PG16. Fabricated or Induced Illness/Perplexing Presentations

Fabricated or induced illness is a clinical situation where a child is, or is very likely to be, harmed due to parents'/carers' behaviour and action, carried out to convince doctors that the child's state of physical and/or mental health or neurodevelopment is impaired (or more impaired than is actually the case).

The term 'Fabricated or Induced Illness by Carers' was first introduced by the Royal College of Paediatrics and Child Health (RCPCH) in 2002.

As there is an ongoing debate about terminology, it is prudent to define the terms of Medically Unexplained Symptoms (MUS), Perplexing Presentation (PP) and Fabricated or Induced Illness:

• Medically Unexplained Symptoms - the child complains of symptoms or is presumed to be genuinely experiencing symptoms that are not explained by any known pathology, but there are likely underlying (usually psychosocial) factors in the child. This may include observations of symptoms if the child is pre- or non-verbal. The symptoms are likely based on underlying factors in the child (usually of a psychosocial nature), and this is acknowledged by both clinicians and parents. MUS can also be described as ‘functional disorders’ and are abnormal bodily sensations which cause pain and disability by affecting the normal functioning of the body. Health professionals and parents work collaboratively to deliver evidence-based therapeutic interventions in the best interests of the child or young person. Perplexing Presentations – the actual state of the child's physical/mental health is not clear yet, but there are alerting signs of possible FII. There is no perceived risk of immediate serious risk to the child's physical health or life.
• Fabricated or Induced Illness – this is a form of child maltreatment in which a child is, or is very likely to be, harmed due to caregivers’ behaviour and actions which are carried out in order to convince health professionals that the child's health is impaired (or more impaired than is actually the case).

There are three main ways of the parent fabricating (making up or lying about) or inducing illness in a child:

• Fabrication of signs and symptoms, including fabrication of past medical history;
• Fabrication of signs and symptoms and falsification of hospital charts, records, letters, documents and specimens of bodily fluid;
• Induction of illness by a variety of means.

The above three methods are not mutually exclusive. Existing diagnosed illness in a child does not exclude the possibility of induced illnesses. The very presence of an illness can act as a stimulus to abnormal behaviour and also provide the parent with opportunities to induce symptoms.

Concerns will be raised for a small number of children when it is considered that the health or development of a child is likely to be significantly impaired or further impaired by the actions of a carer or carers having fabricated or induced illness. The presence of alerting signs where the child's actual physical/mental health state is not yet clear, but there is no perceived risk of immediate serious harm to the child's physical health or life, may be evidence of a 'Perplexing Presentation'.

Perplexing presentations indicate possible harm due to fabricated or induced illness, which can only be resolved by establishing the actual state of health of the child. Not every perplexing presentation is an early warning sign of fabricated illness, but professionals need to be aware of the presence of discrepancies between reported signs and symptoms of illness and implausible descriptions of illnesses and the presentation of the child and independent observations of the child.

Fabricated or induced illness is most commonly identified in younger children. Although some of these children die, there are many that do not die as a result of having their illness fabricated or induced, but who suffer significant long term physical or psychological health consequences.

Fabrication of illness may not necessarily result in a child experiencing physical harm, but there may be concerns about the child suffering emotional harm. They may suffer emotional harm as a result of an abnormal relationship with their parent and/or disturbed family relationships. See Recognising Abuse and Neglect Procedure.

Significant harm is defined in Recognising Abuse and Neglect Procedure as a situation where a child is suffering, or is likely to suffer, a degree of physical, sexual and/or emotional harm (through abuse or neglect) which is so harmful that there needs to be compulsory intervention by child protection agencies in the life of the child and their family.

In working with cases of suspected fabricated or induced illness, the focus must be on the child's physical and emotional health and welfare in the long and short term, and the likelihood of the child suffering significant harm.

Clinical evidence indicates that fabricated or induced illness is usually carried out by the child's mother or a female carer, usually the child's mother (Safeguarding children in whom illness is fabricated or induced, DCSF 2008). Aspects of their behaviour may include: - [Fabricated or Induced Illness by Carers (Royal College of Paediatricians and Child Health, 2009)]

• Not as concerned about the child as medical personnel;
• Remaining with the child on the ward constantly;
• Investing significant emotional/intellectual effort in the illness;
• Having a history of conduct or eating disorders/contact with mental health agencies;
• Other carer uninvolved in child care;
• Reports of a distant passive father.

All professionals who come into contact with children and their families, or adults who are parents, may come into contact with a child or parent where there are suspicions of fabricated or induced illness. These suspicions are likely to centre on discrepancies between what a parent says and what the professional observes.

Fabricated or induced illness is most commonly identified in younger children (77% under five years old) - [McClure et al (1996) study]. The average time to identification was greater than 6 months in a third of cases and more than 1 year in a fifth. - [Schreier and Libow (1993)].

In identifying and recognising fabricated or induced illness, professionals need to concentrate on the interaction of three variables:

• The state of health of the child, which may vary from being entirely healthy to being sick;
• The parental view, which at one end is neglectful, and at the other end causes excessive intervention either directly or indirectly;
• The medical view is equally on a spectrum from being dismissive at one end to performing excessive intervention or treatment at the other.

Concerns may arise when:

• Reported any 'normal' medical condition does not explain the symptoms and signs found on examination;
• Physical examination and results of investigations do not explain reported symptoms and signs;
• New symptoms are reported on resolution of previous ones;
• Reported symptoms and identified signs are not observed in the absence of the parent;
• The child's normal daily life activities are being curtailed beyond that which may be expected from any known medical disorder from which the child is known to suffer;
• Treatment for an agreed condition does not produce the expected effects;
• Repeated presentations to a variety of doctors and with a variety of problems;
• The child denies parental reports of symptoms;
• Specific problems (e.g. apnoea, fits, choking or collapse);
• Child becoming drawn into the parent's illness;
• History of unexplained illnesses or deaths or multiple surgeries in parents or siblings of the family;
• A past history in the parent of child abuse, self harm or somatising, or false allegations of physical or sexual assault.

There may be several explanations for these circumstances, and each requires careful consideration and review.

All professionals who have concerns about a child's health should discuss these with their line manager, their agency's designated safeguarding children adviser and the GP or paediatrician responsible for the child's health. If the child is receiving services from the local authority children's social care, the concerns should also be discussed with them.

If any professional considers that their concerns are not being taken seriously or responded to appropriately, they should discuss this with the designated doctor or nurse for child protection in their local authority area as soon as possible.

If any concerns relate to a member of staff, professionals should discuss this with their line manager and their agency's designated safeguarding children adviser. See also Allegations Against Staff or Volunteers (People in Positions of Trust), who Work with Children Procedure.

All concerns and discussions must be recorded contemporaneously by both parties in their agency records for the child, and the records must be dated and signed.

The signs and symptoms require careful medical evaluation to rule out a range of possible diagnoses. This is likely to include health professionals working closely with professionals in other agencies who have day-to-day contact with the child (e.g. daycare providers or schools).

Where no clear reason for the signs and symptoms can be found, a second medical opinion should be sought, and specialist advice and tests may be required.

If a paediatrician has suspicions that a child is being abused s/he should both seek a second medical opinion and make a referral in line with Referral and Assessment to local authority children's social care - promptly, rather than waiting to be sure. Failure to alert the local authority children's social care and/or the police early enough is likely, in proven cases, to lead to greater suffering by the child. - [Fabricated or Induced Illness by Carers (Royal College of Paediatricians and Child Health, 2009)]

See also: Referral and Assessment Procedure, Referral criteria, which guides the difference in local authority children's social care between s47 and an assessment.

While the child's signs and symptoms are being evaluated and before concerns are confirmed, the consultant paediatrician should retain the lead role, and the priority of police officers (and local authority children's social care) should be to assist the paediatrician in identifying the reason for the child's symptoms. The balance will change when it becomes clear that a crime has been committed.

Whilst professionals should usually discuss any concerns with the family and, where possible, seek agreement to make referrals to local authority children's social care, at no time should concerns about the reasons for the child's signs and symptoms be shared with parents if this information would jeopardise the child's safety or undermine a criminal investigation. See Referral and Assessment Procedure for what to do when not seeking parental permission.

See also: Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children Guidance, Royal College of Paediatricians and Child Health.

As with all other referrals, local authority children's social care should decide, within one working day, what response is necessary. Delay should be avoided by all agencies in all circumstances.

All decisions about what information is shared with parents should be agreed between the police, the local authority children's social care, and the consultant paediatrician, bearing in mind the safety of the child and the conduct of any police investigations.

All decisions about what information is shared with parents should be agreed between the police, local authority children's social care and consultant paediatrician, bearing in mind the safety of the child and the conduct of any police investigations.

The potential outcome of referrals is the same as for any other referral.  See Referral and Assessment Procedure.

Local authority children's social care should undertake an assessment, as with all referrals (see Referral and Assessment Procedure), in collaboration with the paediatrician responsible for the child's health care and relevant other agencies (e.g. the child's school).

The potential outcomes of the assessment should be as described for other referrals in the Referral and Assessment Procedure. If there is reasonable cause to suspect the child is suffering, or likely to suffer, significant harm and immediate protection is required (e.g. if a child's life is in danger through poisoning or toxic substances being introduced into the child's bloodstream) (see Child Protection Enquiries Procedure) an immediate strategy meeting/discussion should take place (see section below) and legal advice must be sought.

Concerns should not be raised with a parent if there is a concern that this action will jeopardise the child's safety or where it may undermine a timely criminal investigation.

If there is reasonable cause to suspect the child is suffering, or likely to suffer, significant harm, local authority children's social care should convene and chair a strategy meeting involving all the key professionals. A meeting, rather than a telephone discussion, is strongly advised when considering this complex form of abuse.

The strategy meeting should be convened in line with the Child Protection Enquiries Procedure. The meeting should be chaired by the local authority's children's social care manager.

Participants must include local authority children's social care, police and the paediatrician responsible for the child's health, and as appropriate:

• A senior ward nurse if the child is an in-patient;
• A medical professional with expertise in the relevant branch of medicine;
• GP;
• Health visitor or school nurse;
• Staff from education settings;
• Local authority legal adviser.

In cases of possible FII, it may be necessary not to inform the parents of the meeting before it takes place to protect the child.

When it is decided there are grounds to initiate a child protection investigation (s47, Children Act 1989), decisions should be made about how the investigation, as the assessment, will be carried out, including:

• Whether the child requires constant professional observation and, if so, whether the carer should be present;
• The designation of a medical clinician to oversee and coordinate the medical treatment of the child to control the number of specialists and hospital staff the child may be seeing;
• Arrangements for the medical records of all family members, including children who may have died or no longer live with the family, to be collated by the consultant paediatrician or other suitable medical clinician;
• The nature and timing of any police investigations, including analysis of samples and covert surveillance (this will be police led and co-ordinated, with advice available from the National Crime Faculty);
• The need for extreme care over confidentiality, including careful security regarding supplementary records;
• The need for expert consultation;
• Any particular factors, such as the child's and family's race, ethnicity, language and special needs, which should be taken into account;
• The needs of the siblings and other children with whom the alleged abuser has contact;
• The needs of parents;
• Obtaining legal advice over the evaluation of the available information (if a legal adviser is not present at the meeting).

See Child Protection Enquiries Procedure.

It may be necessary to have more than one strategy meeting, as the child's circumstances are likely to be complex and a number of discussions may be required to consider whether and when to initiate a s47 enquiry.

Evidence gathered by the police should usually be available to other relevant professionals, to contribute to the s47 enquiry and assessment. There will be occasions when police will not share information to protect a person's identity.  However, if the need to protect the child is greater than the need to protect the source of information, the necessary authority will be sought to share that information.

Suspects' rights are protected by adherence to the Police and Criminal Evidence Act 1984, which usually rules out any agency other than the police from confronting any suspect persons.

As with all child protection investigations, the outcome may be that concerns are not substantiated (e.g. tests may identify a medical condition that explains the signs and symptoms).

It may be that no protective action is required, but the family should be provided with the opportunity to discuss whether they require support.

Where FII is suspected, the child protection investigation may take more time than usual. However, whenever possible and consistent with the child's best interests, professionals should ensure any child protection conference is held within 15 working days of the strategy meeting/discussion, where the decision was made to initiate s47 enquiries, and that regular strategy meetings/discussions take place throughout the investigation.

Where concerns are substantiated, and the child is judged to have suffered, or is likely to suffer, significant harm, a child protection conference must be convened. All evidence should be thoroughly documented by this stage, and the protection plan for the child should already be in place.

Attendance at this conference should be as for other initial conferences (see Child Protection Conferences Procedure), with additional experts invited as appropriate:

• Professional with expertise in working with children in whom illness is fabricated or induced and their families;
• Paediatrician with expertise in the branch of paediatric medicine, able to present the medical findings.

Local authority childrens' social care should only convene an initial conference after reaching the point of discussing professional concerns openly with the parent/s, i.e. when it has been agreed that to do so will not place the child at increased risk of significant harm. This may be some time after the commencement of enquiries under s47 and a series of strategy discussions/meetings while the medical professionals undertake continuing evaluation and the police progress a criminal investigation.

In some cases, legal action may be necessary before this point is reached, in which case the appropriateness of holding an initial conference at this stage will need to be considered.

For further information, see:

• The Government guidance Safeguarding Children in Whom Illness is Fabricated or Induced (DCSF 2008);
• The DVD Incredibly Caring (DCSF 2009) to support the Government guidance;
• The guidance Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children Guidance, 2021).