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Terminology

Rebecca Riley

Attention Deficit Hyperactivity Disorder

Clonidine

Bipolar Disorder

Depakote

Seroquel

 

“Patients who suffer the symptoms of bipolar disorder often begin very early in life, but people frequently come up with other explanations.”

Dr. Jefferson Prince,
child psychiatrist

‘EXTRAORDINARY’

Psychiatrists: Bipolar diagnosis is rare
for young child

It may be underreported because parents often hesitate to get treatment for youngsters, doctor says


The Patriot Ledger

Diagnosing bipolar disorder in a child as young as 2 is highly unusual but not unheard of, according to two Harvard-affiliated child psychiatrists.

Dr. Jefferson Prince, a child psychiatrist at Massachusetts General Hospital in Boston, called such a diagnosis in a 2-year-old “extraordinary.” Dr. John Fromson, chairman of the Department of Psychiatry at MetroWest Medical Center in Framingham, described it as “totally uncommon.”

The two doctors agreed to comment on general medical guidelines. They declined to talk specifically about the case of 4-year-old Rebecca Jeanne Riley, who was allegedly murdered by her parents. Michael and Carolyn Riley are charged with giving their young daughter a lethal dose of clonidine. Rebecca had been prescribed the drug when she was 28 months old to treat hyperactivity and bipolar disorder.

“Patients who suffer the symptoms of bipolar disorder often begin very early in life, but people frequently come up with other explanations,” Prince said. Fromson agreed that the symptoms - extreme agitation, aggressiveness, not sleeping and mood swings - may be labeled or diagnosed as something else, often attention deficit hyperactivity disorder.

The diagnosis will depend on the intensity and frequency of the symptoms, as well as family history. Bipolar disorder may be under-diagnosed in children, Prince said, because “most people don’t bring a 2-year-old to a psychiatrist. It is a terrible dilemma for parents to put their child on medication.”

Prince added that there is still a lot of disagreement over such diagnoses in children.

Making a diagnosis should be based on taking an entire history of the patient, both doctors said. How a child acts in a physician’s office is not necessarily sufficient or accurate, Prince said. Children don’t always display the mania symptoms in the office, just as patients don’t always have angina attacks or seizures in front of a doctor. And a child who is out of control is not necessarily “in mania.”

Prescribing clonidine, a sedative, to small children for hyperactivity is not uncommon, even though it has only been approved by the Food and Drug Administration for adult use to treat high blood pressure, both doctors said. They said it is non-addicting, has been around a long time and is safe at prescribed doses.

“But you have to make sure you get informed consent, that the patient or parent knows about the benefits and risks,” Prince said.

They indicated clonidine is frequently used to help children sleep or for impulsive aggression.

Depakote and Seroquel, approved for bipolar disorder in adults, are also used in children. Fromson said the newer mood stabilizers “have been very helpful with bipolar and may be very appropriate for some children.”

The state medical examiner’s office said Rebecca Riley had the three drugs prescribed for bipolar disorder in her system, plus two over-the-counter cold medicines, when she died Dec. 13 at home in Hull.

Sue Scheible may be reached at sscheible@ledger.com.

Child’s doctor reported

State medical board
to get information
about child psychiatrist
who prescribed drug that contributed to girl’s death


The Patriot Ledger

Plymouth County prosecutors have notified state regulators about the child psychiatrist who prescribed a potent drug that allegedly contributed to the death of a Hull toddler.

Plymouth District Attorney Timothy Cruz said yesterday that his office has sent information on Dr. Kayoko Kifuji of Tufts-New England Medical Center to the Board of Registration in Medicine.

Michael and Carolyn Riley of Weymouth were arraigned yesterday, accused of murdering their 4-year-old daughter, Rebecca Riley, in December by overdosing her with drugs, including clonidine prescribed by Kifuji. The doctor ordered the drug after diagnosing Rebecca with attention deficit hyperactivity disorder and bipolar disorder when she was 28 months old.

Medical examiner Elizabeth Bundock listed the combination of clonidine, the anti-seizure medication Depakote that is also used to treat bipolar disorder and two over-the-counter cold drugs as the cause of Rebecca’s death. The level of clonidine alone was fatal, the doctor said.

Rebecca had also taken a third prescription drug, Seroquel, but it was not cited by Bundock as contributing to her death. Seroquel is also used to treat bipolar disorder.

Clonidine is used to treat high blood pressure in adults and is also prescribed to treat behavioral and mental health issues in children. In the past 12 months, the MassHealth program for low-income families paid for 26,690 orders of clonidine for 3,900 children younger than 12, spokeswoman Brigitte Walsh said yesterday.

Tufts-New England Medical Center said Rebecca Riley’s care “was appropriate and within responsible professional standards.”

Attempts to contact Kifuji through the medical center were unsuccessful. In response to an attempt to reach her, the hospital released a written statement.

“Dr. Kifuji has outstanding credentials and is respected within her field,” the statement said. The hospital called the child’s death “a terrible tragedy” and said it has been helping prosecutors.

“Dr. Kifuji has outstanding credentials and is respected within her field,” the statement said. The hospital called the child’s death “a terrible tragedy” and said it has been helping prosecutors.

At the Rileys’ arraignment yesterday, Plymouth County First Assistant District Attorney Frank Middleton repeatedly referred to clonidine as a drug for adults. “It is not meant to be used by children,” he said.

There has been no formal testing that has found that clonidine is safe or effective for children younger than 12, but it is legal for doctors to prescribe medicines for any purpose once they are approved by the Food and Drug Administration.

Few drugs of any type have been tested in children. “Until the last few years, most prescriptions in pediatrics have been off-label,” Massachusetts General Hospital child psychiatrist Jefferson Prince said.

Psychiatrists use clonidine to treat the symptoms of attention deficit hyperactivity disorder in children. Prince said doctors usually select a stimulant such as Ritalin first, but “if they also have bipolar disorder you have to be careful because you can make the mania worse.” Clonidine is a sedative.

A state trooper’s affidavit said a Weymouth Walgreen’s pharmacy filled a number of clonidine prescriptions for the Rileys when they should have had an ample supply. Several times, Kifuji approved extra pills because Carolyn Riley said she had run out or lost her supply, the affidavit said.

Kifuji told investigators that she strongly objected when Carolyn Riley reported that she sometimes gave Rebecca extra clonidine. The doctor said she threatened to report Riley to the Department of Social Services if she did so again.

However, Carolyn Riley told investigators that Kifuji had authorized the extra doses to help the child get to sleep, the affidavit said.

Kifuji also received calls from a therapist and a nurse at Elden Johnson Early Childhood Center in North Weymouth, where Rebecca was a student, saying they were concerned about the child’s medication, the affidavit said.

Carolyn Riley allegedly disputed the reports and said Rebecca needed the drugs.

Kifuji allegedly diagnosed the child with bipolar disorder and attention deficit hyperactivity disorder based on the parents’ statements and “brief visits” in her office as frequently as twice a month and as seldom as once every two months, the affidavit said.

“In the preschool population a lot is based on the parent report,” Prince said. “Doctors aren’t around all the time so we rely on the people who are.”