Fabricated or Induced Illness (FII) and Perplexing Presentations (PP): Definition, Indicators and Professional Response
Fabricated or Induced Illness (FII) is a form of child abuse where a parent or carer exaggerates, fabricates, induces or causes illness in a child, leading to unnecessary medical investigations, treatment or interventions. FII can result in significant physical, emotional and psychological harm to children and may have long-term consequences for their health and wellbeing.
Perplexing Presentations (PP) are situations where there are concerns about a child’s reported symptoms, presentation, health needs or behaviours, but where the explanation for those concerns is unclear or inconsistent. Not all Perplexing Presentations are cases of FII. However, they may require careful assessment, professional curiosity and multi-agency information gathering to ensure the child’s needs and safety are appropriately considered.
These cases are often complex and require a coordinated multi-agency response involving health professionals, Children’s Social Care, education and other relevant agencies.
This guidance should be read alongside:
What is Fabricated or Induced Illness?
FII occurs when a parent or carer:
- Exaggerates symptoms.
- Fabricates symptoms.
- Misrepresents a child’s health needs.
- Deliberately induces illness.
- Causes injury or ill health.
- Seeks unnecessary investigations or treatment.
The behaviour may be conscious or unconscious, but the focus of safeguarding assessment should always be the impact on the child rather than the motivation of the adult.
FII is relatively uncommon, but when it occurs the consequences for children can be severe.
What are Perplexing Presentations?
A Perplexing Presentation occurs when:
- Reported symptoms are inconsistent with clinical findings.
- Symptoms are difficult to explain medically.
- There are significant discrepancies between observations and reports.
- Concerns persist despite extensive assessment or intervention.
A Perplexing Presentation does not mean FII is present.
Many children have complex health needs, disabilities, rare conditions or symptoms that are difficult to explain. PP requires careful professional assessment and should not lead to assumptions about abuse.
The key consideration is whether the child’s health, wellbeing or development may be adversely affected.
Why FII and PP Matter
Children may experience significant harm as a result of fabricated or induced illness.
Physical Harm
Children may be subjected to:
- Unnecessary investigations.
- Medical procedures.
- Hospital admissions.
- Medications.
- Operations.
- Physical injury.
Emotional Harm
Children may experience:
- Anxiety.
- Emotional distress.
- Trauma.
- Confusion.
- Loss of confidence.
- Dependency on illness identity.
Educational and Social Harm
Children may experience:
- Reduced school attendance.
- Social isolation.
- Limited independence.
- Delayed development.
- Reduced opportunities.
The impact can affect every aspect of a child’s life.
Understanding FII
The Child’s Experience Must Remain Central
The focus should always be:
- What is happening to the child?
- How is the child’s health and wellbeing affected?
- What impact are professional and family responses having on the child?
Professionals should avoid becoming solely focused on adult behaviour and instead understand the child’s lived experience.
FII Is Often Characterised by Patterns
No single indicator is likely to confirm FII.
Concerns often emerge through a pattern of:
- Repeated presentations.
- Escalating concerns.
- Inconsistent information.
- Contradictory accounts.
- Extensive healthcare involvement.
Chronologies are particularly important.
Multi-Agency Information Is Critical
Different agencies may hold different parts of the picture.
Information from:
- Health.
- Education.
- Children’s Social Care.
- Early Help services.
- Mental health services.
may help identify patterns that are not immediately visible.
How Might FII or PP Present?
Concerns may arise where:
- A child’s presentation differs significantly across settings.
- Symptoms are repeatedly reported but not independently observed.
- There are discrepancies between parental accounts and professional observations.
- Extensive assessments fail to identify an underlying cause.
- The child experiences excessive medical intervention.
Professionals should remain open-minded and avoid making assumptions.
Signs and Indicators
Child Indicators
A child may:
- Regularly present as unwell without clear explanation.
- Have frequent hospital appointments.
- Undergo repeated investigations.
- Experience unnecessary medical treatment.
- Show developmental delays linked to illness narratives.
- Display anxiety regarding health.
Parent or Carer Indicators
Professionals may observe:
- Extensive reporting of symptoms.
- Reports that differ from professional observations.
- Resistance to reassurance.
- Requests for further investigations despite negative findings.
- Seeking second or multiple medical opinions.
- Focus on illness despite limited evidence of need.
The presence of these indicators does not confirm FII and should be assessed within the wider context.
Professional Indicators
Professionals may notice:
- Different accounts from different agencies.
- Significant discrepancies between settings.
- Lack of corroborating evidence.
- Reports that cannot be clinically explained.
- High levels of healthcare involvement.
Educational Indicators
Education staff may note:
- High levels of absence.
- Restrictions placed on school participation.
- Differences between school and home presentations.
- Concerns regarding independence and development.
Questions for Professional Curiosity
Professionals should consider:
- What is the child’s day-to-day experience?
- What symptoms have been independently observed?
- What evidence supports reported concerns?
- How does the child present in different settings?
- What explanations have been considered?
- Are there inconsistencies between reports and observations?
- What impact are medical interventions having on the child?
- What information do other agencies hold?
- What does the child say about their experiences?
These questions support balanced and evidence-based assessment.
Practice Considerations
Maintain an Open and Objective Approach
Professionals should:
- Gather evidence carefully.
- Remain professionally curious.
- Avoid assumptions.
- Base decisions on observations and information.
- Consider alternative explanations.
The aim is to understand the child’s needs and experiences rather than to prove wrongdoing.
Focus on the Child’s Lived Experience
Key questions include:
- Is the child receiving unnecessary treatment?
- Is the child missing education?
- Is the child’s development being affected?
- Is illness becoming part of the child’s identity?
- How is the child experiencing professional intervention?
Develop a Chronology
Chronologies are particularly important because concerns often develop gradually.
Professionals should record:
- Medical presentations.
- School attendance.
- Professional observations.
- Agency involvement.
- Significant events.
Patterns often emerge through careful analysis over time.
Professional Challenge
Where information is inconsistent, professionals should:
- Seek clarification.
- Share information appropriately.
- Discuss concerns within supervision.
- Escalate concerns where necessary.
Respectful professional challenge is an important part of safeguarding practice.
What Should Professionals Do?
Immediate Risk
If there are concerns that a child is:
- Being deliberately harmed.
- Receiving harmful treatment.
- At immediate risk of significant harm.
Take Immediate Action
- Contact Children’s Social Care immediately.
- Seek safeguarding advice.
- Contact Police where appropriate.
- Take action to protect the child.
Concerns About FII or Perplexing Presentations
Contact Children’s Social Care (MASH)
Telephone: 0191 424 5010
Monday to Thursday: 8.30am to 5.00pm
Friday: 8.30am to 4.30pm
Out of Hours
Telephone: 0191 456 2093
Referral Routes
Professionals should also seek advice from safeguarding leads and relevant health professionals.
Recording FII and PP Concerns
Professionals should record:
- Direct observations.
- Symptoms observed personally.
- Child disclosures.
- Information provided by family members.
- Professional discussions.
- Attendance information.
- Medical involvement.
- Actions taken.
- Professional analysis.
Records should clearly distinguish between:
- Fact.
- Observation.
- Reported information.
- Professional opinion.
Information Sharing
These cases often require extensive multi-agency information sharing.
Information may include:
- Medical information.
- School attendance and attainment.
- Professional observations.
- Developmental concerns.
- Historical safeguarding information.
- Early Help involvement.
No single agency is likely to hold the full picture.
Further guidance:
Local Guidance and Resources
South Tyneside
Regional
Relevant chapters include:
- Fabricated or Induced Illness
- Children with Disabilities
- Child Protection
- Assessment
- Information Sharing
National Resources
- https://childprotection.rcpch.ac.uk/resources/perplexing-presentations-and-fabricated-or-induced-illness-in-children-guidance/
- NSPCC Fabricated or Induced Illness Guidance
- Working Together to Safeguard Children 2026
Key Practice Message
Fabricated or Induced Illness and Perplexing Presentations are complex areas of safeguarding practice. Professionals should remain curious, objective and evidence-based, focusing on the child’s lived experience and wellbeing. The key question is not whether symptoms exist, but whether the child is being harmed by the way concerns about their health are being presented, interpreted or responded to. Effective multi-agency working, careful recording and professional challenge are essential to protecting children and ensuring their needs are properly understood.