Clinical Findings
Factitious disorder not otherwise specified is reserved for individuals who do not meet the criteria for other factitious classifications. In fact, they can more suitably be called perpetrators. The most common entity in this classification is the individual with MSP. Meadow first used the term MSP in 1977, and it has become widely recognized in pediatric settings. The most common presentation is that of a mother who produces signs or symptoms of disease in one or more of her infants or toddler-age children. In some of these instances, the mother also may produce a factitious disorder in herself. In rare cases, an adult will produce an illness in another adult.

The most frequently seen factitious conditions in children include bleeding, seizures, apnea, diarrhea, vomiting, fever, electrolyte disturbance, or skin lesions. Mothers have been observed in a wide range of behaviors, ranging from smothering their child with a pillow to produce hypoxic seizures to chronically administering ipecac syrup to simulate gastrointestinal disorders. Usually the mothers repeatedly bring their children to pediatricians’ offices and emergency rooms. Although the syndrome is most commonly focused on one child at a time, older siblings may have had similar disorders that were medically unexplained. Substantial mortality is associated with the syndrome: Rosenberg (1987) reported a mortality rate of 9%. Based on a survey of pediatric neurologists and gastroenterologists, Schreier and Libow (1993b) noted that the true prevalence of the disorder is difficult to ascertain but probably is greater than generally estimated because of significant underreporting.

Etiology
Authors have focused on different psychological explanations for MSP. Schreier (1992) hypothesized that the mothers were attempting to develop a relationship with a physician to compensate for early childhood deprivation and abandonment. In his scenario, the child becomes a dehumanized object that the mother manipulates to control the relationship with the physician. Griffith (1988) focused on disturbed family dynamics, often observing an enmeshed family structure in which the mother has a history of somatization and the family has a history of exploitation of children. In most reports, the mother has been described as having a severe personality disturbance. In these cases, the mother may be acting out sadistic impulses toward herself or others that are displaced onto the child.

Typically, the mother appears “perfect” to the unsuspecting physician; the perfection takes the form of appearing attentive and rarely leaving the child’s bedside. Usually the perfect behavior occurs only when the mother believes she is being observed. Nonetheless, primary care physicians usually are astounded to learn that their patients have MSP. Because of their frequent disbelief in the validity of this diagnosis, these physicians may actually hinder child abuse investigations.

Diagnosis
The diagnosis of MSP begins when the evaluating physician has an index of suspicion for a factitious disorder, as described earlier. The main differential diagnosis for MSP is a rare medical condition. With MSP, however, physicians and nurses note that the child’s condition improves dramatically once the child is separated from the mother. In one case, a child having 200 apneic episodes per month had no episodes when separated from the mother. Another useful clue to the detection of MSP is when the mother appears more concerned about obtaining invasive procedures for her child and impressing the medical staff than about the child’s emotional condition.

The physician’s ability to diagnose this condition is enhanced when the health care team collects information about the family from collateral sources. Reports from relatives and siblings may be particularly revealing. Covert videotaping in special hospital rooms may provide direct evidence of a mother’s inappropriate actions. Although this technique may approach the limits of invasion of privacy, many hospital attorneys have regarded the identified child patient as giving implied consent for protection against the mother’s assaults.

Treatment
Once a diagnosis of MSP is suspected or has been made, child abuse authorities must be notified. These authorities are becoming increasingly aware of MSP. If the diagnosis is confirmed, separation of the child and mother appears to be necessary. In many instances, criminal prosecution of the mother is indicated. Even in cases that are not fully prosecuted, the mother is often placed in mandated psychiatric treatment. It is unfortunate that few outcome data are available to predict how effective mandated psychotherapy is with this population. Some authors have suggested that as a minimal criterion for the mother to be allowed unsupervised contact or custody with the child, she must relinquish any denial of the disorder being factitious.

In many cases, family therapy involving the child, father, and siblings has been helpful. The child, if old enough, often requires individual therapy because he or she may develop significant psychological morbidity as a result of the mother’s actions. Some children show conversion symptoms to “cooperate” with their mothers, and others may begin to fabricate their own symptoms. Psychotherapy with the children may help them repair their autonomy, which was subjugated to the mother’s behavior.

Whatever form of treatment intervention is developed for MSP, it requires close collaboration between multiple agencies. Courts, child protective services, police investigators, and prosecutors must participate in the treatment planning. One special consideration is when an older child accuses his or her father of sexual abuse. Investigators need to know that the incidence of false claims of sexual abuse is increased in cases of MSP. Often, the mothers initiate these claims, particularly in marriages in which divorce is a potential outcome. Unquestionably, MSP cases can challenge an entire social system.