Introduction

Our knowledge and understanding of child abuse has evolved "like an onion" since the early 1960's. In the 1990's, an additional form of abuse was identified and known as Munchausen Syndrome by Proxy. In 2001, the Department of Health issued new guidelines to complement "Working Together" and rename this form of abuse as an Illness Induced or Fabricated by Carers with Parenting Responsibilities. They stress the importance of focussing on the child's health and development and how to best safeguard the child's welfare.

Incidence and Prevalence

Research that has been carried out in the past 10 years in the British Isles estimated that the combined annual incidence of this type of abuse in children under 16 years was at least 0.5 per 100,000 and for children under 1 year of age at least 2.8 per 100,000. In a hypothetical district of one million inhabitants, the expected incidence would be one child per year. It is believed, though, that this may be an underestimate as cases may go unrecorded because of the lack of irrefutable evidence or because of misdiagnosis.

Signs and symptoms

Behaviours exhibited by carers when fabricating or inducing illness in a child can include the following:

• deliberately inducing symptoms in children by administering medication or other substances, or by means of suffocation;
• interfering with treatments by over dosing, not administering them or interfering with medical equipment such as infusion lines;
• obtaining specialist treatments or equipment for children who do not require them;

exaggerating symptoms, causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and therefore are harmful and possibly dangerous;

• claiming the child has symptoms which 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;
• alleging psychological illness in a child.

Factors commonly found in cases of the fabricated or induced illness in children:

• Majority of cases are identified in a hospital setting; medical findings provide the evidence of this type of abuse.
• Significant numbers of children will have been well known to health professionals from birth, i.e. consequences of prematurity.
• Medical histories are likely to have started early and have become extensive when abuse is identified.
• Child may be referred to a specialist hospital or might have been seen by a number of professionals.
• Where a child is an in-patient in hospital, it is usual for parents to be involved in the care of their child, including participating in medical tests, taking temperatures and measuring bodily outputs. This can result in treatment and tests being interfered with and reported signs and symptoms continuing whist the child is in hospital. Commonly, parents can be intensely involved with their child, never taking a break nor allowing anyone else to be involved in their child's care.

Key features identified from research:

• Age range of children most commonly identified in younger children.
• Age at onset of symptoms usually much younger than when the abuse is identified because of the length of time it normally takes to identify this type of abuse.
• Gender of carer responsible for the abuse usually carried out by a female carer, normally the child's mother.
• Carers' previous histories:
  • Experience of childhood abuse or privation.
  • Considerable medical and psychiatric histories.
  • Suffering a number of significant bereavements or losses in their lives over a relatively short time span.
• Family relationships relationship problems between the child's parents are common.

Outcomes for children

There has been little research done on the longer-term outcomes for children who had illness fabricated or induced. One study carried out by Bools et al in 1993, was of 54 children. The latter were followed up on average 5.6 years after the abuse had been identified. Of the 54:

• 30 were living with their mother the abuser. Of these, a third had had further illness fabricated and there were significant other types of concerns about another third.
• 24 were in alternative care, either with family members or foster carers. Many were found to suffer from psychological disorders and in many cases a continuation of an earlier disorder.

Berg and Jones in 1999 reported the outcome of work with 17 children and their families who were admitted to the Park Hospital inpatient family unit after the abuse had been identified. In 13 of the cases, therapeutic work was undertaken to establish whether the child could be re-united with their family. Of these, it was recommended that:

• 10 children should be re-united with their natural parents;
• 3 should be placed in alternative care to ensure their safety.

All were followed up at approximately 27 months after discharge from the unit and most had done well in terms of their development, growth and adjustment. One child had been re-abused by her mother but was subsequently cared for solely by her father. The authors of the study:

"cautiously concluded that family re-unification is reasonable to attempt for a selected sub-group of cases of factitious illness by proxy but, where this is attempted, long-term follow-up is necessary in order to assure that psychological maltreatment does not occur and that the parent's mental health is monitored."

Another study carried out by Gray et al in 1995 found evidence of good outcomes for children where the child's safety had been assessed and long-term therapeutic work had been undertaken with families. The research showed that these good outcomes occurred 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, and clear decisions were made about whether the child was able to live with both parents, the non-abusing parent or should be placed in an alternative context.

Conclusion

Both knowledge and experience is still being acquired about the identification of illness that is fabricated or induced in a child by a carer. Research had identified that the way in which the case is managed will have a major impact on the developmental outcomes for the child.

References

Department of Health, Department for Education and Skills and the Home Office (2001) Safeguarding Children in whom Illness is Induced or Fabricated by Carers with Parenting Responsibilities. Department of Health, London.

Berg B and Jones DPH (1999) Outcome of psychiatric intervention in factitious illness by proxy (Munchausen syndrome by proxy). Archives of Disease in Childhood. 81: 0-7.

Bools C N, Neale B A and Meadow S R (1993) Follow up of victims of fabricated illness (Munchausen syndrome by proxy). Archives of Disease in Childhood 69: 625-630

Gray J and Bentovim A (1996) Illness Induction Syndrome: Paper 1 A series of 41 Children from 37 Families Identified at The Great Ormond Street Hospital for Children NHS Trust. Child Abuse and Neglect. 20 8: 655-673

Gray J and Bentovim A and Milla P (1995) The treatment of children and their families where induced iullness has been identified. In: Howarth J and Lawson B (eds) (1995). Trust Betrayed? Munchausen syndrome by Proxy interagency child protection and partnership with families. National Children's Bureau, London. Paragraph 149 162.

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