Should Toddlers or Preschoolers Be Diagnosed with ADHD and Bipolar Disorder?

On February 6, 2007, the parents of Rebecca Riley of Hull, Massachusetts were arrested and charged with murder. Rebecca, 4, died December 13, 2006 after receiving an overdose of the drug clonidine, used to treat Attention Deficit Hyperactivity Disorder (ADHD). Rebecca had been prescribed this drug as well as valproic acid and seroquel at the age of two and one-half based on a diagnosis of ADHD and bipolar disorder. The treating psychiatrist diagnosed these conditions based on the mental health history of her parents (her father is said to have been diagnosed with bipolar disorder and rage disorder, her mother with depression and anxiety disorder) and brief observations of her behavior in the psychiatrist's office. Both of Rebecca's older siblings, ages 6 and 11, were also diagnosed with ADHD and bipolar disorder and prescribed the same drugs.

The case of Rebecca Riley is complicated by allegations of abuse and intentional overdosing in order to keep her quiet. The criminal courts will decide whether her parents are responsible for her death.

One question that will not be answered by the criminal courts is why a baby was diagnosed with ADHD and bipolar disorder and prescribed potent drugs? Is it really possible that all three Riley children suffered from ADHD and bipolar disorder from early childhood and needed potent drugs to regulate their behavior?

Rebecca's home appears to have been seriously dysfunctional. Her 13 year old half sister was removed from the home and put up for adoption due to sexual abuse by Rebecca's father. The Department of Social Services was investigating the family due to alleged physical abuse of Rebecca's brother by her father. The parents both told police that they suffer from psychiatric conditions, with the father claiming to have both bipolar disorder and rage disorder. Is it possible that any disruptive or inappropriate behaviors that may have been exhibited by these children were learned, rather than evidence of a biochemical imbalance? Could it be that appropriate behaviors were simply not taught or modeled in their home?

With the things going on in Rebecca's home, maybe sitting still was not a good idea. Maybe moving around was safer. Or maybe it helped her cope with the emotional trauma she experienced. Is there any way to accurately determine whether the source of unfocused activity in a two to four year old is ADHD, bipolar disorder, environmental reaction, or normal development?

Even in a family where parents exhibit exemplary behavior, toddlers and preschoolers are known for losing control and having tantrums. Some children seem more prone to this than others, even in situations where the quality of parenting does not seem suspect. We've all met socially-adjusted, calm parents who set reasonable boundaries and behavioral expectations for toddlers and preschoolers to no avail. Some kids just seem to demand more control and resist authority more than others in the early stages of development.

Normal toddlers and preschoolers often exhibit dysfunctional behavior because they haven't yet learned social rules. They may bite, kick, scream endlessly, shout no repeatedly when asked to do something, run away when an adult is speaking to them, blame others for their actions; they are also curious and in the blink of an eye might engage in behaviors like smearing the contents of their diapers, playing in toilets, running into the road, wandering off, tasting things that are not meant for human consumption, making art projects out of food, or coloring on walls. Although a toddler is exhausted, he may resist sleep. Although hungry, he may refuse foods he ate yesterday, insisting that he hates them. If an adult engaged in these behaviors, no doubt the adult would be diagnosed with a serious mental disorder. But a two year old?

The National Survey of Children's Health 2003 identified the percent of children in the United States to ever be diagnosed with ADHD as 7.74%. Broken down by state the data showed the state with the lowest percentage of children ever diagnosed with ADHD, reporting 4.95% while the state with the highest percentage of children ever diagnosed with ADHD reported 11.09%. Some 5-6 million school age children annually are prescribed drug treatment for ADHD. About 1% of American children are currently being diagnosed and treated for bipolar disorder. The recent increase in diagnosis of young children with bipolar disorder is a uniquely American phenomenon.

It used to raise eyebrows when potent drugs were prescribed for elementary school age children. Now, it is commonplace. And the trend is reaching down to the preschool and baby population. Can doctors make valid diagnoses of ADHD or bipolar disorder in toddlers and preschoolers?

What do you think? Use the comment section to reply to this question.

Sources: The Boston Globe, 2/6/07; AP 3/23/07 reported on MSNBC.com, http://www.srmhp.org/0201/adhd.html, http://bipolar.about.com/gi/dynamic/offsite.htm?zi=1/XJ/Ya&sdn=bipolar&cdn=health&tm=26&f=20&tt=14&bt=1&bts=0&zu=http%3A//www.dbpeds.org/articles/detail.cfm%3FTextID%3D336