Social workers’ role in cases of fabricated illness

Cases of fabricated or induced illness are rare, hard to prove and, according to some experts, don’t even exist. So how do you deal with a suspected example?

“It’s hard to judge how much risk this child is in and that makes me very uncomfortable,” says Gillian (not her real name) who is involved in a suspected case of fabricated or induced illness (FII). FII is a rare form of child abuse where the carer, usually the biological mother, fakes or actually causes the symptoms of illness in a child. The condition is sometimes known as Munchausen syndrome by proxy.

Gillian’s case was referred to social work by a concerned member of the public. Although the 18-month-old has had five doctors in his short life, none are willing to go on record as saying it is suspected FII. In fact, Gillian says the term FII is rarely used in the multi-agency discussions, even though it is on all the paperwork.

FII is swathed in controversy. This is in part due to a number of women, including Sally Clark and Angela Canning, who were exonerated after being accused of FII and convicted of murdering their children. The Court of Appeal judged that the medical evidence given by the expert witness in these cases, Professor Roy Meadow, was misleading and, as a result, many professionals are wary of getting involved. Some claim the condition does not exist.

In 2008 the government published Safeguarding Children in Whom Illness is Fabricated or Induced, along with a training pack, which describes FII as “rare”. But it is hard to say how rare. A study in 1996 said that incidence of FII in children under the age of 16 was 0.5 per 100,000. In a 1999 study, that figure rose to 89 per 100,000.

Dr Danya Glaser, a child and adolescent psychiatrist at Great Ormond Street Hospital, believes FII probably occurs more frequently than many would expect but adds that the variety of presentations makes it difficult to diagnose.

At the low end of the spectrum, mothers fabricate accounts of their child’s illness. They do not directly harm the child but, instead, give a convincing but untrue account of the illness. Next step up is falsification, where the mother manipulates evidence of the child’s illness. This might include a pretence that medication is being given. At the most extreme end of FII, the child is deliberately harmed with the effects misrepresented to medics.

Dr Glaser says: “Some people think FII is all about mothers trying to kill their child but, actually, the fabricated variety is much more common than illness induction. The underlying dynamic is the parent’s need for her child to be recognised as ill, or more ill than they actually are, rather than the parent wanting her child to be ill or dead.”

The problem for medics is that the child’s symptoms could be perplexing or atypical for a genuine reason, says Dr Glaser.

Often social workers get involved when a doctor gets in touch for help, says Dr Glaser. For example, there may be suspicions because a doctor is unable to find a reason for the perplexing presentation and a parent is resistant to further investigation. In such cases, a doctor may look to the social worker, who has more statutory clout, than a medic to begin child protection investigations if necessary.

The problem is that most social workers only have a sketchy knowledge of FII and Dr Glaser says when doctors call for help social workers are unaware of the issues.

But sometimes it is the social worker who suspects FII and needs to convince a medic. Gretchen Precey, an independent social worker, says ideally social workers should gather as much evidence as possible before speaking to a doctor. “If the medical profession can’t be convinced then the case goes nowhere,” she points out.

But getting evidence of FII is often a long and difficult process. Access to the mother’s medical records can help but this may be hampered by confidentiality and data protection unless a doctor is involved. Covert surveillance can be used, but only when conducted by police and agreed by a child protection conference. It is one example of why it is so important to have a multi-disciplinary approach, even though it can be fraught with difficulties.

“These mothers can be very persuasive and the professional network can be split. A mother may give information to one person that she doesn’t give someone else,” says Ms Precey.

Dealing with a case of FII can be tough because so often social workers start to doubt whether they have made the right call, she says. Specialist support is important, such as from a senior member of the team who develops it as a specialism.

Gillian says she cannot move forward with her FII case, which makes her feel “very anxious”.

“A lot of what we’re doing feels like monitoring. There was one incident where there was a strong worry the mum had induced illness by over-medicating the child. But it would be difficult to convince a court the child needs to be removed from the parents. It’s so difficult.”

Case study:

Lisa Hayden-Johnson was jailed for 39 months in January this year for subjecting her son to 325 medical encounters, including exploratory surgery, over more than six years after she falsely claimed he had cerebal palsy, cystic fibrosis and diabetes. The court was told she claimed over £130,000 in benefits, free cruises and tickets to the X Factor as well as meeting celebrities when her son won a “courage” award.

She bullied and played medical staff off one another and said she was a qualified nurse. The deception was discovered when a case conference was called. Hayden-Johnson panicked and pretended she had been raped to avoid it. Her son has now been taken into care.

Key points

• Tread carefully: Being upfront with parents in a suspected case of FII may scare the mother into easing off the extent of the fabrication or abuse because she knows the authorities are suspicious, or it can prompt an increase in activity to convince medics and social workers of the seriousness of her child’s illness.
• Think about motivation: For example, financial difficulties could mean that an ill child will help parents qualify for extra benefits. Sometimes mothers are struggling to cope and FII behaviour is a way of getting help without having to admit it.
•  Do the detective work: Speak to other members of the family and verify personal history that the parent has given. For example, a mother who claims to have trained as a nurse may turn out to be lying. It does not prove FII, but may show a duplicitous behaviour.
• Be on guard: The nature of FII means that parents are extremely manipulative and convincing and often articulate, middle class and aware of how to invoke complaints procedures.

Case study: Mother was convinced son had bone disorder

Maggie (not her real name) says she was involved in a suspected case of FII four years ago which ended up being impossible to prove despite her own deep suspicions.

Her local authority was the fourth to be involved in the case and numerous doctors had seen the child. The mother told doctors and social workers that she believed her two-year-old son had a bone disorder but Maggie’s visits led her to doubt this. The boy appeared to Maggie’s untrained eye to be developing normally.

When Maggie asked the mother about her own medical history, she told her that she had a bone problem when she was young, but this was never verified.

“It was difficult because it felt like walking on eggshells. I wondered if I was being intrusive and this mother was only trying to find out what was wrong with her child,” says Maggie.

Doctor’s involved in the case were not prepared to back Maggie’s suspicion of FII and when a strategy meeting was called, comprised of Maggie, her supervisor, the police, the NHS and the boy’s nursery, it was decided there was not enough evidence to move forward. The family moved from the area soon after.

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This article is published in the 10 June 2010 edition of Community Care magazine under the headline A tough case to prove 

	To receive a free copy of Community Care Inform‘s expert-written guide on Understanding the Risk to Children in Whom Illness is Fabricated or Induced, email Kim Poupart on kim.poupart@rbi.co.uk To find out more about Community Care Inform and how it can help you in your practice visit www.ccinform.co.uk, or call 0208 652 4848 This offer ends on 24 June 2010