Perplexing Presentations and Fabricated or Induced Illness

There is often uncertainty about perplexing presentations (PP) and fabricated or induced illness (FII) and when safeguarding concerns should be raised. In the UK, there has been a shift towards earlier recognition of possible fabricated or induced illness.

Fabricated or induced illness can cause significant harm to the child either because of being made to be ill or from the treatment that they are given for an illness that they do not have. Harm to the child may take several forms and differ in terms of severity, with children often very confused and anxious about their health and well-being.

If you have concerns that a child is a victim of fabricated or induced illness, a referral should be made to the local authority. You should not seek parental consent before a strategy meeting because this may heighten the risk to the child.

PP and FII must not be considered an issue just for health professionals. As with other possible safeguarding matters, everyone should be alert to the potential signs of fabricated or induced illness.

As professionals working with children and young people daily, education staff are in a prime position to identify inconsistencies in what they are being told about the child’s needs versus how the child is presenting. Initial alerting signs can be identified within education settings. It is then for colleagues in health and social care to carefully determine what is happening e.g., whether an undiagnosed or misdiagnosed medical condition exists, parents/carers are very anxious, parents/carers are fabricating or inducing illness, etc.

How prevalent is it?

There is little information about the prevalence of perplexing presentations and fabricated or induced illness, but it is believed there may be unreported cases because there is not necessarily a clear-cut pattern of incidents. For professionals involved in treating the presenting symptoms, it is not always easy to step back and consider the overall picture. The RCPCH guidance suggests decisions need to be made about whether the perplexing presentation is explained and resolved by a verified medical condition in the child, or whether concerns remain.

Why does fabricated or induced illness occur?

The guidance from the RCPCH says 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. However, a practice guide by the British Association of Social Workers (BASW) reports that “the basis for this claim is case studies of Munchausen’s Syndrome by Proxy (which is exceedingly rare and not the same as FII) and ‘clinical experience’ since there are no statistics nor research on the incidence of FII”.

The research used to inform the RCPCH guidance suggests that there are two possible motivations underpinning the parent’s actions:

1. The parent experiences a gain from the recognition and treatment of their child as unwell. The parent is using the child to fulfil their needs, disregarding the effects on the child.
2. The parent’s mistaken belief, extreme concern and anxiety about their child’s health.

We must also consider the impact of accusations of FII. Research by Cerebra and the BASW practice guide have raised concerns about inequity regarding allegations of FII, and the trauma allegations may cause.

The Cerebra study suggested that:

• FII allegations against parents of disabled children appear to be widespread;
• disabled parents appear to be four times more likely to be accused of FII than non-disabled parents;
• most (84%) FII allegations (which may cause devastating and life-long trauma to those accused) resulted in no follow-up action or were abandoned.

Read more from the NHS about the possible causes of fabricated or induced illness.

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.