A growing number of children in Canada, as in the United States, are being diagnosed with bipolar disorder. Their symptoms include bouts of mania and depression, reckless behaviour, delusions of grandeur and a propensity for suicide.
As Globe and Mail reporter Carolyn Abraham wrote in her Saturday feature, kids as young as 7 are taking powerful cocktails of mood-altering drugs never tested in children, with side effects that include significant weight gain, blood clots and tremors.
Writes Abraham: "Some see the spike as the natural consequence of recognizing a real childhood condition that was previously missed or misdiagnosed. Others say that, just as the rates of attention deficit and hyperactivity swelled in the wake of Ritalin, and Prozac helped spawn the decade of depression in the nineties, childhood bipolar disorder is psychiatry's latest fad - an overdiagnosis driven by fuzzy definitions, new drugs, eager doctors and anxious parents."
What questions do you have about childhood-onset bipolar disorder? Are you concerned about the medication of young children?
Ms. Abraham has joined us online to answer your questions. Your questions and Ms. Abraham's responses appear at the bottom of this page. Remember to refresh your browser.
Carolyn Abraham has been the medical reporter at The Globe and Mail since 1998. She has written extensively on developments in genetics, stem cell research and neuroscience, focusing on the science as well as the social and ethical issues they raise.
She is a four-time winner of the Canadian Science Writers Association national award for medical reporting and has twice won the Edward Goff Penny Memorial Prize from the Canadian Daily Newspaper Association for investigative work and feature writing. Ms. Abraham is the author of the internationally published Possessing Genius: The Bizarre Odyssey of Einstein's Brain (2001), winner of the Canadian Science Writers national book award and a finalist for the Governor General's Award in non-fiction.
She was born in England, and is a graduate of the journalism program at Carleton University, where she also specialized in political science. Before joining The Globe, she was a feature writer for Southam News and a Queen's Park correspondent for The Ottawa Citizen.
Editor's Note: globeandmail.com editors will read and allow or reject each question. Questions may be edited for length, clarity or relevance. HTML is not allowed. We will not publish questions that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.
Brodie Fenlon, globeandmail.com: Thank you very much for joining us Ms. Abraham. We have many questions in the queue, so we'll go straight to our readers.
Matthew H from Winnipeg Canada writes: Thanks for taking the time to answer my question. Having been diagnosed as being bipolar myself when I was 20, I can understand to a certain extent what these children and parents are going through. My question is: Do you think the dramatic rise in bipolar diagnoses in children could be more a product of our society's need to find quick labels for problems? I no doubt believe that there are children who are bipolar, but I fear that many are more likely going through a certain stage they may grow out of, but are medicated because their parents need a quick answer in this hectic world we live in.
Carolyn Abraham: Hello Matthew and thank you for your excellent question. I definitely think society has been primed on many fronts to expect a quick fix to most problems. This is particularly pronounced in matters of medicine -- everyone wants a quick and firm diagnosis, and they want a solution and they want it now. In matters of mental illness in children this may be most dramatic because there is the concern that not intervening quickly will cause irreversible damage to a child's development. The danger of course is that the diagnosis may be too quick in coming, be incorrect, and then the effects of treatment turn out to be worse than the original problem. The diagnosis of bipolar disorder in children is quite likely an example of a label that in many cases has been doled out too easily -- especially in the U.S.
One thing I learned as I researched my story is that there is a dramatic shortage of mental health services for children - and that can only stoke the impatience. According to Children's Mental Health Ontario, every year 25,000 kids are looking for ongoing mental health services, and they face an average wait time of five and a half months. In the interim, parents -- many of them facing ongoing complaints from school teachers etc. -- turn to their general practitioners or paediatricians to do something, anything...So for the most part, in the absence of firm diagnosis, drugs are prescribed. Meanwhile, most experts agree that these kids need slow and long-term supports and only time will really tell what is going on with them.
Michelle Gordon from Vancouver Canada writes: As someone not involved in any way in medical research, I would like to better understand why there is such discrepancy in the medical/research community regarding childhood bipolar disorder. Even more pressing for me than the controversy summarized above (previously under-diagnosed vs. latest medication fad), I would like to also know why there seems to be disagreement about whether it's even possible for bipolar to exist in children or not. Is there really so much uncertainty that we can't even say whether it's a valid diagnosis in children? And perhaps most importantly, why does it seem that to take a label of 'epidemic' for people to stand up and take notice? It's high-time we start recognizing mental health on par with physical health, and it's great that mental health in general has been getting more press recently. Thanks in part to the recently formed Mental Health Commission. But do we really want to only pay attention to those areas that have either progressed or perceived to have progressed to the stage of an epidemic? And how much responsibility for this framing should be placed with the news media? If we are truly going to be a nation of happy healthy Canadians, we must reframe mental health and focus on prevention and health promotion as important components.
Carolyn Abraham: Thank you for your thoughtful questions Michelle, you've raised a number of interesting points. The discrepancy over paediatric or juvenile bipolar disorder, as some call it, is due entirely to the fact that there is no objective diagnosis for it -- no blood, urine or sputum test, no MRI, no scan of any kind can "detect" it. Measuring behaviour is not like measuring cholesterol levels and all sorts of subjective biases come into play. In the UK, where bipolar disorder is rarely diagnosed in children, experts are more likely to see children with these intense mood disorders as having a 'pervasive developmental disorder.' The disagreement over whether or not the condition can exist in children comes from decades of longitudinal research in several countries, involving thousands of school age children. None of these studies have found in these kids any significant prevalence of the manic-like symptoms associated with bipolar disorder that would explain the numbers coming out of the U.S. Outside of the U.S., many experts doubt there is an 'epidemic' of childhood bipolar disorder, what they see is a 'frenzy' to diagnose and treat. Finally, I definitely agree that mental illness has too long been the poor cousin of medical research. We know so precious little about the brain, and yet it is the core of who and what we are and the very progress of society depends on it. Perhaps this will change as neurobiology and neuropsychology take off and more is understood about the genetic underpinnings of psychiatric disorders, and the real chemical and mechanical culprits behind them...but in the interim, it's bound to remain a field riddled with controversy because every diagnosis can be debated infinitely.
Sean L. from Toronto Canada writes: Too many parents looking for an easy excuse to abdicate responsibility - how about less indulging of children's whims and more parenting. Too many parents take the easy route of looking for some medical defect to account for antisocial behaviour stemming from either poor parenting or peer issues, and doctors are all to willing to accommodate this with half-baked diagnoses and prescriptions of drugs. Nine out of 10 times the problem is not really some chemical brain disorder, and could be resolved without drugs.
Carolyn Abraham: I appreciate your point Sean. Certainly there are a number of psychiatrists and other experts in the field who share your view. One U.S. psychiatrist told me that in many cases parents are not waiting to hear a diagnosis -- they want a diagnosis. They have turned to online checklists that not only offer the common symptoms of bipolar disorder in children, but offer tips on what to tell the psychiatrist in order to secure the diagnosis of bipolar disorder. Another psychiatrist mentioned that some families also have higher tolerance levels for "emotionality" than other families. So what is seen as explosive behaviour from one child, is just a normal mode of communication for another....and cultural experience factors into that. Parents I spoke to, and have since heard from, however, in suspecting their child has bipolar disorder, all describe behaviour far beyond the pale of 'normal.' These parents spoke of genuine fear -- not only for themselves, but for their children -- and so professional help of some kind was crucial. I think what the naysayers point out is that no label should be stuck quickly on a child, that meds should be a last resort, and that doctors have to take into full account what's going on in a child's life - at home, at school etc. Without doing so, they say, it's a bit like trying to hear the tune of a song with a train rushing by.
Gil Hughes from North Saanich writes: I am bi-polar. I have been taking Lithium 1200 mgs a day for 26 years. Needless to say it took out my Thyroid so I take medication for that too. I started out fairly quickly, drank heavily for 18 years before I was diagnosed and was only noticed when I was arrested for assault in 1977 ... I have had no medical problems since for 26 years. I have no idea if this disorder would repeat itself if I stopped taking my medication. I do know that until you have had a manic episode that ultimately drives you psychotic, you really have no idea what going through this experience is like. I believe there are far too few doctors who understand this disorder and how it may act over the long term.... ( Brodie Fenlon: Can you tell us, Carolyn, about how well the medical community understands this disorder - in adults or children?)
Carolyn Abraham: Thank you for sharing your experience Gil, and from what I understand, bipolar disorder, previously known as manic depression, really is one of the most misunderstood mental illnesses. Even though its hallmark signs of intense mood swings have been recognized for centuries, it has not received much attention from medical researchers and clinicians until the last couple of decades. Sagar Parikh, a Toronto psychiatrist who has specialized in bipolar research and treatment in adults for 15 years, told me that doctors preferred not to treat these unpredictable, difficult patients for whom there were few effective treatments, and when these patients are between mood states, in their "baseline" state, they also disappear from the system altogether, believing they are no longer in need of help. He also noted that adults with bipolar disorder tend to do 'better than average' in their livelihoods -- perhaps due to a particular creative energy.
All this has hampered research into bipolar disorder until recently -- and the issue of its possible onset in childhood remains very much an open question.
Polou Ha from Toronto writes: Do you think, Ms. Abraham, there's any possibility that childhood bipolar disorder can be wrongly diagnosed when adulthood is reached? Also, is there any awareness or understanding about bipolar disorder in immigrant children of other cultures? Are other countries affected in the same way as children who are born and grow up here in Canada?
Carolyn Abraham: Hello Polou, thanks for your questions. As for your first, most definitely, adult bipolar disorder may in fact be one of the most misdiagnosed mental illnesses. This is because its defining feature is that it has so many faces -- it can look like clinical depression, in a severe episode of mania, with hallucinations, or psychosis, it might look like schizophrenia. Also, many people with bipolar disorder tend to be drawn to 'self-medicating' with drugs or alcohol and if they end up in a hospital in the midst of a manic episode and smelling of liquor, they might be mistaken for alcoholics and offered no help at all.
As for the experience of other countries, my research suggests that this striking rise in the diagnosis among children in the U.S., and to a lesser extent Canada, has not been noted anywhere else in the world. It seems the diagnosis is more likely to be reflective of the cultural attitudes of the doctors diagnosing a child, versus the cultural background of the child.
Ruth Anderson from Switzerland writes: Shouldn't the holistic approach be the first line of treatment, especially with children? Testing for allergies and modifying the diet can go a long way to clearing up behavioural issues. Finding out the deep rooted family issue that is not on anybody's radar screen except for the child's is a key part of any holistic approach and often the most successful.
Carolyn Abraham: Thanks Ruth - I think you are bang-on in your observation on the need to understand the big picture with every child....and adult for that matter. Most experts do agree that children especially need this kind of approach, with talk therapy of some kind, supports in the home and school, and a number of parents and experts have written to me about effective dietary interventions. The trouble, I think, is that given the shortage of mental health resources, medication too often becomes a quick and simple solution -- in the short-term anyhow.
Richard Mitchell from St. Catharines writes: After working in British Columbia as a counsellor in child psychiatry through the 1990s, I watched with alarm gigantic increases in prescriptions for Ritalin and Prozac. This flew in the face of actions from nations like Sweden and Denmark who banned Ritalin decades ago, and the lawsuits against Glaxo-Smith-Klein over Prozac trials ... My fear is that we're seeing the same push from drug companies in their rush to create a new market niche that capitalizes on the general lack of knowledge about the suffering described by families in your article. Most consumers would bring greater criticality to purchasing a used auto than we do to blindly accepting new wonder drugs for our children. The current lack of good research from Health Canada on just how many young people have experienced harm from Prozac and Ritalin is one of many areas for concern left unexplored in your otherwise astute article as we look towards the 'experts' diagnosing yet another wonder drug for children's behaviour. Could you comment on the links between big pharmaceuticals - perhaps their penchant for ghost writing and publication of selective findings - and the general lack of good knowledge and critical thinking here in Canada in this field?
Carolyn Abraham: Oh Richard...where to begin with this monster of a question? Think I'll start with the safety issues you raise. Very few drugs have been extensively tested in children, with psychopharmaceuticals the answer is virtually none. Doctors are free to prescribe off-label to a patient of any age at their discretion, without knowing truly any of the long or short-term side effects of a particular medication, or cocktail.
If, due to shortages in mental health services for kids, those docs are often front-line family physicians -- who have very little training in child psychiatric disorders, or any, the guess work is likely even more pronounced. A number of studies have also shown that general practitioners can be influenced by the marketing practices of pharma companies, who might send reps to their offices, or sponsor educational seminars in attractive locales. As well, it's true that pharma company officials ghost write medical literature -- which also influences prescribing factors. While academic doctors are obliged to disclose their connections to drug companies, it is really unknown what impact the connection might have had on the study design or interpretation of the results.
Drug companies meanwhile generally have no incentive to test their drugs in kids. These meds are already on the market. Doctors are already using them. To be blunt -- why should they make the investment unless it means money in their pockets -- they are after all, businesses. However, as such, they also have brands to protect, so it is also in their interests to do the responsible thing...and publicly, I think it would be tough for them to reject the idea of collecting long-term safety data from the hordes of children now taking their drugs. In the U.S. - the FDA has asked for this, and offered to extend patents in exchange. Certain drug companies have obliged. But in Canada -- where the privacy laws completely shield the discussions between drug companies and health authorities -- no one knows what's happening. The cynical might say that health authorities here have been too concerned about hurting drug company investment into Canadian medical research, and that generally, they can rely on the FDA-collected data.
But yes, in a perfect world, wouldn't it be wonderful if health authorities in Canada demanded that drugs now being routinely given to kids in increasing numbers were actually tested in kids.
Amy Louise Ells from North Bay Canada writes: Dear Ms. Abraham, how would you distinguish between a child's 'normal' mood swings and 'extreme' mood swings which might suggest bipolar? Thanks.
Carolyn Abraham: Hello Amy, thanks for your question. I think it gets to the heart of the controversy. I am definitely no expert in diagnoses, and when I began research for this article, that is exactly what I wondered....giddy one moment, tantrum the next...trouble going to sleep...As one expert joked to me -- "all two year olds are bipolar." In the conservative camp, the experts who feel true bipolar disorder does not really onset until later adolescence, this is their beef. For all sorts of reasons, a child might go through bouts of extreme moodiness, and it may not be at all clear that the behaviour is the result of a lasting neurochemical imbalance. The conservative camp argues that these kids might have something troubling going on that needs addressing, but since it is not clear what it is, don't call it bipolar disorder in the interim. Bipolar disorder is a lifelong condition, it usually results in the prescription of heavy duty drugs for years, if not for life and when no one knows with any statistical certainty that these children will grow up to have classic bipolar disorder -- the cautious say, let's not call it that.
On the other hand, Ben Goldstein, a young psychiatrist I spoke to in the U.S., who had trained in Canada, said Canadian experts have been too cautious. He pointed to certain hallmark symptoms in children that do suggest bipolar disorder. He explained that it's not just trouble going to sleep, for example, but the decreased need for sleep in these kids. They might grab only a few hours a night, but display no signs of fatigue and continue to be high energy. Others noted the delusions of grandeur from these kids....I can swim to Seattle (from BC), I can walk to China, I can fly....Yet others might say this is typical of little kids' fantasies. It can be so very subjective the interpretation of these symptoms. The only way to tell where the truth lies is watching what happens to diagnosed kids as they grow. Research is under way to look at this, but the first results are still a few years away. In the meantime, there is also controversy about what long-term effects the medication might have on the brains of these children, and whether the drugs themselves might not, in the end, lead to some other disorder. In Europe, for example, some experts suspect that the North American willingness to give kids antidepressants has actually resulted in some of the mania being described....
Anonymous, Vancouver Canada writes: Just read about this talk in the paper and I'm late joining in. Having now dealt with this in our family for some years (son is now a young adult), I am wondering if there is any prognosis/data to indicate what these young people will face in adulthood. Any information? Excellent, and for us, relevant article last week. Many thanks.
Carolyn Abraham: Thanks for your question and kind feedback. The data are pretty thin when it comes to predicting what might happen with the children currently diagnosed as having bipolar disorder. From retrospective research, there is the suggestion that adults who could recall having symptoms of bipolar disorder when they were very young also seemed to have a more severe course of illness. For those who support the diagnosis of childhood bipolar disorder this is good reason to intervene with drugs and therapy when children are young in hopes that you might somehow counter the worst effects of the condition. No one yet knows if this is the case. It is a tough and uncomfortable in between world at the moment. I wish you, your son and your family the best of luck.
Dan Thomas from Peterborough Canada writes: How do you address the issue of other adults who express disbelief that a child can have such disorders? As an example a child suffering from depression associated with bipolar disorder is asked by an adult what they have to be depressed about. I find there is quite negative responses to the idea that children and adolescents can have such problems.
Carolyn Abraham: Hello Dan, I think you make a very good point. In a way, it speaks to a much bigger issue going on here: The controversy around childhood bipolar disorder is emblematic of the massive social and cultural shift that has gone on in recognizing childhood mental illnesses. A few decades ago no one really believed kids could even suffer from clinical depression. In the 'dark days,' people blamed cold mothers, bad parenting and told kids to pull up their socks. That of course, has changed a great deal...but since then, many feel the pendulum has swung too far the other way...that society is on the verge of 'medicalizing childhood' with climbing rates of attention deficit-hyperactivity disorders, depression, autism spectrum disorders, mood dysfunctions, oppositional defiance disorder, conduct disorders and now, bipolar disorder. Feed into this all the new medications, the increased general awareness around mental illness (panic and anxiety disorders in adults for example that had previously been unrecognized) and you can understand how it might be inevitable that people will be skeptical of 'the sudden' epidemics stalking so many young minds. I think we're in a new dark phase...On one hand, we rightly understand that mental illness is as real as a physical ailment, that it can strike in the developing brain...but the brain remains a black box -- a stew of sparks and chemicals that no one truly understands. So, blindly, we're flicking at switches, hoping something will turn the right light on....
Brodie Fenlon, globeandmail.com: Thank you again Carolyn. We had far more questions than we could get to today, but we appreciate your thoughtful replies. Any final thoughts before we wrap up?
Carolyn Abraham: Thanks for having me Brodie, and thanks again to everyone who sent so many thoughtful questions and comments. I'm sorry I didn't have time to answer them all.
This story and issue seems to have struck a real nerve with many people - the response has surprised me. It was terrific to have the chance for an exchange like this. Discussions around mental illness have been tucked away too long.
Brodie Fenlon, globeandmail.com: Thanks again to our readers for all your questions. I'm sorry we couldn't get to more of them, but please feel free to continue the discussion here through our comment function.