Caregiver-fabricated or induced illness — formative SAQs

SAQ 1 (10 marks)

A two-year-old boy is admitted for the fourth time in nine months with recurrent apnoea. No nurse or doctor on the ward has witnessed an episode. His mother, a former enrolled nurse, sleeps by his cot and is described by the team as "the most engaged parent on the ward." She is pressing for a central venous line and a gastrostomy to manage what she describes as life-threatening apnoea with feeds. Between her reports the child is observed to feed, play, and grow normally. His inter-episode saturations, examination, growth, and baseline investigations are all normal. ^{[1] [5]}

1. Define caregiver-fabricated or induced illness using the modern child-centred frame, and explain why the term "Munchausen syndrome by proxy" has been replaced. (3) ^[3]
2. List the RCPCH alerting features present in this vignette and outline your immediate assessment and safeguarding actions, including who you would involve and what you would NOT do. (4) ^{[1] [5]}
3. Describe the mechanism(s) by which this child is being harmed, naming the role of the medical team. (3) ^{[1] [3]}

Model answer — SAQ 1

(1) Definition and terminology (3). Caregiver-fabricated or induced illness (FII) is a form of child abuse in which a child is, or is very likely to be, harmed because of a caregiver's behaviour directed at making the child appear or actually be ill — through fabrication (false or exaggerated histories), falsification (tampering with specimens, devices, or records), or induction (actively making the child ill by poisoning, suffocation, or withholding treatment). "Munchausen syndrome by proxy" has been replaced because it centred on the perpetrator's psychopathology and required the clinician to diagnose a mental disorder in the parent, whereas the modern frame centres on the child's welfare and asks only whether the caregiver's behaviour is causing harm. Glaser's 2020 reframing — from "Munchausen by proxy" to child and family-oriented action — is the conceptual hinge: you do not need to prove the caregiver has any psychiatric label to make the child safe. ^[3]

(2) Alerting features, assessment, and safeguarding (4). Alerting features present: symptoms vividly reported by the mother but never witnessed by staff; symptoms that resolve in her absence (the child feeds, plays, and grows normally between reports); a presentation that does not fit any recognised disease pattern; inexplicably normal objective findings between reports; and a caregiver unusually willing to consent to invasive procedures (central line, gastrostomy) and with healthcare knowledge. Immediate actions: escalate to the designated safeguarding lead immediately and never investigate alone; document the gap between reported and witnessed signs contemporaneously, factually, and without accusation; obtain all records across every hospital, GP, pharmacy, and school to surface the cross-setting pattern; admit for observation and plan separation from the suspected caregiver to test symptom resolution; and assess siblings, who are at elevated risk. What I would NOT do: confront or accuse the mother alone or prematurely (risk of escalation, flight, or evidence destruction), continue investigating the fabricated apnoea with further invasive tests, discharge the child to her unsupervised care, or close the file after a single intervention. ^{[1] [5]}

(3) Mechanisms of harm (3). This child is harmed through at least two of the three converging pathways. Direct harm is threatened by the risk of induction if the apnoea is being produced, and by the invasive procedures themselves. Iatrogenic harm is the dominant mechanism here: the medical team, driven by the mother's false narrative, becomes an unwitting agent of the abuse by ordering unnecessary investigations, blood draws, anaesthetics, and the central line and gastrostomy she is requesting — every unnecessary intervention driven by the fabricated symptom is itself a mechanism of harm. The third pathway, psychological and developmental harm, accumulates through the enforced sick role with lost play, socialisation, and a distorted sense of self. The treatment is therefore to stop the iatrogenic harm — pause non-essential investigation, treat only what is objectively demonstrated — and start the safeguarding response. ^{[1] [3]}