The abuse that occurs 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 affected 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 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 has good medical knowledge or a medical background
• the parent or carer does not seem too worried about the child's health, despite being very attentive
• the parent or carer develops close and friendly relationships with healthcare staff, but may become abusive or argumentative if their own views about what's wrong with the child are challenged
• 1 parent (commonly the father) 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)

Types of abuse in FII

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 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.

However, it's likely the parent or carer will have a history of previous traumatic experiences.

Recent studies have shown that mothers who carry out the abuse have abnormal "attachment" experiences with their own mothers, which may affect their parenting and relationship with their children. An example of this is repeatedly seeing a doctor to satisfy an emotional need to get attention for the child.

Child abuse

A 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's worth noting that 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 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 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 all mothers with borderline personality disorder go 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 mothers who carry out FII find the situation of their child being under medical care rewarding.

Other mothers 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.

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 on to medical staff.

Escapism

Another theory is that FII is a way for the mother to escape her own negative feelings and unpleasant emotions.

By creating a permanent crisis situation surrounding her child, she's 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 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 compelling evidence to suggest otherwise.

If FII is suspected

If a healthcare professional suspects 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.

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

They'll 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 consisting 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 to the chronology, such as the child being absent from school.

The full chronology is a critical part of the assessment process. Once complete, the information will be presented to the CPT and the police. The CPT, police and medical staff meet to discuss the best way to proceed with the case.

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

However, only the police have the legal authority to carry out covert video surveillance, which may be used if there's no other way of obtaining information to explain the child's symptoms. This is rare in practice.

Child protection plan

If the child is thought to be at immediate risk of physical harm, social services 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 by social services.

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 carer may be banned from the child's ward.

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

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 that there's sufficient evidence to bring criminal charges, they'll begin to investigate the case.

Further information

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

• Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians