Problems with FII Guidelines

FII and Perplexing Presentations: What is the Evidence Base for and against Current Guidelines, and What are the Implications for Social Services?", Fiona Gullon-Scott and Cathie Long

The British Journal of Social Work, Volume 52, Issue 7, October 2022, Pages 4040–4056

This paper critically examines the UK guidelines on Fabricated or Induced Illness (FII) and Perplexing Presentations (PPs), highlighting their potential to create bias and cause harm to families, particularly those with children who have neurodevelopmental or complex conditions.

Core Argument and Definitions

• FII and PP: The terms FII and PP are used by the Royal College of Paediatrics and Child Health (RCPCH) in the UK. FII is often presented as synonymous with the rare psychiatric diagnosis Factitious Disorder Imposed on Another (FDIoA) (formerly Munchausen Syndrome by Proxy), but its definition is much broader. PP is introduced as a precursor to FII.

• Lack of Evidence: The authors point out that the RCPCH guidelines admit to a limited evidence base for the prevalence, specificity, and sensitivity of FII and the associated "alerting signs" and proposed interventions.

• The Problem: Despite this lack of robust evidence, local authorities across the UK base their Child Protection Policies directly on these RCPCH guidelines.

Concerns with Current Guidelines

1. High Potential for False Positives

• FII/FDIoA is a rare phenomenon. Statistically, using "alerting signs" or "risk criteria" to identify rare occurrences in a large population inevitably leads to a very high rate of false positives (families incorrectly flagged as potential child abusers).

• The paper estimates that even with generous accuracy rates (100% sensitivity, 90% specificity), applying FII risk criteria to the UK child population could result in over 1 million false-positive cases compared to only a few hundred true cases.

• The consequences of being falsely investigated for FII are severe, with families reporting trauma, distress, and family breakdown.

2. Broad and Untested Criteria

• The current FII criteria go beyond intentional fabrication and include unintentional behaviors like "erroneous reporting," "mistaken beliefs," and "anxiety-driven help-seeking."

• This broader scope treats non-intentional, anxiety-driven help-seeking as potentially equivalent to intentional child abuse, without scientific evidence that this behavior is inherently harmful to the child.

• The authors argue that the purported emotional harm from excessive investigation must be weighed against the known psychological harm of family separation and child protection investigations.

3. Bias Against Specific Families

• The guidelines perpetuate implicit and explicit bias against parents of children with neurodevelopmental presentations (like autism) and complex or less well-known conditions (like Ehlers–Danlos syndrome).

• The authors contest the evidence base for linking autism to FII, arguing that the literature cited (like Bass and Glaser) misinterprets earlier studies (like McNicholas et al.) that actually urged caution, as professionals often fail to recognize genuine developmental disorders.

• Studies show that parents with intellectual or developmental disabilities (including autism) are significantly over-represented in the Child Protection System, suggesting a systemic bias.

Implications for Social Services

• Social Workers are urged to critically evaluate the evidence base behind FII/PP guidelines and recognize the statistical likelihood of false positives when dealing with rare conditions.

• The paper stresses the importance of considering the parent's motivations and alternative explanations (such as professional lack of expertise or a genuine, complex condition) rather than simply focusing on the outcome (purported harm).

• The current approach risks institutionalizing parent-carer blame and causing severe trauma to families who are already struggling to get appropriate support and diagnoses for their children.