THE SHORT, DRUGGED, LIFE OF MACAULAY S. - by Fred A. Baughman Jr., MD

THE SHORT, DRUGGED, LIFE OF MACAULAY S.

by Fred A. Baughman Jr. MD


This is the story of Macaulay S. once a real, living, little boy.  His story
could have been set in any grade school, in any county, in any state, in the
US.  Macaulay's story differs from that of most who, nowadays, are
diagnosed, labeled and drugged in US public schools, as nowhere else in the
world, in that he died 9/30/00, one day after his 8th birthday.  I am a
physician, a neurologist.  I am going to share Macaulay's story with you and
try to determine  what factors caused Macaulay's death and whether or not it
was a preventable death.  All of you out there with children in US public
schools where emphasis has been shifted from the literacy and an education
to mental health and drugs to assure it, should listen up.

"Macaulay S:  BD 9/29/92, death 9/30/2000; age  8 yrs, 1 day."

 4/01/96,  3 years, 7 months of age, evaluated for Attention Deficit
Hyperactivity Disorder!"   "Suggestive of ADHD."

Diagnostic criteria for Attention Deficit Hyperactivity Disorder--ADHD, from
the Diagnostic and Statistical Manual-IV (DSM-IV) of the American
Psychiatric Association are as follows:

Six (or more) of the following symptoms of inattention have persisted for at
least 6 months to a degree that is maladaptive and inconsistent with
developmental level; (a) not pay close attention, (b) not sustain attention,
(c ) not listen, (d) not follow through, (e) difficulty organizing, (f) not
sustain mental effort, (g) loses, (h) distractable, (i)  forgetful, or, 6 or
more of the following symptoms of hyperactivity-impulsivity have persisted
for at least 6 months to a degree that is maladaptive and inconsistent with
developmental level: (a) fidgets, (b) leaves seat, (c ) runs & climbs, (d)
isn't quiet, (e) on the go, (f) talks excessively, (g) blurts out, (h) doesn
't wait turn,  (i) interrupts.

Could there be a better description of 3 to 4 year olds?

For billing purposes, quite as if each were a disease, the proper codes are
as follows, 314.00 ADHD, Predominantly Inattentive Type; 314.01 ADHD,
Predominantly Hyperactive-Impulsive Type; 314.01
Attention-Deficit/Hyperactivity Disorder, Combined Type, and 314.9, AD/HD,
NOS (not otherwise specified).

Even if one believes that meeting DSM-IV diagnostic criteria for ADHD
diagnoses a disease, Macauley's doctor, did not meet the diagnostic criteria
as set forth in the DSM-IV.    Whether referring to the inattentive type,
the hyperactive-impulsive type, the combined type, or, to ADHD-NOS,
treatment with Ritalin, 5 mg., morning and noon.     was begun on his first
visit.  There was no waiting to see whether his symptoms persisted for the
requisite 6 months or not.  There was no waiting to see if his symptoms
impaired him in the requisite two or more settings (e.g.,  home, school,
work).  Finally, the DSM-IV points out that "it is especially difficult to
establish this diagnosis in children younger than age 4 or 5 years."
Macauley was 3 years, 7 months.

4/11/96, on 20 mg Ritalin-Sustained Release

8/12/96, 3 years, 11 months, refer to Dr. Gibbs, child psychiatrist.

9/26/96, 3 days before his 4th birthday, "ADHD with very disrupted family
system"   Might the family problems have accounted for his behavior?
Increase Ritalin to 60 mg. SR in the a.m. and Benadryl (diphenhydramine, an
antihistamine) 50 mg. at bed time, in case the Ritalin keeps him awake. His
weight isn't given; can't compute dose in mg./kg.  Seems like a high dose,
even ill-advised.  Here, at less than 4 years of age he is on two
CNS-altering medications.

From a medico-legal point of view, it could be argued (1) that they did not
follow guidelines for a DSM-IV diagnosis in the first place and  (2) even if
they did meet DSM-IV diagnostic criteria, the fact of the matter is that
such criteria do not establish that it, ADHD, is an actual disease, due to a
physical abnormality in the  brain or body of patient.   Nor is Asperger's
syndrome or PDD-NOS an actual disease, due to a physical abnormality in the
brain or body of patient.

1/15/97, 4 3/12 years of age: still on Benadryl, 50 to 100 mg at bed  time,
also Ritalin SR 40 mg. in the a.m., 20 mg at 3 p.m.

2/6/97, 4 4/12 years of age, add clonidine (Catapres 0.1 mg, ½ tab at 6 p.m.
(.05 mg).  He is now on (1) clonidine .05 mg/d, (2) Ritalin SR 60 mg/d  (3)
Benadryl 50-100 mg/d.

4/10/97, 4 years 6 months of age,  "increased irritability," prescribe
clonidine TTS system-1 (0.1 mg/day/1 wk) patch, 1 ½ patch on trunk once/wk,
stop Ritalin, Benadryl 50 a.m., 100 mg. h.s.   He is now on 2
medications-Benadryl, clonidine-Catapres.

4/14/97, 4 6/12 : clonidine patch TSS-2, (0.2 mg/day/wk) patch, one per wk

4/16/97 'headache' dose cut to Catapres-clonidine* TTS-1  0.1 mg./d/wk)
one/wk.

6/20/97  4 9/12, clonidine patch: 0.175 mg./wk., Benadryl 50-100 mg. as
needed.

8/1/97 Claritin, loratidine, an antihistamine, usual dose 10 mg /d.
Sedation is it's main side effect, additive with other CNS depressants, also
dizzy lassitude, incoordination, fatigue, double vision, loss of appetite.
It is prescribed here, for rhinitis.

 10/ 9/97   (5 0/12 years of age)  clonidine .2 mg patch/wk , clonidine 0.1
mg, ¼ to 1/2 tab    prn, Benadryl 50-100 mg. prn

10/ 18/ 97  sinusitis, Lortabs (Claritin, an antihistamine)

11/ 18/97, 5 2/12  sinusitis, prescribe Zithromax, an antibiotic.

1/ 8 /98 (5 4/12 years of age) "having difficulties,"  start Prozac*
(fluoxetine, a specific serotonin reuptake inhibitor--SSRI).  Macauley is
now on Prozac, clonidine, and Benadryl.

1/20/98 stop Prozac, start amitriptyline*, 25 mg/d (Elavil-a tricyclic
antidepressant).  He is now on Elavil, Catapres (clonidine), and Benadryl.
The tricyclic antidepressant, Elavil, when taken with Catapres (clonidine)
can increase BP.   Tricyclic antidepressants, like Elavil, and
antihistamines, like Benadryl can enhance CNS depression.

3/6/98 send to lab to monitor the Elavil (amitriptyline).  Amitrityline in
serum: 27, nortriptyline 49, total is 76, said to be low.

The 1998, Physician's Desk Reference-PDR says: "Because of the wide
variation in the absorption and distribution of tricyclic antidepressants in
body fluids, it is difficult to directly correlate plasma levels and
therapeutic effect.Adjustments should be made according to the patient's
clinical response and not on the basis of plasma levels." "Elavil is an
antidepressant with sedative effects.   mechanism of action in man  not
known."  " .  not recommended  for patients under 12 years of age."
 changes in the EKG, particularly in QRS axis or width, are clinically
significant indicators of tricyclic antidepressant toxicity."

At no time before commencing the drug prescribing was the presence of a
disease first established by physical exam, lab, x-ray, scan, smear, biopsy
or any test of any kind. After the Elavil was begun, it's metabolites
amitriptyline and nortriptyline were found in the blood, evidence of an
abnormality, an intoxication, a disease.  Any foreign substance found in the
blood, urine or any body fluid or tissue is an abnormality, a disease.

In biological psychiatry where the claim is that every symptom is a disease
but none of them are, every new symptom begets a new prescription and every
new drug--foreign compound is an abnormality, a disease, an iatrogenic,
physician-induced disease.

6/11/98, 5 yr 9 mo.  Psychiatrist Gibbs: "more overtly oppositional."

Meds:  Catapres   0.1 mg,  ¼-1/2 po prn;  Catapres   TTS 3, (0.3mg/d/wk)
patch to trunk q 3-4 days, (meaning that the TTS 3 is being changed every
3-4 days instead of every week as intended)  Benadryl 50mg. one or two prn .
Elavil 25 mg. hs

As of now Macauley is on  4 medications; clonidine p.o., clonidine,
transdermal patch, amitriptyline, and Benadryl.

7/8/98   "looking worse, more impulsive,  is hyper, trouble falling asleep."
To what extent might his looking worse, more impulsive, being hyper, having
trouble falling asleep be due to his 'cocktail' of psychiatric drugs?

7/10/98  ( 5 years,10 mo.)  "Up all night without sleeping."  increase
amitriptyline  to 50 h.s. add Paxil (Paroxetine).   He is now on (1) Elavil
(2) Paxil  (3) Catapres (a) tabs and (b) patch,  and (4) Benadryl-4
different, CNS acting drugs.

9/29/98, 6 years and 0 months:  new diagnosis :  "Aspergers syndrome."

Aspergers' Disorder (299.80, DSM-IV, p.75.)  "The essential features of
Asperger's Disorder are severe  and sustained impairment of social
interaction and the development of
restricted, repetitive patterns of behavior, and activities.  The
disturbance must cause clinically significant impairment in
social, occupational, or other important areas of functioning.  In contrast
to Autistic Disorder, there are no clinically significant delays of
languages.  In addition, there are no clinically significant delays in
cognitive development or in the development of age-appropriate self-help
skills, adaptive behavior (other than in social interation), and curiosity
about the environment in childhood."

 "Macaulay wakes at 3-4 in morn wants to play. Gets in fights;  uncontrolled
behavior.   Has severe ADHD."

Ritalin has never helped.  Increase Elavil to 75 and 25  Continue  Catapres)
0.1 mg,  ¼-1/2 po prn, TTS 3, (0.3mg/d/wk) patch to trunk q 3-4 days "Will
have to work with various medications until we find the best combination we
possibly can, because he is going to always have many problems especially if
he truly does have an autistic like  syndrome-- Asperger's syndrome"

10 /15 /98, 6 1/12 yrs of age.  Diagnoses:   (1) Pervasive Developmental
Disorder (PDD), (2) rule out Aspergers syndrome, (3) ADHD spectrum symptoms

Rx. Catapres patch TTS 3 (0.3 mg/d/wk) q 7 days, po Catapres 0.1 mg  ½ to 1
q 24 hrs "for severe agitation or aggression"     Elavil 75 mg h.s.

Laboratory: EKG normal, amitriptyline 110, nortriptyline 112 = 222 with
therapeutic  75-250 (this is assay for Elavil, chemical name amitriptyline).

Affect 'constricted', mood fine.  Impression: (1) Pervasive Developmental
Disorder--NOS (not otherwise specified).

Pervasive Developmental Disorder, Not Otherwise Specified-NOS, DSM-IV,
299.80 including atypical autism): This category should be used when there
is a severe and pervasive impairment in the development of reciprocal social
interaction or verbal and nonverbal communication skills, or when
stereotyped behavior, interests, and activities are present, but the
criteria are not met for specific Pervasive Developmental Disorder,
Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality
Disorder.

Regarding PDD-NOS, Macaulay was said to be learning to read in an age- and
grade-appropriate way.  At times his behavior was age- and
grade-appropriate.  His social and behavioral problems were intermittent,
not inappropriate to his family setting/environment and were not
all-pervasive as required for this diagnosis.  At no time were stigmata of
fetal alcohol syndrome-FAS described, nor was FAS said to be a contributing
factor to his death-none of it's objective, physical features were described
at autopsy.

Also, likely (2) Asperger's syndrome.  Continues to manifest significant
difficulties with stereotypic behaviors and socialization.  Also, (3) ADHD
spectrum symptoms. Catapres patch, also p.o., also Elavil.  "Up all
night.  'very severely aggressive, including threaten others with  knives
and being more hyperactive.

11/17/98  6 2/12  "Grandmother notes without Elavil or clonidine, the
patient would be very severely impulsed, disruptive and aggressive."
      

[Fred A. Baughman Jr., MD:
sounds like psychiatrists talking. It would
be interesting to know if grand mother or parents/family ever asked to have
him weaned, off?]

6 21/99  more off task, more non compliant.  Very knocked out with the
Elavil in the morning dared to go into the creek when told not to, goes to
peers house when told not to, wants to play with knives, fireworks, verbally
aggressive and abusive to grandmother when not get his  way, all over the
place, wild aggressive violating boundaries off task, hyper runs when
supposed to walk, not stay seated and fidgety, discussion of Dexedrine and
of risk of death with 'dex,' clonidine, and Ritalin.  Grandmother want to
not try dex, so it not started  "so dexedrine was never started to target
adhd"
      

[Fred A. Baughman Jr., MD:
this is how they talk just as psych/pharm
cartel wants them to, just as if adhd a 'chem imbalance' just as if the dex
a specific 'chemical balancers', so it is throughout the pseudoscientific
lexicon of the psych/pharm cartel and mental health industry]

physically lashes out chokes and hits..  when given elavil in morn very
sedated
from that.  tts 3 patch, elavil 50, two h.s., clonidine po, prn

9/21/99 7 0/12 learning to read.
      

[Fred A. Baughman Jr., MD:
suggesting he might just be normal
intellectually, educationally, neurologically]

   buspar (buspirone) an
antianxiety agent begun this summer and did well for a week, talking to
people in full sentences.  Less anxious, go to bed readily, non compliant re
homework
      

[Fred A. Baughman Jr., MD:
make of it, of everything a med problem]

  "Impression: PDD, NOS,
likely aspergers sndrome. "ADHD spectrum symptoms associated with PDDNOS"
" Meds" Catapres (cloinidine) tts 3 patch one to trunk q 3-4 days, elavil 50
bid, catapres 00.1  ½ -1  po.

11/15/99 7 2/12 'doing well in 1st grade'
      

[Fred A. Baughman Jr., MD:
suggests he might be neurologically normal.
was neurological evaluation ever done--by a neurologist?]

 Behind in printing, coloring, cutting.  Manageable level of
hyperactivity Only rare need for Catapres (clonidine) p.r.n. (according to
circumstances) p.o.(per os, by mouth) for hyperactivity or aggressive
disorder
      

[Fred A. Baughman Jr., MD:
as if a disease, always, as if a diseases.]

 continue (1) Catapres
patch, also (2) Catapres p.o., also (3) Elavil 50 bid

12/29/99, 7 years, 3 months,   'Grandmother reports she is frustrated that
school does not seem interested in working with communication, daily log,
back and forth, and not acting  on recommendations to get OT (occupational
therapy)  and PT (physical therapy) consults.  Macaulay in Christmas program
did pretty well
      

[Fred A. Baughman Jr., MD:
there just might be a normal or near-normal
child in there]

.   Macaulay has anxiety, especially after school when the patient
continues to have obsessive worries about schedule and routine.Macaulay had
a major panic attack, to many people in the hallway touching him, it was
crowed, he got flushed scared, it was terrible.  "We reviewed the risks,
benefits, indications, side effects of adding a very low dose of Zoloft
      

[Fred A. Baughman Jr., MD:
Sertraline, another SSRI of the prozac
family]

 to attempt to further
assist in anxiety .'  Start Zoloft 25 mg  ½ tab (12.5 mg) per day, increase
Elavil (amitriptyline) which was 152 nanograms/ml on 75 mg per day on 3/31/
99, since Zoloft (sertraline) started, teachers are really seeing some
improvement
      

[Fred A. Baughman Jr., MD:
the same teachers that seemed not
interested in working with communication, daily log, back and forth, not act
on recommendations to get OT and PT consults. They are interested in making
such diagnoses and in getting each diagnosis its' rightful drug
prescription. Few indeed question the drugging or appropriateness of it or
the labeling, but more and more teachers and more and more parents and more
and more laymen and women are waking up and questioning. Had someone done so
in this case Macaulay, probably an entirely normal little boy, would still
be alive today. As it was he is never a day without 2, 3 and now 4
brain-altering, brain-damaging medication, not a one of them having the
purpose of targeting a known neurological, chemical, or biological
abnormality anywhere in his brain or body. And so it goes with every normal
school child thus victimized by mental health, courtesy of the US Department
of Education, courtesy of the US Congress, the US Senate and White house. If
we were once a major power, soon we will not be as fewer and fewer all the
time will be normal, educable, educated, and eligible to fill the billet of
our army air force and marines. This is already a pressing national problem
whether the government acknowledges it or not. An army and navy full of
druggies--never happened says the Pentagon. Eric Harris, the Columbine
shooter, was rejected a week before his rampage due to his psychiatric
history and his having been on Luvox (SSRI-prozac like, fluvoxamine). We are
consuming our young because the Congress and Senate have been paid off and
because they pass laws enabling and speeding the drugging of our normal
children yours and mine-the only prevention/immunization is home
school--many private and parochial schools have already been seduced by the
mental health industry so, if you go that route, interview them carefully
before hand, some are worse than public schools. ]

Get Elavil (amitriptyline) level 1 wk after starting  Zoloft (sertraline, an
SSRI)

2/16/2000, Dr. Sonnek:  Since Zoloft begun teachers seeing improvement,
calmer happier, not as worried.  "Suspect that with Zoloft, patient is less
anxious and able to observe his surroundings.  Impression Pervasive
Developmental Disorder--PDD, NOS (not otherwise specified), likely Asperger'
s syndrome with improvement in stereotypic behaviors,  rechecking.  Continue
1st grade "mainstreaming."

(1) Catapres  TTS 3, one to trunk q 3-4 days, also (2) Catapres  TSS-1 0.1
mg/d/wk patch;
      

[Fred A. Baughman Jr., MD:
#2 is 0.2 mg /d/wk and #3 is 0.3 mg /d/wk;
orally, pills are 0.1, 0.2 , 0.3]

 , (3) Elavil 50 mg bid, (4) Catapres (pill) 0.1 mg, ½ to 1
tab p.r.n. for severe aggression.  Continue one to one aid for his motor
coordination problem; is to have a  thorough OT assessment.
      

[Fred A. Baughman Jr., MD:
on all of these medications can there be
any doubt they would cause incoordination, mental status abnormalities,
generalized neurologic dysfunction, can their be any surprise there exists a
generalized intoxication?]

4/12/2000
      

[Fred A. Baughman Jr., MD:
7 years, 7 months of age]

: grandmother, Vickie, phones, is
increasing (5th medication) Zoloft (sertraline) to 25 mg q a.m. (every
morning)  due to panic attacks.  Feels this dose working well. No anxiety
attacks with this change.    OK'd by Dr. Sonnek.  Grandmother pleased with
improvements, she attributes to Zoloft.
      

[Fred A. Baughman Jr., MD:
what ever became of a normal childhood, of
misbehaving, of discipline, of teaching of child-rearing. Here we have not
just one generation, but two believing that every misbehavior, every
behavior, every emotion is a chemical imbalance to be treated with a
chemical balancer-a pill exactly as per the psychiatric/pharmaceutical
propaganda campaign, exactly as per their perverse neuro-psychiatric, their
perverse 'biologically- based- research, not science, not research at all.
Believing such things, parents, grandparents and teachers cannot possibly,
discipline, rear, educate and prepare a child-the model they are given
leaves it all to psychology, psychiatry and the pharmaceutical
master-exactly as is planned. Physicians, even psychiatrists who insist on
going to medical school, know better, they study pathology, endlessly, they
know and are trained to distinguish disease, for lack of it-from normalcy;
they are co-conspirators in this nightmare. See John le Carre's In Place of
Nations, an essay appearing in The Nation of April 9, 2001 (page 11). It
warns of the essential nature of the world-wide pharmaceutical industry, of
Big Pharma-to late for Macauley Showalter]

" He is eating a lot better (on the Zoloft), and is willing to try more
foods.  He is talking more and being more outgoing.  He is being more
responsive when you ask him questions and he is taking more in.  He is more
inquisitive and asking deeper questions that require deeper answers, and
those are all positive things."
      

[Fred A. Baughman Jr., MD:
and are all attributed to a pill-his
Zoloft]

Grandmother is also very pleased with how patient is doing in OT therapy,
working on some sensory defensiveness
      

[Fred A. Baughman Jr., MD:
whatever the heck this is]

, fine
motor, and gross motor coordination and handwriting skills
      

[Fred A. Baughman Jr., MD:
surely there must be a pill for each of
these 3 things, if not, there will be, as soon as the discrepancy is
noted. ]

.  Grandmother is pleased that she has not needed
to use the Clonidine p.r.n.
      

[Fred A. Baughman Jr., MD:
0.1 mg, ½ to 1 tab p.r.n. for severe
aggression]

 during less structured times, like spring break.
      

[Fred A. Baughman Jr., MD:
-they actually have no prescription for
spring break, what an oversight]

 .  Also
notes improvement in ADHD symptom profile, less hyperactivity, less
impulsive behaviors, but both (to some extent) continue.better than
grandmother expected.  Continue (1) Catapres TTS 3, one to trunk q 3-4 days,
(2) Elavil 2 x 50 mg. p.o., h.s. (hour of sleep) , (3) Catapres 0.1 ½ to 1
tab prn for severe aggression.

5/24/2000 (7 yrs 8 mo.) Grandmother had to increase (4) Zoloft dose to 25
mg. 1 ½ tabs po q am = 37.5 mg /d

6/1/2000 (7 yr 9 MO) Sinusitis, ADHD.  Cefzil 250 mg bid for 10 days
(cefprozil, an antibiotic) Continue Aleve (a non-steroid anti-inflammatory
like ibuprofen)
      

[Fred A. Baughman Jr., MD:
I suspect all medications may predispose
him to the occasional upper respiratory infections he is having]

6/30/2000:  During summer, with less structure, having more home behavior
problems, more frustration with lack of structure, grinding teeth at night
waking in middle of night, more critical of family charging they do not keep
him busy; less patient, not listening at home as well as before, not do what
he is supposed to do.    Since Zoloft begun he is better with people.  He is
definitely more social (since Zoloft)  Better eye contact until just lately.
Taking 1 ½ hours to fall asleep, awake by 6 am asleep by 9 pm.  Grandmother
notes positive change in that he is more alert, but having difficulties
adjusting to changes in routines, changes in emotions and awareness of them.
Impression: PDD, NOS, likely Asperger's syndrome.  Catapres TTS 3, to trunk,
q 3-4 days, Elavil 50 mg 2 hs,  Catapres 0.1 mg ½ to 1 tab po prn for
aggression, continue Zoloft 50 mg ¾ tab q am.  Obtain Elavil blood level.
On Elavil and Zoloft, which could each increase each other's blood levels.

8/11/00 (7 yrs, 11 MO)  Psychiatric follow-up. Grandmother
      

[Fred A. Baughman Jr., MD:
thoroughly psychopharmacologically
indoctrinated]

 notes that Clonidine not changed in
some time and patient seems much more hyperactive and impulsive over the
summer.  Grandmother notes that usually over the summer, the patient's
behavior worsens because he has less structure to follow.  Grandmother notes
when patient ran out of Clonidine patches, his behaviors were severely
'impulsed' and 'hyperactive.'
      

[Fred A. Baughman Jr., MD:
a language all their own]

"His disruption would occur when patient would open things up in the house
and slip things everywhere and make huge messes and be extremely hyperactive
and unmanageable."
      

[Fred A. Baughman Jr., MD:
can you imagine what sort of a chance you
would have had in life with parents/grandparents holding this view of
childhood and what and how children are to be managed]

 .  "Grandmother notes that the
oral Clonidine does not seem to work as well because if he takes to much he
gets sleepy an if he does not take enough, it does not help him at all
and .it seems like his system does not do as well as the Clonidine goes up
and down in his system with the pills.  It is more even with the patch and
he seems to do much better with that."   Grandmother says he is only
sleeping 6 hours a night, from 8 p.m. to 2 a.m.  Gets lots of exercise
during the day.  Grandmother is hopeful that as he enters school, that more
structured activities and more physical exertion, that he will sleep longer
at night.

Grandmother notes that Trazodone (desyrel)  trial at bedtime was not good at
all..
      

[Fred A. Baughman Jr., MD:
yet another pill for yet another symptom.
Trazodone = Desyrel, yet another heterocyclic antidepressant, having
additive side effects with Elavil = amitriptyline, a TCA, a tricylic
antidepressant, both with additive, side effects including risk for lethal
side effects. Were his psychiatrists not aware of the 1995 debate over
whether or not to embargo use of this group of drugs in children due to the
reported cases of sudden cardiac deaths, it would appear so in their adding
Trazodone. I wonder what grandmother meant here in saying that "Trazodone
trial at bedtime was not good at all."]

"Macaulay was very irritable.    It did not help him sleep any better.  He
started feeling and was just more impulsive and irritable." Impression: PDD,
NOS, likely Asperger's syndrome.  Reviewed risks, benefits, and indications
were given.  Medications: (1) Catapres  to TTS 3 patch (0.3 mg/d/1wk apply
one to trunk q 3 days, (2) Catapres TTS 1
      

[Fred A. Baughman Jr., MD:
meaning 0.1 mg/d/wk.]

  apply to
trunk q-3-4 days
      

[Fred A. Baughman Jr., MD:
this an increase to 2 different dose
patches at a time in addition to the oral pill form]

, (3) Elavil 50 mg  two h.s., oral (4)
Catapres 0.1 mg ½ tab to 1 tab h.s. prn for severe insomnia
      

[Fred A. Baughman Jr., MD:
I was not aware insomnia an indication for
Catapres]

.  Amitriptyline was 104 ng./ml. on
4/8/00 with nortriptyline 64 ng./ml.  for total of 168 ng./ml. with
reference range 75-250 ng./ml. .  Dr. Sonnek discussed if behavior improved
with structure at the school and improved and increased routine, there would
be no need to increase the Clonidine patch.  But if his behavior exacerbated
or continues with severe hyperactivity, impulsivity and aggression towards
property or others, or felt with start of school year then it would be
added.
      

[Fred A. Baughman Jr., MD:
This ends all the notes that I have
received from Dr. Sonnek and from the Hutchinson Medical Center. Dictated by
Brian R Bonte DO, McLeod County Coroner, 11/26/00]

9/30/00 (9 yrs. 1 day of age) ".this 8-year-old male was found laying on the
den floor after paramedics had tried to unsuccessfully resuscitate.The mouth
had foam coming out of it, and there was some blood ion the corners of the
mouth and into the right ear.  There was.rigor with dependent livor
(discoloration after death, in dependent parts of the body).  His body
temperature was quite cool.No evidence of foul play was seen.

".this 8-year-old male was found on the couch where he normally slept when
he stayed at his grandmother's, face first on the pillow.  She rolled him
over and saw foam coming out of his mouth.  He was cool and quite stiff.
She rolled him over on the floor and called the ambulance.

".he had not been feeling well since Wednesday, 9/27/00.  He complained of
headache and nausea and was kept home from school on Thursday, at his
grandmothers.  He felt better on Friday, 9/29/00, his 9th birthdays and went
to school.  However, he came home from school complaining of severe
headache.  He fell asleep on the couch on his back at 8:30 in the evening
and was not checked again until the moreing of the 30th at 9:30 a.m. when he
was found with his face buried in the pillow with foam coming out of his
mouth.

Coroner's Report.

His past history is consistent with ADHD
      

[Fred A. Baughman Jr., MD:
-did he ever meet DSM-IV diagnostic
criteria for this diagnosis. If so, that was not made clear in these
records]

  Also 'personality disorder with mania
      

[Fred A. Baughman Jr., MD:
-is this a diagnosis within DSM-IV?]

 .  Also '.diagnosed with Aspergers syndrome which
is a disorder with pervasive developmental disordeer spectrum with a finding
of motor weakness and better rote than abstract reasoning abilities.' 'The
patient also has evidence of fetal alcohol syndrome
      

[Fred A. Baughman Jr., MD:
-no description thereof in this record,
that is no description of physical findings that would allow for diagnosis
of FAS]

  and has a history of social problems with
removal from home of substance abusing parents at the age of 3.'  Mother
sees patient now and then, grandmother administers the medications and
provides most of his care.
      

[Fred A. Baughman Jr., MD:
-it seems]

In past 3 days
      

[Fred A. Baughman Jr., MD:
3 days prior to death, he was given Advil
60 mg. no more than 1 per day, also 2 'sinus' pills, of a combination of
extended release phenylpropanolamine (PPA) with brompheniramine. He was
given this on Thursday night, 9/28, and Friday night, 9/29. Other
medications include medications for his ADHD which include Catapres TTS 3, a
patch every 3-4 days with the last placement having been on Wed., also
Clonidine 0.1 mg p.o. h.s.a s for the past month. He was also on Zoloft 25
mg 1 ½ h.s. and amitriptyline 50 mg 2 tabs h.s.]

[Fred A. Baughman Jr., MD:
-meds were always cleared with Dr. Sonnek,
grandmother did not dose patient independent of physicians.]

The amitriptyline and Sertraline quantities revealed increased level out of
the metabolites..  Nortriptyline and desmethy-sertraline quantities are
equal or greater than the parent compounds, indicating chronic toxicity.
The Clonidine level is increased, but there can be some postmortem
redistribution.  It appears Macaulay was given his medications appropriately
as prescribed.  At this point, there is no evidence of acute toxicity or
overdose.
      

[Fred A. Baughman Jr., MD:
What about the 'chronic toxicity'.]

  The additional toxicology
will hopefully shed additional light on this manner.  Liver amitriptyline,
33 mg per kg, liver nortriptyline 34 mg per kg, total 64 mg /kg.
Interpretation of the amitriptyline reveals amitriptyline plus nortriptyline
in fatal cases is 15 to 500 mg per kg of liver tissue.  Concentrations of
15-30 mg /kg is considered ambiguous as to the cause of death.
      

[Fred A. Baughman Jr., MD:
Macaulays is 64 mg/kg of liver tissue, well
beyond the 'ambiguous' 15-30 mg/kg range.]

"The amitriptyline to nortriptyline ration greater than 1 indicates an acute
or recent ingestion of amitriptyline prior to death.
      

[Fred A. Baughman Jr., MD:
the ratio was 33/34, not > 1 and therefore
not particularly suggestive of acute ingestion, but rather of chronic as we
know to have been the case]

  The Sertraline
(Zoloft) level was 434 and desmethyl-sertraline was 666 nannograms
/milliliter with a reference range of 30-2000.  Clonidien, te level was 13.9
nannograms per ml with a reference range fo 1. To 2.  Sedation has been
associated with serum clonidine concentrations greater than 1.5
nannograms/l.   Toxic concentrations not established.

His blood levels of referenced medication were elevated.  "With regards to
which medication caused his death, it is to yet be determined or may never
be determined.  However, at this time, I feel that there is consideration
that the medications played a role in his death."
      

[Fred A. Baughman Jr., MD:
brilliant. What other cause did you
determine? ]

" Due to the fact that there was chronic toxicity ..the  medications had
been given in conjunction with supervised release per the physicians, I feel
that Macaulay's death was associated from chronic toxicity of multiple
medication, and that there was no acute toxicity or overdose."

".Several different combinations of medications were used and had not been
successful.
      

[Fred A. Baughman Jr., MD:
, I would ask Dr. Bonte, and all of his
attending physicians, what 'successful' would be in this case, just what the
successful end point for all of his prescriptions was intended to be]

  "The
treatment course was gradually accelerated and this may have caused his
demise."
      

[Fred A. Baughman Jr., MD:
indeed it was, indeed it may have,
especially in light of the fact that this child had no diseases other than
the concurrent intoxications due to each and every one of his cardiotoxic,
brain toxic, drugs.]

[Fred A. Baughman Jr., MD:
where exactly was the abnormality in the
patient to be made normal or more nearly normal before the first drugs was
begun, the 2nd , the third, the 4th, the 5th, the 6th? There were none, the
only physical abnormalities idenentified, the only chemical abnormalities
identified, and confirmed by laboratory testing were those due to the
foreign chemical compounds he was put on one after another as treatement for
his behavioral symptoms-none of them diseases, not one. The first drug
caused intoxication # 1, the 2nd, intoxication #2, the 3rd, intoxication #3,
and so on. This little boy died not from any disease shown to exist at any
time in his life other than the concurrent drug intoxications at the hands
of his physicians and for no other reason whatsoever. Moreover all of his
doctors, know or were responsible for knowing that he had no real disease
for which any of his prescribed drugs were scientific, logical treatment. ]

Coroner's Final Summary

Place of Death: Residence, above

Evidence for resuscitation:  There is a defibrillator pad present on the
chest and back

Clothing (a) pair of white socks. (b) pair of blue and white paisley
patterned boxer shorts.  (c ) red, white, and blue short-sleeved shirt.
Also, tan pillow with a slighly discolored area on one side, measuring 10
cm. in diameter.  Multiple medications also received, and an earing with a
clear stone in the left earlobe.

External examination: The body is that of a sell-developed, well-nourished
white male, consistent with stated age of 8 years and one day.  The body
weigs 70 pound and measures 64 inches (5 feet, 4 inches)  Rigor mortis is
easily broken
      

[Fred A. Baughman Jr., MD:
the limbs, stiff with rigor mortis can be
easily bend at the elbow, knee]

.  Livor mortis is predominantly anterior and fixed
      

[Fred A. Baughman Jr., MD:
redness from blood pooling in low parts of
body]

.  There is blanching of the front
of the chest and L cheek, also of the knees and other areas consistent with
clothing folds.  The body is cold to touch following refrigeration.

The head appears normal.  The hair is brown and measures 2-3.5 cm at the
vertex.  The eyes show brown irides
      

[Fred A. Baughman Jr., MD:
iris]

 and pupils equal at 5mm.  The
sclerae
      

[Fred A. Baughman Jr., MD:
white of the eyes]

 and conjuctivae are injected
      

[Fred A. Baughman Jr., MD:
blood-shot]

 but
show no hemorrhage The nose contains an intact nasal septum.

Mouth contains natural dentition and a moderate amount of white foam.

Neck, chest, abdomen normal.

Adherent to the outer portion of the left upper arm is an adhesive patch
labeled B113
      

[Fred A. Baughman Jr., MD:
his clonidine (Catapress TSS) patch meant
to assure the drug flowed constantly, without interruption through his brain
and body so that he would never have an independent, normal, thought,
inclination, or action]

Internal examination:  The body is opened with the routine Y-shaped
thoraco-abdominal incision.  Subcutaneous fat is uniform.  The peritoneal,
pericardial and pleural cavities are opened and cotain no unusual fluid or
adhesions.

'Heart weight: 150 grams.'  "The pulmonary arteries are free of
thromboemboli.'  Spleen weight 200 grams.'  'The liver weighs 1100 grams.the
hepatobiliary tree is unremarkable.'

'The stomach contains approximately 30 ccs of tan-brown fluid.'  'The
bladder is opened and is unremarkable.'  'The neck organs are dissected
after the ches, abdominal and cranial contents have been removed.the vocal
cords are symmetrical and free of abnormalities.'

'The scalp is reflected.the calvarium is intact and shows no evidence of
fracture.the brain weigs 1460 grams.with mild generalized cerebral
edema.serial coronal sections are unremarkable.the spinal cord is removed
and examined.  Cross sections reveal no mass lesions.

Microscopic examination:

Neck structures, trachea, esophagus, spleen, adrenal, pancreas, thyroid,
spinal cord, cerebellum, basal ganglia, midbrain, pons, hippocampus and
cerebral cortex all show no specific abnormality..

Lung shows pulmonary edema
      

[Fred A. Baughman Jr., MD:
water-laden, swollen]

.  Liver shows some focal
sinusoidal congestion
      

[Fred A. Baughman Jr., MD:
what gross or microscopic abnormalities of
ADD, Asperger's syndrome and PDD were found?]

 Date of Death 9/30/00

Toxicology:  Urine and blood: amitriptyline (Elavil) and amitriptyline
metabolites present. Liver amitriptyline, 33 mg/kg; liver nortriptyline
quantitation 34 mg/kg.  Blood sertraline (Zoloft): .434 mg/l:
desmethylsertraline, .666 mg/l.  Serum clonidine (Catapres)13.9 ng/ml.
Gastric amitriptyline (Elavil), 3.51 mg; gastric nortriptyline (a metabolite
of amitriptyline (Elavil), 0.15 mg.  Liver sertraline (Zoloft) [Fred A. Baughman Jr., MD:
 this is a new one]
 and Asperger's syndrome.  Medications included Catapress
TTS (patches), clonidine, Zoloft and amitriptyline.  The decedent has
recently not been feeling well, complaining of headaches and nausea.  The
decedent was found face down on the couch with his head on a pillow.

There is bilateral pulmonary edema and congestion with mild generalized
cerebral edema
      
[Fred A. Baughman Jr., MD:


 diffuse mild brain swelling]



.  The heart was grossly normal
although there was a patent valve,  competent foramen ovale and a thin
myocardial bridge over the proximal left anterior descending coronary
artery.  The bridging is not significant and measures 1-2 mm.

Postmortem toxicology indicates a mixed therapeutic drug toxicity with
chronically high levels of parent and metabolites for sertraline (Zoloft)
and amitrityline (Elavil).  However, gastric amittriptyline levels are low.
This would indicate a chronic toxicity and not an acute overdose.  Review of
the prescription refills appear appropriate and pill counts of pill bottles
received at the time of autopsy appear in order.

The death could be classified as undetermined and attributed to prescribed
amitrityline (Elavil)  and sertraline (Zoloft) toxicity.  ADD and Aspeerger'
s syndrome could be listed as other significant conditions.  BH, MD,
2/08/01.

Are these drug on-label indications for rx of PDD, NOS, Aspergers syndrome,
ADHD, and if so when did they  get FDA approval.

The interview with mother and grandmother showed no evidence of foul play.
The scene showed no irregularities after resuscsitation attempted.
Communication was appropriate.

The grandmother was not aware of any prior injuries..  He had his birtthday
on 9/29, 00, recieved a scooter, and if he had had any head injuries, he did
not compaliain of any pain.

Dr. BR Bonte, County Coroner, 10/3/2000:  Ater discussion with other people,
I have had several different additions.

Dr. Steven Sonnek was his psychiatrist prescribing his medications..he
(Macauley) was on Catapress TTS 3 once per day
      
[Fred A. Baughman Jr., MD:


 -could this be right, I remember no such


frequency from my review of the record]



  Also
amitriiptyline (Elavil) 100 mg once per day along with Zoloft 37.5 mg  once
per day.  He increased the Clonidine to .05 mg to 0.1 once per day as
needed.  He stated that the Catapres, Elavil and Zoloft have been used since
1998 when Dr. Gibbs was caring for the patient.  EKG in 11/99 normal.

There have been allegations from fathers of 2 other children cared for by
ghe grandmother, Vicky Boettcher, that thre has been some dosing of benadryl
to calm the children down.  Physician with Boehringer Ingelheim Drug Co.
said their have been 5 other edeaths reported with combination of Ritalin
and Catapres.

BB Bonte, Coroner, 12 /14/00.  'I.determine that it was a therapeutic, mixed
drug toxicity, manner cannot be determined.  Doctor Sonnek..did not feel
that he was being inappropriate in prescribing these medications.

A sister of Ron Johnson's (father of Macauley) was present, who asked
questions regarding the level of medications and whether the dose was
appropriate.  I stated that in my ascertainment, the child was given the
medications per Doctor Sonneks recommentsation and Doctor Gibss
recommendations.

I discussed the case with Mark Metz (Assistant County Attorney).  I question
whether additional inforfrmation is being received, as afar as the care of
Macaulay S, and whether there were other caregivers that felt that Macaulay
was being overmedicated.  .

" I feel at this time the manner of death cannot be determined, but the
death certificate will be signed as a therapeutic mixed drug toxdicity.  The
other cause s of death include Attention Deficit/Hyperactiivity Disorder,
along with Aspergers
      
[Fred A. Baughman Jr., MD:


 -syndrome]



  and PDD (pervasive developmental
disorder."

Neither Catapres or Elavil were known to be safe or effective in children
this age; they prescribed off-label, i.e. with no scientific basis, i.e.,
without safety or efficacy having been established for this age group; PDR,
'98:  " Safety and effectiveness in pediatric patients below the age of 12
have not been established."

Paxil, paroxetine, an SSRI of the Prozac family, also 'off  label' not then
known to be safe or effective for children this age at that time (98). "Any
psychoactive drug may impair judgement, thinking or motor skills."  PDR, '
98: "Safety and effectiveness in the pediatric population have not been
established."

One sees the practice throughout of prescribing new medications and
changing the doses  for each new symptom as if each was a new disease with a
specific abnormality for which each drug was a specific antidote.
Psychiatrists and other non-scientific physicians have been lead down this
path, and it does generate income-each new label, a new patient, each new
rx, affirmation of that dx.  While before the prescription there was nothing
to find with a test, now, with the patient on a drug or drugs, there is a
need now to monitor the drug/drugs being give, even though such information,
such blood levels, are of little value in judging the patients clinical
responsiveness

For a neurologist, who's obligation it is to know what the patients
unfettered, un-drugged, brain/neurological/mental function is--in fact for
any scientific physician--the conclusion presented with troublesome new
behaviors such as sleeplessness, wildness, and acting crazy would have to be
that all of this could be due to any drugs he is on that act on the brain
and the obligation would be to wean the patient from all drugs and keep off
until it is assured that the drug effects have cleared. It is not medically
sound, and psychiatrists ought be held to this, to keep adding a drug for
every new symptom and adverse behavior; this can only lead to multiple drugs
in the system taking one further all the time from the baseline
mental/neurological status and what the undrugged patient is really like.
If for example a real brain disease is present a brain tumor or subdural
hematoma or a drug induced psychosis, this treating  every symptom with a
drug would only further and further mask diagnosis and prevent definitive
diagnosis and treatment (such as surgery for subdural hematoma).  For all
drug intoxications, the aims is to get all drugs out of the system, the
sooner the better, and at a rate consistent with sound medical treatment.
Where the patient is still medically stable, awake and with normal vital
signs, weaning, i.e., gradually lowering the dose first of one then another
until the patient is off all drugs, is indicated.  In this case they kept
treating every new symptoms despite fact most were probably due to the
interaction of the patient's  multiple CNS- acting drugs, and adding new
psychiatric diagnoses, none of them actual diseases, then drugging for them
too.  This is in no way acceptable medical practice, however prevalent it
may be .

9 98
      
[Fred A. Baughman Jr., MD:


 Again, I wonder if they just say this or if


he has ever met the formal DSM-IV criteria for Aspergers's syndrome? What is


normal sleep pattern with all these drugs in system and still no thought of


stopping all meds to see what the baseline Macauley is actually like. The


number of drugs and the doses continue ever upward]