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Safeguarding Children in whom Illness is Fabricated or Induced (FII)

Please consider this policy in relation to the current national guidance as follows:

Focus should be on the harm to the child, not on understanding the characteristics or motivation of the perpetrator.


Contents

  1. Introduction
  2. Fabricated/Induced Illness
  3. Principles
  4. Behaviours Associated with Fabricated/Induced Illness
  5. Recognition
  6. Medical Evaluation
  7. Sharing Health Information when there are Concerns re FII
  8. Referral to Children’s Social Care
  9. Disclosure of Concerns to the Child’s Carers
  10. Child Protection Conference
  11. Work with Carers who have Fabricated or Induced Illness
  12. Working with Children
  13. Emergency Action
  14. Responsibilities
  15. Covert Video Surveillance
  16. Chronologies
  17. Risk from a Member of Staff

    Appendix 1: Case History - Chronology

    Appendix 2: Possible Warning Signs of Fabricated or Induced Illness

    Further Information and Guidance

    Amendments to this Chapter


1. Introduction

These procedures should be followed if:

  • There are concerns that illness may be being fabricated or induced in a child or;
  • There are concerns that the child’s parent or carer may be fabricating or inducing illness in themselves and that this may cause harm to the child. Such concerns may also apply to unborn children.

Professionals are expected to work in line with the national guidance, ‘Safeguarding Children in Whom Illness is Fabricated or Induced’ (HM Government 2008). The guidance is intended to provide a framework for agencies and professionals to work together at a local level when there are concerns that illness is being fabricated or induced in a child by a carer who has parenting responsibilities for him/her.

This document provides:

  • Guidance for inter-agency practice in handing individual cases;
  • Expected roles and responsibilities for a wide range of professionals working within Health, Children’s Social Care, Police, and Education etc;
  • Key issues for working with families where fabricated or induced illness may be a feature.

The guidance refers to the “fabrication or induction” of illness, which may involve many different types of abusive behaviour.


2. Fabricated/Induced illness

There are three main ways, not mutually exclusive, of a parent/carer fabricating or inducing illness in a child:

  • Fabrication of signs and symptoms, for example, fabrication of past medical history;
  • Falsification of hospital charts, records, letters, documents and specimens of bodily fluids;
  • Induction of illness by a variety of means.


3. Principles

  • Focus should be on the harm to the child, not on understanding the characteristics or motivation of the perpetrator;
  • Keep an open mind;
  • Keep questioning your assumptions;
  • Be familiar with the range of behaviours that perpetrators of FII exhibit;
  • Communicate clearly;
  • Be familiar with barriers to identification of FII;
  • Be open to accept FII and objectively question information given by parents and to evidence it.


4. Behaviours Associated with Fabricated/Induced Illness

Behaviours include:

  • 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;
  • Claiming the child has symptoms, which are unverifiable unless observed directly, such as pain, frequency of passing urine, vomiting, or fits;
  • 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.


5. Recognition

Where illness is being fabricated or induced, extensive, unnecessary medical investigations may be carried out in order to establish the underlying causes for the reported signs and symptoms. The child may also have treatments prescribed or operations, which are unnecessary. These investigations can result in children spending long periods of time in hospital and some, by their nature, may also place the child at risk of suffering harm or even death.

Carers exhibit a range of behaviours when they believe that their child is ill. A key professional task is to distinguish between the over anxious carer who may be responding in a reasonable way to a very sick child and those who exhibit abnormal behaviour. Such abnormal behaviour can be present in one or both parents/carers and often involves passive compliance of the child.

Professionals who have concerns about a child’s health should discuss these with the child’s GP or if known to a hospital service, the consultant paediatrician responsible for the child’s health. Parents should not be informed at this stage.


6. Medical Evaluation

Where there are concerns about possible fabricated or induced illness the signs and symptoms require careful medical evaluation by a paediatrician(s). For children not already under the care of a paediatrician the child’s GP should make a referral to a paediatrician.

The referral needs be by telephone in the first instance allowing the GP and paediatrician to fully discuss the history to this point. A standard clinic referral is inappropriate as this will cause delay.

When a paediatrician suspects FII they should discuss the case with the Trust Named Doctor for Child protection/Designated Doctor for Child Protection.

Many incidents of concern can be warning signs of fabricated or induced illness and practitioners should note the attached ‘Possible Warning Signs of Fabricated or Induced Illness Template’.


7. Sharing Health Information when there are Concerns re FII

Primary care practitioners remain the first point of contact for most health problems in children. Practitioners should share information even if they have ‘niggly concerns’. A risk might only become apparent when a number of people with niggling concerns share them.

In all cases the overriding consideration in making decisions about information sharing must be the child’s safety and well-being. Consideration of siblings/other children in the household must be included in any assessment.

In situations of possible induced or fabricated illness practitioners should not discuss their concerns with the parents / carers. This is because such discussion may increase the risk of significant harm to the child. Decisions about what discussions are to take place with the parents / carers are to be made on an inter-agency basis, following referral to Children’s Social Care.

7.1 Discussion with Named or Designated Doctor for Child Protection

In any case in which a paediatrician suspects FII they must discuss the case with the Named or Designated Doctor for Child Protection. They should then call a meeting of all health professionals to gain a fully holistic view. At this meeting a decision should be made as to whether the child may be at risk of significant harm and if so a referral should be made to Children’s Social Care.

7.2 Chronologies

In all cases of suspected FII a principle chronology should be prepared. The preparation of the chronology should not delay intervention if this would put the child at increased risk of harm. It is the responsibility of the responsible paediatric Consultant to ensure that this chronology is compiled. However all health agencies involved in the child’s care should submit a chronology detailing their care.

7.3 Consent

Consent should not be sought from parents and carers when contributing to FII meeting as this may put the child / young person at increased risk of significant harm.

Information on a carer’s health may also be of great value. Carers should be advised that this information is needed to help the doctor better understand the health problem.

7.4 Sharing health information without consent

The key factors in deciding whether or not to share confidential information without consent are necessity and proportionality i.e. whether the proposed sharing is likely to make an effective contribution to preventing the risk and whether the public interest in sharing information overrides the interest in maintaining confidentiality. In making the decision the practitioner must weigh up what might happen if the information is shared against what might happen if it is not and make a decision based on professional judgement. The nature of the information to be shared is a factor in this decision making, particularly if it is sensitive information where the implications of sharing may be especially significant for the individual or for their relationship with the practitioner and the service.

The reasons for the decision to share or not to share information should be clearly documented.

Where there is a clear risk of significant harm to a child the public interest test will almost certainly be satisfied. There will be some cases where the Practitioner will be justified in sharing limited confidential information in order to make decisions on sharing further information or taking action - the information shared should be necessary for the purpose and be proportionate.

Information can be shared without consent if it can be justified under Section 47 of the Children Act as prevention of significant harm or under a police investigation. The Children Act does not require information to be shared in breach of confidence but a practitioner should not refuse a request for information without considering the relative risks of sharing information, if necessary without consent, against the potential risk to the child if information is not shared.

If a decision is made to share confidential information without consent the Practitioner should explain to the carer that they intend to share the information and why, unless to do so may lead to an unjustified delay in making enquiries about allegations of significant harm or put the child / young person at increased risk of significant harm.

In any case of doubt, advice should be sought from the Designated Doctor / Named Doctor / Named GP or the Safeguarding team.


8. Referral to Children’s Social Care

When a possible explanation for reported or actual signs and symptoms in a child is that they may have been fabricated or induced by a parent/carer, and as a consequence the child’s health or development is or is likely to be impaired, an urgent referral should be made to the safeguarding hub.

When a member of the public contacts the safeguarding hub with a concern around FII the health representative should contact the GP and advise them to review their records and refer to a paediatrician to commence FII process before involving other agencies outside health.

Following assessment of information held by health agencies which determines that the child may be at risk of harm from FII a referral must be made to the safeguarding hub.

8.1 Strategy Meetings

When Children’s Social Care receives a referral and they have concerns that a child is suffering or likely to suffer significant harm they should gather information and convene a strategy meeting. A series of strategy meetings may be required before a conclusion is reached on the need for a Section 47 enquiry. The first strategy meeting may scope the nature of concerns, agree what further information is needed, how this will be gathered, and also whether immediate action is required. All agencies / professionals involved will be asked to bring their completed chronology for this or subsequent strategy meetings. The chronology format should be determined by the Responsible Paediatric Consultant and agreed with all to ensure ease of collation.

This meeting should be chaired by an Independent Reviewing Officer.

Carers will not be aware that the strategy meeting is being held so professionals should not inform carers that the strategy meeting is occurring.

Professionals should be aware that minutes from the strategy meeting may be shared with the family at a later date and if a case subsequently goes to Court will be made available for the Court process.

Staff attending the strategy meetings should be sufficiently senior to be able to contribute to the discussion of often complex information and to make decisions on behalf of their agencies.

8.2 Attendance at Strategy Meetings

The meeting should be organised to ensure that the following professionals can attend:

  • Children’s Social Care;
  • Police Protection Unit (PPU) Cumbria Police;
  • Responsible Paediatric Consultant;
  • Designated or Named Doctor for Child Protection;
  • Relevant Health Safeguarding Team;
  • Named Nurse from acute hospital if appropriate.

In immediate harm cases police, Children's social care and the responsible paediatrician should be involved as a minimum.

If the strategy meeting relates to an unborn child and concerns about mother’s illness behaviour, the following professionals should also attend:

  • Obstetrician;
  • GP;
  • Lead Midwife Safeguarding;
  • Midwife.

The following professionals may also be invited as necessary:

  • Senior Ward Nurse (if the child is an in-patient);
  • GP;
  • Health Visitor;
  • Education staff as appropriate;
  • CAFCASS if involved;
  • The legal advisor for the Local Authority;
  • The legal advisor for health;
  • A medical professional who has expertise in the branch of medicine which deals with the symptoms and illness processes caused by the suspected abuse.

8.3 Decision making

All agencies should provide reports for strategy meetings if time allows. These reports must be checked by the agency safeguarding lead before submission to the meeting. The report can be in the form of a chronology using Appendix 1: Case History - Chronology.

The strategy meeting should decide whether to initiate a child protection enquiry under Section 47. For complex cases, more than one strategy discussion may be required.

The discussion should include:

8.4 Assessment of risk and safety planning

  1. The level of harm the child has already suffered;
  2. The risk of future harm and any complicating factors;
  3. Current safety arrangements already in place;
  4. Whether an immediate safety plan is needed to reduce the risk of harm e.g:
    • Cancelling unnecessary medical procedures;
    • Instituting closer observation of the child;
    • Whether the carers should be allowed on the ward if the child is an inpatient. If this is deemed to be unsafe then an emergency order may be required which will need to be instituted by the local authority:
    • Whether immediate action is needed to safeguard the child, this will result in the Local Authority seeking an Emergency Protection Order.
  5. Any potential implications for other patients or their carers who are on the ward at that time;
  6. Consideration of the child’s safety network and how it may be used to provide immediate safety;
  7. Consideration of how all involved health professionals can work together to ensure a coordinated, informed response to any health problems.

8.5 Information gathering

  1. Any outstanding investigations, further information gathering, and opinions that would be helpful;
  2. The planning of further medical and nursing assessment;
  3. Police would consider the need for forensic sampling, special observation or Covert Video Surveillance;
  4. The inclusion of any new information into the integrated health chronology (and agreement on who should do this);
  5. Any further opinions needed (including specialist child protection opinion or to address a specific clinical issue);
  6. What is known about the carers’ past behaviour, medical history, current health state and any treatment, equipment, aids or benefits being received either for them or the child;
  7. Strengths within the family.

8.6 Action Planning

  1. Plan for communication with carers including how, when, and by who they should be informed of any child protection concerns. This may include the formulation of a Danger Statement/Safety plan that can be clearly understood by parents (the danger statement will be a short, simple, behaviorally based statement that can be used to help family members, carers, and staff to be very clear about what has happened in the past, why agencies are involved with families, and what they worry may happen in the future);
  2. How the child can be given an opportunity to tell their story;
  3. Responsibility for the Multi-Agency Assessment;
  4. The security of medical records. N.B. if the police are carrying out a criminal investigation the police will be responsible for securing relevant documentary evidence: respective health organisations should ensure internal policy requirements are adhered to;
  5. The level of professional observation required;
  6. Addressing the needs of siblings and other children in the family;
  7. Addressing the needs of carers, particularly after disclosure of concerns;
  8. Clarification of who will be the Responsible Paediatric Consultant for the child (if not already explicit).

8.7 Possible outcomes of the Strategy Meeting(s)

  • No further action by Children’s Social Care;
  • Provision of services determined by Early Help Assessment and plan;
  • Continued monitoring by identified professionals of specific concerns;
  • Multi-Agency Assessment – Child & Family Assessment led by the Social Worker;
  • Section 47 / Child & Family Assessment;
  • The police start a criminal investigation;
  • Immediate action to protect the child(ren) – application for an Emergency Protection Order;
  • Or a combination of the above;
  • A further strategy meeting or series of meetings, and/or an Initial Child Protection Conference once the Section 47 investigation is completed;
  • Depending on the circumstances of the case, consideration should be given to the possibility of the use of Covert Video Surveillance (see Section 15, Covert Video Surveillance);
  • The outcome of the meeting must be relayed to all parties in writing to avoid any confusion at a later date.


9. Disclosure of Concerns to the Child’s Carers

If the strategy meeting agrees that there are concerns about FII and that other agencies need to be involved, the possibility of FII will need to be discussed with the carers. The immediate safety of the child if they remain must be considered and a multi-agency plan agreed prior to informing parents/carers of professional concerns.

Professionals should be supported through the process of informing parents and the approach should be agreed and discussed with the multi-agency child protection team and carefully planned beforehand. This could include the formulation of a Danger Statement that can be clearly understood by parents.

Parents should be informed in the presence of at least one other professional. In most cases the discussion will involve the Responsible Paediatric Consultant jointly with a social worker and/or the police. However, in cases where the police obtain evidence that a criminal offence has been committed, it is important that the paediatrician does not confront the carers. This must be left to the police in order to ensure that the carers’ rights are protected in accordance with the Police and Criminal Evidence Act 1984.

The carers should be invited to discuss the child’s progress in an appropriate place which provides privacy and confidentiality. If the child is an inpatient, the meeting should be away from the bedside. If possible, both carers should be present at this meeting.

9.1 Discussion with carers

The discussion may include the following:

  • The fact that FII is the most probable cause for the child’s signs and symptoms;
  • The reasons why the identification of FII seems likely;
  • Any other possible causes for the child’s signs and symptoms;
  • Any further investigations and their likely impact on the decision regarding FII;
  • The plan in terms of any ongoing management of the child’s medical condition and monitoring arrangements, with likely timescales where possible;
  • The prognosis for the child;
  • Supportive services available for a carer who is suspected of abuse and for a non-abusing carer;
  • Follow up arrangements, including a plan for further discussions (consistent with the multi-agency plan agreed at the strategy discussion).

Questions should be invited and answered as honestly and fully as possible. Any areas of uncertainty that are outside the paediatrician’ s expertise should be acknowledged. This potentially difficult meeting must be handled sensitively and without causing unnecessary distress. The carers should have a full explanation of the evidence and what further action is needed. Support should be provided to the suspected perpetrator of the abuse after the meeting.

A detailed note of the discussion should be made in the child’s case notes.

At this stage the child’s carers may request a change of medical team. This should be considered by the child protection team, but it will usually be unhelpful to have a change in medical personnel at this stage. As always the overriding consideration should be the welfare of the child.


10. Child Protection Conference

If the case proceeds to an Initial Conference it is essential that the conference is organised so that key professionals including the Responsible Paediatric Consultant can attend.

Reports for conferences must be checked by the safeguarding lead before submission to the meeting and forwarded in advance of the meeting taking place to the Independent Chair & Reviewing Officer involved. Consideration should be given as to how reports can be best shared with parents/carers prior to the conference. All agencies need to share their conference reports with parents/carers 3 days prior to the conference.


11. Work with Carers who have Fabricated or Induced Illness

To gauge the prognosis for positive change in carers who have fabricated or induced illness it is essential to gain an understanding of:

  • Their capacity to understand and acknowledge the harm which has been caused to the child;
  • The underlying motivations which led them to fabricate or induce illness;
  • The perpetuating factors which supported the continuation of the abuse and the extent to which these could be removed;

It is important to explore what life will be like now that the child has been found to be well or better than previously thought. Carers will require help with constructing an accurate narrative of the past which they can share with significant others in their life, including the family. They will require support in processing feelings of guilt and possibly also sadness.

Thereafter, the carer who caused the abuse will require help in finding alternatives to those factors which previously motivated or supported the fabrication or induction of illness in the child, including, for example, employment and alternative sources of income to disability benefits.


12. Working with Children

Professionals will need to decide when and how to involve the child in the decision making and planning processes.

Children of sufficient age and understanding often have a clear perception of what needs to be done to ensure their safety and wellbeing. In such cases if there is an agreed Danger Statement consideration should be given as to whether and how to share this with the child.

In cases involving older children it is important to ascertain the child’s perceptions, beliefs and feelings about their state of health, particularly their anxieties and beliefs about their future wellbeing. It is also important to elicit the child’s view of their experiences of medical care.

A child who has had illness fabricated or induced will need help in constructing a narrative about their previous state of ill health and about how they have come to recover and resume normal functioning. This could be achieved using the Words and Pictures tool. They will often require help in the process of rehabilitation into normal life, including returning to school.

The process of adjustment and ‘recovery’ should include a review of the child’s view of the carer who caused the abuse, which will be painful and will require the presence and support of another trusted primary carer.

The older child will also require continuing support and guidance in learning how to gauge their own physical symptoms and respond to them in an adaptive and safe way. This support should be sustained over a significant period of time to ensure that the child’s long term developmental needs are met.


13. Emergency Action

Sometimes it may be apparent at the point of referral to Children’s Social Care that emergency action is necessary, for example, when a child’s life is in danger, possibly through poisoning or toxic substances being introduced into the child’s blood stream. Emergency action should normally be preceded by an immediate Strategy Discussion between the Police, Children’s Social Care, Health and other agencies as appropriate.


14. Responsibilities

From the point of referral Children’s Social Care, the Responsible Paediatric Consultant and Police Officers are to work closely together. Lead responsibilities are:

  • Children’s Social Care - for action to safeguard and promote the child’s welfare;
  • The Responsible Paediatric Consultant - for the child’s health care and decisions pertaining to it;
  • The Police - for investigating any crime which may have been committed and the management of how investigations are to be conducted.


15. Covert Video Surveillance

The use of covert video surveillance (CVS) is governed by the Regulation of Investigatory Powers Act 2000 (the 2000 Act). After a decision has been made at a multi-agency strategy discussion to use CVS in a case of suspected fabricated or induced illness, the surveillance should be undertaken by the police. The operation 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.

CVS should be used if there is no alternative way of obtaining information which will explain the child’s signs and symptoms, and the multi-agency strategy discussion meeting considers that its use is justified based on the medical information (see page 73 HMG guidance).


16. Chronologies

The use of chronologies and the attached ‘Possible Warning Signs of Fabricated or Induced Illness Template’ allows for systematic consideration of risk factors and risk assessment.

In compiling chronologies the focus must be on:

  • Ensuring that all practitioners describe precisely what they have observed rather than using unfamiliar terminology. Fact and opinion should be clearly distinguished;
  • Clarifying any concerns about medical information (treatments, expected findings, prognosis etc) with an appropriate Doctor;
  • Focusing on the possible harm to the child, not the motivation of the parent/carer;
  • Any episode in which the parent/carer could be using the medical system to harm the child and all possible episodes of other forms of abuse must be included, including trivial injuries, which may be accidents or due to inflicted harm.

The chronology format will depend on the case. An example template is provided in Appendix 1: Case History - Chronology

A decision should also be made by health professionals involved as to whether the chronology should be categorized using the template ‘Possible Warning Signs of Fabricated or Induced Illness’ Template in Appendix 2: Possible Warning Signs of Fabricated or Induced Illness.


17. Risk from a Member of Staff

There may be times when a member of staff is responsible for the unexplained or inexplicable signs and symptoms in a child. This should be borne in mind when considering how to manage the child’s care. Any such concerns about a member of staff should be discussed with the relevant Named Professional for Child Protection and the agencies allegation lead.

Appendix 1: Case History - Chronology

Click here to view Appendix 1: Case History - Chronology

Appendix 2: Possible Warning Signs of Fabricated or Induced Illness

Possible warning signs of fabricated or induced illness

  1. The order of numbering in the template does not indicate the relative important of each category;
  2. ‘Symptoms’ are subjective experiences reported by the carer or the patient. ‘Signs’ are observable events reported by the carer or patient. ‘Signs’ are observable events reported by the carer or observed or elicited by professionals. Set out below are some examples of behaviour to look out for;
  3. Professionals should bear in mind the limits of the template, which is to give an indication of whether fabricated or induced illness is a possibility.
Category

Possible warning signs.

Please note categories 8 and 10 relate explicitly to parent/carer or siblings of the child concerned.

1. Reported signs and symptoms found on examination are not explained by a medical condition from which the child may be suffering. Here the doctor is attempting to put all the information together to make a diagnosis but the signs and symptoms do not correlate with any recognised disease or where there is a disease known to be present. A very simple example would be a skin rash which did not correlate with any known disease. An experienced doctor must be on their guard if something described is outside their previous experience.
2. Physical examination and results of medical investigations do not explain reported symptoms and signs. Physical examination and appropriate investigations do not confirm the reported clinical story. For example it is reported a child turns yellow (has jaundice) but no jaundice is confirmed when the child is examined and a test for jaundice, if appropriate, is negative. A child with frequent convulsions every day has no abnormalities on a 24 hours video-telemetry (continuous video and EEG recording) even during a so-called ‘convulsion’.
3. There is an inexplicably poor response to prescribed medication and other treatment for the agreed condition does not produce the expected effect. This can result in escalating drugs with no apparent response, using multiple medications to control a routine problem and multiple changes in medication due to either poor response or frequent reports of side effects. On investigation, toxic drug levels commonly occur but may be interspersed with low drug levels suggesting extremely variable administration of medication fluctuating for over-medication to withdrawal of medications. Another feature may be the welcoming of intrusive investigations and treatments by the parent.
4. New symptoms are reported on resolution of previous ones. New symptoms often bear no likely relationship to the previous set of symptoms. For example, in a child where the focus has been on diarrhoea and vomiting, when appropriate assessments fail to confirm this, the story changes to one of convulsions. Sometimes this is manifest by the parents transferring consultation behaviour to another child in the family.
5. Reported symptoms and found signs are not seen to begin in the absence of the carer, i.e. the perpetrator is the only witness of the signs and symptoms. For example, reported symptoms and signs are not observed at school or during admission to hospital. This should particularly realise anxiety of FII where the severity and/or frequency of symptoms reported are such that the lack of independent observation is remarkable. Caution should be exercised when accepting statements from non-medically qualified people that symptoms have been observed. In the case under review there was evidence that the school described episodes as ‘fits’ because they were told that was the appropriate description of the behaviour they were seeing.
6. The child’s normal, daily life activities are being curtailed beyond that which might be expected for any medical disorder from which the child is known to suffer. The carer limits the child’s activities to an unreasonable degree and often either without knowledge of medical professions or against their advice. For example, confining a child to a wheelchair when there is no reason for this, insisting on restrictions of physical activity when not necessary, adherence to extremely strict diets when there is no medical reason for this, restricting child’s school attendance.
7. Over time the child is repeatedly presented with a range of signs and symptoms. At its most extreme this has been referred to as ‘doctor shopping’. The extent and extraordinary nature of the additional consultations is orders of magnitude greater than any concerned parent would explore. Often consultations about the same or different problems are concealed in different medical facilities. Thus the patient might be being investigated in one hospital with one set of problems and the parent will initiate assessments elsewhere for a completely different medical set of problems (or even the same) without informing these various medical professionals about the other consultations.
8. History of unexplained illnesses or deaths or multiple surgeries in parent/carer or siblings of the family. The emphasis here is on the unexplained. Illness and deaths in parents or siblings can frequently be a clue to further investigation and hence a diagnosis in naturally occurring illness. In FII abuse, perpetrators frequently have had multiple unexplained medical problems themselves, ranging from frequent consultations with the general practitioner through to the extreme of Munchausen’s syndrome where there are multiple presentations with fabricated or induced illness resulting in multiple (unnecessary) operations. Self-harm, often multiple, and eating disorders are further common features in perpetrators. Additionally, other children either concurrently or sequentially might have been subject to FII abuse and their medical history should also be examined.
9. Once the perpetrator’s access to the child is restricted, signs and symptoms fade and eventually disappear (similar to category 5 above). This is a planned separation of perpetrator and child which it has been agreed will have a high likelihood of proving (or disproving) FII abuse. It can be difficult in practice, and appear heartless, to separate perpetrator and child. The perpetrator frequently insists on remaining at the child’s bedside, is unusually close to the medial team and thrives in a hospital environment.
10. Exaggerated catastrophes or fabricated bereavements and other extended family problems are reported. This is an extension of category 8. On exploring reported illnesses or deaths in other family members (often very dramatic stories) no evidence is found to confirm these stories. They were largely or wholly fictitious.
11. Incongruity between the seriousness of the story and the actions of the parents. Given a concerning story, parents by and large will cooperate with medical efforts to resolve the problem. They will attend outpatients, attend for investigations and bring the child for review urgently when requested. Perpetrators of the FII abuse, apparently paradoxically, can be extremely creative at avoiding contacts which would resolve the problem. This is incongruity between their express concerns and the actions they take. They repeatedly fail to attend for crucial investigations. They go to hospitals that do not have the background information. They repeatedly produce the flimsiest of excuses for failing to attend crucial assessments (somebody else’s birthday, thought the hospital was closed, went to outpatients at one o’clock in the morning, etc). We have used a term ‘piloting care’, for this behaviour.
12. Erroneous or misleading information provided by parents. These perpetrators are adept at spinning a web of misinformation which perpetuates and amplifies the illness story, increases access to interventions in the widest sense (more treatment, more investigations, more restrictions on the child or help, etc). An extreme example of this is spreading the idea that the child is going to die when in fact no one in the medical profession has ever suggested this. Changing or inconsistent stories should be recognised and challenged.


Further Information and Guidance

For further information and guidance see:

Amendments to this Chapter

This chapter has been extensively updated and should be read throughout.

End.