Perplexing Presentations/Fabricated & Induced Illness

This condensed guidance has been developed in response to the RCPCH Perplexing Presentation / Fabricated or Induced Illness published in February 2021 and should be read in conjunction with this in order to fully understand the context of Fabricated and Induced Illness and perplexing presentations (reference 6).


1. Introduction

1.1 There has been a shift to earlier recognition of possible FII without need for evidence of significant harm. In the absence of clear evidence about risk or harm the recognition of possible FII is better termed perplexing presentation. (See below for definitions).

1.2 In order to respond and navigate the highly complex nature of this form of abuse a systematic multiagency approach is essential to identify indicators at the earliest opportunity and prevent any further harm to the child.

 

2. Definitions

2.1 Fabricated or Induced Illness (FII)

2.1.1 In cases of FII a child is suffering or likely to suffer harm as a result of parent/carer behaviours or actions carried out to convince healthcare professionals that the child’s physical/mental health or neurodevelopment are impaired ( or more impaired than in the case). FII can cause physical, emotional abuse and neglect as a result of these actions, behaviours or beliefs and also as a result of doctors response to these. E.g. overtreatment or over investigation. The motivation of the parents may not always be clear and cases can be FII without definite deception. The parents may fabricate illness (e.g. seizures, mental illness), induce illness (e.g. Salt poisoning, withhold medication) or falsify test results resulting in unnecessary interventions. In some cases parents will misrepresent information when giving history to professionals. Parent may say a particular professional said X had to happen when child presented with Y.

2.2 Perplexing presentations (PP)

2.2.1 In perplexing presentations a child’s presentation is not clearly explained by any genuine illness and there may be alerting signs of possible FII, but the actual state of child’s physical or mental health is not yet clear. Although the situation may be impacting on child’s health or emotional well-being, (e.g. non-attendance at school, use of aids etc.) there is no perceived immediate risk of serious harm. This situation is far more common than FII. Often parents may have sought numerous opinions. There are often discrepancies between reporting from parents and observations of the child. e.g. Parents feel child too anxious to attend mainstream school but when has attended in past school have said they did not display anxiety and did well.

2.3 Medically unexplained physical symptoms

2.3.1 In these cases the Child’s symptoms are genuinely experienced but not explained by any known pathology or disease, they are more likely driven by child factors (usually psychological). E.g. Child who suddenly goes off legs and all investigations normal including neurological examination and imaging. The parents are often on board with diagnosis and will work together with health professionals in children’s best interests to restore health and well-being. These cases should be managed in health by MDT including paediatrician, Physiotherapy, psychologist, Occupational therapy, 0-19 service with support from school as needed to rehabilitate.

 

3. Possible Presentation of Fabricated or Induced illness or Perplexing Presentations

3.1 Parent/carer motivation and behaviour in cases of PP or FII

3.1.1 Research shows there is often a parental need for their child to be perceived as ill or more ill than the child actually is. It is more common for mothers to be perpetrators and fathers may not be aware. In a significant number of cases child does have a verified diagnosis.

3.2.1 There are often two different motivations which may both be present:-

  1. Parents experience gain from recognition and treatment of child being unwell. Some mothers who struggle with management of a child may seek a mental health diagnosis. Material gains include financial support
  2. Second motivation is erroneous beliefs, extreme concern or anxiety about the child’s health. Unlike most typical parents they are often not reassured by health care professionals or negative investigations. This results in changes or doctor or professionals. 

        See RCPCH guidance for further information (reference 6)

3.2 Presenting features

3.2.1 The commonest presentation is erroneous reporting of e.g. symptoms, history, results of previous tests, medical opinions, interventions and diagnoses. Examples:

  • Reporting of symptoms or signs not witnessed
  • Exaggeration of symptoms or signs
  • Manipulation or omission of medication
  • Induction of illness
  • Falsifying test results
  • Obtaining specialist equipment that child does not need
  • Labelling child with mental /health behavioural diagnosis not confirmed
  • Mother persistently requesting behavioural assessments. E.g. ASD/ADHD

3.2.2 It is important to acknowledge and not confuse situation specific behaviour with FII/PP e.g. if a child’s behaviour only occurs with mother and not seen outside of home e.g. at school. This is an example of situation specific presentation and could be due to the parent and child relationship rather than the mother fabricating the phenomena.

 

4. Harm to the Child

 

4.1 Emotional abuse, physical abuse or medical neglect can all be consequence of FII and PP. There is often a confirmed coexisting medical illness in some cases. Both FII and PP can impact in similar ways:

  • Child’s health and experience of healthcare
  • Effect on development and daily life
  • Psychological and health related wellbeing

5. Alerting Signs

5.1 Alerting signs may be present in the child or in the behaviour of the care giver. The paediatrician should consider the overall number and severity of alerting signs.

5.2 Examples in the child

  • Physical, psychological or behavioural symptoms and signs reported but not witnessed independently.
  • Unusual test results e.g. unusual organisms on culture
  • Very poor response to treatment that would normally be very effective
  • Reported problems that are physiologically impossible e.g. large blood loss without a change in haemoglobin (blood count)
  • Unexplained impairment in child’s quality of life such that they require additional aids and are reportedly unable to attend school

 5.3 Examples of care giver behaviour

  • Insistence on continued investigations instead of working with the medical team on alleviating symptoms, especially when the investigations completed already demonstrate no worrying cause for the symptoms described.
  • Repeatedly reporting new symptoms
  • Repeatedly attending health care settings, potentially attending different hospitals and seeking the opinion of different doctors.
  • Providing reports from overseas doctors or private clinics which conflict with best practice and evidence based practice in the UK
  • Repeated non-attendance at appointments, especially for investigations which may disprove the reported symptoms
  • Objection to communication between professionals
  • Frequent complaints about professionals, especially if challenged about reporting of signs and symptoms
  • Talking for the child or not allowing the child to be seen on their own
  • Repeated, unexplained change of school (including home schooling) or GP/medical team
  • Inaccurate statements that the parents make to other professionals about their child’s illness, usually exaggeration.
  • Requests for drastic interventions which clinically are not felt to be required

 

6. Roles and Responsibilities 

6.1 It is the responsibility of a Paediatric Consultant or Psychiatrist (if involved) to determine whether presentation of child by parents is indicative of FII or Perplexing Presentation but requires all professionals involved with child to respond to any emerging concerns by seeking further information from other professionals involved with child and family.

6.2 Professionals from a non-health setting including Education/Early Years/Early Help/Children’s Social Care

6.2.1 Professionals may have concerns because parents are describing a child’s illness or health needs which are not witnessed by the professionals. In such situations professionals should consider the other warning signs. If they remain concerned they should discuss the child with the safeguarding lead within their organisation.

6.2.2 When a parent/carer reports restrictions/limitations for normal school activities due to reported ‘health’ issues, it is important this is verified with health professionals via liaison with the health visitor or school nurse. Consent from the parents to do this should be sought on the grounds that that this is usual practice where a child has an illness which is impacting on their health or development. At this stage the concern about possible PP/FII should not be disclosed to the parent/carer. If parents refuse consent for a discussion with health professionals then this should be discussed with the safeguarding lead to consider whether refusal increases the level of concern.

6.2.3 Professionals should keep careful and secure records of absences and reasons given by parents for absences so that these can be corroborated. The professionals should listen to the child and document what they are saying.

6.2.4 This information should be requested from the parents on the grounds that that this is usual practice where a child has an illness which is impacting on their health or development to get a clear health plan. At this stage the concern about possible PP/FII should not be disclosed to the parent/carer. If parents refuse consent for a discussion with health professionals then this should be discussed with the safeguarding lead to consider whether refusal increases the level of concern.

6.2.5 If the concerns are raised in education or early years settings the practitioner should discuss with health professionals from the 0-19 health service in the first instance.

6.2.6 If the concerns are raised by children's social care, then health information should be requested from the child's general practitioner on potential impact of these diagnoses on the health and development of a child and attendance at school. If this information highlights the child is known to a consultant then information should be sought from that consultant on the medical diagnoses and the potential impact of any diagnoses on the health and development of a child and attendance at school.

6.3 Professionals from Health Setting

6.3.1   0-19 - Health Practitioners:

(1) Where practitioners have concerns that a parent/carer is impairing a child’s health, development or functioning, they should meet with parents/carers to discuss the child’s illness, parental concerns and ascertain which other health professionals are involved.

(2) Parental anxiety and worry about a child’s illness or concerns that their child’s health needs are not being met can be common. This can lead to health-seeking behaviours or exaggeration of symptoms. The practitioner should seek parents/carers consent to discuss the child with those professionals involved including the consultant in an attempt to allay any anxieties at an early stage.

(3) Where the practitioner has on-going concerns about FII/PP and the child is already known to other health professionals, then information should be sought from those professionals regarding the medical illness/diagnosis, and advice or an appropriate care plan should be provided. Although at this point consent is not required it is good practice to inform the parents that you'll be discussing health concerns with the relevant professionals as a standard practice. Concerns about possible FII must be shared with the other health professionals and especially the GP.

In all cases of suspected fabricated and induced illness advice, support and supervision where necessary should be sought from the Safeguarding Children Team or Named Nurse / Named Doctor.

(5) Several different Consultants with different specialities may be seeing child and therefore requires careful co-ordination of health information due to indicator of repeated attendance at health care settings, potentially attending different hospitals and seeking the opinion of different doctors. The Lead Consultant should be considered on a case by case basis following consultation between the Named Doctor from the child’s local NHS hospital and the Designated Doctor. The lead paediatrician will be one who is overseeing child’s care locally. If all care is at the Children’s hospital in Newcastle then a named doctor of local trust may lead on this case or allocate an appropriate paediatrician depending on child’s presentation.

6.3.2  Midwives

(1) Midwives may be alerted to possible FII/PP by mothers own health-seeking behaviour, history of unusual/unexplained illness, unusual complications of pregnancy, and unexplained deaths of previous children. If concerns are raised then previous pregnancy notes should be obtained and the midwife should discuss concerns with the Safeguarding Children Team.

6.3.3  General Practitioners (GPs)

(1) In cases of suspected PP/ FII, the GP is likely to have had a higher level of involvement and knowledge of the child and family than other health professionals.

(2) If there are concerns about PP/FII and the child is not known to a consultant they must be referred to a Paediatrician /or Consultant Child Psychiatrist with expertise in symptoms and signs that are being presented. Where parents refuse for a referral to be made to a local paediatrician or child psychiatrist consideration should be given to the impact this may have in the child.

(3) If no immediate risk of harm i.e. PP, GP should explain need for referral to paediatrician for diagnosis and appropriate management plan. Concerns about PP should be mentioned in referral letter so it is allocated to correct clinic and clinician.

(4) GPs should also discuss concerns with the named doctor or Designated Health Professionals for Safeguarding Children via e mail TVCCG.safeguarding@nhs.net

(5) GPs should ensure that these concerns are recorded within the child’s clinical record.

(6) If there is concern about fabrication or induction of illness then an urgent referral by phone to the on call Paediatric Consultant at relevant acute hospital.

6.3.4   Mental Health Workers (including Child and Adolescent MH, Adult MH & Learning Disability services)

(1) Staff within Mental Health may also be alerted to concerns about possible FII/PP in the process of evaluating children for mental health and behavioural difficulties.   Initial concerns about a child’s presentation should be shared with the Trust’s Safeguarding & Public Protection team.  If concern remains this should be discussed with the Paediatrician or GP that referred the patient and other relevant health professionals.  If concerns continue then the trusts named doctor or named nurse at TEWV should be involved.

I(2) n Adult MH if a patient who is a parent is known to fabricate or induce illness themselves this may increase the risk to the child in relation to possible FII/PP.  If an adult mental health worker has any concerns of this nature about a child’s welfare they should be discussed with the Trust’s Safeguarding & Public Protection team.  Confidentiality may need to be breached without consent in order to protect the child as there is a statutory obligation on all professionals to act in the best interests of children in order to safeguard.

6.3.5  Allied Health Professionals

(1) If staff have concerns about FII/PP in children they are providing therapy and care for they should discuss with the Safeguarding Children Team within their Trust and GP or the practitioner who referred to their service.

6.3.6  Consultant Paediatricians or Consultant Child Psychiatrist

(1) All cases of suspected FII/PP should be led by a Consultant Paediatrician or, Consultant Child Psychiatrist with advice from named doctor and safeguarding team.

6.3.7  Named Doctor/Named Nurse for Safeguarding Children

(1) The Named Doctor/named nurse is there to provide advice and support to the lead consultant; they will be expected to chair health professionals meetings. If the named doctor is also the lead paediatrician then the designated doctor will provide advice and support.

6.3.8  Health Care Practitioners including other Consultant Specialists:

(1) If a Health Care Practitioner including Consultant, other than a Paediatric or CAMHS Consultant, has a concern about PP/FII in a child in their care they should refer to a Consultant Paediatrician or discus with Safeguarding Children Team.

6.3.9  Designated Professionals for Safeguarding Children

(1) Designated doctors can offer safeguarding supervision or facilitate professional discussions, particularly where the presenting issues are very complex. If named doctor is also child’s paediatrician then designated doctor will provide advice and support and chair professional meetings.

 

7. Response to Alerting Symptoms and Signs

7.1 Actions to be taken if there is immediate serious risk to the Child’s health and life - these cases should be managed as FII

7.1.1 This is particularly important in cases of illness induction and deception such as tampering with specimens or feeding tubes and also in cases where open discussion with parents my lead to further harm to the child.

7.1.2 Actions to be taken:

  • Urgent referral to children’s social care +/- police by the responsible consultant, parents should not be made aware of the referral at this point if it is felt this would increase parental behaviour and risk of harm to child.
  • Strategy meeting should be convened
  • Evidence should be secured such as feeding bottles giving sets, nappies, blood urine.
  • Concerns should be documented in the Child health records re FII and handed over to all relevant staff.
  • An alert should be put on the child’s hospital record and communicated to GP and 0-19 service. so that all clinicians and health professionals seeing the child are aware of the concerns. This should be done even before the diagnosis of fabricated induced illness has been confirmed at strategy and Case conference.
  • Consider need for immediate protection – If there are serious concerns that the parents may try to remove the child particularly in hospital and immediate protection is needed and this is best obtained by contacting the police who can use their police protection powers.
  • Decisions about what and when to inform parents of concerns should be decided at the strategy meeting.
  • In all cases where the police are involved, the decision about when to inform the parents (about referrals from third parties) will have a bearing on the conduct of police investigation.

7.2 Actions be taken if there is no immediate risk to the Child’s health and    life: perplexing presentations - perplexing presentations

7.2.1 These cases can be managed as perplexing presentations but as they may go on to cause actual harm or likely harm to the child; they require a carefully planned response. In these cases it is good practice to call a multi-professional meeting or health professionals meeting via the trusts Safeguarding Teams.

7.3 Multi Professionals Meeting

7.3.1 A multi professionals meeting should be convened by the Lead Consultant in conjunction with the Trust(s) Safeguarding Children Team(s) when there are concerns about perplexing presentations and the child is not at the immediate risk. Each professional should provide a summary of their involvement to share at the meeting and a chronology of your involvement may be requested in some instances to support any conflicting information parents are reporting to professionals about their child’s health. Social care will not routinely be invited to this meeting, however if child is known to social worker or early help then they should be invited as professionals involved in child’s care.

7.3.2 If after the meeting or at any point during the investigation and information gathering there are sufficient concerns that a child may be suffering or is likely to suffer significant harm, a referral should be made to Children’s social care as soon as possible in line with safeguarding children multi-agency procedures.

7.4 The health and educational rehabilitation plan

7.4.1 The lead consultant together with other professionals involved in the child's care will develop a health education rehabilitation plan together with the family. In a significant number of perplexing presentations the family will engage with health professionals and the child will work towards a recovery by following the rehabilitation plan. It is important that the child is followed up by the lead consultant to ensure that the plan is been followed. Referrals to early help may be necessary to support this plan.

 

8. Record Keeping

8.1 All notes about a child’s condition should clearly state the facts: who reported the concerns, what was observed, and by whom. If your opinion is that the differential diagnosis includes FII/PP, then this should be clearly stated in the notes. This information may need to be redacted if the notes are shared with the parent/carer.

8.2 Records of key discussions and safeguarding supervision notes about the child’s care should be kept within every organisation’s main health record pertaining to the child to ensure that the child does not come to further harm.

8.3 GP notes should have flags on when there are ongoing concerns about perplexing presentations or FII with a clear plan of referral and management should the child present to the service out of hours or acutely.

 

9. Information Sharing, Consent and Confidentiality

9.1 Parents should be informed of the need to share information between different professionals involved in the child's life. If the parents are not in agreement and you have concerns about the welfare of the child then you must share the information with other professionals without the parents’ consent. If you choose not to share information with other health professionals and this should be clearly documented in the notes. (reference 7)

 

10. Chronologies

10.1 Although chronologies are not essential in management of most cases of PP/possible cases of FII; they are needed in complex cases and cases referred to social care. The preparation of the chronology should not delay a referral to Children’s Social Care (CSC) or any other interventions if this would put the child at risk of harm.

 

11. Referral to Social Care

11.1 Indications for referral to social care

  • All cases of induction of illness, deception or risk of immediate significant harm.
  • Cases where the family have failed to engage in the health and education rehabilitation plan and the child has continued to presenting with perplexing presentations with no plan going forward.
  • Cases where the family refused to allow professionals to share information or actively block the sharing of information between professionals that would aid in a diagnosis and solution to the child's problems.
  • Parents do not agree with multiple professional opinions and fail to change their beliefs about the child's state of health and continue to presents the child with ill health that is having a significant impact on them.

 

12. Response by Children's Social Care

12.1 Children’s social care will decide and record within 1 working day what action is required in response to the referral. Lead responsibility for action taken to safeguard and promote the children’s welfare lies with social care.

12.2 In all cases where it is believed the information indicates suspected FII there should be an assessment undertaken which may result in a multi-agency strategy meeting which considers all children within the family.

12.3 Non-attendance of one or two professionals should not delay the meeting if it is indicated the child may be at risk of significant harm however. Key professionals will include:

  • Team manager children’s social care – Chair
  • Named nurse or Specialist Nurse safeguarding children from relevant organisation
  • Allocated Social Worker
  • Lead Paediatric Consultant/CAMHS Consultant
  • Senior police officer
  • The referrer
  • School or early years setting (appropriate to age of child)
  • Legal advisor to local authority
  • Named/designated doctor
  • Other Allied health professionals involved in the child’s care
  • Other Consultants involved in the child’s care
  • Adult Mental Health Consultant (where involved with a parent)
  • GP

12.4 During the strategy meeting specific consideration must be given to what information is to be shared with the parents and when. In addition, decisions about involving the child in discussions must also take place and consideration must be given to any relevant therapeutic work.

 

13. Police response

13.1 During the process of information sharing and assessment it may become apparent that there are indicators that a crime has been committed. This should be taken into due consideration during all stages of assessment and interventions and the police will provide direction regarding professional intervention in order to avoid disrupting any possible criminal investigation/process.

 

14. Decision Making

14.1The Strategy Meeting should decide whether to initiate a formal enquiry under Section 47. For complex cases, more than one Strategy Discussion may be required.

The discussion should include:

14.1 Assessment of risk and safety planning

  • The level of harm the child has already suffered;
  • Whether police need to progress criminal investigation;
  • The risk of future harm and any complicating factors;
  • Current safety arrangements already in place;
  • Whether an immediate safety plan is needed to reduce the risk of harm e.g.:
  • Cancelling unnecessary medical procedures;
  • Instituting closer observation of the child;
  • Whether the carers should be allowed on the ward if the child is an inpatient. If this is deemed to be unsafe then an emergency order may be required which will need to be instituted by either the police or the local authority.
  • Any potential implications for other patients or their carers who are on the ward at that time;
  • Consideration of the child's safety network and how it may be used to provide immediate safety;
  • Consideration of how all involved health professionals can work together to ensure a coordinated, informed response to any health problems.

 

13.2 Information Gathering

  • Any outstanding investigations, further information gathering, and opinions that would be helpful;
  • The planning of further medical and nursing assessment;
  • The need for forensic sampling, special observation or Covert Video Surveillance;
  • The development of an integrated health chronology (and agreement on who should do this);
  • Any further opinions needed (including specialist child protection opinion or to address a specific clinical issue);
  • What is known about the carers' past behaviour, medical history, current health state and any treatment, equipment, aids or benefits being received either for them or the child;
  • Strengths within the family.

 

13.3 Action Planning

  • Plan for communication with carers including how, when, and by whom they should be informed of any child protection concerns;
  • How the child can be given an opportunity to tell their story;
    1. Responsibility for the Child & Family Assessment;
  • The level of professional observation required;
  • Addressing the needs of siblings and other children in the family;
  • Addressing the needs of carers, particularly after disclosure of concerns;
  • Clarification of who will be the Responsible Paediatric Consultant for the child (if not already explicit).

 

13.4 Possible outcomes of the Strategy Meeting(s):

  • No further action by Children's Social Care;
  • Provision of Services by one or more agencies; (EARLYHELP)
  • Continued monitoring by identified professionals of specific concerns;
  • Child & Family Assessment;
  • Child in need plan
  • Section 47 Assessment;
  • The police start a criminal investigation;
  • Immediate Action to protect the child(ren);
  • A further Strategy Meeting or series of meetings, and/or an Initial Child Protection Conference once the Section 47 investigation is completed.

 

14. Disclosure of Concerns to Carers 

14.1 Professionals should be supported through the process of disclosure and the approach should be agreed and carefully planned beforehand dependent on the circumstances of the case and risk. This discussion should not be done as single agency. A representation from health preferably the Lead Consultant and social care who are going to work with family should be at this discussion with family.

14.2 A detailed note of the discussion should be made in the child's case notes.

 

15. Child Protection Conference

15.1 If the case proceeds to a child protection conference it is essential that the conference is organised so that key professionals including the Responsible Paediatric Consultant can attend.

 

16. Working with Carers Who Have Fabricated Illness and Their Children

16.1 To gauge the prognosis for positive change in carers who have fabricated or induced illness it is essential to gain an understanding of:

  • Their capacity to understand and acknowledge the harm which has been caused to the child;
  • The underlying motivations which led them to fabricate or induce illness;
  • The perpetuating factors which supported the continuation of the abuse and the extent to which these could be removed.
  • The ability to change beliefs about child’s state of health and work with professionals

16.2 It is important to explore what life will be like now that the child has been found to be well or better than previously thought. Carers will require help with constructing an accurate narrative of the past which they can share with significant others in their life, including the family.

16.3 In cases involving older children it is important to ascertain the child's perceptions, beliefs, and feelings about their state of health, particularly their anxieties and beliefs about their future wellbeing. It is also important to elicit the child's view of their experiences of medical care.

 

17. Further Information

18. Weblinks (external)

19. References: