Mother Guilty of Murder--Pediatric Bipolar Disorder Innocent

On February 9th a jury at the Plymouth Superior Court in Massachusetts convicted Carolyn Riley of second degree murder of her daughter, Rebecca, a 4 year old, who died three years ago. Rebecca's father, Michael, will be tried separately for first degree murder next month. A county coroner determined an overdose of the medication, clonidine obtained from a child psychiatrist, caused Rebecca's death. Prosecutors maintained that the parents intentionally overdosed their daughter to "keep her quiet". Apparently the jury didn't accept the parents' defense which had them "just following the doctor's orders."

In essence, Kayoko Kifuji, the child psychiatrist who prescribed clonidine to Rebecca, was exonerated with the mother's conviction. Kifuji worked at the Tufts New England Medical Center. She also prescribed two other medications to Rebecca used frequently in children's psychiatric problems, Seroquel, approved for use by the Food and Drug Administration (FDA) for treating schizophrenia and Depakote, studied and approved for epilepsy. Clonidine, also known as Catapress, was approved and studied for the treatment of hypertension. However, all three drugs are widely used in the treatment of pediatric bipolar disorder - although the FDA has approved none of them for this use. All three are potentially heavily sedating.

In America doctors have the equivalent power afforded gun owners by the "right to bear arms" second amendment to the Constitution. Once awarded a medical license a doctor can prescribe any drug approved by the FDA for any purpose. The doctor is guided by her medical judgment and ethics. However, doctors can be sued or have their licenses terminated if their treatment does not conform to "current medical standards."

Dr. Kifuji determined that Rebecca at age two had hyperactivity and began prescribing drugs to her at that time. Kifuji changed her diagnosis to bipolar disorder at age three. She also made the same diagnosis for Rebecca's brother and sister who were nine and seven. All three were receiving variations of these sedating psychiatric medications. Kifuji, who was granted immunity against prosecution to gain her cooperation, testified during the trial that she relied almost exclusively on reports from Rebecca's mother on the children's aggressive behavior, sleep problems and history of mental illness in the family to make the diagnosis for the three children.

When Rebecca died, Dr. Kifuji initially withdrew from practice. Her license was temporarily suspended. But she is now back working at Tufts. Right from the start, the University defended her, saying her practice with Rebecca was" within medical standards." Subsequently Kifuji, herself, underwent hours of testimony in front of a grand jury but was not indicted. The Board of Registration in Medicine, Massachusetts' medical licensing organization, also allowed her last year to return to practice.

Yet when I tell non-psychiatric colleagues and friends that a three year old was prescribed three psychiatric drugs for bipolar disorder, they are uniformly incredulous or shocked. So apparently were the jurors. Requesting anonymity after the trial, jurors told the Boston Globe, "Every one of us was very angry. Dr. Kifuji should be sitting in the defendant's chair, too. It blew me away." Clearly the jurors and most of the country were unaware of this practice of medicating younger and younger children with these powerful drugs.

However, it is not all that surprising that Tufts and the licensing board backed Kifuji's actions. It is only about 27 miles between where she worked and the Massachusetts General Hospital where Joseph Biederman, head of Harvard's Pediatric Psychopharmacology Clinic, has long espoused the bipolar diagnosis in children. He and his group have claimed the diagnosis can be made in children as young as two and should be followed by aggressive psychiatric drug interventions. I wonder if this crime had taken place anywhere in the country but New England whether the powers that be would have been as supportive of Kifuji.

Biederman has been arguably the most powerful and influential child psychiatrist in the country. Drug companies, eager to promote his views and their wares to other doctors, paid and flew him all over the country. More recently his "science" has come under scrutiny over a series of conflict of interest charges with the drug industry. Even before his public scandals, the American Academy of Child and Adolescent Psychiatry, the official organization of American child psychiatry, published guidelines declaring that bipolar disorder could not be diagnosed in children under six and was a difficult diagnosis to establish in any pre-teen child.

A psychiatrist cynically once remarked, "ADHD drugs are for irritable and irritating kids. Bipolar drugs are for very irritable and very irritating kids." The point is even with controversy over the bipolar diagnosis, the use of anti-psychotic drugs like Seroquel, Risperdal and Zyprexa in the five and under population has doubled in the last five years, particularly among Medicaid and foster children. There are several hundred thousand toddlers in America currently being managed (sedated) by their parents and doctors with these drugs.

Bipolar Disorder Essential Reads

Repeated Escalations to Mania in Bipolar Illness

Navigating Mental Illness Following Inpatient Treatment

Clearly, Kifuji didn't literally put the teaspoons of clonidine that killed Rebecca into her mouth. Still, like gun manufacturers who claim they bear no responsibility when someone misuses a handgun for murder, there's something disingenuous about a doctor who prescribed these drugs and then acknowledges no moral culpability in the death of this unfortunate child.

I question whether the bipolar diagnosis can be reliably made in any child. The new version of the Diagnostic Statistical Manual of Psychiatry V, "the bible" of American Psychiatry is due out in 2013. In news releases anticipating its publication, the plan apparently is to junk the bipolar diagnosis in children for something called temper dysregulation disorder emphasizing the transient nature of the problem (as opposed to the life long implications of bipolar disorder diagnosis) and an emphasis on changing the children's environment rather than using drugs.

So many of these children currently diagnosed as bipolar come from chaotic and turbulent family environments. Still I can imagine situations where these drugs, whatever label is applied to the children, will be used. I don't envy Kifuji and other child psychiatrists who work with indigent families with problem kids. Non-drug interventions, particularly family and parenting therapies are hard to come by and deliver. The child psychiatrist and her medications may be the last resort for keeping these children in their home and out of foster care where they are even more likely to get multiple medications. I am glad I don't have to face that ethical decision several time a day in a busy tertiary care university clinic.

Those that support and back pediatric bipolar disorder and its treatment have an obligation to speak out about the abuse of these drugs in the sedation and occasional deaths of children. Their silence in this case has been deafening. Unfortunately, it will take several more Rebecca Riley tragedies before the public makes it unacceptable for doctors to put these drugs in hands of parents to manage or mismanage the behavior of their very young children.