SCOPE OF THIS CHAPTER
This chapter outlines the key points in relation to fabricated or induced illness and perplexing presentations in children, and how to make a referral to Children's Social Care where there are concerns about a child.
This chapter was reviewed in January 2018 and updated throughout. A flowchart which illustrates the principles which should be followed when managing cases of suspected FII has been added in Appendix 1: Flowchart to Illustrate the Principle of Managing FII. The revised chapter should be read in full.
- Recognition of Possible FII/Perplexing Presentations in a Child
- Possible Impact of FII/Perplexing Presentations in a Child
- Professional Response to Concerns
- Referral to Children's Social Care
- Appendix 1: Flowchart to Illustrate the Principle of Managing FII
Perplexing presentations and Fabricated or Induced Illness (FII) are terms used to describe situations where the child's presentation is not adequately explained by any confirmed genuine illness, and the situation is impacting upon the child's health, development or social wellbeing. True fabricated or induced illness in a child is a behaviour observed in a carer and involves the deliberate deception of professionals.
Harm to the child may be caused through unnecessary or invasive medical treatments, which may be harmful and potentially dangerous, based on symptoms that are falsely described or deliberately manufactured by the carer, and which lack independent corroboration.
The child may additionally suffer emotional harm through restrictions placed on their development and social interaction.
2. Recognition of Possible FII/Perplexing Presentations in a Child
Doctors/paediatricians, health professionals and practitioners from other agencies may have concerns that a child is suffering or likely to suffer Significant Harm as a result of having illness fabricated or induced by their carer. These concerns may arise when:
- A carer reports symptoms and observed signs that are not explained by any known medical condition;
- Physical examination and the 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;
- Frequent attendances at different healthcare settings;
- The child takes on a sick role even in the absence of carer as a learnt behaviour.
There may be a number of explanations for these circumstances and each requires careful consideration and review. Examples are:
- The carer is anxious and has a rather disordered view of the child's state of health;
- The carer holds inappropriate beliefs or expectations about the child's health and illness (this may include parents with a delusional disorder or other mental illness);
- The carer is interacting with the child in a way that involves the child inappropriately assuming the sick role or the role of a disabled child;
- The carer has a familial or cultural style of illness behaviour that affects how children are presented to doctors;
- The child has a rare and as yet undiagnosed condition.
Concerns about a child may be raised by other practitioners, for example nurses, teachers or Social Workers who are working with the child and who may notice discrepancies between reported and observed medical conditions, such as the incidence of fits.
Practitioners working with the child's parents may also note relevant concerns e.g. mental health practitioners, may identify a child being drawn into the parent's illness.
Symptoms that are fabricated are often those where the child may appear well between episodes (such as apnoea, seizures, vomiting, asthma, allergies, and blood loss). Some carers may falsify supporting evidence of illness (e.g. put blood in a nappy or change a chart) and this behaviour may place the child at significant risk. Actual induction of illness by physically doing something to the child (e.g. smothering, poisoning, withholding food) is an ominous and potentially fatal situation and requires urgent action through safeguarding procedures. Symptoms may also be fabricated against a background of true illness.
Adult Mental Health Services may be involved in the assessment, planning, management or treatment of a carer, and adult practitioners may identify a risk to children. In these circumstances liaison should take place between the adult psychiatrist and those responsible for the child's health or assessment.Child and Adolescent Mental Health Services (CAMHS) may identify fabricated or induced emotional or behavioural symptoms in children with whom they work. They may also be asked for urgent advice by other practitioners working with families where FII is a possibility.
3. Possible Impact of FII/Perplexing Presentations in a Child
- A disordered perception of illness and health, leading to anxiety about health and abnormal illness behaviour;
- Inadvertent iatrogenic (caused by medical examination or treatment) harm including admission to hospital, acquired infection, blood tests, x-rays;
- A greater degree of invasive medical attention than is truly justified – in extreme cases, it may include surgical procedures, insertion of lines, artificial feeding, and 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;
- Child victims of FII may be subject to prolonged legal proceedings and are at risk of further abuse and ongoing morbidity due to abuse; and
- Actual illness induction heightens risk significantly as a result of the pain and distress of induced illness, the real risk of death and also of under-treatment of real conditions.
4. Professional Response to Concerns
Concerns about a child's health, should be discussed with the GP or Paediatrician responsible for the child's care. If there is no Paediatrician involved with the child, the situation should be discussed with the Named or Designated Doctor to advise on the way forward. The Named Nurse for the area in which the child lives, should be fully involved. A merged health chronology should be developed, as soon as there is a concern. This should include all involved health professionals.
Any concerns are not usually discussed with the family at this stage as there is a risk that the behaviour may escalate and increase harm to the child or could impact on the evidence gathering. The reasons for not doing so should be recorded.
If any practitioner considers their concerns are not taken seriously or responded to appropriately, these should be discussed with the named or designated doctor or nurse who may review the records.
If any concerns relate to a member of staff, these should be discussed with the relevant named or designated professional who, as well as ensuring the immediate safety of the child, will follow procedures in respect of allegations against staff. See Allegations Against Staff, Carers and Volunteers Procedure.
4.1 Medical Evaluation
The signs and symptoms require careful medical evaluation for a range of possible diagnoses. Where a reason cannot be found for the signs and symptoms, specialist advice and tests may be required.
Normally, the doctor would tell the parent/s that s/he has not found the explanation and record the parental response. Parents should be kept informed of further assessments/investigations/tests required and of the findings.
At no time should concerns about the reasons for the child's signs and symptoms be shared with parents if this information would jeopardise the child's safety.In circumstances where the paediatrician is uncertain as to whether or not to refer a case to Children's Social Care they should discuss the situation with the Child Protection Manager.
5. Referral to Children's Social Care
When there are concerns that the signs and symptoms may have been fabricated or induced by a carer a referral should be made to Children's Social Care. The referral may follow a medical evaluation or be the result of concern by practitioners or members of the public.
Please note - At variance with normal practice, where a referral is being made to Children's Social Care, concerns and information about the referral should only be shared with the family if the professional is confident that this will not place the child at increased likelihood of Significant Harm. This should usually be the decision of a multi-agency meeting.
The Police (City or County Referral Unit) must be informed by Children's Social Care, at the earliest opportunity. Any suspected case of fabricated or induced illness may also involve the commission of a crime and the Police will take responsibility for deciding whether or not to initiate a criminal investigation.
There must be clear agreement between the agencies of the action to be taken, by whom and within what time frame.
All decisions about what information is shared with parents should be agreed between the Police, Children's Social Care, the consultant paediatrician and the referring practitioner, bearing in mind the safety of the child and the conduct of any Police investigations.
If emergency action is required an immediate Strategy Discussion should take place, where possible, between Children's Social Care, the Police, health 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 Meeting in consultation with the Child Protection Manager. A meeting is advisable when considering this complex form of abuse. See Child Protection Section 47 Enquiries Procedure, Strategy Discussions / Meetings.
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 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;
- A medical practitioner with expertise in the relevant branch of medicine;
- Health visitor;
- School Nurse;
- Staff from education settings;
- Local authority legal adviser.
The meeting should be held at a time that ensures the availability of the key practitioners and expertise but should not be delayed in a way that may be detrimental to the welfare of the child.
The strategy meeting should consider:
- Whether the child requires constant professional observation, and is 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);
- Arrangements for the medical records of all family members, including children who may have died or no longer live with the family, to be collated 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 co-ordinated);
- 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 legal adviser is not present at meeting).
Undertaking enquiries into FII can be complex and challenging for practitioners and an individual should not undertake the enquiry in isolation. The strategy meeting should recognise the need to ensure multi-agency co-ordinated 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 meeting particularly to allow time for a detailed medical Chronology to be produced. Decisions must be made and recorded about what information will be shared with the parents, by whom and when. The 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 meeting this should be recorded with clear guidance about when, in the future, they may be informed that the meeting has taken place.
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 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.
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.
As with all Section 47 Enquiries, the outcome may be that concerns are not substantiated - for example tests may identify a medical condition, which explains the signs and symptoms and no protective action is required. In this case the family should be provided with the opportunity to discuss what further help it may require.
Concerns may be substantiated, but an assessment made that the child is not judged to be at continuing risk of harm. The decision not to proceed to an Initial Child Protection Conference must be endorsed by the service manager following discussion with the Child Protection Manager.
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 meeting. 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 responsible for the child's health.
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 with expertise in the branch of paediatric medicine able to present the medical findings.
Appendix 1: Flowchart to Illustrate the Principle of Managing FII
See Flowchart to Illustrate the Principle of Managing FII (see Documents Library, Flowcharts).
For further information please see Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians (Royal College of Paediatrics and Child Health).