Child age 2 dx'd with Bipolar DO and ADHD dies from meds at age 4

[whopper]

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http://www.nytimes.com/2007/02/15/u...&en=8c9cf594e7bae322&ei=5094&partner=homepage

The police said the girl had been taking a potent cocktail of psychiatric drugs since age 2, when she was given a diagnosis of attention deficit disorder and bipolar disorder, which is characterized by mood swings.

The girl's treating psychiatrist has taken a voluntary, paid leave until the case is resolved

Tufts-New England Medical Center, where the child was treated, released a statement supporting its doctor and calling the care "appropriate and within responsible professional standards."

It is not appropriate to judge the case without reading the chart.

However, without claiming the doc here was wrong, how can ANYONE, A LISCENCED PSYCHIATRIST properly dx a 2 year old with bipolar or ADHD? HEck anyone that age is going to cry and whine a lot and show inconsistent sleep, moods and won't be able to give an interview.

Is there some type of standard I'm not aware of? Tufts is a notable institution and they're claiming this doc followed the standard of care.

I'm not understanding how this in pretty much any case can be justified, unless the child was showing some strange ability to speak fluently and discuss sx at age 2.

 

[jjbmsiv]

On the interview trail I'd heard from several people over several different interviews many things about Tufts, none of which were positive. That was pretty striking, considering how consistent it was with particular comments and such. I did not apply nor interview there, and won't be more specific as I don't feel it's proper to do so since it's secondhand, but I'm ultimately surprised just a little less to hear it was from this particular institution.

What a shame. And a sad, sad story.

 

[sdn1977]

Brings up the next question....what motivated mom, dad, gps to bring this child in? In my population of children being treated with some psycoactive substance <10 (n=25 - small #) - at least one parent or guardian (sometimes gp) were also on one as well. Would make a good study...

This is a sore spot for me since I'm not totally against rx drug advertising. But....ads, magazine articles, forums, blogs, etc....are all out there touting one miracle after another. Not too far from the snake oil postulations from the back of a truck in the latter part of the 19th century. They often will come to me and ask about something they saw or read & I'm quick to refer back to their pediatrician - or better yet - our child psych center.

So...for the vulnerable mom, dad, gp - they seek help with crying, sleep disturbance, biting, throwing, tantrums - all can be wnl. Unfortunately, they often will find someone if they look long enough who will give them a drug. They may go thru many, many responsible & careful providers first...but there are others out there who begin with one drug then toss on another & another & another.

I agree with Whopper - it is not for us to judge here...but its more real than not in my dispensing experience!

 

[MBK2003]

It is not appropriate to judge the case without reading the chart.

However, without claiming the doc here was wrong, how can ANYONE, A LISCENCED PSYCHIATRIST properly dx a 2 year old with bipolar or ADHD? HEck anyone that age is going to cry and whine a lot and show inconsistent sleep, moods and won't be able to give an interview.

I'm heading into Child & Adolescent Fellowship this summer, so can't speak from the position of having seen "hundreds of these cases" but can say that if it were me, I would not start a 2,3, or 4 year old on meds (particularly antipsychotics) without consultation from at least one other board certified child psychiatrist who does not have a vested interest in propagating the explosion of childhood onset bipolar disorder.

As a medical student, I did see an outpatient evaluation with a 4 year old child who had such significant pathology that he'd killed multiple pets (torturing animals since age 3), stabbed his toddler sibling, and had been banned from attending any day care in the county due to his violence towards other children. The child demonstrated significant, apparently terrifying, rage attacks precipitated by frustration with limit setting and little to no super ego development. The child psychiatrist evaluating the child did eventually (after an extended evaluation time) start Risperdal, but also put in place 15 hr/wk home-based services for the child and family. He could have been diagnosed as Bipolar, sent off with Rx for depakote & an antipsychotic, and followed monthly for meds, but that would have been suboptimal care.

You can never know without reading the chart and knowing the child, but we shouldn't downplay the role of the V61.20 (parent-child relational problem) in some of the child psychopathology we see.

MBK2003

 

[whopper]

There are a number of possibilities about how a child that young could be dx'd so early. I don't know if any of them are standard of care (several certainly aren't).

I looked up the doctor in question. HE'd the director at Tufts which implies he's must at least have some decent credentials. After all, he's the director in a university hospital.

Medical Director, Adult Psychiatry Consultation and Emergency Psychiatry Service, and Child & Adolescent Eating Disorder Service

While it seems on the surface, the likely possibility is that he just gave some meds to some parents who may have just wanted to shut their kid up, I don't know what really happened For this reason I don't think any of us should judge.

But as of right now, I'm thinking any kid age 2 being brought in by parents for a supposed psychiatric disorder, you'd have to be very very skeptical. I'd chalk it up to bad parenting (which may or may not be the parent's fault) at that point. Dx'ing a 2 year old kid w/ Bipolar & ADHD, man, someone here with good Child psyche experience justify why that could've been done.

I know its not scientific but if you watch Nanny 911, most of the time the problem is just bad parenting. Yet I can see these same kids getting doped up on Seroquel for the same exact behaviors. Again, I know its not scientific, but in cases like this perhaps its better to have some type of intervention where someone lives with the family for a week to check them out. I've seen several cases where parents are doing some pretty whacky things and can't figure out what's wrong...e.g. parents have obese kids and give them about 3000 calories per meal 4x a day but don't see the problem. The only way this was figured out was a nutritionist had to actually have dinner with the family and the kids were given entire large pizza pies and if they didn't finish them, they'd get yelled at.

I did see an outpatient evaluation with a 4 year old child who had such significant pathology that he'd killed multiple pets (torturing animals since age 3), stabbed his toddler sibling, and had been banned from attending any day care in the county due to his violence towards other children.

Very very interesting case. I'd love to hear more about it if you got the time and resources to spare.

 

[50960]

??WTF is this world coming to...

 

[MDVertigo]

While you make some good points, you're getting a little loose on the facts. Dr Kifuji (she) is/was simply director of a few clinics. Not Dept Chair or anything even close.
and, the court documents suggest she had been working with multiple family members over far more than 2 or 3 years.
but, still a lose/lose situation for everyone

 

[whopper]

Thanks for the corrections. I don't believe I did point out the doc as a the Dept Chair, I did point out that the doctor was a director.

IMHO a director is perhaps more so responsible because the director is more directly attached to clinical care. The Dept Chair, while being at the top is more detached and unfortunately sometimes hears things a little too late. Kinda like comparing a sergeant to a general. The sergeant's going to see evreything upfront including the small stuff, while the general only is aware of the big stuff.

I talked to my program director today and his opinion, without judgeing the above case, was that medicating children may in a few decades be potentially seen as the future embaressment of modern psychiatry.

Psychiatry as he stated has several embaressing mistakes such as lobotomies, ECT as a method of punishment, etc. He stated that in his opinion too many doctors out of laziness simply med-up patients without critically examining if they truly have the pathologies that merit the medication.

In a few decades, just as we see lobotomy as a practice that was wrong, so too would future psychiatry may judge medicating children age 2 with a mood d.o.

And again, while not judging the above case, I've seen (As I'm sure plenty of you have seen) plenty of attendings, FPs and GPs liberally dx and give out psychiatric meds without critically examining a patient under DSM criteria for disorders. This type of practice gives psychiatry a bad name.

 

[Adam_K]

I talked to my program director today and his opinion, without judgeing the above case, was that medicating children may in a few decades be potentially seen as the future embaressment of modern psychiatry.

Psychiatry as he stated has several embaressing mistakes such as lobotomies, ECT as a method of punishment, etc. He stated that in his opinion too many doctors out of laziness simply med-up patients without critically examining if they truly have the pathologies that merit the medication.

In a few decades, just as we see lobotomy as a practice that was wrong, so too would future psychiatry may judge medicating children age 2 with a mood d.o.

Wholeheartedly agree.