Perplexing Presentations and Fabricated or Induced Illness

Safeguarding Network

February 2024 - 6 minute read

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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.

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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.

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.

Harm to the child

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.

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.

Spot the signs

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.

What to do

  • Be alert to potential indicators of illness being fabricated or induced in a child.
  • Produce a chronology of reported concerns, including the source of information.
  • Be particularly aware when illnesses and absences are frequent.
  • Relevant staff can offer to work with the family GP to see what the setting can do.
  • Report concerns to your designated safeguarding lead. If you are the DSL, ensure that you're receiving safeguarding supervision.
  • Follow your safeguarding procedures.

The most important question to be considered is whether the child may be at immediate risk of serious harm, particularly from induced illness.

In this situation, 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 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.

DSL Training Materials

  • FII scenario (primary schools) – DSL Information sheet

  • FII scenario (Care) – DSL information sheet

  • FII scenario – Care settings

  • FII scenario (16+) – DSL information sheet

  • FII scenario – 16+ settings

  • FII scenario (SEND) – DSL information sheet

  • FII scenario – SEND settings

  • FII scenario (secondary schools) – DSL information sheet

  • FII scenario – secondary schools

  • Handout for staff

  • FII scenario – Primary schools

  • FII scenario (EYFS) – DSL Information sheet

  • FII scenario – EYFS

  • Fabricated or Induced Illness – Quiz (answers)

  • Fabricated or Induced Illness – Quiz

  • Presenter Notes

  • Presentation


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

  • 2017 Anonymous SCR – Child Y (Fabricated or Induced Illness)

  • 2018 Anonymous SCR – Children F,G and H (Fabricated or Induced Illness)

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