On Sunday September 30, the CBS news program 60 Minutes aired a report entitled “Who Killed Rebecca Riley.” The piece explores the tragic death of four-year old Rebecca Riley due to an overdose of psychiatric medications. In the story, Katie Couric explains how Rebecca had been diagnosed with bipolar disorder at the age of three years and how she had been prescribed several medications to treat her behavioral symptoms. Rebecca’s mother is now in jail, accused of murdering Rebecca by regularly giving her too much of the medication Clonidine, which was one of the medications prescribed for Rebecca by the child psychiatrist. The prosecutors allege that Rebecca’s parents used this medication excessively to keep Rebecca quiet and subdued. Rebecca’s mother states that she gave Rebecca only the prescribed amount of Clonidine.

Numerous questions arise from this story, but the big concern explored here is whether or not “early” diagnosis of bipolar disorder, which has exploded in the last 10 years, is a valid diagnosis, and what are the implications of the diagnosis? In particular, what are the risks of starting such young children on high-powered psychiatric medications that have not been well studied in children?

From my previous postings, you know that I have deep reservations about using the bipolar diagnosis to describe a broad group of children who have explosive, reactive and impulsive behavior patterns. The people who support early diagnosis believe that many of these children will eventually become bipolar and that early diagnosis is warranted. Many in the field, including me, point out that we have no data to support this belief—there is simply no body of research that identifies this pattern. While a small group of these kids will go on to develop bipolar disorder, and a small group of kids develops a true bipolar in childhood, the vast majority of these children suffer from many other issues. Calling them all bipolar does a grave disservice to them and their families and creates the kinds of risks that came into sharp focus in the Rebecca Riley case.

This is not to minimize, in any way, the extraordinary difficulties experienced by these children and families when the children suffer from severe patterns of explosive rages and impulsive, often dangerous behaviors. These are real psychiatric problems with many risks associated with them. These children and families need enormous amounts of support and help, and often medications. But labeling them “bipolar” can become an easy, almost lazy shorthand for them—offering a reason to use the most powerful drugs out there to address these often frightening symptoms.

The process of evaluating these children and families carefully, working up a careful differential diagnosis, in which we explore all the possible conditions that could cause these symptoms is a time-consuming and frustrating task. In fact, for many of these kids, one clear “diagnosis” or explanation won’t fit and won’t provide complete understanding of the situation. So we have to live in an uncomfortable “unknown” place while working with these families, doing the best we can to describe the problems and solve them with an array of tools at our disposal. These include a lot of family and child therapeutic support and problem solving, along with close collaboration with schools. These are essential components to treating these difficult kids, with or without medication in the mix.

Trying to use the most benign medication choices is always best, but can sometimes be even more complicated and demanding in terms of monitoring and adjusting them over time. But shooting from the hip, prescribing these powerful, poorly understood medications for an even less understood diagnosis, seems to me to be a dangerous medical procedure.