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 actions, 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.

The term 'Fabricated or Induced Illness by Carers' was first introduced by the Royal College of Paediatrics and Child Health (RCPCH) in 2002. The RCPCH published updated guidance in 2021 on Perplexing Presentation and FII for more details.

Throughout this document we will use the term 'parent' to mean parent or carer.

As there is 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 which are presumed to be genuinely experienced, and which 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. The health professionals and parents work collaboratively to achieve evidence-based therapeutic work in the best interests of the child or young person
• Perplexing Presentations - the actual state of the child's physical/mental health is not yet clear but there are 'Alerting Signs' (as listed in the RCPCH guidance on PP/FII) 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 to convince health professionals that the child's health is impaired (or more impaired than is actually the case).

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.

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 fall 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. Multi-agency working involving education, social care, and other health services such as adult mental health services and primary care is key in achieving a good outcome.

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, e.g. smothering, tampering with feeds, withholding medications or feeds. This is less common than the above but carries a high risk of serious harm.

The above four methods are not mutually exclusive.

Harm to the child takes several forms.

Physical 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.

Emotional harm in fabricated or induced illness (FII) can arise in several ways. Children may feel confused or anxious when there is a mismatch between what they actually experience and what is reported about their health. They may begin to adopt a "sick role", sometimes reinforced by unnecessary aids such as a wheelchair. Everyday activities can become limited, reducing opportunities for normal development and leading to social isolation.

A child may also feel quietly trapped within the false narrative of illness. As they grow older, they may internalise these experiences, developing learned patterns of unusual illness behaviours and beliefs as a way of making sense of what has happened to them. 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.

(for full list of Alerting Signs, see RCPCH 2021 guidance on PP/FII)

• Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering
• Physical examination and results of medical investigations do not explain reported symptoms and signs
• There is an inexplicably poor response to prescribed medication and other treatment
• New symptoms are reported on resolution of previous ones
• Reported symptoms and found signs are not observed in the absence of the carer
• Over time the child is repeatedly presented with a range of symptoms to different professionals in a variety of settings
• 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
• Limited opportunity for the child to be seen or heard independently, with the parent/carer frequently speaking on the child's behalf; the child may appear to defer to the parent/carer when describing symptoms or providing their history.

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.

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

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.

One of the recognised alerting signs is that parents often may object to professionals communicating with each other. Not having a clear picture risks harm in the ways described above (exposure to unnecessary interventions, or not getting necessary interventions) and therefore multiagency discussions need to take place in order to safeguard the child.

In situations where a child is considered to have a perplexing presentation, it is important to include siblings in the assessment process, recognising that similar concerns may affect other children within the household.

Where there are concerns or suspicion of fabricated or induced illness (FII), practitioners should refer to this guidance alongside the Rotherham Safeguarding Children Partnership (RSCP) Threshold Descriptors and Family Help Guidance. This is to support decision-making and ensure an appropriate and proportionate response when assessing and investigating concerns. It will help to determine level of need, and whether a multi-agency response is required. 

In circumstances where a child may be at immediate risk of significant harm, including where illness is suspected to have been induced, an urgent referral to Children's Social Care and the Police should be made in  accordance with the Referrals Procedure. Where there are concerns about possible fabricated or induced illness (FII), the child's presentation should be subject to careful and thorough medical evaluation to consider a range of potential explanations. This assessment should be undertaken by an appropriate consultant, such as a paediatrician or CAMHS clinician.

If a consultant paediatrician or CAMHS professional is not already involved, a referral should be made to ensure appropriate clinical assessment, to explore any underlying medical or psychological factors, and to support multi-agency information sharing, including the convening of a multi-professional or consensus discussion where indicated.

Parents and carers should usually be informed about the need to gather information from professionals involved with the child, in line with the principles of openness and transparency. However, if sharing this information may place the child at risk of harm, compromise their safety, or prejudice a child protection or criminal investigation, the timing and extent of information shared with parents should be carefully considered, in accordance with safeguarding procedures.

Consensus Meeting:

In cases of a Perplexing Presentation, the lead consultant should convene a multi-professional meeting involving all practitioners engaged with the child. The purpose of this meeting is to establish a shared, evidence-based understanding of the child's actual health and day-to-day functioning, including their physical health, mental health, developmental progress, and social and emotional wellbeing.

Through information sharing, the meeting should seek to agree any verified medical diagnoses or conditions and consider whether these sufficiently explain the alerting signs identified. Where the child's presentation is not fully explained, professionals should consider and articulate any potential or actual harm to the child, including physical, emotional, or developmental harm.

The meeting should result in a clear, coordinated management plan, including what further assessment or intervention is required, and how outcomes and next steps will be communicated to parents or carers, in line with safeguarding principles.

Where further information, specialist opinion, or investigation is required to reach a shared understanding, this should be clearly identified and arrangements made to reconvene a further multi-professional discussion to review additional information and agree next steps.

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.

When a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer and consequently the child's health or development is or is likely to be impaired, a referral should be made to Children's Social Care Services or the 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 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.

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 mental and physical health 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 of parents 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.

Professional disagreements: In the consensus meeting, there may be disagreement about diagnoses or risk. These disagreements need to be resolved within the consensus process so that one consistent professional opinion and management approach can be presented to parents. 

Fabricated or Induced Illness/Perplexing Presentations Procedure

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