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 in order 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). 

It is a relatively rare but potentially lethal form of abuse.

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 actual state of the child’s physical/mental health 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.

It is important that the focus is on the outcomes or impact on the child's health and development and not initially on attempts to diagnose the parent or carer.

The range of symptoms and body systems involved in the spectrum of fabricated or induced illness are extremely wide.

Investigation of Fabricated and Induced Illness and assessment of significant harm to a child falls under statutory framework provided by Working Together to Safeguard Children and Safeguarding Children in whom illness is fabricated or induced (Supplementary guidance to Working Together to Safeguard Children). HM Government 2008. The Royal College of Paediatric and Child Health (RCPCH) provides  procedures for safeguarding children who present with perplexing presentations and FII and offers practical advice for paediatricians on when and how to recognise it, how to assess risk and how to manage these types of presentations in order to obtain better outcomes for children (Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in children – guidance - RCPCH Child Protection Portal).

There are four 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;
• Exaggeration of symptoms/real problems. This may lead to unnecessary investigations, treatment and/or special equipment being provided;
• Induction of illness by a variety of means.

The above four 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.

Concern may be raised at the possibility of a child suffering significant harm as a result of having illness fabricated or induced by their carer.

• Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering; or
• Physical examination and results of medical investigations do not explain reported symptoms and signs; or
• There is an inexplicably poor response to prescribed medication and other treatment; or
• New symptoms are reported on resolution of previous ones; or
• Reported symptoms and found signs are not observed in the absence of the carer; or
• Over time the child is repeatedly presented with a range of symptoms to different professionals in a variety of settings; or
• The child's normal, daily life activities, such as attending school, are being curtailed beyond that which might be expected from any known medical disorder from which the child is known to suffer;
• Excessive use of any medical website or alternative opinions.

There may be a number of explanations for these circumstances, and each requires careful consideration and review.

Concerns may also 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/seizures

Professionals who have identified concerns about a child's health should discuss these with the child's GP or consultant paediatrician responsible for the child's care.

Where there is a suspicion of FII, practitioners should consider this guidance carefully when fulfilling their role in assessing and investigating their concerns effectively.

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 alerting signs are present, they should be discussed with the Named Doctor, Named Nurse or Surrey Heartlands ICB Designate Safeguarding Team: Safeguarding in Surrey - ICS (surreyheartlands.org). Alerting signs do not amount to fabrication but require further investigations to see if the child has an underlying illness.

If any professional considers their concerns are not taken seriously or responded to appropriately, these should be discussed with the Surrey Heartlands ICB Designated Doctor or Designated Nurse: Safeguarding in Surrey - ICS (surreyheartlands.org). The Surrey FaST process (see also: SSCP Finding Solutions Together Poster) should also be referred to.

If any concerns relate to a member of staff, these should be discussed with the relevant Named or Surrey Heartlands ICB Designated Professional and the SSCP Allegations Against Staff, Carers and Volunteers Procedure should be followed.

If alerting signs are found in primary care or by education or allied health professionals in the community, it is appropriate that a referral is made by the GP to a paediatrician/CAMHS professional via Mindworks: (Home: Mindworks Surrey (mindworks-surrey.org), as the resolution lies in ascertaining the actual state of the child’s health.

In situations where the child may be at immediate risk of serious harm through an induced illness an immediate referral to Surrey Police by calling 999 who can then use their police protection powers or online (see: Surrey Police, How to report possible child abuse) and Surrey Children’s social care using a Request for Support Form: Report a concern about a child or young person - Surrey County Council and referencing The Continuum of Support threshold document: Report a Concern should be made in accordance with the Referrals Procedure. and the safety of any siblings should also be considered.

Children who have had illness fabricated or induced require coordinated help from a range of agencies.

Joint working is essential, and all agencies and professionals should:

• Be alert to potential indicators of illness being fabricated or induced in a child;
• Be alert to the risk of harm which individual abusers may pose to children in whom illness is being fabricated or induced;
• Share and help to analyse information so that an informed assessment can be made of children's needs and circumstances including an up to date Chronology;
• Contribute to whatever actions and services are required to safeguard and promote the child's welfare;
• Assist in providing relevant evidence in any criminal or civil proceedings.

Consultation with peers or colleagues in other agencies 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.

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.

Where there are concerns about possible fabricated or induced illness, the signs and symptoms require careful medical evaluation for a range of possible diagnoses by a paediatrician.

If no paediatrician is already involved, the child's GP should make a referral to a paediatrician.

Where, following a set of medical tests being completed, a reason cannot be found for the reported or observed signs and symptoms of illness, further specialist advice and tests may be required.

Normally the consultant paediatrician will tell the parent(s) that they do not have an explanation for the signs and symptoms.

Parents/Carers 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/carers if this information would jeopardise the child's safety and compromise the child protection process and/or any criminal investigation. All practitioners should be mindful of situations where to inform the parents/carers of the referral would place a child at increased risk of harm.  In this situation, carers would not be informed of the referral before a multiagency discussion has taken place. This would usually be in the form of a formal strategy discussion. Guidance for sharing of information can be referred to: Surrey Multi-Agency Information Sharing Protocol - Surrey County Council / Information sharing advice for safeguarding practitioners - GOV.UK.

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 Surrey Children's Social Care Services or Surrey Police (see Referrals Procedure):

• Lead responsibility for the coordination of action to safeguard and promote the child's welfare lies with Children's social care;
• Any suspected case of fabricated or induced illness may involve the commission of a crime and therefore the police should always be involved;
• The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care.

In cases where the Surrey 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.

Perplexing Presentations (PP) denotes the presence of alerting signs to possible FII, in the absence of the likelihood of immediate serious risk to the child’s physical health or life. Perplexing Presentations nevertheless indicate possible harm to the child which can only be resolved by establishing the actual state of health of the child. They therefore call for a carefully planned response. This will be led by the responsible clinician (Responsible Paediatric Consultant or Child Psychiatrist) with advice from the Named Doctor.

The essence of the response is to establish the current state of health and functioning of the child and resolve the unexplained and potentially harmful situation for the child. The term Perplexing Presentations and management approach can and should be explained to the parents and the child, if the child is at an appropriate developmental stage. Reflecting with parents about the differing perceptions that they and the health team have of the child’s presenting problems and possible harm to the child may be very helpful in some cases, particularly if it is done at an early stage.

If the initial concerns arise directly from school as opposed to health, it is recommended that school explain to the parents that information is required from health to understand the concerns e.g., poor school attendance. It is then appropriate for either the parents or education to contact health (either GP, consultant paediatrician or child psychiatrist) with their query about the actual health of the child. If the parents do not agree to a health assessment and the sharing of information about the child, we recommend that schools then follow their internal safeguarding policies. Professionals should refrain from using FII terminology, as the state of the child’s health has not yet been assessed.

If primary healthcare is the only contact for the child, then the GP should refer to a paediatrician for further assessment of the child’s health. If concerns arise within General Practice, we recommend that there should be consultation with the Named GP for Safeguarding Children.

A responsible Paediatric Consultant or Child Consultant Psychiatrist should be identified with advice from the Named Doctor and the health safeguarding team (who do not have clinical responsibility for the child).

Responding to PP requires a multidisciplinary approach, although the Responsible Consultant continues to have overall clinical responsibility for the child and that the background safeguarding processes are supported by the Named Doctor and the health safeguarding team. The Surrey Heartlands ICB Designated Doctor may need to provide appropriate support in these challenging cases.

The essence of management is establishing, as quickly as possible, the child’s actual current state of physical and psychological health and functioning, and the family context. The Responsible Consultant will need to explain to the parents and the child (if old enough) the current uncertainty regarding the child’s state of health, the proposed assessment process and the fact that it will include obtaining information about the child from other caregivers, health providers, education and social care if already involved with the family, as well as likely professionals’ meetings. Wherever possible this should be though working collaboratively with the parents. If they do not give agree for this to happen, the parents’ concerns about this process should be explored and can often be dispelled. However, under the NHS’ interpretation of General Data Protection Regulations (GDPR) for the UK information sharing can take place without consent if: there are safeguarding concerns, it is in the best interests of the child, is necessary and proportionate and is done in a manner according to the Art 34, GDPR (see Local Resources: Art. 34 GDPR – Communication of a personal data breach to the data subject - General Data Protection Regulation (GDPR).

When paediatricians become concerned about a perplexing presentation, an opinion from a tertiary specialist may be necessary. Parents themselves may request another opinion and it is their right to do so. However, this opinion given should be supplied with all the background information to help in informing the opinion and to avoid the repetition of investigations unnecessarily. There may need to be one or more professionals’ meetings to gather information, and these can be virtual meetings. Where possible, families should be informed about these meetings and the outcome of discussions as long as doing so would not place the child at additional risk. Care should be given to ensure that notes from meetings are factual and agreed by all parties present. Notes from meetings may be made available to parents, on a case-by-case basis and are likely to be released to them anyway should there be a Subject Access Request for the health records according to the agencies Information Governance Policies and in line with guidance on sharing 3^rd party information.

For some cases the key to differentiating between erroneous and true reports of symptoms and signs is a period of close or constant observation of the child. This can be overt observation by a nurse or other professional (e.g. teacher), not covert surveillance. For all cases but especially out-patient cases, as many sources of information as possible should be gathered, in particular the child’s functioning at school.

If careful medical assessment suggests that the child does not have any medical condition or a medical condition is exaggerated or appears misunderstood then the symptoms are ‘medically unexplained’ this can be presented to the child’s family as ‘good news’, with reassurance that most children either spontaneously improve over time with or without a clear medical (and educational plan if necessary) plan for support/rehabilitation and that no further investigations or treatments will be initiated unless the situation objectively changes.

A plan for rehabilitation of the child to normal activities, stopping any current unnecessary medical treatment and ongoing medical monitoring will be needed.

Involvement of MindWorks Surrey may be helpful; in particular the family may need to be helped to think through how their lives will be different if the child is no longer ‘ill’ and be helped to construct a credible narrative about the child’s ‘recovery’.

After attempting a reassuring, non-invasive approach to the perplexing symptoms and reported signs or the parents do not support the Health and Education rehabilitation plan (HERP) (see Local Resources: Appendix B), if the carers reject the doctor’s hypothesis and insist on further intervention or further opinions, or if they ‘sack/dismiss’ the doctor concerned and demand a change of doctor, or if the child develops new and unexplained physical symptoms or signs (e.g. faltering growth) or reported non-physical symptoms, e.g. anxiety, autism etc. then a judgment will need to be made as to whether a child safeguarding referral needs to be made to Surrey Children’s Social Care. The views of the child should be ascertained if possible, ideally without the parents/carers present.

It is important that the situation for the child is resolved and that they are able to return to a more normal lifestyle. If that does not happen, despite attempts by the treating team to help, or if contact is broken so that no information is available, a safeguarding referral to Surrey Children’s Social Care is indicated.

If the response from any partner agency is felt to be inadequate, then the SSCP escalation process should be followed as previously addressed.

If at any stage new information should come to light to suggest the child is currently suffering significant harm, then a referral to Surrey Children’s Services (and Surrey Police if immediate protection is required) must be made.

Whilst cases of fabricated or induced illness are relatively rare, the term encompasses a spectrum of behaviour which ranges from a genuine belief that the child is ill through to deliberately inducing symptoms by administering drugs or other substances. At the extreme end it is fatal, or has life changing consequences for the child.

Contrary to normal professional relationships with parents, being challenging about suspicions from the start may scare off a parent thus making it more difficult to gain evidence. There may also be an unintended consequence in increasing the harmful behaviour in an attempt to be convincing.

Parents who harm their children this way may appear to be plausible, convincing and have developed a friendly relationship with practitioners before suspicions arise. They may also demonstrate a seemingly advanced and sophisticated medical knowledge which can make them difficult to challenge. Practitioners should demonstrate professional curiosity and challenge in an appropriate way and with coordination between the agencies.

Fabricated or Induced Illness

Safeguarding Children in Whom Illness is Fabricated or Induced (supplementary guidance to Working Together to Safeguard Children), HM Government 2008

Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children Guidance, Royal College of Paediatricians and Child Health 2021

Information sharing advice for safeguarding practitioners - GOV.UK (www.gov.uk) 

Surrey Multi-Agency Information Sharing Protocol - Surrey County Council (surreycc.gov.uk)