Munchausen’s syndrome by proxy
Fabricated or induced illness (FII) is a rare form of child abuse. It occurs when a parent or carer, usually the child’s biological mother, exaggerates or deliberately causes symptoms of illness in the child.
FII is also known as Munchausen's syndrome by proxy. 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.
However, healthcare professionals in the UK prefer to use the term fabricated or induced illness, or factitious disorder imposed on another. This is because the term Munchausen's syndrome by proxy places the emphasis on the person carrying out the abuse, rather than the victim.
The term Munchausen's syndrome by proxy is still widely used in other countries.
Behaviours in FII
The term FII covers a wide range of cases and behaviours involving parents seeking healthcare for a child. This ranges from extreme neglect (failing to seek medical care) to induced illness. Behaviours in FII include:
a mother or other carer who convinces their child they are ill when 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
How common is fabricated or induced illness?
It's difficult to estimate how widespread FII is, because many cases may go unreported or undetected. In an average population of one million people, around one child per year would be affected.
The British Paediatric Surveillance Unit (BPSU), which is a specialist unit that assists research into rare childhood conditions, carried out a study of FII cases. It identified 97 cases of FII in the UK over a two-year period.
However, it's likely that this figure underestimates the true prevalence 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. However, cases have been reported in which the father, foster parent, grandparent, guardian, or a healthcare or childcare professional was responsible.
It's 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 involved in cases of FII 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.
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 mothers also have Munchausen's syndrome.
A high proportion of mothers also have a type of mental health problem called borderline personality disorder, which is characterised by emotional instability, impulsiveness and disturbed thinking.
There have been several reported cases where illness was fabricated or induced for financial reasons – for example, to claim disability benefits.
FII is a child protection issue and cannot be treated by the 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 don't 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's 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.
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 parent or carer's underlying psychological problems. However, parents or carers involved in FII are difficult to treat, because most do not admit their deceptions and refuse to admit their abusive behaviour. Therefore, in many cases, the child is permanently removed from their care.
Children affected by FII can experience long-term consequences in terms of 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's estimated that around 1 in 16 will die as a result of this abuse. A further 1 in 14 will experience long-term or permanent injury.
Signs of fabricated or induced illness
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.
The National Institute for Health and Care Excellence (NICE) guidance on when to suspect child maltreatment (PDF, 235kb) states that fabricated or induced illness may first be suspected if:
physical or psychological examination and diagnostic tests do not explain the reported signs and symptoms
One or more of the following warning signs must also 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, 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
Other warning signs
Other identified warning signs include:
the parent or carer having 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 – or overly worried in relation to the health professional in charge of their child's care
the parent or career trying to maintain a close and friendly relationship with medical staff, but quickly becoming abusive or argumentative if their own views on what is wrong with the child are challenged
one parent (usually, but not always, the father) having little or no involvement in the care of the child
the parent or carer encouraging 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)
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:
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
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
Causes of fabricated or induced illness
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.
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 ability to secure bonds with their children. An example of this is repeatedly seeing a doctor to satisfy an emotional need to get attention for the child.
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's worth noting that most people who were 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 abuse.
Some case studies also revealed that the mother may have experienced the death of another child, or a difficult pregnancy.
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. However, 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 have been involved in FII have reported feeling a sense of resentment towards their child because they have a happy childhood, unlike their own.
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.
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 is able to focus her thoughts on the treatment of her child, while keeping her own negative feelings and emotions at bay.
Diagnosing fabricated or induced illness
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 interests 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 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.
What happens next?
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 underway.
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. It's important to assign a person to construct the chronology, as this is a critical part of the assessment process.
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 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 then 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's 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, 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, 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.
If the police decide that there's sufficient evidence to bring criminal charges, they will begin to investigate the case.
Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians (PDF, 836kb) – produced by the Royal College of Paediatrics and Child Health.
Treating fabricated or induced illness
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 don't understand 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 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 reality.
Children affected by FII may also need help returning to a normal lifestyle, including going back to school.
It's also common for older children to feel loyal to 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:
family therapy – the father may need individual help, especially if he is the main caregiver
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 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 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.
Munchausen's syndrome by proxy