Perplexing Presentations and Fabricated or Induced Illness

There is an ongoing debate regarding the terminology. These definitions are from the Royal College of Paediatrics and Child Health (RCPCH) Perplexing Presentations/Fabricated or Induced Illness in Children guidance.

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 parental 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.

This may take several forms including:

• harm to the child’s health – repeated and unnecessary appointments/tests, induction of illness (poisoning/suffocation);
• the effect on the child’s development and daily life – including limited and interrupted attendance at their education setting, the child’s normal activities being limited, the child assuming a sick role and the child being socially isolated;
• the child’s psychological health and well-being – the child may be actively aware of the parent’s deception and may be confused and/or anxious.

Education settings are well placed to notice prolonged or frequent absence. Parents or carers involved in fabricated or induced illness may seek support and attention from their child’s setting. Be aware of the following signs:

• The child has limited/interrupted attendance and education.
• The child’s normal daily life activities are limited (not allowed to join in PE, for example).
• The child assumes a sick role (e.g., with the use of unnecessary aids, such as wheelchairs).
• Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering.
• There is an inexplicably poor response to prescribed medication and other treatment.
• New symptoms are reported after the resolution of previous ones.

If you are concerned that a child may be at immediate risk of serious harm, particularly from induced illness, an urgent child protection referral must be made to the police and children’s social care. This should lead to a strategy meeting. The safety of any siblings must also be considered.

Professionals must ensure that:

• there is clear and direct communication between the professionals involved (i.e., not relying solely on the parent to report back on appointments, etc.);
• concerns are documented carefully (and chronologically) in the child’s safeguarding record;
• case records explicitly state who provided the source of the information being recorded and when;
• a paediatrician or other suitably qualified medical practitioner (e.g., named doctor/nurse) is asked to review the case records from an independent viewpoint and provide an opinion.

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

The professional’s meeting should be led and chaired by health colleagues, usually the named doctor for safeguarding children. An educational setting’s role is to gather information, assess this and pass it to the investigating team, as well as be there as safe adults for the child or young person.

Keep talking and noticing – maintain effective communication with students, be curious about their experiences both in and out of their education setting. Take steps to gain their voice directly from them.   

Collaborate early - where health is reported as an area of concern for a student, seek to engage with the family and any involved health professionals at an early stage. This has the benefit of supporting the child in a consistent way and helps professionals create a strong shared understanding of what the health needs are.

Create an open and approachable culture in school– help students think about their needs and highlight accessible places where they can get support if they feel they need this.   

Consider how vulnerabilities might impact on individuals– think about the specific circumstances of individual students and their families and whether there might be times and situations when there might be an increased need for communication and support.  

Keep a chronology– identifying fabricated or induced illness is not necessarily about one event but an accumulation of several different concerns and observations. It's important that these are noted at the time to allow the building of a bigger picture of the experiences of the child or young person. 

Challenge cultural assumptions– just because something is allegedly culturally acceptable does not make it non-abusive or mean that it should be ignored. 

Know the signs and know what to do– use the checklists above, your safeguarding procedures and be confident to raise fabricated or induced illness as a possibility via your setting’s procedures. 

Take action– and keep taking action until you know children and young people are safe.