The causes of fabricated or induced illness (FII), also known as Munchausen’s syndrome by proxy, are not fully understood, and more research is needed.

However, previous traumatic experiences in the life of the parent or carer responsible 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. Learn more in borderline personality disorder.

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

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.

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).

Healthcare professionals will naturally assume that a parent or carer will always act in the best interest of a child in their care, 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

If the senior paediatrician also suspects FII, they will put together a detailed record of all the available information that is related to the child’s medical history. This is called a chronology.

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.

Covert (secret) video surveillance may be used to collect evidence that can help to confirm a suspicion of FII.

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. This power is rarely used in practice.

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 care of the parent or carer. 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 suspected FII the child is already in hospital. 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.

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 parent or carer kept them away from school due to a fabricated illness.

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 that there is sufficient evidence to bring criminal charges they will begin to investigate the case.

More information

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

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 deliberately causes symptoms of illness in the child.

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.

However, healthcare professionals in the UK prefer to use the term fabricated or induced illness because the term Munchausen’s syndrome by proxy places the emphasis on the person carrying out the abuse, rather than the child who is the victim.

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

There has been some controversy in the media regarding FII, with some commentators suggesting it is not a real phenomenon. But there is a great deal of evidence to suggest that the condition does exist. The evidence of abuse includes hundreds of case files from more than 20 different countries, the confessions of mothers and other carers, the testimony of children and secret video footage.

Behaviours in FII

The term FII covers a wide range of cases and behaviours. These include:

• a mother or other carer who convinces their child they are ill when in fact they are perfectly healthy
• a mother or other carer who exaggerates or lies about their child’s symptoms
• a mother or other carer 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 or other carer who deliberately induces symptoms of illness, for example by poisoning her child with unnecessary medication or other substances

Learn more in signs of fabricated or induced illness.

How common is fabricated or induced illness?

It is difficult to estimate how widespread FII is because many cases may go unreported or undetected.

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.

However, it is likely that this figure underestimates the true incidence of FII.

FII can involve children of all ages, but the most severe cases usually involve children under five.

In over 90% of reported cases of FII the child’s mother is responsible for the abuse. But cases have been reported in which the father, foster parent, grandparent, guardian, or a healthcare or childcare professional was responsible.

Motivation

It is not fully understood why FII occurs.

In cases where the mother is responsible, 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.

In particular, a high proportion of mothers involved in FII have been found to have a type of mental health problem called borderline personality disorder, which is characterised by emotional instability and disturbed thinking. 

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

Learn more in causes of fabricated or induced illness.

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.

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.

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 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, which is open 24 hours a day, seven days a week, on 0808 800 5000.

Learn more in diagnosis of fabricated or induced illness.

Treatment

In cases of FII, the first priority is to protect the child. This may involve removing the child from the care of the person responsible. If the child is in hospital, it may involve removing the responsible parent or carer from the ward.

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

Learn more in treatment of fabricated or induced illness.

Outlook

Children who are affected by FII can experience long-term consequences for their physical health, as well as significant psychological and emotional trauma.

A 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.

In cases involving administering unnecessary medicines or other substances, it is estimated that around 1 in 16 will die as a result of this abuse. A further 1 in every 14 will experience long-term or permanent injury.

The abuse that occurs in cases of fabricated or induced illness (FII) takes a range of forms, but there are warning signs to look for.

Warning signs

Warning signs that may indicate that a child is being subjected to FII, also known as Munchausen syndrome by proxy, include:

• the parent or carer 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 parent or carer 
• if a particular health problem is resolved, the parent or carer 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 parent or carer seeks multiple opinions from a range of different healthcare professionals
• the parent or carer often has good medical knowledge or a medical background
• although the parent or carer is very attentive to the child and stays with them constantly in hospital, they do not seem too worried about the child’s health
• the parent or career often tries to maintain a close and friendly relationship with medical staff but can quickly become abusive or argumentative if their own views on what is wrong with the child are challenged
• the other parent has little or no involvement in the care of the child
• 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)
• 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
• 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 parent or carer may carry out behaviour from several or all categories.

The categories are:

• fabricating symptoms and manipulating test results to suggest the presence of 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

Previous case reports of FII have uncovered evidence of:

• parents or carers lying about their child’s symptoms
• parents or carers 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

Parents or carers 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

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 the abuse stops.

Older children, particularly those who have been abused for many years, will have more complex problems. For example, many older children who are affected by FII believe that they are really ill. They 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 the lies of their parent or carer and and reality.

Children affected by FII may also need help returning to a normal lifestyle, including returning to school.

It is also common for older children to feel loyalty towards their parent or carer, and a corresponding sense of guilt if that parent or carer is removed from the family.

The parent or carer

Treatment of a parent or carer responsible for FII will include a combination of:

• intensive psychotherapy
• family therapy

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

The aim of family therapy is 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 that their relationship with their child can be closely monitored.

The best results occur in cases where the parent or carer:

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

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

However, treating people 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 need to be referred to a specialist psychiatric unit, because their needs are too complex to be dealt with by local adult psychiatric services.