Fabricated or Induced Illness, also known as Munchausen by proxy syndrome, by carers is a form of child abuse (Bass and Jones, 2011). It has been well documented in literature but can be complex in nature. It can have an emotional, physical and social impact on children and in some cases lead to disability or the death of the child (Bass and Adshead, 2007).
School nurses can play an important part in identifying suspected cases of fabricated or induced illness. Their position within the heart of the school-age community enables them to be well placed to provide information and knowledge relating to the families they are working with. The school nurse may be the only health representative working with a family on a regular and consistent basis and can provide accurate information that may need to be shared with other agencies. This article looks at the challenges facing school nurses but also focuses on the importance of accurate information gathering and the use of chronologies when identifying and working with suspected cases.
‘Fabricated or induced illness by carers is a relatively rare form of child abuse in which a parent or carer seeks medical intervention by fabricating or inducing symptoms in a child.’
Background
Fabricated or induced illness by carers is a relatively rare form of child abuse in which a parent or carer seeks medical intervention by fabricating or inducing symptoms in a child. The first population-wide study was conducted by McClure et al (1996), who estimated that the combined annual incidence in the British Isles of these forms of abuse in children under the age of 16 years was at least 0.5 per 100 000 and for children under the age of 1 year at least 2.8 per 100 000. Hence practitioners may never be involved with a case in their career. However, studies have identified that there can be substantial under-reporting of fabricated or induced illness cases (Ban and Shaw, 2019). Cases can go unrecognised for long periods, leading to poor outcomes (Barber and Davis, 2002). McClure's research showed that 8 out 128 children died as a direct result of abuse.
Understanding the nature of fabricated or induced illness has proved challenging for many health professionals. A theme emerging from the literature is the difficulty in recognising the condition and the variety of behaviours that can be attributed to the carer who fabricates or induces the illness (Birkbeck, 2010). In recent literature fabricated or induced illness has been described as being indicated by perplexing presentations or medically unexplained symptoms (Bass and Glaser, 2014; Ban and Shaw, 2019). It has been quoted as being one of the most complex and difficult conditions made worse by the controversy surrounding the detection of the condition (Downey, 2001; Cumbria Area Child Protection Committee, 2004). There has also been some speculation as to the existence of this condition with some authors suggesting that it may not really exist (Liddle, 2005). This psychological disorder causes a parent or other care giver to fabricate or induce illness in his or her child and then present the child for medical treatment (Royal College of Paediatrics and Child Health [RCPCH], 2009). The adult's attention-seeking behaviour can escalate to the point of causing severe physical harm. Although most of the literature supports the view that mothers are often reported perpetrators there have been some cases where the couples have colluded jointly (RCPCH, 2009). What motivates an individual to undertake this activity has been cited as being complex but the perpetrators' own childhood experiences also need to be considered, with some authors recognising that a perpetrator's own childhood background could lead them to falsify and induce illness in their children to seek attention (Bass and Glaser, 2014). Professionals need to be mindful that no common single profile may identify a perpetrator of fabricated or induced illness (Bools, 2007).
‘… perpetrators may go to great lengths to avoid detection by means of changing doctors and visiting different hospitals.’
In August 2002, the Department of Health (DH) published definitive guidance on safeguarding children. This was called ‘Safeguarding Children in Whom Illness is Fabricated or Induced’ and followed a year-long consultation exercise during which the health department invited comment on a document entitled ‘Safeguarding Children in Whom Illness is induced or Fabricated by Carers with Parenting Responsibilities’ (DH, 2001). The Working Together to Safeguard Children (Department for Education [DfE], 2018) supplementary guidance sets out roles and responsibilities of different professionals. This document highlights the role of school nurses in safeguarding children and young people, as well as providing health assessments, help to the child and family, acting as an advocate on their behalf and co-ordinating the delivery of support services. All the documents address the dilemmas faced by health professionals in terms of working together with families in cases of fabricated or induced illness.
‘With the wide-ranging presentations, distinguishing what constitutes simply an exaggeration of symptoms versus actual induction of symptoms is very challenging. Health professionals need to distinguish between the very anxious parent and the one who is fabricating illness and may be affecting the health and development of their children.’
Recognising the condition
The condition of fabricated or induced illness is very difficult to recognise due to the variety of behaviours that can be attributed to a carer who fabricates or induces illness in the child, Birkbeck (2010). Table 1 lists some of the common indicators of fabricated or induced illness.
Table 1. Common indicators of FII
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The multitude of presentations has led to much debate about key features of this form of maltreatment. The RCPCH (2002) noted that fabrication of illness can simulate almost any disorder. With the wide-ranging presentations, distinguishing what constitutes simply an exaggeration of symptoms versus actual induction of symptoms is very challenging. Health professionals need to distinguish between the very anxious parent and the one who is fabricating illness and may be affecting the health and development of their children. Action taken by a clinician must be determined by the perception of harm or potential harm to the child. The RCPCH (2002) suggested that changing the name from Munchausen by proxy to fabricated or induced illness raises awareness of the wide-ranging presenting features that may lead to physical injury and psychological harm to the victim. Many changes have taken place in the naming of the condition since Meadow first described Munchausen syndrome by proxy in 1977. Adapting the term to fabricated or induced illness or perplexing presentation keeps the focus on the presenting features of the child who needs to be protected rather than on the psychopathology of the parent. Research conducted by Bass and Jones (2011) stressed the importance of understanding the psychopathology of perpetrators of fabricated or induced illness. Their study looked at 28 women who were diagnosed with fabricated illness over a period of 15 years. The lack of available subjects over this length of time may indicate how rare this condition can be. This study highlights the relevance of the parent or carer background in this type of abuse as mentioned previously. The authors observed that over half of the sample had previous experiences of childhood sexual abuse or loss of a parent through divorce, separation or bereavement. The researchers concluded that for some participants these early experiences appear to have had a direct bearing on deceptive behaviours later in life, including lying in adolescence. This research highlighted several factors that may be associated with mothers who have a risk of demonstrating fabricated or induced illness. These included those associated with mothers' lifetime history and those associated with recent or current behaviour. The lifetime history factors would be extremely challenging for a health-care professional to discover and could only be obtained through direct communication with the parent or family members involved. The recent risk factors would be more easily recognised and may include frequent GP visits and the child's frequent absence from school. The research conducted by Bass and Jones (2011) does indicate that multi-professional agencies including social services, paediatric services, school staff, school nurses and health visitors were first to raise the alarm when fabricated or induced illness was suspected. This reiterates the importance of all professionals working together as highlighted in the government policy Working Together (Department for Education [DfE], 2018).
One of the challenges facing professionals can be the subtle interpretation of the things reported by the caregiver, which may lead to a distortion in views. Caregivers may also build up a good rapport with the staff working with their children. The offender may also be knowledgeable about health care and may sometimes be a medical worker or nurse (Beard, 2007; Criddle, 2010).
School nurses' role
School nurses are often in a very privileged position when working with children and families to be able to gather information when carrying out assessments. They spend a substantial amount of time in obtaining a history and therefore may be instrumental in early detection. By careful and sensitive questioning, information gathered can lead the practitioner to question discrepancies in the parents' reporting.
As discussed above, fabricated or induced illness can have many presentations from persistent vomiting, respiratory conditions, seizures and other symptoms, including fever, infection, bleeding or failure to thrive (Criddle, 2010). While some of these conditions are common, multiple illnesses or repeated episodes of conditions can raise concern. The school nurse is in a unique position to document all the episodes reported even if the parent or care giver changes doctor or paediatrician. When collating history of the family, the need to document accurate information from birth can be vital to seeing patterns in behaviours. Parents may seek further interventions from health to perpetuate the fabricated or induced illness. Collecting the information and compiling the chronology can take many months or even years to identify and show the signs of fabricated illness.
Documentation is crucial to all aspects of nursing practice (Nursing and Midwifery Council, 2018). The importance of health chronologies in collating events can highlight trends that may not be evident if viewed alone. The health chronology aims to provide a clear, factual account of all significant health events in a child's life to date. It is useful to include dates and times of events, treatments attended (including A&E, hospital visits etc.), meetings and school absence records. It can help early indication of an emerging pattern of need, concern and/or risks, and in the identification of patterns of medical treatments (Department for Children, Schools and Families [DCSF], 2008). This information may be useful if parents have more than one child, they are seeking advice on, as this may show similar traits in treatments sought. When combined with other health chronologies, the information obtained can provide insight and joined up thinking (Ban and Shaw, 2019). Many authors have agreed that chronologies can go a long way to providing enough evidence to confirm diagnosis of fabricated or induced illness (Sanders and Bursch, 2002).
In order to achieve positive outcomes and safely protect children there needs to be irrefutable evidence that the condition being presented does not match the evidence seen (Cabral, 2014b). School nurses need to encourage their health colleagues, GPs and paediatricians to submit chronologies when cases are suspected. This information is essential during child protection processes and provides a comprehensive record of interaction with the family. Cabral (2014b), in her paper identifying cases of fabricated, exaggerated or induced illness, discusses that there needs to be exemplary documentation including a chronology of events. Consideration may need to be given to this as a training need, since formalised teaching on the use of chronologies for some staff may be limited. All documentation needs to be factual and objective, especially as the case may reach court proceedings. In addition, it is important to document the relationship between the parent and the child and ensure this is supported by examples.
School nurses need to be aware of this form of child abuse and the important role which they can play in early identification and response. They may find themselves well placed to identify risk factors; for example, poor attendance at school, multiple visits to the GP and A&E attendance (Bass and Jones, 2011). Being involved with the family from the outset can provide important opportunities for early detection and intervention to prevent escalation RCPCH (2002). Often, however, perpetrators may go to great lengths to avoid detection by means of changing doctors and visiting different hospitals (Lazenbatt and Taylor, 2011). It is therefore essential that all concerns are documented early and the information is shared with members of the health care team, including the GP, paediatrician, nursing manager and the local safeguarding team. The importance of early assessment and the need to gain accurate records of history has been another theme to emerge from the literature (Howarth, 2003; Cabral, 2014a). All documentation should be kept in accordance with current legislation and follow data protection regulations (Royal College of Nursing, 2020). Early identification and successful intervention will give the greatest chance of long-term positive outcomes.
Building a relationship with a family can have many challenges, and it can take many meetings before family members will share information openly. There may be limited information gained on the first meeting and the health practitioner needs to draw on all their assessment skills in building up a picture of family life. Understanding a parent's background could help understand why a child may present with any particular illness but this is not without its challenges, since the nurse's attention is mainly focused on the child and the background information of the parents may take a while to establish.
‘School nurses need to be aware of this form of child abuse and the important role which they can play in early identification and response.’
Working in partnership with a family is at the centre of school nurses' role and can itself cause a real dilemma for the health professional who suspects fabricated or induced illness. The skill of the practitioner here lies in knowing when family-centred care is not in the best interests of the child for fear of perpetuating the fabrication (Howarth, 2003; Powell, 2007).
Studies by Bass and Jones (2011) and Adshead and Bluglass (2005) reported that accurate record keeping is essential in understanding what is fact and what the carer has reported. School nurses need to exert their professional curiosity (i.e. their communication skill to explore and understand what is happening within a family rather than making assumptions or accepting things at face value) and be suspicious when faced with puzzling or complex cases that may show inconsistencies in reporting or presentation. A heightened awareness of fabricated or induced illness may increase professional curiosity and a desire to examine case notes when exposed to perplexing presentations in practice (Ban and Shaw, 2019).
Recommendations for practice
All nurses need to have the necessary skills and clinical confidence to enable them to recognise fabricated or induced illness and to notice when discrepancies are occurring and be aware of the need to discuss suspicions, primarily with the local safeguarding team through safeguarding supervision. This should be encouraged through training and embedded in practice and is part of the Nursing and Midwifery Council (NMC, 2018) Code of Conduct and also the NMC Standards of Proficiency for Specialist Community Public Health Nurses (NMC, updated 2018). The Working Together document (DfE, 2018) advises supplementary guidance for fabricated or induced illness should be incorporated into local agencies Safeguarding Procedures to support and encourage collaborative multi-agency working. All professionals should have an understanding of their roles and responsibilities and work together in such cases of suspected fabricated or induced illness.
The case reviews and discussion papers reviewed here have all highlighted the importance of training to improve professional practice and safeguard children. The importance of sharing training can build on knowledge and ensure that all agencies can work toward effective decision-making when fabricated or induced illness is suspected. It is recognised, however, that training needs of one discipline may be different to those of another. As school nurses have moved away from the NHS and are now commissioned through local authorities, this may also raise differences in understanding and clarity of the role that school nurses can undertake when fabricated or induced illness is suspected. Understanding the local safeguarding guidance provides a good and essential starting point but it is the sharing of information early across the agencies that may be key to ensuring a safe and successful outcome for the child. Professionals may find that they come up against some resistance by other agencies to follow their own guidelines. Where there may be concerns on the immediate harm or suffering to the child it is important that all local safeguarding procedures are followed. Knowing when to escalate these cases to other agencies and child protection teams is essential. Where there is a suspicion of fabricated or induced illness it is essential that school nurses discuss this with their safeguarding advisor and, where necessary, make a referral to children's social care in accordance with the local referral process. Children who have had illness fabricated require coordinated help from a range of agencies including education.
Professionals need to be alert to the variety of ways in which fabricated or induced illness can present and can be through recognition of certain warning signs (Table 1). Electronic record keeping and documentation through chronologies is essential in order to have knowledge of what details are facts and what details the carer has reported. This information can then be shared with other agencies at professional strategy meetings, which would be chaired by children's social care services.
Conclusions
This paper highlights the complexity of fabricated or induced illness but also the unique position that school nurses are in to be able to identify potential fabricated or induced illness. Sharing information with all professionals is a key message when cases are suspected. Evidence of fabricated or induced illness relies heavily on good thorough documentation and a chronology of the events can provide a real insight to the life and experiences of the child.
Public health leaders need to consider teaching and training in writing good chronologies, indicating that key sources and events can provide a good picture of the experiences for the child. Safeguarding teams are invaluable in providing help and support to nurses to produce a chronology. They can advise on format and content, particularly if there is no local guidance already in place. Nurses need to ensure the documentation remains objective and should refrain from charting biased opinions. Birkbeck (2010) reported that for health professionals to be effective within their practice they need to have effective training and robust supervision. Local authorities need to establish good robust inter-agency training on safeguarding, including on fabricated or induced illness in children (DCSF, 2008).
Many studies focus on the behaviours demonstrated by the mother (Schreier, 2004), but there appears to be a real lack of research into the emotional impact of fabricated or induced illness on children (Bools, 1996). Perhaps more studies need to be undertaken to help health professionals gain a better understanding of and more able to recognise and support parents presenting with this condition and their children. Attending regular training updates and ensuring that, as competent practitioners, we understand this complex condition can improve the knowledge to recognise the signs of fabricated or induced illness. Failure to do so may result in this abuse continuing.
KEY POINTS
- Fabricated or induced illness is a rare form of child abuse and can be difficult to recognise
- School nurses hold a unique position working within a community setting to be able to identify potential cases of fabricated or induced illness
- Part of the school nurse's role is good assessment and communication skills allowing them to work alongside other multi-agency professionals in identifying patterns and trends of this form of abuse
- The use of good documentation, in particular health chronologies, is key to enabling fact-based decisions to recognise and prevent potential child harm due to this form of abuse.