1. JJRR Fabricated or Induced Illness Lite Bite Dr Jan Reiser Consultant Paediatrician Designated Doctor for Child Protection E&N Herts NHS Trust East and North Hertfordshire NHS Trust

2. JJRR Objectives  For professionals to :  Understand the definitions of FII  To recognise the barriers to diagnosis  To recognise the indicators of FII  To know their role in the recognition and management of FII

3. JJRR Learning agreement  Everyone’s contribution is of equal value  We are all responsible for our own learning  Mobile phones off/ on silent  Acknowledge difference  Confidentiality, but not if safeguarding  Challenge opinions not the person  Start and end on time  Listen to each other/ speak one at a time

4. JJRR Royal College of Paediatrics and Child Health 2009  Suggested Definition: ‘An infant or child who suffers harm (or risk of harm) as a result of being presented for medical attention with symptoms or signs of illness which have been fabricated or induced by a carer.’  Definition based upon harm to the child  Deliberate behaviour  Includes Fabrication, Falsification and Induction of illness

5. JJRR Definition & Spectrum  Fabrication Verbal Verbal Past medical historyPast medical history FitsFits DiarrhoeaDiarrhoea Falsification of symptoms or records Falsification of symptoms or records BleedingBleeding Sputum in CFSputum in CF Many others Many others  Induction Poisoning Laxatives Smothering Ie causing an illness Neglect Illness induction Over- anxious Illness fabrication Exaggeration Laidback Unconcerned Ignoring real illness ‘Normality’

6. JJRR Fabricated or Induced Illness Requires the participation of 3 persons! Carer Professional Child

7. JJRR Indicators  Symptoms and signs found not explained by known condition  Examination and tests do not explain reported symptoms & signs  Inexplicably poor response to treatment  New symptoms develop as old ones excluded

8. JJRR Indicators  Reported symptoms and signs do not begin in absence of carer  Normal life curtailed more than condition suggests Eg asthma school loss with no signs Eg asthma school loss with no signs  Over time repeatedly presents with multiple problems  Once perpetrators access restricted symptoms & signs improve

9. JJRR Mechanisms of Harm to the Child  Direct harm through induction of physical signs of ill health.  Indirect harm through hospitalisation, investigation and unnecessary treatments.  Psychological harm: Directly due to the fabrications Directly due to the fabrications Due to associated problems Due to associated problems

10. JJRR Perpetrators of FII Characteristics of illness fabricators and inducers in 313 cases: Characteristics of illness fabricators and inducers in 313 cases: Predominantly mothers (89%). Predominantly mothers (89%). Previous contact with mental health services reported in 30%. Previous contact with mental health services reported in 30%. Personal histories of fabricators included reports of physical and sexual child abuse (25%). Personal histories of fabricators included reports of physical and sexual child abuse (25%). Reports of distant, passive or absent fathers. Reports of distant, passive or absent fathers. Page 29 of Fabricated or Induced Illness by Carers, Royal College of Paediatrics and Child Health, 2002 Page 29 of Fabricated or Induced Illness by Carers, Royal College of Paediatrics and Child Health, 2002

11. JJRR Barriers to Recognition (1)  Ignorance about this kind of abuse  Disbelief – do not believe that FII exists.  Avoidance – do not want to have anything to do with FII.  Fear of complaints – the implication for litigation, trust and professional bodies.  Do not recognise own role – and responsibility in possible cases of maltreatment.  Are not used to working with deceit  Used to asking mothers for information and help regarding their children

12. JJRR Barriers to Identification (2) The Nature of the Maltreatment  Rarity.  ‘Diagnosis’ not easily made.  ‘Diagnosis’ needs to be made cautiously.  A serious form of maltreatment.  Child’s history v child’s presentation.  Child’s presentation v clinical findings.  Mother ‘befriending’ professionals

13. JJRR Making a Referral  A referral should be made to children’s social care if you consider the child is a child in need, including in need of protection.  If making the referral by telephone confirm in writing within 48 hours.  Children’s social care should acknowledge the referral within one working day.  Do not discuss with parents until strategy for this is agreed

14. JJRR Strategy Discussion  Should involve all key professionals responsible for the child’s welfare, senior enough to contribute to discussion.  If relevant include: - Medical experts - Medical experts - Police - Police - (Local Authority solicitor) - (Local Authority solicitor)  More than one strategy discussion may be necessary.

15. JJRR Recording (1)  Keep a record of events.  Record any discussions with the child and/or carer including quotes of what they said.  Note the time, date, place and names of other people who were present.  Store records in secure way.

16. JJRR Issues for Professionals  Ongoing assessment may take some time.  Uncertainty may be present for a while: uncertainty may be reduced…  The outcome of assessment may be a decision that it is not FII.  Consider a debriefing.

17. JJRR Multidisciplinary Approach Multidisciplinary Approach Practitioners working with cases of FII should recognise:  Different professional roles and responsibilities.  Inter-dependence.  Working as part of a multidisciplinary team.  Working to an agreed plan.  Understanding of who to turn to for advice.  Feelings of others – double deceiving.  Importance of trust – open discussion in closed meetings.

18. JJRR Chronologies Purpose:  Enables patterns of presentation for medical treatment to be recognised for child and across generational boundaries.  Informs decisions about services and change. Should include:  Medical, psychiatric and social histories of child, parents, siblings and significant others.

19. JJRR HSBC Website  www.hertssafeguarding.org.uk www.hertssafeguarding.org.uk  Look up Herts Policies  Link to FII is  http://hertsscb.proceduresonline.com/chap ters/p_fab_ill.html#referral http://hertsscb.proceduresonline.com/chap ters/p_fab_ill.html#referral http://hertsscb.proceduresonline.com/chap ters/p_fab_ill.html#referral

20. JJRR Questions

21. JJRR What to do  If you suspect a child is subject to FII 1. Discuss with senior colleague 2. Refer to CSF 3. Do not discuss with parent/carer! 4. Strategy meeting CSFCSF PaediatricianPaediatrician GPGP SchoolSchool PolicePolice

22. JJRR Thank You!

23. JJRR Exercise

24. JJRR Case Study  8 Year old boy – Harry  GP 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 reported Diarrhoea and abdominal pain reported Mother suspects food allergyMother suspects food allergy On an avoidance dietOn an avoidance diet Symptoms persist intermittentlySymptoms persist intermittently

25. JJRR Case Study  School Many absences because of health problems Many absences because of health problems 70% attendance 70% attendance Mother reports severe asthma and food allergies Mother reports severe asthma and food allergies Not allowed to do PE Not allowed to do PE Not allowed any school food Not allowed any school food Playtime - runs about without restriction or cough Playtime - runs about without restriction or cough

26. JJRR Case Study  Questions 1. What are potential causes of harm to Harry if this illness is imagined or exaggerated? 2. What are useful next steps (to confirm concerns)? 3. What are further useful tools to investigate the possibility of FII 4. What are potential further risks if mother learns of the concerns 5. What are impediments to diagnosing and managing this problem

27. JJRR What are potential causes of harm to Harry if this illness is imagined or exaggerated?  Unnecessary investigations  Unnecessary medication  Missing school  Social exclusion  Emotional consequences of illness role

28. JJRR What are useful steps to confirm concerns?  Discuss concern with senior colleague  Refer concern to Children’s Social Care  Record what has occurred and what was said  Prepare chronology  Do not to discuss concerns with mother

29. JJRR What are useful further tools to investigate this possibility  Strategy meeting with all professionals  Chronology of events  List all professionals who are involved  Direct communication between professionals  Distinguish reported problems and objective evidence  Record all that occurs or is reported

30. JJRR What are potential further risks if mother learns of the concerns  Change of school  Change of doctor(doctor shopping)  Change of symptoms(symptom migration)  Induction of illness  Change of effected child

31. JJRR What are impediments to diagnosing and managing this problem  Do not believe in FII  Do not understand own role  Fear of complaints  Believe it’s a complex diagnosis  Fear of missing a rare medical diagnosis  Mother ‘befriending’ professionals  Child with disability

32. JJRR Questions

33. JJRR What to do  If you suspect a child is subject to FII 1. Discuss with senior colleague 2. Refer to CSF 3. Do not discuss with parent/carer! 4. Strategy meeting Children’s ServicesChildren’s Services PaediatricianPaediatrician GPGP SchoolSchool PolicePolice

34. JJRR Read the case scenario and consider the following questions  What are your concerns about the welfare of the child and possible impairment to their health or development?  What evidence do you have to support your concerns?  Who would you share your concerns with?  What do you think you should do next to safeguard and promote the welfare of the child?  What would you record and where?