Early on the morning of Dec. 13, police officers responding to a 911 call arrived at a house in Hull, Mass., a seaside town near Boston, and found a 4-year-old girl on the floor of her parents’ bedroom, dead.
She was lying on her side, in a pink diaper, the police said, sprawled across some discarded magazines and a stuffed brown bear.
Last week, prosecutors in Plymouth County charged the parents, Michael and Carolyn Riley, with deliberately poisoning their daughter Rebecca by giving her overdoses of prescription drugs to sedate her.
The police said the girl had been taking a potent cocktail of psychiatric drugs since age 2, when she was given a diagnosis of attention deficit disorder and bipolar disorder, which is characterized by mood swings.
The parents have pleaded not guilty, with their lawyers questioning whether the child should have been prescribed such powerful drugs.
The case has shaken a region known for the excellence of its social and medical services. The director of the state’s Department of Social Services has had to defend his agency, which had been investigating the case before the girl’s death.
The girl’s treating psychiatrist has taken a voluntary, paid leave until the case is resolved. And New Englanders are raising questions that are now hotly debated within psychiatry, and which have broad implications for how young children like Rebecca Riley are cared for.
Tufts-New England Medical Center, where the child was treated, released a statement supporting its doctor and calling the care “appropriate and within responsible professional standards.”
Indeed, the practice of aggressive drug treatment for young children labeled bipolar has become common across the country. In just the last decade, the rate of bipolar diagnosis in children under 13 has increased almost sevenfold, according to a study based on hospital discharge records. And a typical treatment includes multiple medications.
Rebecca was taking Seroquel, an antipsychotic drug; Depakote, an equally powerful mood medication; and Clonidine, a blood pressure drug often prescribed to calm children.
The rising rates of diagnosis and medication use strike some doctors and advocates for patients as a dangerous fad that exposes ever-younger children to powerful drugs. Antipsychotics like Seroquel or Risperdal, which are commonly prescribed for bipolar disorder, can cause weight gain and changes in blood sugar — risk factors for diabetes.
Some child psychiatrists say bipolar disorder has become an all-purpose label for aggression.
“Bipolar is absolutely being overdiagnosed in children, and the major downside is that people then think they have a solution and are not amenable to listening to alternatives,” which may not include drugs, said Dr. Gabrielle Carlson, a professor of psychiatry and pediatrics at Stony Brook University School of Medicine on Long Island.
Paraphrasing H. L. Mencken, Dr. Carlson added, “Every serious problem has an easy solution that is usually wrong.”
Others disagree, insisting that increased awareness of bipolar disorder and use of some medications has benefited many children.
“The first thing to say is that the world does not see the kids we see; these are very difficult patients,” said Dr. John T. Walkup, a child and adolescent psychiatrist at the Johns Hopkins University School of Medicine.
Dr. Walkup said that when drug treatment was done right, it could turn around the life of a child with a diagnosis of bipolar disorder.
Dr. Jean Frazier, director of child psychopharmacology at Cambridge Health Alliance and an associate professor at Harvard, said that up to three-quarters of children who exhibit bipolar symptoms become suicidal, and that it is important to treat the problem as early as possible.
“We’re talking about a serious illness with high morbidity, and mortality,” Dr. Frazier said, “and for some of these children the medications can be life-giving.”
Still, most child psychiatrists agree that there are still questions about applying the diagnosis to very young children. Recent research has found that most children who receive the diagnosis are emotionally explosive but do not go on to develop the classic features of the disorder, like euphoria. They are far more likely to become depressed.
And many therapists have found that some patients referred to them for bipolar disorder are actually suffering from something else.
“Most of the patients I see who have been misdiagnosed have been told they have bipolar disorder,” said Dr. Bessel van der Kolk, a professor of psychiatry at Boston University who runs a trauma clinic.
“The diagnosis is made with no understanding of the context of their life,” Dr. van der Kolk said. “Then they’re put on these devastating medications and condemned to a life as a psychiatry patient.”
Details about what happened to Rebecca are still emerging. A relative of her mother, Carolyn Riley, 32, told the police that Rebecca seemed “sleepy and drugged” most days, according to the charging documents.
One preschool teacher said that at about 2 p.m. every day the girl came to life, “as if the medication Rebecca was on was wearing off,” according to the documents.
Defense lawyers are also focusing on the question of medication. “What I want to know,” said John Darrell, a lawyer for Mr. Riley, “is how in the world you diagnose a 2-year-old and give her these strong medicines that are not approved for children.”
A lawyer for Rebecca’s psychiatrist, Dr. Kayoko Kifuji of Tufts-New England Medical Center, did not return calls seeking comment.
Some experts say the temptation to medicate can be powerful.
“Parents very often want a quick fix,” Dr. Carlson said, “and doctors rarely have much time to spend with them, and the great appeal of prescribing a medication is that it’s simple.
“To me one of the miracle of children’s brains is that we don’t see more harm from these treatments.”