8.20 Fabricated or Induced Illness
- Medical Evaluation
- Referral to Children's Social Care
- Initial Response to the Referral
- Strategy Meeting
- Section 47 Enquiry
- Police Investigation
- Outcome of Section 47 Enquiries
- Initial Child Protection Conference
- Pre-birth Child Protection Conference
- Professional Differences
This form of abuse has also been known as:
This section outlines the procedures to follow when professionals are concerned that the health or development of a child is likely to be significantly impaired by the actions of a carer having fabricated or induced illness. In these cases the issue of information sharing is particularly difficult and this is referred to in the following paragraphs.
Further guidance and flowcharts are provided in document 'Safeguarding Children in Whom Illness is Fabricated or Induced'. (DCSF 2008)
The Royal College of Paediatricians and Child Health, updated in October 2009 'Fabricated or induced illness by Carers', provides further guidance for medical clinicians. (LINKS)
Fabricated or induced illness in a child is a condition whereby a child suffers harm through the deliberate action of her/his main carer and which is duplicitously attributed by the adult to another cause.
There are 3 main ways of the carer fabricating or inducing illness in a child:
The above are not mutually exclusive.
Carers exhibit a range of behaviours when they wish to convince others that their child is ill. Fabricated or induced illness is often but not exclusively associated with emotional abuse. The following list of behaviours exhibited by carers can be associated with fabricating or inducing illness in a child. This list is not exhaustive and should be interpreted with an awareness of cultural behaviours and practices that can be mistakenly construed as abnormal behaviours:
Concerns may be raised by professionals who are working with the child e.g. nurses, teaching staff, social workers and early years staff in a variety of setting, and who may notice discrepancies between reported and observed medical conditions.
Professionals working with the child's parents may also note these concerns, e.g. mental health professionals, may identify a child being drawn into the parents illness.
Doctors / paediatricians may be concerned at the possibility of a child suffering Significant Harm as a result of having illness fabricated or induced by her/his carer. These concerns may arise when:
There may be a number of factors that staff working in schools and early years settings should be aware of that can indicate a child may be at risk of harm. Some of these factors can be:
For a small number of children, concerns will be raised 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. Where the impairment is such that there are concerns the child is suffering or is likely to suffer Significant Harm the guidance set out in this section should be followed.
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.
Professional staff should consult or seek support from their designated or named professional if they are concerned about a child.
If there is suspicion that a member of staff is responsible for unexplained or inexplicable symptoms in a child, then the Allegations Against People who Work with, Care for or Volunteer with Children Procedure must be followed, as well as referral to Children's Social Care to ensure the safety of the child(ren).
Please see Flow chart 1 - medical evaluation where there are concerns regarding signs and symptoms of illness, which is on page 57 of the government guidance document Safeguarding Children in whom Illness is Fabricated or Induced (DCSF 2008) (including Flowcharts).
The signs and symptoms require careful medical evaluation for a range of possible diagnoses. This should be informed by a medical chronology, which should include events in relation to any siblings of the child.
A lead paediatrician identified at the Strategy Discussion/Meeting will coordinate the medical information.
All tests and their results should be fully and accurately recorded. It is important that the child's record is not altered in any way, e.g. through tampering with test results.
The name of the person reporting any observations should be legibly recorded and dated.
Where a reason cannot be found for the signs and symptoms, specialist advice and tests may be required.
Parents should be kept informed of findings from these medical investigations but at no time should concerns about the reasons for the child's signs and symptoms be shared with the parent if this information would jeopardize the child's safety.
Medical evaluation can be complicated by some parents' reluctance to leave the child. Where appropriate every effort should be made to see the child alone.
Normally, the doctor would tell the parent(s) that (s)he has not found the explanation and record the parental response.
Referral to Children's Social Care
The Making a Referral Procedure should be followed when there are concerns that a possible explanation for the signs and symptoms of illness is that they may have been fabricated or induced by a carer.
As with all other child protection concerns, the response by Children's Social Care will be in accordance with Section 4, Response to Child Protection Referrals.
Professionals should in general seek to discuss any concerns about a child's welfare with the family. Discussion with the parents or carer about the referral should only be done where such discussion and agreement seeking will not place a child at increased risk of Significant Harm.
As set out in Information Sharing and Confidentiality, a referral should be made without the consent or knowledge of the parents where to do so would place the child at increased risk of Significant Harm.
In cases of possible fabricated illness the decision about what the parents will be told, by whom and when will be agreed between the referrer and Children's Social Care. This will be further agreed at any Strategy Meetings.
Initial Response to the Referral
A decision should be made whether a Strategy Meeting is required to decide whether to carry out a Section 47 Enquiry and what further action should be taken.
Careful attention should be given to ensuring that all professionals involved in the Strategy Meeting are clear about each other's concerns and that adequate opportunity is given to pursue all professional perspectives and to consider the full range of explanations and potential avenues of inquiry. Extra care should be given to clarifying expectations and agreed actions to ensure a shared understanding of the issues.
A Strategy Meeting must be chaired by, at a minimum level, the first line manager or child protection adviser. If operational managers chair the Strategy Meeting, a child protection adviser or manager should be informed and consulted.
This meeting requires the involvement of key senior professionals responsible for the child's welfare. At a minimum this must include Children's Social Care, the Police and the paediatric consultant responsible for the child's care.
The following must be invited:
When it is decided that there are grounds to initiate a Section 47 Enquiry, decisions should be made about how the Section 47 Enquiry, as part of the Child and Family Assessment, will be carried out.
In addition to the decisions usually taken at a Strategy Meeting, additional factors to address are:
Investigating this specific circumstance is complex and disturbing for practitioners and one worker should not undertake the investigation in isolation. The Strategy Meeting should recognise the need to ensure multi-agency coordinated working and good supervision.
If at any point there is medical evidence that the child's symptoms are being fabricated or induced, action may be required to ensure the child's life is not put at risk. 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's Social Care, the Safeguarding Investigations Unit, the lead paediatrician and other agencies, as appropriate. However this should not delay the use of immediate protection if required - see the sub-section on Immediate Protective Action in the Action on Receipt of Referrals Procedure.
It is very likely that more than one Strategy Meeting will be necessary. 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 a Section 47 Enquiry.
It may also be necessary to have an interim protection plan for the child or children concerned pending the holding of a Child Protection Conference - and this should be determined at the Strategy Meeting.
Section 47 Enquiry
The Child and Family Assessment should include the systematic gathering of information about the history of the child and each family member, building on that already gathered during the course of each agency's involvement with the child. Particular emphasis should be given to health (physical, emotional and psychiatric), education and employment as well as receipt of state benefit and charitable donations relating to a disabled child, social and family functioning and any history of criminal involvement. Carers may present as very plausible and well informed as to the nature of the child's medical problems.
It is important to assess the child's understanding, if old enough, of their symptoms and the nature of their relationship with each significant family member (including all caregivers), each of the caregiver's relationships with the child, the parents' relationship both with each other and with the children in the family as well as the family's position within their community.
A full chronology from each agency should be developed which may assist in informing the Child and Family Assessment.
Any decision to confront any person should not be made unless in conjunction and with the full agreement of the police (see Police Investigation).
It is important to keep a focus on the impact of the carer's behaviour on the child when assessing levels of risk.
Children under the age of 5, especially pre-verbal children and children with an existing diagnosed illness, disability and/or communication difficulties, are at greatest risk because of their inherent vulnerability.
Before placing children with members of either extended family, be sure that a thorough assessment of them has taken place. Illness induction may 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. This may be hard to ascertain if the alternative carer is a relative.
An adult 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.
Any evidence gathered by police should 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.
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 that will explain the child's signs and symptoms. (Police Officers planning surveillance in cases of suspected fabricated or induced illness may seek advice from the National Crime Agency, Tel: 0370 496 7622, firstname.lastname@example.org.)
The primary aim of covert video surveillance is to identify if a child is having illness induced. Obtaining criminal evidence is of secondary importance.
Once this decision has been made, the police will be responsible for applying for the appropriate authority under the Regulation of Investigatory Powers Act 2000. If that authority is granted, the police have sole responsibility for implementing and undertaking any such surveillance. Good practice advice for police officers is available from the National Crime Faculty.
The safety and health of the child is the over-riding factor in the use of covert video surveillance, and the medical consultant responsible for the child's care should ensure that the necessary medical and nursing staff supports the police operation.
All non-police staff involved will receive appropriate training from the police, and understand the need for strict secrecy during the operation.
Outcome of Section 47 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. In this situation, it is important to discuss with the parents, drawing on knowledge of the implications of the medical condition for the child and family members' lives, what further help or support they may require.
Where test results are inconclusive and/or where it is not possible to draw firm conclusions and fabrication is still a possibility it is important to try to understand the origin of the symptoms and to consider whether further help for the family is required.
There may be substantiated concerns that a child has suffered Significant Harm, but it is agreed between agencies that a plan for ensuring the child's future safety and welfare can be developed and implemented without the need of a Child Protection Conference. In such circumstances agencies involved should be satisfied that the child is not at continuing risk of harm. In this instance a Child in Need Plan should be developed and should include careful ongoing monitoring by health and other agencies.
Where concerns are substantiated and the child is judged to be currently suffering or at risk of suffering Significant Harm, a Child Protection Conference must be convened. All evidence should be thoroughly documented by this stage and the Child Protection Plan already agreed at the Strategy Meeting for the child, should be already in place.
Initial Child Protection Conference
Attendance at the conference should be as for other initial conferences, with the additional experts invited as appropriate:
Usual consideration should be given to the involvement of family members. However it may not be possible for all family members to be present at the same time. The extent and manner of involvement of family members should be informed by what is known about them. The abusing carer may not be able to acknowledge their behaviour to their partner for fear of what this knowledge would do to their relationship. They should not be put under pressure to talk about their part in fabricating or inducing illness within the conference. The non abusive parent or carer may have no knowledge of the abuse or they may have had some understanding which now makes better sense to them but not wish to discuss it at a conference. Again they need not to discuss their knowledge in such a public setting should be respected.
These are matters which can be extremely complex in these cases and should be addressed outside the conference and in advance of the conference date with the conference chair and other key professionals.
Pre-birth Child Protection Conference
A pre-birth conference should be convened where there is evidence of illness having been fabricated or induced in an older sibling or other child, and given consideration during the pregnancy of a woman who is known to have abused a child in this way. Consideration should also be given to the safety of the unborn child where the mother is known to demonstrate fabricating or inducing behaviours in her own presentation.
A pre-birth child protection conference should be convened if, following Section 47 Enquiries either the unborn child's health is considered to be at risk or the baby is likely to be at risk of harm following his or her birth.
Because of the difficult nature of Fabricated illness there is even greater likelihood of differences of opinion between professionals. For all agencies where there is disagreement between professionals the Resolution of Professional Disagreements Procedure should be followed.
When there is a difference of medical opinion regarding any matter relating to fabricated or induced illness, the Designated Doctor should be asked to review the case and will draw the final conclusion.