5.10 Fabricated or Induced Illness/Perplexing Presentation Guidance

SCOPE OF THIS CHAPTER

The Royal College of Paediatricians and Child Health (RCPCH) 2021 ’Perplexing Presentations (PP)/Fabricated or Induced Illness’ provides detailed guidance for professionals, particularly those working in Health (paediatricians, psychiatrists and other clinicians) and should be read in conjunction with this document.

1. Introduction

Fabricated and Induced Illness (FII) is a clinical situation in which a child is, or is very likely to be, harmed due to parent/carer(s)behaviour and action, carried out in order to convince doctors that the child’s state of physical and/or mental health and neurodevelopment is impaired (or more impaired than is actually the case). FII results in physical and emotional abuse and neglect, as a result of parental actions, behaviours or beliefs and from doctors’ responses to these. The parent does not necessarily intend to deceive, and their motivations may not be initially evident.

There are three main ways of the carer fabricating or inducing illness in the child:

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

The range of symptoms and body systems involved in the spectrum of fabricated or induced illness are extremely wide, as can be the medical services in which children present, spanning primary, secondary and tertiary care, including independent providers.

2. Perplexing Presentations (PP)

The RCPCH have extended the definition of FII to include the term ‘Perplexing Presentations’. This has been introduced to describe the commonly encountered situation when there are alerting signs of possible FII, but not yet amounting to likely or actual significant harm. The actual state of the child’s physical, mental health and neurodevelopment is not yet clear, but there is no perceived risk of immediate serious harm to the child’s physical health or life.

Signs of PP can include:

• The presence of discrepancies between reports
• The presentation of the child and/or independent observations of the child differ significantly from parental report
• Implausible descriptions
• Unexplained findings
• Parental behaviour

3. Medically Unexplained Symptoms (MUS)

Medically Unexplained Symptoms is a situation in which the child complains of symptoms that are presumed to be genuinely experienced, but which are not fully explained by any known pathology. The symptoms are likely based on underlying factors in the child (often of a psychosocial nature) and this is acknowledged by both clinicians and parents. MUS can also be described as ‘functional disorders’; abnormal bodily sensations which cause pain and disability by affecting the normal functioning of the body. The health professionals and parents work collaboratively in the best interests of the child or young person.

4. Harm to the Child

Harm from FII can be caused directly by the parent/carer – either intentionally or unintentionally – but can also be supported or caused by the doctor’s actions, which can cause harm inadvertently.  As FII is not a category of harm in itself, the harm may be expressed as emotional abuse, medical or other neglect, or physical abuse.

1. Effects on the child’s health and experience of healthcare, eg:
1. Repeated unnecessary investigations or treatments which may be physically or psychologically distressing
2. Genuine illness may be overlooked by doctors due to repeated presentations
3. Illness may be induced by parents (eg poisoning, suffocation, withholding food or medications) – thereby threatening the child’s health or life
2. Effects on the child’s development and daily life, eg:
1. Disrupted school attendance/education
2. Limitation to normal daily life activities
3. Child may assume the ‘sick role’ eg unnecessary use of wheelchair
4. Social isolation
3. Effects on the child’s psychological well-being
1. May be anxious or confused about their state of health
2. May develop a false view of themselves as sick and vulnerable, which may be exacerbated by information obtained from social media use and which can persist into adulthood
3. May start to collude with parent’s illness deception

5. Alerting signs of possible FII

Alerting signs are not proof of FII – a single alerting sign is unlikely to indicate fabrication. Paediatricians/CAMHS professionals must look at the overall picture which includes the number and severity of alerting signs, each requiring careful consideration and review.

1. In the child, eg:
1. Reported symptoms and signs (physical, psychological or behavioural) not observed independently in their reported context
2. Unusual results of investigations
3. Inexplicably poor response to treatment
4. Some reported characteristics of child’s illness are physiologically impossible (eg large blood loss without a drop in haemoglobin)
5. Unexplained impairment of child’s daily life (eg school attendance)
2. Parent/carer behaviour, eg:
1. Insistence on continued investigation, rather than symptom alleviation, when full investigations have not explained the reported symptoms and signs
2. Repeated reporting of new symptoms
3. Repeated presentations to medical settings (including Emergency Departments)
4. Inappropriate seeking of multiple medical opinions
5. Child repeatedly not being brought to appointments
6. Objection to communication between professionals
7. Frequent vexatious complaints about professionals
8. Refusal to allow the child to be seen on their own
9. Talking for/over the child/child frequently defers to parent
10. Repeated changes of school, GP, Paediatrician or health team
11. Factual discrepancies in statements made by parents about their child’s illness
12. Parents/carers pressing for irreversible/drastic treatment options without clear clinical need, or need based solely on parental report

Where one alerting sign is identified it is essential to look for others.

6. Alerting Signs Identified by Other Professionals

Concerns may also be recognised by other professionals (eg within schools) 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). Those who have concerns regarding FII/PP should discuss these concerns with Safeguarding Leads within their own organisation and agree on the next steps, which may include explaining to parents that it is necessary to obtain a ‘health view’ on the presentation. 

Professionals who have identified concerns about a child’s health should discuss these with the child’s GP or with the consultant paediatrician or psychiatrist responsible for the child’s care, if involved.

The GP is likely to have had a higher level of involvement and knowledge of the child and family than other health professionals.  GP’s involvement and contribution to the management of PP/ FII concerns is therefore essential to ensure that all key information about the child is shared.  GPs will also be aware of parental health issues – including both physical and mental health – and these should be taken into consideration as part of any assessment and information sharing.

Cases which remain of concern should be discussed with the ICB Designated Safeguarding Team and, where appropriate, referred to a Consultant Paediatrician or Consultant Psychiatrist (depending on the presentation) by the child’s GP for an overview and medical assessment.

7.  Consultation and Communicating with Parents/Carers

Unplanned intervention or discussion with the parents/carer regarding concerns about fabricated or induced illness may put the child at a higher risk of harm. It is essential that services are co-ordinated and advice is taken from health professionals before discussions with parents or carers take place.

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;
• 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.

Where a child has moved or been involved with multiple agencies important knowledge can be missing, and as such it will be imperative to obtain information about their input and any concerns they may have had about the family.

8. Medical Evaluation

Alerting signs and symptoms of possible FII 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 medical investigations 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 paediatrician would tell the parent/s that an explanation for the signs and symptoms has not been found and record the parental response. Parents frequently seek additional medical opinions, and it is not uncommon for medical professionals to be collusive in this process. GPs and hospital doctors may inadvertently collude with the family to attempt to find a unifying diagnosis to explain the symptoms. However, the child risks being subjected to unnecessary and often invasive tests. To curtail this, it is good practice to ensure that once the possibility of FII is raised that a ‘paediatrician of reference’ is identified who can triage and challenge tests and referrals.

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 if this information would jeopardise the child’s safety and compromise the child protection process and/or any criminal investigation.

9. Immediate Serious Risk to Child’s Health or Life

The most important question to be considered is whether the child may be at immediate risk of serious harm, particularly by illness induction. This is most likely to occur when there is evidence of frank deception, interfering with specimens, unexplained results of investigations suggesting contamination or poisoning or actual illness induction, or concern that an open discussion with the parent might lead them to harm the child

In this scenario an urgent referral must be made to the police and children’s social care as a case of likely significant harm due to suspected or actual FII.

10. Perplexing Presentation Cases – no immediate risk to Child’s Health or Life

The response to Perplexing Presentations is a complex and time-consuming process, and should be undertaken by the responsible paediatric or CAMHS consultant with advice from their Trust’s Named Doctor and Safeguarding Team. If the responsible consultant is also the Named Doctor for their Trust, or if the Named Doctor also requires support around a case, advice can be provided by the ICB Designated Doctor and ICB Safeguarding Team. The essence of management is to establish, as quickly as possible, the child’s actual current state of physical and psychological health and functioning, and the family context. The consultant will need to explain to the parents (and the child if old enough) the uncertainty regarding the state of the child’s health, the proposed assessment process, and the fact that this will involve obtaining information from other caregivers, health providers, education and Children’s social care if involved, as well as likely professionals’ meetings.

The consultant will need to collate all current medical/health involvement, verify any reported diagnoses, obtain information about the child’s functioning (including, for example, school attendance and attainment), elicit the parents’ and child’s views, wishes and beliefs (speaking to them alone if appropriate) and consider whether further definitive investigations or referrals for specialist opinions are warranted or required. Wherever possible this assessment should be done collaboratively with the parents. If they do not agree, their concerns should be explored and can often be dispelled. However, under the NHS’ interpretation of GDPR information sharing can take place without consent if:

• There are safeguarding concerns
• It is in the best interests of the child
• It is necessary and proportionate and is done in a manner according to the regulations

Strong parental objections could indicate a referral to Children’s Social Care on the grounds of medical neglect – that the doctors are unable to establish the health and medical needs of the child.

The medical review will include a multi-professional Consensus Meeting to establish whether opinion is:

(a) That symptoms and signs can be explained by a verified illness, or symptoms are medically unexplained (MUS) but free from parental suggestion and child will not come to harm, or

(b) Physical and/or psychopathology does not fully explain the concerns and there are continuing uncertainties about the child’s current state of health and the nature and level of possible harm to the child.

11. The Health and Education Rehabilitation Plan (HERP)

Where there are continuing uncertainties about the child’s current state of health and possible harm to the child as in b) above, this should be communicated to the parents and child at a meeting with the responsible consultant and a colleague, such as the Named Doctor or Nurse. A Health and Education Rehabilitation Plan (HERP) should be developed and implemented with the child and family. This should happen regardless of the status of Children’s Social Care involvement at this stage. Negotiation with the parents, and child (as appropriate to their developmental level) is essential as engagement with such a plan is necessary for it to work.  The HERP is owned by Health, but can involve education, Children’s Social Care and other agencies as appropriate, and should be shared with an identified GP.

The lead health professional for the HERP 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 will need to help them work alongside professionals to implement the plan.  There should be discussion with the child’s identified 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.

The HERP 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 considered to be a concern. It is important that the child is not discharged from paediatric care, even in the absence of any verifiable medical illness, until it is clear that rehabilitation is proceeding.

If it becomes clear that the parents/carers do not consent to the HERP, or do not engage with an agreed plan, then a referral to Children’s Social Care should be made including, if possible, a chronology. The referral should be discussed with the parents, outlining the professional concerns.

12. Transitions

From the age of 16, young people are presumed in law to have the capacity to make decisions about their health. However, those aged 16–17 often need additional support as they move towards independence and transition from children to adult health services. This period can be particularly challenging for young people with ongoing health conditions, unexplained or functional disorders, or where there are concerns about fabricated or induced illness (FII). Care must be taken to ensure they do not lose support during this transition.

Timely, effective information sharing between children’s and adult services, and with the young person’s GP, is essential. Coordinated care, including joint meetings with relevant professionals, the young person, and their family, supports safe planning and continuity of care.

All health professionals should be familiar with the Mental Capacity Act 2005, which applies to those aged 16 and over. The Act assumes capacity unless proven otherwise, supports individuals to make their own decisions wherever possible, and requires any decisions made on behalf of someone without capacity to be in their best interests and the least restrictive.

Working with 16–17-year-olds provides an important opportunity to understand their views, concerns, and hopes for the future. Young people should be empowered to make informed decisions about their health, with parental views considered but with decisions led by the young person wherever they have capacity

13. Cultural considerations

Different cultures may have varying styles of illness behaviour and presentation to professionals, and it is important that this is carefully considered by those working with the family to ensure that it does not lead either to wrongful interpretation of indicators of FII or, conversely, missed safeguarding signs.

14. Referral to Children’s Social Care

When a probable explanation for the signs and symptoms is that they may have been fabricated or induced by a carer, or where parents have not consented to or engaged with a HERP, 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 in accordance with the Norfolk Referrals Procedure. If a child is already open to Children’s Social Care a strategy discussion should be requested.

Whilst professionals should, in general, discuss any concerns with the family and, where possible, seek agreement before making a referral to Children’s Social Care Services, this should only be done where such discussion and agreement will not place a child at increased risk of suffering or likely to suffer Significant Harm.  Advice about potential discussions and referrals should be sought from the employing organisation’s Named Doctor or Safeguarding Team, or the ICB Safeguarding Team.

Children’s Social Care Services should decide within one working day how to respond and what actions should be taken. Decisions should be agreed between the referrer and the recipient of the referral about what the parents will be told, by whom and when.

From the point of the referral, all professionals involved with the child should work together as follows:

• Lead responsibility for action to safeguard and promote the child’s welfare lies with Children’s Social Care Services;
• 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 or consultant psychiatrist is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child’s health care and dissemination of health information and health updates to the rest of the network.

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.

Where there are professional disagreements, for example concerning the need for, or the outcome of a referral, local Escalation/Resolving Professional Disagreements policy should be followed. 

15. Immediate Protection

If at any point there is medical evidence to indicate the child’s life is at risk or there is a likelihood of serious immediate harm, an application for an Emergency Protection Order or Police Protection powers should be used to secure the immediate safety of the child.

16. Strategy Discussion/Meeting

If there is reasonable cause to suspect that the child is suffering, or likely to suffer Significant Harm, the Children’s Social Care Services should convene a Strategy Discussion/Meeting involving all the key professionals.

Unless there is an emergency, this should be a Strategy Meeting, chaired by a senior manager from the Children’s Social Care Services.

If emergency action is the required response, for example, if a child’s life is in danger through poisoning or toxic substances being introduced into the child’s blood stream, an immediate Strategy Discussion should take place.

The Strategy Discussion/Meeting requires the involvement of key senior professionals responsible for the child’s welfare. At a minimum, this must include Children’s Social Care Services, the Police and the Paediatric Consultant responsible for the child’s health.

Additionally the following should be invited to Strategy Meetings 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 and School Nurse;
• Staff from education settings;
• Local authority’s Legal adviser;
• Named Doctor/Nurse
• Designated Doctor/Nurse

Where the Strategy Discussion/Meeting decides that a Section 47 Enquiry should be initiated, see Section 14, Section 47 Enquiry and Assessment.

Decisions about undertaking covert video surveillance and keeping records should be made at a Strategy Discussion/Meeting (see Section 18, Covert Video Surveillance).  Specific policing tactics will be discussed with relevant personnel outside of this forum. Any such decision should be clearly recorded, with reasons given why it is necessary.

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.

For some children it may be necessary to initiate legal proceedings immediately.

17. Section 47 Enquiry and Assessment

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 about how the Section 47 enquiry will be carried out including:

• What further information is required about the child and family and how it should be obtained and recorded;
• The child’s current safety and any plans in place to mitigate risk of harm
• Whether it is necessary for records to be kept in a secure manner and how this will be ensured;
• Whether the child requires constant professional observation and if so, whether or when carer(s) should be present;
• Who will carry out what actions, by when and for what purpose, in particular planning further paediatric assessment(s);
• Any particular factors, such as the child and family’s culture, religion, ethnicity and language which should be taken into account;
• The needs of siblings and other children with whom the alleged abuser has contact;

• Exploration of the wider family network
• The needs of parents or carers including learning needs, physical disabilities, mental health, substance use;
• The nature and timing of any police investigations, including analysis of samples and covert video surveillance (see Section 18, Covert Video Surveillance);
• How information will be shared with parents and at what stage;
• The most efficient method and timing of converting partners’ information into an evidential format to police for investigative purposes.
• Obtaining legal advice over evaluation of the available information (where a legal adviser is not present at meeting).

18. Police Investigation

All agencies involved with the child and their family should work in close collaboration to ensure effective joint agency decision making and shared responsibility towards achieving safety and a positive outcome for the child.

In cases where a criminal offence is suspected and a prosecution is contemplated, it is important that the suspects’ 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.

See Section 21, Covert Video Surveillance in relation to Covert Video Surveillance.

19. Outcome of Section 47 Enquiry and Assessment

19.1 Concerns Not Substantiated

As with all Section 47 Enquiries, the outcome may be that concerns are not substantiated. This may be because further assessment, shared multi-agency analysis or medical evaluation identifies an explanation for the child’s presentation, such as a verified medical condition or other needs that do not indicate significant harm.

Where protective action is not required, partners should consider whether the child and family would benefit from coordinated Family Help or Child in Need support. In line with the Families First approach, this should be based on a shared understanding of need, strengths, risk and protective factors, with the family and relevant agencies working together to agree proportionate support, clear outcomes and review arrangements.

Where support is required, the plan should identify the most appropriate lead professional or practitioner, set out how agencies will work together with the family, and ensure information is shared lawfully and effectively so that progress can be reviewed and any emerging concerns responded to promptly.

19.2 Concerns Substantiated but No Continuing Suffering or likely to Suffer Significant Harm

Where concerns are substantiated but the assessment concludes that the child is not suffering, and is not likely to suffer, continuing Significant Harm, the rationale for not progressing to an Initial Child Protection Conference must be clearly evidenced, endorsed by the relevant manager within Children’s Social Care Services, and recorded on the child’s record. This decision should be informed by multi-agency information sharing and analysis, including the views of health, police, education and any other relevant partners.

A multiagency planning discussion should consider what ongoing Family Help, Child in Need or other coordinated support is required to meet the child’s needs and strengthen safety and wellbeing. Any request from a senior manager, or from a named or designated professional in an involved agency, for an Initial Child Protection Conference to be convened should be considered within the multiagency safeguarding arrangements, with the decision and rationale clearly recorded.

19.3 Concerns Substantiated and Continuing Suffering or likely to Suffer Significant Harm

Where concerns are substantiated and the child judged to be suffering or likely to suffer Significant Harm, an Initial Child Protection Conference must be convened. All evidence must be documented by this stage and a safety plan for the child must already be in place.

The Initial Child Protection 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.

20. Initial Child Protection Conference

Attendance at this conference should be as for other initial conferences – see Initial Child Protection Conferences Procedure – although specific decisions about the participation of the parents/carers will need to be discussed with the Conference Chair and the following experts invited as appropriate:

• A professional with expertise in working with children and families where a care giver has fabricated or induced illness in a child;
• A paediatric consultant with expertise in the branch of paediatric medicine, able to present the medical findings.

Each agency should contribute a written report to the conference (see Section 12.2, Other Agency Reports to Conference of Initial Child Protection Conference Procedure) which sets out the nature of its involvement with the child and the family.

The child may have been seen by a number of professionals over a period of time: Children’s Social Care Services have responsibility for ensuring that, as far as is possible, this multiagency chronology (with special emphasis on the child’s medical history) has been systematically brought together for the conference. Where the medical history is complex, this should be done in close collaboration with the paediatric consultant responsible for the child’s health care. The health history of any siblings should also be considered. The Conference Chair has responsibility for ensuring that additional or contradictory information is presented, discussed and recorded at the conference.

Careful consideration should be given to when agency reports will be shared with the child’s parents. This decision will be made by the Conference Chair, in consultation with the professional responsible for each report.

If the family has recently moved, procedures for children crossing boundaries should be followed to ensure appropriate sharing of relevant information.

The conference should decide whether the child is suffering or likely to suffer Significant Harm, and therefore in need of a Child Protection Plan. If this is the case, an outline Child Protection Plan should be developed stating clearly what action will be taken to safeguard the child immediately after the conference, as well as in the longer term.

The conference should also consider what action if any is required to protect siblings in the family.

21. Covert Video Surveillance

In very rare cases where there are concerns about FII, covert video surveillance (CVS) may be used. The use of CVS is governed by the Regulation of Investigatory Powers Act 2000.

After a recommendation has been made at a Strategy Discussion to use CVS in a case of suspected fabricated or induced illness, the responsibility for undertaking the surveillance lies with 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 recorded materials. Covert surveillance is rarely if ever indicated. When it is determined that it may be indicated the police will discuss with the hospital legal and possibly ethics teams.

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.

All personnel including nursing staff who will be involved in its use should have received specialist training.

Children’s Social Care should have a contingency plan in place, which can be implemented immediately if covert video surveillance provides evidence of the child suffering Significant Harm.

• Summary Flow Chart for Paediatric Response to Alerting Signs of possible Fabricated or Induced Illness/Perplexing Presentation