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Fabricated or Induced IllnessFabricated or Induced IllnessLite BiteLite Bite

Dr Jan ReiserDr Jan ReiserConsultant PaediatricianConsultant Paediatrician

Designated Doctor for Child ProtectionDesignated Doctor for Child ProtectionE&N Herts NHS TrustE&N Herts NHS Trust

East and North HertfordshireNHS Trust

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ObjectivesObjectives

For professionals to :For professionals to :

Understand the definitions of FIIUnderstand the definitions of FII To recognise the barriers to diagnosisTo recognise the barriers to diagnosis To recognise the indicators of FIITo recognise the indicators of FII To know their role in the recognition To know their role in the recognition

and management of FIIand management of FII

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Learning agreementLearning agreement

Everyone’s contribution is of equal valueEveryone’s contribution is of equal value We are all responsible for our own learningWe are all responsible for our own learning Mobile phones off/ on silentMobile phones off/ on silent Acknowledge differenceAcknowledge difference Confidentiality, but not if safeguardingConfidentiality, but not if safeguarding Challenge opinions not the personChallenge opinions not the person Start and end on timeStart and end on time Listen to each other/ speak one at a timeListen to each other/ speak one at a time

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Royal College of Paediatrics and Royal College of Paediatrics and Child Health 2009Child Health 2009

Suggested Definition: Suggested Definition: ‘An infant or child who suffers ‘An infant or child who suffers harm (or risk of harm) as a result of being presented for harm (or risk of harm) as a result of being presented for medical attention with symptoms or signs of illness which medical attention with symptoms or signs of illness which have been fabricated or induced by a carer.’have been fabricated or induced by a carer.’

Definition based upon harm to the childDefinition based upon harm to the child Deliberate behaviourDeliberate behaviour Includes Fabrication, Falsification and Induction of illnessIncludes Fabrication, Falsification and Induction of illness

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Definition & SpectrumDefinition & Spectrum

FabricationFabrication VerbalVerbal

• Past medical historyPast medical history• FitsFits• Diarrhoea Diarrhoea

Falsification of symptoms or Falsification of symptoms or recordsrecords

• Bleeding Bleeding • Sputum in CFSputum in CF

Many othersMany others

InductionInduction PoisoningPoisoning LaxativesLaxatives Smothering Smothering Ie causing an illnessIe causing an illness

NeglectIllnessinduction

Over-anxious

Illnessfabrication

Exaggeration

Laidback

Unconcerned

Ignoring real illness

‘Normality’

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Fabricated or Induced IllnessFabricated or Induced Illness

Requires the participation of 3 persons! Requires the participation of 3 persons!

Carer Professional Carer Professional

ChildChild

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Indicators Indicators

Symptoms and signs found not Symptoms and signs found not explained by known conditionexplained by known condition

Examination and tests do not explain Examination and tests do not explain reported symptoms & signsreported symptoms & signs

Inexplicably poor response to treatmentInexplicably poor response to treatment New symptoms develop as old ones New symptoms develop as old ones

excludedexcluded

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IndicatorsIndicators

Reported symptoms and signs do not begin Reported symptoms and signs do not begin in absence of carerin absence of carer

Normal life curtailed more than condition Normal life curtailed more than condition suggestssuggests Eg asthma school loss with no signsEg asthma school loss with no signs

Over time repeatedly presents with multiple Over time repeatedly presents with multiple problemsproblems

Once perpetrators access restricted Once perpetrators access restricted symptoms & signs improvesymptoms & signs improve

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Mechanisms of HMechanisms of Harm to the arm to the ChildChild

Direct harm through induction of physical Direct harm through induction of physical

signs of ill health.signs of ill health.

Indirect harm through hospitalisation, Indirect harm through hospitalisation,

investigation and unnecessary treatments.investigation and unnecessary treatments.

Psychological harm:Psychological harm:

Directly due to the fabricationsDirectly due to the fabrications

Due to associated problemsDue to associated problems

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Perpetrators of FIIPerpetrators of FII

Characteristics of illness fabricators and Characteristics of illness fabricators and inducers in 313 cases:inducers in 313 cases:

Predominantly mothers (89%).Predominantly mothers (89%). Previous contact with mental health services Previous contact with mental health services

reported in 30%.reported in 30%. Personal histories of fabricators included reports Personal histories of fabricators included reports

of physical and sexual child abuse (25%).of physical and sexual child abuse (25%). Reports of distant, passive or absent fathers.Reports of distant, passive or absent fathers.

Page 29 of Page 29 of Fabricated or Induced Illness by CarersFabricated or Induced Illness by Carers, Royal College of Paediatrics and Child Health, 2002, Royal College of Paediatrics and Child Health, 2002

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Barriers to Recognition (1)Barriers to Recognition (1) Ignorance Ignorance about this kind of abuseabout this kind of abuse

Disbelief Disbelief – do not believe that FII exists.– do not believe that FII exists.

AvoidanceAvoidance – do not want to have anything to do with – do not want to have anything to do with FII.FII.

Fear of complaintsFear of complaints – the implication for litigation, trust – the implication for litigation, trust and professional bodies.and professional bodies.

Do not recognise own roleDo not recognise own role – and responsibility in – and responsibility in possible cases of maltreatment.possible cases of maltreatment.

Are not used to working with Are not used to working with deceitdeceit

Used to asking mothers for information and help Used to asking mothers for information and help regarding their childrenregarding their children

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Barriers to Identification (2)Barriers to Identification (2)The Nature of the MaltreatmentThe Nature of the Maltreatment

Rarity.Rarity. ‘‘Diagnosis’ not easily made.Diagnosis’ not easily made. ‘‘Diagnosis’ needs to be made cautiously.Diagnosis’ needs to be made cautiously. A serious form of maltreatment.A serious form of maltreatment. Child’s history v child’s presentation.Child’s history v child’s presentation. Child’s presentation v clinical findings.Child’s presentation v clinical findings. Mother ‘befriending’ professionalsMother ‘befriending’ professionals

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Making a ReferralMaking a Referral

A referral should be made to children’s A referral should be made to children’s social caresocial care if you consider the child is a child if you consider the child is a child in need, including in need of protection.in need, including in need of protection.

If making the referral by telephone confirm If making the referral by telephone confirm in writing within 48 hours.in writing within 48 hours.

Children’s social care should acknowledge Children’s social care should acknowledge the referral within one working day.the referral within one working day.

Do not discuss with parents until Do not discuss with parents until strategy for this is agreedstrategy for this is agreed

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Strategy DiscussionStrategy Discussion Should involve all key professionals Should involve all key professionals

responsible for the child’s welfare, senior responsible for the child’s welfare, senior enough to contribute to discussion.enough to contribute to discussion.

If relevant include:If relevant include:

- Medical experts- Medical experts

- Police- Police

- (Local Authority solicitor)- (Local Authority solicitor) More than one strategy discussion may be More than one strategy discussion may be

necessary.necessary.

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Recording (1)Recording (1)

Keep a record of events.Keep a record of events.

Record any discussions with the child Record any discussions with the child and/or carer including quotes of what they and/or carer including quotes of what they said.said.

Note the time, date, place and names of Note the time, date, place and names of other people who were present.other people who were present.

Store records in secure way.Store records in secure way.

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Issues for ProfessionalsIssues for Professionals

Ongoing assessment may take some time.Ongoing assessment may take some time. Uncertainty may be present for a while: Uncertainty may be present for a while:

uncertainty may be reduced…uncertainty may be reduced… The outcome of assessment may be a The outcome of assessment may be a

decision that it is not FII.decision that it is not FII. Consider a debriefing.Consider a debriefing.

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Multidisciplinary ApproachMultidisciplinary Approach

Practitioners working with cases of FII Practitioners working with cases of FII should recognise:should recognise:

Different professional roles and responsibilities.Different professional roles and responsibilities.Inter-dependence.Inter-dependence.Working as part of a multidisciplinary team.Working as part of a multidisciplinary team.Working to an agreed plan.Working to an agreed plan.Understanding of who to turn to for advice.Understanding of who to turn to for advice.Feelings of others – double deceiving.Feelings of others – double deceiving.Importance of trust – open discussion in closed meetings.Importance of trust – open discussion in closed meetings.

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ChronologiesChronologies

Purpose:Purpose: Enables patterns of presentation for medical Enables patterns of presentation for medical

treatment to be recognised for child and across treatment to be recognised for child and across generational boundaries.generational boundaries.

Informs decisions about services and change.Informs decisions about services and change.

Should include:Should include: Medical, psychiatric and social histories of child, Medical, psychiatric and social histories of child,

parents, siblings and significant others.parents, siblings and significant others.

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HSBC WebsiteHSBC Website

www.hertssafeguarding.org.uk Look up Herts PoliciesLook up Herts Policies

Link to FII isLink to FII is http://hertsscb.proceduresonline.com/chap

ters/p_fab_ill.html#referral

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QuestionsQuestions

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What to doWhat to do

If you suspect a child is subject to FIIIf you suspect a child is subject to FII1.1. Discuss with senior colleagueDiscuss with senior colleague

2.2. Refer to CSFRefer to CSF

3.3. Do not discuss with parent/carer!Do not discuss with parent/carer!

4.4. Strategy meetingStrategy meeting• CSFCSF• PaediatricianPaediatrician• GPGP• SchoolSchool• PolicePolice

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Thank You!Thank You!

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ExerciseExercise

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Case StudyCase Study

8 Year old boy – Harry8 Year old boy – Harry GPGP

Diagnosis of asthma Diagnosis of asthma • blue inhaler, brown inhaler, tabletblue inhaler, brown inhaler, tablet• Regularly repeated prescriptionRegularly repeated prescription• No admissionsNo admissions• No chest deformityNo chest deformity

Diarrhoea and abdominal pain reportedDiarrhoea and abdominal pain reported• Mother suspects food allergyMother suspects food allergy• On an avoidance dietOn an avoidance diet• Symptoms persist intermittentlySymptoms persist intermittently

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Case StudyCase Study

SchoolSchool Many absences because of health problemsMany absences because of health problems 70% attendance70% attendance Mother reports severe asthma and food Mother reports severe asthma and food

allergiesallergies Not allowed to do PENot allowed to do PE Not allowed any school foodNot allowed any school food Playtime - runs about without restriction or Playtime - runs about without restriction or

cough cough

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Case StudyCase Study QuestionsQuestions1.1. What are potential causes of harm to Harry if What are potential causes of harm to Harry if

this illness is imagined or exaggerated?this illness is imagined or exaggerated?2.2. What are useful next steps (to confirm What are useful next steps (to confirm

concerns)?concerns)?3.3. What are further useful tools to investigate the What are further useful tools to investigate the

possibility of FIIpossibility of FII4.4. What are potential further risks if mother learns What are potential further risks if mother learns

of the concernsof the concerns5.5. What are impediments to diagnosing and What are impediments to diagnosing and

managing this problemmanaging this problem

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What are potential causes of harm to Harry What are potential causes of harm to Harry if this illness is imagined or exaggerated?if this illness is imagined or exaggerated?

Unnecessary investigationsUnnecessary investigations Unnecessary medicationUnnecessary medication Missing schoolMissing school Social exclusionSocial exclusion Emotional consequences of illness Emotional consequences of illness

rolerole

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What are useful steps to confirm What are useful steps to confirm concerns?concerns?

Discuss concern with senior colleagueDiscuss concern with senior colleague Refer concern to Children’s Social CareRefer concern to Children’s Social Care Record what has occurred and what was Record what has occurred and what was

saidsaid Prepare chronologyPrepare chronology Do not to discuss concerns with motherDo not to discuss concerns with mother

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What are useful further tools to What are useful further tools to investigate this possibility investigate this possibility

Strategy meeting with all professionalsStrategy meeting with all professionals Chronology of eventsChronology of events List all professionals who are involvedList all professionals who are involved Direct communication between professionalsDirect communication between professionals Distinguish reported problems and objective Distinguish reported problems and objective

evidenceevidence Record all that occurs or is reportedRecord all that occurs or is reported

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What are potential further risks if What are potential further risks if mother learns of the concernsmother learns of the concerns

Change of schoolChange of school Change of doctorChange of doctor (doctor shopping)(doctor shopping) Change of symptomsChange of symptoms (symptom (symptom

migration)migration) Induction of illnessInduction of illness Change of effected childChange of effected child

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What are impediments to diagnosing and What are impediments to diagnosing and managing this problemmanaging this problem

Do not believe in FIIDo not believe in FII Do not understand own roleDo not understand own role Fear of complaintsFear of complaints Believe it’s a complex diagnosisBelieve it’s a complex diagnosis Fear of missing a rare medical diagnosisFear of missing a rare medical diagnosis Mother ‘befriending’ professionalsMother ‘befriending’ professionals Child with disabilityChild with disability

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QuestionsQuestions

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What to doWhat to do

If you suspect a child is subject to FIIIf you suspect a child is subject to FII1.1. Discuss with senior colleagueDiscuss with senior colleague

2.2. Refer to CSFRefer to CSF

3.3. Do not discuss with parent/carer!Do not discuss with parent/carer!

4.4. Strategy meetingStrategy meeting• Children’s ServicesChildren’s Services• PaediatricianPaediatrician• GPGP• SchoolSchool• PolicePolice

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Read the case scenario and Read the case scenario and consider the following questionsconsider the following questions

What are your concerns about the welfare of the What are your concerns about the welfare of the child and possible impairment to their health or child and possible impairment to their health or development?development?

What evidence do you have to support your What evidence do you have to support your concerns?concerns?

Who would you share your concerns with?Who would you share your concerns with? What do you think you should do next to What do you think you should do next to

safeguard and promote the welfare of the child?safeguard and promote the welfare of the child? What would you record and where?What would you record and where?