Fabricated or induced illness - 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.

Warning signs

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