Review of Literature
Labels for FII:
Munchausen's Syndrome by Proxy (MSbP) - Meadow, 1977
Factitious Illness by Proxy - Bools, 1996; Jones & Bools, 1999
Induction Syndrome - Gray et al, 1995
MSbP - thought to be almost impossible to work with
Planned risk reduction - not considered
But this was in the 1990’s…..

A decade on - how much has changed?
“Fabrication of induction of illness in children still provokes considerable fear among professional groups and leads to difficulties within the professional system itself.”
Bass, C & Adshead, G 2007
“A mother who smothers her infant is not necessarily mentally ill.
She has demonstrated harmful behaviour; she may or may not have a medical diagnosis as well.”
Gwen Adshead, 2005

Now, in 2008:
“The key issue is not what term to use to describe this type of abuse, but the impact of fabricated or induced illness on the child’s health and development, and consideration of how best to safeguard and promote the child’s welfare.”
(Supplementary Guidance on Working Together to Safeguard Children, HM Department for
Children, Schools and Families, 2008)
Fabricated or Induced Illness is a form of child abuse, no matter how it may be described or labelled

Commentators agree that FII is a relatively rare form of child abuse
One study suggested:
ｷ the incidence of FII, non-accidental suffocation and poisoning for children under 16 was
5 per million of the population.
ｷ this incidence was found to be considerably greater for children under 1 year old - 28 per million.
ｷ sibling abuse was more common than re-abuse of the previously abused child.
Source: McClure et al (1996)

Some key aspects of FII

Perpetrator - usually mother, but not always

First manifested through primary care settings

Most cases confirmed in a hospital setting

Detection requires detailed and painstaking enquiry

Can take time for FII abuse to be detected
Safety Planning in High Risk Cases, Fabricated or Induced Illness,
Susie Essex and Margaret Hiles. August 2008

The Carer’s Behaviour - 1
Fabrication and falsification:

Fabrication of signs and symptoms

Fabrication of past medical history

Giving false accounts of symptoms such as
‘she suddenly stops breathing’ or ‘he is having fits’

Falsification of hospital charts and records

Providing a false specimen of bodily fluids e.g. putting substances in a child’s urine sample

The Carer’s Behaviour - 2
Induced Illness:

Inducing symptoms of illness:



Administering medications inappropriately
Smothering to simulate apnoea attack
Tampering with hospital equipment

Exaggeration of illness to gain the attention of professionals, resulting at times in unnecessary and possibly invasive investigations
A significant number of children in whom illness is fabricated will have been known to health professionals from birth

The Carer’s Behaviour - 3
Recognising the Problem Behaviour

Identifying the abnormal behaviour

Awareness of cultural behaviour and practice

Assessment and opinion of expert specialist psychiatrist
“psychiatric expertise cannot determine what happened when facts are disputed, and no diagnosis determines behaviour, either past or future.”
(Gwen Adshead, 2005)

2008 - Guidance from the UK Government Department for Children, Schools and Families

“Following identification of fabricated or induced illness
in a child by a carer, the way in which the case is managed
will have a major impact on the developmental outcomes for the child…..
…..however the extent to which the parents have acknowledged some responsibility will also affect the outcome .”
2008 UK Government guidance
No recent UK research on outcomes
Available evidence from the 1990’s is of generally poor outcomes for children who had illness fabricated or induced
Although there could be positive outcomes…..

Positive outcomes where:

Cases were managed within a child protection framework

Therapeutic interventions were focused on the protection of the child

A thorough assessment was undertaken of the family's functioning and its ability to change and protect the child

Clear decisions were made about where the child should reside
Our practice results concur with this view, and raise questions about the need for parental admission of culpability

Cecchin, Lane and Ray Irreverence 1992

The empirical evidence is that lack of compliance, rather than denial, is the best indicator of re-abuse.
(E Farmer, M Owen 1995)
By leaving denial relatively unchallenged the
Resolutions approach allows families to comply, in cooperation and partnership with agencies, about the future safety of their children.



This light globe seems faulty

This light globe
Still seems faulty… …but now we’ve installed a whole new lighting system!

Innate personality traits
Internal inhibitions
External inhibitions
Access to child
(Based on the work of D.Finkelhor 1986)




Conversation with George Walker and Helen Young 1998
For further reading to understand the stance in a risk reduction program see chapter 3 in
‘ Working with ‘Denied’ Child Abuse, The Resolutions Approach.’
Susie Essex and Andrew Turnell

1.
2.
3.
4.
5.
6.
Timescale, based on research
Significant people, know the concerns
Safety network, prepared to be active and proactive
Professional network prepared to be active
Network members, give active support and a non-critical gaze
Other practical issues, meals, snacks, medicines etc
Rota and active help to address key aspects of literature


Pretend, what if scenarios

Worker thinking of pretend scenarios, informed by literature

Pretend and practise, telephoning and response
1.
Parent telephoning
2.
First person visits

1.
2.
3.
4.
Active cover each day and each night
Need first person in day and first person in night
Clear about who does weekends and what about holidays?
If all going well progress to non-active cover

Family Members





Mother: Mari 24
Father: Ralph 32
Jodie
Dual Heritage 2 nd Generation
White UK
born Autumn 2006
Hospital age 1 month Apnoea attack
age 6 weeks Apnoea attack and rash
age 3 months rash possible Apnoea
Previous Child Death
New Baby Due
Boy Eli age 10 months in 2005
Easter 2008
The Safety Network

Grandmother: dual heritage white UK and black British

Great Uncle Frank and girlfriend Jo (Grandpa died 2005, white UK)

Godmother: Connie

Church friends: Pastor Mark and Cheryl etc….

DAY First
Monday Tuesday Wednesday Thursday Friday
Granny God- mother
Connie
God- mother
Connie
Granny Pastor
Mark
Reserve Cheryl Cheryl Granny Great
Uncle
Frank and Jo
Cheryl
NIGHT First
Reserve
Godmother
Connie
Granny Granny
Granny God- mother
Connie
God- mother
Connie
Godmother
Connie
Great
Uncle
Frank and Jo
Granny Godmother
Connie

DAY First
Saturday Sunday
Great
Uncle
Frank
Pastor
Mark
Reserve Cheryl Godmother
Connie
NIGHT First God- mother
Connie
Granny
Reserve Granny God- mother
Connie
HOLIDAYS
Granny will go with the family to her caravan , she can call Connie for help
Or...
Great Uncle Frank and
Jo will go with the family to their apartment in
Portugal

Words and Pictures for Jodi
In 2006, in the Winter, Jodi had a rash on her face.
The doctor came to see Jodi.
Grandma Sophie was there, as she had been looking after Jodi.
The doctor gave Mum and Dad a letter, saying ‘Please take Jodi to Hospital.’

Jodi went to the Hospital. Mummy told them Jodi seemed a bit floppy in the night. The doctors said ‘The rash might be a virus, but we need to check.’
Jodi stayed in Hospital.

The doctors were worried as this was the third time in 3 months that Jodi had come to Hospital since she was born.
The doctors talked to another doctor…..
…..then they talked to Social Services and other people.

There was a big meeting - a Case Conference.
The doctor said ‘We are very worried about Jodi’s rash.’
The Case Conference decided to ask another doctor in London to see Jodi.

In London, Mummy and Daddy said Jodi had one rash and had been to hospital lots because she was ill.
The doctors seemed to say different things.
The Social Worker said this is confusing and worrying.
We need a Judge to help sort it out.

If there is any sort of emergency, e.g. grandma or Connie is ill, or anything where someone needs extra help. there is a rota of help people on the family list.
Ralph, Mari, Grandma or Connie will ring someone on the rota.
(There is a back up for advice, e.g.
Health Visitor 9036128 Social Worker 9061572 or the Pastor Mark 9045829).
They will always phone Children and Young People Services Social
Care to let them know any unexpected changes either day or night.

•   These guidelines are based on Ralph as the primary carer and
Mari as the supportive carer.
•   This means Ralph will have to take care of Jodi and the new baby and be responsible for the intimate care.
•
Mari will have someone else present at all times.
(this will help to create clarity about future responsibilities as outlined in previous reports)

•   Initially, when the new baby is born, Grandma will come to stay.
•
Connie will also come every day to help.
•
There will be an approved person present at all times.
•   If Grandma or Connie need to go to the toilet etc. they will make sure
Jodi is safe in a room with her toys, and take the new baby with them.
Mummy and Daddy will stay in the kitchen or living room.