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Fabricated and induced illness: the nursing role in everyday practice

Sue Birbeck
SRN RM HV Cert BSc MA
Named Nurse Child Protection
NHS Eastern and Coastal Kent Community Services

Fabricated or induced illness by carers (FII) is a highly complex type of child abuse. It can have an emotional, physical and social impact on children, depending upon their age and the level of abuse; it can also be associated with other forms of child abuse and can lead to disability or death of the child.1,2 The defining characteristic of FII is illness in a child that is exaggerated, and fabricated or induced by the carer. Being involved with a case of FII can have a profound effect on both experienced and less experienced nursing professionals, and cause them to feel apprehensive and vulnerable.2

A variety of behaviours can be attributed to the carer who fabricates or induces illness in a child, and this can make any suspicions difficult to establish. Carers can appear genuinely caring or naturally concerned about their child. They may be aggressive, threaten legal action or question the health professional's competence or integrity.3,4 A carer may appear “less concerned than nursing staff about their child”, or almost disappointed about results that show the child does not have an illness or disability.5 There are additional complications if the child is involved in the fabrication. This can make the detection of fabrication almost impossible. According to a report by Cumbria Area Child Protection Committee, “Of all forms of recognised child abuse, fabricated or induced illness presents most challenge to all professionals”.6

Carers are encouraged to look after their child when they are admitted to hospital. This gives them the opportunity to tamper with specimens or fail to give medication as prescribed. The nursing staff rely on the carer to accurately describe the history of the child's illness, which can be accepted and documented in the records as fact. The treatment and care are made on the basis of this information.

The presence of a carer on the ward or in the clinic setting may prevent the child from speaking openly about the abuse and, equally, may prevent the professional from asking the right questions.6 The Department of Health's (DH) Working Together guidance emphasises the importance of listening to children; however, in reality, it is often the carer who is listened to.7
Some carers may be poor historians and others may set out to deliberately deceive the health professional. Nursing staff must accurately document their observations of the child, as poor history-taking can contribute to the misdiagnosis of FII. The carer's behaviour and attitudes to health professionals can “vary widely … distinguishing between different motivations for the behaviour … is not always easy”.8

It remains difficult for many nurses to acknowledge that a carer would intend to induce illness or fabricate symptoms in their own child.9 As a consequence, they may ignore concerns about the child, which can result in a delay in the decision to intervene. This can lead to further harm to a child who is being abused.

This controversial area of practice can result in conflict and dissent among professionals who have differing views and opinions about the nature of the child's illness, resulting in further distraction and confusion.10

Training
The many reviews of child deaths from child abuse and neglect over the last 30 years, including cases of FII, have concluded that poor information-sharing, communication failures and lack of, or poor-quality, training are common themes.11,12 Training is seen as an important way to improve professional practice and safeguard children.7 All nursing and other health professionals need to have the necessary skills to recognise FII, to notice when discrepancies are occurring and be aware of the need to discuss suspicions. This should be encouraged through training and embedded within practice. Inter-agency training is acknowledged as a valuable way to improve understanding of roles and responsibilities in relation
to FII.

Defining FII is not straightforward. The defining characteristics need to be considered following analysis of the child's medical history. Raitt and Zeedyke state, “The essential feature [of FII] is the deliberate production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care”.13

The title FII has replaced the term Munchausen syndrome by proxy (MSBP) in accordance with the guidance from the DH published in 2002 and due to a greater understanding of the condition.14 The use of the term FII should encourage professionals to focus on the presenting features of the child, and recognise the harm that is caused to the child.1 This guidance stresses that considering the characteristics or motivation of the perpetrator is not beneficial and may result in a loss of focus on the welfare and safety of the child.

Although guidelines have emerged to support nurses and other healthcare staff to deal with cases of FII, this remains a challenging and complex area of child protection with many professionals feeling anxious about defining FII. The DH Working Together document advises that the supplementary guidance for FII should be incorporated into local agencies safeguarding procedures to support and encourage joint working.7 It recognises that access to robust procedures is essential to support staff.

A study undertaken by McClure et al found that eight out of 128 children (6%) died as a direct result of FII.1 Some “suffer long-term or permanent physical disability”; and others can suffer a variety of emotional difficulties, which depend on the age of the child and the extent of the abuse, from “feeding problems in a young child to behavioural problems in adolescence”.3,15 The DCFS document noted that an approximation of one child in a million per head of the population is likely to be an underestimate.3

Some presentations may pose little risk to the child, while others may suffer from the emotional and social effects of assuming a sick role and the disruption of education by prolonged absence from school.16 Other effects are likely to be as a result of repeated presentations to health settings and multiple medical investigations or procedures.

Some children fabricate symptoms for the same reasons that adults do.17 Sanders describes some children as being involved in a “continuum of collusion”; for example, where children are young they may be naïve and unwittingly involved, an older child may have a passive acceptance of the situation, a much older child may be actively participating in the fabrication or even involved actively in the harm.3 When the child is actively involved in the process, this increases the complexity of the situation.1

Nursing and other health professionals must be alert to the variety of ways in which FII can present. These will vary according to whether the carer is fabricating or inducing illness in the child. The degree of FII can vary enormously and can “fall in a continuum from mild to very severe (and rare) forms of abuse”.18 The identification of FII can be through the recognition of certain warning signs; however, these can be present in a variety of situations as the condition can present in a number of ways. The carer may invent the illness to gain attention, induce illness by giving non-prescribed or prescribed substances, or maintain the child's illness or disability by withholding medication or treatment.

Carers can present falsified specimens, which are used to support the false detail, but do not injure the child, eg, the addition of glucose to urine to suggest diabetes or induced illness, which is directly harmful to the child.2

These acts of omission or commission can impact on the child in a variety of ways. The harm, or likelihood of harm, to the child should be identified. It is important to recognise the clinical features and signs as warning signs and not substitute them for diagnostic signs. Some warning signs can be seen in disability or genuine illness and, therefore, can appear contradictory.

There may be FII in a child with a pre-existing physical illness or disability; this gives the carer the opportunity to exaggerate symptoms. Bools cites fabrication in “the setting of genuine physical illness with children being under-treated or over-treated with a harmful impact on their mental and physical wellbeing'.19 Disabled children are more likely to suffer all types of child abuse than non-disabled children, with the signs of the abuse being mistaken for their disability.7

 is more likely to occur in a young child, and health professionals are usually the first to be suspicious about the carer's behaviour, which can alert them to feel the carer is causing harm to their child. However, it is often difficult to separate the behaviour of a genuinely caring person from the behaviour of a carer intent or unwittingly harming their child.20,21 This is often why dealing with cases of FII is so complex.

If complaints are threatened or made against health professionals for considering FII, this can cause great emotional anxiety.22 For many professionals this level of anxiety may cause them to retract statements or reports about suspicions they may have about the carer. The impact of these complaints can be disabling and may lead to impulsive and ill-considered action in order to get rid of the anxiety and affect their ability to deal with other cases of FII.6

There is likely to be a wide variation in attitudes and abilities among healthcare staff regarding FII. Nurses and other health professionals may also have personal and professional responses to FII that can influence their practice.23 There are likely to be nurses who are unskilled in the recognition of FII, and this limited knowledge could cause them to become unwitting accomplices.5,24 When nursing staff discover the carer is the source of the child's distress they may find it hard to accept they have been deceived, causing them to question their ability to assess the relationship between the carer and the child.17,21 Some nursing staff may feel guilty about their helplessness and the impact of their decisions if mother and child are separated, or experience feelings of anger towards the mother, or perpetrator.

Nursing staff can feel unsure about their role when there are suspicions about FII and the level of support they should access.25 Various studies have noted that when health professionals had the opportunity to discuss their concerns they realised they were expressing similar feelings to others involved in these complex cases and appreciated being able to verbalise their emotions.

Conclusion
It is important that effective training and robust supervision and support systems are in place to support nursing staff. Accurate record-keeping is essential in helping to understand what detail is fact and what detail the carer has reported. Eminson and Postlethwaite recommend sharing concerns with another professional with more specific or expert knowledge.8 This could be an informal discussion, although formal supervision is of more benefit. They state: “Good supervision is essential in helping professionals to deal with the emotional issues of child protection”.27

Supervision is not always readily available in the healthcare setting, but nurses need to discuss their concerns as soon as they notice discrepancies are occurring and they have concerns about the welfare of a child.28 Proving suspicions about FII is likely to be difficult and health professionals may be unsure how to proceed; but inaction allows the abuse and harm to continue.29

References
1. Department of Health (DH). Safeguarding Children in Whom Illness is Fabricated or Induced: A review of the implementation of the 2002 guidance within the NHS. London: DH; 2008.
2. Royal College of Paediatrics and Child Health (RCPCH). Fabricated or Induced Illness by Carers: A Practical Guide for Paediatricians. London: RCPCH; 2009.
3. Bools C. Fabricated or induced illness in a child by a carer: a reader. Oxford: Radcliffe Publishing; 2006.
4. Fulton D. Early recognition of Munchausen Syndrome by Proxy. Critical Care Nursing Quarterly 2000;23(2):39.
5. Laird E. Nurses' knowledge of Munchausen Syndrome by Proxy. Paediatr Nurs 2001;13(7).
6. Cumbria Area Child Protection Committee (CACPC). Report To Cumbria Child Protection Committee Serious Case Review. Available from: www.cumbria.gov.uk/socselibrary/content/internet/327/3823713560.pdf
7. Department of Health (DH). Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. London: DH; 1999.
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22. Wilson RG. Fabricated or induced illness in children. Munchausen Syndrome by Proxy comes of age. BMJ 2001;323:297.
23. Horwarth J. Developing good practice in cases of fabricated or induced illness by carers: new guidance and the training implications. Child Abuse Review 2003;12(1).
24. Terry L. Fabricated or induced illness in children. Paediatr Nurs 2004;16(1):15.
25. Bools C. Fabricated or induced illness in a child by a carer: a reader. Oxford: Radcliffe; 2006: 110.
27. Faugier J, Butterworth T. Clinical supervision: a position paper. Manchester: University of Manchester;1994.
28. Department for Children Schools and Families (DCSF). What to do if you are worried a child is being abused. London: DCSF; 2006.
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