What steps should you take when you believe that a pupil is displaying symptoms that are deliberately induced or fabricated? Jenni Whitehead summarises revised guidance for how schools should deal with this type of abuse, and stresses the importance of inter-agency communication

Revised guidance on managing cases of fabricated illness has been published to bring previous guidance into line with Working Together to Safeguard Children: A Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children (HM Government 2006) and the Framework for the Assessment of Children in Need and their Families (Department of Health et al, 2000).

The new guidance, Safeguarding Children in Whom Illness is Fabricated or Induced, suggests that debate between professionals over terms used to describe the fabrication or induction of illness in a child may cause a loss of focus on the welfare of the child. We used to refer to this type of abuse as Munchausen’s syndrome by proxy but this term became unpopular following the trial, conviction and then acquittal of a number of mothers who had been accused of causing the death of their children. This guidance refers to the fabrication of signs and symptoms. This can include verbal descriptions of sickness in the child made by parents/carers to school-based staff and may go as far as the fabrication of past medical history including falsification of hospital charts, reports, letters and documents.

The parents/carers may even induce an illness or signs of illness in the child through the administration of inappropriate medicines, poisons or other substances and in some cases children have been subjected to intrusive medical procedures in order to establish or rule out a medical condition.

The child may suffer emotional and psychological abuse, becoming convinced that they are ill, that they cause upset and worry to the family, that they are not able to participate in normal childhood activities and are dependent on medicines or medical procedures.

The child’s fabricated illness may become the family’s main focus and the child may develop a fear of being ‘well’ and causing the family system to break down.

Schools have a significant part to play in recognising possible cases of fabricated of induced illness and in sharing their concerns with children’s social care through agreed child protection procedures. Schools are not investigative agencies and the guidance is very clear that school staff should not attempt to investigate where they have a concern that a child may be subjected to fabricated or induced illness.

Schools are often very aware of the over-anxious parent, especially in respect of Reception class and Year 1 children and part of the difficulty in these cases is distinguishing between these parents and those who display abnormal behaviour in respect of their child. School-based staff are sometimes the first professionals to raise concerns, but often in such cases there is a history of concern mostly from health professionals.

Identification of fabricated or induced illness
Fabricated or induced illness is often, but not exclusively, associated with emotional abuse. Teachers and other education staff need to be aware of factors that could indicate fabricated illness, including:

  • frequent and unexplained absences from school, particularly from PE
  • regular absences to keep a doctor’s or a hospital appointment
  • repeated claims by parent(s) that a child is frequently unwell and that he/she requires medical attention for symptoms which, when described, are vague in nature, difficult to diagnose and which teachers/early years staff have not themselves noticed, eg headaches, tummy aches, dizzy spells, frequent contact with opticians and/or dentists or referrals for second opinions
  • the child disclosing some form of ill-treatment to a member of staff or complaining about multiple visits to the doctor
  • the child or his or her parent(s) relating conflicting or patently untrue stories about illnesses, accidents or deaths in the family
  • school and early years staff being alert to any significant change in the child’s physical or emotional state, in his or her behaviour or failure to develop and draw these to the attention of the named person
  • Where there is a sibling in the same institution, teachers/early years staff should discuss their concerns with each other to see if children of different ages in the same family are presenting similar concerns.

Obviously, there may be other reasons why children frequently miss school. The child may be genuinely ill (the school nurse may be able to help to establish if this is the case) or the child may be subjected to bullying, and this possibility should be explored.

Managing individual cases
The guidance suggests that before members of staff refer their concerns to the named person for child protection, they should keep a diary of events, including a record of absences and the reasons for absence given by the parent (where known). Keeping such a diary is useful, however, there is a risk that this form of monitoring could be seen as a means to an end. I would suggest that where a member of staff has a concern they should report it immediately to the named person. If it is then decided that a period of monitoring should begin before referring on to children’s social care a very clear plan of the monitoring process should be agreed, including:

  • Who among the staff team needs to know about the monitoring process?
  • What should staff be looking out for?
  • How long should they monitor before reporting back?
  • How should their observations be recorded and where should such records be kept?

Monitoring without a clear plan does not protect children from abuse; prolonged monitoring can delay action leaving a child at risk of significant harm.

Each time a member of staff records an incident they should be advised to date and sign the record and where other members of staff are present at the time of the incident their names should also be recorded. Remember also that child protection records should be kept separate from the child’s curriculum file and should be kept securely.

The named person will need to make a professional judgement as to when to refer to children’s social care. Where a named person is concerned about possible fabricated illness or induced illness, I would suggest that they do this early. The guidance draws on research that suggests that in many cases health professionals have raised concerns when the child was much younger and a school’s concern may add to a building picture. The named person can seek advice from their education designated officer but this should not delay referral to children’s social care.

Working together
I cannot stress enough the importance of agencies working together when faced with concerns that a child may be suffering from fabricated illness. In this type of abuse it is common for the parent to try to play one agency off against the other. If a parent suggests that they have informed their social worker of a change in their circumstances, do not presume this to be the case, always double check by ringing the social worker yourself. Make sure your school nurse knows of school’s concerns as they act as a useful link to GPs and other health professionals. It is sometimes useful to make a joint referral to children’s social care between school and health professionals. Multi-agency strategy meetings or professional’s meetings are useful in this area of work, allowing all parties to keep up to date with events.

Watch out for your staff! Parents/carers who are involved in fabricating illness may single out and latch on to an individual staff member whom they may perceive as more sympathetic to their case and then use this person to argue on their behalf.

Inducing illness in children through the administration of drugs and poisons is dangerous. The parent, while not intending permanent harm, may overdose the child and in worst cases cause untreatable damage or death.

Carers’ behaviours associated with fabricated or induced illness
The guidance describes a range of behaviours associated with fabricated illness or induced illness, but stresses that the list is not exhaustive and it is essential that school-based professionals seek advice from the appropriate agencies where they have concerns about a parent or carer’s behaviour. The list includes:

  • deliberately inducing symptoms in children by administering medication or other substances, by means of intentional transient airways obstruction or by interfering with the child’s body so as to cause physical signs
  • interfering with treatments by overdosing with medication, not administering them or interfering with medical equipment such as infusion lines
  • claiming the child has symptoms that are unverifiable unless observed directly, such as pain, frequency of passing urine, vomiting or fits. These claims result in unnecessary investigations and treatments which may cause secondary physical problems
  • exaggerating symptoms which are unverifiable unless observed
  • directly, causing professionals to undertake investigations and treatments that may be invasive, unnecessary and therefore harmful and possibly dangerous
  • obtaining specialist treatments or equipment for children who do not require them
  • alleging psychological illness in a child.

Supporting the child
The child who is subjected to this form of abuse may have a very distorted sense of self, and may see themselves as inadequate, incapable and unworthy. In more extreme cases the child may find it difficult to distinguish between themselves and their parent, or may develop an idea that their body belongs to others. These are difficult issues to tackle and staff are likely to find it hard to bring the child’s view of themselves up without being seen by the parent as a threat to their belief system. The positive work that schools can do with such children may be under constant threat of sabotage by the parent. Remember that in such cases the child may genuinely believe that they are ill, this has been taught to them often over a long period of time and will not come right overnight.

There is a risk that the child will be labelled by staff as lazy or someone who holds the rest of the class back. The child needs help to learn that they are able to do the same things as other children and small steps forward need positive reinforcement. If the child gets excited because they have accomplished a task that they thought they couldn’t do and wants to tell their parent, try to be with them when they do to reinforce their good progress but also to support them if the parent does not respond appropriately. However, some children may be reluctant to share their success with their parent because they are all too aware of the likely reaction. Remember the parent has a need to believe that their child is ill and incapable and may not take kindly to you sharing contrary evidence with them.

If the child has difficulty trying a new activity, remind them of previous step forwards and try to break down more difficult tasks into smaller steps.

The child may have difficulty developing and maintaining friendships. Other children may view them as strange or useless or may be quite frightened of them or their parent/s. Try to ensure that they are paired or in groups with children who are able to cope with their differences and that will encourage them rather than allow them to sit back without participating.

School may be the child’s one safe haven, a place where they can show their skills and abilities, a place where people listen to them because they are who they are and not just an extension of their parent or a product of their ‘illness’.

We are unable to publish reader comments about individual child protection concerns on this website. If you are worried about a child please call the NSPCC Helpline on 0808 800 5000 for help and advice. Alternatively you can contact your Local Safeguarding Children Board (LSCB) through your local council.