Symptoms

The abuse that occurs in fabricated or induced illness (FII) takesa 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
• theparent or carerhas good medical knowledge or a medical background
• the parent or carerdoesn't seem too worried about the child's health, despite being very attentive
• theparent or carer develops close and friendly relationships with healthcare staff, but may become abusive or argumentative iftheir 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
• theparent or carerencourages 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. Theseare 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 thanpoisoning 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 carerslying about their child's symptoms
• parents or carers deliberately contaminating or manipulating clinical tests to fake evidence of illness for example, byadding 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