San Francisco Chronicle
Monday, June 18, 2007
Rebecca was a 4-year-old girl who died, according to the medical examiner, from an overdose of clonidine, also known as Catapress. This drug is most widely prescribed to lower blood pressure but is also routinely employed by child psychiatrists to aid in sleep and to control unruly behavior in children. America is the only country that addresses the public health crisis of children's bad behavior with medications. No other society uses psychiatric drugs as widely as we do.
In this case, clonidine was one of only three psychiatric drugs given to Rebecca for the treatment of her purported psychiatric illness -- bipolar disorder. Her parents are being held for murder, charged with intentionally overdosing their daughter. Their defense: They were only following the doctor's orders.
Kayoko Kifuji, the child's psychiatrist, working at the Tufts-New England Medical Center, has withdrawn from her practice and is not answering any questions. Her license has been temporarily suspended. But she was not some extreme outlier practicing some voodoo alchemy on this child. Indeed, Tufts-New England issued a statement after the arrest of Rebecca's parents that her care "was appropriate and within responsible professional standards."
The Riley case is confusing, and responsibility for her death will ultimately decided by the courts. But her particular diagnosis and treatment have uncovered what one child psychiatrist called "the hidden tsunami" of children's mental health: the vast increase in the number of children receiving the bipolar diagnosis and the concomitant growth in the use of "mood stabilizing" drugs.
Rebecca was diagnosed at age 2 1/2 as having bipolar disorder, the new name for manic-depression. This diagnostic label conferred on Rebecca the same implications of being a chronic mental patient requiring drug treatment for the rest of her life. The conference in Pittsburgh fiercely debated the question: Can or should children that young be diagnosed with a disorder that ostensibly lasts a lifetime?
In addition to clonidine, Rebecca was also prescribed Seroquel, an anti-psychotic, and Depakote, an anti-convulsant. Neither drug is approved by the FDA for bipolar disorder in children. There are scant studies to justify such use. Is it appropriate to be prescribing these medications to someone so young?
There always have been unruly and difficult children. Rebecca's mother described her as, on the surface, very irritable, but the household was highly dysfunctional (Rebecca's older brother and sister were also on bipolar medications).
Nearly 3.5 million children in the United States take drugs for conditions such as attention deficit hyperactivity disorder. About 1.5 million children received an anti-psychotic prescription in 2006. While these drugs can be helpful in the short-term to improve children's behavior, they are not the moral equivalent to addressing aspects of their home life that are contributing to their problems. All these drugs have potential short and long-term side effects. Yet medication is often the desperate "quick fix" answer to chronic and difficult social problems.
Even if we agree on the need to medicate these children, should we be labeling children as young as age 2 as bipolar? Debate rages within professional circles. The most recent guidelines issued three months ago by the American Academy of Child and Adolescent Psychiatry specifically caution against the use of this diagnosis and its treatment in children younger than 6. Still, it may not be coincidental that the Tufts Medical Center is only a short drive from Harvard University, where that institution's pre-eminent child psychopharmacology clinic has been at the forefront of broadening and promoting the bipolar diagnosis for more and younger children.
Many doctors question the tie between any child's behavior and the adult bipolar condition. Given the predictable turbulence of adolescence (not to mention the terrible 2s), shouldn't one wait until children reach their early 20s before assigning this lifelong sentence? Other doctors say we cannot afford to wait to aggressively treat these problems of childhood, even though clear prospective links between the behaviors of bipolar illness of children to the later adult disorder have not been established.
Of course, the pharmaceutical industry's influence also cannot be denied. It vigorously promotes with millions of dollars the research and professional "education" that supports the pediatric bipolar diagnosis.
While the conference in Pittsburgh raised troubling questions about the bipolar "epidemic" in children, it will not change in the short term the way America copes with very difficult children. In the meantime, the practical aspects of addressing children's extreme behavior in an otherwise underfunded mental health system will tilt doctors toward making such a diagnosis and using these sedating and potentially dangerous drugs.
Lawrence Diller, M.D., practices behavioral-developmental pediatrics in Walnut Creek and is the author of "The Last Normal Child" (Praeger, 2006).