Holistic Medicine! Off Track!

[Michael Scally MD]

Steps toward a cure
Steps toward a cure - The Boston Globe

By Yvonne Abraham
Globe Columnist / February 21, 2010

Her mother’s murder trial has been over for a couple of weeks now, but I’m still haunted by little Rebecca Riley.

Why did no one manage to rescue this 4-year-old child as her parents pumped her full of powerful psychotropic drugs, drugs that would kill her? And how could the doctor who blithely prescribed those drugs have escaped even the slightest penalty?

Tufts Medical Center, where Dr. Kayoko Kifuji works, has had almost nothing to say about the case, other than to blandly defend the doctor’s care for Rebecca as professional and appropriate.

The silence is understandable, I suppose - Kifuji faces a malpractice suit brought on behalf of Rebecca’s estate, one Tufts is right to worry will cost the hospital dearly - but it is ultimately indefensible. And so I put some questions to Tufts last week. Why is Kifuji still employed there? Is the hospital dealing with other children the way Kifuji dealt with Carolyn Riley’s? Has anything changed since that poor kid’s awful death?

They wouldn’t address the first question, of course. But I was invited to sit down with Dr. John Sargent, chief of child psychiatry, to talk about the others. He came to Tufts just over a year ago, championing an approach to treating children that seems worlds away from Kifuji’s.

She continued to prescribe drugs for the Riley children despite numerous red flags - some raised by health professionals alarmed that the children were so heavily medicated. Where Kifuji shut others out, Sargent said he believes therapists should seek out the opinions of other counselors, health care workers, educators, social workers.

“You have to take a holistic approach,’’ he said. “You look at a number of factors outside your office. I want to know the kid’s life out there. . . . I expect that of everybody who works with me.’’

Sargent also demands that his staff spend plenty of time watching the children in their care: how they play, how they interact with their parents, how they handle challenges. The Riley children were sometimes asleep in their strollers during visits to Kifuji.

He says he uses great caution before he prescribes mood-altering drugs for kids. A no-brainer, though not, it would seem, for Kifuji.

Sargent says a shift in psychiatric treatment of children has been underway for at least five years across the whole field - not just at Tufts, and not necessarily as a response to Riley’s 2006 death.

But he conceded this much: “Any time you’re involved in a situation that has an outcome you wish hadn’t happened, it makes you look at what you’re doing. The leadership has changed and the focus of the leadership has changed.’’

Kifuji is very closely supervised these days, according to the hospital. On Thursday, Sargent called her “a tremendously dedicated, gracious, hard-working person who truly loves children.’’

Obviously, she didn’t kill Rebecca. Carolyn Riley did. (Riley’s husband, Michael, is also charged in the murder). A grand jury declined to indict the doctor in Rebecca’s death. Two Tufts reviews found that Kifuji didn’t break any rules.

But that doesn’t make her actions any less disturbing. Kifuji’s decisions put those drugs in the Rileys’ hands. And they’re decisions some other doctors refused to make: At one stage, Carolyn was traveling 100 miles to see Kifuji in Boston because nobody in Springfield would give her the drugs she wanted.

In recruiting Sargent, well-known for looking beyond the prescription pad in treating kids, Tufts has made a major move in the right direction. Listening to him talk about his caring, careful approach to his work, I was comforted by the possibility that some good might come from Rebecca’s death.

But as long as Kifuji remains on his staff, I’ll have my doubts.

Yvonne Abraham is a Globe columnist. She can be reached at Abraham@globe.com

 

[Michael Scally MD]

Mother Guilty of Murder--Pediatric Bipolar Disorder Innocent
Doctor Innocent in Massachusetts, Guilty Everywhere Else
Mother Guilty of Murder--Pediatric Bipolar Disorder Innocent | Psychology Today

Published on February 20, 2010

On February 9th a jury at the Plymouth Superior Court in Massachusetts convicted Carolyn Riley of second degree murder of her daughter, Rebecca, a 4 year old, who died three years ago. Rebecca's father, Michael, will be tried separately for first degree murder next month. A county coroner determined an overdose of the medication, clonidine obtained from a child psychiatrist, caused Rebecca's death. Prosecutors maintained that the parents intentionally overdosed their daughter to "keep her quiet". Apparently the jury didn't accept the parents' defense which had them "just following the doctor's orders."

In essence, Kayoko Kifuji, the child psychiatrist who prescribed clonidine to Rebecca, was exonerated with the mother's conviction. Kifuji worked at the Tufts New England Medical Center. She also prescribed two other medications to Rebecca used frequently in children's psychiatric problems, Seroquel, approved for use by the Food and Drug Administration (FDA) for treating schizophreniaand Depakote, studied and approved for epilepsy. Clonidine, also known as Catapress, was approved and studied for the treatment of hypertension. However, all three drugs are widely used in the treatment of pediatric bipolar disorder - although the FDA has approved none of them for this use. All three are potentially heavily sedating.

In America doctors have the equivalent power afforded gun owners by the "right to bear arms" second amendment to the Constitution. Once awarded a medical license a doctor can prescribe any drug approved by the FDA for any purpose. The doctor is guided by her medical judgment and ethics. However, doctors can be sued or have their licenses terminated if their treatment does not conform to "current medical standards."

Dr. Kifuji determined that Rebecca at age two had hyperactivity and began prescribing drugs to her at that time. Kifuji changed her diagnosis to bipolar disorder at age three. She also made the same diagnosis for Rebecca's brother and sister who were nine and seven. All three were receiving variations of these sedating psychiatric medications. Kifuji, who was granted immunity against prosecution to gain her cooperation, testified during the trial that she relied almost exclusively on reports from Rebecca's mother on the children's aggressive behavior, sleep problems and history of mental illness in the family to make the diagnosis for the three children.

When Rebecca died, Dr. Kifuji initially withdrew from practice. Her license was temporarily suspended. But she is now back working at Tufts. Right from the start, the University defended her, saying her practice with Rebecca was" within medical standards." Subsequently Kifuji, herself, underwent hours of testimony in front of a grand jury but was not indicted. The Board of Registration in Medicine, Massachusetts' medical licensing organization, also allowed her last year to return to practice.

Yet when I tell non-psychiatric colleagues and friends that a three year old was prescribed three psychiatric drugs for bipolar disorder, they are uniformly incredulous or shocked. So apparently were the jurors. Requesting anonymity after the trial, jurors told the Boston Globe, "Every one of us was very angry. Dr. Kifuji should be sitting in the defendant's chair, too. It blew me away." Clearly the jurors and most of the country were unaware of this practice of medicating younger and younger children with these powerful drugs.

However, it is not all that surprising that Tufts and the licensing board backed Kifuji's actions. It is only about 27 miles between where she worked and the Massachusetts General Hospital where Joseph Biederman, head of Harvard's Pediatric Psychopharmacology Clinic, has long espoused the bipolar diagnosis in children. He and his group have claimed the diagnosis can be made in children as young as two and should be followed by aggressive psychiatric drug interventions. I wonder if this crime had taken place anywhere in the country but New England whether the powers that be would have been as supportive of Kifuji.

Biederman has been arguably the most powerful and influential child psychiatrist in the country. Drug companies, eager to promote his views and their wares to other doctors, paid and flew him all over the country. More recently his "science" has come under scrutiny over a series of conflict of interest charges with the drug industry. Even before his public scandals, the American Academy of Child and Adolescent Psychiatry, the official organization of American child psychiatry, published guidelines declaring that bipolar disorder could not be diagnosed in children under six and was a difficult diagnosis to establish in any pre-teen child.

A psychiatrist cynically once remarked, "ADHD drugs are for irritable and irritating kids. Bipolar drugs are for very irritable and very irritating kids." The point is even with controversy over the bipolar diagnosis, the use of anti-psychotic drugs like Seroquel, Risperdal and Zyprexa in the five and under population has doubled in the last five years, particularly among Medicaid and foster children. There are several hundred thousand toddlers in America currently being managed (sedated) by their parents and doctors with these drugs.

Clearly, Kifuji didn't literally put the teaspoons of clonidine that killed Rebecca into her mouth. Still, like gun manufacturers who claim they bear no responsibility when someone misuses a handgun for murder, there's something disingenuous about a doctor who prescribed these drugs and then acknowledges no moral culpability in the death of this unfortunate child.

I question whether the bipolar diagnosis can be reliably made in any child. The new version of the Diagnostic Statistical Manual of Psychiatry V, "the bible" of American Psychiatry is due out in 2013. In news releases anticipating its publication, the plan apparently is to junk the bipolar diagnosis in children for something called temper dysregulation disorder emphasizing the transient nature of the problem (as opposed to the life long implications of bipolar disorder diagnosis) and an emphasis on changing the children's environment rather than using drugs.

So many of these children currently diagnosed as bipolar come from chaotic and turbulent family environments. Still I can imagine situations where these drugs, whatever label is applied to the children, will be used. I don't envy Kifuji and other child psychiatrists who work with indigent families with problem kids. Non-drug interventions, particularly family and parenting therapies are hard to come by and deliver. The child psychiatrist and her medications may be the last resort for keeping these children in their home and out of foster care where they are even more likely to get multiple medications. I am glad I don't have to face that ethical decision several time a day in a busy tertiary care university clinic.

Those that support and back pediatric bipolar disorder and its treatment have an obligation to speak out about the abuse of these drugs in the sedation and occasional deaths of children. Their silence in this case has been deafening. Unfortunately, it will take several more Rebecca Riley tragedies before the public makes it unacceptable for doctors to put these drugs in hands of parents to manage or mismanage the behavior of their very young children.

 

[Ra Ether]

A bipolar diagnosis as early as age 2????????? Are you kidding me????
Truly disturbing.

 

[Ra Ether]

She continued to prescribe drugs for the Riley children despite numerous red flags - some raised by health professionals alarmed that the children were so heavily medicated. Where Kifuji shut others out, Sargent said he believes therapists should seek out the opinions of other counselors, health care workers, educators, social workers.

“You have to take a holistic approach,’’ he said. “You look at a number of factors outside your office. I want to know the kid’s life out there. . . . I expect that of everybody who works with me.’’

Sargent also demands that his staff spend plenty of time watching the children in their care: how they play, how they interact with their parents, how they handle challenges. The Riley children were sometimes asleep in their strollers during visits to Kifuji.

Dr. Kifuji determined that Rebecca at age two had hyperactivity and began prescribing drugs to her at that time. Kifuji changed her diagnosis to bipolar disorder at age three. She also made the same diagnosis for Rebecca's brother and sister who were nine and seven. All three were receiving variations of these sedating psychiatric medications.

A psychiatrist cynically once remarked, "ADHD drugs are for irritable and irritating kids. Bipolar drugs are for very irritable and very irritating kids." The point is even with controversy over the bipolar diagnosis, the use of anti-psychotic drugs like Seroquel, Risperdal and Zyprexa in the five and under population has doubled in the last five years, particularly among Medicaid and foster children. There are several hundred thousand toddlers in America currently being managed (sedated) by their parents and doctors with these drugs.

UN-FRIGGIN-BELIEVABLE!!!!! Are these children even tested thoroughly (blood work) before being pumped with these dangerous drugs???

 

[HeadDoc]

the whole series of articles is confusing. From the title of the article, the journalist was implying the possibility of a cure. There is no cure for bipolar disorder or ADHD. There are behavioral interventions which greatly reduce the symptoms. There are some data to suggest that a certain number of children w. ADHD outgrow it. I have often suspected that these people cope better.

Psychiatry as practiced in many places has become psychopharmacology. This is a shame. When I practiced back in NYC in the 70's and 80's I competed with psychiatrists for clients. Now, they hand me their clients for therapy. Good for me ----but maybe not so good for the client. This puts the burden of coordinated trx on the psychiatrist and myself----which gets done. As 50% of people on psychotropics are getting them from the primary care docs, the coordination becomes even more important.

IN the case sited in the article, this severely (presumably) disordered child was being treated w. medicine alone. This is bad news from a treatment perspective. Biederman does not advocate this and yet his name is dragged in.

The family showed up with their children asleep. This is after a long drive--something that young children do not do well, generally. Klonopin or benedryl?

ADHD runs from 4 to 8% of the population. Bipolar d.o. runs around 1%. Bipolar and concurrent ADHD about .4%. Many clinicians I know have never seen a case of the latter. I have seen about 3. These kids are like nothing you can imagine. Can you imagine a 4-5 year old attacking his mother with a knife? Trying rip a phone off the wall when she is trying to call police for help?

Here in PHoenix, I have found an agency that is willing to do the home based training and intervention w. children like this. Medicine alone is not the answer.

Multidisciplinary treatment--yes! Holistic medicine---what is that?

 

[Michael Scally MD]

the whole series of articles is confusing. From the title of the article, the journalist was implying the possibility of a cure. There is no cure for bipolar disorder or ADHD. There are behavioral interventions which greatly reduce the symptoms. There are some data to suggest that a certain number of children w. ADHD outgrow it. I have often suspected that these people cope better.

Psychiatry as practiced in many places has become psychopharmacology. This is a shame. When I practiced back in NYC in the 70's and 80's I competed with psychiatrists for clients. Now, they hand me their clients for therapy. Good for me ----but maybe not so good for the client. This puts the burden of coordinated trx on the psychiatrist and myself----which gets done. As 50% of people on psychotropics are getting them from the primary care docs, the coordination becomes even more important.

IN the case sited in the article, this severely (presumably) disordered child was being treated w. medicine alone. This is bad news from a treatment perspective. Biederman does not advocate this and yet his name is dragged in.

The family showed up with their children asleep. This is after a long drive--something that young children do not do well, generally. Klonopin or benedryl?

ADHD runs from 4 to 8% of the population. Bipolar d.o. runs around 1%. Bipolar and concurrent ADHD about .4%. Many clinicians I know have never seen a case of the latter. I have seen about 3. These kids are like nothing you can imagine. Can you imagine a 4-5 year old attacking his mother with a knife? Trying rip a phone off the wall when she is trying to call police for help?

Here in PHoenix, I have found an agency that is willing to do the home based training and intervention w. children like this. Medicine alone is not the answer.

Multidisciplinary treatment--yes! Holistic medicine---what is that?

I find that psychology/psychiatry is a field still finding its legs. For myself, it is probably one of the hardest, if not the hardest, fields to fully understand. But, it is moving forward. I hope that researchers develop techniques to better measure both diagnosis and treatment. What do you think of CBT?

 

[HeadDoc]

I was trained as an old fashioned behavior therapist. CBT was just getting started in NYC under Albert Ellis while I was finishing a two year post do. I do both almost intuitively. Over the past two or three years, mostly as a result of attending annual workshops offered by the neuroscience group at UCLA, my interests have focused on attachment, emotional development as a part of attachment, hypothetical neuroscience underpinning of development and psychotherapy. On the latter, I've studied and participated in allot of mindfulness based intervention for stress, anxiety, and depression. The next step in my own practice would be to develop a number of process and outcome measures for each client. If I don't do this, I am sure that at some point it will become a practice standard anyway. I have found the mindfulness as a useful part of trx for ADHD and bipolar d.o. (w/o psychosis) as there is a significant deficit in self-regulation for both.

 

[Ra Ether]

The family showed up with their children asleep. This is after a long drive--something that young children do not do well, generally.

!!!!!

*smh*

 

[Michael Scally MD]

Holistic nutrition is weak on science, strong on selling supplements
Holistic nutrition is weak on science, strong on selling supplements - latimes.com

Among other things, holistic nutritionists may teach that fluoride and pesticides are lethal, that most diseases and detrimental behaviors are diet-related and that many people would benefit from taking numerous supplements.

"Holistic nutrition." You may not know the term, but you've surely heard its claims. Among other things, holistic nutritionists (or HNs, as they call themselves) may teach that fluoride and pesticides are lethal, that most diseases and detrimental behaviors are diet-related and that many people would benefit from taking numerous supplements. I've read plenty of articles by HNs in which they assert that they are disparaged by mainstream medicine and warn you not to trust modern medicine.

As a fitness trainer, I care about the nutrition advice my clients get. Health, after all, takes multifaceted effort — and more than a few of the people I work with seem to be swayed by holistic nutrition bunk.

I'm not the only one in my field to get burned up by it: Leigh Peele, a personal trainer certified by the National Assn. of Sport Medicine, coined the term "shock nutrition" to describe the scare tactics many HNs espouse.

"Fear sells well," Peele told me. "It's not that the glass is half empty — it's paranoia that the glass is going to jump off the counter and kill you."

I consulted Dr. Stephen Barrett, the retired psychiatrist and consumer advocate who operates the website QuackWatch.org, "an international network of people who are concerned about health-related frauds, myths, fads, fallacies, and misconduct." When I asked about the field of holistic nutrition, he replied: "I wouldn't call it a field — I would call it a marketing term. I've never encountered a science-based practitioner who referred to themselves as 'holistic.' I regard it as a red flag."

Barrett added that although some HNs offer solid dietary advice, the "vast majority" are more focused on "selling dietary supplements. You pay for a consultation and end up spending hundreds or thousands of dollars on pills that you don't need and which may not be safe."

He's also critical of the training HNs get, usually online. "What is missing from correspondence schools is … clinical experience," he said. Anyone studying to become a registered dietitian spends at least a year working with patients under close supervision from an experienced professional. There is no such requirement for students training to be HNs.

Barrett said no HN program he knows of is accredited by an organization recognized by the U.S. Department of Education. The Federal Trade Commission asserts on its website that, with few exceptions, legitimate institutions are accredited by Department of Education-recognized organizations.

So what do aspiring HNs study? I did some searching and was bombarded by ads for one in particular — Hawthorn University, an online school offering master's and doctorate degrees in holistic nutrition from Whitethorn, Calif. From its website:

"Students examine holistic, systemic cleansing and detoxification support options such as specific dietary and herbal protocols, juicing, fasting, hydrotherapy and the use of saunas."

(An article at MayoClinic.com by gastroenterologist Michael Picco states that colon cleansing is "generally unnecessary and at times may even be harmful"; toxicologist Alan Boobis from Imperial College in London stated on the website Sense About Science: "The body's own detoxification systems are remarkably sophisticated and versatile.... It is remarkable that people are prepared to risk seriously disrupting these systems with unproven 'detox' diets.")

"With individualized diet and lifestyle recommendations, most thyroid conditions will resolve without medication."

(When my wife, a family physician, read this she made a reference to male bovine droppings.)

"Discover how genetic engineering works, understand the health risk associated with genetically modified foods, and recognize how you and your children are at risk .... students will examine what they can do to reduce the risk of disease resulting from GM foods and how to alter the continuation of the fraud and deception within the food industry."

(Tufts University professor of nutrition Jeffrey Blumberg told me, "I would not have a problem eating them. Almost everyone in North America already does.")

Hawthorn school director Paula Bartholomy told me, "Holistic refers to taking into consideration the whole person." On supplements, she said, "students are taught that food is the first viable solution" but "students are made aware of quality supplement product lines."

Hawthorn's programs are recommended by the National Assn. of Nutrition Professionals, or NANP. But the university is not listed in the Department of Education's database of accredited postsecondary institutions and programs.

I spoke with NANP media relations advisor Jonny Bowden (who holds a correspondence PhD in holistic nutrition from the now-defunct Clayton College of Natural Health, which was accredited by the American Assn. of Drugless Practitioners and the American Naturopathic Medical Accreditation Board, neither of which is recognized by the secretary of Education).

Bowden said, "We don't want to be too worshipful of science, because there are no scientific studies that prove water puts out fire, but fire departments use it," and "doctors are getting a biased view because of Big Pharma." When I asked him whether holistic nutritionists have a similar bias from selling supplements, he said that there is good evidence supporting supplementation. "There is nothing wrong with making a profit from providing good information," he added.

Bowden provides lots of that "good information" on his website, where he offers more than 200 supplements for sale. (One is called PaleoCleanse, which I guess is for flushing out undigested saber-tooth tiger steaks.)

Barrett isn't the only one who takes issue with holistic nutritionists. Blumberg said, "Anyone can call themselves that. I am unaware of any licensing requirement and there are no standards, so it is really meaningless."

While I agree that people should focus on eating foods in their natural state rather than processed garbage, HNs take that ball and run with it into the deep end of a pool of quinoa and goji berries. Taking nutrition advice from the graduates of HN schools makes as much sense as hiring Ozzy Osbourne to drive a school bus.

I recommend science-based practitioners to my clients — such as registered dietitians, who have real degrees from accredited universities. RDs aren't always perfect either: Their professional organization, the American Dietetic Assn., has an overly cozy relationship with the food industry, receiving substantial funding from companies such as Coca-Cola, PepsiCo, Kellogg's, the National Dairy Council and the National Cattlemen's Beef Assn.

There are bad medical doctors and bad RDs, but I'm willing to bet the majority of them provide sound advice. It makes sense to listen to people who base their nutritional recommendations on science rather than those who believe that illnesses like autism, depression and thyroid conditions can be cured with vitamins and herbs.

Vitamins and herbs that they will happily sell you.

Fell is a certified strength and conditioning specialist in Calgary, Canada.