Kate Grieve provides a guide to cases involving Fabricated or Induced Illness (FII) and the many factors to be considered and analysed by practitioners, experts and judges in these complex proceedings.
In cases of Fabricated or Induced Illness (FII), a carer intentionally causes or fabricates illness in a child in their care. Carers may simply exaggerate or fabricate the child’s symptoms by falsifying medical history or tampering with tests in order to make the child appear ill, or they may deliberately induce symptoms through various methods including poisoning, starvation, or suffocation.
Where illness is being induced or fabricated, unnecessary and invasive medical investigations may be carried out causing the child to spend periods in hospital and attend unnecessary medical appointments. This places the child at risk of significant physical harm as a result of the treatment they receive but also puts the child at risk of significant emotional harm as a result of inter alia: an abnormal relationship with their carer; disturbed relationships with other family members; and a loss of their personal identity through the adoption of a ‘sick role’.
Perpetrators of FII are typically mothers, and the victims are usually their young children. The most common illness presentations are: seizures; failure to thrive; vomiting and diarrhoea; asthma and allergic reactions; and infections. The initial assaults by the carer are then usually compounded by subsequent painful medical procedures performed in an effort to diagnose and treat what may appear to be a perplexing and elusive medical condition.
FII is not a mental illness as can be diagnosed. Perpetrators will have various psychological, psychiatric, and environmental features leading to the behaviour of fabricating or inducing illness in a child. FII is a form of child abuse where the perpetrator uses medical professionals as tools to subject the child to harm.
In R v LM  QCA 192 at para. 67 (4 June 2004) the Supreme Court of Queensland, Australia, held that “the term factitious disorder (Munchausen’s Syndrome) by proxy is merely descriptive of a behaviour, not a psychiatrically identifiable illness or condition”.
Three ingredients are required for this form of abuse: a dependent child available to the carer under her or his control, influence or behest; the carer presents the child to the health care system with invented symptoms or fabricated signs; and a health care system exists in which doctors, nurses and other health care professionals have almost unlimited capacity in terms of resources and technology to undertake investigations and interventions with children.
The fabrication or induction of illness in a child by a carer has been considered to be rare. McClure et al (1996) carried out a two-year study to determine the epidemiology of Munchausen Syndrome by Proxy (now known as FII), non-accidental poisoning and non-accidental suffocation in the UK and the Republic of Ireland. The study included data from 128 confirmed cases notified to the British Paediatric Association Surveillance Unit during the period September 1992 to August 1994.
Based on this data, the researchers estimated that the combined annual incidence in the British Isles of these forms of abuse in children under 16 years old was at least 0.5 per 100,000 and for children under 1 year at least 2.8 per 100,000. The authors calculated that “in a hypothetical district of one million inhabitants therefore, the expected incidence is approximately one child per year”.
This study showed that reported rates of fabricated or induced illness varied greatly between different health service regions and the researchers suggested it was under-reported nationally. At the time of their study the findings also suggested that paediatricians considered that the identification of FII had to be virtually certain before a child protection conference was be initiated. As a result, a number of cases may be unrecorded because of the absence of irrefutable evidence despite the high levels of concern about harm to the child. Consequently the estimate of one child per one million is likely to be an under-estimate.
Watson et al in 1999 used an inclusion criteria which was more broad and as result estimated a significantly higher prevalence rate of 89 per 100,000 over a two-year period. From the data available, most general pediatricians are likely to encounter very few confirmed cases involving deliberate and persistent deception or illness induction during their careers, but it is likely that there will be a larger number of children where the possibility of FII is raised.
International research findings suggest that up to 10% of children subjected to FII die, whilst around 50% experience long-term consequent morbidity. In the British Isles study, McClure et al (1996) it was found that 8/128 (6%) children died as a direct result of this type of abuse. A further 15 (12%) required intensive care and an additional 45 (35%) suffered major physical illness, again as a result of abuse. Whilst the way in which a child’s circumstances are managed will impact on their outcomes, some who present at hospital in a life-threatening situation, having been poisoned for example, may not survive.
In the McClure study, 83 (65%) of the 128 index children had at least one sibling and of these, 15 (12%) had a sibling who had died previous to their being identified (a total of 18 deaths). Five (4%) of these deaths had been classified as Sudden Infant Deaths. Information about the death or abuse of siblings may only become known to professionals after a family history has been collated.
Some sibling deaths may have been unexplained or ascribed to natural causes, while others may have been known to have occurred as a result of abuse. Previous reported physical abuse of siblings is common in children subject to FII and previous abuse may have included the fabrication or induction of illness in their siblings. Clearly, any child is likely be considered to be at risk of significant harm because of abuse inflicted on siblings, or the death of siblings as a result of abuse.
The follow-up study of 54 children who were known to have had illness fabricated or induced, Bools et al (1993) found a range of emotional and behavioural disorders as well as school related problems including: difficulties in attention; concentration; and non-attendance.
These difficulties were present both in children who were living with their abusing parent and those who had been placed with alternative carers. That suggested a need for treatment regimes which specifically address the child’s ongoing needs throughout their childhood.
McGuire and Feldman (1989) also reported a range of disorders in children known to have had illness fabricated or induced which depended on the child’s age: feeding disorders in infants; withdrawal and hyperactivity in pre-school children; and direct fabrication or exaggeration of their own physical symptoms by older children and adolescents.
A Paediatrician who suspects FII should have regard to The Royal College of Paediatrics and Child Health (RCPCH) Guidance Fabricated or Induced Illness by Carers (FII): a Practical Guide for Paediatricians  (reviewed in 2012) . The aim and reasons for the 2012 review are set out in the introduction, “we, as paediatricians, must act together with all the statutory and non-statutory agencies charged with protecting children”.
The RCPCH Guidance sets out a non-exhaustive spectrum of cases where FII concerns arise. This spectrum includes: simple anxiety; misperceived symptoms with genuine belief about the perceived illness; exaggeration or non-treatment of real problems, fabrication, or induction of illness; delusional disorders on behalf of the carer; and unrecognised genuine medical conditions.
The Guidance also sets out the indicators which should alert professionals to the possibility of FII, the risks to child, and steps to be taken by the treating professionals including the designation of a responsible paediatric consultant who is responsible for the child’s health and is the key clinical lead for the case providing an overview of treatment.
It is important that timely agreement is made of who takes on this responsibility. The responsible paediatric consultant should begin by assessing the safety of the child, particularly in the case of suspected non-accidental poisoning and suffocation. Clear patterns of constant and careful observation of the child should be instituted. Discussions with a senior colleague in children’s social care may also be helpful in deciding whether and when a referral should be made. It is at this stage that local authorities may become involved and consider initiating proceedings.
At some time in their careers, all consultant paediatricians are likely to be faced with a child whom they suspect some or all of their signs and symptoms of illness are being fabricated or induced. This may include children referred to them or children with whom they are already involved.
Where there are concerns about a child’s safety and welfare, discussion with children’s social care can be on the basis of suspicion of significant harm; the concern does not have to be proved before contacting children’s social care. Referrals can also be made because the child is considered to be a child in need under s.17 of the Children Act 1989.
In 2008, the Department for Children Schools and Families published supplementary guidance to Working Together to Safeguard Children namely Safeguarding Children in whom illness is fabricated or induced . Child Protection professionals must have regard for this guidance. In Coventry City Council v X, Y and Z (Care Proceedings: Costs)  1 FLR 1045 Mr Justice Ryder was critical of the local authority for failing to follow the recommended procedures.
The National Institute for Health and Care (“NICE”) includes the alerting features of FII in its own guidelines, When to suspect child maltreatment: NICE guideline , published in March 2013. The alerting features are divided into two, according to the level of concern, with recommendations to either 'consider' or 'suspect' maltreatment: consider means that maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis; to suspect means a serious level of concern about the possibility of child maltreatment but is not proof of it.
Practitioners are advised to suspect fabricated or induced illness if a child's history, physical or psychological presentations or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture and one or more of the following is present: reported symptoms and signs only appear when the carer is present or are only observed by the carer; an inexplicably poor response to prescribed medication or other treatment; new symptoms are reported as soon as previous ones have resolved; there is a history of events that is biologically unlikely; despite a definitive clinical opinion being reached, multiple opinions from both primary and secondary care are sought and disputed by the carer and the child continues to be presented for investigation and treatment with a range of signs and symptoms; the child's normal daily activities such as school attendance are being compromised; or the child is using aids to daily living more than would be expected for any medical condition that the child may have.
The RCPCH, Working Together, and NICE Guidance are essential reading for legal practitioners. Practitioners may also benefit from reading serious case reviews in respect of deaths arising from this form of abuse .
FII cases can include very large amounts of medical evidence from a number of medical institutions. Once in proceedings, obtaining a paediatric overview from an independent expert consultant paediatrician for the purposes of a fact-finding hearing can distil this evidence. Practitioners should consider sources of evidence not limited to the child’s General Practitioner or local hospital. Carers may have sought treatment from a wide range of medial professionals: dentists; private clinicians; and hospitals and walk-in clinics far from the child’s home.
Evidence of treatment may be found in the child’s GP notes or records of referral. When issuing proceedings the relevant local authority should consider the time required to undertake the task of obtaining and distilling this evidence. Covert observation may have taken place in the hospital setting and court orders will be required to obtain these recordings and other medical data.
The RCPCH Guidance emphasises that ‘the key tool in diagnoses is the [medical] chronology… however the preparation of the chronology should not delay intervention if this would put the child at increased risk’. As a result, a chronology may not be available when the initial safeguarding referral is made.
If proceedings are issued, the court may find a chronology drafted by legal practitioners or by a legal nurse consultant  instructed under part 25 of the Family Procedure Rules 2010 helpful when marshalling large amounts of medical evidence.
The NICE Guidance suggest that where primary care staff, including GPs, have concerns regarding possible FII they should ensure the child is referred to a paediatrician for a paediatric assessment. However, the Guidance also recommends this should not delay a referral being made to children’s social care when it is appropriate. In practice, the instruction of a paediatric overview may more likely be directed by the court. The overview will assist in determining whether a carer has been fabricating or inducing symptoms but the issue of whether the child has suffered significant harm will be determined by the court.
When a paediatrician suspects FII a strategy meeting will be held with the appropriate child protection professionals. The local authority will undertake safeguarding; this may include court proceedings. A Scott Schedule and directions to a fact-finding are a usual course. Practitioners should consider the RCPCH Guidance when drafting a letter of instruction not forgetting the necessity of a chronology.
A specialist adult psychiatric assessment may be sought when there is a moderate to high level of suspicion that a carer has been inducing symptoms or a court has made a finding of fact that such behaviour has occurred.
To inform core assessments, child protection conferences, and/or the welfare stage of court proceedings it will be important to obtain an assessment from a psychiatrist who is familiar with:
- the relevant developmental and family psychiatric literature; and
- risk and mental disorder literature, especially in relation to personality disorder, since this is the diagnosis most often made in these situations.
Information should be sought from mental health clinicians involved in any ongoing treatment of the carer. However, it is important to remember that the presence of an adult mental disorder is not evidence of fabrication or induction of illness in the child; that requires a paediatric evaluation.
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 for an example see www.cumbria.gov.uk/eLibrary/.../3823713560.pdf
 for an example look at: http://www.lnctips.com/MedicalChronology