4.4 Fabricated or Induced Illness in children and young people by Carers (FII): Procedures and Guidance

Lord Justice Ryder wrote, in a court judgement from 2005:

 “The terms ‘Munchausen Syndrome by Proxy’ and ‘Factitious (and Induced) Illness (by Proxy)’ are child protection labels that are merely descriptions of a range of behaviours, not a paediatric, psychiatric or psychological disease that is identifiable. In reality, the use of the label is intended to connote that in the individual case there are materials susceptible of analysis by paediatricians and of findings of fact by a Court concerning fabrication, exaggeration, minimisation or omission in the reporting of symptoms and evidence of harm by act, omission or suggestion (induction).

For my part, I would consign the label MSBP to the history books and however useful FII may apparently be to the child protection practitioner I would caution against its use other than as a factual description of a series of incidents or behaviours that should be accurately set out (and even then, only in the hands of the paediatrician or psychiatrist/psychologist).

What I seek to caution against is the use of the label as a substitute for factual analysis and risk assessment. “

[2005] EWHC 31 (Fam) https://www.familylawweek.co.uk/site.aspx?i=ed109

This guidance strongly promotes the recommendations of Lord Justice Ryder

Fabricated or Induced Illness is a term used increasingly by professionals from all agencies involved in safeguarding and protecting children. However, there remains debate and disagreement about the nature and definitions of Fabricated or Induced Illness (FII). For the purposes of this guidance, FII is considered as, ‘a clinical situation where a child has suffered or is likely to suffer significant harm through the fabrication, falsification, or induction of illness by a carer and/or from responses to these parental actions by health professionals.

• By using the term FII, health professionals are expressing their concerns that the child has suffered or is likely to suffer significant harm.
• in describing the harm, all professionals, health, and non-health, are encouraged to use the language of Working Together, which is multi-agency.

Terms used by the Royal College of Paediatrics and Child Health include:

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/carers work collaboratively to achieve evidence-based therapeutic work in the best interests of the child or young person.

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 harm), 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/carer’s 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)/carer(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/carer’s actions, behaviours or beliefs and from doctors’ responses to these. The parent or carer 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. In order for this physical abuse to be considered under FII, evidence will be required that the parent’s/carer’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.

Terms from NICE Guidance CG89 include:

Alerting Features – these are clinical features associated with child maltreatment that may be observed when a child presents to healthcare professionals.

Consider – to consider child maltreatment means that maltreatment is one possible explanation for the alerting feature.

Suspect – to suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but not proof of it.

In recognising the harm caused by FII, the effect and impact on the child should be the major concern of professionals caring for the child. Professionals are encouraged to consider the lived experience of the child and to listen to the voice of the child.

Rather than concentrating on diagnoses, professionals should consider the following:

• How is the child in terms of health and well-being?
• Is the child living as normal a life as possible?
• What is preventing the child reaching their expected and achievable outcomes?

Induction of illness, falsification and fabrication describe different clinical situations as listed below:

Induction of Illness:  Induction of illness is rare. The commonest forms of induced illness are poisoning (usually by prescription medications) and suffocation. When the illness induction stops, the child may return to normal health but can still remain at risk of further harm. Further harm is likely to occur from medical interventions to investigate the cause of the child’s illness (iatrogenic harm) and the emotional impact on the child.

Falsification of Illness:  Falsification of illness is also rare. Clinical samples reported to be from the child can be tampered with or may not come from the child. For example, (e.g., non-human blood on clothing reported to have come from the child; urine samples can have sugar or blood added to them; thermometers can be warmed up with hot water).

Results of medical tests can be falsified or letters reportedly from health practitioners can be forged. Photographs reportedly of the child may be from another child or faked to look like a medical condition.

Fabrication of Illness:  Fabrication of illness is commonly encountered by health professionals. The situation can often be resolved through open discussion and careful management, however, where this is not possible, the child can sometimes experience significant harm.

Parents or carers may or may not realise that they are giving an incorrect account of the child’s health. Their description will depend upon multiple factors including parental health and health beliefs, culture, previous experience of healthcare and experience of childcare. Naïve exaggeration and deceitful lying could both be described as fabrication but are very different in how they should be managed.

Alerting signs are not evidence of FII. However, they are indicators of 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.

Some alerting signs are initially recognised by community or primary health care professionals such as health visitors, GPs or community paediatricians, Social Care staff or by professionals in pre-school/early years, schools and other educational settings. Others are first noted by hospital-based paediatricians or in Child and Adolescent Mental Health Services (CAMHS).

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 behaviours. Alerting signs may be recognised within the child or in the parent’s behaviour. A single alerting sign by itself is unlikely to indicate possible fabrication. It is important to look at the overall picture which includes the number and severity of alerting signs.

Alerting signs in the child

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

Alerting signs in the Parent/Carer

Clinical evidence indicates that fabricated or induced illness is usually carried out by the child’s mother or a female carer, (Safeguarding children in whom illness is fabricated or induced, DCSF 2008). However, practitioners should also be aware of the possibility of other perpetrators including fathers, grandparents, siblings or other children, or practitioners (Fabricated or Induced Illness by Carers, Royal College of Paediatricians and Child Health, 2009).

Parents/carers may have the following history or exhibit a range of alerting behaviours when they wish to convince others that their child is ill:

• Parents’/ Carers’ 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’/carers’ 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/Carers pressing for irreversible or drastic treatment options where the clinical need for this is in doubt or based solely on parental reporting.

These patterns of behaviours are coercive, isolating and controlling and are patterns we see in a grooming process. Parents/Carers could be grooming professionals through behaviours which could seek to initially get professionals to feel sorry for them, ingratiate themselves and then this can move on to intimidation.

Significant harm is defined in the multi-agency Continuum of Need Incorporating Threshold Guidance as a situation where a child is suffering, or is likely to suffer, a degree of physical, sexual and/or emotional harm (through abuse or neglect) which is so harmful there needs to be statutory intervention by child protection agencies in the life of the child and their family.

It is important to judge the severity of harm to the child rather than severity of a parent’s/ carer’s actions. Severity of harm to the child should be assessed both by the intensity of each aspect of harm and by the cumulative effect of all the aspects. Whilst the motivation of the parent/carer is irrelevant to the determination of whether the child has suffered or is likely to suffer harm, motivation needs to be considered when planning how to manage the problem.

In the context of FII harm may be caused by physical abuse, emotional abuse or neglect. Although some of these children die, there are many that do not die as a result of having their illness fabricated or induced, but who suffer significant long term physical or psychological health consequences.

Physical abuse may include unnecessary pain and discomfort from unnecessary surgery, anaesthetic, medical investigations, procedures & treatments or through the precipitation of an illness by withholding medication.

Emotional abuse may include making the child unnecessarily anxious about their health and/or experience of healthcare, inducing psychiatric disorders and psychosocial difficulties causing social isolation so that the child’s sense of self is damaged.

Neglect may include disrupted education with unnecessary school absence and/or parental restrictions on participation in usual activities and genuine illness being overlooked.

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Voice of the child

The child’s views are important to ensure we understand how they view their symptoms and any concerns or worries that they may have. Children must be given opportunities to have their views explored, away from parents, in settings where they feel safe. Children can find it difficult to express views independently of their parents. In instances where a child is non-verbal or has communication difficulties either by language or ability, then the support of interpreting and/or specialist communication may need to be sought.

Engaging with parents/carers.

Previous FII guidance suggested that parents/carers should not be informed of safeguarding concerns until multiagency assessment had taken place. However, it is now agreed that parents/carers should be kept informed unless this would place the child at real risk of further harm.

In order to address alerting features before further harm is caused to a child, it is important that professionals are able have honest discussions with parents/carers and children at the earliest opportunity, so that a plan can be agreed to ensure the child’s wellbeing.  However, a decision of who, how and when this should happen needs to be agreed by the professionals involved with the child and family at an early multi-agency discussion/professionals meeting

If it is considered that a child is being harmed through FII, as with any other safeguarding concern, professionals should inform parents/carers (and children if appropriate) about referral to Children’s Services unless this would place the child at risk of further harm. An example where parents/carers might not be informed of contact with Children’s Services is in induced illness where poisoning is suspected. In this situation immediate protection may be needed to keep the child safe.

If you are uncertain whether to inform parents/carers take advice from your safeguarding lead or the named or designated doctor for safeguarding children. It is advised that you avoid terms such as fabrication or fictitious illness but explain to the parent/carer that they appear to be misunderstanding or processing the medical information in a way that may cause harm to their child for example missing school or not being able to participate in certain activities and therefore a referral to Children’s Social Care is being made to support them and the professionals involved with the child in understanding the medical needs of the child and to ensure that the risk to the child is reduced by supporting them with a Health and Education Rehabilitation plan.

If professionals decide not to share safeguarding concerns with parents/carers, there should be a well-considered risk assessment with clear documentation and early multi-agency discussion. Advice on whether to share safeguarding concerns in the context of FII can be obtained from Designated and/or Named Health Professionals. Professionals should note that seeking relevant permissions and informing parents and carers is to be reviewed on a regular basis by Managers, lead paediatrician and Named Doctor/Nurse, alongside partner agencies.

Careful, factual records should be kept, detailing who reported any concerns, what was observed, and by whom. Records of discussions, including about safeguarding concerns, should be kept within the child’s records (including their main health record), to ensure that this information is readily available to those involved in the child’s care, aiming to prevent further harm.

Records should include a clear explanation of the specific concerns and, where appropriate, a risk analysis based on the concerns and the professional’s opinion of these. Similarly, documentation of the harm to a child should use the recognised forms of harm. Records must include a clear account of what has or has not been discussed with the child and parents/carers.

It is recommended that professionals use caution or avoid the term ‘Fabricated or Induced Illness’ when writing records , it may be helpful to use terms such as ‘we are concerned that the parent/care giver is processing information about the child’s health in a manner that may cause harm to the child’.

All professionals who have concerns about a child’s health should discuss these with their line manager, their agency's designated safeguarding children adviser and the GP or paediatrician responsible for the child's health. If the child is receiving services from local authority Children's Social Care, the concerns should also be discussed with them.

Actions if the initial concerns arise directly from education and not health.

It is recommended that school explain to the parents/carers that information is required from health to understand the concerns e.g. poor school attendance. It is then appropriate for education to contact health (either GP, consultant paediatrician or child psychiatrist) with their query about the actual health of the child.  If parents/carers do not agree to health assessment or sharing of information, advice can be sought from organisational safeguarding leads and/or from Named or Designated Health Professionals.

If primary healthcare (GP) is the only contact for the child, then they may wish to refer to an appropriate secondary care consultant for further assessment of the child’s health. The referral must be explicit about the alerting features. If the response from health is felt to be inadequate, education can contact either the Named GP or Named Doctor for Safeguarding Children for advice.

Action in cases where there are alerting signs with no immediate serious risk to the child’s health / life (Perplexing presentations)

In perplexing cases opportunities for multi-agency sharing of information, collaboration, planning and challenge should take place on a regular basis via review multi-agency meetings.

A “Responsible Consultant “, i.e., a consultant paediatrician (or, in cases of fabricated mental illness, a senior CAMHs practitioner), will lead on case management with a focus on the child’s voice and their current state of health, functioning, and involvement with health services.  If initial concerns are raised in primary care or education, then a referral to an appropriate consultant should be made as in 3.4.32.

Where there are concerns about more than one child in a family, each child may have a different or the same Responsible Consultant depending on the needs of the children involved.  If there is disagreement about who should be the Responsible Consultant for a child, this should be discussed with the Named and/or Designated Doctor.

The Responsible Consultant should lead in liaising with all the other professionals involved to reach consensus about the child’s health and management and then will discuss with the child and family.

• clear explanation of medical findings from examination and investigation and what health conditions have or have not been diagnosed.
• After full appraisal of the situation, where appropriate, an agreement should be made with the family to reframe the medical management from primarily investigative and diagnostic to rehabilitation.
• The need to liaise with other non-health agencies involved with the child particularly education and share relevant information about the child and advise the parents/carers that they will be requesting a chronology from each agency involved in the child’s care ( see section 9)
• The proposed Health and Education Rehabilitation Plan

A Health and Education Rehabilitation Plan

A Health and Education Plan should be agreed and implemented. The “Responsible Consultant” will lead on the plan, but this must be shared with all agencies involved. The plan must specify timescales and intended outcomes and be monitored and reviewed regularly.  The Plan may include:

• Reducing/stopping unnecessary medication (e.g., analgesics, continuous antibiotics)
• Resuming oral feeding
• Offering graded physical mobilisation.
• Optimal education needs to be re-established (when the child is of school age)
• Support for the child and family

When FII is considered and/or suspected, parental or carer non-engagement, disguised and/or partial compliance are common, and need to be managed by the Responsible Consultant, together with the multi-agency team.  If the parents/carers do not engage and/or oppose professionals plan for the child, the professional will have to consider whether the parents’ /carers’ actions or non-actions might lead to the child suffering significant harm and so whether referral to children’s services is indicated.

If parents/carers do not engage with the plan and the child is not considered to be at risk of significant harm the case should be reviewed to see whether monitoring and containment are appropriate. Advice may be sought from named or designated health professionals. If the child has a social worker allocated by Children’s Services, Children’s Services will take the lead for safeguarding, working closely with the multi-agency team, particularly health and education, who will take the lead for their aspects of the case.

Action When significant harm is suspected (FII) (Flowchart 2)

The process for the management of cases where there are concerns that a child has suffered or is likely to suffer significant harm from FII is the same as for any other case of child maltreatment. Child Protection Section 47 Enquiries: Procedure.

If at any stage, the Responsible Consultant or other professionals have concerns that the child has suffered or is likely to suffer significant harm, then the MASH should be contacted, and an urgent strategy discussion must take place with the Responsible Consultant (can include a Named or Designated Health professional) and action taken to make the child safe in accordance with each agency’s role and responsibility.  Social Care, in this scenario, must. invite their Legal Representative to the Strategy Meeting.  Other agencies should consider taking their own legal advice if there are concerns regarding non engagement or disguised compliance.

If there is evidence of illness induction or frank deception, such as interfering with specimens or medicine charts, urgent contact should be made with MASH, or, if needed, out of hours, with police and/or children’s services. If there are concerns of illness induction whilst a child is on the ward, for example a parent/carer interfering with medication, equipment or charts, then action should be sought to remove the parent/carer from the ward as they pose a risk to children at that point.

Chronologies are a useful tool in Perplexing Presentations or cases of FII. They should:

• Answer specific questions related to the suspected suffering of harm.
• Have an agreed scope and timespan. They should give a complete picture of attendances, non-attendances and appointments cancelled at short notice, but they do not need to include each and every contact with the child. They should not consist of a simple print-out of the child’s entire case record.
• Include an analysis/comment on each episode listed.
• Not be commenced until there is agreement on who will overview and analyse the multiagency chronology.

Chronologies should be compiled by individuals who have the expertise and ability to recognise and comment on any significant episodes. The Responsible Consultant (with support from the Named and/or Designated Doctor) is usually best placed to overview and analyse the combined multi-agency chronology and provide a report on this.

See Appendix 1 for the agreed multiagency chronology format. It is important that the headings and format are agreed across organisations and agencies so that they can be collated easily.

In most circumstances, there is agreement between professionals as to whether or not a child is at risk of significant harm and the process that should be followed. However, professional challenges should be seen as part of healthy professional working relationships. If there are concerns about the health response from professionals (including concerns from education settings), advice can be sought from the Named GP, the Named Doctor for Safeguarding in a community or hospital trust, or from Designated Health Professionals.

If any professional considers that their concerns are not taken seriously or responded to appropriately, they should escalate their concerns following the Multi-agency Escalation, Challenge and Conflict Resolution Procedure. https://bscb.procedures.org.uk/pkqlq/joint-working-procedures-and-guidance/escalation-challenge-and-conflict-resolution-procedure

The following guidance has been issued by government and by standard setting organisations: 

Working Together 2018 does not mention FII and FII is not a specified form of child abuse. It states that, “Physical abuse may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child”. (Page 106, WT 2018) 

https://www.gov.uk/government/publications/working-together-to-safeguard-children--2

The National Institute for Health and Care Excellence (NICE) guidance: Child maltreatment:when to suspect maltreatment in under 18s, updated in Oct 2017, contains limited guidance on when to consider or suspect FII (Paras 1.2.11-12).

 https://www.nice.org.uk/guidance/cg89

The RCPCH published updated FII guidance in 2021: ‘Perplexing presentations/fabricated or induced illness in children’. This guidance is written primarily for paediatricians but can be helpful for other health professionals.

https://childprotection.rcpch.ac.uk/resources/perplexing-presentations-and-fii/

The Royal College of Psychiatrists produced guidance for psychiatrists last updated in March 2020: ‘Assessment and management of adults and children in cases of fabricated or induced illness(FII)’

 https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mhpolicy/college-reports/cr223.pdf?sfvrsn=658db320_2

Appendix 1: Flowchart 1

Appendix 2: Flowchart 2

Appendix 3: Chronology of Significant Events Template