Fabricated or induced illness in children

Reflecting on Practice Questions raised by the participants during Child Protections Practitioners Forum training and development session on 6th & 8th December 2017: How do we support staff who are working with concerns over fabricated and induced illness for a child? How do workers manage their anxieties and frustrations when they have concerns over fabricated and induced illness for a child? Why does it take so long for fabricated and induced illness to be confirmed? Is it more prevalent for younger children? What information should be recorded when staff start to worry about fabricated and induced illness? Who can confirm whether there is fabricated and induced illness? During the training and development sessions some of the questions were answered within the following presentation. Other queries were explored as part of the group discussion.

The Forth Valley Child Protection Guidance AGENDA ITEMS INCLUDE: What is Harm and Significant Harm in a Child Protection Context? What is Risk in a Child Protection Context ? Recording and Analysing Information Non Engaging Families Risk Assessment of Accumulative Concerns Each of these items should be taken into account when addressing the possibility of: Fabricated or Induced Illness…… page 99

DESCRIPTION Fabricating an illness: Inducing an illness: Claiming the child has symptoms which are unverifiable unless observed directly, such as pain, frequency of passing urine, vomiting or fits. These claims result in unnecessary investigations and treatments which may cause secondary physical problems; Exaggerating symptoms which are unverifiable unless observed directly, causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and therefore are harmful and possibly dangerous. Inducing an illness: Deliberately inducing symptoms in children by administering medication or other substances, by means of intentional transient airways obstruction or by interfering with the child’s body so as to cause physical signs. Interfering with treatments by over dosing with medication, not administering them or interfering with medical equipment such as infusion lines. HM Government (2008) Safeguarding children in whom illness is fabricated or induced:

DESCRIPTION Fabricated and Induced Illness is a spectrum of disorders rather than a single entity. At one end : less extreme behaviours include a genuine belief that the child is ill. At the other end : the behaviour of carers includes them deliberately inducing symptoms.

How common is Fabricated and Induced Illness? It's difficult to estimate how widespread FII is because many cases may go unreported or undetected. One study published in 2000 estimated 89 cases in a population of 100,000 over a two-year period. However, it's likely that this figure underestimates the actual number of cases. This can involve children of all ages, but the most severe cases are usually associated with children under five. Prevalence is up to six times higher with children under the age of 1 year. In more than 90% of reported cases, the child's mother is responsible for the abuse. However, there have been cases where the father, foster parent, grandparent, guardian, or a healthcare or childcare professional was responsible.

CAUSES It's not fully understood why some parents or carers fabricate or induce illness in their child. However, it's likely the parent or carer will have a history of previous traumatic experiences. Recent studies have shown that mothers who carry out the abuse have abnormal "attachment" experiences with their own mothers, which may affect their parenting and relationship with their children. An example of this is repeatedly seeing a doctor to satisfy an emotional need to get attention for the child.

CAUSES Role Playing: A theory is that FII is a kind of role playing. It allows a mother to adopt the role of a caring and concerned mother, while at the same time allowing her to pass the responsibility of caring for a child onto medical staff. Escapism :Another theory is that FII is a way for the mother to escape her own negative feelings and unpleasant emotions. By creating a permanent crisis situation surrounding her child, she's able to focus her thoughts on the treatment of her child, while keeping her own negative feelings and emotions at bay.

CAUSES Personality disorder : A high proportion of mothers involved in FII have been found to have a personality disorder and, in particular, a borderline personality disorder. Sometimes, people with personality disorders find reward in behaviour or situations that other people would find intensely distressing. It's thought that some mothers who carry out FII find the situation of their child being under medical care rewarding. Other mothers who've been involved in FII have reported feeling a sense of resentment towards their child because they have a happy childhood, unlike their own. It's important to note that not all mothers with borderline personality disorder go on to abuse their children.

Warning signs The abuse that occurs in fabricated or induced illness (FII) takes a range of forms and can be difficult to recognise, but there are warning signs to look out for. A clinician may suspect fabricated or induced illness if, after carrying out examinations and tests, there appears to be no explanation for the child's symptoms. Agencies may suspect FII when the mother is telling conflicting information to different people. They should also look out for one or more of the following warning signs:- …………… Warning signs

Symptoms only appear when the parent or carer is present The only person claiming to notice symptoms is the parent or carer The affected child has an inexplicably poor response to medication or other treatment If one particular health problem is resolved, the parent or carer may then begin reporting a new set of symptoms The child's alleged symptoms don't seem plausible – for example, a child who is supposedly lost a lot of blood but doesn't become unwell Warning signs

The child's daily activities are being limited far beyond what you would usually expect as a result of having a certain condition –for example, they never go to school in case they might have difficulty using the toilet The parent or carer has good medical knowledge or a medical background 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 healthcare staff, but may become abusive or argumentative if their own views about what's wrong with the child are challenged Warning signs

One parent (commonly the father) has little or no involvement in the care of the child The parent or carer has a history of frequently changing GPs or visiting different hospitals for treatment, particularly if their views about the child's treatment are challenged by medical staff The parent or carer encourages medical staff to perform often painful tests and procedures on the child (tests that most parents would only agree to if they were persuaded that it was absolutely necessary) Warning signs

Risks to the child International research findings suggest that up to 10% of children in whom illness is induced die and about 50% experience long-term consequent morbidity (HM Government, 2009). In the UK, McClure et al (1996) found that 8 out of 128 (6%) children died as a direct result of illness induction. Many of the children who do not die suffer significant long-term consequences including long-term impairment of their physical, psychological and emotional development (DoH et al 2002; DoH, 2000). Bools et al. (1993) found a range of emotional and behavioural disorders, and school-related problems including difficulties in attention and concentration and non-attendance. There has been little research undertaken on the longer-term outcomes for children exposed to FII. Edinburgh University Research 2011

Intervention – Key points to consider The focus of any intervention should always be to identify and minimise harm to the child regardless of the motivation of the perpetrator. Being honest about suspicions may scare off the parent, making it difficult to gain evidence, attract undue media attention, or worse, can lead to an increase in harmful behaviour in an attempt to be more convincing. Researchers offer cautionary advice: it is crucial to do the detective work. Maintaining a balance between the child’s and family’s needs versus the risks of harm is difficult and uncomfortable. Edinburgh University Research 2011

Intervention – Key points Multi-agency collaboration and communication is crucial in diagnosis and any form of child maltreatment, including FII. Social Services have lead responsibility for investigating safeguarding issues in children. Health and social care professionals should comply with all reasonable requests for assistance and should seek to work in close partnership. This is especially important in suspected FII cases because of the uniquely medical nature of the concerns. Edinburgh University Research 2011

Intervention – Key points Consider motivation. For example, the family might be having financial trouble and fabricating or inducing an illness may entitle them to extra welfare benefits. Verify the personal histories of family members, as lies may have been told (for example, that one of the family members has a medical background). Remember that some parents may be extremely manipulative and convincing. They may be intelligent enough to research medical conditions, and know how to invoke complaints procedures.

Working with children and families There should be a presumption of openness, joint decision making, and a willingness to listen to families and capitalise on their strengths, but the guiding principle should always be what is in the best interests of the child. However keeping in mind that being honest about suspicions may scare off the parent, making it difficult to gain evidence, or can lead to an increase in harmful behaviour in an attempt to be more convincing. Where it is suspected or confirmed that illness has been fabricated or induced in a child, all decisions about what and when to tell parents and children should be taken by senior staff within the multi-agency team.

References: HM Government (2008) Safeguarding children in whom illness is fabricated or induced: supplementary guidance to Working Together to safeguard children. Nottingham: DCSF Publications. Edinburgh University Research 2011 : Fabricated or induced illness in children: A rare form of child abuse? https://www.nhs.uk/conditions/Fabricated or induced illness