Perplexing Presentations and Fabricated or Induced Illness

There may be times when a parent or carer presents a child as ill or more unwell/more disabled than the child actually is. There are many reasons why this can happen, but children can experience physical harm, emotional harm and neglect as a result of this form of abuse.

There is often uncertainty about Perplexing Presentations and Fabricated or Induced Illness and the threshold at which safeguarding procedures should be invoked and, 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 through 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 wellbeing.

If you have concerns that a child is victim of Fabricated or Induced Illness, then a referral should be made to the local authority. You should not seek the consent of the parents prior to a strategy meeting, as research tells us this can heighten the risk to the child.

It is important that this is not just considered an issue for health. As with all safeguarding matters, it is for everyone to be alert to the potential signs of Fabricated or Induced Illness. As professionals working with children and young people daily, staff in schools are in a prime position to identify inconsistencies in what they are being told about the needs of the child versus how the child is presenting and initial alerting signs are commonly identified within school and educational settings.

Definition of perplexing presentations and fabricated or induced illness

There is an ongoing debate regarding the terminology.  The most up to date definitions are from the RCPCH 2021 Perplexing Presentations-FII 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 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.
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How prevalent is it?

There is little information about the prevalence of Perplexing Presentations and Fabricated or Induced Illness, but it is believed there are many unreported cases as 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 and research suggests that many children have an underlying diagnosed medical condition.

Where there are concerns about a Perplexing Presentation or potential Fabricated or Induced Illness

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

In this situation, 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.

Professionals must also 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.);
  • Documenting concerns carefully in the child’s safeguarding record (chronologically);
  • Case records explicitly state who the source of the information being recorded was and when the information was provided;
  • 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.

Harm to the child ...

This may take several forms including:

  • The child’s health – repeated and unnecessary appointments/tests, induction of illness (poisoning/suffocation);
  • Effect on the child’s development and daily life – including limited and interrupted school attendance and education, the child’s normal activities are 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 colluding with the parent’s illness deception and the child may be confused and anxious.
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Why does fabricated or induced illness occur?

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.

Research suggests that there are two possible motivations underpinning the parent’s need:

  1. the parent experiences a gain from the recognition 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 and;
  2. the parent’s erroneous belief, extreme concern and anxiety about their child’s health.

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

Spotting the signs

Schools are well placed to notice prolonged or frequent absence from education.  Also, parents or carers involved in Fabricated or Induced Illness may seek support and attention from schools. Be aware of the following signs:

  • 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);
  • 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 on resolution of previous ones.
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What you can do

  • Be alert to potential indicators of illness being Fabricated or Induced in a child;
  • Produce a chronology, including the source of information;
  • Be particularly aware when illnesses and absences are frequent;
  • Offer to link in with the family GP to see what the school can do;
  • Report concerns to your Designated Safeguarding Lead. If you are the DSL, ensure that you are receiving safeguarding supervision;
  • Follow your safeguarding procedures.
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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 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.  Schools’ 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.

Resources

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

    Part of our safeguarding insights section, this is a more in-depth look fabricated and induced illness, the varying presentations and what we know from serious case reviews.

  • Safeguarding children in whom illness is fabricated or induced

    Statutory guidance on protecting children where carers or parents make a child ill or pretend a child is ill.

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

    Between November 2015 and March 2017, the Local Safeguarding Children Board (the LSCB) conducted a Serious Case Review (SCR) in relation to the services provided for a teenage boy, referred to in this report as Child Y. Child Y’s circumstances are believed to be an example of fabricated or induced illness (FII) which has severely impaired his health and development. Details of his contact with health professionals and the impact of the treatments that he has received are set out in section 2 of this report. Child Y has a younger teenage sister and her contact with services is also considered, but in less detail.

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

    This Serious Case Review relates to a large family where concerns about fabricated and induced illness came to the fore in 2013. Several of the children in the family have extensive medical histories,including invasive surgical interventions. Their perceived medical needs impacted on their educational, social and emotional development. Over a
    significant period, a large number of hospitals and health practitioners were involved with the children; different hospitals treating different children and at times different hospitals treating the same child.

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  • Training resources for DSLs to use in team meetings
  • Reference documents for additional information
  • Handout for school staff summarising fabricated or induced illness
  • Quiz to test staff understanding
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