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From infancy, kids can easily be unsettled by disruptions in their circadian cycles, as parents of newborns and toddlers learn whenever they try to change nap times. Bipolars, regardless of age, are also reactive to fluctuating schedules; many things can destabilize patients, but Keck believes that sleep deprivation and time-zone changes are the most upsetting.
For this reason, parents of bipolar kids are urged to enforce sleep schedules firmly and consistently. Bedtime must mean bedtime, and morning must mean morning. While that can be hard when an actively manic child is still throwing a tantrum two hours after lights-out, a combination of mood-stabilizing drugs and an enforced routine may even bring some of the most symptomatic kids into line. Teens, who are expected to do a lot more self-policing than younger children, must take more of this responsibility on themselves, even if that means a no-excuses adherence to a no-exceptions curfew.
Also important is diet. Caffeine can be a mania trigger for bipolars, so teens are advised to stay away from coffee and tea. Bipolar kids of all ages must also be careful with less conspicuously caffeinated foods such as sodas and chocolate. And for adolescents and teens, staying free of alcohol and drugs is critical. Not only is the risk of addiction high, but treatment of the underlying bipolar problem is much more difficult if the patient's mind is clouded by recreational chemicals.
For children old enough to benefit, the second leg of treatment is individual therapy, which includes social-rhythms work--learning to balance meals, sleep, studies and recreation. If a triggering incident such as a divorce or death kicked the condition off, the doctor can help the child process that too.
The last, perhaps hardest element of treatment is family therapy. Bipolar disorder, like schizophrenia, depression and certain anxiety conditions, is powerfully influenced by surroundings. When an identical twin suffers from bipolar, the other twin has only a 65% chance of developing it too. Conversely, adopted children with no genetic legacy for bipolar have a 2% chance of coming down with the condition if they are raised in a home with one nonbiological bipolar parent. Clearly, something is in play besides mere genes, and that something is environment. Raise a child in a steady and stable home, and you reduce the odds that the illness will gain a toehold, which is why counselors work hard to teach parents and kids how to minimize family discord.
One strategy is to avoid too much negatively expressed emotion. Tough love, for example, is a good idea in principle, but in some situations it can do more harm than good, especially if it makes kids who can't control their behavior feel worse about themselves. When family arguments do break out, they need to be conducted in a controlled way. Psychology professor David Miklowitz of the University of Colorado encourages families to avoid what he calls the "three volley," a provocation followed by a rejoinder, then a rebuttal. Hold the volleys to just one or two, and you'll avoid some domestic breakdowns.