ARTICLE: Fabricated or Induced Illness – A matter for schools? By Andrew Martin of Safeguarding Network
NAPCE recently teamed up with Safeguarding Network to publish a series of articles concerned with keeping children and young people safe in the school environment.
We are now delighted to bring you the second instalment, which focuses on the subject of Fabricated or Induced Illness.
Safeguarding Network was established in 2017 by John Woodhouse and Andrew Martin, two social workers with more than 40 years combined experience working with children and young people.
The organisation is concerned with the increasing requirement on schools to fill the void left by decreasing social care budgets and the sparse support available for schools when responding to a matter not deemed to meet the social care thresholds.
Fabricated or induced illness: a matter for schools? By Andrew Martin
Why do I need to know about fabricated or induced illness (in 60 seconds)
Fabricated or induced illness (previously commonly known as Munchausen’s by proxy) is a lesser known form of physical abuse. Although the illness is primarily a health issue, there are significant implications for schools. Fabricated or induced illness is considered to cover a spectrum of issues, ranging from over anxious parents to parents who are deliberately harming their children for their own gain.
As professionals working with children and young people daily, staff in schools are in a prime position to identify inconsistencies in what they are being told about the needs of the child versus how the child is presenting. Numerous Serious Case Reviews tell us that there is also a need for schools to maintain a respectful uncertainty and ensure that they challenge where necessary – including challenging the parent and health professionals, regardless of where they may be on the perceived hierarchy within the health system.
School staff are also best placed to hear the voice of the child – something which is often lost in cases of fabricated or induced illness.
Due to the nature and levels of workloads that as professionals we must deal with daily, as soon as we see the word illness there is a natural response to classify that as a health issue and – at most – make a mental note to speak to the school nurse. Therefore, to be considering fabricated or induced illness as an issue for schools we have to be aware that we may be pushing at a closed mental door. As we will see however it is something that we do need to be aware of.
Indeed, this sense of illness being a health issues is, in some sense reinforced by the Department for Education. If you search through Keeping Children Safe in Education 2018 for the term, or its shorthand of FII, you will find only one mention in the “Additional advice and support” section of Annex A, simply a link to the 2008 government guidance, Safeguarding children in whom illness is fabricated or induced. Fabricated or induced illness is also briefly mentioned in Ofsted guidance for inspectors as an area where safeguarding action may be required to protect children and learners, but again little there is substance behind it.
This lack of emphasis on fabricated or induced illness may be due to research suggesting that FII is a rare form of abuse. The NHS cites a widely quoted study from 2000 which estimated the number of cases of FII at just 89 per 100,000 over a two year period. When compared to figures from 2016/17 for sexual offences against under 18’s which equate to around 500 per 100,000 in a one year period, this does show why it is considered rare. However, as the research itself identifies, there are a number of caveats to the 89 per 100,000 figure, and there is consensus that the true figure may be higher.
Although not specifically referenced in the body of Keeping Children Safe in Education 2018, all staff should be aware of FII through its inclusion in the definition of physical abuse in Part one of the document:
Physical abuse: a form of abuse which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child. (para 43, p.14, Part one, Keeping Children Safe in Education, 2018 – emphasis added)
Defining fabricated or induced illness
Most documents on FII do not provide a definition of fabricated or induced illness, instead talking about the ways in which it may occur. The pan-London child protection procedures do however offer the following definition:
Fabricated or induced illness is a condition whereby a child has suffered, or is likely to suffer, significant harm through the deliberate action of their parent and which is attributed by the parent to another cause.
The deliberate actions of a parent or parents that tend to centre around them lying about or making up health issues fall into three main groupings:
- Fabrication of signs and symptoms – this may include making up or altering past medical histories.
- Fabrication of signs and symptoms along with falsification of hospital records / charts / letters and other documents. In some cases, parents may also go so far as to falsify specimens of bodily fluids.
- Induction of illness through a variety of means, which may include poisoning and other ways.
You may hear people still refer to Munchausen’s or Munchausen’s Syndrome by Proxy – this term was replaced with the current fabricated or induced illness as Munchausen’s refers to a psychiatric illness and there was concern that this was meaning that parents who harmed their children in this way were being labelled with a psychiatric illness that they may not have.
||WAY IN WHICH PARENT PRESENTS
||LEVEL OF PARENTAL INSIGHT
||LEVEL OF RISK
||Simple anxiety, lack of knowledge about illness, over interpretation of normal features of childhood that may in some cases be linked to depression in carer.
||Carer may be affected by issues such as inability to cope with other personal or social stresses, for example mental ill health.
||Carer can usually be reassured although likely to come back in the future.
||Seldom reaches level of significant harm
||Symptoms are misinterpreted by carer or may be perpetuated / reinforced by the carer. Carer may genuinely believe that their child is ill or have fixed beliefs about illness.
||The ‘illness’ may be serving a function for the carer and potentially older children (referred to as secondary gains).
||Carer can be difficult to reassure. Carer and professionals may not agree on the cause of the symptoms and/or need to investigate further.
||Some risk of significant harm including emotional harm, impact on education or social isolation.
||Carer actively promotes sick role by exaggeration, non-treatment of real problems, fabrication (lying) or falsification of signs, and/or induction of illness.
||There may be a history of frequent use of, or dependence on, health services. The ‘illness’ may be serving a purpose for the carer or meeting their own mental health needs.
||Carer cannot be reassured, and their objectives are often diametrically opposed to those of professionals.
||High risk of harm, always because of over intervention and often severe.
||Carer suffers from diagnosable psychiatric illness (e.g. delusional disorder) which leads them to believe the child is ill.
||The carer’s mental health is the primary underlying issue.
||Carer lacks insight into their involvement in the child’s reported illness.
||May be a risk of harm.
||There are genuine unrecognised medical issues which become apparent after initial investigation around possible FII.
||Carer’s behaviour will usually be appropriate for the signs displayed by the child, although this may change if there are child protection interventions.
||Risk of harm due to delay in correct diagnosis and following child protection routes.
Whilst most of us can identify parents who fit the detail in example 1 (and not just in relation to medical needs), the greatest risk is presented by those parents who fit the detail in example 3.
Impact on schooling
Whilst research shows that the most severe and dramatic events are usually seen in children under the age of five, FII is seen in children of all ages (NSPCC, 2011). Arguably, the reason for the greater severity in under 5’s is that FII requires acts to be done to children (either by the parent or by doctors) and therefore as a child gets older they are more likely to ask questions and start to challenge the “perceived wisdom” of the parent. However, as identified by the NSPCC (ibid.) some children can become so indoctrinated in their “sick” persona that they may go on to simulate their own illnesses or start to act in a way that supports their parents’ position (as seen in this Serious Case Review). Cases are also seen where the description of the child and their illness does not fit the child that is seen in school.
Any child’s medical needs can have an impact on their day to day schooling, however in cases of fabricated or induced illness, the impact is likely to be significant. Schools may find themselves having to adjust premises, routines, etc. to ensure that they are compliant with the Disability Discrimination Act 1995 and Equality Act 2010, and that they have staff who are trained in various medical procedures. A child’s attendance at school may be severely disrupted due to medical appointments or having days off due to being unwell. Cases often identify that the abuser can be highly manipulative and frequently well informed about the different features of the ‘illness’, meaning that they are very hard to challenge.
As a school there is therefore a need to be aware of patterns of absence (does your data manager / business manager regularly report any concerns?), and whether staff asking questions leads to increased absence. Schools should also be aware of cases where there are multiple moves of school or the suggestion of home schooling for an ill child and should question what the reason for this may be. Evidence suggesting that this is part of the pattern when there are cases of fabricated or induced illness.
Respectful uncertainty was introduced as a concept by Lord Laming in his enquiry into the death of Victoria Climbié.
The concept of “respectful uncertainty” should lie at the heart of the relationship between the social worker and the family. It does not require social workers constantly to interrogate their clients, but it does involve the critical evaluation of information that they are given. People who abuse their children are unlikely to inform social workers of the fact. For this reason at least, social workers must keep an open mind. (para 6.602, p.205, The Victoria Climbie Enquiry)
For our purposes, the term “social workers” can be replaced by “professionals”. This approach is key when considering cases of suspected fabricated or induced illness.
Serious Case Reviews demonstrate that often there is a mismatch between information being presented to one agency and information being presented to another. Schools see the children for prolonged periods of time throughout the year. During this time there can be significant differences between what the parents report as happening whilst the children are in their care and what the staff see daily.
Another term that can be applied here is professional dangerousness. The term is attributed to Tony Morrison (1990) and describes the process where the behaviour of professionals involved in child protection work means that they inadvertently collude with the family they are working with or act in a way that increases the dangerous dynamics that are present. In cases of fabricated illness there is a risk that human nature will mean that subconsciously we do not want to countenance the idea that parents, and particularly mothers, would want to seek medical assistance that would harm their child. For most parents, the natural response would be to only agree to what can be highly invasive procedures if they were convinced that they were absolutely necessary. Therefore if a procedure is being recommended and the parents are agreeing to it, it is natural to think it must be necessary.
A lack of respectful uncertainty was seen in the case of Daniel Pelka. Whilst the case is more commonly known for the alcohol misuse and domestic abuse in his mother’s relationships and the physical abuse of Daniel, there was also a lesser identified element of fabricated or induced illness present.
The Serious Case Review identified that although Daniel was only at school for two terms before he died, in that time there were concerns that he was scavenging for food in bins and craving for food (he was stealing food from other children’s lunchboxes and eating secretively). When the mother was challenged about this she stated that he had a health condition and requested that the school supported her in making sure that he only ate what was in his lunchbox. However, Daniel’s reported obsession with food did not match up to what staff were seeing in relation to his appearance – one member of staff telling the subsequent criminal trial that he appeared to be “wasting away”. The Serious Case Review found that assumptions were “too readily made that his problems were medically based”. The suggestion is that the mother was falsifying the health condition to cover up the abuse that was happening at home, and that she and her partner were inducing medical problems by force feeding him salt, with this being planned as a punishment if he was considered to have been eating too much.
Common themes which potentially evidence disguised compliance include the focus on improving one issue to deflect attention from other areas, being critical of professionals, and not engaging with services or avoiding contact with professionals. In cases of fabricated or induced illness one or more of these traits is often seen, for example:
- Parents will pick up prescriptions but then not give the medication to the child.
- Telling health professionals that the child’s school is not supporting the care plan, whilst telling school that none of he health professionals are able to attend meetings.
- Parents not agreeing to referrals being made or services being provided or agreeing and then withdrawing their consent / not attending.
- Parents blocking access to the child or making sure that they are always present when the child is seen.
It is therefore important that we focus on the question “what does this mean for the child?”, and if we are concerned about something the parent is doing, are we concerned about significant harm?
Alongside questioning what a parent’s behaviour means for a child, we also the need to feel able to challenge fellow professionals. Within many systems there are hierarchies; however safeguarding network are strongly of the view that there is no such thing as a hierarchy in safeguarding and child protection. Very often it is the person who perceives themselves to be at the bottom of the hierarchy and believes that they have the least knowledge who has the most contact with the child and is best placed to know if there is something happening that is concerning.
In relation to fabricated or induced illness the power associated with the hierarchy within health can go across agencies, with other agencies deferring to the power and knowledge of others deemed to be “more experienced in these matters”. For example, one Serious Case Review found that because the child was receiving medical care from a “centre of excellence” everyone involved relied on their skills to manage the treatment and concerns that were present in education and other health sectors were not flagged up because the involvement of the specialist service added a confirmation bias (e.g. when we want something to be true we will look for things that confirm it is true). In this case the bias was that professionals did not want to believe that the mother was harming her children and the involvement of a specialist centre meant that the child must genuinely be ill. No-one involved was questioning what they were being told and the situation had been manipulated by the mother. This case review also found that the school had not made a referral to Children’s Social Care because they felt that on the basis of their concerns alone, the threshold for involvement of a social worker would not be met. The review argued that the referral should have been made and then a discussion held.
Voice of the child
As with many other forms of abuse, evidence suggests that the voice of the child is often lost in cases of FII. In one case that went to review the children stated:
- Health professionals appeared very reliant on what their mother was saying, and they felt they “were not an important part of the conversation”.
- One child knew they were having unnecessary treatment but did not feel that they had the opportunity to tell anyone.
- Another child spoke of not wanting the treatment and being scared, but then feeling that it was OK because their mother was there.
Whilst some of these comments can be levelled arguably at health professionals, the child who did not feel that they had the opportunity to tell anyone was a school-age child and did attend school on a frequent basis. Did he not feel able to approach school staff? Perhaps he felt / believed he should not talk to school staff about his health issues?
Fabricated or induced illness is not as common a form of abuse as others we may see; however, there is often a significant impact for the child and their family and, in some cases the risk of harm is significant. As non-medical professionals we may not feel able to challenge consultants and other medical professionals about specific health issues. However, as with other forms of abuse school staff will know the children they work with and will be able to identify if what they are told and what they see are not adding up. This inconsistent information then needs to be followed up in the same way as other concerns are – and escalated if necessary.
A common message from Serious Case Reviews on this matter (including those mentioned in this article) is that where there are significant, ongoing medical issues the school should be in direct contact with the relevant health professionals to talk through the issues and any concerns, and professionals should not rely on the parents to convey messages.
For further information and advice on what do you do next, visit Safeguarding Network here: https://safeguarding.network/fabricated-or-induced-illness/