Fabricated or Induced Illness / Perplexing Presentations

1. Definition

Fabricated or Induced Illness is a clinical situation where a child is, or is very likely to be, harmed due to parents/carers behaviour and action, carried out in order to convince doctors that the child state of physical and/or mental health or neurodevelopment is impaired (or more impaired than is actually the case).

It is a relatively rare but potentially lethal form of abuse.

Royal College of Paediatrics and Child Health guidance Perplexing Presentations (PP)/Fabricated or Induced Illness in Children (2021) uses the following definitions:

Medically Unexplained Symptoms

The child complains of symptoms which are genuinely experienced but not fully explained medically. The symptoms are likely to be based on underlying factors in the child (usually of a psychosomatic or psychosocial nature), and can represent the expression of psychological illness through physical symptoms. This is acknowledged by both clinicians and parents, who work collaboratively to achieve therapeutic work in the best interests of the child.

Perplexing Presentations (PP)

The presence of alerting signs of possible Fabricated or Induced Illness but when the actual state of the child's physical/mental health is not yet clear and there is no perceived risk of immediate serious harm to the child's physical health or life. The actual state of the health of the child will need to be established.

The essence of alerting sings is the presence of discrepancies between reports, presentation of the child and independent observations of the child, implausible descriptions and unexplained findings or parental behaviour.

Fabricated or Induced Illness (FII)

A clinical situation in which a child is, or is very likely to be, harmed due to parental behaviour and action, carried out in order to convince doctors that the child's state of physical and/or mental health or neurodevelopment is impaired or more impaired than is actually the case. FII can result in emotional and physical abuse and neglect as a result of parental actions, behaviours or beliefs and from doctors' responses to these. This can include inadvertent harm caused by medical professionals such as unnecessary invasive investigations/procedures. The parent does not necessarily intend to deceive, and their motivations may not be initially evident. Previously known as Munchausen Syndrome by Proxy.

Concerns will be raised for a small number of children when it is considered that the health or development of a child is likely to be significantly impaired or further impaired by the actions of a carer or carers having fabricated or induced illness. The presence of alerting signs where the actual state of the child's physical/mental health is not yet clear but there is no perceived risk of immediate serious harm to the child's physical health or life may be evidence of a “Perplexing Presentation”.

Perplexing presentations indicate possible harm due to fabricated or induced illness which can only be resolved by establishing the actual state of health of the child. Not every perplexing presentation is an early warning sign of fabricated illness, but professionals need to be aware of the presence of discrepancies between reported signs and symptoms of illness and implausible descriptions of illnesses and the presentation of the child and independent observations of the child. It is important that the focus is on the outcomes or impact on the child's health and development and not initially on attempts to diagnose the parent or carer.

The range of symptoms and body systems involved in the spectrum of fabricated or induced illness are extremely wide.

Investigation of Fabricated and Induced Illness and assessment of significant harm to a child falls under statutory framework provided by Working Together to Safeguard Children and Safeguarding Children in whom illness is fabricated or induced (Supplementary guidance to Working Together to Safeguard Children). HM Government 2008.

2. Risks

There are four main ways of the carer fabricating or inducing illness in a child:

  • Fabrication of signs and symptoms, including fabrication of past medical history;
  • Fabrication of signs and symptoms and falsification of hospital charts, records, letters and documents and specimens of bodily fluids;
  • Exaggeration of symptoms/real problems. This may lead to unnecessary investigations, treatment and/or special equipment being provided;
  • Induction of illness by a variety of means.

The above four methods are not mutually exclusive.

Harm to the child may be caused through unnecessary or invasive medical treatment, which may be harmful and possibly dangerous, based on symptoms that are falsely described or deliberately manufactured by the carer, and lack independent corroboration.

Concern may be raised at the possibility of a child suffering significant harm as a result of having illness fabricated or induced by their carer.

3. Indicators

  • Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering; or
  • Physical examination and results of medical investigations do not explain reported symptoms and signs; or
  • There is an inexplicably poor response to prescribed medication and other treatment; or
  • New symptoms are reported on resolution of previous ones; or
  • Reported symptoms and found signs are not observed in the absence of the carer; or
  • Over time the child is repeatedly presented with a range of symptoms to different professionals in a variety of settings; or
  • The child's normal, daily life activities, such as attending school, are being curtailed beyond that which might be expected from any known medical disorder from which the child is known to suffer;
  • Excessive use of any medical website or alternative opinions.

There may be a number of explanations for these circumstances and each requires careful consideration and review.

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

Professionals who have identified concerns about a child's health should discuss these with the child's GP or consultant paediatrician responsible for the child's care.

4. 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 (eg 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 (eg 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. Protection and Action to be Taken

Where there is a suspicion of FII, practitioners should consider this guidance carefully when fulfilling their role in assessing and investigating their concerns effectively.

In situations where the child may be at immediate risk of serious harm through an induced illness and immediate referral to the police and Children's Services Trust in accordance with the Contacts and Referrals Procedure.

Children who have had illness fabricated or induced require coordinated help from a range of agencies.

Joint working is essential, and all agencies and professionals should:

  • Be alert to potential indicators of illness being fabricated or induced in a child;
  • Be alert to the risk of harm which individual abusers may pose to children in whom illness is being fabricated or induced;
  • Share and help to analyse information so that an informed assessment can be made of children's needs and circumstances including an up to date Chronology;
  • Contribute to whatever actions and services are required to safeguard and promote the child's welfare;
  • Assist in providing relevant evidence in any criminal or civil proceedings.

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

The signs and symptoms require careful medical evaluation for a range of possible diagnoses.

Normally, the doctor would tell the parent/s that they have not found the explanation for the signs and symptoms and record the parental response.

Where there are concerns about possible fabricated or induced illness, the signs and symptoms require careful medical evaluation for a range of possible diagnoses by a paediatrician.

If no paediatrician is already involved, the child's GP should make a referral to a paediatrician.

Where, following a set of medical tests being completed, a reason cannot be found for the reported or observed signs and symptoms of illness, further specialist advice and tests may be required.

Normally the consultant paediatrician will tell the parent(s) that they do not have an explanation for the signs and symptoms.

Parents should be kept informed of further medical assessments/ investigations/tests required and of the findings but at no time should concerns about the reasons for the child's signs and symptoms be shared with parents if this information would jeopardise the child's safety and compromise the child protection process and/or any criminal investigation.

When a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer and as a consequence the child's health or development is or is likely to be impaired, a referral should be made to the Children's Services Trust or the Police (see Contacts and Referrals Procedure):

  • Lead responsibility for the coordination of action to safeguard and promote the child's welfare lies with the Children's Services Trust;
  • Any suspected case of fabricated or induced illness may involve the commission of a crime and therefore the police should always be involved;
  • The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care.

In cases where the police obtain evidence that a criminal offence has been committed by the parent or carer, and a prosecution is contemplated, it is important that the suspect's rights are protected by adherence to the Police and Criminal Evidence Act 1984.

6. Management of Suspected Cases

For more information see Fabricated or Induced Illness Flowchart.

6.1 Initial Response

Any health professional may come across a child who they suspect may have an illness that is fabricated or induced. They may suspect that an adult with whom they work is the perpetrator of such abuse, or that another child may be the abuser, a parent, a carer or a professional. It is their responsibility to seek advice on their concerns if they are not sure what to do, and take action in consultation with their line manager and relevant others. The health professional must consult with their Named Doctor and/or Named Nurse who will determine appropriate next actions.

The Designated Professionals for Safeguarding Children should be involved from the earliest stages in all cases of actual or potential FII and should facilitate Strategy Meetings and staff support. 

There may be other explanations, apart from FII for these concerns. Therefore careful consideration and review is necessary and professionals should remain open to all possibilities at this stage. It may be appropriate at this stage that the Safeguarding Children Professionals review the child's health record and seek advice from the responsible paediatrician where applicable. The Safeguarding professionals may decide it is relevant at this point, where safe to do so, to organise a health professional meeting to discuss concerns and to ensure other professionals cannot provide evidence of illness rather than FII. In other cases, it may be decided that immediate protection is indicated and the case should be referred to Doncaster Children's Services Trust at this stage, see Contacts and Referrals Procedure.

Where an initial health meeting is indicated all key health professionals, including the GP and any Consultants that have worked with the child should attend and contribute to the creation of a Chronology. The meeting will be confidential and chaired by a Safeguarding Children Designated Professional. Parents or carers will not be invited to this meeting but a key part of the meeting will relate to whether there is a need to refer the case to the Children's Services Trust and what needs to be done to inform and involve parents. The medical evaluation will consider signs and symptoms, parental/carer and children's behaviour, results of tests and observations which have been noted by professionals.

Where concerns remain, a medical opinion should be sought through an identified Lead Paediatrician who may be the responsible Consultant Paediatrician in charge of the child's care. The Lead Paediatrician will then co-ordinate all aspects of the identification of FII, clinical management of the suspected case, communication with the parents/carer, named and designated professionals and links with the Children's Services Trust.

A thorough medical examination should be undertaken by a Paediatrician. If the child is not already under such care, then the GP should make the referral. However, this may also be carried out as a result of initiating Section 47 Enquiries.

6.2 Referral to Doncaster Children's Services Trust

If it is decided that the child is suffering or likely to suffer Significant Harm as a result of suspected FII, there should be a referral to the Children's Services Trust. Following receipt of such a referral, Health, Police, the Children's Services Trust, and any other involved agencies (see Referrals Procedure) should work together to safeguard and promote the welfare of the child. The Children's Services Trust will take the lead in co-ordinating the response. The Police should be involved, as fabricating illness is a criminal offence and therefore a Police investigation may follow.

The Children's Services Trust 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 a Children and Families Assessment should be undertaken.

6.3 Children and Families Assessment

The aim of the Children and Families Assessment is to determine whether the child is in need or whether there are concerns about Significant Harm, and the nature of services required. On completion of the Children and Families Assessment, careful consideration should be given by the Social Worker and the Consultant Paediatrician responsible for the child's health care, as to what the parents or carers should be told, when and by whom, taking account of the child's welfare.

If it becomes clear that there is reasonable cause to suspect the child is suffering or is likely to suffer Significant Harm, 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 protection may be required (i.e. Police Protection or Emergency Protection Order).

If the health Chronology is not available at this stage, it is essential that it is commenced.

6.4 Strategy Discussion

Where there is reasonable cause to suspect the child is suffering, or is likely to suffer Significant Harm, the Children's Services Trust should convene a Strategy Discussion, preferably a meeting. It should at minimum, include the Children's Services Trust, the Police, the Paediatrician responsible for the child's care and, if the child is an inpatient, senior member of the nursing staff or Safeguarding Professional. It is also important to consider seeking advice from, or having present, a medical professional who has expertise in the branch of medicine which deals with the symptoms, illness processes caused by suspected abuse (i.e. respiratory, renal, gastroenterology, or neurology).

Professionals involved with the child such as the GP, health visitor, school nurse, staff from education settings or others involved should be invited as appropriate. The local authority solicitor may also be invited to 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. Any decisions about undertaking covert surveillance should be made at the Strategy Meeting.

6.5 Making Suspected Perpetrators Aware

If a parent or 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. The aim of the decision is to protect the child from further possible harm and safety issues must be addressed. The Children's Services Trust should involve the Police, the child's Consultant Paediatrician, the senior ward nurse (if the child is an inpatient) and other relevant professionals in making these decisions.

If it is believed that a criminal offence is being/has been committed and that prosecution is a viable option, a Police Officer should caution the suspect. In such circumstances no one else should approach a parent or carer 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 FII. A Child Protection Social Worker should inform the parents or carers of any steps being taken to ensure the safety of the child.

It may be that the above tasks will not be undertaken at the same time. If a criminal investigation is being pursued then a Police Officer and Doctor should raise the issue with the parent or carer (followed by a social worker explaining measures to protect the child). If not, then the Doctor and Social Worker should approach the parents/carers together.

6.6 Section 47 Enquiries

The nature of any further medical investigations will depend upon the evidence available about how the child's 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 care givers), each of the caregiver's relationship with the child, the parent's relationship with each other and the children in the family, as well as the family's position within their community.

The Children and Families Assessment should 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 a considered 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 psychologists may be involved in specific assessments relating to the child's developmental progress; child and adolescent mental health professionals and adult mental health professionals may be involved in assessments of individuals or families.

6.7 Gathering Information/Evidence

From the time suspicions are 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 subsequently handled them. This is to ensure continuity in any possible court proceedings.

In rare cases Police investigations have used visually recorded covert surveillance. The safety and health of the child (both long term and short term) is the overriding factor in planning and implementing covert surveillance (see Section 5.14, Covert Video Surveillance).

Alongside medical investigations utilised to establish either a genuine cause of symptoms or evidence of inducement of illness, there is a need to establish whether there are changes when controls are put in place. These could include restricting a child's intake of food and drink to that provided by the hospital, ensuring medication is administered by hospital staff or separation of parent/carer and child.

Practitioners should not be influenced by suspected perpetrators having a medical background, as this can be used to obtain misplaced confidence in their parenting/caring and so cover abusive behaviour.

Wherever possible, information from the parent or carer should be verified. A non-abusive partner may be able to corroborate a parent/carers account. The GP may provide information that substantiates reports of previous illness and interviewing others, such as those who are said to have witnessed episodes of apnoea (stopping breathing) or other symptoms could be useful.

In order to determine a medical history of attention received by the child a Chronology should be produced;

  • The Chronology should include details of the date and place of every known medical consultation and with whom;
  • The record should provide details of the symptoms and whether they were witnessed by medical staff or reported to them;
  • Any tests/investigations conducted and their results.

Comment can be given on any discrepancy between the findings and the history given by the parent or carer, or that between the parent/ 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.

6.8 Recording Information

Careful and detailed note taking by all staff, including health professionals, 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. Records should be timed, dated and signed legibly. Most importantly, records should be confidential and kept in a secure place so unauthorised persons cannot access them.

6.9 Attendance at the Initial Child Protection Conference

All relevant professionals who have been involved in the child's life should attend the conference, as well as those who are likely to be involved in future work with the child and their family.

Additionally, consideration should be given to inviting any medical professionals who have expertise in the branch of paediatric medicine relevant to the child's symptoms and illness processes caused by the suspected abuse.

The decision whether to invite the child to the Child Protection Conference should be based on their age, their capacity to understand what will be discussed and the emotional impact of their situation and circumstances. For those children who do not attend the Child Protection Conference, based upon their level of understanding, consideration should be given as to who will tell them what has been discussed and how their safety will be ensured.

Although exceptional to normal 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 of the family members from all or part of the conference. This decision should be based upon considerations of ensuring the child's safety and may be made by the Conference Chair on a case by case basis. Steps may also be required to protect professional staff from intimidation either in the conference of after it.

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

6.10 Information for Conference

Doncaster Children's Services Trust is responsible for ensuring that, as far as is possible, a joint Chronology has been drawn up from professionals 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 FII. 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 or carers. This decision will be made by the Initial Child Protection Conference Chair, in consultation with the professional responsible for each report.

6.11 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 upon 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 steps should be put in place to ensure all these actions do not take place in future. This may mean that the child has to be separated from the abusing parent or carer and if possible cared for solely by the other parent/carer. If the abusing parent or carer is unwilling to leave the house, the child will be placed in an alternative family context, or remain in hospital for further medical treatment before he/she is well enough to be discharged. To avoid repeat abuse parental/carer contact may have to be closely supervised by a professional whose level of knowledge enables them to be alert to the precursors of further episodes of 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. It may be necessary to instigate legal proceedings either immediately or soon after the Conference has ended. This decision should be taken by Doncaster Children's Services Trust 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 any siblings in the family. It is possible that abusive behaviour could be transferred 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.

6.12 Adult Mental Health

Adult Mental Health Service guidance should be sought at the earliest opportunity for the adult parent or carer, especially if there is a history of psychiatric illness manifesting harm to self or others. A referral should be made immediately if appropriate. Consideration should be given as to the need for an expert opinion i.e. Consultant Psychiatrist or Psychologist, with respect to a diagnosis.

6.13 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 professional who has recognised experience in the field of fabricated or induced illness and is able to provide additional support to the meeting.

6.14 Covert Video Surveillance (CVS)

After serious consideration a decision may have been made at the Strategy Discussion or Child Protection Conference to use Covert Video Surveillance. 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 Strategy Meeting/Child Protection Conference 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 chief executive Trust Board member must be consulted throughout the planning and implementation of this process.

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

Telephone: 0370 496 7622
E-mail: communication@nca.x.gov.uk

The 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/Child Protection Conference and all relevant staff briefed on the arrangements for the child's healthcare and safety. All decisions to undertake covert video surveillance should be recorded in the child's professional records and signed by a Senior Manager within each organisation.

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 this method of 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.

Doncaster Children's Services Trust should have a contingency plan in place, which can be implemented immediately if CVS provides evidence of child abuse. If there is no evidence of abuse the child may be determined to be a Child in Need.

7. 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.

After the assessment has been completed, child protection procedures should be followed - see Referrals Procedure. This must include the development of a Child Protection Plan to protect the child under the categories of either Physical or Emotional Abuse. The range of legal powers available to swiftly protect a child and prevent a parent or carer from removing the child from hospital needs to be considered, as in other child abuse cases. 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 the 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 or carer to obtain access to the child.

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

8. Issues

Whilst cases of fabricated or induced illness are relatively rare, the term encompasses a spectrum of behaviour which ranges from a genuine belief that the child is ill through to deliberately inducing symptoms by administering drugs or other substances. At the extreme end it is fatal, or has life changing consequences for the child.

Contrary to normal professional relationships with parents, being challenging about suspicions from the start may scare off a parent thus making it more difficult to gain evidence. There may be an unintended consequence in increasing the harmful behaviour in an attempt to be convincing.

Parents who harm their children this way may appear to be plausible, convincing and have developed a friendly relationship with practitioners before suspicions arise. They may also demonstrate a seemingly advanced and sophisticated medical knowledge which can make them difficult to challenge. Practitioners should demonstrate professional curiosity and challenge in an appropriate way and with coordination between the agencies.