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Thursday, January 07, 2010

Murder Trial to test public attitudes towards mental illness

Preschooler diagnosed with ADHD dies from overmedication: Parents on Trial for Murder

Rebecca Riley was diagnosed with ADHD and a bi-polar disorder before her third birthday. Her treatment was supervised by a respected pediatric psychologist, who prescribed two powerful medications, normally reserved for adults. While not approved for such use by the FDA, such "off label" uses are at the professional discretion of the treating physician, and are not uncommon.

Just over a year later, Rebecca Riley died.

The Massachusetts Medical Examiner concluded that her death was caused by an overdose of her medicine. Her parents, Michael and Carolyn Riley, on trial for her murder, claim that she died from pneumonia contracted shortly before her death. A grand jury refused to indict the girl's physician, concluding that the prescribed dosage was not to blame. Rather, the grand jury indicted the parents for murder on the theory that they intentionally overmedicated their daughter to make her easier to manage.

Read about the trial here.

There is some incriminating evidence that the Rileys will have to counter during their trial. School officials, including the school nurse, reported that the girl was often listless and non-responsive in school, sometimes requiring assistance just to get on or off the school bus. In addition, according to the girl's doctor, Mrs. Riley often requested additional refills of her daughter's medicine, claiming that she had lost or damaged bottles of pills. Finally, the Rileys' other two children have also been diagnosed with similar conditions and are being treated in a similarly aggressive way.

Are all these children really mentally ill?

Without a "smoking gun," per se, the outcome of this case will depend, to a great deal, on public perceptions of pediatric mental illness in the modern era. There are clearly countervailing trends and it remains to be seen how they will balance out.

On the one hand, psychiatry (with a big assist from neuroscience) has come a long way in identifying the physiological and neurological causes (or at least traces) of many previously undiagnosed (or misdiagnosed) conditions. We no longer throw women into insane asylums for "bad humors" or "hysteria." Most members of the public believe that depression actually exists and has a neurological foundation. People now appreciate the hereditary influences on alcoholism and other forms of "abhorrent" behavior. Americans generally recognize that soldiers and witnesses to war really do express post traumatic stress disorders. Mental illness is no longer a taboo subject the way it was even 50 years ago.

On the other hand, the public is clearly skeptical of the increasing propensity of mental health professionals to assign a syndrome name to virtually every form of unusual or undesirable behavior. Most current adults were raised during a time when behavioral problems among students were handled behaviorally, rather than psychologically. Children were expected -- required -- to behave themselves in school and at home. There were certainly allowances made for kids who were fidgety or had difficulty paying attention, but children were generally held accountable for their own actions. The primary objection to the current climate of diagnosing every other kid with some kind of disorder or syndrome is that we are raising a generation of people who won't know how to be responsible for their own decisions and actions. By making excuses for our kids, we are raising a nation of excuse-makers.

Modern pediatric psychiatry and parenting on trial

With these countervailing trends in play, how will jurors in this case perceive of the actions of Rebecca Riley's parents? Some may be inclined to defer to the girl's psychiatrist, excusing the parents for doing the same. They gave her these drugs because their doctor said it was OK. The doctor must have seen Rebecca on a regular basis. If she didn't seem concerned, then the parents had no way of knowing that Rebecca was in any kind of danger.

Other jurors will be skeptical of the parents' motives. A parent can get some doctor to diagnose a kid with some kind of disorder if they push hard enough. These folks obviously wanted to medicate their daughter to make their own lives easier. Why didn't they focus on trying to be better parents?

The wild card in this debate might just be the Rileys' handling of their other children. Jurors are notoriously bad at understanding and processing arguments based on probabilities. Unfortunately for the lawyers in this case, conveying the implications of the diagnoses of Rebecca's siblings requires the jurors to wrestle with such issues.

Consider the numbers: It is estimated that roughly 1 out of every 9 American children has some level of diagnosable ADHD. That is about 11%. One might then conclude that the chance of all three Riley children having ADHD is 0.11 cubed, or 0.0013 -- roughly one in a thousand. (Apparently only about 1/3 of children with ADHD receives the treatment she requires. As such, public perception would be that only about 4% of children have ADHD.) By such logic, it is extremely unlikely that the Riley kids got similarly diagnosed purely by chance. With such astronomical odds against it, the parents must really have been pushing doctors to diagnose ADHD.

Such logic is spurious, however, because it assumes that the incidence of ADHD among siblings are independent events. In truth, due to the shared genetics and physiology of siblings, having a brother or sister with ADHD substantially increases the chance of a child having the disorder.
When one child in a family has ADHD, a sibling will also have the disorder 20% to 25% of the time, says geneticist Susan Smalley, PhD, co-director of the Center for Neurobehavioral Genetics at the David Geffen School of Medicine at UCLA ( About 15% to 40% of children with ADHD will have at least one parent with the same condition.
By this logic, the fact that both of Rebecca's siblings have been diagnosed with ADHD makes it substantially more likely that Rebecca was correctly diagnosed with ADHD. If having one sibling with ADHD would increase the likelihood of Rebecca having it by almost three times, having two afflicted siblings would likely increase the chances five-fold.

This leaves the jurors in a tricky bind. Everything turns on the reliability of the doctor's diagnostic techniques. If her diagnoses of Rebecca's siblings were correct, her diagnosis of Rebecca almost certainly was, too. On the other hand, if her methods were suspect, the likelihood that she properly diagnosed Rebecca's condition, in particular, drops dramatically.

How to explain this to jurors

I have written in other blog entries about the "perils of probability." I also regularly discuss this issue with attorneys to whom I give presentations. It is very difficult to teach enough probability theory to jurors that they actually "get it." Don't expect them to be able to replicate the math. On the other hand, it is possible to provide them with enough insight to appreciate the nature of the results. My advice: Use visual aids to convey comparisons between probabilities. Analogize to decisions-under-risk with which jurors might be familiar. Make sure that your expert witnesses are excellent teachers. Jurors perceive as more reliable those witnesses who are seen as "helpful."

Regardless of the exact presentation strategies a litigator employs, she would always be wise to test its efficacy in advance. You might think your expert's explanation is crystal clear, but you can't be sure until you present it to a group of ordinary people and find out what they think. If your case turns on the "perils of probability," as the Riley case seems to, some sort of pretrial jury study (focus group research) is absolutely essential.

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