Rebecca’s diagnosis questioned
The Patriot Ledger
The validity of a diagnosis of bipolar disorder in a child as young as Rebecca Riley “has yet to be established,” according to the leading organization for child psychiatrists in the United States.
A paper published by the American Academy of Child and Adolescent Psychiatry last year brings into question the diagnosis Dr. Kayoko Kifuji made when Rebecca was just 28 months old. Kifuji said Rebecca experienced both bipolar disorder and attention deficit hyperactivity disorder.
The paper urges caution in diagnosing children under the age of 6.
“When you start reducing the age (at diagnosis) to that low, you’re really in dangerous waters,” said Dr. Christopher Bellonci, a child psychiatrist in Needham. “If you apply adult criteria, then every 4-year-old should seem to have bipolar disorder.”
Diagnosing very young children with bipolar disorder and other severe mental illness requires “a very good neuropsychiatric workup and assessment,” said Frank Laski, executive director of Mental Health Legal Advisors Committee, a state-supported legal advocacy group for the mentally ill.
Kifuji also diagnosed the toddler with attention deficit hyperactivity disorder, a much more common illness that can go hand in hand with a bipolar diagnosis, and which can have similar symptoms. According to the affidavit state police filed in the case, Kifuji had diagnosed all three of the Riley children with bipolar disorder and ADHD.
Based on the diagnoses, Kifjui prescribed powerful drugs for the children. This past week their parents were charged with 4-year-old Rebecca’s murder after investigators determined that she had been given far too much of one drug, clonidine, over a period of months.
Kifuji voluntarily agreed to stop practicing while she is investigated by the state Board of Registration in Medicine. She has not been charged with any crime and has not admitted any wrongdoing.
Diagnosing children so young, particularly with bipolar disorder, is difficult because symptoms can be confused with developmental phases or developmental disorders.
Still, there is a growing recognition in the psychiatric field that very young children can and do have severe mental illness, although the understanding of disorders in preschoolers is far behind knowledge of illnesses in older children.
Dr. Helen Eggers, a child psychiatrist and epidemiologist at Duke University Medical Center, has done extensive studies on preschool children with mental illness. Her research has found that psychiatric disorders are as common in very young children as they are in older children - about one in 10 experiences a disorder that causes social or developmental impairment.
“In the last five years we’ve made tremendous strides in diagnosis and recognition of the problem,” she said. “And now the next step is we have to train people to identify these problems in young kids as well as identify effective treatments.”
Doctors are still trying to determine the most effective ways to treat preschoolers with mental illness. But Eggers said the hope is that if children can be helped early, they will avoid the ravages that mental illness can wreak on a growing child.
“I think if we can identify these disorders early, maybe we can really prevent a lot of the pain and distress that happens later,” she said.
Still, she said, psychologists are only beginning to figure out how bipolar disorder may manifest itself in very young children.
“There’s tremendous controversy about the diagnosis of bipolar across childhood, and particularly with very young children there is no data,” Eggers said.
Adult bipolar disorder - often called manic-depression - is marked by dramatic changes in mood, from extreme elation to intense depression. Swings can be relatively short or it can take months to switch from one end of the spectrum to the other. Sleep disturbances occur in most adult patients having manic episodes.
The illness can look different when manifested in children.
According to the American Academy of Child and Adolescent Psychiatry, children with bipolar disorder may be more likely to have rapid up-and-down cycles, even during the course of a day.
For toddlers, according to the academy “there are no definitive studies outlining a developmentally valid method for assessing manic symptoms.”
Adding to the difficulty is that bipolar disorder in children often occurs alongside other disorders, like ADHD, that may have similar symptoms.
“In the best of cases, it’s not easy, particularly when you have another entity, like attention deficit disorder, where a significant amount of the important symptoms overlap,” said Dr. John Fromson, a child psychiatrist from Waltham. “You’re also dealing with developmental issues. It’s not a routine or easy thing to do.”
Some typical childhood symptoms of bipolar disorder, Fromson said, are tantrums, frequent arguments and flying off the handle easily.
“Those are also developmental things that would be very appropriate for a 2-year-old to be manifesting, and henceforth the colloquialism the terrible twos,” he said.
Sometimes behavior that presaged a bipolar diagnosis is more obvious in retrospect. According to the Child and Adolescent Bipolar Foundation, symptoms of the disorder can occur as early as infancy.
“Mothers often report that children later diagnosed with the disorder were extremely difficult to settle and slept erratically,” the foundation says on its Web site. “They seemed extraordinarily clingy, and from a very young age often had uncontrollable, seizure-like tantrums or rages out of proportion to any event.”
Julie Jette may be reached at firstname.lastname@example.org.