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

The term FII covers a wide range of behaviours involving parents seeking healthcare for a child. This ranges from extreme neglect (failing to seek medical care) to induced illness.

FII can involve children of all ages, but the most severe cases usually involve children under 5. The child’s mother is responsible for the abuse in 90% of reported cases. However father, grandparent, guardian or any other carer (including professionals) can also be responsible.

Recognising FII behaviour in parents/carers

A parent or carer who:

• convinces their child they are ill when they are perfectly healthy
• exaggerates or lies about their child’s symptoms
• deliberately induces symptoms of illness, for example by poisoning their child
• withholds food which results in the child failing to develop physically and mentally at the expected rate
• demands diagnoses which would mean access to an education setting or monetary benefits.

Warning signs in a parent or carer’s behaviour medical staff may identify

The parent or carer:

• tries to maintain a close and friendly relationship with medical staff, but quickly becomes abusive or argumentative if their own views on what is wrong with the child are challenged
• 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)
• lies about their child’s symptoms.
• deliberately contaminates or manipulates clinical tests to fake evidence of illness for example by adding glucose to urine samples (to suggest diabetes) or placing their blood on child’s clothing to suggest unusual bleeding
• poisons their child with unsuitable and non prescribed medicine
• infects their child’s wounds or injects the child with dirt or faeces (stools) 
• does not treat or mistreats genuine conditions so they will get worse. This includes mismanagement of prescriptions
• disengages when the child is sent to a specialist for treatment or investigation after having repeatedly attended GPs or A&E.

Signs of FII

FII may first be suspected if physical or psychological examination and diagnostic tests do not explain the reported signs or symptoms.

To support concerns one or more of the following will be present:

• symptoms only appear when the parent or carer is present
• the only person claiming to notice symptoms is the parent or carer
• the affected child has an inexplicably poor response to medication or other treatment
• if a particular health problem is resolved, the parent or carer suddenly begins reporting a new set of symptoms
• the child’s history of symptoms does not result in expected medical outcomes, for example, a child who has supposedly lost a lot of blood but doesn’t become unwell
• the parent or carer has a history of frequently changing GPs or visiting different hospitals for treatment
• the child’s daily activities are being limited far beyond what you would usually expect as a result of having a condition, for example, missing school due to the number of medical appointments.

This is not an exhaustive list.

Categories 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 parent or carer may carry out behaviour from several or all categories.

• Exaggerating or fabricating symptoms and manipulating test results to suggest the presence of an illness.
• Intentionally withholding nutrients from the child or interfering with nutritional intake.
• 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.
• Deliberately smothering the child to induce unconsciousness.

Causes of FII

The cause of FII is not fully understood, however previous traumatic experiences in the life of the parent or carer responsible seem to play an important role.

• One study found 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 (most parents who were abused as a child do not go on to abuse their own children).
• One or both parents may have a history of self harm or drug or alcohol abuse.
• The parent may have experienced the death of another child, or a difficult pregnancy.
• A high proportion of mother’s involved in FII have been found to have personality disorder and, in particular, a borderline personality disorder.
• A high proportion of mothers involved in FII have been found to have so-called “somatoform disorders”, where they experience multiple, recurrent physical symptoms. A proportion of these mother’s also have Munchausen’s syndrome. Munchausen’s syndrome, also known as factitious disorder, is a condition where a person pretends to be ill or causes illness or injury to themselves. FII was previously known as Munchausen’s syndrome by proxy.
• It allows the parent to adopt the role of a caring and concerned parent whilst at the same time allowing them to pass responsibility of caring for a child onto medical staff.
• Another theory is that FII is a way for the parent to escape their own negative feelings and unpleasant emotions.

The impact on the child

The following are examples of impact of suffering abuse from FII. Whilst it is well documented that children who have been abused or neglected are likely to suffer impairment to their health and development, it cannot be assumed that all children suffering impairment have been abused.

• The child may learn to collude with their carer in the management of a non-existent condition before eventually fabricating an illness in themselves. These children may also lose the ability to identify true illness and become unable to act appropriately if they are ill.
• Range of emotional and behavioural disorders, and school related problems including difficulties in attention and concentration and non-attendance.
• Feeding disorders in infants, withdrawal and hyperactivity in pre-school children and direct fabrication or exaggeration of their own physical symptoms in older children and adolescents.
• Long term impairment of their physical, psychological and emotional development.

Children may suffer emotional harm as a result of an abnormal relationship with the parent or carer responsible for the abuse. FII may also result in death.

What to do

The majority of cases of FII in children are confirmed in a hospital setting because medical findings provide evidence of this type of abuse. The school health team and school nurses can be consulted. A chronology of contacts and behaviours should be kept as supportive evidence.

Following identification of FII in a child, the way the case is managed will have a major impact on the developmental outcomes for the child. The extent to which the parent or carer acknowledges some responsibility for fabricating or inducing illness in their child will also affect these outcomes for the child.

Where a professional has concerns of FII they should explore where it is on the scale. For example, from parental concern or anxiety, through to suspected significant harm.

The professional should make a referral in line with local safeguarding procedures. They will usually refer the case to a community paediatrician. A 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.

The impact on a professional

It is important to recognise the impact on a professional when working or trying to identify FII.

Support should be made available to them. Working with such cases can be extremely stressful and time is needed to gather evidence.

Only the police have the legal authority to carry out covert surveillance.

This FII guidance should be read alongside the Kent and Medway Safeguarding Procedures.