Fabricated or induced illness (FII) is a rare form of child abuse. It happens when a parent or carer exaggerates or deliberately causes symptoms of illness in the child.

The parent or carer tries to convince doctors that the child is ill, or that their condition is worse than it really is.

The parent or carer does not necessarily intend to deceive doctors, but their behaviour is likely to harm the child. For example the child may have unnecessary treatment or tests, be made to believe they're ill, or have their education disrupted.

FII used to be known as "Munchausen's syndrome by proxy" (not to be confused with Munchausen's syndrome, where a person pretends to be ill or causes illness or injury to themselves).

Signs of fabricated or induced illness

Fabricated or induced illness (FII) covers a wide range of symptoms and behaviours involving parents or carers seeking healthcare for a child. This ranges from exaggerating or inventing symptoms, to deliberately making the child ill.

Behaviours in FII can include a parent or carer who:

• persuades healthcare professionals that their child is ill when they're healthy
• exaggerates or lies about their child's symptoms
• manipulates test results to suggest the child is ill, for example, by putting glucose in urine samples to suggest the child has diabetes
• deliberately induces symptoms of illness, for example, by poisoning their child with unnecessary medicine or other substances

Cases where the parent or carer wrongly reports symptoms are much more common than cases where they induce illness in the child.

Why fabricated or induced illness happens

The reasons why FII happens are not fully understood.

The parent or carer will have a need for their child to be treated as if they're ill, or as being more unwell than they really are. Their behaviour is intended to convince doctors that the child is ill.

This may be because the parent or carer gains something, such as attention, support or closeness to the child. Or it may be because they have anxiety or incorrect beliefs about their child's health, and they need these beliefs to be confirmed and acted upon.

The parent or carer is not always fully aware of the reasons for their own behaviour.

A large number of parents or carers involved in FII have borderline personality disorders characterised by emotional instability, impulsiveness and disturbed thinking.

Some parents or carers involved in FII have so-called "somatoform disorders", where they experience multiple, recurrent physical symptoms. A proportion of these parents or carers also have Munchausen's syndrome.

Some parents or carers have unresolved psychological and behavioural problems, such as a history of self-harming, or drug or alcohol misuse. Some have experienced the death of another child.

There have also been several reported cases where illness was fabricated or induced for financial reasons. For example, to claim disability benefits.

What to do if you suspect a child is at risk

FII is a child safeguarding issue and cannot be managed by the NHS alone.

Medical professionals who suspect FII is happening should liaise with social services and the police, and must follow local child safeguarding procedures.

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

If you suspect someone you know may be fabricating or inducing illness in their child, do not confront them directly. It's unlikely to make the person admit to wrongdoing, and it may give them the opportunity to dispose of any evidence of abuse.

You can contact your local social services department, or telephone the NSPCC's child protection helpline on 0808 800 5000, or email the NSPCC at help@NSPCC.org.uk. The helpline is open from 10am to 4pm Monday to Friday.

How a case is managed

The child

The first priority is to protect the child, find out their true state of health and restore them to good health. Health professionals will create a health and education rehabilitation plan for the child.

The local authority children's social care team may also be involved. They may remove the child from the care of the person responsible. If the child is in hospital, the parent or carer may need to be removed from the ward.

The child may need help returning to a normal lifestyle, including going back to school. Younger children and babies who do not understand what was happening often make a good recovery after the abuse stops.

Older children, particularly those who've been abused for many years, may have more problems. For example, many affected children believe they're really ill. They need help and support to develop a more realistic understanding of their health.

It's common for older children to feel loyal to their parent or carer, and a sense of guilt if that person is removed from the family.

The parent or carer

Once the child is safe, it may be possible to treat the parent or carer's underlying psychological problems. This may include a combination of:

• intensive psychotherapy
• family therapy

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

Family therapy aims to resolve any tensions within the family, improve parenting skills and attempt to repair the relationship between the parent or carer and the child.

In more severe cases, the parent or carer may be compulsorily detained in a psychiatric ward under the Mental Health Act so their relationship with the child can be closely monitored.

Parents or carers involved in FII are difficult to treat because most do not admit their deceptions and refuse to recognise their abusive behaviour. In some cases, the child is permanently removed from their care.

The best results are achieved in cases where the parent or carer:

• understands and acknowledges the harm they've caused
• is able to communicate the underlying motivations and needs that led them to fabricate or cause illness
• is able to work together with healthcare and other professionals

The abuse that happens in fabricated or induced illness (FII) takes a range of forms and can be difficult to recognise, but there are warning signs to look out for.

Warning signs

A clinician may suspect fabricated or induced illness if, after carrying out examinations and tests, there appears to be no explanation for the child's symptoms. For more information, you can read the NICE guidance about when to suspect child maltreatment in under 18s.

They should also look out for 1 or more of the following warning signs:

• symptoms only appear when the parent or carer is present
• the only person claiming to notice symptoms is the parent or carer
• the parent or carer does not let healthcare professionals see the child on their own
• the parent or carer talks for the child, or the child refers to the parent or carer rather than speaking for themselves
• the child has an inexplicably poor response to medicine or other treatment
• if 1 particular health problem is resolved, the parent or carer may then begin reporting a new set of symptoms
• the child's alleged symptoms do not seem plausible – for example, a child who has supposedly lost a lot of blood but does not become unwell
• the parent or carer has a history of frequently changing GPs or visiting different hospitals for treatment, particularly if their views about the child's treatment are challenged by medical staff
• the child's daily activities are being limited far beyond what you would usually expect for a certain condition – for example, they never go to school or have to wear leg braces even though they can walk properly
• the parent or carer does not accept reassurance or recommended treatment, and insists on continued investigations or new treatments
• the parent or carer 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)

Types of abuse in FII

Previous case reports of FII have uncovered evidence of parents or carers:

• exaggerating, distorting or lying about their child's symptoms, medical history, tests or diagnoses
• falsifying documents
• deliberately contaminating or manipulating clinical tests to fake evidence of illness, for example, by adding blood or sugar to urine samples
• poisoning their child with unsuitable and non-prescribed medicine
• infecting their child's wounds or injecting the child with dirt or poo
• inducing unconsciousness by suffocating their child
• not treating or mistreating genuine conditions so they get worse
• withholding food, resulting in the child failing to develop physically and mentally at the expected rate

It's not fully understood why some parents or carers fabricate or induce illness in their child.

The parent or carer may gain something, such as attention or support, from the child being treated as ill. Or they may have anxiety or incorrect beliefs about the child's health.

It's likely the parent or carer will have a mental health condition or a history of previous traumatic experiences that helps to explain their behaviour.

Child abuse

Research has found some parents and carers who were known to have fabricated or induced illness in their child were victims of physical and sexual abuse during their own childhood.

But most people who are abused as children do not go on to abuse their own children.

Previous medical history

One or both parents may have a history of self-harm or drug or alcohol misuse.

Some case studies also revealed that the mother may have experienced the death of another child, or a difficult pregnancy.

Personality disorder

A high proportion of parents and carers 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 a person 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. It's important to note that not everyone with borderline personality disorder goes on to abuse their children.

Sometimes, people with personality disorders find reward in behaviour or situations that other people would find intensely distressing. It's thought that some parents or carers who carry out FII find the situation of their child being under medical care rewarding.

Other parents or carers who've been involved in FII have reported feeling a sense of resentment towards their child because they have a happy childhood, unlike their own.

Anxiety disorder

Some parents have an anxiety disorder that makes them have unfounded anxieties about their child's health.

Some parents also have health anxiety about themselves.

They may be motivated by genuine worries about the child, but because these worries are unfounded their behaviour can harm the child.

Somatic symptom disorder

Some parents have a somatic symptom disorder, or somatoform disorder.

This means they genuinely feel pain or other symptoms, but it's related to underlying emotional difficulties rather than physical health conditions.

It can be very difficult to confirm a suspected case of fabricated or induced illness (FII).

Healthcare professionals will naturally assume that a parent or carer will always act in the best interests of a child in their care, unless there's strong evidence to suggest otherwise. They will also want to make sure they do not miss any genuine health conditions.

If FII is suspected

If a healthcare professional notices signs of FII, they'll usually refer the case to a community paediatrician.

A senior paediatrician will examine the medical evidence to determine whether there's a clinical explanation for the child's symptoms. They may also seek further specialist advice and arrange further testing. They will consider whether the child should be admitted to hospital so that nurses can observe them directly.

If the senior paediatrician also suspects FII, they'll put together a detailed record of all the available information related to the child's treatment and involvement with health services. They'll explore how the family is functioning, the parents' views, and the child's views if they're old enough.

They'll record their concerns in the child's health records, so that any other clinicians who see the child are aware of the concerns.

Healthcare professionals will meet to discuss the concerns and agree on whether the signs can be explained by a diagnosed health condition, or whether it appears to be a case of FII. The parents will usually be told the outcome of the meeting, and future plans will be discussed with them.

If there's thought to be a risk of harm to the child, healthcare professionals will also refer the case to children's social care.

Health and education rehabilitation plan

Whether or not the child is referred to children's social care, healthcare professionals will create a health and education rehabilitation plan for the child.

The plan will cover the actions needed to resolve the situation and help the child recover, such as:

• stopping any unnecessary medicines or treatment
• getting the child back to school
• psychological support for the child and the family

Doctors will usually lead on creating the plan, and education and social care professionals may also be involved. The child's parents or carers will be asked to support the plan.

A lead professional (usually a paediatrician or other health professional, or sometimes a social worker) will review the plan regularly with the family, until the child is healthy and there are no longer any concerns.

If the parents or carers will not agree to a plan, or do not support it, the child will be referred to children's social care who will take any steps needed to prevent harm.

Referral to children's social care

If the child may be at risk of harm, for example if there's evidence that the parent or carer may be making the child ill, healthcare professionals will refer the case to the local authority children's social care team and the police.

They will decide whether to tell the parents or carers about the referral.

Children's social care teams consist of a number of different professionals. They're employed by local authorities responsible for protecting children from abuse and neglect.

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

The children's social care team will usually ask the healthcare professionals to provide a detailed record of the past events in the child's medical history.

Once complete, the information will be presented to the children's social care team and the police. The social care, 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, children's social care will remove them from the care of the parent or carer. The child may be placed in the care of another relative or in foster care.

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

As the child is commonly at risk of significant physical or mental harm, a child protection plan is drawn up. This plan takes into account the child's health and safety needs, as well as their educational or social needs. For example, the child may have been deprived of regular education because their parent or carer kept them away from school.

As part of the child protection plan, the parent or carer may be asked to have a psychiatric assessment or family therapy. If they refuse to comply with the child protection plan, the child may be removed from their care.

Police investigation

If the police decide there's enough evidence to bring criminal charges, they'll investigate the case.

In rare cases, covert (secret) video surveillance may be used to collect evidence that can help to confirm a suspected case of FII.

Only the police have the legal authority to do this, and it's only done if there's no other way of getting information needed to explain the child's symptoms.

Further information

The Royal College of Paediatrics and Child Health (RCPCH) has published information and guidance about the protection of children in cases of FII:

• RCPCH guidance: perplexing presentations and fabricated or induced illness in children