital charts, records, letters and documents and specimens of bodily fluids;
- Induction of illness by a variety of means – including smothering, poisoning, with-holding medication or food.
The above four methods are not mutually exclusive.
Harm to the child may occur in different ways including- physical harm through induction of illness or unnecessary admission to hospital, investigation and treatment. Emotional harm can occur as a result of an abnormal relationship with the parent and or the child may develop abnormal illness or health-care seeking behaviour themselves.
Investigation of FII and assessment of significant harm to a child falls under statutory framework provided by Working Together to Safeguard Children and Safeguarding Children in whom illness is fabricated or induced (Supplementary guidance to Working Together to Safeguard Children). HM Government 2008.
Agencies and practitioners need to be mindful that where a child has suffered, or is likely to suffer, significant harm, it is essential to make an immediate referral to Children's social care in accordance with the Referrals Procedure.
Children who have had illness fabricated or induced require coordinated help from a range of agencies.
Joint working is essential, and all agencies and professionals should:
- Be alert to potential indicators of illness being fabricated or induced in a child;
- Be alert to the risk of harm which individual abusers may pose to children in whom illness is being fabricated or induced;
- Keep clear, contemporaneous records of concerns and observations; share and help to analyse information so that an informed assessment can be made of children's needs and circumstances including an up to date Chronology;
- Contribute to whatever actions and services are required to safeguard and promote the child's welfare;
- Assist in providing relevant evidence in any criminal or civil proceedings.
Some other important general issues in relation to FII cases are discussed in the last section, at the end of this procedure.
The abuse that occurs in FII takes a range of forms and can be difficult to recognise, but there are indicators which should alert professionals to the possibility. The range of symptoms and body systems involved in the spectrum of FII is extremely wide. Many children affected by FII will have a past or current genuine medical problem, including children with disabilities. FII can be more difficult to detect in children who have existing health needs.
Suspicion of FII may be raised in primary care, by mental health professionals or by teachers initially, but is often first considered when the child is seen in an outpatient clinic or is an inpatient in hospital. A clinician may first suspect FII, when after examination and investigations of the child, there appears to be no explanation for the child's symptoms.
The following warning signs should also be watched out for:
Specific issues about the child's illness
- The child's alleged symptoms don't seem plausible;
- Physical examination and investigation results do not explain reported symptoms and signs;
- Symptoms only appear when the parent or carer is present;
- Inexplicably poor response to treatment;
- New symptoms are reported on resolution of previous ones;
- Objective evidence of fabrication, falsification or tampering.
- The parent or carer encourages medical staff to perform often painful tests and procedures on the child (that most parents would only agree to if they were persuaded were absolutely necessary);
- The parent or carer has a history of frequently changing GP, or visiting different hospitals or doctors for investigations or treatment, particularly if their views about the child's diagnosis or treatment are challenged;
- The parent or carer remains on the ward constantly;
- The parent or carer doesn't seem too worried about the child's health, despite being very attentive;
- The parent or carer develops close and friendly relationships with staff, but may become abusive or argumentative if their own views about the child are challenged;
- The parent or carer has good medical knowledge or a health background;
- One parent (commonly the father) has little or no involvement in the care of the child;
- The parent or carer expresses concerns that they are under suspicion for FII, or a relative raises concerns about FII.
There may be a number of explanations for these circumstances and each requires careful consideration and review.
Any professional, other than a GP in the community or a Consultant Paediatrician within a hospital, who have identified concerns about a child's health should discuss their concerns with the child's GP or consultant paediatrician responsible for the child's care.
3. Emerging Concerns and Managing Uncertainty
Many parents present to services with varying levels of anxiety about their child's health. Often the initial action for health professionals is to acknowledge and address the issues with the family, without embarking on further invasive investigations or unnecessary treatment. Such early intervention may enable the clinician to identify issues or causes of stress within a family unit or carer, reassure them and signpost to appropriate services.
Healthcare and other professionals will naturally assume that a parent or carer will give an accurate history and always act in the best interests of a child in their care, unless there is compelling evidence to suggest otherwise.
In the majority of cases of FII, when concerns first emerge there will be uncertainty and insufficient evidence to confidently confirm abuse, or the nature of the risk to the child. The next stage requires meticulous gathering of objective evidence and keeping an open mind to all possibilities – including FII, genuine medical problems or a combination of both.
The presenting signs and symptoms require careful medical evaluation for a range of possible causes, by a paediatrician. If no paediatrician is already involved, the child's GP should make a referral to a paediatrician, including where relevant, supporting information from other health professionals – such as health visitor, community or school nurses or therapists. Professionals must remain open-minded to all possible explanations.
Parents should be kept informed of further medical assessments/ investigations/tests required and of the findings but at no time should concerns about the possibility of FII being the cause of the child's signs and symptoms, be shared with parents, if this information would jeopardise the child's safety and compromise the child protection process and/or any criminal investigation.
Following completion of medical investigations, if a reason cannot be found for the reported or observed signs and symptoms of illness, further specialist advice and tests may be required, and the case should be discussed with the Named or Designated Doctor.
The following is a checklist that can be used by any professional dealing with a possible case of FII:
- Focus on safeguarding and promoting the welfare of the child at all times;
- Discuss with a safeguarding lead in own organisation or agency;
- Complete a detailed chronology, including what is objective evidence and what is reported by parents. Use a chronology template. (At a later stage a combined chronology including information from all health providers and other involved agencies will be needed);
- List inconsistencies, and gather other information from family and other professionals (who have day to day contact with the child – e.g. nursery, school) to clarify inconsistencies;
- Continue to observe child and family to see if patterns are emerging, or new concerns arising;
- Keep detailed records, and be specific about the evidence base/source of information;
- Test alternative explanations – consider second opinion, review with senior colleague or expert, complete medical investigations;
- Continue to reassess in the light of new information;
- Consider cross referencing the chronologies for different children and adults in the family - as illness behaviour can switch between different members;
- Discuss with Named or Designated doctor;
- Consider a professionals' meeting to gather information;
- Consider consultation with a Senior Manager in Children's Social Care with experience of FII. (FII is rare and many social workers will not have experience of FII);
- Access local and National guidance on FII.
If at any stage there is evidence the child has suffered, or is likely to suffer, significant harm it is essential to make a referral to Children's social care in accordance with the Referrals Procedure.
When, as a result of the assessment and actions detailed above, a possible explanation for the signs and symptoms 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 Services or the Police (see Referrals Procedure):
- Children's Social Care has the lead responsibility for the coordination of action to safeguard and promote the child's welfare;
- Any suspected case of FII may involve the commission of a crime and therefore the police should always be involved. First contact with the police is normally made by Children's social care;
- The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care.
Children's Social Care should convene an urgent strategy meeting involving all key professionals, and this must be chaired by a Children's Social Care Manager. Attendees must include social care, police and the paediatrician responsible for the child's health, and any other relevant professionals such as senior ward nurse (if child is in-patient), relevant specialist paediatrician, GP, HV, staff from education setting, named or designated doctor, local authority legal advisor.
In cases of possible FII, it may be necessary not to tell the parents about the meeting prior to it taking place in order to protect the child.
When it is decided that there are grounds to initiate a child protection investigation (section 47 Children Act), decisions will be made at the strategy meeting about how the investigation and assessment will be carried out including:
- Whether the child needs constant professional observation and, if so, whether the carer should be present. For children who are not currently inpatients, this may necessitate a planned admission to hospital;
- One consultant paediatrician should be appointed as lead clinician, and co-ordinate the medical treatment and input;
- Parents should be kept informed of further medical assessments/ investigations/tests required and of the findings but at no time should concerns about the reasons for the child's signs and symptoms be shared with parents if this information would jeopardise the child's safety and compromise the child protection process and/or any criminal investigation;
- There should be a detailed and meticulous investigation – involving the collection of information from all relevant health organisations and professionals, social services and nursery/school;
- A combined detailed chronology with information from all agencies produced. This often provides key information to confirm whether the situation is abusive or not;
- Relevant and proportionate health information obtained on parents/carers and siblings;
- Consider producing a combined family chronology;
- Consideration of the nature and timing of any police investigations, including analysis of samples and covert surveillance (the latter should be police led and co-ordinated);
- Extreme care over confidentiality, including security regarding supplementary records;
- The need for expert advice or second opinions;
- The needs of the siblings and any other children with whom the alleged abuser has contact;
- The needs of the parents;
- Legal advice.
Children's social care should only convene an initial Child Protection Case conference after reaching the point of openly discussing the professionals' concerns with the parents (i.e. when it has been agreed that to do so will not place the child at increased risk of significant harm). This may be some time after the commencement of the investigation under section 47. Sometimes several strategy discussions/meetings are needed while the medical professionals undertake continuing evaluation and the police progress a criminal investigation.
In some cases Children's social care will discuss with their legal team and may take legal action at an early stage in the investigation.
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.
If any professional considers that their concerns are not taken seriously, or responded to appropriately, they should discuss this as soon as possible with the designated doctor for child safeguarding, or escalate concerns using the Conflict Resolution Policy.
When there are concerns or suspicions that a member of staff may be responsible for FII in a child, this should be discussed with their line manager and their agency's designated safeguarding lead. See also Allegations Against Staff or Volunteers.
Whilst cases of FII are relatively rare, the term encompasses a spectrum of behaviour which ranges from a genuine belief that the child is ill through to deliberately inducing symptoms by administering drugs or other substances. There are often grey cases, where it can be difficult to determine where on this spectrum a case lies, and exactly whether there is risk of significant harm.
Contrary to normal professional relationships with parents, professionals being challenging about suspicions from the start may scare off a parent thus making it more difficult to gain evidence. There may be unintended consequences in increasing the harmful behaviour in an attempt to be convincing.
Parents who harm their children this way may appear to be plausible, convincing and have developed a friendly relationship with practitioners before suspicions arise. They may also demonstrate a seemingly advanced and sophisticated medical knowledge which can make them difficult to challenge. Practitioners should demonstrate professional curiosity and challenge in an appropriate way and with coordination between the agencies.
Impact on professionals: Working with children and families where FII is suspected or confirmed can be stressful, challenging and distressing. Practitioners are likely to need support to enable them to deal with their feelings in relation to these cases. In addition, in some cases professionals can unwittingly collude with parents and find it difficult to accept the possibility of FII. This can result in anger between colleagues who believe or disbelieve the parent, and lead to splitting of professionals. It is important that effective support and supervision is available and provided when needed.
Fabricated or Induced Illness by Carers: A Practical Guide for Paediatricians, Royal College of Paediatricians and Child Health, Oct 2009