Fabricated or Induced Illness (including 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 or Induced Illness and assessment of significant harm to a child falls under statutory framework provided by Working Together to Safeguard Children and Safeguarding Children.

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.

In addition, the emotional, psychological and social development of the child may be negatively impacted.

For further details on the harm to the child see RCPCH 2021, Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children. RCPCH guidance. [Chapter 4,  page number 16] Royal College of Paediatrics and Child Health.

• 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. They are not in themselves evidence of Fabricated or Induced Illness but indicators of possible Fabricated or Induced Illness.

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.

Fabricated or Induced Illness is based on the parent’s underlying need for their child to be recognised and treated as ill or more unwell/more disabled than the child actually is (when the child has a verified disorder, as many of the children do). Fabricated or Induced Illness may involve physical, and/or psychological health, neurodevelopmental disorders and cognitive disabilities. There are two possible, and very different, motivations underpinning the parent’s need: the parent experiencing a gain and the parent’s erroneous beliefs.   For further information on parental motivation and behaviour see RCPCH 2021, Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children. RCPCH guidance. [Chapter 4 and page number 13] Royal College of Paediatrics and Child Health.

Where there is a suspicion of Fabricated or Induced Illness, practitioners should consider this guidance carefully when fulfilling their role in assessing and investigating their concerns effectively.  In addition, the Royal College of Paediatrics and Child Health (RCPCH) Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children guidance should be used to support process and procedure.

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.

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.

Necessary referral to children’s social care

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).

The referral to children’s social care should be discussed with parents and the reasons for professional concern explained. The emphasis should be on the nature of the harm to the child including physical harm, emotional harm, medical or other neglect and avoidable impairment of the child’s health or development.

In order to help to ensure that the referral is acted upon appropriately it should describe the concerns, define the harm and provide evidence of inability of the health professionals to manage the situation on a voluntary basis. The referral should include all of the following, using plain language:

• A clear explanation of any verified diagnoses with a clear description of the functional implications of the diagnosis(es) for the child;
• Details of the nature of the concerns;
• Description of independent observations of the child’s actual functioning, medical investigations, detailing all medical services involved and the consensus medical and professional view about the child’s state of health;
• Information given to the parents and child about diagnoses and implications;
• Description of the help offered to the child and the family to improve the child’s functioning (eg the Health and Education Rehabilitation Plan, see RCPCH guidance);
• The parents’ response;
• Full description of the harm to the child, and possibly to the siblings, in terms of physical and emotional abuse, medical, physical and emotional neglect.

Response requested from children’s social care

The reason for referring the child to social care is the need to reduce the harm to the child. Children's social care in turn undertake an assessment to determine whether the significant harm threshold has been reached, what the child’s needs are and to intervene to reduce or prevent harm. This should include supporting the Health and Education Rehabilitation Plan (as per RCPCH guidance). In addition, the child will need to be protected from being taken to health professionals unnecessarily by the parent if they continue to give unreliable information about the child, as health professionals unaware of the full context will not have the necessary information on which to assess the child which may be to the detriment of the child’s health and wellbeing.

If the referral is declined as not reaching the threshold for children’s social care assessment and support, or the response does not appear to be appropriate, then every effort should be made for health and children’s social care to understand each other’s professional opinions and if necessary the local dispute resolution/ escalation procedures should be used.  

Children’s social care will often request a chronology from health to inform their assessment. In cases of professional dispute, the evidence contained within a full chronology may be invaluable, along with the comprehensive referral (described above) with a health assessment report outlining evidence of professional concerns, the impact on the child and actions taken so far by health professionals to attempt to resolve the issues.

Strategy meetings / discussion

If there is reasonable cause to suspect the child is suffering, or is likely to suffer significant harm, children’s social care must convene and chair a strategy discussion that involves all the key professionals responsible for the child’s welfare. It should, at a minimum, include children’s social care, the police, the GP and/or paediatric consultant responsible for the child’s health and the community paediatric nursing service or if the child is an in-patient, a senior ward nurse. It is also important to consider seeking advice from the designated safeguarding doctor and/, or having present, a paediatrician who has expertise in the branch of medicine, for example respiratory, gastroenterology, neurology or renal which deals with the symptoms and illness processes caused by the suspected abuse. This would enable the medical information to be presented and evaluated from a sound evidence base. Other professionals involved with the child such as the GP, health visitor and staff from education settings should be involved also as appropriate. It may be appropriate to involve the local authority’s solicitor at this meeting. Staff should be sufficiently senior to be able to contribute to the discussion of often complex information, and to make decisions on behalf of their agencies.

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 and what is happening for the child.

The strategy discussion/ meeting should be used to:

• Share available information; to collate a multi-agency chronology. All agencies should prepare and bring their own chronology to the strategy meeting;
• Agree the conduct and timing of any criminal investigation; and
• Decide whether enquiries under section 47 of the Children Act 1989 should be undertaken, or assessment under section 17 Children Act 1989.

NB: Strategy discussions/meetings may be independently chaired.

In cases of suspected FII decisions should also be made at the strategy discussion about:

• Whether the child requires constant professional observation and, if so, whether or when the carer(s) should be present;
• Whether it is necessary for records to be kept in a secure manner to safeguard the child’s welfare, and how this will be ensured;
• What immediate and short-term action is required to support the child, and who will do what by when;
• Further paediatric assessment;
• Any factors such as the child and family's culture, ethnicity and language which should be taken into account;
• Factors that should be considered if the child is disabled;
• The needs of siblings and other children with whom the alleged perpetrator has contact;
• The nature and timing of any police investigations, including the analysis of samples. This is particularly pertinent if covert video surveillance is being considered.

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, child protection powers should be used to  secure the immediate safety of the child.

More than one strategy discussion may be necessary. This is likely where the child’s circumstances are very complex, and a number of discussions are required to consider whether and, if so, when to initiate section 47 enquiries.

Legal advice about how to proceed should always be sought and made directly available to doctors who are responsible for making clinical decisions in these cases. Such advice should be documented in medical and children’s social care records.

When it is decided that there are grounds to initiate a Section 47 Enquiry as part of a Social Work 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;
• 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 factors, such as the child and family's culture, religion, ethnicity and language which should be taken into account;
• Effective communication between colleagues is essential if to ensure a good outcome for the child is to be achieved. Concerns about FII should be mentioned in all communications about the case, and the responsible social worker and paediatric consultant should be the main conduit for communications.
• The needs of siblings and other children with whom the alleged abuser has contact;
• The needs of parents or carers;
• The nature and timing of any police investigations, including analysis of samples and covert surveillance. The use of covert video surveillance (CVS) is governed by the Regulation of Investigatory Powers Act 2000
• All personnel including nursing staff who will be involved surveillance use should have received specialist training.
• Children's Social Care Services team should have a contingency plan in place, which can be implemented immediately if covert video surveillance provides evidence of the child suffering Significant Harm.
• How information will be shared with parents and at what stage.

Outcome of Enquiries:

• Concerns not substantiated - determine and agree ongoing help and support of the child and family and the best means of meeting these
• Concerns substantiated, but child not judged to be at continuing risk of significant harm – children’s social care, in consultation with other agencies, should take carefully any decision not to proceed to an Initial Child Protection Conference where it is known that a child has suffered significant harm as a result of fabricated or induced illness
• Concerns substantiated, and child judged to be at continuing risk of harm - initiate an Initial Child Protection Conference

To note:

• 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 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