FII and Perplexing Presentations: What is the Evidence Base for and against Current Guidelines, and What are the Implications for Social Services?

Families of autistic children, or those with complex or rare conditions, are finding themselves at increased risk of being investigated by Social Services for fabricated and induced illness, a form of child abuse based on what was previously known as Munchausen syndrome by proxy. This article explores how the current broad and non-evidenced definition and guidelines from the Royal College of Paediatrics and Child Health may be fuelling this increase, and discusses the impact on families and the implications for Social Services. Fabricated or induced illness (FII) and perplexing presentations (PPs) are the terms used by the Royal College of Paediatrics and Child Health (RCPCH) in the UK. FII is presented as if synonymous with Munchausen syndrome by proxy, a rare presentation which is now known in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition as factitious disorder imposed on another (FDIoA). However, FII is not a diagnosis, and the definition is far broader than FDIoA. RCPCH admit that there is a limited evidence base for the prevalence, specificity or sensitivity of FII and the associated 'alerting signs', and yet local authorities across the UK have Child Protection Policies developed directly from the RCPCH guidelines. An increasing number of families of children with neurodevelopmental presentations (such as autism), or presentations of complex or less well-known conditions such as Ehlers-Danlos syndrome, are finding themselves being investigated for FII by Social Services, and consequently labelled as potential 'perpetrators' of child abuse, on the basis of FII guidelines. The present article discusses the issues relating to FII and PP, how current guidelines are creating implicit and explicit bias against certain kinds of families and the implications for Social Services.