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. There is a range of terminology used to categorise this form of abuse, although it is often known as Munchausen's syndrome (Asher, 1951; Gawn and Kauffmann, 1955) by proxy (Meadow, 1977). In today's literature, particularly in the UK, the term fabricated or induced illness in a child by a carer (FII) is preferred. FII is a descriptive term and not a discrete medical syndrome, ensuring it covers a wide range of situations, while also shifting the focus to the child. According to safeguarding guidance from the Department for Education et al (2008), there are three ways a carer may fabricate or induce illness (Box 1). All health professionals need to be aware of this issue; many perpetrators do have increased and fabricated illness themselves, so may be seen frequently in various healthcare settings (Lazenbatt and Taylor, 2011).
Epidemiology, incidence and prevalence
The first population-wide estimates were made by McClure et al (1996) by collating 128 reports of Munchausen's syndrome by proxy, non-accidental poisoning and non-accidental suffocation sent to the British Paediatric Association Surveillance Unit (BPASU) over a 2-year period. They described an annual combined incidence of Munchausen's syndrome by proxy, non-accidental poisoning, and non-accidental suffocation as 0.5 per 100 000 children under 16 years, with males and females affected equally. Their analysis highlighted that cases mostly included children less than 5 years old, with children under 1 having the highest incidence of 2.8 per 100 000 children (McClure et al, 1996). Nonetheless, studies have identified that there is significant under-reporting of FII (McClure et al, 1996; Davis, 2009). The reasons for this are complex; the plethora of professionals involved can complicate and delay diagnosis, especially in cases with repeated presentations, and the broad spectrum of FII including milder cases that may never be reported (McClure et al, 1996; Davis, 2009).
Although FII is relatively uncommon, it is associated with high morbidity and mortality and is often not recognised until the child has suffered significant harm (Lazenbatt and Taylor, 2011), heightening the need for earlier recognition and intervention. Research suggests the death rate for FII could be as high as 10% with a further 50% of children suffering long-term morbidity (Department for Education et al, 2008). A systematic review identifying 451 cases of FII found that 6% of children had died, and 7.3% suffered permanent or long-term injury (Sheridan, 2003). McClure et al (1996) found that of the 128 children identified by the BPASU, 8 (6%) died and 15 (12%) required intensive care.
The evidence available shows that FII affects both sexes equally (McClure et al, 1996; Sheridan, 2003) but is most common in children under 5 with the age of diagnosis varying from 20 months (McClure et al, 1996), to 21.8 months (Sheridan, 2003), or 2.7 years (Denny et al, 2001).
According to Morrell and Tilley (2012) women are implicated in FII abuse in an estimated 90–98% of cases. Mothers are identified as the perpetrator in approximately 76% of cases (Sheridan, 2003). Figure 1 illustrates the increasing concern of health professionals in relation to parental/carer behaviours and attitudes toward their child's health and wellbeing.
Warning signs and symptoms
In cases of FII the child's symptoms are often non-specific, intermittent, and rely heavily on the history acquired from the carer. Anomalies in test results and/or examinations may not be repeated in further presentations (Davis, 2009; Royal College of Paediatrics and Child Health (RCPCH), 2009). Feeding problems and bowel-related symptoms are frequently reported (RCPCH, 2009). Other presentations include unexplained collapse/an apparent life-threatening event (ALTE) or seizures. It is paramount to note that FII may present to any specialty, anywhere. Box 2 illustrates potential indicators of FII.
Impact on the child
As a result of the magnitude and diverse nature of FII, the child is likely to undergo many tests, investigations and procedures with an inherent risk of harm and even death (Department for Education et al, 2008). Some procedures may be irreversible or may promote reliance on medical aids such as nasogastric feeding tubes or wheelchairs. On the whole, investigations are usually non-invasive, but can involve long periods of hospital admission (Zeitlin, 2016). These investigations are often unnecessary and perpetuate the ‘sick child’ role, which ultimately inhibits the child's participation in normal activities of daily life (Bass and Glaser, 2014). Such experiences of iatrogenic illness can result in the child having a distorted view of health and believing that they are indeed ill (RCPCH, 2009).
Bools et al (1993) followed up children from their own earlier study and concluded that children affected by FII will develop emotional, behavioural and school-related problems (Bools et al, 1993). McClure et al (1996) uncovered that siblings also experienced abuse; this occurred in 34 out of 83 families in which the child subjected to FII had at least one sibling.
Perpetrator
Motivation for FII is complex, involving multiple factors, so compiling a single common profile of perpetrators is futile (Bools, 2007). Rand and Feldman (2001) highlighted that many of the perpetrators were victims of abuse and FII as a child, or lived in a household where such abuse was occurring. The perpetrator's own childhood experiences and, more frequently, their own fictitious disorders could precipitate the falsification and induction of illness in children (Feldman and Hamilton, 2006; Criddle, 2010; Morrell and Tilley, 2012). Bass and Jones (2011) considered that up to 65% of perpetrators had evidence of a fictitious disorder in the past or at the time of investigation. Exaggerating or falsifying their child's illness allows the perpetrator to play the role of a caring parent—maintaining focus on investigation and treatment of the child to keep their own negative emotions at bay.
Stirling (2007), on behalf of the American Academy of Pediatrics Committee on Child Abuse and Neglect, proposed that the diagnosis of FII is not dependent on the motives of the perpetrator, in line with other forms of child abuse. Understanding the motives of the perpetrator of abuse may direct the course of action but is not pertinent to the nurse as the main cause for concern is to protect the child from further harm.
Collaborative working
Documentation is crucial to all aspects of nursing practice (Nursing and Midwifery Council, 2018) but is of particular importance in cases where FII is suspected. Many authors agree that thorough documentation and chronologies can provide enough evidence to confirm a diagnosis of FII (Sanders and Bursch, 2002; Davis, 2009; Dye et al, 2013). A heightened awareness of FII may increase a professional's curiosity and desire to examine case notes when exposed to perplexing presentations in practice. Analysing medical records for patterns of abnormal behaviour and inconsistencies is the most common means of identifying FII (Sanders and Bursch, 2002). Once suspicions have been raised, it is important that these concerns are escalated quickly to specialist professionals so swift appropriate action can be taken.
Although the process of identifying FII is complex, the primary goal is to protect the child from further harm by working efficiently across all disciplines. It is important to note that, should the perpetrator become suspicious, there is an increased risk of harm to the child with the potential for illness induction to produce measurable symptoms in the child. The best interests of the child (and siblings) are paramount over criminal prosecution of the carer.
Fish et al (2005) clarified the distinct difference between child protection hearings and criminal prosecution. Criminal prosecution depends on proof ‘beyond reasonable doubt’ that the perpetrator of abuse has committed certain acts and has done so with criminal intent (Fish et al, 2005). This principle does not apply when safeguarding children, in which the goal is to minimise or eliminate the potential of harm. Working collaboratively with the multidisciplinary team, including police and children's safeguarding services, ensures professionals are working together to protect the child.
Considerations for clinical practice
Identifying future cases of FII and safeguarding children is often the result of health professionals examining cases that pique their curiosity and, sadly, thinking the unthinkable. These are the cases in which sharing information and collaborating with other Trusts and local authorities is crucial to uncovering potential cases of FII. Evidence of FII relies heavily on thorough documentation across the multidisciplinary teams and a clear chronology of presentations. Remember, FII is a descriptive term and not a discrete medical syndrome—it can happen in any specialty, to any child.