Children's mental health and camp: what is our role?

Few children's issues have drawn more attention, or been more controversial, than those involving their mental health. For example, in the past twenty years, Attention Deficit/Hyperactivity Disorder (ADHD) has become a household term; depression has attained the status of a "real" illness; and the use of medications to treat children with emotional problems has become commonplace. As these issues permeate the public domain, intense debate has followed regarding the assumed dangers of assigning diagnostic labels to children, as well as giving them powerful drugs for treatment. As camp professionals, we are likely to be faced first-hand with children who have emotional or behavioral problems. A basic understanding of children's mental health issues and what our role should be regarding campers with these issues are discussed in this article.

How Are Diagnoses Made and What Do They Mean?

Mental health diagnoses are made following criteria outlined in a book called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Using methods including psychological testing and diagnostic interviews, mental health professionals determine whether or not a child's problem matches a given diagnostic label in terms of the kind, intensity, and duration of symptoms he or she exhibits. For a symptom to "count" toward a diagnosis, it must cause either distress (to the child or those around him or her) or dysfunction in his or her daily life. Determining if such a symptom is present requires the judgment of a trained clinician.

The DSM-IV-TR follows a "medical," or "categorical" model of diagnosis. The categorical model assumes that a child either has a disorder, or does not. In other words, there are two kinds of people in the world: those who have depression and those who do not; those who have a broken arm, and those who do not, etc. Of course, within each category there are levels of severity, (e.g., a hairline fracture versus a compound fracture), but the critical issue is that by meeting criteria for a diagnosis, a child is categorically different in some way from a child without one. The categorical model works well for most medical conditions because diagnoses have specific treatment procedures attached to them. In other words, a medical diagnosis is usually "prescriptive"--a child with strep throat usually has a bacterial infection for which he or she will be prescribed an antibiotic; a child with a broken arm will have the bone set, placed in a cast, and then follow a specific physical rehabilitation plan. Obviously, doing all of this requires a great deal of training, but that is the basic idea.

Some clinicians (to be fair, probably a minority, in which I include myself) do not find the categorical model particularly helpful in our everyday clinical work. The implications of this seemingly semantic argument are actually quite important. Using the reasoning of the categorical model, a child could have ten of the twelve symptoms required for a diagnosis of ADHD (for example) and be given the same "no diagnosis" label as a child with no symptoms. This implies that both children are in the same "group"--which strikes many clinicians as a bit silly at least, and potentially dangerous at worst.

With some important exceptions, giving a child a diagnosis usually does not provide much guidance about why the problem exists, what processes have led to the problem's development, or what we should do to help. Finally, and most relevant to camp, children with the same diagnosis can, and often do, express their problems in different ways. A child might even express the same disorder with different symptoms (or not express the symptoms at all) in different contexts. This may sound confusing and frustrating, and it is. Knowing a camper's diagnostic label, in and of itself, only gives a general idea of what we can expect from him or her on a daily basis.

Still, it is helpful to know what these general tendencies are. Below is a listing of descriptions of some of the more common childhood mental health problems. These should be thought of as broad generalizations--because camp is a unique environment. Sometimes, it is quite structured, while at other times it is deliberately unstructured. It is also important to remember that many symptoms described below are "normal" in moderation--everyone feels anxious and sad on occasion, but that does not mean a clinical disorder is present.

Anxiety Disorders

Anxiety disorders are the most common disorders in childhood, affecting about 10 percent of children. They seem to be slightly more common in girls, but the overall gender difference in prevalence is minimal. There are several distinct anxiety diagnoses, such as generalized anxiety disorder, separation anxiety disorder, obsessive-compulsive disorder, etc., though they share several features. The first is excessive worry; perhaps about the future, being laughed at by others, something bad happening to a parent, and so on. Most (though not all) anxiety disorders are not characterized by particularly strange or bizarre worries. Instead, these children worry about more things--more often--then children without anxiety disorders. Children with anxiety disorders are sometimes described as "little adults" because they tend to appear much more concerned about the world around them, rather than carefree and enthusiastic, like many children without excessive anxiety.

Second, children with anxiety disorders suffer from what emotion researchers call physiological hyperarousal. This can mean anything from physical signs of stress (e.g., increased heart rate, high blood pressure) to feelings of intense panic or terror, appearing "jumpy" or easily startled, or somatic problems like headaches and stomachaches.

Anxiety disorders are typically treated successfully with a psychological treatment called cognitive-behavioral therapy, in which they learn mental strategies to reduce worrying and behavioral strategies to reduce their level of arousal.

Mood Disorders

Mood disorders include both depression (technically, major depressive disorder) and bipolar disorder (previously known as manic-depression). They affect between 3 and 8 percent of children, depending on how the disorder is defined, and become more common as children age. To meet criteria for a mood disorder, a child must exhibit a clear change in mood that is much more intense than "normal." This change must occur for a specific amount of time, depending on the particular mood disorder. Many adolescents with depression are very sad and no longer enjoy the activities they used to enjoy. Depression can, however, present as intense irritability instead of sadness--particularly for boys and younger children in general. Depressed children also tend to appear withdrawn, easily fatigued, and show disturbances (increases and decreases) in sleep and appetite. In severe cases, suicidal thoughts and attempts occur.

Treatment research indicates that in most cases, depression can be most effectively treated with a combination of medication and psychological treatment, rather than either one alone.

Bipolar disorder is a particularly controversial diagnosis for children. There is a wide range of disagreement among many researchers about how this disorder presents in childhood, though there is some emerging consensus. Bipolar disorder does not simply mean a child has "mood swings." It is more accurate to think of bipolar children going through three mood states: a manic episode, a depressive episode, and "normal" mood. A manic episode can present in a variety of ways--including bouts of extreme irritability often described as "rages"; an enormous increase in physical energy (to the point where the need for sleep diminishes significantly); extremely positive mood (extreme euphoria that is far too intense given the child's surroundings); bursts of creativity; grandiosity; engaging in risky behaviors (like a child believing she can fly, or trying to dodge traffic on a busy street); and even losing contact with reality, which is called psychosis. After experiencing mania, children with bipolar disorder can go through a period of normal mood or a depressive episode. Going through these extremes in mood is called cycling. Experts disagree on what constitutes a cycle, and how often cycles typically occur.

Bipolar disorder could be the most serious diagnosis in children's mental health, and almost always requires medication, making it one problem (like ADHD, see below) where getting the correct diagnostic label is critical for appropriate treatment.

Attention Deficit/Hyperactivity Disorder (ADHD)

ADHD is a well-known condition, occurring in between 3 and 5 percent of children, more commonly in boys. It is usually diagnosed relatively early in childhood. It is not caused by excessive sugar intake, food coloring, or diet. While there are children whose behavior is affected by these things, they have nothing to do with ADHD. ADHD is characterized by three "kinds" of symptoms:

* difficulty regulating attention;

* excessive physical activity; and

* impulsivity.

Sometimes symptoms are localized to attention problems, such as difficulty focusing, trouble organizing themselves, forgetfulness, distractibility, trouble following instructions, etc. Such children are diagnosed with ADHD, Inattentive Type, and are often "missed" by doctors because they do not display signs of hyperactivity.

In more rare cases, symptoms are localized to hyperactivity and impulsivity, such as always appearing "on the go"; difficulty sitting still; and difficulty waiting their turn when in line, in games, and in conversation, etc. This is called ADHD, Hyperactive-Impulsive Type.

When both problems are present, the child is diagnosed with ADHD-Combined Type. The Combined and Inattentive Types are, by far, the most common, but all three are likely to be treated in a similar manner.

When I conduct workshops on mental health issues, I always ask how many people think ADHD is overdiagnosed. At least 90 percent of the people in the room raise their hands. The perception that any active, enthusiastic child (particularly a boy) is quickly labeled and medicated is unfortunate, because it diminishes the seriousness of the problem and the necessity of being treated primarily with medication.

Recent treatment research has established that medication is more effective for treating ADHD symptoms compared to behavioral interventions and individual psychological treatment--though the latter approaches are very effective for the additional problems that tend to occur along with ADHD. ADHD, assuming it has been properly diagnosed, is therefore another "useful" label.

Eating Disorders

Eating disorders most commonly refer to anorexia and bulimia nervosa, both of which are very serious conditions. They occur almost exclusively in adolescent, Caucasian girls from middle- to upper-middle class backgrounds--though they seem to be on the rise in other groups as well. Although DSM-IV-TR reports that full-blown eating disorders are extremely rare, I find this hard to believe. Whenever I am speaking to a large group of people, nearly every woman nods her head when asked if she knows someone with serious eating or body image problems. Because girls and women who suffer from these disorders tend to experience intense feelings of shame and guilt, I suspect they are unlikely to describe their problems to unfamiliar people doing epidemiological research, and that both disorders are more common than researchers think.

Along with an intense fear of becoming overweight and preoccupation with body image, both anorexia and bulimia can include binging and purging. Binging has no specific definition, but refers broadly to eating a tremendous amount of food, usually high calorie food and sweets, in a short period of time. Purging refers to behaviors intended to compensate for a binge, such as purposely throwing up, abusing laxatives, or excessive exercising. Even self-starvation can be thought of as a purge. By definition, children with bulimia binge or purge (usually doing both), as do girls with the binging and purging type of anorexia. The other subtype of anorexia is characterized by extreme self-starvation.

The other main difference between bulimia and anorexia is body weight. Girls with anorexia weigh significantly less than they should given their size and build--and often show physical and psychological signs of starvation, such as cessation of the menstrual cycle or constantly fantasizing about food or cooking. Girls with bulimia tend to be in the normal range for weight. Eating disorders are very difficult to treat and very dangerous, as up to 5 percent of girls with anorexia will die from the damage it does to their body.

What Is Our Role at Camp?

Because of the myriad of issues associated with any child's mental health, we must prepare our staff to work with them in several ways:

* Be wary of how labels can affect how we interpret a camper's behavior. For example, ask your staff how they would react if they were getting the following camper in their bunk or cabin:

- Billy is a great kid. He is creative, outgoing, and has a bunch of different interests. He has lots of energy, and will jump into all sorts of new activities, even if he has never tried them before. Or, Billy has ADHD.

Similar situations can be easily developed for other labels. This is an effective exercise for helping staff learn how their preconceived notions can affect relationships with their campers even before they start.

* Encourage staff to put their personal opinions about the validity of a child's diagnosis aside.

- First, inform your staff that mental health problems do exist. This is not a matter of belief or opinion. This is a matter of science, and the science is clear.

- Second, remind your staff that we cannot possibly know if the camper was tested and diagnosed properly, so it is not our place to question it.

- Third, remind your staff that regardless of the camper's diagnosis, camp tends to be a unique environment. As noted above, it is difficult to predict how any given camper, with any problem, will behave in such an environment, particularly if their disorder is being successfully managed.

- It is appropriate to train staff members to make observations as long as they can keep an open mind--and to give them the tools to communicate their observations to parents in a compassionate, objective manner. In fact, this can provide critical information to parents about their child's development, whether they have a diagnosis or not.

Educate, Observe, and Communicate

Mental health problems in childhood are serious matters that require specific staff training. Camps are in a unique position to provide opportunities for children with emotional and behavioral problems to grow, just like anyone else. As camp professionals, our role is to educate our staff about children's mental health problems, teach them how to observe with an open mind, and to facilitate communication to parents.

Ethan Schafer, Ph.D., has a doctorate in child clinical psychology, and works with Spectrum Psychological Associates in the Cleveland area. He is also an adjunct assistant professor of psychology at Case Western Reserve University and consults with summer camps and camp organizations.

Ethan Schafer, Ph.D.

RELATED ARTICLE

Give your staff the tools to communicate their observations to parents in a compassionate, objective manner. Staff can provide critical information to parents about their child's development, whether they have a diagnosis or not.

Suggestions for staff-to-parent communication

* DO describe to parents what you have seen, in specific, concrete terms, noting details about how long a problem has existed and whether or not it improved, such as, "She cried for the first few days and seemed sad for the last two weeks," or, "He seemed to have trouble organizing his belongings and following directions over the course of the summer."

* DON'T use words that sound like labels, such as, "She seems depressed," or, "He seems to have an attention problem."

* DO report positive aspects of their camp experience as well. Remind staff that parents are likely to take the information they receive seriously, so feedback must be done with care, concern, and attention to their child's positive traits.

* DON'T suggest medication or any other kind of treatment. This is rarely, if ever, appropriate.

* DO describe how the camper has coped with his or her problems at camp, if applicable, such as, "She seemed nervous about other kids laughing at her but was able to participate well in small group activities."

* DON'T communicate with parents when frustrated with a child's behavior or performance at camp. It is very difficult to follow the suggestions listed above when one is upset.

* DO discuss with staff what to say when other children ask about medications being passed out at meals or in other situations. One appropriate answer is "I don't know, but it's not really any of our business."

* DON'T speculate about what the medications are for, as many medications are given for a variety of problems.

Resources

* The American Psychological Association -- www.apa.org

* The National Alliance for the Mentally III -- www.nami.org

* American Psychiatric Association: Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., American Psychiatric Association, 2000.

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