FII may also overlap with actual illness, which makes it difficult to identify, and genuine illness can be overlooked.
What is perplexing presentation
Perplexing presentation is used to describe a commonly encountered situation when there is a presence of alerting signs to possible fabricated or induced illness and the child or young person's physical and mental health and neurodevelopment is not yet clear, but there is no perceived risk of immediate serious harm to the child or young person's physical health or life.
What is fabricated or induced illness
Fabricated or induced illness (FII) is a clinical situation in which a child, young person (or an adult) is, or is very likely to be, harmed due to the actions of their main carer. These actions are usually taken in order to convince doctors that the individual's state of physical and/ or mental health and neurodevelopment is impaired, or is more impaired than it actually is.
FII results in emotional and physical abuse and neglect. It is a relatively rare but potentially lethal form of abuse. FII is also sometimes called Munchausen Syndrome by proxy, Meadow Syndrome, Medical Child Abuse, Medically Unexplained Symptoms and Paediatric Falsification Condition.
How FII presents to practitioners
A parent or carer may:
- exaggerate or invent signs and symptoms of illness
- be dishonest regarding past medical history
- falsify hospital records and charts
- provide incorrect medical samples
- interfere with equipment or samples
- induce symptoms by intentional poisoning, suffocation or starvation of a child
This list is not exhaustive; any potential FII concerns should be discussed with your safeguarding team and/ or Duty and Advice.
Alerting signs to possible FII
FII can be very difficult to spot and the following possible warning signs require careful review to rule out other explanations.
Alerting signs for children and young people:
- reporting signs and symptoms that are not observed independently by professionals
- unusual investigation results, for example biochemical findings, unusual infective organisms
- inexplicably poor response to prescribed treatment
- unexplained characteristics of the child's illness that may be physiologically impossible, for example persistent negative fluid balance, large blood loss but no drop in haemoglobin levels
- the child's normal, daily life activities are being curtailed beyond that which might be expected from any medical disorder from which the child is known to suffer, including school attendance, the use of aids such as wheelchairs and social isolation.
Alerting signs for parents/ carers:
- parental and child discrepancies in the child's physical/ mental health and neurodevelopment
- new symptoms are reported on resolution of previous ones, and/ or symptoms and signs are not observed in the absence of the carer
- frequent 999 or 111 calls/ attendances at the emergency department
- the child is not brought to appointments that would provide a definitive diagnosis
- over time, the child is repeatedly presented with a range of symptoms to different professionals in a variety of settings
- inability to accept clinical management and reassurance, or seeking clinically unwarranted investigations, referrals, treatments, disability aids or irreversible surgical options that are not indicated
What practitioners should do
Multi-agency working is essential and practitioners in all agencies need to be aware of the West Yorkshire Consortium Inter Agency Safeguarding and Child Protection online procedures for managing FII. These guidelines clearly set out how all agencies and individuals should manage cases of FII.
If initial concerns arise directly from school, it is recommended that school explain to the parents that information is required from health to understand the concerns, for example poor school attendance, the use of aids.
If any practitioner has concerns about a situation being indicative of FII, they should discuss these with their own agency safeguarding lead. In health agencies, they should also consult the Designated Health Professional. If there is not a safeguarding lead available within their agency, practitioners should contact the Duty and Advice team.
Practitioners 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. The paediatric consultant (who may be a specialist rather than general paediatric gastroenterologist) is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care. If there is no paediatrician involved in the child's care, the GP should discuss with their safeguarding team and Designated Doctors whether a referral to a paediatrician is indicated.
Unlike in other circumstances when contacting the Duty and Advice team, concerns about FII should not be discussed with the family and consent to share information should not be sought until a strategy discussion has taken place and it is decided that to do so will not place the child at increased risk of significant harm.
Parents should be kept informed of further medical assessments, investigations or tests required and of the findings. However, at no time should concerns about the reasons for the child's signs or symptoms, including the use of FII terminology, be shared with parents if this information would jeopardise the child's safety and compromise the child protection process and/ or any criminal investigation.
A strategy discussion led by the Children's Social Work Service (CSWS) including - at a minimum - the Police, CSWS and the Consultant Paediatrician responsible for the child's care should take place to agree if a Section 47 child protection enquiry under the Children Act 1989 is required. If so, a plan of action will be developed including when and how the parent/ carer will be advised of the concerns in order that the child can be appropriately safeguarded.
Where practitioners have differences in opinion about how to proceed, they should seek to resolve these through the Leeds Safeguarding Children Partnership (LSCP) Concerns Resolution Process.
If a practitioner believes that a child is at immediate risk of harm, they must contact the Police on 999.
Key contacts and further information
Practitioners can contact the Duty and Advice Team on phone 0113 376 0336 or the out of hours Emergency Duty Team on phone 0113 240 9536.
Further guidance on FII and perplexing presentation is available from:
- The West Yorkshire Consortium online procedures, which includes a flowchart setting out actions to take at each stage in relation to FII concerns
- Information for practitioners from the LSCP on the use of chronologies
- Guidance on FII produced by the Royal College of Paediatrics and Child Health
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