Analysis

Perplexing presentations in children: how to act on fabricated or induced illness

Guidance for nurses on identifying and safeguarding children at risk

Nurses should be aware of children with perplexing presentations that could have been induced or fabricated and be prepared to put safeguarding procedures in place

  • A parent may fake their childs condition to obtain sympathetic attention or even a material gain, or simply due to mistaken anxiety
  • Royal College of Paediatrics and Child Health guidance says safeguarding procedures can be invoked even without proof of deliberate deception
  • Such parental actions, behaviours or beliefs may result in physical and emotional abuse and neglect of the child

Children repeatedly brought into healthcare settings with reported symptoms not observed independently by healthcare staff may be cases of fabricated or induced illness, known as FII.

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Nurses should be aware of children with perplexing presentations that could have been induced or fabricated and be prepared to put safeguarding procedures in place

  • A parent may fake their child’s condition to obtain sympathetic attention or even a material gain, or simply due to mistaken anxiety
  • Royal College of Paediatrics and Child Health guidance says safeguarding procedures can be invoked even without proof of deliberate deception
  • Such parental actions, behaviours or beliefs may result in physical and emotional abuse and neglect of the child
Nurses should be aware of children with perplexing presentations that could have been induced or fabricated and be prepared to put safeguarding procedures in place
Picture: iStock

Children repeatedly brought into healthcare settings with reported symptoms not observed independently by healthcare staff may be cases of fabricated or induced illness, known as FII.

Repeated presentations are a warning sign that healthcare professionals are urged to look out for in new guidance on identifying and caring for children exposed to FII. Once known as Munchausen syndrome by proxy, FII is relatively rare but such cases can be difficult and complex for nurses and their colleagues when they arise.

The RCN says the guidance will be useful for nurses who work with children and those who work in wider areas of child health, including health visitors and school nurses.

Uncertainty about the criteria for suspecting or confirming FII

The Royal College of Paediatrics and Child Health (RCPCH), which produced the guidance, acknowledges there is uncertainty among healthcare professionals about the criteria for suspecting or confirming FII and the threshold at which safeguarding procedures should be invoked.

16 years

Legal age at which children are considered competent to make decisions about their health

‘There has been a shift towards earlier recognition of possible FII (which may not amount to likely or actual significant harm), and intervention without the need for proof of deliberate deception,’ it says. The document sets out new and wider definitions of FII and ‘perplexing presentations’, which is abbreviated as PP.

FII is a clinical situation in which a child is, or is deemed very likely to be, harmed due to parent behaviour or actions to convince doctors that the child’s health or neurodevelopment is impaired. These parental actions, behaviours or beliefs result in physical and emotional abuse and neglect of the child.

Look out for discrepancies, implausible descriptions and unexplained findings or parental behaviour

PP is the ‘commonly encountered situation’ when there are alerting signs of possible FII – not yet amounting to harm – but the actual state of the child’s health or neurodevelopment is unclear and there is no perceived risk of immediate serious harm.

To spot these cases, healthcare professionals should be looking out for discrepancies between reports and independent observations of the child, implausible descriptions and unexplained findings or parental behaviour.

RCPCH officer for safeguarding Alison Steele says it is rare for parents or carers to deliberately induce illness in a child by poisoning them or withholding treatment.

‘Most cases are based on incorrect beliefs or misplaced anxiety which, when unchecked, can cause children to undergo harms ranging from missing school and seeing friends to undergoing unnecessary and painful or even harmful tests and treatments.’

Signs of fabricated illness

In the child

  • Reported physical, psychological or behavioural symptoms and signs not observed independently in their reported context
  • Unusual results of investigations
  • Inexplicably poor response to prescribed treatment
  • Some characteristics of the child’s illness may be physiologically impossible, such as persistent negative fluid balance or large blood loss without a drop in haemoglobin
  • Unexplained impairment of child’s daily life, including school attendance, use of aids such as wheelchairs and social isolation
How to detect some of the signs of fabricated illness in children
Picture: iStock

Parental behaviour

  • Repeated presentations at medical settings including emergency departments
  • Repeated reporting of new symptoms
  • Child repeatedly not brought to appointments, often due to cancellations
  • Inappropriately seeking multiple medical opinions
  • Providing reports by doctors from abroad which conflict with UK medical practice
  • Insistence on continued investigations instead of focusing on symptom alleviation when reported symptoms are unexplained by any known medical condition
  • Unable to accept reassurance or recommended management, and insistence on further clinically unwarranted investigations, referrals or new treatments sometimes based on internet searches
  • Objection to communication between professionals, or frequent vexatious complaints about professionals
  • Not letting the child be seen on their own, or talking for the child
  • Repeated or unexplained changes of school, GP or paediatrician/health team
  • Factual discrepancies in statements to professionals or others about their child’s illness
  • Pressing for irreversible or drastic treatment options where the clinical need for this is in doubt or based solely on parental reporting

Source: Royal College of Paediatrics and Child Health (2021)

A 2018 RCPCH members’ survey which obtained responses from 216 doctors, many of whom work in safeguarding, found 92% had dealt with a PP case in the previous 12 months and 30% had seen more than five. The survey highlighted the complexity of these cases, with respondents reporting almost 70 different presentations.

The most common were feeding difficulties, behaviour that challenges, musculoskeletal symptoms and gait disorders. In the majority of cases the main concerns were erroneous reporting and avoidance strategies by parents, with only a few cases of falsification of records or illness induction.

The survey also revealed the time-consuming nature of such cases for healthcare professionals.

Anxiety disorders may lead a parent to have unfounded worries about their child’s health

Clinical experience and research indicate that the mother is nearly always involved in FII or the instigator of it. The caregiver may be a single parent or acting alone, unbeknown to the father. The father may be unaware, be suspicious but sidelined, or may be actively involved.

1977

Professor Sir Roy Meadow first described the condition Munchausen syndrome by proxy

While parental mental ill health is not always present in cases of FII, it may help to explain some of the parents’ motivations and behaviours.

Personality disorders are most likely to be found in parents who derive a clear gain from having their child regarded as ill or more ill than they are.

Anxiety disorders may lead the parent to have unfounded anxieties about their child’s health, to an extent which is harmful to the child.

Some social media support groups may post inaccurate information which can lead to harm by parents
Picture: iStock

Danger of inaccurate information on the internet

Support groups and social media may spread inaccurate information that can lead to harm by parents.

While these can provide an important source of support for parents and families about childhood illness, healthcare professionals should be aware that support groups exist for some conditions about which there is divided medical opinion.

Also, some social media support groups may post inaccurate information and discuss diagnoses and how to obtain them, which can lead to harm.

Source: Royal College of Paediatrics and Child Health (2021)

FII is based on the parent’s underlying need for their child to be recognised and treated as ill from a physical, psychological, neurodevelopmental or cognitive condition or disability. Often the child already has a verified health disorder, highlighting the complexity of understanding these cases.

Parents use different approaches to convince healthcare professionals. These include presenting and erroneously reporting the child’s symptoms, history, results of investigations, medical opinions, interventions and diagnoses. There may be exaggeration, distortion, misconstruing of innocent phenomena in the child, or invention and deception.

Some parents can withhold food or medication to induce illness in their child
Picture: iStock

A less common way of engaging healthcare professionals is through physical actions, with an element of deception. Such actions range from falsifying documents, interfering with investigations and specimens, such as putting sugar or blood in the child’s urine specimen, interfering with lines and drainage bags, withholding food or medication, and inducing illness.

Motivations for parents trying to deceive healthcare professionals about their child’s health

There are two possible and different motivations for such a parent’s behaviour.

First the parent experiences some sort of gain from the recognition and treatment of their child as unwell. This could be material, including financial support for care, improved housing, holidays, assisted mobility and preferential car parking.

Some seek sympathetic attention or continued physical closeness with their child. Parents who struggle with their child’s behaviour may seek an inappropriate justification, such as attention deficit hyperactivity disorder or autism spectrum disorder.

Second is a motivation based on erroneous beliefs. Parents may have extreme concern and anxiety about their child’s health, including nutrition, allergies and treatments.

This can include a mistaken belief that their child needs additional support at school and misinterpretation of aspects of a child’s presentation and behaviour. In pursuit of an explanation – and increasingly aided by the internet – the parent develops a belief about what is wrong with their child.

‘In contrast to typical parental concern, the parent exhibiting such behaviour cannot be reassured by health professionals or negative investigations,’ the guidance says. A parent may not be aware of their motivation, and both motivations may be present.

Leila Francis, RCN Children and Young People Staying Healthy Forum steering committee member and designated nurse safeguarding children
Leila Francis

Exaggeration of symptoms can be difficult to prove

RCN Children and Young People Staying Healthy Forum steering committee member and designated nurse safeguarding children Leila Francis says nurses should be aware of FII signs.

‘Children and young people with perplexing presentations often have a degree of underlying illness,’ says Ms Francis. ‘This means exaggeration of symptoms is difficult to prove and even harder for health professionals to manage and treat appropriately.

‘The guidance provides a framework for practitioners, which could allow them to intervene before a child or young person is harmed. This can also identify when immediate action may be required.

‘All employers have a duty to ensure that health and care practitioners can access training to support them in identifying children who may be at risk.’

Challenging cases: the mother disconnecting her baby’s feed

Coral Rees, advanced paediatric nurse practitioner for child health
Coral Rees

Advanced paediatric nurse practitioner for child health Coral Rees says that despite its rarity fabricated or induced illness (FII) needs to be considered by children’s nurses.

‘I have only seen one case of fabricated illness in my career and that was with a baby who was failing to thrive despite the parent saying they were feeding,’ says Ms Rees, who works at the Children’s Hospital for Wales in Cardiff.

‘Lots of investigations were performed and the child was eventually put on nasogastric feeding in hospital.

‘The child was put in foster care and thrived when fed normally’

‘It was only when feed was discovered in the mother's bed next to the cot that we realised she had been disconnecting the feed. The child was put in foster care and thrived when fed normally.’

The Royal College of Paediatrics and Child Health guidance will help nurses with these challenging cases, she says. ‘These cases are incredibly rare but need to be considered when the clinical picture and investigations performed don't fit the story that is being told by a parent or caregiver.

‘This guidance is helpful for all healthcare professionals as it explains what the motivation is behind perplexing presentations and FII while also helping us to recognise concerning signs in parent's behaviour.’

Ms Rees says that when FII is being considered, nurses should keep the child and family under close observation in the ward environment, documenting parental behaviours and interactions with the child.

Alerting signs point to the need for further investigation

If a nurse spots an alerting sign it is essential to look for others. Alerting signs by themselves do not amount to fabrication, but do point to the need for further investigation to ascertain whether the child has an underlying illness.

Signs should be discussed with the named doctor, named nurse or safeguarding health team. If alerting signs are found in primary or community care or education settings, a paediatrician or child and adolescent mental health professional should be involved to assess the child’s health.

2002

Royal College of Paediatrics and Child Health adopted the term ‘fabricated or induced illness by carers’ or FII

If there is an immediate risk to a child’s health or life, particularly by illness induction, the RCPCH recommends urgent referral to the police and children’s social care. Sibling safety should also be considered.

Healthcare professionals should secure any potential evidence such as feed bottles, nappies and vomit samples. Concerns should be documented in the child’s health records. This is important in case the child is seen by other clinicians who are unaware of the situation.

If concerns remain, the child may need to be referred to children’s social care

If there is no immediate risk of harm, and the child has PP, steps should be taken to assess the child’s health and resolve the unexplained and potentially harmful situation.

This process of investigation may find a full medical explanation to eliminate concerns about FII. However, when concerns remain there may be a need to refer to children’s social care.

The aim is for the child to resume their normal life, with reduced medical intervention, a return to school and other activities. It is hoped that parents or carers support the process to improve their child’s health and well-being, and that a plan can be developed.


Find out more

Royal College of Paediatrics and Child Health (2021) Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children Guidance

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