Fabricated or Induced Illness and Perplexing Presentation
Scope of this chapter
Please also see Children with a Disability and Child Abuse Procedure where the concern relates to a disabled child.
This chapter should be read in conjunction with Royal College of Paediatrics and Child Health guidance – Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children (last published 2009, Updated February 2021).
Fabricated or Induced Illness is a rare, potentially lethal form of abuse.
FII is a clinical situation in which a child is, or is very likely to be harmed, due to parents behaviour and action, carried out in order to convince people that the child’s state of physical and/or mental health and development is impaired (or more impaired than it actually is).
It is important that the focus is on the outcomes or impact on the child and not initially on attempts to diagnose the parent or carer. This can inflict both physical and emotional harm.
Please see Safeguarding Children in Whom Illness is Fabricated or Induced which was issued by the Department for Children, Schools and Families in 2008 (as guidance supplementary to Working Together to Safeguard Children) and provides further essential guidance which practitioners should always consult where there are suspicions of fabricated or induced illness.
The Royal College of Paediatricians and Child Health 2021 guidance 'Perplexing Presentations (PP)/ Fabricated and Induced Illness in Children' provides further guidance for medical clinicians.
There are three main ways of the carer fabricating 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 and documents and specimens of bodily fluids;
- Induction of illness by a variety of means.
The above three methods are not mutually exclusive.
Harm to the child may be caused through unnecessary or invasive medical treatment, which may be harmful and possibly dangerous, based on symptoms that are falsely described or deliberately manufactured by the carer, and lack independent corroboration.
The RCPCH have extended the definition of FII by introducing the term Perplexing Presentations (PP). PP describes a situation where there are alerting signs of possible FII that have not yet amounted to likely or significant harm. The child’s physical, mental health and neurodevelopment is not yet clear but there is no perceived risk of immediate harm to the child’s physical health or life. The alerting signs include:
- The presence of discrepancies between reports;
- The presentation of the child/independent observations differing from parental reports;
- Implausible descriptions;
- Unexplained findings;
- Parental behaviour.
In In Medically Unexplained Symptoms (MUS), a child’s symptoms are not fully explained by any known pathology. The symptoms are usually psychologically based 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 can impact on daily life. The health professionals and parents work collaboratively to in the best interests of the child or young person. Generally, MUS is not considered a safeguarding issue but in some cases may involve PP or FII.
Doctors/paediatricians may be concerned at the possibility of a child suffering Significant Harm as a result of having illness fabricated or induced by their carer. The following three aspects should be considered when assessing potential harm to the child.
Child’s health and experience of healthcare
- Repeated (unnecessary) medical appointments, examinations, investigations or procedures – distress to child;
- Illness may be induced e.g. poisoning, suffocation, withholding food or medicine – threatening health or life.
Effects on daily life and development
- Limited or interrupted school attendance;
- Normal daily life activities are limited;
- Social isolation.
Child’s psychological and health-related wellbeing
- Anxiety about state of health;
- False self-view of being sick and vulnerable;
- May be active collusion with parent’s deception.
The essence of alerting signs is the presence of discrepancies between reports, presentations of the child and independent observations of the child, implausible descriptions and unexplained findings. They are indicators of FII/PP and require further assessment and investigation.
Alerting signs in the child
- Reported symptoms and signs (physical or behavioural) not observed independently;
- Unusual results of medical investigations;
- Inexplicably poor response to treatment;
- Characteristics of illness that are physiologically impossible eg large blood loss with no drop in haemoglobin;
- Impairment of child’s daily life beyond that explained by known level of illness eg missed school, need for aids.
Alerting signs in parental behaviour
- Parental insistence on continued investigations instead of focusing on symptom alleviation when symptoms not explained by a known medical condition;
- Insistence on continuing investigation even when tests have already been undertaken and not identified a difficulty;
- Repeated reporting of new symptoms;
- Repeated attendance at medical settings;
- Inappropriately seeking multiple medical opinions;
- Child repeatedly not brought to appointments, often due to cancellations;
- Not able to accept reassurance or recommended management, insistence on more, clinically unwarranted investigations, referrals or treatments (sometimes based on internet searches);
- Objection to communication between professionals;
- Frequent vexatious complaints about professionals;
- Not allowing child to be seen on their own;
- Repeated or unexplained changes of school, GP or paediatrician;
- Factual discrepancies in statements parents make to professionals or others about their child’s illness.
Concerns may be raised by other professionals who are working with the child and/or parents/carers who may notice discrepancies between reported and observed medical conditions, such as the incidence of fits.
Concerns about a child's health should be discussed with a Health professional who is involved with the child such as the school nurse, GP or paediatrician.
If any professional considers their concerns are not taken seriously or responded to appropriately, these should be discussed with the Designated Doctor or Designated Nurse.
Consultation with colleagues is an important part of the process of making sense of the underlying reasons for these signs and symptoms. The characteristics of fabricated or induced illness are that there is a lack of the usual corroboration of findings with signs or symptoms or, in circumstances of diagnosed illness, lack of the usual response to effective treatment. It is this puzzling discrepancy which alerts the medical staff to possible harm being caused to the child.
The signs and symptoms require careful medical evaluation for a range of possible diagnoses.
All professionals should routinely keep records relating to the child. Whenever unusual features are noted as described above it is extremely important that detailed records are maintained of events, reported illnesses, parent / carer explanations of illness and absences from school and child's symptoms when carer present and in her/his absence
Information sharing between professionals at this stage is absolutely crucial.
Concerns about a child's health should be discussed as early as possible with the appropriate health professional responsible for the child's health e.g. GP, paediatrician.
Where a child is undergoing significant ongoing medical treatment, liaison must always take place with the GP to assist in the confirmation of diagnosis and subsequent treatment.
If any professional considers their concerns are not responded to appropriately, the concerns should be discussed with the designated doctor or nurse and /or the professional's own lead, designated or named professional.
Normally, the doctor would tell the parent(s) that (s)he has not found the explanation for the signs and symptoms and record the parental response.
Parents should be kept informed of further medical assessments/ investigations/tests required and of the findings but 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 and compromise the child protection process and/or any criminal investigation.
For cases of PP, a Health and Education Rehabilitation Plan should be developed and implemented, whatever the status of Children’s Services’ involvement. Please note: this Plan is owned by Health, but can involve education, Children’s Services and other agencies, and should be shared with an identified GP.
The Lead Health Professional for the Plan will be a Consultant Hospital Paediatrician, Consultant Community Paediatrician or Consultant Child and Adolescent Psychiatrist, who will regularly review the Plan with the family and other identified professionals. Consideration needs to be given to what support the family require to help them to work alongside professionals to implement the Plan. There should be a discussion with the child’s registered GP regarding what role they may be able to take in supporting the management and care of the child. Optimal education needs to be re-established (for school aged children), with appropriate support for the child and family.
Once the need for a Plan has been identified, Health can contact Children’s Services Customer Service for background information on the child/family by completing this form and emailing to this address Protectedreferrals.cs@hertfordshire.gov.uk.
The Plan should continue until agreement has been reached by professionals that the child has been restored to optimal health and functioning, and the alerting signs are no longer of concern.
If the parents do not consent to a Plan, or do not engage with an agreed Plan, then the child should be referred to Children’s Services and, if possible, include a chronology. The referral to Children’s Services should be discussed with the parents, outlining the professional concerns. See Contacts and Referrals Procedure.
When a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer and as a consequence the child's health or development is or is likely to be impaired, a referral should be made to Children's Services in accordance with the Contacts and Referrals Procedure.
Whilst professionals should, in general, discuss any concerns with the family and, where possible, seek agreement to making referrals to Children's Services, this should only be done where such discussion and agreement seeking will not place a child at an increased likelihood of suffering Significant Harm - see Information Sharing and Confidentiality Procedure.
Whilst Children's Services have lead responsibility for action to safeguard and promote the child's welfare, the decision about how to respond to the referral should be taken in consultation with the Consultant Paediatrician responsible for the child's health care and the Police as any suspected case of fabricated or induced illness may also involve the commission of a crime.
All decisions about what information is shared with parents should be taken jointly, bearing in mind the safety of the child.
In cases where the Police obtain evidence that a criminal offence has been committed by the parent or carer, and a prosecution is contemplated, it is important that the suspect's rights are protected by adherence to the Police and Criminal Evidence Act 1984.
If there is reasonable cause to suspect that the child is suffering or likely to suffer Significant Harm, Children's Services should convene a Strategy Discussion/Meeting involving all the key professionals.
If emergency action is the required response, that is, if a child's life is in danger, an immediate Strategy Discussion/Meeting should take place, i.e. on the same day as the receipt of the Referral.
Except in an emergency, a Strategy Meeting should be held, chaired by a manager from Children's Services, when considering this form of abuse.
The Strategy Meeting requires the involvement of key senior professionals responsible for the child's welfare. At a minimum, this must include Children's Services, the Police and the Paediatric Consultant responsible for the child's health. Additionally the following should be invited 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/School Nurse;
- Staff from education settings if appropriate;
- Local authority's legal adviser;
- Designated Nurse.
Where the Strategy Discussion/Meeting decides that a Section 47 Enquiry should be initiated, see Section 7, Section 47 Enquiry and Assessment.
It may be necessary to have more than one Strategy Discussion/Meeting. This is likely where the child's circumstances are very complex and a number of discussions are required to consider whether and, if relevant, when to initiate a Section 47 Enquiry.
There may be circumstances where concerns have not been substantiated but doubts remain as to the reasons for a child's presentation and fabricated or induced illness remains as a possibility. In these circumstances it may be appropriate for the Strategy Discussion/Meeting to agree further assessment or monitoring as necessary to establish an adequate explanation and then re-convene. These further assessments may be of a single or multi-agency nature. Care must be taken to keep monitoring timescales so that concerns are not allowed to drift over long periods of time.
When it is decided that there are grounds to initiate a Section 47 Enquiry as part of an Assessment, decisions should be made at the Strategy Discussion/Meeting about how the Section 47 Enquiry will be carried out including:
- The need for extreme care over confidentiality, including careful security regarding supplementary records;
- Each agency should provide a written chronology of the contacts they have had with the child and family;
- The need for expert consultation;
- 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 and presented in a chronological form by the Consultant Paediatrician or other suitable medical clinician. If the family has recently moved, contact should be made and information obtained from the paediatric services in the area where the family previously lived;
- The designation of a medical clinician to oversee and co-ordinate the medical treatment of the child to keep to a minimum the number of specialists and hospital staff the child may be seeing;
- Any particular factors, such as the child and family's culture, religion, ethnicity, language and special needs which should be taken into account;
- The needs of siblings and other children with whom the alleged abuser has contact;
- The needs of parents;
- Whether the child requires constant professional observation to ensure his or her safety;
- The nature and timing of any Police investigations, including analysis of samples and covert video surveillance (see Section 10, Covert Video Surveillance);
- Obtaining legal advice over evaluation of the available information (where a legal adviser is not present at meeting).
Any evidence gathered by the Police should be available to other relevant professionals, to inform discussions about the child's welfare and contribute to the Section 47 Enquiry and Assessment.
In cases where a criminal offence is suspected and a prosecution is contemplated, it is important that the suspect's rights are protected by adherence to the Police and Criminal Evidence Act 1984, which would normally rule out any agency other than the Police confronting the suspect.
As with all Section 47 Enquiries, the outcome may be that concerns are not substantiated - e.g. tests may identify a medical condition, which explains the signs and symptoms.
In these circumstances, it may be that no protective action is required, but the family should be provided with the opportunity to discuss what further help it may require. In these circumstances, the Assessment will be completed.
The decision not to proceed to an Initial Child Protection Conference must be endorsed by the relevant manager within Children's Services and recorded on the relevant records and database. An Inter Agency Planning Meeting may be considered to meet the needs of the child and promote his/her welfare.
In all circumstances the assessments may demonstrate that services should be provided to the child and family to support them and promote the child's welfare as a Child in Need.
Where concerns are substantiated and the child is judged to have suffered, or is likely to suffer, Significant Harm, an Initial Child Protection Conference must be convened.
The conference should be held within 15 working days from the last Strategy Discussion i.e. the point at which the decision to initiate the Section 47 Enquiry was made.
Attendance at this conference should be as for other initial conferences although specific decisions about the participation of the parents/carers will need to be discussed with the Conference Chairperson - see Child Protection Conferences Procedure
The following additional experts should also be invited as appropriate:
- A professional with expertise in working with children in whom illness is fabricated or induced and their families; or
- Paediatrician with expertise in the branch of paediatric medicine able to present the medical findings.
Each agency should contribute a written report to the conference, which sets out a chronology of their involvement with the child and the family. This is particularly important for health professionals.
As decided at the Strategy Meeting, all available medical notes (including GP, health visitor and all local hospital notes) should have been reviewed before the conference and a detailed chronology of the medical history of the child and any siblings drawn up. This should be presented tat the Initial Child Protection Conference.
The lead responsibility for covert video surveillance is carried by the Police.
All decisions to undertake covert video surveillance should be taken at the highest level within Hertfordshire Police on the recommendation of a Strategy Meeting and should be clearly recorded, with reasons given why it is necessary.
Where there is any doubt about the use of covert video surveillance, legal advice should be sought.
The decision should be notified to the Director of Children's Services and the Chief Executive of the relevant NHS Trust.
The decision will only be made if there is no alternative way of obtaining information to explain the child's signs and symptoms and its use is justified on the medical information available.
The primary aim of the surveillance is to identify whether a child is having an illness induced; and the obtaining of criminal evidence is of secondary importance. The safety of the child is the overriding factor.
The necessary action to implement the decision will be the responsibility of the Police, who should obtain the necessary authorisation under the Regulation of Investigatory Powers Act 2000. If that authority is granted, the Police have sole responsibility for implementing and undertaking any such surveillance, including the supply and installation of any equipment and the security and archiving of the video-tapes.
Any use of covert surveillance by the Police should be carried out in accordance with good practice advice available from the National Crime and Operation Faculty, the ACPO (2004) Manual of Surveillance Standards and the ACPO (2004) (now known as The National Police Chiefs’ Council (NPCC)) Policy for Covert Monitoring Posts, both of which are held by the National Specialist Law Enforcement Centre (NSLEC).
Police Officers planning surveillance in cases of suspected fabricated or induced illness may seek advice from the Specialist Operations Centre, Covert Advice Team, Telephone 0845 000 5463, soc@npia.pnn.Police.uk.
All personnel including nursing staff who will be involved in its use should have received specialist training.
Children's Services should have a contingency plan in place, which can be implemented immediately if covert video surveillance provides evidence of the child suffering Significant Harm.
Last Updated: December 7, 2023
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