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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' (not to be confused with Munchausen's syndrome, where a person pretends to be ill or causes illness or injury to themselves).

This page covers:

Signs of fabricated or induced illness

How common is FII?

Causes

What to do if you suspect a child is at risk

How a case is managed

Signs of fabricated or induced illness

FII covers a wide range of symptoms 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:

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

Learn more about the signs of fabricated or induced illness.

How common is FII?

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

One study published in 2000 estimated 89 cases of FII in a population of 100,000 over a two-year period. However, it's likely that this figure underestimates the actual number of cases of FII.

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

In more than 90% of reported cases of FII, the child's mother is responsible for the abuse. However, there have been cases where the father, foster parent, grandparent, guardian, or a healthcare or childcare professional was responsible.

Why does fabricated or induced illness occur?

The reasons why FII occurs aren't fully understood. In cases where the mother is responsible, it could be that she enjoys the attention of playing the role of a "caring mother".

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

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

Some 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.

Read more about the possible causes of fabricated or induced illness.

What to do if you suspect a child is at risk

FII is a child safeguarding issue and can't be managed 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 safeguarding procedures.

If your job involves working with children – for example, if you're a nursery worker or teacher, you should inform the person in your organisation who's responsible for child safeguarding 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, you shouldn't 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. It's open 24 hours a day, seven days a week.

Read more about what to do if you suspect fabricated or induced illness.

How a case is managed

The child

The first priority is to protect the child and restore them to good health. This may involve removing 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 don't understand they were victims of abuse often make a good recovery once the abuse stops.

Older children, particularly those who've been abused for many years, will have more complex 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. They may also need to learn how to tell the difference between the impaired perception of their parent or carer and reality.

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:

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

Parents or carers involved in FII are difficult to treat because most don't admit their deceptions and refuse to recognise their abusive behaviour. Therefore, in many cases, the child is permanently removed from their care.

The best results occur 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 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 one 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 medication or other treatment
  • if one particular health problem is resolved, the parent or carer may then begin reporting a new set of symptoms
  • the child's alleged symptoms don't seem plausible  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
  • the parent or carer has good medical knowledge or a medical background
  • the parent or carer doesn't 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
  • one 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)

Patterns and levels of abuse

The patterns of abuse found in cases of FII usually fall into one of six categories. These are ranked as follows, from least severe to most severe:

  • 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 substance of low toxicity – for example, using laxatives 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 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

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 are abused as children don't 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 onto 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 underway.

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.

 

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