1.4.22 Fabricated or Induced Illness

SCOPE OF THIS CHAPTER

Safeguarding concerns may be raised when a child presents in an unusual way. They may have unusual symptoms, or not respond as expected to usual management, or present unusually often. At this stage there are a number of possibilities including:

  • True medical cause;
  • Overanxiety, inexperience or mental illness in parent affecting their perception of child's symptoms;
  • "True" Fabricated or Induced Illness (FII), a potentially serious diagnosis.

The presentation is "perplexing". Practitioners will need to establish the cause, and in particular consider the possibility of Fabricated or Induced Illness by the carer.

The aim of this pathway is to help in that assessment.

This is multi-agency guidance, because although presentations most commonly occur in health, concerns may also arise in any agency working with children and families, and practitioners require a shared understanding of the issues, and a multi-agency response. The aim is that where FII is occurring, it is recognised and children's welfare safeguarded.

The guidance is necessarily detailed as it reflects the often highly complex nature of this form of abuse, and the particular challenges for all professionals in terms of recognising and responding to possible FII.

Guidance is also provided for practitioners working with lower-risk presentations where there may be a phase of uncertainty during which FII cannot be easily ruled in or out.

AMENDMENT

This guidance was completely rewritten and added to the procedures manual in September 2019. Please note - The Royal College of Paediatrics and Child Health (RCPCH) guidance 'Fabricated or Induced Illness (FII) by Carers - A Practical Guide for Paediatricians' 2009 is currently being updated. Once this review is complete the following guidance will be reviewed and updated as required in line with the revised RCPCH guidance.

Flowchart Summary for Perplexing Presentation when Fabricated or Induced Illness Considered - Amber or Red Pathways

1. Introduction

'The common starting point for concern about Fabricated or Induced Illness (FII) is that the child's clinical presentation is not adequately explained by any confirmed genuine illness, and the situation is impacting upon the child's health or social wellbeing"1. In FII, the child suffers harm through the deliberate report or action of a parent/carer, so that the child is presented as ill when they are not ill, or more ill than is actually the case.

The term 'perplexing presentation' (PP) is used at the early stages when a child first presents, or when other possibilities for the presentation are possible.

personal behaviours in relation to child illness with influencing factors

There is a spectrum of parental behaviour towards their child's illness (or perceived illness), which is influenced by many factors (see Figure 1 above). Overanxious behaviours are part of the normal range, but can shade into over-anxiety and exaggeration. Fabrication and induction can be seen as an extreme and pathological end of this side of the spectrum. This guidance covers both Fabricated or Induced Illness, and also perplexing presentations where FII may be one of the differential diagnoses. Other differential diagnoses for perplexing presentations include: a true medical cause; parental over anxiety or inexperience; mental illness in parent affecting their perception of the child's symptoms. Table 1 - Spectrum of Cases where FII Concerns may Arise further illustrates the spectrum of cases where FII concerns may arise. FII overlaps with emotional and physical abuse.

Within the FII part of the spectrum, 'true' FII involving deliberate deception of medical services by parent/carer, and high risk to the child, is relatively rare. It is important to recognise it and act on it, because it is a potentially lethal form of abuse. In these cases, very prompt action may be required.

The range of symptoms and body systems involved in the spectrum of PP/FII is extremely wide. Children may present to a correspondingly wide range of medical services, spanning primary, secondary and tertiary care.

In all cases it is helpful to focus on keeping the child safe, avoiding harm, and minimising any impact on the child's health and development. In the USA the term "medical abuse" is used. This emphasises that much of the harm is actually done by "duped" professionals". An important part of the approach is therefore to limit or control the health response, through avoiding unnecessary investigation or treatment.

2. When to consider FII

FII should be considered if a child is being presented as ill when they are not, or as more ill than is actually the case, because of the parent or carer's report or action (usually the mother). Often there is discrepancy between parental accounts of illness and observations of professionals, and puzzlement within the health team.

Although life-threatening FII is rare, presentations where FII should be considered are common in both primary and secondary care settings.

FII is not a diagnosis of exclusion, and should be considered when the indicators of concern for FII are present (Table 2 - Indicators of concern for FII) (although note that some of these may occur in genuine medical presentations). Note possible barriers to recognising FII (Table 3).

Table 1 - Spectrum of Cases where FII Concerns may Arise

Click here to view Table 1 - Spectrum of Cases where FII Concerns may Arise.

Table 2 - Indicators of Concern for FII

Indicators of Concern for FII

Table 3 - Possible barriers to recognising FII

Possible barriers to recognising FII

(Please note Tables 2 and 3 are adapted with permission from City of York and North Yorkshire Safeguarding Children Partnerships' Fabricated and Induced Illness Multi-Agency Practice Guidance) Numbers from the tables can be used in the chronology template (Appendix 1: FII Chronology Template).

There may be a number of explanations for these circumstances which can include undiagnosed or unusual medical conditions; each requires careful consideration and review.

Concerns may also be raised by other professionals who are working with the child and/or parents/carers who may notice discrepancies between reported and observed medical conditions, such as the incidence of fits.

Professionals who have identified concerns about a child's health should discuss these with the child's GP or consultant paediatrician responsible for the child's care. If any professional has concerns about a situation being indicative of Fabricated or Induced Illness, then these should be discussed with their safeguarding and child protection lead.

3. Why is it important to recognise and respond to FII?

It is important to recognise and respond appropriately to FII because children are harmed and sometimes killed by it.

The child can be harmed directly both physically and emotionally (through illness induction and taking on a sick role) and indirectly due to the medical response (where the child suffers unnecessary examinations, investigations, procedures and treatments). This results in:

  • Unnecessary painful, harmful investigations / procedures;
  • Morbidity/death;
  • Chronic invalidism;
  • Actual disease;
  • Significant psychological damage;
  • FII behaviour as an adult.

Research demonstrates the risks of serious illness and death (e.g. in a review of 451 cases, 6% died and 7.3% had long term or permanent injury (Sheridan, 2003). It is likely that these significant risks apply to severe cases (as considered within the 'Red pathway' in this document), rather than the whole spectrum of potential FII.

The potential impact of FII on the child is summarised by the RCPCH (2013) as follows:

  • A disordered perception of illness and health, leading to anxiety about health and abnormal illness behaviour;
  • (Inadvertent) Iatrogenic harm including admission to hospital, exposure to hospital acquired infection, blood tests or X-rays;
  • A greater degree of invasive medical attention than is truly justified. In extreme cases this may include surgical procedures, insertion of venous lines, artificial feeding, anaesthesia or more prolonged hospital admissions;
  • 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 on-going morbidity due to abuse;
  • With illness induction comes further heightened risk;
  • The pain and distress of induced illness, including the possibly severe physical abuse or starvation;
  • A significant risk of death (around 10% in some studies; though there is likely to be selection bias); and
  • A risk of under-treatment for real conditions.

4. Overall approach to FII

FII is a form of child abuse, and the usual safeguarding and child protection procedures apply. Children who are suspected to have illness fabricated or induced require coordinated help from a range of agencies. In contrast to work with other forms of abuse, it may be important and appropriate not to share information or seek consent from the parents / carers at times, since this may put the child at further risk.

Consultation with peers or colleagues in other agencies is an important part of the process of making sense of the underlying reasons for these signs and symptoms. The characteristics of Fabricated or Induced Illness are that there is a lack of the usual corroboration of findings with signs or symptoms or, in circumstances of diagnosed illness, lack of the usual response to effective treatment. It is this puzzling discrepancy which alerts the medical staff to possible harm being caused to the child.

5. Early Identification and Intervention

Early Help (sometimes called Early Support or Early Intervention) is an approach to providing support to potentially vulnerable children, young people and their families as soon as problems begin to emerge (e.g. see local early help guidance). The principle is that it is better to act early in the evolution of a problem or concern, rather than wait until it becomes obvious and severe. This may be applicable to children where FII is unlikely and the risks are low, or where concerns are not substantiated. This also helps provide good clear documentation on attempts to support and advise carers.

6. Medical Evaluation

Where there are concerns about possible FII, the signs and symptoms require careful medical evaluation for a range of possible diagnoses. A lead clinician who will do this should be identified and agreed. This should usually be a paediatrician, unless the risk is low and a containment approach (see Section 10, Amber Pathway is proving effective. In such cases there should be a low threshold to make a referral to a paediatrician, particularly for review of specific symptoms.

If several consultant paediatricians are involved, a lead consultant should be agreed between them (usually the person most involved in the area where FII concerns are manifesting). If there is difficulty identifying a lead clinician, this should be discussed with the relevant Named Doctor who will advise who should take on this role.

In general the following should be considered:

  • Where, following any investigations (if needed), a reason cannot be found for the reported or observed signs and symptoms of illness, further specialist advice may be required;
  • Parents should be kept informed of further medical assessments / investigations/tests required and of the findings. Normally the consultant paediatrician will tell the parent(s) that they do not have an explanation for the signs and symptoms and record the parental response;
  • Concerns about the reasons for the child's signs and symptoms should not be shared with parents if this information would jeopardise the child's safety and compromise the child protection process and/or any criminal investigation. See Working Together to Safeguard Children and relevant national and local safeguarding guidance.
A diagnosis of FII may take a considerable amount of time, including collation of information, formulating a plan and communicating that to the parents, and then implementing the plan and monitoring progress.

7. Chronologies

The purpose is to build a clear picture of all potentially relevant events in the child's life, with analysis, to help make a judgement on the nature and level of risk to the child.

Key Points

  • Use Appendix 1: FII Chronology Template;
  • Summarise key information – don't just replicate the child's health record;
  • Pay particular attention to the specific concerns that have been raised about the child;
  • Clearly state what has been said, by whom and to whom;
  • Record what has been reported or observed and whether this was observed by professionals;
  • Record the source of information e.g. 'History taken from Mother';
  • Write in a way that can be understood by colleagues from other non-medical or professional backgrounds;
  • Where appropriate, condense a large amount of information into short summary sentence. e.g. 'John was on the ward between 1 June and 4 June there are no recorded incidents of diarrhoea';
  • The comments section of the chronology can be used to highlight where there are particular 'warning signs' as identified in Table 2 - Indicators of Concern for FII;
  • Add comments to entries as relevant e.g. "mum presented him with wheeze - no signs seen".

7.1 Timescales

Chronologies should go back as far as possible. In some instances a child may be said to have had a condition for many years. It is important where possible to confirm or refute specific information e.g. where a child is said to have been given a specific diagnosis, evidence of that diagnosis should be sought. Where evidence is not found, the chronology should show that evidence has not been located.

8. Evaluating Risk – The Red and Amber Pathways

Where FII is considered to be a possibility, the risk of serious, immediate harm to the child should be evaluated (Table 2 - Indicators of Concern for FII):

Red Pathway

Follow this pathway if risk of serious harm, or evidence of illness induction or deception:

  • Presentation is a life threatening symptom e.g. turning blue, fits;
  • Evidence of deception;
  • Evidence of physical actions by carers to produce an illness picture (interfering with reports, specimens, investigations, withholding medications or food, poisoning).

In this group it will often become relatively clear that an illness is being fabricated or induced, especially as information from various sources is assembled.

Examples

  • Inducing symptoms e.g. a rash through application of chemical to the skin; smothering until loss of consciousness; poisoning e.g. through giving excessive salt by mouth or nasogastric tube; injecting insulin;
  • Fabricating or tampering with investigation processes to produce abnormal results e.g. false data on charts; warming thermometers; adding blood to urine;
  • Interfering with treatment processes and equipment: e.g. withholding or substituting medication; infecting intravenous lines; turning oxygen down or off; tampering with ventilation equipment.

Amber Pathway

Follow this pathway if low risk of serious harm, no evidence of illness induction or deception:

  • Symptoms or concerns are not serious or life-threatening;
  • Symptoms or concerns relate only to what the parent/carer is saying or reporting, not to physical actions;
  • There is no evidence of deception or falsification, although there may be concern about it.

Also take account of the indicators in Table 2 - Indicators of Concern for FII when judging level of risk.

In these children the presentations are puzzling. Much of the harm relates to medical over-investigation or treatment, which can be minimised through following this pathway. The pathway is intended to help clarify, address and contain the concerns.

Examples

  • Unexplained medical symptoms;
  • Children whose parents/carers are excessively anxious, leading to apparent exaggeration of symptoms and excessive reliance on support from health professionals;
  • The various modalities of FII are not mutually exclusive and may occur together. In practice red and amber pathways may overlap. If in doubt, follow the red pathway.

9. Red Pathway

Immediate Action

See also: Appendix 2: Flowchart Summary for Perplexing Presentation when Fabricated or Induced Illness Considered - Amber or Red Pathways

Ensure Safety

  • If there is immediate or potential serious threat to the child (e.g. include tampering with medical equipment, administering harmful substances, withholding or switching treatments, evidence of smothering), take urgent steps to secure the child's safety and prevent further harm;
  • If not already an in-patient, consider immediate admission via ambulance (not allowing carers to bring child in alone), or other action to ensure the child's safety.

Escalate and Refer

  • If in hospital, escalate to the most senior medical and nursing staff on site, call police immediately and secure any evidence. Inform the consultant;
  • An urgent referral should be made to Children's Social Care Services, who should make a rapid decision and respond immediately. Also consider a referral to police. An emergency protection order or police protection powers may be needed;
  • Usually an urgent Strategy Meeting will be arranged which must include the paediatrician with primary responsibility for the case.

Review Management

  • Review medical management plans in the light of the new information. Some planned investigations, procedures or treatments may now be inappropriate;
  • This may include stopping administration of a harmful substance or inappropriate treatment, replacing equipment, or taking specimens for toxicology.

Preserve evidence

  • Keep any substances or equipment or clothes that might constitute evidence for a later; police investigation in secure storage (such as a controlled drugs cabinet / lines / bedding);
  • Ideally these should be locked away by two professionals working together to preserve chain of evidence or given to police.

Identify lead clinician

  • Identify which clinician will take a lead for the health aspects of the process. For inpatients, this will be the lead consultant managing the patient.

Seek safeguarding advice

  • Advice should be taken at the earliest opportunity from named or designated doctor for children's safeguarding, and children's safeguarding team should be alerted.

Keep thorough records

  • Events should be documented in detail, along with professional details of all staff involved.

Don't confront parents

  • Confronting parents with concern about FII is best avoided at this point. It may sometimes increase risk to the child, or compromise any criminal or safeguarding process. Plans for communication with parents should be agreed at the Strategy Meeting.

Referral and Further Action

Referral

  • FII is a form of child abuse so usual procedures apply. A referral should be made to Children's Social Care Services (and the Police if needed) in accordance with the Referral Procedure. A rapid decision and response is required (1 working day). A Strategy Meeting should be convened involving appropriate professionals (health, social care, police, and consider legal and education).

Strategy Meeting

  • The Strategy Meeting may also consider: level of risk to the child and any siblings; how the child might be given opportunity to share their story; need for further investigations, observations, management; need for a police investigation; information sharing with parents (what should be shared, when, and by whom); needs of carers, particularly after disclosure.

Chronologies

  • Detailed chronologies should be made as soon as possible and a multi-agency chronology should then be assembled urgently, ideally for consideration at the first Strategy Meeting. This is normally led by the lead paediatrician for the child, or social care. If there is doubt about who will assemble the chronology, advice should be sought from the Named Doctor. A standard chronology template should be used (e.g. see Appendix 1: FII Chronology Template).

Observation

  • A (further) period of admission may be helpful for closer observation and decisions about management. This should be planned carefully with clear instructions and understanding of issues by nursing and other staff involved;
  • Covert video surveillance (CVS) is almost never necessary, since if indicated, then the threshold for care proceedings will already have been reached. Where it is under serious consideration, senior advice from within health, police and social care should be sought, including involving designated professionals. Any CVS would be carried out by police not health workers.

Outcome of Section 47 Enquiry and Single Assessment

Concerns Not Substantiated

  • As with all Section 47 Enquiries, the outcome may be that concerns are not substantiated - e.g. tests may identify a medical condition, which explains the signs and symptoms;
  • It may be that no protective action is required, but the assessment concludes that services should be provided to the child and family to support them and promote the child's welfare as a Child in Need, or through Early Help. In these circumstances, appropriate assessment should be completed and planning meetings held to discuss the conclusions, and plan any future support services with the family;
  • It may be appropriate for further management to follow the Amber Pathway;

Concerns Substantiated and Continuing Risk of Significant Harm

  • Where concerns are substantiated and the child judged to be suffering or likely to suffer Significant Harm, an Initial Child Protection Conference may be convened or the child may be made subject to a Court order e.g. an Interim Care Order.

10. Amber Pathway

See also: Appendix 2: Flowchart Summary for Perplexing Presentation when Fabricated or Induced Illness Considered - Amber or Red Pathway

This pathway should be followed where the child has presented in a perplexing or unusual way and the possibility of Fabricated or Induced Illness is being considered, but the risk of serious harm is low.

  • An early decision should be made about whether the Red Pathway would be more appropriate, and this should be kept under review throughout. If in doubt, escalate to the Red Pathway;
  • The Amber Pathway is slower paced and may take weeks or months: the urgency and timescale is proportionate to the degree of risk and likelihood of FII;
  • Regularly consider whether any of the spectrum of presentations outlined in Table 2 - Indicators of Concern for FII may apply.

Detailed chronology and multi-professional working

  • Professionals involved should compile their own chronologies and agree who is responsible for merging these. Advice can be sought from named professionals. See Section 7, Chronologies, and the template in Appendix 1: FII Chronology Template;
  • The aim is to build up a clear understanding of all the child's health presentations, and who is involved. It is helpful to talk to the child about their own concerns, anxieties and beliefs about their symptoms. Reports and records of other professionals should be sought, including the child's GP, who may have important background knowledge. It may be appropriate to approach school or nursery. It is important to build up a full picture of the child's daily functioning including school, activities, aids etc;
  • All of this should be done openly with parents where possible unless this would put the child at risk. Parents will usually be pleased that their concerns are being taken seriously and information is being gathered together to make a thorough assessment. Lack of engagement with the process, or refusal for further information to be sought, would increase concern.

Consider involving social care

  • Not always necessary at this point, but appropriate if FII thought quite likely, or other social issues have been identified, or a social care perspective might help towards understanding the child's problems;
  • Consider carefully whether to inform parents at this stage, and if in doubt, take advice from Named professionals. The child's welfare and safety is the overriding priority;
  • Early Help approaches may be applicable and helpful.

Identify lead clinician and avoid mixed messages

  • Where multiple professionals are involved, communication can become difficult and mixed messages are likely. It is best to agree one person who will take a lead, usually the clinician most involved. They will be the main channel of communication with the parents and lead in decisions about further investigation;
  • This could be the GP, but consider a paediatric referral for an opinion about the specific presenting symptoms. A discussion with Named or Designated Safeguarding professionals may be helpful, according to the nature of the problem and local arrangements. Concerns should be clearly summarized in the referral, including the possibility of FII.

Discuss with named professional for safeguarding

  • Because these situations can be complex with potentially serious repercussions, the lead clinician should discuss with their Named / designated Safeguarding Doctor / Nurse.

Contain anxiety and make a clear plan for parents

  • Where excessive parental anxiety is part of the presentation, this should be contained through having a lead person, avoiding mixed messages, avoiding continued investigation, appropriate and repeated reassurance (including in writing) and having clear pathways of support (what to do and who to contact if…);
  • Attention should be given to the parent(s)' own support networks and mental and physical health, if these are thought to be contributing to anxiety. A referral for mental health support may be appropriate;
  • Agree a clear plan for next steps with parents, and communicate this to other professionals involved.

Avoid medical testing /treatment that is not clearly indicated, restore normality

  • Harm to the child can be mainly through the excessive response of (usually health) professionals, in terms of over-investigation and treatment;
  • Aim to draw a line and reach the point where parents can be told "We have investigated enough".;
  • This may need multi-professional or multi-speciality discussion. If a further opinion is sought, they need to be aware of the context, and investigations already done;
  • Where possible, aim to restore the child's daily functioning to nearer normality.

A period of admission may be helpful for closer observation

  • Occasionally in cases of medical uncertainty, a period of in-patient admission is helpful to observe in detail what is happening;
  • This is arranged transparently with the family, explaining that this is part of good practice in these situations and the ward team will ideally be involved in all the details of the child's care and observation;
  • All staff involved should be clear about the nature of the concerns, and the purpose of the admission, including what is to be particularly observed, and how this should be documented.

A 'double-decker' meeting (first 'deck' with all professionals, second 'deck' small group of key professionals with parents)

  • There will usually need to be at least one meeting of all professionals involved, and then a smaller meeting with parents. How these are arranged will depend on the details of the child's presentation. If FII is thought quite likely and/or risk is considered quite high, then initial professionals' meetings may need to be without parents' knowledge;
  • Such situations should be discussed with the Named Safeguarding Professionals, and usually with Children's Social Care Services;
  • The 'double-decker' approach refers to a two-stage meeting process, where first all the relevant professionals meet (the first 'deck'), and then a key group from that meeting go to a smaller meeting with the parents (the second 'deck') to relay the key messages and agree next steps.

A 'Good news' meeting with parents

  • Often the process outlined above has led to clarity amongst all professional involved where they can say to parents "We are confident there is no serious underlying medical problem, and we want to work with you to enable your child to live as normally as possible despite any symptoms";
  • This message should be given positively with constructive planning to limit the impact of on-going symptoms on the child's well-being;
  • This may involve a period of rehabilitation and graded return to normal activity (including school attendance);
  • Psychological input may be helpful. Social care or other agencies may also be involved.

Clear plan for monitoring progress and when to escalate

  • The response to, and progress after, the meeting is key and may further clarify whether this is FII. Careful monitoring is needed for weeks and months afterwards, with an agreement regarding when escalation to a formal safeguarding pathway (the Red Pathway) would be needed. It is important to agree who will monitor progress;
  • Outcomes that would increase concerns regarding FII would include: parents wishing to 'sack' the lead paediatrician and refusing to work with them; attempting to move the child out of area or to a different hospital; refusal to engage with any agreed process; increasing physical symptoms (still without any medical explanation); new or more dangerous symptoms.

11. Roles & Responsibilities in Recognising and Responding to Possible FII

In all cases of suspected fabricated and induced illness advice and support should be sought from the appropriate agency safeguarding lead, or Named and Designated Professionals for Safeguarding.

Professionals not from a Health setting including Education/Early years/Early Help/Children's Social Care

  • 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 in Table 2 - Indicators of Concern for FII. If they remain concerned or have heightened concerns they should discuss the child with their safeguarding lead;
  • If concerns remain, then the child should be discussed with relevant health professionals (e.g. GP, paediatrician, 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 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;
  • When a parent/carer reports restrictions or limitations for normal school activities due to reported 'health' issues, it is important this is verified;

Health visitors and school nurses

  • If practitioners have concerns that a parent/carer is impairing a child's health, development or functioning by Fabricated or Induced Illness, they should meet with parents/carers or discuss the child's illness, parental concerns and ascertain which other health professionals are involved;
  • After discussion it may be that some parents may have misunderstood information, are anxious about their child or have concerns that their child's needs are not being met. This may 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;
  • Where the practitioner has on-going concerns about FII 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 - at this point consent is not required;
  • Concerns about possible FII must be shared with the other health professionals (including GPs).

Midwives

  • Midwives may be alerted to possible FII 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 must discuss concerns with their safeguarding lead or a named professional for safeguarding.

General Practitioners (GPs)

  • In cases of suspected FII, the GP is likely to have had a higher level of involvement and knowledge of the child and family than other health professionals. GPs' involvement and contribution to the management of FII concerns is essential to ensure that all key information with regard to the child is shared. GPs will also be aware about parental health issues – including both physical and mental health – and these should be taken into consideration as part of any assessment and information sharing;
  • If there are concerns about the welfare of a child and FII is a consideration, the child's needs are paramount and the GP has a duty to share any relevant and proportionate information that may impact on the welfare of a child. This includes sharing relevant information about parents and carers as well as the child. GPs are well placed to recognise early symptoms and signs of FII in a child, and as the primary record keeper of all health records, can play a key role in recognising patterns of worrying behaviour from multiple presentations at different settings;
  • For children on the Amber pathway, the clinician already leading management (who may be the GP or Paediatrician, or other clinician) may continue as the lead clinician for the FII concern, with advice from the appropriate agency safeguarding lead, or named and designated professionals for safeguarding. Red pathway cases not known to a consultant should normally be referred to a Consultant Paediatrician, Child Psychiatrist or Clinical Psychologist (dependent upon the presenting issues) with expertise in symptoms and signs that are being presented;
  • When a referral is made the GP should make it clear about their concerns re possible FII in the referral letter. This letter should not be copied to parent/carers. Timeliness of the referral will depend on presentation. For example if there are signs or symptoms of induced illness such as suffocation or poisoning then same day referral is needed with a concurrent urgent referral to Children's Social Care Services;
  • When recording concerns about FII, GPs should ensure that these concerns are recorded within the child's clinical record but that the entry is not visible on online access, as parental awareness of the concern may escalate the risk to the child.

Child and Adolescent Mental Health Workers

Staff within CAMHS may also be alerted to concerns about possible FII in the process of evaluating children for mental health and behavioural difficulties.

  • Repeated requests for a diagnosis of conditions such as Attention Deficit Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD), especially when assessments have ruled out these conditions, should raise the index of suspicion for FII. However, it should be noted that it is not uncommon for parents to request second opinions, and consideration should be made to the fact that there are a number of children who do get a diagnosis of ADHD/ASD when reassessed. A repeat parental request for another medical/CAMHS opinion should not automatically trigger an investigation for FII, as this might be inappropriate;
  • In CAMHS cases of FII there have usually been many requests for assessments for mental health diagnoses with repeated requests for second/third/fourth opinions;
  • Initial concerns about a child's presentation should be shared with the Paediatrician or GP that referred the patient and other relevant health professionals.

Adult Mental Health Services

Adult mental health staff may become concerned about the welfare of a child in relation to possible FII. These concerns may be increased if a patient who is a parent is known to fabricate or induce illness in themselves, although this can exist within the parent's presentation and not the child's. If an adult mental health worker has any concerns of this nature about a child's welfare they should be discussed with the appropriate safeguarding lead or named professional for safeguarding. 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 children.

Allied Health Professionals

If staff have concerns about FII 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. They should also discuss with their clinical manager.

Consultant Paediatricians, Consultant Child Psychiatrist or Consultant Clinical Psychologist

All Red Pathway cases of suspected FII should be led by a Consultant Paediatrician, Consultant Child Psychiatrist or Consultant Clinical Psychologist (dependent upon the concerns). This Consultant should take a lead role in this process, with advice from the local hospital safeguarding team and Named Doctor. During the thorough medical evaluation, the Lead Consultant should obtain information from the GP and other Consultants who have been involved in the child's care. This may include relevant information about the parent's health and the siblings.

Other Consultant Specialists

If another Consultant, other than a Paediatric or CAMHS Consultant, has a concern about FII in a child in their care they should refer to a general or community Paediatrician (depending on local arrangements). If there are immediate concerns for the child's safety an immediate referral should be made to Children's Social Care Services.

Designated Professionals for Safeguarding Children

Designated Professionals provide a valuable source of expert advice and support to health care professionals and colleagues from partner agencies. They can offer safeguarding supervision or facilitate professional discussions, particularly where the presenting issues are very complex.

12. Resolving Professional Disagreements and Escalation

  • Cases where FII is suspected are often complex, and professionals may disagree about the best way forward, either within or across agencies;
  • Disagreements are best avoided by an open and thorough approach that involves all professionals working with the child and family from early on, taking careful account of each person's perspective and concerns;
  • This is particularly important in professionals' meetings, where all involved with the child should be present if possible, and the meeting should be chaired by a colleague with experience of FII and chairing difficult safeguarding meetings;
  • If professional disagreements arise, these should be resolved or escalated according to the procedure for Resolving Multi Agency Professional Disagreements and Escalation Procedure.

13. Meeting Minutes

  • All meetings where FII is being considered as a possible explanation of a child's presentation should be minuted, recording who was present, observations, discussion and decisions reached;
  • Draft minutes should be circulated by Children's Social Care Services for approval by all present, followed by final agreed minutes. This is important for clarity of process, and because of potential medico-legal or criminal proceedings that may follow.

14. References and Key Sources

This guidance takes account of 'Safeguarding Children in Whom Illness is Fabricated or Induced' (HM Government 2008 and Working Together to Safeguard Children.

A report by the Royal College of Paediatricians and Child Health (RCPCH) entitled 'Fabricated or Induced Illness by Carers' (2009) provides more in-depth information for professionals, particularly those in health, describing the role of paediatricians and other healthcare professionals, and recommending how they should work with professionals from other agencies.

See also: Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children Guidance, Royal College of Paediatricians and Child Health 2021

This guidance takes account the 'RCPCH Child Protection Companion' (2013) and work by Danya Glaser and colleagues, listed below

Perplexing Presentations (Including FII). In: RCPCH Child Protection Companion (2013).

Roesler TA, Jenny C. (2008) Medical Child Abuse: Beyond Munchausen Syndrome by Proxy. American Academy of Pediatrics.

Anonymous. Fabricated and Induced Illness: Multi-Agency Practice Guidance. York: City of York and North Yorkshire Safeguarding Children Boards; 2017:1-20.

Postlethwaite RJ, Benson E, Quinn K, et al. (2004) Report to Cumbria Child Protection Committee of Events Leading to the Death of Michael Who Was the Victim of Fabricated or Induced Illness (FII) (Formerly Known as Munchausen Syndrome by Proxy).

Sheridan MS (2003). The deceit continues: an updated literature review of Munchausen Syndrome by Proxy, Child Abuse & Neglect.

Davis P, Glaser D, Humphrey C, et al. (2009) Fabricated or Induced Illness by Carers (FII): a Practical Guide for Paediatricians.

Bass C, Glaser D. (2014) Early recognition and management of fabricated or induced illness in children. Lancet.

Davis P, Murtagh U, Glaser D. (2018) 40 years of fabricated or induced illness (FII): where next for paediatricians? Paper 1: epidemiology and definition of FII. Archives of Disease in Childhood.

Glaser D, Davis P. (2018) For debate: Forty years of fabricated or induced illness (FII): where next for paediatricians? Paper 2: Management of perplexing presentations including FII. Archives of Disease in Childhood.

Appendix 1: FII Chronology Template

Click here to view Appendix 1: FII Chronology Template.

Appendix 2: Flowchart Summary for Perplexing Presentation when Fabricated or Induced Illness Considered - Amber or Red Pathway


Appendix 2: FII