On F= ebruary 9th a jury at the Plymouth Superior Court in Massachusetts convi= cted 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, cause= d 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 h= ad them "just following the doctor's orders."
In essence, Kayoko K= ifuji, the child psychiatrist who prescribed clonidine to Rebecca, was e= xonerated with the mother's conviction. Kifuji worked at the Tufts New E= ngland Medical Center. She also prescribed two other medications to Reb= ecca used frequently in children's psychiat= ric problems, Seroquel, approved for use by the Food and Drug Admini= stration (FDA) for treating schiz= ophrenia 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 treatmen= t of pediatric bipolar disord= er - although the FDA has approved none of them for this use. All t= hree 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 bega= n prescribing drugs to her at that time. Kifuji changed her diagnosis t= o bipolar disorder at age three. She also made the same diagnosis for R= ebecca's brother and sister who were nine and seven. All three were rec= eiving variations of these sedating psychiatric medications. Kifuji, wh= o was granted immunity against prosecution to gain her cooperation, testified during the trial that she relied al= most exclusively on reports from Rebecca's mother on the children's aggr= essive behavior, sleep problems and history of = mental illness in the family to make the diagnosis for the three childre= n.
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 pr= actice 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' me= dical licensing organization, also allowed her last year to return to pr= actice.
Yet when I tell non-psychiatric colleagues and friends tha= t a three year old was prescribed three psychiatric drugs for bipolar di= sorder, they are uniformly incredulous or shocked. So apparently were t= he 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 mo= st of the country were unaware of this practice of medicating younger an= d younger children with these powerful drugs.
However, it is not a= ll that surprising that Tufts and the licensing board backed Kifuji's ac= tions. It is only about 27 miles between where she worked and the Massa= chusetts General Hospital where Joseph Biederman, head of Harvard's Pedi= atric 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 a= s two and should be followed by aggressive psychiatric drug intervention= s. I wonder if this crime had taken place anywhere in the country but N= ew England whether the powers that be would have been as supportive of K= ifuji.
Biederman has been arguably the most powerful and influenti= al child psychiatrist in the country. Drug companies, eager to promote = his views and their wares to other doctors, paid and flew him all over t= he country. More recently his "science" has come under scrutiny over a = series of conflict of interest charges with the drug industry. Even bef= ore his public scandals, the American Academy of Child and Adolescent Ps= ychiatry, the official organization of American child psychiatry, publis= hed guidelines declaring that bipolar disorder could not be diagnosed in= children under six and was a difficult diagnosis to establish in any pr= e-teen child.
A psychiatrist cynically once remarked, "ADHD drugs are for irritable and irritating kids. Bi= polar drugs are for very irritable and very irritating kids." The point= is even with controversy over the bipolar diagnosis, the use of anti-ps= ychotic drugs like Seroquel, Risperdal and Zyprexa in the five and under= population has doubled in the last five years, particularly among Medic= aid and foster children. There are several hundred thousand toddlers in= America currently being managed (sedated) by their parents and doctors = with these drugs.
Clearly, Kifuji didn't literally put the teaspoo= ns of clonidine that killed Rebecca into her mouth. Still, like gun man= ufacturers who claim they bear no responsibility when someone misuses a = handgun for murder, there's something disingenuous about a doctor who pr= escribed these drugs and then acknowledges no moral culpability in the d= eath of this unfortunate child.
I question whether the bipolar dia= gnosis can be reliably made in any child. The new version of the Diagno= stic Statistical Manual of Psychiatry V, "the bible" of American Psychia= try is due out in 2013. In news releases anticipating its publication, = the plan apparently is to junk the bipolar diagnosis in children for som= ething called temper dysregulation disorder emphasizing the transient na= ture of the problem (as opposed to the life long implications of bipolar= disorder diagnosis) and an emphasis on changing the children's environm= ent rather than using drugs.
So many of these children currently d= iagnosed as bipolar come from chaotic and turbulent family environments.= Still I can imagine situations where these drugs, whatever label is ap= plied to the children, will be used. I don't envy Kifuji and other child psychiatrists who work with indigent fa= milies with problem kids. Non-drug interventions, particularly family a= nd parenting therapies are hard to come by and deliver. The child psych= iatrist and her medications may be the last resort for keeping these chi= ldren in their home and out of foster care where they are even more like= ly to get multiple medications. I am glad I don't have to face that eth= ical decision several time a day in a busy tertiary care university clin= ic.
Those that support and back pediatric bipolar disorder and its= treatment have an obligation to speak out about the abuse of these drug= s in the sedation and occasional deaths of children. Their silence in t= his case has been deafening. Unfortunately, it will take several more R= ebecca Riley tragedies before the public makes it unacceptable for docto= rs to put these drugs in hands of parents to manage or mismanage the beh= avior of their very young children.
Links:
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[2] http://www.psychologytoday.com/blog/the-last-normal-child