Fabricated or induced illness (FII) is also known as “Munchausen’s syndrome by proxy” and usually occurs when a parent or carer exaggerates or deliberately causes symptoms of illness in their child.
It is usually the mother who is involved and may try to persuade healthcare professionals that their child is ill when they are healthy (DCSF, 2008).
There are three main ways in which this might take place. In the case of fabricated illness, the parent or carer might exaggerate or lie about the child’s symptoms. If they also manipulate the test results to suggest that they really are ill then this is described as falsification. For example, by putting glucose in urine samples to indicate that the child has diabetes.
Where illness is induced this might include treating the child in such a way that they demonstrate the symptoms. For example, by giving the child unnecessary medication or other substances that can have a detrimental affect. Cases have been reported of parents or carers infecting a child’s wounds or even inducing unconsciousness through suffocation. Genuine illnesses might remain untreated and in some extreme cases a child might even be starved so that they do not develop physically.
FII is usually associated with younger children although a child of any age might be affected. Although the mother is usually responsible, there have been cases of extended family or even a healthcare or childcare professional behaving in this way.
The motives
The motives for FII are not clear but are believed to be linked to the desire to continue in the role of a carer looking after an ill child. The parent might enjoy the attention of their child receiving medical care, for example.
There are occasionally financial incentives, perhaps where fundraising has taken place and donations are made to provide care for a child. Another explanation is that it might enable parents to mask resentful and negative feelings towards the child by focusing on the treatment and passing the responsibility of care onto medical staff.
The behaviour often runs alongside other emotional difficulties or personality disorders and might occur in people with a history of self-harm, drug and/or alcohol misuse. In some cases parents have experienced the death of another child previously.
The warning signs
It is a complex condition and one that is difficult for others to understand in terms of its motivation. This can make it particularly difficult to spot as it is in opposition to the behaviour that we usually expect from those so close to the child, particularly the mother.
According to the NHS, fabricated or induced illness might be suspected when tests have been carried out but there appears to be no explanation for the child’s symptoms. Although it is likely to be the child’s GP who is in a position to identify FII, schools should also be aware of the warning signs:
- Symptoms only appear when the parent is present.
- The only person noticing the symptoms is the parent.
- There is a poor response to medication or other treatment that is hard to explain.
- When one health problem is solved another one appears with a new set of symptoms.
- Symptoms are not plausible – for example when a child has supposedly lost a lot of blood but appears not to be unwell.
- There is a history of a frequent change of GPs particularly when there has been a challenge by medical staff.
- The parent does not seem too worried about the child’s health although they are very attentive.
In the case of a school, it is likely that the possibility of FII may be picked up as a result of attendance issues.
Identifying FII
Children who are experiencing FII may have a poor attendance record and be kept away from school as a result of a succession of health problems. Of course, in the vast majority of cases the reasons for absence of children on medical grounds are legitimate. However, it is worth your attendance officer also being informed about FII and the possible signs.
Teachers and other school staff should be alert to:
- Frequent and unexplained absences from school, particularly from PE lessons.
- Regular absences to keep a doctor’s or a hospital appointment.
- Repeated claims by a parent that a child is frequently unwell and that he/she required medical attention for symptoms which are vague in nature, difficult to diagnose and which teachers have not noticed themselves.
Where FII is suspected, the method of verifying the reasons for a child’s absences should continue. It might be that the illnesses ascribed to the child include headaches, tummy aches, dizzy spells and there may be frequent contact with opticians and/or dentists or referrals for second opinions. The child themselves might complain about frequent visits to the doctors.
There may also be other physical signs, many of which you would pick up as a safeguarding issue with other possible causes. For example, a child who appeared to be constantly hungry or who did not appear to be receiving the advocated medical treatment. Again, there could be other reasons for these types of behaviour but the school’s role is to report concerns and investigations will follow.
A child experiencing FII may have difficulties concentrating when they are in school, pre-school children may be withdrawn or hyperactive and older children and adolescents may exaggerate their own physical symptoms. They may have learnt to collude with the parent and manage a non-existent condition or even fabricate or induce illness in themselves.
What to do
Although this is a rare condition schools should make staff aware of its existence. In particular, your designated safeguarding lead (DSL) should be familiar with the condition and be aware of the signs and how to apply the school’s safeguarding procedures should it be suspected.
Where there is a sibling in the school the DSL might talk to their teachers to see if children of different ages in the same family are presenting similar concerns. The school nurse might also be consulted and make a contribution to any initial discussions about the possibility of FII.
It is important not to approach the parent or carer if FII is suspected as they are unlikely to admit that it is taking place and may subsequently cover up any evidence. Instead, your DSL should contact social services and have ready a list of any events, days and times, that suggest that this might be a case of FII. It is useful to keep a diary that includes a record of absences and the reasons for them given by the parent.
Children who have experienced FII are likely to need multi-agency support and children’s social care is responsible for the co-ordination of the multi-agency child protection plan. Social care will be the main point of contact for the school and other agencies.
The 2008 guidance document Safeguarding children in whom illness is fabricated or induced (DCSF) is old but still offers useful information about the condition that can be shared with staff.
- Suzanne O’Connell is a freelance education writer and a former primary school headteacher.
Further information & resources
Safeguarding children in whom illness is fabricated or induced (old government guidance), Department for Children, Schools and Families (DCSF), 2008: http://bit.ly/2P7KoNG