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Alex Chodkowski looks at a consultation document designed to improve joint working where a child's illness is fabricated or induced by a carer.

Government guidance Safeguarding Children in Whom Illness is Induced or Fabricated by Carers with Parental Responsibilities is designed to provide a framework within which agencies can devise ways of working together where illness may be fabricated or induced in a child by a carer.

It is considered to be rare: one study quoted reports the incidence as one per million head of population. But it also suggests this abuse is under-reported; identification must be virtually unequivocal before child protection procedures are employed, even where concern about harm to the child is high. In the study of 128 children where fabricated or induced illness was suspected:

- 6 per cent died.

- 11 per cent had a sibling who had previously died.

- 15 per cent required intensive care.

- 35 per cent suffered major physical illness.

Many suffered long-term consequences including impairment of physical, psychological and emotional development.

The study describes the perpetrator as usually the child's mother, often with a history of childhood abuse or medical problems, and often previously treated for mental health problems.

However, another study¹ states that there is no classic perpetrator profile - while it is usually the mother, fathers, other relatives and nurses have also been implicated.

Following identification, the way in which professionals manage the case can have a major impact on the child's developmental outcomes. Evidence shows good outcomes where children's safety was addressed and long-term therapeutic work was undertaken with the family.

Social workers and other professionals need to be aware of indicators of this abuse. They should be trained in recognising behaviours exhibited by carers, as well as recognising characteristics of artificial illness, namely:

- Numerous physical complaints described in the child.

 - Symptoms present a confused picture not conforming to easily recognisable conditions.

- Symptoms are serious or unusual but unverifiable.

- Parents attempt to justify their stories in unusual ways.

- The child shows few physical signs.

- There are extensive claims of illness supposedly identified at other hospitals.

- The child is usually accompanied by his or her mother.

- The mother often gives a history of illness herself.

Research shows that over half of these children are aged under-five. It is important to gain information about the abuse by observing the child's interactions with family, peers and professionals and noticing differences between contact with different people, as well as listening to the child.

Listening to children and hearing their messages requires training and special skills, including the ability to win trust and promote a sense of safety. Most children feel loyalty towards those who care for them, or may not have concepts to describe what has happened. Some may fear reprisals or their removal from home.

The guidance recommends training at a number of levels to meet the needs of staff. The framework set out in Working Together outlines three stages of training for staff who have different degrees of decision-making responsibility for children's welfare, and it sets out the importance of joint working. Training on fabricated or induced illness in children requires specialist knowledge and should be tailored to address the range of professional roles and responsibilities. Training programmes should be regularly reviewed and updated in light of research and practice experience.

- Department of Health, Home Office & Department for Education and Skills, "Safeguarding Children in Whom Illness is Induced or Fabricated by Carers with Parental Responsibilities, Supplementary Guidance to Working Together to Safeguard Children," DoH, HO & DfES, 2001

Alex Chodkowski is a child care information system researcher at the Social Services Research and Development Unit (SSRADU) at Oxford Brookes University

References

¹ RM Reece, Child Abuse: Medical Diagnosis and Management, Lea and Febiger, 1994

² DM Eminson and RJ Postlethwaite, "Factitious Illness: Recognition and Management", Archives of Disease in Childhood, Vol 67, 1992