5.10 Fabricated or Induced Illness
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.
The British Association of Social Work (BASW) 2022 ‘Fabricated or Induced Illness and Perplexing Presentations’ also provides guidance for Social Work Practitioners.
Fabricated and Induced Illness (FII) is a clinical situation in which a child is, or is very likely to be, harmed due to parent(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 – 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.
- Effects on the child’s health and experience of healthcare, eg:
- Repeated unnecessary investigations or treatments which may be physically or psychologically distressing
- Genuine illness may be overlooked by doctors due to repeated presentations
- Illness may be induced by parents (eg poisoning, suffocation, withholding food or medications) – thereby threatening the child’s health or life
- Effects on the child’s development and daily life, eg:
- Disrupted school attendance/education
- Limitation to normal daily life activities
- Child may assume the ‘sick role’ eg unnecessary use of wheelchair
- Effects on the child’s psychological well-being
- May be anxious or confused about their state of health
- May develop a false view of themselves as sick and vulnerable
- 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. Clinicians must look at the overall picture which includes the number and severity of alerting signs, each requiring careful consideration and review.
- In the child, eg:
- Reported symptoms and signs (physical, psychological or behavioural) not observed independently in their reported context
- Unusual results of investigations
- Inexplicably poor response to treatment
- Some reported characteristics of child’s illness are physiologically impossible (eg large blood loss without a drop in haemoglobin)
- Unexplained impairment of child’s daily life (eg school attendance)
- Parent behaviour, eg:
- Insistence on continued investigation, rather than symptom alleviation, when full investigations have not explained the reported symptoms and signs
- Repeated reporting of new symptoms
- Repeated presentations to medical settings (including Emergency Departments)
- Inappropriate seeking of multiple medical opinions
- Child repeatedly not being brought to appointments
- Objection to communication between professionals
- Frequent vexatious complaints about professionals
- Refusal to allow the child to be seen on their own
- Talking for/over the child/child frequently defers to parent
- Repeated changes of school, GP, Paediatrician or health team
- Factual discrepancies in statements made by parents about their child’s illness
- Parents pressing for irreversible/drastic treatment options without clear clinical need, or need based solely on parental report
Where the paediatrician/CAMHS professional identifies one alerting sign it is essential to look for others.
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 or psychiatrist responsible for the child’s care. Further advice can be sought from Norfolk’s Designated Safeguarding Children’s Team on 01603 257164.
6. 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.
7. 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 in an 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 is able to triage and challenge tests and referrals.
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.
8. 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.
9. 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 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 Designated Doctor and Designated Safeguarding Children 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.
10. 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 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.
11. 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 Referrals Procedure.
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 Designated Safeguarding Children 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.
12. 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.
13. 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 if appropriate;
- 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 institute legal proceedings either immediately or soon after the Child Protection Conference has ended.
14. 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;
- 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;
- The needs of parents or carers;
- 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).
15. Police Investigation
Any evidence gathered by the Police must be available to other relevant professionals, to inform discussions about the child’s welfare and contribute to the Section 47 Enquiry and Assessment.
Any evidence or information from other relevant professionals should be made expeditiously available to police to aid investigations.
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 18, Covert Video Surveillance in relation to Covert Video Surveillance.
16. Outcome of Section 47 Enquiry and Assessment
16.1 Concerns Not Substantiated
As with all Section 47 Enquiries, the outcome may be that concerns are not substantiated – e.g. tests may identify a medical condition, which explains the signs and symptoms.
It may be that no protective action is required, but the assessment concludes that services should be provided to the child and family to support them and promote the child’s welfare as a Child in Need. In these circumstances, the Assessment should be completed and a planning meeting held to discuss the conclusions, and plan any future support services with the family.
16.2 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 judged to be at continuing risk of harm, the decision not to proceed to an Initial Child Protection Conference must be endorsed by the relevant Manager within Children’s Social Care Services and recorded on the relevant records and database. Again, a planning meeting to consider future action may be considered as an appropriate format to meet the needs of the child and promote his/her welfare.
Any request by a senior manager, or a named or designated professional in an involved agency that a Child Protection Conference be convened should be agreed.
16.3 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 an interim Child Protection 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.
17. 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 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, contact should be made and information obtained from the paediatric services in the area where the family previously lived.
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.
18. 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