It’s no wonder that people think psychiatrists are a bunch of hacks.

Rebecca Riley was a four year-old girl, diagnosed with bipolar disorder at the age of 2.5 (!!!), who was found dead in Hull, Massachusetts, presumably due to

“intoxication due to the combined effects” of the drugs clonidine, valproic acid (Depakote), dextromethorphan, and chlorpheniramine….

For reference, clonidine is a blood pressure medication that is sedating (and thus has been used to promote sleep and reduce (aggression in kids).

Valproic acid is a mood stabilizer and anticonvulsant (prevents seizures) that is commonly used in the treatment of bipolar disorder. Frequent side effects include weight gain and sedation. (Then there’s the minor details of possible liver inflammation and pancreatitis (inflammation of the pancreas).)

Dextromethorphan is an “antitussive” (prevents coughing). You can also get high off of it—if you consume enough of the stuff.

Micromedex tells me that chlorpheniramine (which I’ve never heard of before) is used for allergies—like Benadryl.

According to news reports, she also received quetiapine (tradename: Seroquel), an antipsychotic medication, from her psychiatrist. The major side effects of quetiapine include weight gain and sedation. It can also cause blood pressure to drop, such that people feel light-headed.

Prior to her death, school administrators had noted that she had been “a little too quiet”. Probably because she was “a little too sedated”.

There does not exist any criteria that are clearly valid or reliable for the diagnosis of bipolar disorder in children (1). The assumption is that criteria for adult bipolar disorder can be applied to kids, though researchers in that area simultaneously agree that adjustments are necessary for this diagnosis in kids. It’s kinda like saying, “It’s basically the same thing, but only different.”

The criteria that some researchers (2) use to diagnose bipolar disorder in kids include:

Elated mood:

• “… it can be very misleading to see a happy child laughing in the office in the context of a miserable history (e.g., school suspensions, family fights).”

Grandiose delusions:

• “A common presentation for bipolar children is to harass teachers about how to teach a class; this harassment is often so intense that teachers telephone parents, begging them to ask their children to desist.”
• “Another common grandiose manifestation in children as young as seven is to steal expensive items and be impervious to police officers who attempt to make them understand that what they have done is wrong and illegal.”
• “Common adolescent grandiose delusions include are that they will achieve a prominent profession (e.g., lawyer) even though they are failing at school, i.e., the belief that they can have a high attainment when they have failing school grades bypasses the laws of logic.”

High activity level:

• “Manic adolescents will wait until their parents are asleep and then go out “partying”….

Pressured speech, racing thoughts:

• “… children state that they are not able to get anything done because their thoughts keep interrupting.”

Hypersexuality:

• “Children may masturbate frequently, initially openly, and then when told not to do it publicly will simply make frequent trips to the bathroom to continue the stimulation.”
• “Adolescents develop romantic fantasies and delusions about teachers.”

Risk taking:

“Interest in money appears in young children when they start their own businesses in school and when they begin to order multiple items, trips, and plane tickets….”

What?

These criteria significantly overlap with the range of normal. Should every kid who is experiencing difficult social stressors never laugh? Can’t kids be obnoxious and tell off the teacher? Are kids “mentally ill” for possessing dreams and aspirations? Do kids who disobey their parents have a condition that is only treatable with medications? Is distractibility a marker of pathology?

And, for the love of God, KIDS MASTURBATE. That’s part of normal—yes, normal—development. It happens. And shouldn’t we congratulate kids for changing their behavior after receiving admonitions (kindly or otherwise) and conducting their business in private? After all, at least they’re not telling their teachers how to masturbate properly.

And what kid hasn’t had a crush on a teacher? And where do kids get the idea that money is an important facet of life? Isn’t that cultural in nature?

The article that cites these criteria does list them as if they are valid and reliable—which they’re totally not. We cannot rely on these criteria for diagnosis and since diagnosis guides treatment, the treatment (medications) is faulty due to the weakness of the evidence.

And no one is jumping up to conduct a randomized, placebo-controlled, double-blinded study on kids and medications because of all the ethical issues involved (although I recall reading somewhere that Harvard had done something like that… though I can’t find the citation now). Would you want your kid (baby sister/brother/cousin/et al.) to receive medications at uncertain doses with uncertain effects with uncertain outcomes? Do we even know how quetiapine or valproic acid or whatever affects neuronal (read: brain) development? Particularly at the age of TWO? Or, heck, even FOUR? The brain is a miraculous organ that changes dramatically well through adolescence. Just what are we doing to the neurochemistry of the brain through the introduction of these substances?

We don’t even know how valproic acid works in the treatment of bipolar disorder in adults.

The only argument I can come up with as to how these researchers justify diagnosis and subsequent treatment of bipolar disorder in kids is one that is frequently used with pregnant women: “The effects of the disease may be more harmful than the effects of the medications.” (For example, non-depressed, non-anxious pregnant women get better prenatal care, have more optimized nutritional status, smoke less, use fewer drugs, and drink less alcohol (3). Suicide is also the third most common cause of maternal death in the U.S. (4) One can thus argue that the benefits of antidepressant use outweigh the risks to the fetus.) If, however, we can’t even offer valid and reliable definitions for the disease, how can we possibly argue that treatment of this amorphous disease has any benefit?

Another facet of this is that there are some adults with bipolar disorder who state that they believe they developed this condition when they were children (1). (Side note: Using the above criteria, more than 10% of kids meet those criteria for bipolar disorder… and in adults, the prevalence is closer to 1%. This means that (a) the child and adolescent criteria for diagnosis are inaccurate, (b) the condition “burns out”, or (c) we’re measuring the wrong things.) Are we invalidating these adults by stating that bipolar disorder just doesn’t exist in kids? (Of course, who is going to remember that they had symptoms when they were two years old?)

One last aspect I’d like to address is how psychiatric training varies by region. The rumor mill tells me that child and adolescent psychiatry in Washington State is arguably the most conservative in the country; “play therapy” (where the thought is kids “play out” their issues under the watchful eyes of the therapist) is considered irrelevant and is generally not practiced here. Although there are certainly child and adolescent psychiatrists here who prescribe many, many medications to kids, the general push is to remove as many medications as possible and use behavioral interventions, structure, etc. in treatment. This is apparently in significant contrast to the East Coast, where apparently many more psychiatrists believe in the “bipolar child” paradigm—and as one moves out West, skepticism tramples this belief underfoot. The major proponents for bipolar disorder in kids (including the author of the above criteria) are all located East of the Mississippi River.

The case of Rebecca Riley is tragic on many different levels—it cries for reform throughout the system on many levels, particularly in the realm of education. We need to learn more about valid and reliable diagnosis for psychiatric disorders, both in kids and adults. We need to learn more about appropriate treatments—and not just in the realm of pharmacology—for these conditions. We need to provide this information—all of it, not just the parts that sound benign—to patients and their families. We also need to facilitate discussion with patients and families such that they feel comfortable asking questions about their care; this results in more thorough coverage of risks and benefits, encourages collaboration (e.g. increased frequency in follow-up, etc.), and improves the therapeutic relationship. We need to stop labeling behavior as pathological just because it causes us inconvenience. We also need to stop using diagnoses as means of absolving us of our responsibilities (”it was the bipolar that made me say those mean things to you; it wasn’t me”). We, as providers, need to stop colluding in these goals: We need to stop the belief that a pill will always cure everything.

That is all.

(1) Harris, J. Child & Adolescent Psychiatry: The Increased Diagnosis of “Juvenile Bipolar Disorder”: What Are We Treating? Psychiatr Serv 56:529-531, May 2005

(2) Geller B, Luby J: Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 36:1168–1176, 1997

(3) Wisner KL, Zarin DA, Holmboe ES, Appelbaum PS, Gelenberg AJ, Leonard HL, Frank E. Risk-benefit decision making for treatment of depression during pregnancy. Am J Psychiatry. 2000 Dec;157(12):1933-40.

(4) Appleby L. Suicide during pregnancy and in the first postnatal year. BMJ. 1991 Jan 19;302(6769):137-40.