Fabricated or induced illness (FII) is a rare form of child abuse. It occurs when someone who is caring for a child, usually the child’s biological mother, fakes or actually causes the symptoms of illness.

The term ‘mother’ will be used throughout this article to describe the perpetrator of FII. However, it should be made clear that a small number of cases of FII have involved the father, foster parent, grandparent, guardian, or a healthcare or childcare professional.

FII is also known as Munchausen syndrome by proxy. Munchausen's syndrome is a condition where a person pretends to be ill or causes illness or injury to themselves. See the Health A-Z topic about Munchausen's syndrome for more information about this condition.

The term Munchausen syndrome by proxy is sometimes used to describe when someone fabricates or causes illness or injury to others. However, healthcare professionals in the UK prefer to use the term fabricated or induced illness for the two main reasons below.

• Munchausen syndrome by proxy places the emphasis on the person carrying out the abuse rather than the child who is the victim of abuse.
• The term Munchausen syndrome by proxy has been misinterpreted as a psychiatric diagnosis when, in fact, it was designed to describe a particular pattern of abuse.

The term Munchausen syndrome by proxy is still widely used in other countries.

Range of cases

The term FII covers a wide range of cases and behaviours ranging from moderate to severe. For example, these might be:

• a mother who convinces her child they are ill when in fact they are perfectly healthy
• a mother who exaggerates or lies about her child’s symptoms
• a mother who manipulates test results to suggest the presence of illness, for example by putting glucose in urine samples to suggest the child has diabetes
• a mother who deliberately induces symptoms of illness, for example by poisoning her child with inappropriate medication

How common is fabricated or induced illness?

It is difficult to estimate exactly how widespread FII is because many perpetrators of abuse are very good at disguising their actions.

The British Paediatric Surveillance Unit (BPSU), which is a specialist unit that assists researchers into rare childhood conditions, carried out a study of cases of FII.

The study identified 97 cases of FII in the UK over a two-year period. This equates to one child in every 5,000 being affected by FII.

However, it is highly likely that this figure underestimates the true scale of the problem. Another expert study estimates that the number of children affected by FII could be as high as one in every 1,100.

Most cases of FII involve young children, with 20 months being the average age at diagnosis. In 90% of reported cases of FII the child’s mother is responsible for the abuse.

Motivation

It is not fully understood why FII occurs, but a number of theories have been suggested. It could be that the mother enjoys the attention of playing the role of a ‘caring mother’.

A large number of mothers who have been involved in cases of FII have had a previous history of unresolved psychological and behavioural problems, such as a history of self harming or drug or alcohol misuse, or have experienced the death of another child.

There have been several reported cases where illness was fabricated or induced for financial reasons, for example to claim disability benefits. However, it is not known exactly how widespread this practice is because, unlike in the ‘classic’ pattern of FII, mothers who are involved in this type of deception tend to avoid visiting doctors to prevent their deception being discovered.

Child protection

FII is a child protection issue and cannot be treated by the NHS alone. Medical professionals who suspect FII is taking place should liaise with social services and the police, and must follow local child protection procedures.

The first priority is to protect the child. This may involve removing the child from their mother’s care or, if the child is in hospital, removing the carer from the ward.

Once the child is safe it may be possible to treat the mother’s underlying psychological problems. However, women who are involved in FII are notoriously difficult to treat because most refuse to admit their abusive behaviour. Therefore, in many cases, the child is permanently removed from their care.

Outlook

Children who are affected by FII often experience significant trauma and are often subjected to significant levels of abuse. The BPSU study found that one in four victims of FII still had significant physical and/or psychological problems two years after the abuse had stopped.

It is estimated that 1 child in every 16 will die as a result of the abuse that they receive. A further 1 in every 14 will experience long-term or permanent injury.

Warning signs

The warning signs that may indicate that a child is being subjected to fabricated or induced illness (FII), also known as Munchausen syndrome by proxy, are:

• the mother reports signs and symptoms that are not explained by any known medical condition
• physical examination and diagnostic tests do not explain the reported signs and symptoms
• the affected child has an inexplicably poor response to medication or other treatment
• the only person claiming to see noticeable symptoms is the mother
• if a particular health problem is resolved, the mother suddenly begins reporting a new set of symptoms
• the child’s daily activities are being limited far beyond what you would usually expect as a result of having a certain condition, for example, they never go to school or have to wear leg braces even though they can walk properly
• the mother seeks multiple opinions from a range of different healthcare professionals
• the mother often has good medical knowledge or a medical background
• although the mother is very attentive to the child and stays with them constantly in hospital, she does not seem to be too worried about the child's health
• the mother often tries to maintain a close and friendly relationship with medical staff but can quickly become abusive or argumentative if her own views on what is wrong with the child are challenged
• the father has little or no involvement in the care of the child
• the mother encourages medical staff to perform often painful tests and procedures on the child (tests that most parents would only agree to if they were persuaded that it was absolutely necessary)
• the mother has a history of frequently changing GPs or visiting different hospitals for treatment, particularly if her views about her child’s treatment are challenged by medical staff
• there is direct evidence that the child’s symptoms are being fabricated, for example, if testing finds that the blood in a baby’s nappy is menstrual blood

Patterns and levels of abuse

The patterns of abuse found in cases of FII usually fall into one of six categories. These are ranked below from least severe to most severe. In the more severe cases of FII, the mother may carry out behaviour from several or possibly all categories.

The categories are:

• fabricating symptoms and manipulating test results to suggest the presence of illness
• withholding nutrients from the child
• inducing symptoms by means other than poisoning or smothering, such as using chemicals to irritate their skin
• poisoning the child with a poison of low toxicity, for example, using a laxative to induce diarrhoea
• poisoning the child with a poison of high toxicity, for example, using insulin to lower a child’s blood sugar level (causing hypoglycaemia)
• deliberately smothering the child to induce unconsciousness

In turn, the levels of abuse can range from moderate to severe. Previous case reports of FII have uncovered evidence of:

• mothers lying about their child’s symptoms
• mothers deliberately contaminating or manipulating clinical tests to fake evidence of illness, for example by adding blood or glucose to urine samples, placing their blood on the child’s clothing to suggest unusual bleeding, or heating thermometers to suggest the presence of a fever
• poisoning their child with unsuitable and non-prescribed medicine
• infecting their child’s wounds or injecting the child with dirt or faeces (stools)
• inducing unconsciousness by suffocating their child
• not treating or mistreating genuine conditions so they will get worse
• withholding food, which results in the child failing to develop physically and mentally at the expected rate

Reported symptoms

Mothers involved in fabricating or inducing illnesses usually allege symptoms that only happen at certain times, such as seizures (fits) and vomiting.

The most commonly reported symptoms in cases of FII are listed below, in order of most to least common:

• seizures (fits)
• apparently life-threatening events, for example, a mother may claim that her baby suddenly stopped breathing for a few minutes
• being unusually drowsy
• vomiting blood or passing blood in their stools
• feeding difficulties
• bowel disturbances, such as constipation and diarrhoea
• asthma
• vomiting
• heartburn
• spitting or coughing up blood
• skin rashes, wounds or other types of skin injury
• fabricated disability, for example, pretending that a young child has hearing difficulties
• false allegations that other people have abused the child
• blood in the child’s urine
• falsely claiming that the child has taken an accidental overdose

What to do if you suspect FII

If you suspect that someone you know may be fabricating or inducing illness in their child, it is not recommended that you confront them directly. A direct confrontation is unlikely to make a person admit to doing anything wrong and it may give them the opportunity to dispose of any evidence of abuse.

The person carrying out the abuse is also likely to seek advice from another healthcare professional or medical centre, which may result in the abuse going unreported for far longer.

If your job involves working with children, for example if you are a nursery worker or teacher, you should inform the person in your organisation who is responsible for child protection issues. If you do not know who this is, your immediate supervisor or manager should be able to tell you.

Alternatively, you can contact your local social services department or telephone the NSPCC’s child protection helpline, which is open 24 hours a day, seven days a week, on 0808 800 5000.

The exact cause or causes of fabricated or induced illness (FII) are unknown, and more research is needed to discover the definitive cause. However, previous traumatic experiences in the mother’s life seem to play an important role.

Child abuse

One study found that almost half of mothers who were known to have fabricated or induced illness in their child were victims of physical and sexual abuse during their own childhood.

However, it is worth noting that most people who were abused as children do not go on to abuse their own children.

Personality disorder

A high proportion of mothers involved in FII have been found to have a personality disorder and, in particular, a borderline personality disorder.

Personality disorders are a type of mental health problem where an individual has a distorted pattern of thoughts and beliefs about themselves and others. These distorted thoughts and beliefs may cause them to behave in ways that most people would regard as disturbed and abnormal.

A borderline personality disorder is characterised by emotional instability, disturbed thinking, impulsive behaviour and intense but unstable relationships with others.

Sometimes, people with personality disorders find a kind of reward in behaviour or situations that other people would find intensely distressing. It is thought that some mothers who carry out FII are not doing it out of any genuine malice or dislike of their child, but they somehow find the situation of their child being under medical care and supervision rewarding and comforting.

However, other mothers who have been involved in FII have reported feeling a sense of resentment towards their child because their child has a happy childhood, unlike their own. It is this feeling of resentment that triggers the abusive behaviour.

Role playing

A further theory is that FII is a kind of role playing. It allows a mother to adopt the role of a caring and concerned mother, while at the same time allowing her to pass the responsibility of caring for a child onto medical staff.

Escapism

Another theory is that FII is a way for the mother to escape from her own negative feelings and unpleasant emotions. By creating a permanent crisis situation surrounding her child, she is able to focus her thoughts on the treatment of her child while keeping her own negative feelings and emotions at bay.

It can be very difficult for healthcare professionals to diagnose a case of fabricated or induced illness (FII).

Doctors, particularly paediatricians (specialists in treating children) are taught that ‘mother knows best’ and, in most cases, mothers have a natural and instinctive ability to spot when something is not right with their child. Therefore, their opinions should always be taken seriously.

Healthcare professionals will naturally assume that a mother will always act in the best interest of her child unless there is compelling evidence to suggest otherwise.

If FII is suspected

If a healthcare professional suspects FII, they will usually refer the case to a senior paediatrician. The senior paediatrician will examine the medical evidence to determine whether there is a clinical explanation for the child’s symptoms. They may also seek further specialist advice and arrange further testing.

Chronology

The paediatrician will put together a chronology, which is a detailed record of all the available information that is related to the child’s medical history. They will also contact the local authority’s child protection team (CPT) to inform them that concerns have been raised about the child’s safety and that an investigation is under way.

CPTs are teams that consist of a number of different professionals. They are employed by local authorities that are responsible for protecting children from abuse and neglect.

Other agencies that are involved with the child’s welfare, such as their school or social services, may be contacted in case they have information that is relevant to the chronology, such as the child being absent from school.

Once the chronology is complete, the information will be presented to the CPT and the police. The CPT, police and medical staff will meet to discuss the best way to proceed with the case.

Child protection plan

If the child is thought to be at immediate risk of physical harm, social services will remove the child from the mother’s care. The child could be placed under the care of another relative or under the care of social services in foster care.

In many cases of FII the child is already in hospital so they will be moved to a safe place inside the hospital so that their medical assessment can continue. Alternatively, the carer may be banned from the child's ward.

A child will be taken into care in almost all cases that involve physical harm and in around half of cases where the mother is only fabricating, not inducing, symptoms of illness.

While fabricating symptoms may not seem to be a serious form of abuse, it can cause intense emotional and psychological distress to a child.

If it is thought that the child is at risk of significant physical or mental harm a child protection plan will be drawn up.

The child protection plan will take into account the child’s health and safety needs and also their educational or social needs. For example, in the past the child may have been deprived of regular education because their mother kept them away from school due to a fabricated illness.

As part of the child protection plan, the mother may be asked to agree to having a psychiatric assessment or family therapy. If she refuses to comply with the child protection plan the child may be removed from her care.

If the police decide that there is sufficient evidence to bring criminal charges they will begin to investigate the case. As part of the investigation they can use covert (secret) video surveillance to determine whether the mother is inducing symptoms. However, this power is rarely used in practice.

Only the police have the legal authority to carry out covert video surveillance. It will only be used if there is no other way of obtaining information to explain the child’s symptoms.

The following documents contain more information about the recommended guidelines regarding the protection of children in cases of FII:

• Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians (PDF 836kb) - produced by the Royal College of Paediatrics and Child Health

The child

The first aim in treating a child who has been affected by fabricated or induced illness (FII) is to restore them to good health. Younger children and babies who do not understand that they were victims of abuse often make a good recovery once their mother’s abuse stops.

Older children, particularly those who have been abused for many years, will have more complex problems and needs. For example, many older children who are affected by FII believe that they are really ill and will need help and support to develop a more realistic understanding of their health. They may also need to learn how to tell the difference between their mother’s lies and reality.

Children affected by FII may also need help rehabilitating back into a normal lifestyle, for example, returning to school. It is also common for older children to feel loyalty towards their mother and a corresponding sense of guilt if their mother is removed from the family.

The mother

Treatment for the mother will include a combination of:

• intensive psychotherapy
• family therapy

The aim of psychotherapy is to uncover and resolve the issues that caused her to fake or induce illness in her child.

The aim of family therapy is to resolve any tensions within the family, improve the mother’s parenting skills and attempt to repair the relationship between the mother and child.

In more severe cases, the mother may be compulsorily detained in a psychiatric ward under the Mental Health Act so that her relationship and contact with her child can be closely monitored.

The best results occur in cases where the mother:

• understands and acknowledges the harm that she has caused to her child
• is able to communicate the underlying motivations and needs that led her to fake or cause illness
• is able to work together with healthcare and other professionals

Many mothers will experience feelings of guilt and depression for which they will need to receive additional treatment.

However, treating women who are involved in this type of abuse is often very challenging because they can lack a clear understanding of what they have done to their child and remain in a state of denial about the consequences of their actions. Many women need to be referred to a specialist psychiatric unit because their needs are too complex to be dealt with by local adult psychiatric services.