18.2 Fabricated or induced illness (FII) and Perplexing Presentations (including FII by carers)

This form of abuse has also been known as:

• Fabricated illness by proxy;
• Factitious illness by proxy;
• Munchausen Syndrome by proxy;
• Illness Induction Syndrome.

There is also a group of children that present with perplexing/medically unexplained symptoms (“perplexing presentations”). Perplexing presentations may include cases of functional disorders (conditions with a psychological cause of the symptoms) and those cases that medical professionals are unable to explain based on their clinical assessment and medical investigations. Rarely in some of these cases, are symptoms being reported to gain support that may not be required or recommended by health and education professionals. This group can include cases where a parent (or child) is exaggerating symptoms, misreporting or misunderstanding conditions.

The common starting point for both ‘Perplexing Presentations’ (PP) and fabricated or induced illness (FII) is that the child’s clinical presentation is not adequately explained by any confirmed illness, and the situation is impacting upon the child’s health or social wellbeing. There is a spectrum of presentations with what is referred to by paediatricians as the rarer ‘true’^[1] FII involving deliberate deception of medical services by the carer which may involve actions to falsify specimens or investigations, or induction of actual illness in the child.

[1] RCPCH, 2003

The initial approach to both FII and PP is to establish which, if any, symptoms or conditions are genuine. This will require consultation with the child’s paediatrician(s)/clinician(s) and consideration of the child’s lived experiences and the family/social context.

The Royal College of Paediatrics and Child Health (RCPCH) recognise that cases of perplexing presentations are an increasingly common issue for professionals and require a different approach to ‘true’ FII.

This section outlines the procedures to follow when professionals are concerned that the health or development of a child is likely to be significantly impaired by the actions of a carer having fabricated or induced illness. In these cases the issue of information sharing is particularly difficult and this is referred to in the following paragraphs.

In the early stages following concerns being raised it may not be clear whether this is a perplexing presentation or whether the case involves deliberate fabrication or illness induction (FII).

Doctors/clinicians may feel under pressure to investigate and treat the child, without really understanding what condition the child is suffering from. The clinical information may simply ‘not add up’, and experienced paediatricians may be reduced to wondering ‘What is Going On?’ They may attempt to explain the child’s symptoms by inventing a brand new, previously un-described or medically illogical hypothesis to explain the child’s symptoms. Often professionals are concerned about the possibility of complaints that a significant medical condition has been missed.

It is often unclear in these cases whether the carer is actively fabricating their child’s illness, whether they are simply an anxious parent with a distorted view of their child’s state of health, whether the carer holds inappropriate beliefs or expectations about health and illness, or if the parent and child are interacting in a way that involves the child assuming the ‘sick role’ or the role of a disabled child. Sometimes there are familial or cultural styles of ‘illness behaviour’ that affect how children are presented to doctors. Most of these cases, at least in the initial stages, do not need a safeguarding approach and are probably not ‘true’ FII cases. It should be considered at this stage whether the child is experiencing the forms of emotional abuse or neglect, including medical and/or educational neglect.

If at any point there are concerns about ‘true’ FII follow the specific section on FII  8.20.25

Possible impact of perplexing presentations on the child:

• A disordered perception of illness and health, leading to anxiety about health  and abnormal illness behaviour
• Inadvertent iatrogenic harm including admission to hospital, acquired infection, blood tests, x-rays, painful procedures etc.
• A greater degree of invasive medical attention than is truly justified – in extreme cases, it may include surgical procedures, insertion of lines, artificial feeding, anaesthesia
• Interference with normal life, including school attendance, social activities, relationships or educational achievement
• Older children may support their parents/carer in the perplexing presentation, even to the point of being complicit with active deceit
• Actual illness induction heightens risk significantly – of the pain and distress of induced illness, the real risk of death and also of under-treatment of genuine conditions.

Further guidance and flowcharts are provided in the RCPCH Child Protection Companion (2017).

Medically Unexplained Symptoms (MUS)

In Medically Unexplained Symptoms (MUS), a child’s symptoms, of which the child complains and which are presumed to be genuinely experienced, are not fully explained by any known pathology. The symptoms are likely based on underlying factors in the child (usually of a psychosocial nature) and this is acknowledged by both clinicians and parents. 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. The health professionals and parents work collaboratively to achieve evidence-based therapeutic work in the best interests of the child or young person.

In 2018, the Royal College of Psychiatrists and the Paediatric Mental Health Association (PMHA) developed a guide to assessing and managing medically unexplained symptoms (MUS) in children and young people14 and a recent editorial is very helpful15. Experienced clinicians report that, on occasion, MUS may also include PP or FII.

Perplexing Presentations (PP)

The term Perplexing Presentations (PP) has been introduced to describe the commonly encountered situation when there are alerting signs of possible FII (not yet amounting to likely or actual significant harm16), when the actual state of the child’s physical, mental health and neurodevelopment is not yet clear, but there is no perceived risk of immediate serious harm to the child’s physical health or life. The essence of alerting signs is the presence of discrepancies between reports, presentations of the child and independent observations of the child, implausible descriptions and unexplained findings or parental behaviour.

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 and neurodevelopment is impaired (or more impaired than is actually the case). FII results in physical and emotional abuse and neglect, as a result of parental actions, behaviours or beliefs and from doctors’ responses to these. The parent does not necessarily intend to deceive, and their motivations may not be initially evident. It is important to distinguish the relationship between FII and physical abuse / non-accidental injury (NAI). In practice, illness induction is a form of physical abuse (and in Working Together to Safeguard Children, fabrication of symptoms or deliberate induction of illness in a child is included under Physical Abuse17). In order for this physical abuse to be considered under FII, evidence will be required that the parent’s motivation for harming the child is to convince doctors about the purported illness in the child and whether or not there are recurrent presentations to health and other professionals. This particularly applies in cases of suffocation or poisoning.

Alerting signs

(RCPCH 2021) – these are features in the child/situation that alert professionals to possible PP or FII and are typified by discrepancies between reports, presentations of the child and independent observations of the child, implausible descriptions and unexplained findings or parental behaviours.

Alerting signs are not evidence of FII but they can indicate possible FII (not amounting to likely or actual significant harm and, if associated with possible harm to the child, they amount to general safeguarding concerns. A single alerting sign by itself is unlikely to indicate possible fabrication. Paediatricians/professionals must look at the overall picture which includes the number and severity of alerting signs.

Alerting signs may be recognised within the a) child or b) in the parent’s/carers behaviour.

Alerting Signs in the child:

• Reported physical, psychological or behavioural symptoms and signs not observed independently in their reported context
• Unusual results of investigations (eg biochemical findings, unusual infective organisms)
• Inexplicably poor response to prescribed treatment
• Some characteristics of the child’s illness may be physiologically impossible eg persistent negative fluid balance, large blood loss without drop in haemoglobin
• Unexplained impairment of child’s daily life, including school attendance, aids, social isolation

Alerting Signs in parent behaviour:

• Parents’ insistence on continued investigations instead of focusing on symptom alleviation when reported symptoms and signs not explained by any known medical condition in the child
• Parents’ insistence on continued investigations instead of focusing on symptom alleviation when results of examination and investigations have already not explained the reported symptoms or signs
• Repeated reporting of new symptoms
• Repeated presentations to and attendance at medical settings including Emergency Departments
• Inappropriately seeking multiple medical opinions
• Providing reports by doctors from abroad which are in conflict with UK medical practice
• Child repeatedly not brought to some appointments, often due to cancellations
• Not able to accept reassurance or recommended management, and insistence on more, clinically unwarranted, investigations, referrals, continuation of, or new treatments (sometimes based on internet searches)
• Objection to communication between professionals
• Frequent vexatious complaints about professionals
• Not letting the child be seen on their own
• Talking for the child / child repeatedly referring or deferring to the parent
• Repeated or unexplained changes of school (including to home schooling), of GP or of paediatrician / health team
• Factual discrepancies in statements that the parent makes to professionals or others about their child’s illness
• Parents pressing for irreversible or drastic treatment options where the clinical need for this is in doubt or based solely on parental reporting.

Paediatricians should refer to the relevant section the RCPCH Child Protection Companion.

An empathetic, considered but boundaried approach is required to manage these situations and support children and families. Honest communication of professional concerns is important, unless this will place the child at risk of serious harm.

Most Perplexing presentation situations will not involve immediate risk of harm to a child. These situations may take considerable time to support parents and unpick the issues/reported issues.

Perplexing Presentations (PP): there some cases of PP which include functional disorders (involve a psychological element to the symptoms) and those cases that medical, allied health, psychology and other professionals are unable to explain based on their clinical assessment and medical investigations and/or when symptoms are being reported to gain support that may not be required or recommended by health professionals. They can include cases where a parent(s) is/are exaggerating symptoms or misreporting conditions.

Presenting features may include:

• A carer reporting symptoms and signs that are not explained by any known medical condition.
• Physical examination and results of investigations do not explain the symptoms or signs reported by the carer.
• The child has an inexplicably poor response to prescribed medication or other treatment, or intolerance of treatment.
• Acute symptoms and signs are exclusively observed by/in the presence of one carer.
• On resolution of the child’s presenting problems, the carer reports new symptoms or reports symptoms in different children in sequence.
• The child’s daily life and activities are limited beyond what is expected due to any disorder from which the child is known to suffer, for example partial or no school attendance and the use of seemingly unnecessary special aids.
• The carer seeks multiple opinions inappropriately.

For some cases the key to differentiating between erroneous and true reports of symptoms and signs is a period of close or constant observation of the child. This can be overt observation by a nurse or other professional (eg. teacher), not covert surveillance. For all cases but especially out-patient cases, as many sources of information as possible should be gathered, in particular the child’s functioning at school.

If careful medical assessment suggests that the child does not have any medical condition or a medical condition is exaggerated or appears misunderstood then the symptoms are ‘medically unexplained’ this can be presented to the child’s family as ‘good news’, with reassurance that most children either spontaneously improve over time with or without a clear medical and/or psychological (and educational plan if necessary) plan for support/rehabilitation (referred to by the RCPCH as a Health and Education Rehabilitation Plan) and that no further investigations or treatments will be initiated unless the situation objectively changes.

A plan for rehabilitation of the child to normal activities, living with/alongside the symptoms, stopping any current unnecessary medical treatment and ongoing medical monitoring will be needed.

Involvement of local CAMHS or other psychological services may be helpful; in particular the family may need to be helped to think through how their lives will be different if the child is no longer ‘ill’ and be helped to construct a credible narrative about the child’s ‘recovery’.

After attempting a reassuring, non-invasive approach to the perplexing symptoms and reported signs or the parents do not support the Health and Education Rehabilitation Plan,  if the carers reject the doctor’s hypothesis and insist on further intervention or further opinions, or if they ‘sack/dismiss’ the doctor concerned and demand a change of doctor, or if the child develops new and unexplained physical symptoms or signs (e.g. faltering growth) or reported non-physical symptoms, e.g. anxiety, autism etc. then a judgment will need to be made as to whether a child safeguarding referral needs to be made. The views of the child should be ascertained if possible, ideally without the parents/carers present. Professionals should consider if the child is suffering or is at risk of neglect and/or emotional abuse. 

The child’s wishes and goals, perception and understanding of their reported/diagnosed conditions and home and school life must be ascertained.

If a further medical opinion is sought it is important that the person giving the opinion is fully aware of the background and concerns. Clinicians should never allow themselves to be ‘browbeaten’ into arranging tests or treatments that are not clinically indicated.

It is important that the situation for the child is resolved and that they are able to return to a more normal lifestyle. If that does not happen despite attempts by the treating team to help, or if contact is broken so that no information is available, a safeguarding referral is indicated.

In a minority of cases, there may be clear evidence that the carer is an unreliable historian. If, for example, aspects of the history have been convincingly proven not to be true, mutually exclusive accounts have been given, the history is medically implausible and cannot be attributed to parental anxiety, limited ability or disordered health beliefs, then that is a significant risk factor that requires referral under safeguarding procedures.

Adverse Childhood Experiences (ACEs)

When working with children and their families where there are perplexing illnesses or concerns about fabricated or induced illness, professionals should explicitly explore whether the child is currently experiencing, or has previously experienced, adverse childhood experiences such as physical, sexual or emotional abuse, neglect, domestic abuse, child sexual or criminal exploitation, bereavement, parental/caregiver alcohol or drug misuse, severe parental mental health issues, or a parent going to prison

 Adverse Childhood Experiences such as these can have a detrimental impact on the physical, mental and emotional wellbeing of a child. Professionals should also be mindful that parents and caregivers may themselves have experienced adverse childhood experiences.

Fabricated or induced illness in a child is a condition or situation whereby a child suffers harm through the  deliberate action of their main carer and which is duplicitously attributed by the adult to another cause.

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 including iatrogenic harm, RCPCH 2021

The initial approach to both FII (and PP) is to establish which, if any, symptoms or conditions are genuine. This MUST involve consultation with the child’s paediatrician/clinician(s) and consider the child’s lived experiences and the family/social context.

Child victims of FII may be subject to prolonged legal proceedings and are at risk of further abuse and ongoing morbidity due to abuse.

Cases of both FII and perplexing presentations often involve or occur in association with other forms of abuse, particularly the various forms of emotional abuse and neglect and these must be considered as part of any referral or assessment.

Cases of FII being referred to CSC and requiring immediate safeguarding and protection will invariably come from the acute hospitals and paediatricians. These situations, which are rare, will require immediate strategy discussion without parents being informed.

 The following diagram outlines the pathway approach to be followed after identification of alerting signs: 

Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance

Most cases (unless ‘true FII) should involve health care professionals meeting to clarify the conditions/illnesses and plan how to manage the child.

If there is no immediate risk of harm, cases of perplexing presentations/possible FII should be discussed with the professional(s) who are working with the child and family to decide whether the threshold for referral to Children’s Social Care has been met.

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

Perplexing Presentations can indicate possible harm to the child which can only be resolved by establishing the actual state of health of the child.

In most cases this will be a carefully planned response, led by the responsible clinician with advice from their Named Doctor for Safeguarding Children, usually in the secondary, and occasionally tertiary centre, in which paediatricians or CAMHS clinicians are employed.

The essence of the response is to establish the current state of health and functioning of the child and resolve the unexplained and potentially harmful situation for the child:-

• The term Perplexing Presentations and management approach can and should be sensitively explained to the parents and the child, if the child is at an appropriate developmental stage.
• Reflecting with parents about the differing perceptions that they and the health team have of the child’s presenting problems and possible harm to the child may be very helpful in some cases, particularly if it is done at an early stage.

It is important to consider the harm for each reported diagnosis/condition:

Harm to the child takes several forms, some caused directly by the parent, intentionally or unintentionally, but may be supported by the doctor; others are brought about by the doctor’s actions, the harm being caused inadvertently.

As FII is not a category of maltreatment in itself, these forms of harm may be expressed as emotional abuse, medical or other neglect, or physical abuse. There is also often a confirmed co-existing physical or mental health condition.

The following three aspects need to be considered when assessing potential harm to the child:

 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
• Genuine illness may be overlooked by doctors due to repeated presentations
• Illness may be induced by the parent (eg poisoning, suffocation, withholding food or medication) potentially or actually 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
• The child assumes a sick role (eg with the use of unnecessary aids, such as wheelchairs)
• The child is socially isolate 

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
• The child may be silently trapped in falsification of illness
• The child may later develop one of a number of psychiatric disorders and psychosocial difficulties. 

A Multi-Professionals’ Meeting can be held in cases of perplexing presentations to reach a consensus about the child’s state of health.  This type of meeting should never be held in place of a Strategy Discussion.

The agency that is requesting the meeting must consider whether the parents/carers should be informed of the meeting beforehand.  Unless there is a significant risk of immediate, serious harm to the child’s health or life, parents/carers should be informed.  If the parents/carers (or child, where appropriate) have not been informed of the meeting, then agreement should be sought from invited agencies that the meeting will occur without the family being informed and the rationale for decision making must be clearly minuted.

A Multi-Professionals’ Meeting should include all health professionals involved with the child and family, including GPs, Consultants, private doctors and other significant professionals who have observations about the child, including education and children’s social care if they have already been involved. Use of video conferencing will increase likelihood of professional’s attendance.

Where the meeting is to discuss complex matters and to develop a more comprehensive picture of the family’s circumstances it is not necessary to gain consent for the meeting to take place.

In some situations, it may be appropriate to conduct the meeting in two parts involving the relevant professionals in the first part and inviting the parents/carers to the second part of the meeting.

If the child and/or parents/carers, when informed of the meeting, raise an objection to it taking place, consideration should be given to whether concerns are enough to require a different approach (i.e., a Strategy Discussion).

Families must be informed when personal data is being shared or processed as part of a Multi-Professionals Meeting, but their consent is not required for the purposes of safeguarding and promoting the welfare of a child. Normal rules of confidentiality apply in that only information relevant to ensuring the safety and welfare of the children in the family should be shared.

The convening agency is responsible for initiating the Multi-Professionals Meeting and should ensure the minutes of the meeting and agreed actions are distributed to all attendee’s and where appropriate, the family. The minutes should capture the main areas of need and the action plan developed to address them. Records must provide a clear statement of what has and has not been discussed with parents.

Where the parents/carers have not been directly involved in the meeting, agreement needs to be reached on which professional will be expected to feedback to them on its outcome, if relevant.

Please see Child Protection Companion – RCPCH Child Protection Portal

The signs and symptoms require careful medical evaluation for a range of possible diagnoses. This may be informed by a medical chronology. Assessment should include consideration of health and/or other concerns regarding any siblings of the child.

A lead paediatrician/clinician MUST be identified who will coordinate the medical care and analysis of the medical information. Practitioners should contact the hospital/child development centre/service where the child is being treated or was recently treated if this is not possible.

If the child does not have a paediatrician/clinician the child should be referred to a paediatrician/clinician whose clinical practice is in the main symptoms the child is presenting with.  

 Please contact the Named Doctor in the health service if there is an issue in identifying a lead paediatrician.

All tests and their results should be fully and accurately recorded. It is important that the child's record is not altered in any way, e.g. through the carer tampering with the child’s observation charts or medical records. It is also important that any samples e.g. urine are taken from the child by a healthcare professional and that the carer does not have the opportunity to add any substances to, or otherwise contaminate the sample.

The name of the person reporting any observations should be legibly recorded and dated.

Where a reason cannot be found for the signs and symptoms, specialist advice may be required.

Parents should be kept informed of findings from medical investigations, however in cases of true FII and where the child could be at risk of deliberate induction at no time should concerns about the reasons for the child's signs and symptoms be shared with the parent if this information would jeopardize the child's safety.

Medical evaluation can be further complicated by some parents' reluctance to leave the child. Where appropriate every effort should be made to see the child alone and gain their views of their reported condition/illnesses.

The doctor should inform the parent(s), ideally with a chaperone, of the outcome of the investigations and confirm that no serious underlying medical condition has been found. If a genuine medical condition has been identified that does not preclude normal activities or engagement this should be clearly communicated to the parents and documented in medical records.

Parents and the child should be reassured regarding the positive outcome and given a framework to help them understand the child’s reported symptoms.

The doctor should clearly communicate that no further investigations are indicated and where appropriate support the parents/child to engage in any rehabilitation, treatment or psychological intervention to return to normal activity. This discussion needs to be documented and the parental response recorded.

The Making a Referral Procedure should be followed when there are concerns that a possible explanation for the signs and symptoms of illness is that they may have been fabricated or induced by a carer, including symptoms that have been exaggerated and there is concern that this is impacting adversely on the child. 

Criteria to refer to CSC:

• 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.

The referral to Children's social care should be on the basis that the child’s functioning and/or development is being avoidably impaired by the parents’ behaviour and any harm caused has now become significant.

Parental disagreement may take the following forms:

• active dispute
• requesting additional unwarranted investigations
• seeking further inappropriate medical opinion(s)
• continuing to seek unnecessary or alternative further diagnoses
• declining the Plan and/or the rehabilitation process fails to proceed (eg if the plan requires to attend school and they are no longer doing so).

The referral to children’s social care should be discussed with parents and the reasons for professional concern explained (again unless professionals feel the child is at immediate risk of harm, refer to FII guidelines).

The emphasis should be on the nature of the harm to the child including physical harm, emotional harm, medical or other neglect and avoidable impairment of the child’s health or development.

Professionals in health should be aware that they do not always have all the pieces of the safeguarding jigsaw puzzle.

When a decision is being made about whether to refer children to children’s social care, professionals should consider whether they have all the information from other agencies which is required to inform their risk assessment about levels of harm. If there is concern that they do not have this information particularly when parents decline to give consent for information sharing, a referral to children’s social care may be necessary because of professional inability to assess the level of harm without the intervention of children’s social care.

Assessment should include the functional impairment of the diagnosis or alleged diagnosis which has been objectively observed.

As with all other child protection concerns, the response by Children's Social Care will be in accordance with Section 4, Response to Child Protection Referrals

If emergency action is required an immediate Strategy Discussion should take place, where possible, between Children's Social Care, the Police, Health (must include a lead paediatrician and ideally a Named Doctor for safeguarding children) and other agencies as appropriate. However this should not delay the use of immediate protection if required.

Where there are reasonable concerns that a child has or is likely to suffer Significant Harm, Children's Social Care will convene a Strategy Discussion in consultation with the Child Protection Manager. A meeting is advisable when considering this complex form of abuse.

This meeting requires the involvement of key senior practitioners responsible for the child's welfare. At a minimum this must include Children's Social Care, Police and the Paediatric Consultant or Mental Health clinician responsible for the child's health. Additionally the following should be invited as appropriate:

• A senior ward nurse if the child is an in-patient;
• The child’s paediatrician(s)/medical practitioner with expertise in the relevant branch of medicine and the Named Doctor(s) from relevant health provider(s);
• GP;
• Health visitor;
• School Nurse;
• Staff from education settings;
• Local authority legal adviser.

The meeting should be held at a time and location that ensures the availability of the key practitioners ESPECIALLY THE LEAD PAEDIATRICIAN unless the Social Work Manager feels a delay may be detrimental to the welfare of the child.

 In all cases professionals should endeavour to meet timescales HOWEVER key professionals (especially the lead paediatrician/GP/medical teams) need to attend and in certain circumstances this may cause a delay. If delay does occur, the reasoning behind this must be recorded.

The strategy discussion should consider:

• Whether the child requires constant professional observation, and if so, whether the carer should be present;
• Which medical clinician should oversee and co-ordinate the medical treatment of the child (to organise the number of specialists and hospital staff the child may be seeing);
• Careful consideration for arrangements for the medical records of all relevant family members, including children who may have died or no longer live with the family, as these records might also need to be reviewed by the consultant paediatrician or other suitable medical clinician;
• The nature and timing of any Police investigations, including analysis of samples and covert surveillance (this will be Police led and coordinated);
• The need for extreme care over confidentiality, including careful security regarding supplementary records;
• The need for expert consultation;
• Any particular factors, such as the child and family's race, ethnicity, language and special needs which should be taken into account;
• The needs of siblings and other children with whom the alleged abuser has contact;
• The needs of parents or carers;
• Obtaining legal advice over evaluation of the available information (where a legal adviser is not present at meeting).

• It may also be necessary to have an interim protection plan for the child or children concerned pending the holding of a Child Protection Conference - and this should be determined at the Strategy Discussion.
• The question of whether the parents should be informed of any or all of the concerns and if so when and by whom should be considered at each and every strategy discussion and the decision clearly documented.

Undertaking enquiries into FII can be complex and challenging for practitioners and an individual should not undertake the enquiry in isolation. The Strategy Discussion should recognise the need to ensure multi-agency coordinated working and good supervision.

If at any point there is medical evidence that the child's symptoms are being fabricated or induced, action may be required to ensure the child's life is not put at risk.

It may be necessary to have more than one strategy discussion particularly to allow time for a detailed medical Chronology to be produced and for information and updates from agencies to be reviewed. Should there be ongoing concerns or changes in significant information, a review Strategy discussion will be convened which must include all named professionals and local clinicians known to the family.  Legal advice may be required in the strategy discussions.  Decisions must be made and recorded about what information will be shared with the parents, by whom and when. This decision should be guided by a clear assessment of the risk to the children as a result of informing the parents of the concerns.

Where a decision is made that parents should not be informed of the strategy discussion and professional concerns this should be recorded with clear guidance about when, in the future, they may be informed that the meeting has taken place.

All decisions need to be agreed by the meeting, signed off and recorded clearly in the minutes

In circumstances where there is concern that a child may be experiencing FII a Children's Social Care Single Assessment should usually be completed in collaboration with the consultant paediatrician or lead clinician responsible for the child's health care.

If a second medical opinion has not been obtained, the consultant paediatrician should give consideration to requesting one at this or at any subsequent stage in the process if indicated.

The outcomes of the Children's Social Care single assessment should be made in consultation with the consultant paediatrician and Police with agreement reached regarding what the parents should be told. Concerns should not be raised with a parent if it is judged that this action will jeopardise the child's safety.

The outcomes of the Children's Social Care single assessment should be made in consultation with the consultant paediatrician and Police with agreement reached regarding what the parents should be told. Concerns should not be raised with a parent if it is judged that this action will jeopardise the child's safety.

The outcomes of the Children's Social Care single assessment should be made in consultation with the consultant paediatrician and Police with agreement reached regarding what the parents should be told. Concerns should not be raised with a parent if it is judged that this action will jeopardise the child's safety.

The outcomes of the Children's Social Care single assessment should be made in consultation with the consultant paediatrician and Police with agreement reached regarding what the parents should be told. Concerns should not be raised with a parent if it is judged that this action will jeopardise the child's safety.

Any evidence gathered by Police should be made available to Children's Social Care and other relevant practitioners, to inform discussions and decisions about the child's welfare and contribute to the Section 47 Enquiry and Children's Social Care Single Assessment, unless this would be likely to prejudice criminal proceedings.

Normally the Police, rather than practitioners from other agencies, are responsible for questioning a person in connection with a suspected criminal offence and this would be usual in cases of FII.

The Family Assessment (also referred to a Child and Family Assessment or Strengthening Families Assessment) should include the systematic gathering of information about the history of the child and each family member, building on that already gathered during the course of each agency's involvement with the child. Particular emphasis should be given to health (physical, emotional and psychiatric), education and employment as well as receipt of state benefit and charitable donations relating to a disabled child, social and family functioning and any history of criminal involvement. Carers may present as very plausible and well informed as to the nature of the child's medical problems.

It is important to assess the child's understanding, if old enough, of their symptoms and the nature of their relationship with each significant family member (including all caregivers), each of the caregiver's relationships with the child, the parents' relationship both with each other and with the children in the family as well as the family's position within their community.

A full chronology from each agency should be developed which may assist in informing the Family Assessment (also referred to a Child and Family Assessment or Strengthening Families Assessment).

Any decision to confront any person should not be made unless in conjunction and with the full agreement of the police (see Police Investigation).

It is important to keep a focus on the impact of the carer's behaviour on the child when assessing levels of risk.

Children under the age of 5, especially pre-verbal children and children with an existing diagnosed illness, disability and/or communication difficulties, are at greatest risk because of their inherent vulnerability.

Before placing children with members of either extended family, be sure that a thorough assessment of them has taken place. Illness induction may be a feature of the family behaviour in previous generations. Any alternative carer should demonstrate an ability to believe that the suspected abuser may have posed a risk to the child. This may be hard to ascertain if the alternative carer is a relative.

An adult psychiatrist should be involved at the point at which there is moderate to high suspicion that a parent has been inducing symptoms or a court has made a finding of fact that such behaviour has occurred.

As with all Section 47 Enquiries, the outcome may be that concerns are not substantiated e.g. tests may identify a medical condition, which explains the signs and symptoms. In this situation, it is important to discuss with the parents, drawing on knowledge of the implications of the medical condition for the child and family members' lives, what further help or support they may require.

Where test results are inconclusive and/or where it is not possible to draw firm conclusions and fabrication is still a possibility it is important to try to understand the origin of the symptoms and to consider whether further help for the family is required.

Where a decision is made not to proceed to an Initial Child Protection Conference it must be endorsed by the service manager following discussion with the Child Protection Manager. In this instance a Child in Need Plan should be considered and if developed it should include careful ongoing monitoring by health and other agencies.

Where concerns are substantiated and the child judged to be suffering or at risk of suffering significant harm, an Initial Child Protection Conference must be convened.

The Initial Child Protection Conference should be held within 15 working days from the last Strategy Discussion. This meeting requires the involvement of key senior practitioners responsible for the child's welfare. At a minimum this must include Children's Social Care, Police and the lead paediatric consultant or lead clinician responsible for the child's health and/or the Named Doctor for Safeguarding (if possible).

Attendance should be as for other Initial Child Protection Conferences, with the following specialists invited as appropriate:

• Practitioners with expertise in working with children in whom illness is fabricated or induced and their families;
• Paediatrician or lead clinician with expertise in the branch of paediatric medicine able to present the medical findings.

It is essential that the consultant paediatrician, lead clinician and GP contribute and if possible provide a chronology and a full report. A full chronology may not be available for the initial strategy discussion; the need for a chronology will be decided at the strategy discussion.

Usual consideration should be given to the involvement of family members. However it may not be possible for all family members to be present at the same time. The extent and manner of involvement of family members should be informed by what is known about them. The abusing carer may not be able to acknowledge their behaviour to their partner for fear of what this knowledge would do to their relationship. They should not be put under pressure to talk about their part in fabricating or inducing illness within the conference. The non-abusive parent or carer may have no knowledge of the abuse or they may have had some understanding which now makes better sense to them but not wish to discuss it at a conference. Again their need not to discuss their knowledge in such a public setting should be respected.

These are matters which can be extremely complex in these cases and should be addressed outside the conference and in advance of the conference date with the conference chair and other key professionals.

A pre-birth conference should be convened where there is evidence of illness having been fabricated or induced in an older sibling or other child, and given consideration during the pregnancy of a person who is known to have abused a child in this way. Consideration should also be given to the safety of the unborn child where the pregnant person is known to demonstrate fabricating or inducing behaviours in their own presentation.

A pre-birth child protection conference should be convened if, following Section 47 Enquiries either the unborn child's health is considered to be at risk or the baby is likely to be at risk of harm following their birth.

Child victims of FII may be subject to prolonged legal proceedings and are at risk of further abuse and on-going morbidity due to abuse.

Perplexing Presentations and FII are likely to disrupt the child’s education considerably. Where these concerns arise, liaison with school may be very helpful. Important issues may include:

• Attendance may be very poor.
• The school may be able to confirm or refute some of the history given by the carer.
• There may be discrepancies between the child’s observed functioning at school and that reported by the carer.
• The carer may have sought additional special educational support that was inappropriate.
• The child may make relevant allegations to school staff.
• The school may have relevant background information.

The concerns may primarily relate to school, or may be primarily medical presentations with an impact on school life.

The child’s opinion about school and attendance must be sought.

Examples of perplexing presentations and FII may include reported ADHD symptoms, features of eating disorders or Autistic Spectrum Disorders. It may be difficult sometimes to know whether the parent genuinely believes that the child has the reported diagnosis or not. Sometimes parents have a ‘vested interest’ in a diagnosis such as ADHD or ASD because it creates a focus on the child rather than questioning the quality of parenting. Some children may develop an ADHD or ASD ‘phenocopy’ (i.e. clinical features resembling that condition) arising as a result of previous abuse or neglect. Pecuniary advantage such as DLA or the acquisition of stimulant drugs for illicit use may also be an issue.

FII and Perplexing Presentations may be associated with profound restriction of normal activities. In some cases the parent may genuinely believe that their child has a disability or needs to be ‘protected’ from the outside world.

Conditions such as hearing loss, vision impairment or inability to walk may be fabricated.

Some children with a genuine disability may become victims of FII as they are vulnerable and place great demands on their carers.

Illness induction may also cause disability, for example due to asphyxial brain injury in suffocation cases, limitation of developmental opportunities or prolonged sedation with drugs.

Deliberate fabrication of sexual abuse events in a child may result in repeated medical assessments and involvement of other agencies. This would be harmful for a child and bears similarities to FII. Whether it should strictly be regarded as a type of FII is debatable, but where there is a coexistence of true ‘medical’ FII and fabrication of sexual abuse they may be regarded as two parts of the same problem. In the context of acrimonious divorce or disputed contact, a parent may misconstrue a child’s account or behaviour to indicate sexual abuse by the other parent.

As with all these situations, if the carers’ behaviour results in harm to the child or places them at risk, a referral to Children’s Services is indicated.

There are rare cases where children have suffered FII abuse before dying as a ‘Sudden Infant Death’ (SID), and there is a higher than expected rate of previous sudden infant deaths in siblings of FII cases. Death ‘per se’ cannot be an FII, but there is clearly an association in some families 

When a pregnant person fabricates illness in themselves this raises serious concerns about the welfare of the child after birth and justifies a pre-birth strategy discussion and probably a case conference.

If the woman is jeopardising the unborn child by her actions then this is an urgent situation which should be discussed in a multiagency context.

There is no evidence base from which to predict the outcome for the child in these cases but anecdotally in many FII cases the carer has a very complex history, including obstetric issues, and in some there is clear evidence of fabrication or induction of their own illness during or prior to the pregnancy or precipitation of a premature delivery

Professionals should in general seek to discuss any concerns about a child's welfare with the family. Discussion with the parents or carer about the referral should only be done where such discussion will not place a child at increased risk of Significant Harm. This is unlikely to be a significant risk in most perplexing cases but could be significant in cases of suspected or actual induced medical symptoms.

Where a referral is made without the consent or knowledge of the parents a written rationale should made as set out in the Information Sharing and Confidentiality guidance, explaining why obtaining consent would place the child at increased risk of Significant Harm.

In cases of possible fabricated illness the decision about what the parents will be told, by whom and when will be agreed between the relevant medical professionals and Children's Social Care and other key agencies, including the Local Authority legal representation. This must be considered at any Strategy Discussions

Any evidence gathered by police should be available to other relevant professionals, to inform discussions and decisions about the child's welfare and contribute to the Section 47 Enquiry and Family Assessment (also referred to a Child and Family Assessment or Strengthening Families Assessment), unless this would be likely to prejudice criminal proceedings.

It is important that suspects' rights are protected by adherence to the Police and Criminal Evidence Act 1984, which would normally rule out any agency other than the police confronting any suspect persons.

Covert video surveillance is a legitimate investigative tool, but its use should only be considered when a multi-agency Strategy Discussion has agreed there is no other available way of obtaining information that will explain the child's signs and symptoms. (Police Officers planning surveillance in cases of suspected fabricated or induced illness may seek advice from the National Crime Agency, Tel: 0370 496 7622; email: communication@nca.x.gsi.gov.uk.

The primary aim of covert video surveillance is to identify if a child is having illness induced. Obtaining criminal evidence is of secondary importance.

Once this decision has been made, the police will be responsible for applying for the appropriate authority under the Regulation of Investigatory Powers Act 2000. If that authority is granted, the police have sole responsibility for implementing and undertaking any such surveillance. Good practice advice for police officers is available from the National Crime Faculty.

The safety and health of the child is the over-riding factor in the use of covert video surveillance, and the medical consultant responsible for the child's care should ensure that the necessary medical and nursing staff support the police operation.

All non-police staff involved will receive appropriate training from the police, and understand the need for strict secrecy during the operation.

 The Pan Sussex Child Protection and Safeguarding Policy and Procedures Group recommend the following statement is read out at all relevant meetings.

Professional Difference Statement:

It is acknowledged that when working in the arena of safeguarding, it is inevitable that from time to time there will be professional differences.  This is a positive activity and a sign of good professional practice and effective multi-agency working.   During this meeting practitioners, irrespective of their seniority are encouraged to say if they feel that decisions, practice or actions do not effectively ensure the safety or well-being of the child/children.

Because of the difficult nature of FFI and PP there is an even greater likelihood of differences of opinion between professionals. For all agencies where there is disagreement between professionals the Resolution of Professional Disagreements Procedure should be followed.

When there is a difference of medical opinion regarding any matter relating to fabricated or induced illness or PP, the Designated Doctor should be consulted how best to resolve the issue.

In the event of single or multi-agency complaints the agencies and authorities need to be linked in managing the complaints procedure(s).

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