Fabricated or Induced Illness

Safeguarding Children in Whom Illness is Fabricated or Induced (supplementary guidance to Working Together to Safeguard Children, HM Government 2008) recognises that the use of terminology to describe the fabrication or induction of illness in a child has been the subject of considerable debate between professionals.  That guidance states that:

There are three main ways of the carer fabricating or inducing illness in a child. These are not mutually exclusive and include:

• Fabrication of signs and symptoms. This may include fabrication of past medical history;
• Fabrication of signs and symptoms and falsification of hospital charts and records, and specimens of bodily fluids. This may also include falsification of letters and documents;
• Induction of illness by a variety of means.

Royal College of Paediatrics and Child Health guidance Perplexing Presentations (PP)/Fabricated or Induced Illness in Children (2021) uses the following definitions:

The following are indicators that should alert any professional to concerns that a child is suffering, or at risk of suffering Significant Harm as a result of having Illness Fabricated or Induced (FII) by their carer:

• A carer reporting symptoms and observed signs that are not explained by any known medical condition;
• A carer reporting to professionals that a diagnosis has been made by another professional when this is not true, and giving conflicting information to different professionals;
• Missed appointments especially if the appointments are not leading in the desired direction for the carer;
• Physical examination and results of investigations that do not explain symptoms or signs reported by the carer;
• The child having an inexplicably poor response to prescribed medication or other treatment, or intolerance of treatment;
• Acute symptoms that are exclusively observed by/in the presence of the carer;
• On resolution of the child's presenting problems, the carer reporting new symptoms or reporting symptoms in different children in sequence;
• The child's daily life and activities being 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;
• Objective evidence of fabrication - for example, the history of events given by different observers appearing to be in conflict or being biologically implausible (such as small infants with a history of very large blood losses who do not become anaemic, or infants with large negative fluid balance who do not lose weight); test results such as toxicology studies or blood typing; evidence of fabrication or induction from covert video surveillance (CVS);
• The carer expressing concern that they are under suspicion of FII, or relatives raising concerns about FII;
• The carer seeking multiple opinions inappropriately.

There may be a number of explanations for these circumstances and each requires thorough and thoughtful review.

A characteristic of FII in the child is a discrepancy between the findings of the professional and signs and symptoms reported and/or observed. In diagnosed organic illness the professional may observe a lack of usual response to proven effective treatment (i.e. a child who suffers from asthma). It is this puzzling disparity that alerts the professional to the potential for harm to the child particularly where over time the child is repeatedly presented with a range of signs and symptoms or reported symptoms and found signs are not seen to begin in the absence of the carer:

• FII may be manifest in a child in a number of ways. Fabrication of signs of illness may include false reporting of current symptoms or a fabrication of previous medical history. In addition to false reporting; falsification of letters, documentation and hospital charts and physical interference with specimens such as urine or stool samples may also be seen. Induction of illness can be achieved by a variety of means including, but not limited to, administration of household substances to induce vomiting, salt poisoning, withholding or over administration of medications, withholding of nutrition or intentional suffocation;
• FII is relatively common in children who have an existing medical diagnosis including children with disabilities and developmental difficulties. This may be in the form of exaggeration of symptoms or unexpected responses to medications or treatment. Statistics show that disabled children are at increased risk of abuse *(Jones et al, 2012). FII can easily remain unappreciated in children who already have existing health care needs;
• The needs of the child and the potential for significant harm must always be the first priority; however it is important to consider what secondary benefit the parent/carer may receive by presenting their child to services in this way. This can take many forms. It is important to note that the exaggeration or falsification of conditions, existing or otherwise, may be perpetrated in an attempt to retain or qualify for financial aid in the form of disability living allowance. 

The presenting signs and symptoms need careful evaluation for a range of possible causes. Professionals must remain open minded to all possible explanations. When dealing with their concerns for a child, a child may present for medical/health attention with unusual and puzzling symptoms that are not attributable to any organic disease and yet which do not involve deliberate fabrication or deception.

Concerns that a child's illness may be fabricated or induced are most likely to come from health professionals. However, any agency in contact with a child may become concerned, for example education staff where a child is frequently absent from school on questionable health grounds or nursery staff may not observe fits in a child who is described by a parent to be having frequent fits etc. It is essential that a paediatrician is involved in the assessment of FII. However the paediatrician will almost always need the help of social care and other agencies in gathering information needed to confirm or refute the diagnosis. The paediatrician will play a key role in the collation and interpretation of health information/evidence for non-health professionals.

_{*Jones, L. et al (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet 380(9845): 899-907.}

Harm to the child takes several forms. Some of these are 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. The following three aspects need to be considered when assessing potential harm to the child. 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.

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 (e.g. 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 (e.g. with the use of unnecessary aids, such as wheelchairs);
   • The child is socially isolated.
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.

It must be acknowledged that parents may present to services with varying levels of anxiety and the initial actions for professionals may be in acknowledging and addressing these issues with the family without embarking on further invasive tests or investigations. Such early intervention may enable a clinician to identify causes of stress within a family unit which can then be signposted to appropriate services.

In the majority of cases of identifying FII, there will be uncertainty and insufficient evidence to confidently identify abuse or the nature of the risk (if any) to the child may be unclear.

N.B. Uncertainty can be reduced by establishing facts.

The following checklist can be used by any professional dealing with a possible case of FII:

• Focusing on safeguarding and promoting the welfare of the child at all times;
• Complete a chronology, listing what is evidence-based. This should be started before a referral to children’s social care unless the concerns are urgent or there is already evidence of significant harm (see exemplar Chronology Template below);
• There is a need to cross reference the chronologies for different children in the family as illness behaviour can switch between different children in the family;
• Listing inconsistencies and gathering more information from family members and other professionals to clarify inconsistencies;
• Continuing to observe child and family - are patterns emerging?
• Keeping detailed records: being specific about the evidence base/source of information - for example, observation, informed opinion, hearsay, etc;
• Testing alternative explanations; review with a senior colleague or expert; complete medical tests and social work assessment; Paediatricians should discuss these cases with their named or designated doctor;
• Continuing to re-assess the situation in light of new information;
• It is usually not appropriate to share concerns about FII with parents at this stage, but plans need to be agreed between the lead paediatrician and the social worker manager regarding the appropriate response to managing concerns in order to protect the child. Also what it is or is not appropriate to discuss with the parents depending on circumstances but trying to be as open and transparent as possible needs to be agreed and documented between the different agencies /professionals involved;
• Evaluating alternatives - as Sherlock Holmes said, 'Exclude the impossible and the solution lies in what remains, however unlikely';
• Accessing information on the legal issues and national and local guidance.

Incredibly Caring. Department for Children, Schools and Families. 2008.

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

If the health professional has concerns about the mental health of the carer they should consider if a referral to the mental health access team would be appropriate. This assessment would then be available to inform the overall assessment. This referral would have to be made with the consent of the adult.

Joint working is essential, and all professionals should:

• Be alert to potential indicators of illness being fabricated or induced in a child;
• Be alert to the risk of harm which individual abusers may pose to children in whom illness is being fabricated or induced;
• Share and help to analyse information so that an informed assessment can be made of children's needs and circumstances;
• Contribute to whatever actions and services are required to safeguard and promote the child's welfare;
• Assist in providing relevant evidence in any criminal or civil proceedings;
• It is an expectation that a senior health professional leads for health and the same should apply for all other agencies as these cases are complex and difficult;
• A Health Professionals meeting should be arranged by the lead Paediatric Consultant following the collation of chronologies. All professionals involved with the child and family who have produced chronologies will be invited to review and discuss the case and contribute to the decision making process around future management. The chair of the meeting should be determined for each case and is likely to be the Responsible Paediatric Consultant or Named Doctor in their absence. Minutes of the meeting will be recorded and agreed actions will be distributed to those in attendance. If there are any professional disagreements around the management of FII, staff will inform named health professionals. Staff should follow the escalation process if there are disagreements.

If any professional considers that their concerns are not taken seriously or responded to appropriately, they should discuss this as soon as possible with the designated doctor or designated nurse for child protection/safeguarding.

If any concerns relate to a member of staff, professionals should discuss this with their line manager and their agency's nominated safeguarding children lead. Where there are concerns or suspicions that a member of staff may be responsible for FII in a child, see the Managing Allegations of Abuse Made Against Adults Who Work with Children and Young People Procedure.

All concerns and discussions must be recorded contemporaneously in their agency records for the child, dated and signed.

Information gathered from the child's records and tabulated in the form of a chronology is key to confirming whether the situation is abusive. The documentation of facts and evidence in this format often reveals a startling picture. Getting the facts agreed and seeing the overall pattern is crucial and often very revealing.

The development of a chronology may be a staged process completed initially by the professional who has concerns. Depending on the emerging themes in this chronology, Children's Social Care may then be involved. The chronology plays an important role in any multi-agency assessment of risk. Your chronology may be one of several chronologies to identify an emerging theme of risk to the child. Chronologies will be needed if the case goes to a Strategy Meeting convened by Children's Social Care.

The preparation of the chronology should not delay intervention if this would put the child at increased risk of Significant Harm. If you believe a child is at immediate risk of Significant Harm you should immediately make a referral to Children's Social Care - see the Making Referrals to Children's Social Care Procedure.

Where there are concerns about possible FII, the signs and symptoms require careful medical evaluation for a range of possible diagnoses by a paediatrician.

If no paediatrician is already involved, the child's GP should make a referral to a paediatrician.

Where, following a set of medical tests being completed, a reason cannot be found for the reported or observed signs and symptoms of illness, further specialist advice and tests may be required.

Normally the consultant paediatrician will tell the parent(s) that they do not have an explanation for the signs and symptoms.

Parents should be kept informed of further medical assessments / investigations/tests required and of the findings but 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 and compromise the child protection process and/or any criminal investigation.

Where there are suspicions of FII in a child, a referral must be made to Children's Social Care in accordance with the Making Referrals to Children's Social Care Procedure.

From the point of the referral, all professionals involved with the child should work together as follows:

• Lead responsibility for action to safeguard and promote the child's welfare lies with Children's Social Care;
• Any suspected case of FII may involve the commission of a crime and therefore the police should always be involved;
• The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care.

In cases of suspected FII, discussing concerns with parents or carers prior to making a referral may place the child at increased risk of Significant Harm. It is in the child's interests that the parents/carers are not informed of the referral at this stage. The multi agency decision of when and how parents/carers will be informed of concerns will be made at a later stage.

Following the receipt of the referral, Children's Social Care has lead responsibility for undertaking an Assessment. This will include circumstances in which FII by the carer is suspected. Children's Social Care will conduct the assessment in conjunction with the doctor who has lead responsibility for the child's health care (usually a consultant paediatrician) and other relevant agencies.

Children's Social Care will coordinate the process of systematic information gathering to build up a medical, psychiatric and social history and an understanding of the child's needs and the parents' capacity to meet the child's developmental needs. Children's Social Care should ensure that a comprehensive chronology of the child's history is compiled.

Children's Social Care is responsible for convening Strategy Discussions/Meetings and, when appropriate, Initial and Review Child Protection Conferences, in order to review the child's situation and to decide and plan any further action that may be necessary. In cases of FII, the Strategy Discussion will always take the form of a face-to-face meeting, chaired by a manager from Children's Social Care - for further information, please see the Strategy Discussions Procedure. Any agency may request a Strategy Meeting or Child Protection Conference, if it has concerns that a child may be or is suffering Significant Harm.

At all stages it is important to discuss what information will be shared with parents and by whom. Clear decisions need to be made about who will monitor the child’s health and development.

Working with children and families where it suspected or confirmed that illness is being fabricated or induced in a child requires sound professional judgments to be made. It is demanding work that can be distressing and stressful. Practitioners are likely to need support to enable them to deal with the feelings the suspicion or identification of this type of abuse engenders. It can be very distressing to a professional person, who has come to know a family well and trusted them, to have to deal with their feelings when they learn a child's illness has been caused by actions of that child's primary carer.

Possible known emotional responses to FII by staff are:

• Self-doubt;
• Fear leading to inaction;
• Loss of self-respect, self-esteem;
• Failure / didn't recognise the signs/symptoms;
• Feelings of failing the child;
• Anger at colleagues who disbelieve/believe;
• Loss of trust;
• Anger at parents / how could they have used me?
• Feeling of being manipulated;
• Feeling of being duped;
• Fear of litigation/misdiagnosis;
• Misdiagnosis;
• Disbelief;
• Denial;
• Reluctance or unwillingness to pass on/share information;
• Fear of being criticised;
• Fear of challenging more senior colleagues/professionals and dealing with the power differential;
• Helplessness;
• Feeling unable to prepare a statement of evidence and/or giving evidence in court;
• Fear of becoming frozen, unable to make decisions;
• Becoming defensive;
• Inability to treat the parents in a professional manner;
• Knowing I was wrong/right.

This is not an exhaustive list.

Incredibly caring, Department of Children, Schools and Families 2008.

In this area of work, it is a possibility that complaints may be expressed by parents/carers about one or more members of staff and their handling of the case. During assessment parents may formally complain about any member of staff.

Any complaint should not detract from the seriousness of concerns for the child.

Staff will need good support systems from their organisation to help them deal with a complaint made against them.

Experience has shown that children can be subjected to abuse by those who work with them in any and all settings. Where there are concerns or suspicions that a member of staff may be responsible for FII in a child, see the Managing Allegations of Abuse Made Against Adults Who Work with Children and Young People Procedure.

Royal College of Paediatrics and Child Health (2021) Perplexing Presentations (PP)/Fabricated or Induced Illness by Carers (FII) in Children. RCPCH, London.

Department for children, schools and families (2008) Incredibly Caring. Radcliffe Medical Press. Abingdon.

Safeguarding children in whom illness is fabricated or induced (HM Government 2009).

*Jones, L. et al (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet 380(9845): 899-907.

Manchester