Drugs doses called threat

Four-year-old Rebecca Riley was prescribed three different powerful medicines, none of which were approved by the federal government for psychiatric use in young children.

She was taking Seroquel, a antipsychotic drug that is only rarely given to older children who need medication to control violent streaks that pose a threat to themselves or others.

The preschool child was also given Depakote, an antiseizure drug that is used to treat bipolar illness in adults, but has no established dosage for use as a psychiatric drug for children.

The girl was also taking clonidine, a blood pressure drug authorized for use by adults only, but some doctors have prescribed it for hyperactive children who have trouble sleeping. The dosage prescribed by her psychiatrist was at the high end of what many doctors say is safe for children of her age.

Rebecca's psychiatric treatment by Dr. Kayoko Kifuji of Tufts-New England Medical Center was highly experimental and posed a potential threat to the girl's health, some pediatricians and psychiatrists said. All three drugs given to the girl were prescribed "off label," meaning they were for uses not approved by the US Food and Drug Administration.

Doctors in many specialties prescribe drugs off label; however, they run greater risks when they do so because the medication has not been rigorously tested for safety and efficacy for these additional uses. Doctors say prescribing multiple off-label drugs together can be particularly risky because their interactions have not been adequately studied.

About two years before Rebecca died Dec. 13 of an overdose, which police say was an act of child abuse by her troubled parents, Dr. Kifuji diagnosed the two-year old girl with bipolar disorder and attention deficit hyperactivity disorder, according to a police investigator's report. The psychiatrist had already diagnosed mental disorders for Rebecca's two older siblings, whom she met while practicing in Springfield. Dr. Kifuji's diagnosis of Rebecca was a result of knowing the family mental health history, as well as relying on Rebecca's mother's description of the girl's behavior and the doctor's own observations of Rebecca during office visits, records show.

Soon thereafter, Rebecca was put on three medications, which were designed to stabilize her moods and help her sleep, according to records. The decision to medicate a young child on those drugs, at potent doses, should have instantly alarmed pediatricians and social workers familiar with the girl's case, said some psychiatrists.

"Having a 4-year-old on [those] three medications and the intensity of the medications, I'd have big concerns," said Dr. Candida Fink, a child psychiatrist from New Rochelle, N.Y., who specializes in bipolar illness. "These are big-gun medications."

In the investigator's report, Rebecca's preschool teachers repeatedly cited the girl's extreme lethargy and said the girl seemed more energetic when the effects of the drugs wore off. A nurse also said that the girl did not exhibit the kind of aggressive behavior that sometimes warrants potent drugs.

Fink, who consults with government agencies nationwide and works with the American Psychiatric Association, said the medications all have serious potential medical side effects, including damage to organs and extreme sedation. Any psychiatrist is entering uncharted territory when prescribing these to young children, and should run regular blood tests to make sure a child is not suffering serious bodily damage. It remains unclear, based on public records so far, whether blood tests were conducted.

Kifuji has voluntarily agreed to stop practicing while the state Board of Registration in Medicine examines her prescriptions and treatment of the child. Kifuji has not responded to efforts to reach her, but her lawyer, J.W. Carney Jr. , defended her actions. He said the doctor has a lengthy record of caring for the Riley family and excellent qualifications as a board-certified doctor in pediatrics and child psychiatry.

Carney said he questions the validity of anyone's criticisms of Kifuji's care when they have "never examined the child or her siblings and never reviewed her medical records or lab reports."

But Dr. Eli Newberger, a pediatrician and specialist on child abuse, joined some other physicians in questioning how a 4-year-old girl would be given such a powerful mix of drugs and receive a diagnosis of bipolar disorder at the age of 2.

Newberger said it is particularly shocking given that the psychiatrist had to know that the family had a history of domestic violence and other troubles and that the mother's account of a child's behavior in such circumstances cannot be relied upon.

"It's not just a question of dosages; it's a question of the appropriateness of the initial diagnosis and treatment," he said.

The autopsy showed the girl died of the "combined effects" of clonidine and Depakote in her system, as well as two drugs contained in over-the-counter cough medication she was taking the night she died.

The autopsy also indicated that Rebecca's heart and lungs were damaged due to "prolonged abuse of these prescription drugs, rather than one incident." The manner of death was ruled a homicide due to "intentional overmedication with clonidine."

Rebecca's parents were arraigned Tuesday on first-degree murder charges in her death.

The questions about Rebecca's daily drug exposure are being raised as the state's Department of Social Services commissioner says his agency is not equipped to oversee the complex psychiatric and medical decisions made for children under its care. He has called for the hiring of medical experts to be assigned to DSS, so that social workers can consult when they have questions about a child's care.

Patricia Wen can be reached at wen@globe.com.