Fabricated or Induced Illness/Perplexing Presentations

1. Definition

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.

2. Risks

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.

Behaviours include:

Deliberately inducing symptoms in children by administering medication or other substances, or by means of intentional suffocation;

Interfering with treatments by over dosing, not administering them or interfering with medical equipment such as infusion lines;

Claiming the child has symptoms which are unverifiable unless observed directly, such as pain, frequency of passing urine, vomiting, or fits;

Exaggerating symptoms, thereby causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and therefore are harmful and possibly dangerous;

Obtaining specialist treatments or equipment for children who do not require them;

3. Indicators

• 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.

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.

4. Sharing Health Information when there are Concerns

Practitioners remain the first point of contact for most health problems in children. Practitioners should share information even if they have 'niggly concerns'. A risk might only become apparent when a number of people with niggling concerns share them.

In all cases the overriding consideration in making decisions about information sharing must be the child's safety and well being.

Professionals who have concerns about a child's health should discuss these with the child's GP or if known to a hospital service, the consultant paediatrician responsible for the child's health.

In situations of possible induced or fabricated illness practitioners should not discuss their concerns with the parents/carers. This is because such discussion may increase the risk of significant harm to the child. Decisions about what discussions are to take place with the parents/carers are to be made on an inter-agency basis, following referral to Children's Social Care.

Discussion with Named or Designated Doctor for Child Protection

In any case in which a paediatrician suspects FII they should discuss the case with the Named or Designated Doctor for Child Protection. In some cases it may be appropriate first to have a health professionals meeting to enable all health information about the child to be shared. At this meeting a decision should be made as to whether the child may be at risk of significant harm and if so a referral should be made to Children's Services.

Chronologies

5. Protection and Action to be Taken

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

In situations where the child may be at immediate risk of serious harm through an induced illness an immediate referral to the police and children's social care should be made in accordance with the Referrals Procedure.

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 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.

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 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.

6. Issues

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.

7. Covert Video Surveillance

The use of covert video surveillance (CVS) is governed by the Regulation of Investigatory Powers Act 2000 (the 2000 Act). After a decision has been made at a multi-agency strategy discussion to use CVS in a case of suspected fabricated or induced illness, the surveillance should be undertaken by the police. The operation should be controlled by the police and accountability for it held by a police manager. The police should supply and install any equipment, and be responsible for the security of and archiving of the video tapes.

CVS should be used if there is no alternative way of obtaining information which will explain the child's signs and symptoms, and the multi-agency strategy discussion meeting considers that its use is justified based on the medical information. (see Safeguarding children in whom illness is fabricated or induced, Use of covert video surveillance (GOV.UK))

8. Chronologies

The use of chronologies and the 'Possible Warning Signs of Fabricated or Induced Illness Template' allows for systematic consideration of risk factors and risk assessment. In compiling chronologies the focus must be on:

• Ensuring that all practitioners describe precisely what they have observed rather than using unfamiliar terminology. Fact and opinion should be clearly distinguished;
• Clarifying any concerns about medical information (treatments, expected findings, prognosis, etc) with an appropriate Doctor;
• Focusing on the possible harm to the child, not the motivation of the parent/carer;
• Any episode in which the parent/carer could be using the medical system to harm the child and all possible episodes of other forms of abuse must be included, including trivial injuries, which may be accidents or due to inflicted harm.

The chronology format will depend on the case. An example template is provided in Appendix 1: Case History - Chronology.

Appendix 2: Possible warning signs of fabricated or induced illness outlines some possible signs of fabricated or induced illness.

9. Risk from a Member of Staff

Appendices

Click here to view Appendix 1: Case History - Chronology

Click here to view Appendix 2: Possible warning signs of fabricated or induced illness

Further National Information

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, Royal College of Paediatricians and Child Health, 2021

Local Information

Gateshead

NOTE: Practitioners in Gateshead should instead use the documents in Local Resources:

• FII/PP - Multi Agency Practice Guidance;
• FII/PP - Process (flowchart);
• Appendix (word version) - Templates (1. professionals meeting, 2. health and education plan, 3. combined health chronology).

Newcastle

When Fabricated or Induced Illness is suspected Flowchart 1

When Fabricated or Induced Illness is suspected Flowchart 2

South Tyneside

Pathway for Suspected Perplexing Presentations (PP)/Fabricated and Induced Illness (FII) in STSFT (South Tyneside and Sunderland NHS Foundation Trust)