3.9.3 Fabricated or Induced Illness

1. Introduction

All parents / carers demonstrate a range of behaviours in response to their children being ill or being perceived as ill. Some may become more stressed or anxious than others. However, there are some parents / carers, who for differing reasons may either induce of fabricate illness in their child. Such incidents are not commonplace. But they can significantly impact on the child's physical and emotional development.

The purpose of this procedure is to provide practice guidance to Sheffield Children Safeguarding Partnership partner agencies on managing perplexing presentations and fabricated and induced illness, FII, and information to Safeguard and Promote the Welfare of Children for whom there is a risk of Significant Harm or who are suffering actual harm as a result of FII.

2. Definition

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 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) 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 actions, behaviours or beliefs and from doctors' responses to these. The parent 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 (and in Working Together to Safeguard Children, fabrication of symptoms or deliberate induction of illness in a child is included under Physical Abuse). In order for this physical abuse to be considered under FII, evidence will be required that the parent'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.

3. Aim

The aim of this guidance is to support SCSP partner agency staff to:

• Be aware of the signs and symptoms of perplexing presentations and fabricated or induced illness;
• Be aware of how fabricating or inducing illness in children may impact on their physical or emotional development;
• Understand why parents / carers may take such action;
• Respond to any concerns they may have that a child is suffering from fabricated or induced illness;
• Understand what action may occur as a result of such a response.

4. Fabricated or Inducted Illness

4.1 Overview

For a small number of children, concerns will be raised when it is considered that their health or development is likely to be significantly impaired, or further impaired, by the actions of a carer or carers having fabricated or induced illness, such that the child is suffering or is likely to suffer Significant Harm.

Health practitioners are taught to listen to the concerns of parents about their children's health and to act on these. Part of their role is not only to treat the sick child but also, in collaboration with other practitioners, to assist parents to respond appropriately to the state of their children's health. Some children may not be unwell but parents need reassurance that they are indeed well, whilst others may experience continuing difficulty in recognising that their child is healthy and exhibiting normal childhood behaviours. Some parents may be helped to interpret and respond appropriately to their child's actions and behaviours, whilst others may continue to be anxious and/or are unable to change their beliefs.

It is this latter group of parents who are more likely to present their children for medical examination although the children are healthy. Skilled practitioner intervention is likely to enable most parents to learn how to interpret their child's state of health and manage their own anxieties. There may be some parents for whom such early interventions are ineffective. These parents may have particular needs, which result in them persistently presenting their child(ren) as ill and seeking investigations and medical treatments.

4.2 Incidence and Prevalence

The incidence rate of fabricated or induced illness is quite rare. McClure et al (see Appendix 2: References for Fabricated or Induced Illness) calculated that in a hypothetical district of one million inhabitants, the expected incident rate would be one child per year. In Sheffield, that would be less than one case per year. However, they also suggested that there was under-reporting in this area for a number of reasons:

• That paediatricians considered that the identification of FII had to be virtually certain before a Child Protection Conference is initiated;
• The absence of recorded cases because of the lack of irrefutable evidence even though the concern about the child is significant;
• The cases may also present in ways which result in unnecessary medical interventions, for example, where symptoms are verbally reported to surgeons who then carry out operations without questioning the basis of this information.

Therefore the prevalence rate is likely to be more than the estimated incidence of less than one case per year in Sheffield.

5. Harm to the Child

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.

5.1 Severity

Severity of FII can be considered in two ways: a) severity of the parent's actions, b) severity of the harm to the child.

a) Severity of the parent's actions

This can be placed on a continuum of increasing severity which ranges from anxiety and belief-related erroneous reports, to deception by fabricating false reports, to interfering with samples through to illness induction. However, there is no evidence about the likelihood or factors associated with a parent moving from one point on this continuum to another.

b) Severity of harm to the child

The different aspects of harm to the child may coexist. Severity of the harm to the child needs to be assessed according to both the intensity of each aspect of the harm, and by the cumulative effect of all the aspects.

Moreover, with the exception of illness induction (which can lead to serious illness and occasionally death of the child) the nature of the parent's motivations and the severity of their actions bear little relation to severity of harm to the child.

Therefore, in assessing the severity of the situation, it is important to focus on the harmful effects on the child, rather than gauge severity by what the parent is saying or doing. Although if there are clear deceptive parental actions or illness induction, it is likely that the harm to the child will be more severe.

5.2 Siblings

In some families, only one child is subject to FII or has a PP and this child may initially have had a genuine illness which began the relationship between the parent and health professionals. In other families, several children may be affected by FII or have a PP simultaneously or sequentially. Siblings who are not subject to FII or have a PP may become very concerned and distressed by the apparent ill-health of their affected sibling or may feel and be neglected.

5.3 Other victims

There have been reports of FII perpetrators also abusing spouses or animals. There may need to be consideration of referral to Adult Safeguarding or the RSPCA.

5.4 Gender of Parent / Carer Responsible for the Abuse

Clinical evidence indicates that fabricated or induced illness is usually carried out by a female parent / carer, usually the child's mother, although fathers and other women have been known to be responsible. Whoever is the alleged abuser, it is likely that they have been undertaking the majority of the child's daily care. That does not necessarily mean that another parent / carer were mere bystanders in the process of illness induction. Each family should be assessed individually to understand the dynamics at play.

5.5 Parent / Carers' previous Histories

There is no evidence to support a unique profile of carers who fabricate or induce illness in their children. There is, however, evidence that as with many parents who abuse or neglect their children, specific aspects of their histories are likely to have been troubled. This requires careful assessment but may reveal:

Physical health: A significant number of parents are likely to report having experienced genuine medical problems, which may or may not be substantiated by medical investigations. They may also have a history of inflicting deliberate self-harm. The mothers may have a complicated obstetric history. For some mothers, there may have been practitioner concern about them causing their own miscarriages.

Psychiatric history: A significant number of parents will have been assessed or treated for mental health problems. Following a formal psychiatric assessment, some may have been diagnosed with a personality disorder, but others may have no diagnosable psychiatric disorder.

Parents also report having suffered a number of significant bereavements or losses in their lives with these often having taken place within a relatively short time span. This may have included miscarriage, stillbirths, the deaths of parents or other supportive family member, or the loss of a partner through separation or divorce.

5.6 Other Possible Perpetrators

Although in the majority of such cases it is the mother who is the abuser, practitioners should also be aware of the possibility of other perpetrators including siblings or other children, or practitioners.

If a practitioner is concerned that a colleague or worker from another agency, including volunteers or foster carers, is fabricating or inducing illness in a child, they should immediately inform their line manager and the named practitioner for safeguarding within their agency. A referral should be made to the LADO (Local Authority Designated Officer). See Allegations against Persons who work with Children (including Staff, Carers and Volunteers) Procedure. Advice can be obtained from Sheffield Safeguarding Children Advisory Service - see Local Contacts.

5.7 Family Relationships

Relationship problems between the child's parents are common, although they may not have been acknowledged prior to child welfare concerns being raised. Similarly, a number of parents may have experienced problems associated with taking on the role of parenthood. These may have been presented early on in their parenting careers.

5.8 Outcomes for Children

There has been little research conducted on the longer-term outcomes for children in these circumstances, but the available evidence suggests that outcomes have been poor for many children who had illness fabricated or induced. Bools et al (1993) (see Appendix 2: References for Fabricated or Induced Illness) noted that nearly half of the children in their study were living with alternative carers but suffered ongoing psychological problems. Over half were still living with their mother (who was the abuser) and had either suffered further fabricated illness or other significant concerns. Nearly half of the 54 children in the study had unacceptable outcomes including conduct and emotional disorders, and difficulties at school including non-attendance, in addition to re-abuse.

In summary, following identification of fabricated or induced illness in a child by a carer, the way in which the case is managed will have a major impact on the developmental outcomes for the child. The extent to which the parents have acknowledged some responsibility for fabricating or inducing illness in their child will also affect these outcomes for the child.

6. Alerting Signs to Possible FII

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, or by professionals in pre-school/early years, schools and other educational settings. Others are first noted by hospital-based paediatricians or in Children and Young People’s Mental Health Services (CYPMHS). 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. Paediatricians must look at the overall picture which includes the number and severity of alerting signs.

6.1 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.

6.2 Parent behaviour

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

7. Response to Alerting Signs

If one alerting sign is present, it is essential to look for others. Alerting signs should be discussed with the Named Doctor, Named Nurse or health safeguarding team. Alerting signs by themselves do not amount to fabrication but mandate further investigation to ascertain whether the child has an underlying illness.

At the point of alerting signs being identified, consideration of possible mental ill-health in the parent is not immediately relevant. While it may transpire later that the alerting signs were not indicative of FII, it is imperative that their presence is acted upon. If alerting signs are found in primary care or by education or allied health professionals in the community, it is appropriate that a paediatrician/CAMH professional becomes involved as the resolution lies in ascertaining the actual state of the child's health. One of two courses of action need to be followed depending on whether there is or is not an immediate serious risk to the child's health/life.

7.1 Immediate serious risk to child's health / life

The most important question to be considered is whether the child may be at immediate risk of serious harm, particularly by illness induction. This is most likely to occur when there is evidence of frank deception, interfering with specimens, unexplained results of investigations suggesting contamination or poisoning or actual illness induction, or concerns that an open discussion with the parent might lead them to harm the child. In this situation, the following are important considerations:

• An urgent referral must be made to the police and children's social care as a case of likely significant harm due to suspected or actual FII, and this should lead to a strategy discussion that includes health representatives as per the latest interagency guidance. The safety of siblings also needs to be considered;
• Securing any potential evidence (e.g. feed bottles or giving sets, nappies, blood/urine/ vomit samples, clothing or bedding if they have suspicious material on them);
• Documenting concerns in the child's health records (e.g. 'this unusual constellation of symptoms, reported but not independently observed, is worrying to the extent that, in my opinion, there is potential for serious harm to the child'). This is important in case the child is seen by other clinicians who are not aware of the concerns;
• Considering whether the child is in need of immediate protection and measures taken to reduce immediate risk;
• In very rare cases, covert video surveillance may be used as part of multi-agency decision-making and is led by the police.

All practitioners should be mindful of situations where to inform the parents of the referral would place a child at increased risk of harm. In this situation, carers would not be informed of the referral before a multi-agency discussion has taken place. This would usually be in the form of a formal strategy discussion.

Very urgent protection of the child is best obtained by contacting the police who can then use their police protection powers, as it will take children's social care a number of hours to obtain an Emergency Protection Order. However, children's social care should be contacted at the same time as the police. If the Named Doctor or responsible paediatric consultant are of the opinion that the threshold for likely or actual significant harm is possibly met (as per the criteria under section 47 of the Children Act 1989) either as a matter of urgency or in a planned manner, they must make a referral to children's social care.

Once the child's safety has been ensured and child protection plans are in place, the steps described below will still apply.

7.2 Alerting signs with no immediate serious risk to the child's health / life – Perplexing Presentations (PP)

The term Perplexing Presentations (PP) denotes the presence of alerting signs to possible FII, in the absence of the likelihood of immediate serious risk to the child's physical health or life. Perplexing Presentations nevertheless indicate possible harm to the child which can only be resolved by establishing the actual state of health of the child. They therefore call for a carefully planned response. This will be led by the responsible clinician with advice from the Named Doctor, usually in the secondary, and occasionally tertiary centre, in which paediatricians or CYPMHS clinicians are employed. The essence of the response is to establish the current state of health and functioning of the child and resolve the unexplained and potentially harmful situation for the child. The term Perplexing Presentations and management approach can and should be explained to the parents and the child, if the child is at an appropriate developmental stage. Reflecting with parents about the differing perceptions that they and the health team have of the child's presenting problems and possible harm to the child may be very helpful in some cases, particularly if it is done at an early stage.

If the initial concerns arise directly from school as opposed to health, it is recommended that school explain to the parents that information is required from health to understand the concerns e.g. poor school attendance. It is then appropriate for either the parents or education to contact health (either GP, consultant paediatrician or child psychiatrist) with their query about the actual health of the child. If the parents do not agree to a health assessment and the sharing of information about the child we recommend that schools will then need to decide what action they should take following their national safeguarding guidance. At this stage, professionals should refrain from using FII terminology, as the state of the child's health has not yet been assessed. If primary healthcare is the only contact for the child, then they may wish to refer to a paediatrician for further assessment of the child's health. 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. If concerns arise within General Practice, we recommend that there should be consultation with the Named GP for Safeguarding Children in the first instance.

At any stage during this process, should new information come to light to suggest that the child is currently suffering from significant harm, referral to children's social care and/or the police must be made, alongside the process outlined in this guidance. The urgency with which this is done and whether or not parents are informed about the referral before a professional multi-agency discussion will vary according to the circumstances of each case.

7.3 Response to Perplexing Presentations (PP)

This is a complex and time-consuming process, led by the Responsible Paediatric or CYPMHS Consultant with advice from the Named Doctor and the health safeguarding team (who do not have clinical responsibility for the child) – all should be supported and have protected time to provide the necessary focus. Responding to PP requires a multidisciplinary approach, although it is imperative that the responsible consultant continues to have overall clinical responsibility for the child and that the background safeguarding processes are supported by the Named Doctor and the health safeguarding team.

If the Responsible Paediatric or CYPMHS Consultant (who may change during the process) is also the Named Doctor, then another paediatrician in the Trust will need to undertake this consultative role, possibly the Designated Doctor. This means that safeguarding decisions can be made objectively, free from duress, threats and complaints and the responsible paediatric consultant has appropriate support in these challenging cases.

The essence of management is establishing, as quickly as possible, the child's actual current state of physical and psychological health and functioning, and the family context. The responsible paediatric consultant will need to explain to the parents and the child (if old enough) the current uncertainty regarding the child's state of health, the proposed assessment process and the fact that it will include obtaining information about the child from other caregivers, health providers, education and social care if already involved with the family, as well as likely professionals meetings. Wherever possible this should be done collaboratively with the parents. If they do not give agree for this to happen, the parents' concerns about this process should be explored and can often be dispelled. However, under the NHS' interpretation of General Data Protection Regulations (GDPR) for the UK information sharing can take place without consent if: there are safeguarding concerns, it is in the best interests of the child, is necessary and proportionate and is done in a manner according to the regulations. Strong parental objections could indicate a referral to children's social care on the grounds of medical neglect - that the doctors are unable to establish the state of health and medical needs of the child.

When paediatricians become concerned about a perplexing presentation, an opinion from an experienced colleague needs to be obtained and a tertiary specialist may be necessary. Parents themselves may request another opinion and it is their right to do. However, this opinion giver should be supplied with all the background information to help in informing the opinion and to avoid the repetition of investigations unnecessarily. The seeking of multiple alternative opinions, particularly when there has already been a reasonable diagnostic formulation, is almost always harmful to the child and may well increase concern about FII.

There may need to be one or more professionals' meetings to gather information, and these can be virtual meetings. Where possible, families should be informed about these meetings and the outcome of discussions as long as doing so would not place the child at additional risk. Care should be given to ensure that notes from meetings are factual and agreed by all parties present. Notes from meetings may be made available to parents, on a case by case basis and are likely to be released to them anyway should there be a Subject Access Request for the health records.

7.4 Child's health and wellbeing

The responsible paediatric consultant should:

• Collate all current medical/health involvement in the child's investigations and treatment, including from GPs, other Consultants, and private doctors, with a request for clarification of what has been reported and what observed. (This is not usually a request for a full chronology, which would need to include all past details of health involvement and which is often not relevant at this point);
• Ascertain who has given reported diagnoses and the basis on which they have been made, whether based on parental reports or on professional observations and investigations;
• Consider inpatient admission for direct observations of the child, including where relevant the child's input and output (fluids, urine, stool, stoma fluid as applicable), observation chart recordings, feeding, administration of medication, mobility, pain level, sleep. If discrepant reports continue, this will require constant nurse observations. Overt video recording may be indicated for observation of seizures and is already in widespread use in tertiary neurology practice to assess seizures (which must be consented to by parents);
• Consider whether further definitive investigations or referrals for specialist opinions are warranted or required;
• Obtain information about the child's current functioning, including: school attendance, attainments, emotional and behavioural state, peer relationships, mobility, and any use of aids. It is appropriate to explain to the parents the need for this. If the child is being home schooled and there is therefore no independent information about important aspects of the child's daily functioning, it may be necessary to find an alternative setting for the child to be observed (e.g. hospital admission).

7.5 Parents' views

The responsible paediatric consultant should:

• Obtain history and observations from all caregivers, including mothers and fathers; and others if acting as significant caregivers;
• If a significant antenatal, perinatal or postnatal history regarding the child is given, verify this from the relevant clinician;
• Explore the parents' views, including their explanations, fears and hopes for their child's health difficulties;
• Explore family functioning including effects of the child's difficulties on the family (e.g. difficulties in parents continuing in paid employment);
• Explore sources of support which the parent is receiving and using, including social media and support groups;
• Ascertain whether there has been, or is currently, involvement of early help services or children's social care. If so, these professionals need to be involved in discussion about emerging health concerns;
• Ascertain siblings' health and wellbeing;
• Explore a need for early help and support and refer to children's social care on a Child in Need basis, where appropriate depending on the nature and type of concerns, with agreement from parents.

7.6 Child's view

The responsible paediatric consultant should:

• Explore the child's views with the child alone (if of an appropriate developmental level and age) to ascertain:
  • The child's own view of their symptoms;
  • The child's beliefs about the nature of their illness;
  • Worries and anxieties;
  • Mood;
  • Wishes.
• Observe any contrasts in verbal and non-verbal communication from the child during individual consultations with the child and during consultations when the parent is present.

It is important to note that some children's and adolescents' views may be influenced by and mirror the caregiver's views. The fact that the child is dependent on the parent may lead them to feel loyalty to their parents and they may feel unable to express their own views independently, especially if differing from the parents.

The responsible paediatric consultant should provide signposting advice for children, young people and their parents on where appropriate to access more information or support.

7.7 Reaching a consensus formulation about the child's current health, needs, and potential or actual harm to the child

The aim of the full medical and psychosocial review is to gain clarity about any verified illnesses, and any remaining Perplexing Presentations. Binary thinking about difficulties, regarding them as either physical or psychological is unhelpful, as both will be relevant. As is often the case, several doctors and other health professionals will have been involved in diagnoses and treatment.

Consensus about the child's state of health needs to be reached between all health professionals involved with the child and family, including GPs, Consultants, private doctors and other significant professionals who have observations about the child, including education and children's social care if they have already been involved. A multi-professional meeting is required in order to reach consensus. This professionals meeting should be chaired by the Named Doctor (or a clinician experienced in safeguarding with no direct patient involvement) to ensure a degree of objectivity and to preserve the direct doctor-family relationship with the responsible clinician. Parents should be informed about the meeting and receive the consensus conclusions with an opportunity to discuss them and contribute to the proposed future plans (see below).

It is the number and severity of the concerns in the alerting signs which led to the need to investigate the perplexing presentation. The decision that has to be made is whether, on the one hand, the perplexing presentation can be explained by either a verified condition/s or by medically unexplained symptoms emanating from the child or, on the other hand, whether there is concern that the child is coming to harm either by fabrication of symptoms by the parents and/or their by their fixed erroneous beliefs about the child's health.

In order to resolve these concerns, a decision needs to be made about whether the perplexing presentation is explained and resolved by a verified medical condition in the child, or whether concerns remain.

In order to resolve this, a consensus needs to be reached in a meeting between all professionals about the following issues:

• Either:
  • That all the alerting signs and problems are explained by verified physical and/or psychiatric pathology or neurodevelopmental disorders in the child and there is no FII (false positives);
  • Medically Unexplained Symptoms from the child free from parental suggestion;
  • That there are perplexing elements but the child will not come to harm as a result.
• Or:
  • That any verified diagnoses do not explain all the alerting signs;
  • The actual or likely harm to the child and/or siblings;
• And agree all of the following:
  • Whether further investigations and seeking of further medical opinions are warranted in the child's interests;
  • How the child and the family need to be supported to function better alongside any remaining symptoms, using a Health and Education Rehabilitation Plan (see below for details);
  • If the child does not have a secondary care paediatric Consultant involved in their care, consideration needs to be given to involving local services;
  • The health needs of siblings;
  • Next steps in the eventuality that parents disengage or request a change of paediatrician in response to the communication meeting with the responsible paediatric consultant about the consensus reached and the proposed Health and Education Rehabilitation Plan.

Significant disagreements between health professionals about any important aspects of the diagnosis and medical management of the child, will need to be resolved. In such cases, the Named or Designated Doctor for Safeguarding Children should convene and chair a Health Professionals Meeting to agree on the medical issues.

The Designated Doctor can only perform this role if they have never been clinically involved with the case. Trusts need to establish alternative arrangements for another Designated Doctor from a neighbouring area to chair such a meeting in the eventuality that this is required. There must be a clear escalation policy to the Medical Director where there are significant concerns about how a case is being managed within any healthcare organisation. Clear record keeping of meetings, discussions and decisions is vital.

7.8 Communication to parents and child

Once health consensus has been achieved, a meeting should be held with the parents, the responsible paediatric consultant and a colleague (never a single professional). The meeting will explain to the parents that a diagnosis may or may not have implications for the child's functioning, and that genuine symptoms may have no diagnosis. It is preferable to acknowledge the child's symptoms rather than use descriptive 'diagnoses'. It is often useful to use the term 'issues/concerns' in clinical letters rather than 'diagnoses' in these circumstances.

The current, as of now, consensus opinion is offered to the parents with the acknowledgment that this may well differ or depart from what they have previously been told and may diverge from their views and beliefs. A plan is then made with the parents about what to explain to the child and what rehabilitation is to be offered and how this will be delivered. This plan should be negotiated with the parents and child if of sufficient maturity, as engagement in such a plan is necessary for it to work. The plan should be explained to younger children even if they are not sufficiently mature to be involved in the plan's construction. It is premature, and important not to discharge the child from paediatric care even if there is no current verified illness to explain all the alerting signs, until it is clear that rehabilitation is proceeding.

The RCPCH have developed guidance for paediatricians and health professionals on how best to achieve consensus with parents, particularly on the prevention, recognition and management of conflict in paediatric practice, some of the principles are applicable to general routine care.

7.9 Whether to refer to children's social care at this point

If there is actual or likely harm to the child or siblings, the implication is that the child has been subject to FII. The question of future harm to the child hinges on whether the parents recognise the harm and are able to change their beliefs and actions in such a way as to reduce or remove the harm to the child. In order for this to be tested the consensus medical view about the child's actual state of health and the consequences needs to be discussed with the parents and the child in terms of likely reduced medical intervention, the child's improved daily functioning and a revised view of the child's state of health. This requires the co-construction of a Health, Education and Rehabilitation Plan with the parents and child and implementation of this plan (see details below). However, the question arises as to whether in addition to this, there needs to be a referral to children's social care at this point.

Working Together (2018) guidance for England states variously:

• 'Anyone who has concerns about a child's welfare should make a referral to local authority children's social care and should do so immediately if there is a concern that the child is suffering significant harm or is likely to do so.'
• 'If a practitioner has concerns about a child's welfare and considers that they may be a child in need or that the child has suffered or is likely to suffer significant harm, then they should share the information with local authority children's social care and/or the police.'
• 'Where a child's need is relatively low level, individual services and universal services may be able to take swift action. Where there are more complex needs, help may be provided under section 17 of the Children Act 1989 (children in need). Where there are child protection concerns (reasonable cause to suspect a child is suffering or likely to suffer significant harm) local authority social care services must make enquiries and decide if any action must be taken under section 47 of the Children Act 1989.'

In some situations, the severity of the harm to the child therefore mandates immediate referral to children's social care due to the level of harm that has been, or is likely to be, caused to the child. In some cases, if parents and child (if of an appropriate developmental level) are able to understand the need for and are able to agree a Health and Education Rehabilitation Plan, immediate referral to children's social care may not be necessary as long as the plan is being monitored carefully, proceeding satisfactorily and agreed goals are being reached. The decision whether to refer to children's social care at this point in the process lies ultimately with local health professionals working within their multi-agency procedures. If a referral is made, the reasons for this referral will need to be discussed with the family beforehand and, from a health point of view, the Health and Education Rehabilitation Plan will need to continue wherever possible regardless of referral.

Professionals in health should be aware that they do not always have all the pieces of the safeguarding jigsaw puzzle. When a decision is being made about whether to refer children to children's social care, professionals should consider whether they have all the information from other agencies which is required to inform their risk assessment about levels of harm. If there is concern that they do not have this information particularly when parents decline to give consent for information sharing, a referral to children's social care may be necessary because of professional inability to assess the level of harm without the intervention of children's social care.

7.10 Liaising with General Practitioners (GPs)

GPs hold lifelong relationships with patients. They may have extensive knowledge and relationships with multiple generations of families. It is essential that GPs are kept fully informed and involved in the management of children with perplexing presentations or where there are concerns about FII so they can support children and their families as appropriate as well as work in partnership with other professionals involved to ensure the best outcomes for children.

8. Health and Education Rehabilitation Plan

This plan should be developed and implemented, whatever the status of children's social care involvement is.

Development of the Health and Education Rehabilitation Plan requires a coordinated multidisciplinary approach and negotiation with parents and children and usually will involve their attendance as appropriate at the relevant meetings. There may well be a number of acceptable approaches and in most cases engagement and agreement by the child and family is pivotal to the success of the Plan. The Plan is led by one agency (usually health) but will also involve education and possibly children's social care. It should also be shared with an identified GP. The Plan must specify timescales and intended outcomes. There needs to be agreement about who in the professional network will hold responsibility for coordinating and monitoring the Plan, and who will be the responsible paediatric consultant (most likely to be a secondary care paediatrician). Consideration needs to be given to what support the family require to help them to work alongside professionals to implement the Plan. This may include psychological support and / or referral to children's social care for additional support.

The Plan requires health to rationalise and coordinate further medical care and may include:

• Reducing/stopping unnecessary medication (e.g. analgesics, continuous antibiotics);
• Resuming oral feeding;
• Offering graded physical mobilisation.

There should be a discussion with the patient's registered GP regarding what role they may be able to take in supporting the management and care of the patient.

Optimal education needs to be re-established (when the child is of school age), with appropriate support for the child and family.

An example Health and Education Rehabilitation Plan template has been provided in Appendix A of the RCPH Guidance.

8.1 Psychological work

The Health and Education Rehabilitation Plan should detail how the child and caregivers will be psychologically supported. This is multifaceted and requires a coordinated child and family mental health approach, which may or may not involve CYPMHS, depending on local referral criteria. Psychological support should aim to:

• Help the child to adjust to a better state of health, by using coping strategies for symptoms with a cognitive behavioural approach. The child might also need support for the loss of gains associated with being a sick child;
• Help the child and the family, including the siblings, to construct an account which explains the evolution of the child's difficulties as well as the improvement in the child. This needs to be truthful and may be distressing to the child who will need support;
• Explore the parent's motivations, including: anxiety, compassion, beliefs, fulfilment of needs, and the implications and likely changes for the parent when the child's state of health is improved and the child is functioning optimally. This will require helping the parent to adjust to having a well or better child;
• Consider the need for referral of the parent by the GP to adult mental health services. This is in order for both the parent and professionals to better understand the nature of the parent's actions, any mental health diagnoses, motivations, prognosis and likely capacity to change, indication of treatment to effect change and who is likely to provide treatment.

8.2 Regular review of Plan

The Health and Education Rehabilitation Plan needs to be reviewed regularly with the family according to the timescales for achieving the specified outcomes, especially regarding the child's daily functioning. This should continue until the aims have been fulfilled and the child has been restored to optimal health and functioning and the previous alerting signs are no longer of concern. Agreement needs to be reached by the professionals involved and the family about who will review the plan and when. It is essential to identify a lead professional to coordinate care and organise regular review of the plan. This may be the previous responsible consultant paediatrician or another more appropriate health professional as decided by the multi-disciplinary team. Appropriate health professionals to lead on the plan will vary on a case by case basis and could include:

• Consultant Hospital Paediatrician;
• Consultant Community Paediatrician;
• Consultant Child and Adolescent Psychiatrist.

If the child has either a Child in Need or a Child Protection Plan it may be appropriate for a social worker to take the lead in coordination in conjunction with health and education teams, as the aims of the Health and Education Rehabilitation Plan would form part of that plan. It is important to guard against what might be seen as disguised compliance by the parents.

An important aspect of the fulfilment of the Health and Education Rehabilitation Plan is the parent's ability to now hold a realistic view of the child's health and health-related needs and to be seen to have communicated this to the child.

8.3 Long term follow-up

All children who have required a Health and Education Rehabilitation Plan, unless there is a permanent positive change in primary caregivers, will require long term follow up by a professional at the closure of the plan. Depending on individual circumstances it is advisable to continue to be alert to possible recurrence of concerns either in the child(ren) or their siblings. Education and primary health are the appropriate professionals to monitor the children's progress and to identify re-emerging or new concerns.

9. Referrals to Children's Social Care

If it is decided that the child is at risk of, or likely to suffer Significant Harm as a result of suspected fabricated or induced illness, the practitioner should make a referral to the Sheffield Safeguarding Hub (see Local Contacts). See Referrals Procedure.

Following receipt of such a referral health, police and Children's Social Care, and any other involved agencies should work together to Safeguard and Promote the Welfare of the Child. The police should be involved, as fabricating or inducing illness is a criminal offence and therefore a police investigation may follow.

Children's Social Care should decide, in consultation with the other agencies as what, if any, further action is appropriate. If no further action is taken, feedback should be given to the referrer and any other agency involved. Alternatively, it may be decided that action is required. Therefore an Assessment under Section 17 may be appropriate.

9.1 Assessment

An Assessment may be conducted to determine whether the child is in need or whether there are concerns about Significant Harm, the nature of any services required, and whether a further, more detailed Assessment should be undertaken. On completion of the Assessment, careful consideration should be given by the Lead Social Worker and the consultant paediatrician responsible for the child's health care, as to what the parents should be told, when and by whom, taking account of the child's welfare.

The time taken to complete the Assessment may be very brief if it quickly becomes clear that there is reasonable cause to suspect the child is suffering or is likely to suffer Significant Harm, in which case a Strategy Discussion should be held. If there is evidence to indicate the child's life is at risk or there is likelihood of serious, immediate harm, emergency legal action (e.g. Police Protection or Emergency Protection Order) may be required. See Assessments Procedure for more information.

It is essential at this stage that the compilation of a medical Chronology is commenced (see Section 7, Guidance for Gathering Information / Evidence and Section 8.1, Information for the Conference.

9.2 Chronology

A full chronology consists of a list of significant past events that have occurred during the child's life, by date and time. Chronologies are usually compiled using a template which has a number of headed columns with information about the source of the entry, what actually happened or was observed and by whom, what was said, and an analysis of this. It is useful for organisations within a particular locality to have the same chronology template so that information can be merged easily from different health providers. However, the exact chronology format may vary on an individual case basis, dependent on the child's need / circumstances.

Suggested headings for chronologies:

• When and what was reported;
• By whom;
• What was observed;
• By whom;
• What action was taken and on what basis;
• What the outcome of the action was;
• Analysis.

Chronologies of significant health events are useful in understanding recurring patterns of behaviour and concerns in PP and FII. In cases involving PP, the initial assessment should focus on understanding the child's current functioning and any discrepancies between what is reported and what the child is observed or considered to be able to achieve, given objective medical information about proven pathology (physical and psychiatric). Chronologies are particularly valuable when there is uncertainty about the extent or pattern of past reported illnesses/significant events and/or there is a requirement to make a case for a significant harm threshold for child protection or court proceedings.

Although very useful, chronologies are usually time consuming to compile and are not always necessary. Assessment of current functioning and a management plan should not await the production of chronologies as appropriate action for the child should not be delayed.

Health chronologies should be compiled by multi-professional health teams and must include an experienced and senior health professional that fully understands the presenting health issues so as to interpret significant events through this lens (usually a consultant paediatrician or a Child and Adolescent Psychiatrist).

Chronologies should aim to be objective in determining which significant events are included. They must contain balanced information, including significant positive information about family functioning or test/observation results not necessarily in keeping with the overall concerns. Recording of facts in chronologies should be kept separate from opinion and analysis, but it is important that this is included in order for non-health professionals to easily make sense of the information presented.

Although chronologies are often requested as standalone documents, they can be misleading without a summary and overall analysis. This analysis should include proven diagnoses, important comments by both parents and child, information about parent/child perception of illness, important discrepancies in reporting and observed health information and recurring patterns of behaviour/presentation. This analysis could include commentary on whether the overall situation is likely to meet the significant harm threshold.

The Summary Diagram at 7.2 in the RCPCH Guidance outlines the pathway approach to be followed after identification of alerting signs.

9.3 Strategy Discussion / Meeting

If there is reasonable cause to suspect the child is suffering, or is likely to suffer Significant Harm, Children's Social Care should convene a Strategy Discussion, preferably a meeting. See Strategy Discussions Procedure. It should at a minimum, include Children's Social Care, Police, the lead paediatrician responsible for the child's health and, if the child is an in-patient, a senior nurse from the ward. It is also important to consider seeking advice from, or having present, medical practitioner who has expertise in the branch of medicine, for example, respiratory, gastroenterology, neurology or renal, which deals with the symptoms and illness processes caused by the suspected abuse and the named / designated doctor for safeguarding children.

Practitioners involved with the child such as the GP, health visitor, staff from education settings or other workers involved, should also be invited as appropriate. The Local Authority's solicitor may also be invited to attend this meeting. Staff should be sufficiently senior to be able to contribute to the discussion of information, which is often complex, and to make decisions on behalf of their agencies. Decisions about undertaking covert video surveillance should be made at a Strategy Meeting.

9.4 Making Suspected Perpetrators Aware

If a parent/carer is the suspected perpetrator of the abuse, at the point it is decided to hold a Strategy Discussion careful thought should be given to what they are told, when and by whom. Children's Social Care should involve the Police, the child's consultant paediatrician, the Senior Ward Nurse (if the child is an in-patient) and other relevant practitioners in making these decisions.

If it is believed that a criminal offence is being / has been committed and that a prosecution is a viable option, a police officer should caution the suspect. In such circumstances no one else should approach a parent about the concerns, without first discussing the possibility with the investigating police officers. An arrest may ultimately be necessary.

The consultant paediatrician should explain why the symptoms presented are believed to be due to fabricated or induced illness. A child protection social worker should inform the parents/carers of any steps being taken to ensure the safety of the child.

Not all these tasks will be performed at the same time. If a criminal investigation is being pursued then a police officer and doctor should be the ones to raise the issue with the parent (followed by a social worker explaining measures to protect the child). If not, then a doctor and a social worker should approach the parent together.

9.5 Section 47 Enquiries and Assessment

The nature of any further medical tests will depend on the evidence available about how the signs and symptoms are being caused. It is important to assess the child's understanding, as appropriate to their age, of their symptoms. The nature of their relationship with each significant family member (including all caregivers), each of the caregivers' relationships with the child, the parents' relationships with the child, the parents' relationship with each other and the children in the family, as well as the family's position within their community should also be taken into consideration.

The Assessment should also include the systematic gathering of information about the history of the child and each family member, building on that already gathered during the course of each agency's involvement with the child. Assessment of an unborn child should also be undertaken and a Pre-Birth Conference held if there is considered to be risk.

Particular emphasis should be given to health (physical and mental), education and employment as well as receipt of state benefits relating to a disabled child, social and family functioning and any history of criminal involvement. A range of specialist assessments may be required. For example, physiotherapists, occupational therapists, speech therapists and child psychologists may be involved in specific assessments relating to the child's developmental progress; Children and Young People’s Mental Health Services (CYPMHS) practitioners and adult mental health practitioners may be involved in assessments of individuals or families.

10. Guidance for Gathering Information / Evidence

In cases of suspected fabricated or induced illness, and when children are patients in hospital.

From the time suspicions are first aroused, all specimens of urine, blood and any other required samples should be retained, securely stored, and a record made of who took each one and who subsequently handled them. This is to ensure continuity in any possible Court proceedings. If the use of Covert Video Surveillance to gather evidence is discussed, guidance as detailed at Section 9, Covert Video Surveillance (CVS) should be followed.

As well as medical tests and investigations to find either a genuine cause for a child's symptoms or evidence of inducement of illness there is a need to establish if there are changes when controls are put in place. These could include restricting a child's intake of food and drink to only that provided by the hospital, ensuring medication is only administered by staff, or separation of parent and child.

Practitioners should not be 'influenced' by suspected perpetrators having a medical background; as they can use this to obtain misplaced confidence in their parenting and so cover abusive behaviour.

As far as possible, information given by the parent should be verified. A partner may be able to corroborate a parent / carer's account; the G.P. may provide information that substantiates reports of previous illness; and interviewing others who are said to have witnessed episodes of apnoea (stopping breathing) attacks or other symptoms could be informative.

Often there will be a need to painstakingly go through all medical notes to piece together the history of attention received by the child. A chronological record should then be produced with each entry giving:

• The date and place of each consultation and with whom;
• What the symptoms were and, if possible to distinguish, whether they were seen by medical staff or just reported to them;
• Any tests/investigations carried out and their results.

Comment can then be made on any discrepancy between the findings and the history given by the carer, or between that given by the carer and others, together with a view as to whether this is a result of fabrication or not. In addition, any disparity between the medical findings and known medical entities should be noted and a different diagnosis for the child's condition(s) given, in order of likelihood.

10.1 Recording Information

Careful and detailed note taking by all staff, including health practitioners, is very important for any subsequent police investigation or court action. Any unusual events should be recorded and a distinction should be made between events reported by the parent / carer and those actually witnessed by staff. Notes should be timed, dated and signed legibly. Most importantly, notes should be confidential and kept in a secure place so that unauthorised persons cannot access them. Storage of these records should be in accordance with agencies record policies.

11. Attendance at the Initial Child Protection Conference

All relevant practitioners who have been involved in the child's life should attend the Initial Child Protection Conference, as well as those who are likely to be involved in future work with the child and their family. For more information see Initial Child Protection Conference.

As well as the practitioners detailed above, it is important to consider seeking advice from, or having present, a medical practitioner who has expertise in the branch of paediatric medicine, e.g. respiratory, gastroenterology, neurology or renal, which deals with the symptoms and illness processes caused by the suspected abuse. This would enable the medical information to be presented and evaluated from a sound evidence base.

The decision to include a child in a Child Protection Conference should be based on their age and capacity to understand what will be discussed. Some children may not understand what has been happening to them and may, therefore, find it difficult to understand what practitioners are discussing. Others may be very clear but may not have been able to talk to a trusted adult or may not have been listened to. In both situations it may be inappropriate to include the child. All children in whom illness has been fabricated or induced are likely to have suffered emotional abuse. If they do not attend the conference, consideration should be given as to who will tell them what was discussed. The safety of the child following the conference must also be carefully considered and an understanding of how it is to be ensured conveyed to the child.

Although exceptional to standard practice, in the case of a child in whom illness may have been fabricated or induced, it may be necessary to exclude one or more family members from all or part of the Conference. This decision should be based on considerations of ensuring the child's safety and be made by the Conference Chair on a case-by-case basis. Steps may also be required to protect practitioner staff from intimidation either in the Conference or after it.

The extent and manner of involvement of family members should be informed by what is known about them. The abusing carer may not be able to acknowledge their behaviour to their partner, the non-abusive parent may have had no knowledge of the abuse or they may have had some understanding, which now makes better sense to them. These are matters which should be addressed outside the conference in a sensitive manner.

11.1 Information for the Conference

Children's Social Care has responsibility for ensuring that, as far as is possible, a joint chronology has been drawn up from practitioners who have seen the child over a period of time, with special emphasis on the child's medical history. The health history of siblings should also be considered, and action taken accordingly if there is any concern about their care. This includes risk of harm other than fabricated or induced illness. The Chair has responsibility for ensuring that additional or contradictory information is presented, discussed and recorded in the Conference.

Careful consideration should be given to when agency reports will be shared with the child's parents. This decision will be made by the Initial Child Protection Conference Chair, in consultation with the practitioner responsible for each report.

11.2 Action and Decisions for Conference

Particular attention should be given in the Child Protection Plan as to what steps will be necessary to safeguard the child. These will depend on the nature of the harm suffered by the child. If the child's life has been threatened by, e.g. attempted smothering, poisoning or introducing noxious substances intravenously, all necessary measures should be put in place to ensure that these actions cannot take place in the future. This may mean that the child has to be separated from the abusing parent, and if possible cared for solely by the other parent, or, if the abusing parent is unwilling to leave the house, placed in an alternative family context, or remain in hospital for further medical treatment before being well enough to be discharged. To avoid repeat abuse, contact may have to be closely supervised by a practitioner whose level of knowledge enables them to be alert to the precursors of further abuse.

Conference participants must be clear what actions will be taken to safeguard the child immediately after the Conference, as well as in the longer term. For some children it may be necessary to institute legal proceedings either immediately or soon after the Conference has ended. This decision should be taken by Children's Social Care in conjunction with its legal advisors. It is important that the doctors involved agree to support this action, since it is their medical evidence, which will form a key part of the evidence presented to a Court.

The Conference should also consider what action is required to protect siblings in the family. Abusive behaviour may transfer to another child in the family, once the identified child is placed in a safe environment.

Knowledge of the parents/ carers' medical and psychiatric histories, in particular the abuser/s, should be considered. Services for the parents / carers may be required immediately, e.g. if there is a history of self-harming behaviour or a likelihood they may attempt suicide or develop other types of psychiatric symptoms.

11.3 Adult Mental Health

Adult Mental Health Service guidance should be sought at the earliest opportunity for the adult carer, especially if there is a history of psychiatric illness and self-harming behaviour. A referral should be made, if appropriate, immediately.

11.4 Consultation

As fabricated or induced illness is a relatively rare phenomenon, it is unlikely that all members of the Strategy Meeting will have previous experience to work with the child and / or parent carer without expert support. Therefore consideration should be given to consultation with a practitioner who has recognised experience in the field of fabricated or induced illness and is able to provide additional support to the meeting.

12. Covert Video Surveillance (CVS)

After serious consideration a decision may be made at the Multi-Agency Strategy Discussion to use Covert Video Surveillance (CVS). The surveillance will be undertaken by the police, the operation controlled and the accountability for it held by a Police Manager. CVS should be used if there is no alternative way of obtaining information which will explain the child's signs and symptoms, and the Multi-Agency Strategy Meeting considers that its use is justified based on the medical information available. All personnel including nursing staff, who will be involved in its use should have received specialist training in this area.

The lead medical consultant responsible for the child's care should ensure that the necessary medical and nursing staff are available to provide the child with immediate and appropriate health care when necessary. The level and nature of health involvement during the period of covert surveillance should be agreed at the Strategy Discussion and all relevant staff briefed on the arrangements for the child's health care. All decisions to undertake covert video surveillance should be recorded in the child's records and signed by a Senior Manager.

Police Officers planning surveillance in cases of suspected fabricated or induced illness may seek advice from the National Crime Agency.

The safety and health of the child is the overriding factor in the planning and carrying out of covert video surveillance. The primary aim of undertaking covert video surveillance is to identify whether the child is having illness induced, of secondary importance is the obtaining of criminal evidence. Legal advice should be sought where appropriate, or in cases of doubt.

Children's Social Care should have a contingency plan in place, which can be implemented immediately if C.V.S. provides evidence of child abuse. If there is no evidence of abuse the child may be a child in need.

13. Action in the Absence of a Diagnosis of Fabricated or Induced Illness

A diagnosis of fabricated or induced illness does not have to have been made in order to protect a child, even though it is suspected. Action can be taken where it can be established that Significant Harm has occurred, or is likely to occur, and that it can be attributed to a person with parental responsibility.

Once an assessment has been made the normal Child Protection Procedures should be followed and registration be considered under the categories of either Physical or Emotional Abuse. See Developing and Implementing a Child Protection Plan Procedure for more information. As in other cases, the range of legal powers available to swiftly protect a child and prevent a parent from removing the child from hospital need to be considered. These include Police Protection, Emergency Protection Order and Child Assessment Orders. A Child Assessment Order allows for a child to be assessed in hospital, provided it is specifically requested. This would need to be stated in advance in the proposed plan in the application to the Court.

Careful consideration needs to be given to an alternative placement of a child away from the family home, with relatives or family friends. This is because people close to the parent / carer may find it difficult to accept the existence of fabricated or induced illness as an explanation for the child's condition. This may make it easier for the parent / carer to obtain access to the child.

The response of the suspected parent / carer to these measures will set parameters for how much she or he can be worked with, both in terms of her/his own treatment and in ensuring the welfare of the child.

Appendix 1: Fabricated and Induced Illness Flowchart

Click here to view Appendix 1: Fabricated and Induced Illness Flowchart.

Appendix 2 : Flowchart from RCPCH Guidance, 7.2

Appendix 2 : Flowchart from RCPCH Guidance, 7.2 outlines the pathway approach to be followed after identification of alerting signs.

Appendix 3 : Template for Health and Education Rehabilitation Plan from RCPCH Guidance, 12.1

Appendix 3: Template for Health and Education Rehabilitation Plan from RCPCH Guidance, 12.1 outlines the pathway approach to be followed after identification of alerting signs.

Appendix 4: References for Fabricated or Induced Illness

Bass C and Adshead G, 2007 Fabrication and induction of illness in children: the psychopathology of abuse Advances in Psychiatric Treatment13: 169-177

Bools C N, Neale B A and Meadow S R, 1993 Follow up of victims of fabricated illness (Munchausen Syndrome by Proxy) Archives of Disease in Childhood.69: 625-630

Gray J and Bentovim A, 1996

Illness Induction Syndrome: Paper I - A series of 41 Children from 37Families Identified at The Great Ormond Street Hospital for Children NHS Trust. Child Abuse and Neglect.20 8: 655-673.

Gray J, Bentovim A and Milla P, 1995 The treatment of children and their families where induced illness has been identified. In: Horwath J and Lawson B (eds), 1995 Trust Betrayed? Munchausen Syndrome by Proxy: Inter-Agency Child Protection and Partnership with Families. National Children's Bureau, London.

McClure R J, Davis P M, Meadow S R and Sibert J R, 1996 Epidemiology of Munchausen syndrome by proxy: non-accidental poisoning and non-accidental suffocation. Archives of Disease in Childhood.75: 57-61.

Neale B, Bools C and Meadow R (1991) Problems in the assessment and management of Munchausen Syndrome by proxy abuse. Children and Society.5 4: 324-333.

Sanders M J, 1995 Symptom coaching: Factitious disorders by proxy with older children.

Special Issue: The impact of the family on child adjustment and psychopathology. Clinical Psychology Review.15: 423-442.