What Killed Rebecca Riley?

On Dec. 13, 2006, police responded to a 911 call and found a little girl lying dead on the floor next to her parents' bed. The autopsy revealed that she had died from an overdose of psychiatric drugs. Rebecca Riley was being treated for bipolar disorder, or manic depression, even though she was just four years old.

If that sounds unusual to you, it's not. As Katie Couric reports, until recently the disorder was believed to emerge only in adults. Now, it is estimated that there are nearly one million children diagnosed as bipolar, making it more common than autism and diabetes combined. And to treat it, doctors are administering some medications that have yet to be approved for children. In the case of Rebecca Riley, that cocktail of medications proved fatal and now her parents have been charged with her murder.

"Constantly getting into things, running around, not being able to settle down," Riley remembers.

"Did you ever think, 'Well, she's two and a half years old.' There's this thing called the terrible 2's. Did you think this could, in fact, be normal?" Couric asks.

"Yes," Riley tells Couric. "The psychiatrist said that she thought that it was more than just normal."

The toddler who could barely speak in full sentences was diagnosed with bipolar disorder after several sessions over eight months. She had just turned 3. And she wasn't the only one in the family: her ten-year-old brother and four-year-old sister were already being treated for the same illness by the same doctor at Tufts-New England Medical Center. Rebecca was eventually prescribed three medications to stabilize her mood: Seroquel, an anti psychotic; Depakote, an anti seizure drug; and Clonidine, a blood pressure medication -- medications that would ultimately prove fatal on Dec. 13th.

Riley says she thought Rebecca had just a little bit of a cold and gave her daughter "Children's Tylenol Plus Cough & Runny Nose."

In the middle of the night, Riley remembers her daughter didn't want to go to sleep. "So I brought her in the room. She was right beside me on the floor. And I laid down and went to sleep," she recalls.

Before she put her to bed that night, next to her on the floor, Riley says she gave her daughter half a Clonidine.

Asked why, Riley tells Couric, "Because she hadn't been able to get to sleep since six o'clock."

"Then what happened?" Couric asks.

"Then I woke up to the alarm in the morning. And knelt down to wake her up. And there was no waking her up," Riley replies.

Riley says she knew at that point that her daughter had died. Carolyn Riley and her husband Michael were charged with first-degree murder.

The prosecutor alleged at their arraignment in February that they were overdosing Rebecca by repeatedly giving her more medication than she was prescribed. "It was used on Rebecca, her sister and her brother for one simple purpose by these defendants: to knock them out and make them sleep," the prosecutor claimed.

But the Rileys claim that they were following doctor's orders. 60 Minutes wanted to talk to the psychiatrist, Dr. Kayoko Kifuji, but she declined. Instead 60 Minutes got a statement from her hospital: "The care we provided was appropriate and within responsible professional standards."

60 Minutes did obtain a copy of Rebecca's medical records. In them, Dr. Kifuji notes Rebecca's increased risk of mental illness because of her family history. She diagnosed Rebecca after Carolyn said her daughter was - quote - "driving me crazy" and her mood switches within a minute. She would eventually prescribe the preschooler more than ten pills a day.

Riley says she did feel that that was a lot of pills for a little girl, but she says she went ahead and gave Rebecca the prescriptions. "I trusted the doctor," she says.

Dr. Kifuji has stopped practicing, pending a ruling by the state medical board. But her lawyer has said she was just practicing mainstream psychiatry. It's now estimated that nearly one million children like Rebecca Riley have been diagnosed with bipolar disorder, or manic depression. And while some psychiatrists told 60 Minutes that early diagnosis is saving lives, a growing number of doctors say it is being over-diagnosed.

60 Minutes went to talk to one of the leading proponents of the diagnosis of bipolar disorder in children and whose research Dr. Kifuji has said influenced her. He is Dr. Joseph Biederman, professor at Harvard and head of child psychopharmacology at Mass General Hospital.

"Previous studies that were conducted in the '70s and '80s determined it was very, very rare for a child to have bipolar disorder. And now you're saying up to a million children are running around with this," Couric remarks. "Why such a sea change?"

"The idea is rare if you define it in very strict ways," Dr. Biederman explains. "Our contribution has been to describe the many ways that this condition may emerge in children that may make it a little bit more diagnosable and less rare than people have thought about it."

The classic adult definition for manic depression or bipolar disorder is dramatic mood swings from severe highs to severe lows, which can last for weeks or months. Dr. Biederman's definition for children, though, is much broader. It emphasizes extreme irritability and at least four other symptoms such as recklessness, sleeplessness and hyperactivity. And while most doctors now believe that a child can be bipolar, there is no definitive medical test.

Now there's a cottage industry of bestselling books, magazine covers and Internet sites where you can test your child online. But even the top researchers can not agree on exactly what bipolar disorder looks like in children or at what age it can be diagnosed.

"The average age of onset is about four," Biederman says. "It's solidly in the preschool years."

"What about those who say, 'Oh, come on Dr. Biederman, a preschooler displaying these characteristics is often acting like a preschooler,'" Couric asks.

"Absolutely not," Biederman says. "The bar to consider a diagnosis in a very young child is very high."

Asked if he worries that his work is being used or applied too broadly and that too many children are being diagnosed as a result, Biederman tells Couric, "I am not so concerned if a practitioner recognizes that the symptoms have to be severe, debilitating, devastating, to consider the diagnosis."

Rhys Hampton was three years old when he began to have violent and explosive outbursts. After a year of treatment, his mother, Diana, says a psychiatrist told her he thought Rhys was bipolar.

"Would you describe his behavior as behavior that is extraordinary, severe, dangerous, and effects every, single aspect of his life?" Couric asks.

"Yeah. Every single aspect of his life," Hampton says.

"Bipolar disorder is also described as manic depression. Did he ever get depressed? Did he ever get sad?" Couric asks.

"He would tell us, you know, 'You don't love me.' 'You don't like me.' 'I don't like myself.' 'I hate myself.' 'I'm stupid.' 'Nobody likes me.' 'I wanna die.' Four-year-olds don't talk like that," Hampton says.

After Rhys' psychiatrist suggested a fourth medication, the Hamptons said "Enough."

They took their son to Seattle Children's Hospital, where they were told Rhys wasn't bipolar. He now takes medication for hyperactivity and a sleep disorder. And he's learning to deal with his explosive moods through a behavioral program.

"I mean, there's no comparison to the child that we're parenting today, as opposed to the one that we had last year," Hampton says.

Dr. John McClellan, who's familiar with Rhys' case, says the children's psychiatric hospital he runs in Washington state is filled with kids who have been misdiagnosed as bipolar. He says it has become a catchall for aggressive and troubled children.

"I think it's a problem to label kids with a major adult psychiatric disorder when they're five years old or when they're three years old," Dr. McClellan says. "Little kids are not adults. And little kids do things that if an adult did them, it would be evidence of a mental health problem."

"Having said that, if someone is bipolar and it presents later in life, doesn't it make sense that these issues exist really from birth?" Couric asks.

"No, that does make sense," McClellan says. "The problem is symptoms like irritability or recklessness or high energy when you're an eight-year-old don't necessarily predict in the long run developing bipolar disorder. Some might. Do you expose all those kids to medications to prevent the one kid that's going to get it?"

"Not that I don't use medicines, I do but the average kid comes into my hospital now on four different medicines. We had one kid that was recently admitted to our in-patient program that was on 12 psychotropic agents. At some level, there needs to be something else that's used besides just continuing to add medication after medication," McClellan says.

Dr. McClellan says we don't really know how these drugs interact or effect developing brains because most are being used off-label, which means they haven't been approved by the FDA for use in children.

"Does it disturb you or worry you that many of these medications, most of these medications are being used off-label, and have not been tested in children?" Couric asks Biederman.

"Yes. I recognize the fact that we have a gap in knowledge," Biederman says. "But the patients that come to me, and the families in tears and despair with these type of problems, I in good faith cannot tell them, 'Come back in ten years until we have all the data in hand.' I still need to use medicines that I am assuming that if they work in adults, with appropriate care and supervision, may also work in children."

Many parents told 60 Minutes their children are so out of control and disruptive, medication is the only option. A parent who took her children to Biederman's Mass General clinic, Maria Lamb says she depends on medication for eight-year-old Annie and nine-year-old Casey, who his mother says would rage for hours when he was just two years old. Casey was recently admitted to a psychiatric hospital when he was taken off one of his medications.

"I don't think they would be able to function. I wish they could. It was a last resort, seeing the kind of rages they would have, destroying their room, kicking the door off the hinges," Lamb says.

But during one recent visit, Maria's worried that Annie is eating incessantly. Dr. Biederman's partner Dr. Janet Wozniak says it could be a side effect from one of Annie's three medications and suggests another medicine may help.

"Actually its most common usage has been to help people with alcohol addictions resist alcohol. But it seems to also have an effect on food cravings," Dr. Wozniak remarked.

One of the biggest problems with these medications is side effects, including major weight gain, hand tremors, shakes, drooling and muscle spasms. And side effects are at the heart of the Rebecca Riley case.

Carolyn Riley tells Couric she never observed any sluggish or lethargic behavior in her daughter.

"This is what her preschool teacher said. She was like a floppy doll. So tired, she had to be helped off the bus. She had a tremor and had to go to the bathroom almost constantly. So how could she have these side effects at school, and yet, you never observed them at home?" Couric asks.

"I don't know," Riley replies. "She never acted like that at home at all."

But the prosecutor is charging the Rileys with murder because, he says, they ignored the warning signs and instead just kept giving Rebecca more pills than she was prescribed, even in the last few days of her life. And key to the case: 200 additional pills Carolyn Riley got from the pharmacy. She insists she was only replacing pills that were lost or damaged.

"For those who see you as somebody, who just wanted her kids to be less annoying and bothersome, who gave them too many pills because she couldn't deal with it, you would say?" Couric asks.

"I don't know. They weren't annoying. They were my life," she says.

"According to the medical examiner, her heart and lungs were damaged, and this was due to prolonged abuse of these prescription drugs, rather than one incident. Prolonged abuse of these prescription drugs," Couric remarks.

"Yes. And the doctor had Rebecca on .35 milligrams, daily, for months. And I didn't know anything about dosages. How much was fatal," Riley says.

The medical examiner ruled that Rebecca died of a drug overdose from a mix of medications. And that the amount of Clonidine alone would have been fatal.

Today, awaiting trial, Carolyn Riley says she now knows more about bipolar disorder than she ever did when her daughter was alive.

Asked if she thinks Rebecca was really bipolar, Riley says, "Probably not."

"What do you think was wrong with her, now?" Couric asks.

"I don't know," she says. "Maybe she was just hyper for her age."

Produced By Kyra Darnton