Perplexing Presentation / Fabricated or Induced Illness: A matter for schools?

This is part of our safeguarding insights section.  Our aim is to provide you with a broader understanding of a specific topic through a researched and referenced article that contributes towards your professional development and ensures that you can support your staff accordingly.

15 minute read

DSLs and Safeguarding Teams

Introduction

Due to the nature and levels of workloads that professionals must deal with daily, as soon as the word ‘illness’ is seen there is a natural response to classify that as a health issue and – at most – make a mental note to speak to the school nurse about it.

Indeed, this sense of illness being a health issue is, in some sense, reinforced by the Department for Education.  If you search through Keeping Children Safe in Education 2020 for the term, or its shorthand of FII, you will find only one mention in the “Additional advice and support” section of Annex A, simply a link to the 2008 government guidance, Safeguarding children in whom illness is fabricated or induced.  Fabricated or Induced Illness is also briefly mentioned in Ofsted guidance for inspectors as an area where safeguarding action may be required to protect children and learners, but again little there is substance behind it.

Physical abuse

This lack of emphasis on Fabricated or Induced Illness may be due to research suggesting that it is a rare form of child abuse.  The NHS cites a widely quoted study from 2000 which estimated the number of cases of Fabricated or Induced Illness at just 89 per 100,000 over a two year period. When compared to figures from 2016/17 for sexual offences against under 18’s which equate to around 500 per 100,000 in a one year period, this does show why it is considered rare.  However, as the research itself identifies, there are a number of caveats to the 89 per 100,000 figure, and there is consensus that the true figure may be higher.

Although not specifically referenced in the body of Keeping Children Safe in Education 2020, all staff should be aware of Fabricated or Induced Illness through its inclusion in the definition of physical abuse in Part one of the document:

Physical abuse: a form of abuse which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child. (para 43, p.14, Part one, Keeping Children Safe in Education, 2020 – emphasis added)

However, the new guidance from the RCPCH (2021) places schools and educational settings at the centre of the safeguarding process, including the introduction of a Health and Education Rehabilitation Plan which is agreed by professionals and families and is an essential feature of the management in all cases whether or not children’s social care are involved.

Definitions

As highlighted above, there is an ongoing debate regarding the terminology.  The most up to date definitions are from the RCPCH 2021 Perplexing Presentations - FII Guidance, which describe Medically Unexplained Symptoms (MUS), Perplexing Presentations (PP) and Fabricated or Induced Illness (FII).

Term	Definition
Medically Unexplained Symptoms (MUS)	The child’s symptoms, of which the child complains, and which are genuinely experienced, are not fully explained by any known pathology but with likely underlying factors in the child (usually of a psychosocial nature), and the parents acknowledge this to be the case. The health professionals and parents work collaboratively to achieve evidence-based therapeutic work in the best interests of the child or young person. MUS can also be described as ‘functional disorders’ and are abnormal bodily sensations which cause pain and disability by affecting the normal functioning of the body.
Perplexing Presentations (PP)	Presence of alerting signs when 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.
Fabricated or Induced Illness (FII)	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 or neurodevelopment is impaired (or more impaired than is actually the case). FII results in emotional and physical abuse and neglect.

Features of Perplexing Presentations and Fabricated and Induced Illness

Evidence tells us that the mother (or female caregiver) is nearly always involved or is the instigator of Fabricated or Induced Illness and that the father’s involvement is variable.  It is rare for fathers to be solely involved.  Rarely foster carers have been known to be involved and there is currently no data on same sex couples.

As highlighted, there are two possible motivations underpinning the parent’s need: the parent experiences a gain and the parent’s erroneous belief.

1. In the first, the parent experiences a gain (not necessarily material) from the recognition and treatment of their child as unwell. The parent is thus using the child to fulfil their own needs, disregarding the effects on the child. This could include seeking an inappropriate mental health diagnosis such as for ADHD or ASD;
2. The second motivation is based on the parent’s erroneous beliefs, extreme concern and anxiety about their child’s health (e.g. nutrition, allergies, treatments). This can include a mistaken belief that their child needs additional support at school and an Education Health and Care Plan (EHCP).

In Fabricated or Induced Illness, parents’ needs are primarily fulfilled by the involvement of doctors and other health professionals.  The parent’s actions and behaviours are intended to convince health professionals, particularly paediatricians, about the child’s state of health.  It is important to note that, as is common in child neglect, the parent is not usually ill-intentioned towards their child per se.  Nonetheless, they may cause their child direct harm, unintentionally or in order to have their assertions reinforced and believed.

Harm to the child

Harm to the child may take several forms and differ in terms of severity.  Some harm is caused directly by the parent, intentionally or unintentionally, but may be supported by the doctor; others are brought about by the doctor’s actions, with the harm being caused inadvertently.  Examples include:

1. Child’s health and experience of healthcare

• The child undergoes repeated (unnecessary) medical appointments, examinations, investigations, procedures & treatments, which are often experienced by the child as physically and psychologically uncomfortable or distressing;
• Illness may be induced by the parent (e.g. poisoning, suffocation, withholding food or medication) potentially or threatening the child’s health or life.

2. Effects on child’s development and daily life

• The child has limited / interrupted school attendance and education;
• The child’s normal daily life activities are limited (not able to join in PE for example);
• The child assumes a sick role (e.g. with the use of unnecessary aids, such as wheelchairs);
• The child is socially isolated.

3. Child’s psychological and health-related wellbeing

• The child may be confused or very anxious about their state of health;
• The child may develop a false self-view of being sick and vulnerable and adolescents may actively embrace this view and then may become the main driver of erroneous beliefs about their own sickness. Increasingly young people caught up in sickness roles are themselves obtaining information from social media and from their own peer group which encourage each other to remain ‘ill’;
• There may be active collusion with the parent’s illness deception.

If alerting signs are identified by education settings, it is appropriate that a paediatrician professional becomes involved as the resolution lies in ascertaining the actual state of the child’s health.   

Responding to alerting signs

Fabricated or Induced Illness - Immediate serious risk to child’s health / life

The most important question to be considered is whether the child may be at immediate risk of serious harm, particularly by illness induction as defined by the Children Act 1989 / Working Together to Safeguard Children / Keeping Children Safe in Education.

In this situation, the following are important considerations:

• An urgent referral must be made to the police and children’s social care (generally via MASH or local equivalent) as a case of likely significant harm due to suspected or actual harm. This should lead to a strategy meeting and the safety of siblings also needs to be considered;
• Documenting concerns carefully in the child’s safeguarding record;
• Considering whether the child needs immediate protection and measures taken to reduce immediate risk.

Schools should be mindful of situations where to inform the parents of the referral would place a child at increased risk of harm.  In this situation, carers would not be informed of the referral before a multi-agency discussion has taken place, which would usually be in the form of a formal strategy meeting.

Perplexing Presentations (PP) - Alerting signs with no immediate serious risk to the child’s health / life 

The term Perplexing Presentations (PP) denotes the presence of alerting signs to possible Fabricated or Induced Illness, in the absence of the likelihood of immediate serious risk to the child’s physical health or life.  Perplexing Presentations nevertheless indicate possible harm to the child which can only be resolved by establishing the actual state of health of the child. They therefore call for a carefully planned response.

If the initial concerns arise directly from school, it is recommended that school explain to the parents that information is required from health to understand the concerns, e.g. poor school attendance.  It is then appropriate for education, with the parents’ consent to contact health (either GP, consultant paediatrician or child psychiatrist) with their query about the actual health of the child.

If the parents do not agree to a health assessment and the sharing of information about the child, schools need to decide what action they will take.  Safeguarding Network would recommend that national safeguarding guidance is utilised, and safeguarding supervision is sought to explore concerns.

At this stage, professionals should refrain from using Fabricated or Induced Illness terminology, as the state of the child’s health has not yet been assessed.

Reaching a consensus about the child’s current health, needs, and potential or actual harm to the child

Consensus about the child’s state of health needs to be reached between all health professionals involved with the child and family, and other significant professionals including education.  A multi-professional meeting is required in order to reach consensus.

The professionals meeting should be led and chaired by health colleagues, which would generally be the Named Doctor for safeguarding children.  The child’s parents should be informed about the meeting and receive the consensus conclusions with an opportunity to discuss them and contribute to the proposed plans.

In order to resolve these concerns, a decision needs to be made about whether the perplexing presentation is explained and resolved by a verified medical condition in the child, or whether concerns remain.

In order to resolve this, a consensus needs to be reached in a meeting between all professionals and in all cases, agreement must be made regarding:

• How the child and the family need to be supported to function better alongside any remaining symptoms, using a Health and Education Rehabilitation Plan (see below for details);
• Next steps regarding what to do if the parents disengage or request a change of paediatrician in response to consensus reached and the proposed Health and Education Rehabilitation Plan.

Whether to refer to children’s social care at this point

If there is actual or likely harm to the child or siblings, the implication is that a referral is needed to children’s social care as per Working Together to Safeguard Children (2018) which states:  ‘Anyone who has concerns about a child’s welfare should make a referral to local authority children’s social care and should do so immediately if there is a concern that the child is suffering significant harm or is likely to do so.’

The question of potential future harm to the child hinges on whether the parents recognise the harm and are able to change their beliefs and actions in such a way as to reduce or remove the harm to the child, which requires the co-construction of a Health, Education and Rehabilitation Plan with the parents and child, and implementation of this plan.

In some cases, if parents and child (if of an appropriate developmental level) are able to understand the need for and are able to agree a Health and Education Rehabilitation Plan, immediate referral to children’s social care may not be necessary as long as the plan is being monitored carefully, proceeding satisfactorily and agreed goals are being reached. The decision however lies with the professionals who are working within their multi-agency procedures.

Health and Education Rehabilitation Plan

Development of the Health and Education Rehabilitation Plan requires a coordinated multidisciplinary approach and negotiation with parents and children and usually will involve their attendance as appropriate at the relevant meetings.  An example of a plan is included below.

Key points:

• The Plan requires health to rationalise and coordinate further medical care;
• The Plan requires educational access to be optimised;
• The Plan is led by one agency (usually health) but will also involve education and possibly children’s social care;
• The Plan must specify timescales and intended outcome;
• The Plan needs to be reviewed regularly with the family according to the timescales for achieving the specified outcomes, especially regarding the child’s daily functioning;
• If Children’s Services are involved, the Plan should form part of a Child in Need or a Child Protection Plan;
• Schools are in a prime position to monitor the children’s progress (long term) and to identify re-emerging or new concerns.

If the Health and Education Rehabilitation Plan is not working,  if the parents disagree with the consensus feedback and an effective Health and Education Rehabilitation Plan cannot be negotiated, or it becomes apparent that there is lack of engagement with the Plan which had been agreed with them, then it is necessary to refer the child to children’s social care as per Working Together to Safeguard Children (2018) / Keeping Children Safe in Education (2020).

Impact on schooling

Whilst research shows that the most severe and dramatic events are usually seen in children under the age of five, Fabricated or Induced Illness is seen in children of all ages (NSPCC, 2011).  Arguably, the reason for the greater severity in under 5’s is that Fabricated or Induced Illness requires acts to be done to children (either by the parent or by doctors) and therefore as a child gets older they are more likely to ask questions and start to challenge the “perceived wisdom” of the parent.

However, as identified some children can become so indoctrinated in their “sick” persona that they may go on to simulate their own illnesses or start to collude with their parents position (as seen in this Serious Case Review).  Cases are also seen where the description of the child and their illness does not fit the child that is seen in school.  As part of the collation of information, schools should share information about the child’s current functioning, including school attendance, attainments, emotional and behavioural state, peer relationships, mobility, and any use of aids.

Any child’s medical needs can have an impact on their day to day schooling, however in cases of Fabricated or Induced Illness, the impact is likely to be significant and may not fit with the school’s experience of the child.  Schools may find themselves having to adjust premises, routines, etc. to ensure that they are compliant with the Equality Act 2010, and that they have staff who are trained in various medical procedures.  A child’s attendance at school may be severely disrupted due to medical appointments or having days off due to being unwell.  Cases often identify that the abuser can be highly manipulative and frequently well informed about the different features of the ‘illness’, meaning that they are very hard to challenge.

As a school there is therefore a need to be aware of patterns of absence (does your data manager / business manager regularly report any concerns?), and whether staff asking questions leads to increased absence.  Schools should also be aware of cases where there are multiple moves of school or the suggestion of home schooling for an ill child and should question what the reason for this may be. Evidence suggesting that this is part of the pattern when there are cases of Fabricated or Induced Illness.

Respectful uncertainty

Respectful uncertainty was introduced as a concept by Lord Laming in his enquiry into the death of Victoria Climbié.

The concept of “respectful uncertainty” should lie at the heart of the relationship between the social worker and the family. It does not require social workers constantly to interrogate their clients, but it does involve the critical evaluation of information that they are given. People who abuse their children are unlikely to inform social workers of the fact. For this reason, at least, social workers must keep an open mind. (para 6.602, p.205, The Victoria Climbie Enquiry)

For our purposes, the term “social workers” can be replaced by “professionals”.  This approach is key when considering cases of suspected fabricated or induced illness.

Serious Case Reviews demonstrate that often there is a mismatch between information being presented to one agency and information being presented to another.  Schools see the children for prolonged periods of time throughout the year.  During this time there can be significant differences between what the parents report as happening whilst the children are in their care and what the staff see daily.

Another term that can be applied here is professional dangerousness. The term is attributed to Tony Morrison (1990) and describes the process where the behaviour of professionals involved in child protection work means that they inadvertently collude with the family they are working with or act in a way that increases the dangerous dynamics that are present.  In cases of Fabricated or Induced Illness there is a risk that human nature will mean that subconsciously we do not want to countenance the idea that parents, and particularly mothers, would want to seek medical assistance that would harm their child.  For most parents, the natural response would be to only agree to what can be highly invasive procedures if they were convinced that they were absolutely necessary. Therefore, if a procedure is being recommended and the parents are agreeing to it, it is natural to think it must be necessary.

Daniel Pelka

A lack of respectful uncertainty was seen in the case of Daniel Pelka.  Whilst the case is more commonly known for the alcohol misuse and domestic abuse in his mother’s relationships and the physical abuse of Daniel, there was also a lesser identified element of Fabricated or Induced Illness present.

The Serious Case Review identified that although Daniel was only at school for two terms before he died, in that time there were concerns that he was scavenging for food in bins and craving for food (he was stealing food from other children’s lunchboxes and eating secretively).  When the mother was challenged about this, she stated that he had a health condition and requested that the school supported her in making sure that he only ate what was in his lunchbox.  However, Daniel’s reported obsession with food did not match up to what staff were seeing in relation to his appearance – one member of staff telling the subsequent criminal trial that he appeared to be “wasting away”.  The Serious Case Review found that assumptions were “too readily made that his problems were medically based”.  The suggestion is that the mother was falsifying the health condition to cover up the abuse that was happening at home, and that she and her partner were inducing medical problems by force feeding him salt, with this being planned as a punishment if he was considered to have been eating too much.

Disguised compliance

Common themes which potentially evidence disguised compliance include the focus on improving one issue to deflect attention from other areas, being critical of professionals, and not engaging with services or avoiding contact with professionals.  In cases of Fabricated or Induced Illness one or more of these traits is often seen, for example:

• Reported physical, psychological or behavioural symptoms and signs not observed independently in their reported context
• Inexplicably poor response to prescribed treatment (despite parents collecting prescriptions and saying that they have given the drugs)
• Unexplained impairment of child’s daily life, including school attendance, aids, social isolation
• Playing professionals off against each other, such as telling health professionals that the child’s school is not supporting the care plan
• Parents blocking access to the child or making sure that they are always present when the child is seen.

It is therefore important that we focus on the question “what does this mean for the child?” and if we are concerned about something the parent is doing, are we concerned about significant harm?

Challenge

Alongside questioning what a parent’s behaviour means for a child, we also the need to feel able to challenge fellow professionals.  Within many systems there are hierarchies; however,

Safeguarding Network are strongly of the view that there is no such thing as a hierarchy in safeguarding and child protection.  Very often it is the person who perceives themselves to be at the bottom of the hierarchy and believes that they have the least knowledge who has the most contact with the child and is best placed to know if there is something happening that is concerning.

In relation to Perplexing Presentations and Fabricated or Induced Illness the power associated with the hierarchy within health can go across agencies, with other agencies deferring to the power and knowledge of others deemed to be “more experienced in these matters”.  For example, one Serious Case Review found that because the child was receiving medical care from a “centre of excellence” everyone involved relied on their skills to manage the treatment and concerns that were present in education and other health sectors were not flagged up because the involvement of the specialist service added a confirmation bias (e.g. when we want something to be true we will look for things that confirm it is true).  In this case the bias was that professionals did not want to believe that the mother was harming her children and the involvement of a specialist centre meant that the child must genuinely be ill.  No-one involved was questioning what they were being told and the situation had been manipulated by the mother.  This case review also found that the school had not made a referral to children’s social care because they felt that based on their concerns alone, the threshold for involvement of a social worker would not be met.  The review argued that the referral should have been made and then a discussion held.

Voice of the child

As with many other forms of abuse, evidence suggests that the voice of the child is often lost in cases of Fabricated or Induced Illness.  In cases of Perplexing Presentations and Fabricated or Induced Illness, it is essential that:

The child’s views are explored with the child alone (if of an appropriate developmental level and age) to ascertain:

• the child’s own view of their symptoms;
• the child’s beliefs about the nature of their illness;
• worries and anxieties;
• mood;
• wishes.

Close observation is needed and any contrasts in verbal and non-verbal communication from the child during conversations should be noted.  It is important to note that some children’s and adolescent’s views may be influenced by and mirror the caregiver’s views.  The fact that the child is dependent on the parent may lead them to feel loyalty to their parents and they may feel unable to express their own views independently, especially if differing from the parents.

Whilst some of these comments can be levelled arguably at health professionals, evidence from Serious Case Reviews suggests that some children do not feel that they can tell anyone about what is happening to them.  Schools therefore need to consider how they provide a safe space for children to share their concerns with a professional, who will believe what they say and act appropriately.

In summary

Many schools will have a child/children where the school staff are concerned or perplexed about the child’s presentation.  This may be due to the history not matching what they observe on a day to day basis, or when the child appears to have an intensive level of health intervention, which impacts on their school attendance and in extreme circumstances, the school may recognise signs that the parent is Fabricating or Inducing Illness.

Whilst we acknowledge that this is not a commonly seen form of child abuse, the risk of harm to the child is high, as is the long-term impact to the child if the concerns are not appropriately addressed.

As non-medical professionals you may not feel able to challenge consultants and other medical professionals about specific health issues.  However, as with other forms of abuse, school staff will know the children they work with and will be able to identify if what they are told and what they see are not adding up.

Where there are concerns, including those felt to be below the threshold for referral into children’s social care, the school should play an integral role in forming a consensus view regarding the harm, or potential harm the child is experiencing.  The Health and Education plan recognises the impact on the child, not just from a health perspective but from a wider education and welfare perspective too and seeks to enable parents to make meaningful changes.

As with all forms of abuse, due to the complexity of Perplexing Presentations and Fabricated or Included Illness, it is essential that schools have access to robust safeguarding supervision.  Safeguarding supervision creates the safe environment needed to allow the practitioner think and reflect, take responsibility for their own practice and response to the identified safeguarding needs.