1. CHILDREN IN WHOM ILLNESS IS FABRICATED OR INDUCED SUE THOMPSON SAFEGUARDING CHILDREN NURSE SPECIALIST. RGN;RHV; BSC (Hons); MA

2. WHAT IS FABRICATION OR INDUCED ILLNESS? Munchausen syndrome by proxy (Meadow 1977) Factitious Illness by Proxy (Bools 1996; Jones & Bools 1999) Illness Induction syndrome (Gray et al 1995) Fabrication or induction of illness in a child (FII) (Department of Health 2002)

3. DEFINITION Fabricated or induced illness (FII) 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. (LSCB 2007:164)

4. INCIDENCE & PREVALENCE Fabrication or induction of illness in a child by a carer is considered to be rare McClure et al (1996) – 2-year study – the researchers estimated that the combined annual incidence in the British Isles of these forms of abuse in children under 16- years was at least 0.5 per 100,000 and for children under 1-year at least 2.8 per 100,000.

5. The study also showed that reported rates of fabricated or induced illness varied greatly between different health service regions and the researchers suggested it is under-reported nationally.

6. RESPONDING TO REPORTED SIGNS & SYMPTOMS Extensive, unnecessary medical investigations may be carried out in order to establish the underlying causes for the reported sign & symptoms. The child may also have treatments prescribed or operations which are unnecessary. Carers exhibit a range of behaviours when they believe that their child is ill.

7. LIST OF BEHAVIOURS ASSOCIATED WITH FII. Deliberately inducing symptoms in children by administering medication or other substances, or by means of intentional suffocation. Interfering with treatments by over dosing, not administrating 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 in passing urine, vomiting or fits.

8. Exaggerating symptoms, causing professionals to undertake investigations & treatments which may be invasive, are unnecessary and therefore are harmful & possibly dangerous. Obtaining specialist treatments or equipment for children who do not require them Alleging psychological illness in a child

9. EARLY HISTORY & CONCERN ABOUT THE CHILD’S HEALTH A large number of children in whom illness is fabricated or induced will have been known to health professionals from birth. Non –organic failure to thrive is a common feature of this group of children. At the point fabrication or induction of illness is confirmed the child may have organic problems which will require on-going medical treatment.

10. The medical histories of this group of children is likely to start early & in many instances will have become extensive by the time the suspected abuse is identified. When a child is in hospital, it is usual for carers to be very involved in the care of their child, including participating in medical tests etc. Where illness in being fabricated or induced by a carer, these normal hospital practices afford the carer the opportunity to continue this behaviour

11. IMPACT OF FII ON THE HEALTH OR DEVELOPMNENT OF A CHILD International research findings suggest up to 10% of these children die and approximately 50% experience long-term morbidity. Suffer significant long-term consequences. FII may not necessarily result in the child experiencing physical harm but the emotional impact must be seriously considered

12. Impact on learning Bool et al (1993) found a range of emotional and behavioural disorders & school related problems including difficulties in attention, concentration & non-attendance Earlier study in 1989 reported a range of disorders – feeding disorders in infants; withdrawal & hyperactivity in pre-school; direct fabrication or exaggeration of physical symptoms by older children & adolescents

13. WHAT SHOULD WE BE DOING? –Becoming concerned if reported information by carer is frequent & start becoming more complex – routinely records should be kept –Frequent time off school for medical appointments that may start escalating must be closely monitored and may need to be verified by school nurse to alleviate concerns –Request for medication may escalate or become problematic – school nurse is the pathway to verify what the child should be taking and instigating care plan

14. –A chronology of what is reported can be useful to maintain a focus & carers responses should be recorded –Discuss your worries with your Child Protection Designated Officer –Discuss health worries with your school health nurse, who can seek further health information via GP or verify what is being reported

15. Professional meeting may result in a more focused approach and plan of action As chronology becomes clearer always consider undertaking ‘what if’ Referring concerns to Children Schools & Families ‘Concerns should not be raised with parents if it is judged that this action will jeopardise the child’s safety’ (LSCB 2007:170)

16. CASE STUDY Introduction to case School Health Nurse raised concerns about Morphine being administered in a syringe in school to a 6-year old More questions being asked of the school Contact with the child’s GP Contact with child’s Paediatrician Contact with Tertiary services

17. Professionals meeting of health professionals and CSF – more information from tertiary services required Further professional meeting including police & tertiary services Child Protection investigation, conference and name placed on Hertfordshire Child Protection Register

18. Child Protection plan is to: – slowly take child off medication –Reintegrate child back into full time schooling –Closely monitor the behaviour of parents to the child –Work closely with GP to ensure no un- necessary referrals are made within health –Consider wishes and feelings of the child

19. SUMMARY OF CASE Child was slowly taken off all medication with close monitoring Within 2-weeks the child was back into full time schooling and any absences were closely monitored Extensive work was commenced with parents Liaison with GP and all agencies continued for a lengthy period of time

20. QUESTIONS