- Email: [email protected]
Consulting to Summer Camps
Child Adolesc Psychiatric Clin N Am 16 (2007) 807–816
Consulting to Summer Camps Bob Ditter, Med, LCSW 72 Montgomery Street, Boston, MA 02116, USA
This summer, approximately 10 million children and 1 million adults will go to a camp program of some kind.1 As the number of children going to camp has grown (the American Camp Association estimates that the number of children going to camp in 2007 will be between 1% and 3% higher than 2006), so has the need for qualified, focused, competent consultation to camp professionals. In addition to increased enrollment, several factors have increased the need for consultation to children’s summer camps from the allied health professions. First, the overall awareness and diagnosis of childhood disorders and syndromes have expanded greatly in the last 15 years. Some of these disorders, such as bipolar illness in children, Asperger’s syndrome, and childhood autism, only recently have been understood more fully [1]. The number of children going to camp with a diagnosis has increased in concert with this new awareness. Likewise, with advances in the use of psychotropic and other medications in children, more children are marching off to camp on drugs whose side effects and efficacy most camp professionals do not understand fully.2 Another factor feeding the increased need for consultation to summer camps is the increased availability of camp programs to general and special needs populations. Camps currently represent a broad range of programs, including local city or town recreation department day programs, elaborate multi-week day camps, day and resident sports clinics and camps, 1- and 2-week resident camps operated by agencies and foundations (eg, Girl
E-mail address: [email protected] 1 The American Camp Association is a nonprofit, charitable organization that accredits camps throughout the United States. There are more than 2400 American Camp Association–accredited camps in the United States that have met more than 300 health and safety standards to earn American Camp Association endorsement. 2 Camp health nurses report a significant increase in the overall number of medications with which children report to camp. Allergy medications are the other category of drugs that have increased in presence in children’s summer camps. 1056-4993/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.chc.2007.05.004 childpsych.theclinics.com
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Scouts, YMCA, JCC, Salvation Army, Boys and Girls Clubs), camps for special populations, such as persons who have diabetes, muscular dystrophy, Crohn’s disease and colitis, children’s oncology camps, and burns camp, to name a few. Longer term, private, independent camps with general and specialized programming, such as horseback riding, wilderness tripping, sailing, and water sports, also are in operation. With camp within reach of so many more childrendincluding children with special needs who before the late 1980s could not be served in a camp programdit is no surprise that camp professionals are encountering more behaviors with which they need help. One other significant factor in the landscape of children’s summer camps deals with camp professionals themselves. Camp started as an outgrowth of school, beginning with the Gunnery Camp in the mid-nineteenth century. The Gunnery Camp is considered the first organized American camp. Frederick W. Gunn and his wife, Abigail, operated a home school for boys in Washington, Connecticut. In the summer of 1861, they took the whole school on a 2-week trip into the woods. The class hiked to their destination and then set up a campsite. The students spent their time boating, fishing, trapping, and practicing camp crafts. The trip was so successful that the Gunns continued the tradition for 12 years [2]. What began as an expedition and a way to get children out into the wilderness soon grew into a movement. New Englanddwith Maine, Vermont, and Upstate New York taking the leaddbecame the site of sophisticated camps for children that emphasized camp crafts, community living, and values education. Many of these camps were an extension of school, allowing children to get out into the fresh air and learn in a more experiential way. As a result, most camp professionals were educators, not mental health practitioners or childhood development specialists. After World War II, camps focused on physical skill development in activities such as canoeing, tennis, various field and water sports, rock climbing, and tripping. In keeping with this trend, most camp directors were athletes or teachers. Even as the emphasis in camping more recently has been placed on the emotional and social growth of campers through small group living, there has been little change in the backgrounds of the folks running those programs. Many camp professionals still lack formal training in child development, child psychology, or social work; most have backgrounds in education, recreation, business, or physical education. Most camp directors also have multiple duties that range from the care and development of their physical plant, to health and safety standards, to hiring, employment, and insurance issues. The demands on their time make it less likely that they can develop a deep understanding of childhood behavior or medication issues. One other trend has affected consultation to children’s summer camps: the increased demand on the part of nervous parents for greater oversight and competent supervision of their children. In reaction to the horrors of nightly news reports, replete with child abductions, school shootings, child
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abuse cases, and other instances of violence, many parents have become increasingly anxious about their children’s safety3 and have demanded a more sophisticated level of expertise at camp regarding their children’s emotional well-being. In response, many camps have either retained the services of a mental health professional at camp, just as they have a camp nurse or physician at camp, or they have such an individual ‘‘on call.’’ The practice of having a social worker or psychologist on call or at camp for part of the summer undoubtedly will grow as parents come to expect a higher level of expertise and service with regard to their children. Who is the client? One of the most important questions in consulting is knowing who your client is. Although a consultant may be called by the camp director, it is usually because of the behavior of a particular camper. Is the camper the client or is the director? The parents of the camper are, after all, paying the camp bill and are not only responsible for the health and well-being of their child but also are entitled to consent to any intervention involving an allied health professional before it occurs. Although a consultant may educate a director or other camp employee in some general sense about the behavior of the child and may even give general suggestions, it is unwise and unethical for an outside consultant to actually interview or interact directly with a camper without first informing parents and getting their consent.4 In addition to these constituents, the counselors and other staff members, such as program staff (the people who run the activities) or supervisory staff (the head counselor or unit director), may be struggling with a camper’s behavior and may need some direction or pointers about how best to deal with or contain that child’s behavior. The other campers are also undoubtedly affected by the behavior of every child in their group. So who is the client? This question is not unlike the one faced by the child mental health worker who is called by parents who have their own set of concerns but whose reality may be different from that of the child or of the school professionals who have their other interests at stake. My answer to this question is, in part, that your ‘‘client’’ is first and foremost the child, who, after all, may not be able to articulate or advocate for his or her own needs and then the well-being of the overall camp. As in the case of the child mental health professional who practices from a community-based
3 Dr. Mogel [3] asserts that parents’ anxiety about their children’s well-being in an uncertain world has led to an overprotective, overinvolved style of parenting. 4 Consultants should not expect camp professionals to always know to follow this protocol, so it is important to educate them about it and adhere to it before having any direct contact with a particular camper.
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perspective (one that sees the child as a member of, contributor to, and benefactor of the larger community), knowing how to speak to all the constituents in the life of the child has benefits to the overall life experience of that child. At camp, knowing how to educate a camp director, give pointers to the attending counselors responsible for the child’s care at camp, and reassure parents and give them additional resources is an important component to a consultation. There may be times, for example, when a consultant must help a director establish guidelines for keeping a child or sending a child home. Each member of the camp communitydthe director, counselor, camper, and the camper’s parentsdneeds help with this decision in different ways. The director needs sound guidelines; the counselors need understanding and a way of explaining the events to the other children; the camper needs help with the sense of failure; and parents need reassurance and may need additional resources for their child in the aftermath of his or her departure. Salient facts When consulting with camps, certain specific facts about the program may have significant bearing on the type of information or advice given. From my experience, I have identified five important factors that have a bearing on the kind of advice or consultation I offer a camp. Whether the camp is a day or resident (sleep-away) camp. Certain behaviors or medications that can be managed in a day program, in which the child returns home every night, cannot be managed in a resident program simply because they are too volatile or need greater parental or adult supervision than can be guaranteed in a resident program. Likewise, there may be children who fare better away from their community. Having the benefit of the ‘‘fresh start’’ would favor a resident camp program and indicate against a local day program. The duration of the program. Some behaviors or medications can be managed for a week but not for 3 or 4 weeks. Knowing how long a child will be involved in the program may have a significant impact on whether the child can participate in the program at all or for some abbreviated time. Along these lines, I have often suggested that a child shorten his or her stay at camp if it means leaving after a relatively successful stay rather than overstay and risk that the resulting overall experience might be negative. What, if any, special demands or requirements there are in the program itself. Some general camps may have more options for children, making it promising for a child to be involved, whereas a more rigorous, less flexible program would be inadvisable. For example, a child who has bipolar illness may be able to manage wood shop, arts and crafts, and some field and water sports but not an intensive wilderness tripping program or a more exclusive sports program in which hydration and fatigue might make it dangerous for the child to participate.
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The willingness or ability of the camp to provide specific support to a child and the family that might go beyond usual practice. For example, a child who has diabetes, routinely takes his or her own blood sugar measurements, and administers his or her own insulin and is enrolled in a general camp program may need a private place to perform that routine and be provided the opportunity to report regularly to his or her parents while being properly supervised by a trusted adult at camp. A child on lithium treatment for bipolar illness may need an adult to monitor his or her activity level, fatigue, and hydration, alternately making sure that the child is getting the necessary rest and water and communicating frequently with parents and watching for the early warning signs of overactivity that the child may not see or wish to hear about if it means missing out on some activities with friends. Not all camps are prepared for or equipped to provide such supervision, service, and care. One of the ‘‘jobs’’ of a good consultant in a case like this is to determine if that level of care can be provided confidently and competently. The competency level of the medical or support staff (unit leader or other supervisory staff). Having someone in the organization who has a more sophisticated understanding of a certain disorder or behavior, whether as an informed parent or as part of their out-of-camp profession, can make a difference as to whether a youngster can be maintained in a particular camp program. My experience is that the level of expertise among camp professionals varies widely, especially because there is no recognized training program for camp directors. It is their personal experience, or the personal experience of their staff, that comes into play. For example, one camp I consulted to had a camp nurse whose own son had severe attention deficit hyperactive disorder. She had taken it upon herself to become highly informed about attention deficit hyperactive disorder and was much more able to help supervise and advise the staff and implement specific suggestions I had made, which I would not have offered had someone with her caliber of understanding not been available. This nurse was, in a sense, my ‘‘on the inside’’ ally. Determining who has what expertise or experience can help determine not only whether a specific child can be managed but also whether more complex suggestions can be implemented successfully. Group living and the community factor There is one aspect of camp that permeates all types of camps, whether day or resident, long- or short-term, that needs consideration when consulting to summer camps. All camps operate with children in groups, which are, in effect, small communities. This approach means that not only does a child’s behavior affect everyone else in the group but also that the group affects the child’s behavior. For a child to be successful at camp, he or she must be successful in the group to a certain degree. What follows are two different examples.
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Case 1 Several years ago I was consulting to a co-ed resident camp with a 7-week program when the behavior of a 12-year-old girl was brought to my attention. The girl, ‘‘Josie,’’ was in her first year at camp. Although she was quiet, she seemed to fit in with the other girls in her cabin and had ostensibly made a good adjustment to camp. Approximately 1 week after the start of camp, Josie began evidencing some bizarre behavior. First, she wandered away from the other girls and talked to herself during cabin clean-up and rest hour. Eventually it came to the attention of counselors that she was collecting dead insects and had constructed an ‘‘insect cemetery’’ next to her cabind a development that made her wary cabin mates even more skeptical of her behavior. It came out that she had begun writing in other girls’ journals things such as, ‘‘You will die!’’ The last straw was when she was caught placing a sanitary napkin that she had taken from one of her counselor’s belongings onto another campers bed after saturating it with red ink from a magic marker. By that time her bunk mates were entirely afraid of her unpredictable and off-putting behavior. After speaking to her parents and checking with the health center, it came out that Josie had started taking Prozac approximately 3 weeks before the start of camp, which would have meant that she was on week 5 of her treatment. I strongly recommended that Josie leave camp with her parents, get a consultation from a qualified child psychiatrist, and not return unless the camp could get a clean bill of health from that professional. The director of the girls’ unit to which Josie belonged felt that Josie could not return to camp and be successful because the other girls had been so put off by her behavior that she was afraid they would ostracize her upon her return. I communicated this information to the psychiatrist whom the parents, after much resistance, chose for the consultation. (The parents were resistant to removing their daughter from this prestigious camp for fear of the impact it would have on her reputation at camp and in her community, where many children at this camp lived.) After seeing the girl for two or three separate sessions back home, the psychiatrist concluded that she had been having a reaction to the Prozac, which is well known, as he put it, in pubescent girls, and that a change in her medication would eliminate her bizarre behavior. He felt strongly that the camp had no reasonable argument for keeping her out of camp. Although medically correctdthe girl did return to camp and her bizarre behavior did stopdwhat the psychiatrist failed to understand and failed to address was the communal aspect of camp life. What the counselors and the unit director needed to bring this girl back into her cabin were some suggestionsdworked out with the parents’ consentdabout how to explain her previous behavior to her cabin mates. Without such a plausible explanation, simple enough and credible enough for the other girls to understand, Josie simply walked back into a hostile environment. Such a situation was
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harmful not only to Josie but also to the other girls. Failing to impress this upon Josie’s parents, who needed to work together with the camp and the psychiatrist to arrive at something that would be acceptable to them and be credible to the other girls, Josie’s summer had a less happy ending than might have been possible. She was simply marginalized and isolated by the other girls, and no amount of coaxing or talking seemed to change this until approximately the last week of camp. Even so, Josie never returned and the opportunity was lost. Case 2 The second example involved a 13-year-old boy, ‘‘Mike,’’ who was diagnosed with bipolar illness and came to camp on lithium. To take lithium safely, the boy needed to have access to extra water and had to be monitored closely so he would not become overheated or overtired. Either of these two conditions resulted in extended agitated outbursts and made his behavior challenging to manage. The camp agreed to take the boy on, partly because his counselor was a mature, responsible individual who was up for the task. Once again, however, the communal nature of camp life was not taken into consideration. The other boys could not help but notice the extra attention Mike received from his counselor and the extra rest periods he took, the times he did not have to participate, and the extra bottled water he received. Because Mike and his parents did not want to tell the other boys the truth about his bipolar illness for fear of Mike being stigmatized, the other boys had no way to make sense of what seemed to them like special attention. The consultant, who was Mike’s therapist at home, conferred with the camp about the possibility of Mike attending and did an excellent job preparing the camp for the physical requirements of Mike’s condition. The consultant failed to understand, however, that Mike would be living and playing in a small group in which his behavior would be scrutinized by his peers. The health of his friendships suffered as a result of poor or inadequate advice given to the parents (allowing them to insist that the other boys be told ‘‘nothing’’) and the lack of preparedness of the camp for dealing with the social ‘‘fallout.’’ Once again, consultants must consider that children at camp live, work, play, and relate in a community in which their behavior impacts others and in which their ‘‘success’’ may depend as much on good peer relations as on the right medication or other protocols.
The consultant as educator Because many camp professionals lack training in areas of child development, medicine, or child psychology, one of the main roles consultants play with camp professionals is that of educator. Behaviors such as cutting, eating disorders, attention deficit hyperactive disorder, obsessive compulsive disorder, enuresis, and Tourette syndrome may show up at camp at some
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point or other. One task of the competent consultant is to educate camp professionals about the myths and realities of these behaviors and then help directors create ways to determine whether children who present with these behaviors can be maintained at camp and, if so, develop the agreements, protocols, or stipulations necessary for the child and the other campers to have a safe and successful experience. Case 1 One example involves cutting behavior. While visiting a co-ed resident camp a few years ago, I was approached by the head counselor of the teen girls. She told me that one of her counselors had come to her with some concerns about a 13-year-old female camper, ‘‘Sarah.’’ Sarah evidently told some of her cabin mates that she been cutting herself at home, that she had done so for approximately 3 months before coming to camp, and that her parents ‘‘didn’t know.’’ One of the girls who heard Sarah’s story became upset and secretly approached her counselor, who then came to the head counselor, who came to me. (This manner of information transfer is typical at camp. There are even times when a camper swears peers or a counselor to secrecy, only to reveal a ‘‘secret’’ that is a bombshell that the listener did not count on and does not know how to respond to or handle.) The head counselor was concerned because she was afraid Sarah was at risk for killing herself and she wanted some help knowing what to do. My first task was to take the head counselor with me to the director and determine a response. My second task was to educate the director and the head counselor about cutting behavior, including information that although it is self-injurious behavior, it is not suicidal. The motive for much cutting behavior in teens, I explained, is to gain a sense of control in a world in which they typically feel grossly out of control. As counterintuitive as that might seem, cutters often talk about a sense of calm they gain by focusing on their pain. Although not a behavior to be left unsubstantiated and managed, most cutting is not life-threatening. My goal was to lessen the anxiety of the head counselor as a prelude to developing a plan. The next step was to have the head counselor discretely check the story of the upset camper who had informed her counselor. This was an attempt to get as much information as possible before calling Sarah’s parents. Even if Sarah was inventing this story, such fabrication might indicate that Sarah might be troubled in a way that warranted attention. Her parents were predictably incredulous and disbelieving. First, they refused to admit that their daughter could be so distraught as to do such a thing. Maybe more importantly, they were sure that such behavior could never go unnoticed by them. I suggested to the parents that either way, whether Sarah was telling the truth or fabricating, the camp had an obligation to tell them and it made sense to speak to her about it. (They were not sure about because, to quote them, ‘‘Why give her attention for something that must obviously be false?’’) I countered with the fact that several other campers heard her story and that
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even if it were untrue, she was already getting attention. Either way, the camp needed assurance from Sarah that she would stop saying these things to other campers (and that if she did need to talk to someone about it, she could speak to any adult on staff she trusted). If her story were true, the camp needed Sarah to agree not to engage in such behavior while at camp and agree that she and her parents would have a plan for Sarah to talk to a professional about it. The upshot was that not only did Sarah confess that her story was true but also she revealed scars on her upper arm (above her sleeve) from times she had cut while at home before camp. Her parents, still incredulous, were told to take Sarah from camp to get her evaluated by an outside professional, and the other girls were reassured that Sarah would be fine and that she was getting the help she needed. (There was no taking back what Sarah had revealed to them, so damage control was needed.) The girls in Sarah’s cabin also were asked not to talk to other campers about it out of respect for Sarah’s privacy. They were also told that if she came back to camp, they could be sure that she was fine (this would be the only way she would be allowed to come back to camp) and they would not have to worry about her cutting herself. The head counselor had this group discussion with their counselor present (and with Sarah not present). The girls were also asked if they had ever known anyone else who had cut themselves, partly as a way to see if there was any other fallout from Sarah’s revelation. Sarah did return to camp after being seen by a mental health professional, who later began on-going therapy with Sarah after camp but who thought Sarah was not in danger of cutting at camp. (Camp, for Sarah, was respite from the stresses of her life at home, so there was no urge to cut at camp.) Sarah willingly agreed to a ‘‘contract’’ about not cutting and talking to a trusted adult if she ever felt the urge or if she just needed to talk about private matters. She ended the summer happily and came back to camp for several successive summers. Level of consultation There are many levels of consulting to summer camps. First there is consultation about an individual camper who may have medication or behavior issues, which may require a combination of education, assessment of the camp’s ability to manage the child’s behavior, and assessment of the child’s ‘‘readiness’’ for camp. There may be consultation before camp to assess whether the child is ready or to ascertain what would need to be in place in terms of agreements, behavioral strategies, and personnel for a child to be successful in any given program. There is a deeper level, on-going consultation in which the consultant develops a more long-term relationship with the director and other personnel. In such arrangements, although it is the director who may be ‘‘paying the bill,’’ any consultant, to be effective, must win over the people who actually execute the program and supervise the campers. In a world of
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greater anxiety on the part of parents, the trend is toward more consultation in deeper, long-term relationships, in which the overall health of the camp culture and program can be developed and shaped into an ever-improving, healthy experience for camper, staff, and parents alike.
Summary An increased need for consultation to summer camps from the allied health/mental health fields is seen as a result of several factors. A wider range of camp options appealing to a broader audience has made camp available to more children, including camps for special populations, such as children who have diabetes, asthma, oncologic conditions, and Crohn’s disease. There also has been an increase in awareness and expertise in the diagnosis of childhood disorders, such as attention deficit hyperactive disorder, obsessive compulsive disorder, attachment disorder, Asperger’s syndrome, and childhood-onset bipolar illness. As more children are put on psychotropic and other medications, more children come to camp with medication side effects or requirements that camp professionals need help preparing for and understanding. Camps have multiple clients, including the identified camper, the camper’s parents, the staff, and the camp community as a whole. Special consideration needs to be given to the community aspect of camp, as a child’s behavior will undoubtedly affect other campers around her as well as the confidence level of the staff. Reactions to medications or exhibition of certain behaviors will have an impact on the community overall, and a critical part of the consultation may be the need to address the reactions of other campers or staff. Key information necessary to providing adequate consultation include such things as duration of the camp session, whether it is a day or resident program, the overall competence of the staff, including staff in the health center, and particular demands of the camp program. How long a child may require to tolerate certain conditions may have a significant impact on the consultation given. Using examples of typical consultations, specific steps were covered in ascertaining proper information and creating a plan in response to each.
References [1] Koplewicz HS. It’s nobody’s fault: new hope and help for difficult children and their parents. New York: Times Books, Random House; 1996. [2] Nicodemus T. Camp through the decades. Available at: http://www.acacamps.org/campmag/ cm037decades.php. Accessed July 27, 2007. [3] Mogel W. The blessing of a skinned knee. New York: Peguin Books; 2001.
Consulting to Summer Camps Bob Ditter, Med, LCSW 72 Montgomery Street, Boston, MA 02116, USA
This summer, approximately 10 million children and 1 million adults will go to a camp program of some kind.1 As the number of children going to camp has grown (the American Camp Association estimates that the number of children going to camp in 2007 will be between 1% and 3% higher than 2006), so has the need for qualified, focused, competent consultation to camp professionals. In addition to increased enrollment, several factors have increased the need for consultation to children’s summer camps from the allied health professions. First, the overall awareness and diagnosis of childhood disorders and syndromes have expanded greatly in the last 15 years. Some of these disorders, such as bipolar illness in children, Asperger’s syndrome, and childhood autism, only recently have been understood more fully [1]. The number of children going to camp with a diagnosis has increased in concert with this new awareness. Likewise, with advances in the use of psychotropic and other medications in children, more children are marching off to camp on drugs whose side effects and efficacy most camp professionals do not understand fully.2 Another factor feeding the increased need for consultation to summer camps is the increased availability of camp programs to general and special needs populations. Camps currently represent a broad range of programs, including local city or town recreation department day programs, elaborate multi-week day camps, day and resident sports clinics and camps, 1- and 2-week resident camps operated by agencies and foundations (eg, Girl
E-mail address: [email protected] 1 The American Camp Association is a nonprofit, charitable organization that accredits camps throughout the United States. There are more than 2400 American Camp Association–accredited camps in the United States that have met more than 300 health and safety standards to earn American Camp Association endorsement. 2 Camp health nurses report a significant increase in the overall number of medications with which children report to camp. Allergy medications are the other category of drugs that have increased in presence in children’s summer camps. 1056-4993/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.chc.2007.05.004 childpsych.theclinics.com
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Scouts, YMCA, JCC, Salvation Army, Boys and Girls Clubs), camps for special populations, such as persons who have diabetes, muscular dystrophy, Crohn’s disease and colitis, children’s oncology camps, and burns camp, to name a few. Longer term, private, independent camps with general and specialized programming, such as horseback riding, wilderness tripping, sailing, and water sports, also are in operation. With camp within reach of so many more childrendincluding children with special needs who before the late 1980s could not be served in a camp programdit is no surprise that camp professionals are encountering more behaviors with which they need help. One other significant factor in the landscape of children’s summer camps deals with camp professionals themselves. Camp started as an outgrowth of school, beginning with the Gunnery Camp in the mid-nineteenth century. The Gunnery Camp is considered the first organized American camp. Frederick W. Gunn and his wife, Abigail, operated a home school for boys in Washington, Connecticut. In the summer of 1861, they took the whole school on a 2-week trip into the woods. The class hiked to their destination and then set up a campsite. The students spent their time boating, fishing, trapping, and practicing camp crafts. The trip was so successful that the Gunns continued the tradition for 12 years [2]. What began as an expedition and a way to get children out into the wilderness soon grew into a movement. New Englanddwith Maine, Vermont, and Upstate New York taking the leaddbecame the site of sophisticated camps for children that emphasized camp crafts, community living, and values education. Many of these camps were an extension of school, allowing children to get out into the fresh air and learn in a more experiential way. As a result, most camp professionals were educators, not mental health practitioners or childhood development specialists. After World War II, camps focused on physical skill development in activities such as canoeing, tennis, various field and water sports, rock climbing, and tripping. In keeping with this trend, most camp directors were athletes or teachers. Even as the emphasis in camping more recently has been placed on the emotional and social growth of campers through small group living, there has been little change in the backgrounds of the folks running those programs. Many camp professionals still lack formal training in child development, child psychology, or social work; most have backgrounds in education, recreation, business, or physical education. Most camp directors also have multiple duties that range from the care and development of their physical plant, to health and safety standards, to hiring, employment, and insurance issues. The demands on their time make it less likely that they can develop a deep understanding of childhood behavior or medication issues. One other trend has affected consultation to children’s summer camps: the increased demand on the part of nervous parents for greater oversight and competent supervision of their children. In reaction to the horrors of nightly news reports, replete with child abductions, school shootings, child
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abuse cases, and other instances of violence, many parents have become increasingly anxious about their children’s safety3 and have demanded a more sophisticated level of expertise at camp regarding their children’s emotional well-being. In response, many camps have either retained the services of a mental health professional at camp, just as they have a camp nurse or physician at camp, or they have such an individual ‘‘on call.’’ The practice of having a social worker or psychologist on call or at camp for part of the summer undoubtedly will grow as parents come to expect a higher level of expertise and service with regard to their children. Who is the client? One of the most important questions in consulting is knowing who your client is. Although a consultant may be called by the camp director, it is usually because of the behavior of a particular camper. Is the camper the client or is the director? The parents of the camper are, after all, paying the camp bill and are not only responsible for the health and well-being of their child but also are entitled to consent to any intervention involving an allied health professional before it occurs. Although a consultant may educate a director or other camp employee in some general sense about the behavior of the child and may even give general suggestions, it is unwise and unethical for an outside consultant to actually interview or interact directly with a camper without first informing parents and getting their consent.4 In addition to these constituents, the counselors and other staff members, such as program staff (the people who run the activities) or supervisory staff (the head counselor or unit director), may be struggling with a camper’s behavior and may need some direction or pointers about how best to deal with or contain that child’s behavior. The other campers are also undoubtedly affected by the behavior of every child in their group. So who is the client? This question is not unlike the one faced by the child mental health worker who is called by parents who have their own set of concerns but whose reality may be different from that of the child or of the school professionals who have their other interests at stake. My answer to this question is, in part, that your ‘‘client’’ is first and foremost the child, who, after all, may not be able to articulate or advocate for his or her own needs and then the well-being of the overall camp. As in the case of the child mental health professional who practices from a community-based
3 Dr. Mogel [3] asserts that parents’ anxiety about their children’s well-being in an uncertain world has led to an overprotective, overinvolved style of parenting. 4 Consultants should not expect camp professionals to always know to follow this protocol, so it is important to educate them about it and adhere to it before having any direct contact with a particular camper.
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perspective (one that sees the child as a member of, contributor to, and benefactor of the larger community), knowing how to speak to all the constituents in the life of the child has benefits to the overall life experience of that child. At camp, knowing how to educate a camp director, give pointers to the attending counselors responsible for the child’s care at camp, and reassure parents and give them additional resources is an important component to a consultation. There may be times, for example, when a consultant must help a director establish guidelines for keeping a child or sending a child home. Each member of the camp communitydthe director, counselor, camper, and the camper’s parentsdneeds help with this decision in different ways. The director needs sound guidelines; the counselors need understanding and a way of explaining the events to the other children; the camper needs help with the sense of failure; and parents need reassurance and may need additional resources for their child in the aftermath of his or her departure. Salient facts When consulting with camps, certain specific facts about the program may have significant bearing on the type of information or advice given. From my experience, I have identified five important factors that have a bearing on the kind of advice or consultation I offer a camp. Whether the camp is a day or resident (sleep-away) camp. Certain behaviors or medications that can be managed in a day program, in which the child returns home every night, cannot be managed in a resident program simply because they are too volatile or need greater parental or adult supervision than can be guaranteed in a resident program. Likewise, there may be children who fare better away from their community. Having the benefit of the ‘‘fresh start’’ would favor a resident camp program and indicate against a local day program. The duration of the program. Some behaviors or medications can be managed for a week but not for 3 or 4 weeks. Knowing how long a child will be involved in the program may have a significant impact on whether the child can participate in the program at all or for some abbreviated time. Along these lines, I have often suggested that a child shorten his or her stay at camp if it means leaving after a relatively successful stay rather than overstay and risk that the resulting overall experience might be negative. What, if any, special demands or requirements there are in the program itself. Some general camps may have more options for children, making it promising for a child to be involved, whereas a more rigorous, less flexible program would be inadvisable. For example, a child who has bipolar illness may be able to manage wood shop, arts and crafts, and some field and water sports but not an intensive wilderness tripping program or a more exclusive sports program in which hydration and fatigue might make it dangerous for the child to participate.
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The willingness or ability of the camp to provide specific support to a child and the family that might go beyond usual practice. For example, a child who has diabetes, routinely takes his or her own blood sugar measurements, and administers his or her own insulin and is enrolled in a general camp program may need a private place to perform that routine and be provided the opportunity to report regularly to his or her parents while being properly supervised by a trusted adult at camp. A child on lithium treatment for bipolar illness may need an adult to monitor his or her activity level, fatigue, and hydration, alternately making sure that the child is getting the necessary rest and water and communicating frequently with parents and watching for the early warning signs of overactivity that the child may not see or wish to hear about if it means missing out on some activities with friends. Not all camps are prepared for or equipped to provide such supervision, service, and care. One of the ‘‘jobs’’ of a good consultant in a case like this is to determine if that level of care can be provided confidently and competently. The competency level of the medical or support staff (unit leader or other supervisory staff). Having someone in the organization who has a more sophisticated understanding of a certain disorder or behavior, whether as an informed parent or as part of their out-of-camp profession, can make a difference as to whether a youngster can be maintained in a particular camp program. My experience is that the level of expertise among camp professionals varies widely, especially because there is no recognized training program for camp directors. It is their personal experience, or the personal experience of their staff, that comes into play. For example, one camp I consulted to had a camp nurse whose own son had severe attention deficit hyperactive disorder. She had taken it upon herself to become highly informed about attention deficit hyperactive disorder and was much more able to help supervise and advise the staff and implement specific suggestions I had made, which I would not have offered had someone with her caliber of understanding not been available. This nurse was, in a sense, my ‘‘on the inside’’ ally. Determining who has what expertise or experience can help determine not only whether a specific child can be managed but also whether more complex suggestions can be implemented successfully. Group living and the community factor There is one aspect of camp that permeates all types of camps, whether day or resident, long- or short-term, that needs consideration when consulting to summer camps. All camps operate with children in groups, which are, in effect, small communities. This approach means that not only does a child’s behavior affect everyone else in the group but also that the group affects the child’s behavior. For a child to be successful at camp, he or she must be successful in the group to a certain degree. What follows are two different examples.
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Case 1 Several years ago I was consulting to a co-ed resident camp with a 7-week program when the behavior of a 12-year-old girl was brought to my attention. The girl, ‘‘Josie,’’ was in her first year at camp. Although she was quiet, she seemed to fit in with the other girls in her cabin and had ostensibly made a good adjustment to camp. Approximately 1 week after the start of camp, Josie began evidencing some bizarre behavior. First, she wandered away from the other girls and talked to herself during cabin clean-up and rest hour. Eventually it came to the attention of counselors that she was collecting dead insects and had constructed an ‘‘insect cemetery’’ next to her cabind a development that made her wary cabin mates even more skeptical of her behavior. It came out that she had begun writing in other girls’ journals things such as, ‘‘You will die!’’ The last straw was when she was caught placing a sanitary napkin that she had taken from one of her counselor’s belongings onto another campers bed after saturating it with red ink from a magic marker. By that time her bunk mates were entirely afraid of her unpredictable and off-putting behavior. After speaking to her parents and checking with the health center, it came out that Josie had started taking Prozac approximately 3 weeks before the start of camp, which would have meant that she was on week 5 of her treatment. I strongly recommended that Josie leave camp with her parents, get a consultation from a qualified child psychiatrist, and not return unless the camp could get a clean bill of health from that professional. The director of the girls’ unit to which Josie belonged felt that Josie could not return to camp and be successful because the other girls had been so put off by her behavior that she was afraid they would ostracize her upon her return. I communicated this information to the psychiatrist whom the parents, after much resistance, chose for the consultation. (The parents were resistant to removing their daughter from this prestigious camp for fear of the impact it would have on her reputation at camp and in her community, where many children at this camp lived.) After seeing the girl for two or three separate sessions back home, the psychiatrist concluded that she had been having a reaction to the Prozac, which is well known, as he put it, in pubescent girls, and that a change in her medication would eliminate her bizarre behavior. He felt strongly that the camp had no reasonable argument for keeping her out of camp. Although medically correctdthe girl did return to camp and her bizarre behavior did stopdwhat the psychiatrist failed to understand and failed to address was the communal aspect of camp life. What the counselors and the unit director needed to bring this girl back into her cabin were some suggestionsdworked out with the parents’ consentdabout how to explain her previous behavior to her cabin mates. Without such a plausible explanation, simple enough and credible enough for the other girls to understand, Josie simply walked back into a hostile environment. Such a situation was
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harmful not only to Josie but also to the other girls. Failing to impress this upon Josie’s parents, who needed to work together with the camp and the psychiatrist to arrive at something that would be acceptable to them and be credible to the other girls, Josie’s summer had a less happy ending than might have been possible. She was simply marginalized and isolated by the other girls, and no amount of coaxing or talking seemed to change this until approximately the last week of camp. Even so, Josie never returned and the opportunity was lost. Case 2 The second example involved a 13-year-old boy, ‘‘Mike,’’ who was diagnosed with bipolar illness and came to camp on lithium. To take lithium safely, the boy needed to have access to extra water and had to be monitored closely so he would not become overheated or overtired. Either of these two conditions resulted in extended agitated outbursts and made his behavior challenging to manage. The camp agreed to take the boy on, partly because his counselor was a mature, responsible individual who was up for the task. Once again, however, the communal nature of camp life was not taken into consideration. The other boys could not help but notice the extra attention Mike received from his counselor and the extra rest periods he took, the times he did not have to participate, and the extra bottled water he received. Because Mike and his parents did not want to tell the other boys the truth about his bipolar illness for fear of Mike being stigmatized, the other boys had no way to make sense of what seemed to them like special attention. The consultant, who was Mike’s therapist at home, conferred with the camp about the possibility of Mike attending and did an excellent job preparing the camp for the physical requirements of Mike’s condition. The consultant failed to understand, however, that Mike would be living and playing in a small group in which his behavior would be scrutinized by his peers. The health of his friendships suffered as a result of poor or inadequate advice given to the parents (allowing them to insist that the other boys be told ‘‘nothing’’) and the lack of preparedness of the camp for dealing with the social ‘‘fallout.’’ Once again, consultants must consider that children at camp live, work, play, and relate in a community in which their behavior impacts others and in which their ‘‘success’’ may depend as much on good peer relations as on the right medication or other protocols.
The consultant as educator Because many camp professionals lack training in areas of child development, medicine, or child psychology, one of the main roles consultants play with camp professionals is that of educator. Behaviors such as cutting, eating disorders, attention deficit hyperactive disorder, obsessive compulsive disorder, enuresis, and Tourette syndrome may show up at camp at some
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point or other. One task of the competent consultant is to educate camp professionals about the myths and realities of these behaviors and then help directors create ways to determine whether children who present with these behaviors can be maintained at camp and, if so, develop the agreements, protocols, or stipulations necessary for the child and the other campers to have a safe and successful experience. Case 1 One example involves cutting behavior. While visiting a co-ed resident camp a few years ago, I was approached by the head counselor of the teen girls. She told me that one of her counselors had come to her with some concerns about a 13-year-old female camper, ‘‘Sarah.’’ Sarah evidently told some of her cabin mates that she been cutting herself at home, that she had done so for approximately 3 months before coming to camp, and that her parents ‘‘didn’t know.’’ One of the girls who heard Sarah’s story became upset and secretly approached her counselor, who then came to the head counselor, who came to me. (This manner of information transfer is typical at camp. There are even times when a camper swears peers or a counselor to secrecy, only to reveal a ‘‘secret’’ that is a bombshell that the listener did not count on and does not know how to respond to or handle.) The head counselor was concerned because she was afraid Sarah was at risk for killing herself and she wanted some help knowing what to do. My first task was to take the head counselor with me to the director and determine a response. My second task was to educate the director and the head counselor about cutting behavior, including information that although it is self-injurious behavior, it is not suicidal. The motive for much cutting behavior in teens, I explained, is to gain a sense of control in a world in which they typically feel grossly out of control. As counterintuitive as that might seem, cutters often talk about a sense of calm they gain by focusing on their pain. Although not a behavior to be left unsubstantiated and managed, most cutting is not life-threatening. My goal was to lessen the anxiety of the head counselor as a prelude to developing a plan. The next step was to have the head counselor discretely check the story of the upset camper who had informed her counselor. This was an attempt to get as much information as possible before calling Sarah’s parents. Even if Sarah was inventing this story, such fabrication might indicate that Sarah might be troubled in a way that warranted attention. Her parents were predictably incredulous and disbelieving. First, they refused to admit that their daughter could be so distraught as to do such a thing. Maybe more importantly, they were sure that such behavior could never go unnoticed by them. I suggested to the parents that either way, whether Sarah was telling the truth or fabricating, the camp had an obligation to tell them and it made sense to speak to her about it. (They were not sure about because, to quote them, ‘‘Why give her attention for something that must obviously be false?’’) I countered with the fact that several other campers heard her story and that
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even if it were untrue, she was already getting attention. Either way, the camp needed assurance from Sarah that she would stop saying these things to other campers (and that if she did need to talk to someone about it, she could speak to any adult on staff she trusted). If her story were true, the camp needed Sarah to agree not to engage in such behavior while at camp and agree that she and her parents would have a plan for Sarah to talk to a professional about it. The upshot was that not only did Sarah confess that her story was true but also she revealed scars on her upper arm (above her sleeve) from times she had cut while at home before camp. Her parents, still incredulous, were told to take Sarah from camp to get her evaluated by an outside professional, and the other girls were reassured that Sarah would be fine and that she was getting the help she needed. (There was no taking back what Sarah had revealed to them, so damage control was needed.) The girls in Sarah’s cabin also were asked not to talk to other campers about it out of respect for Sarah’s privacy. They were also told that if she came back to camp, they could be sure that she was fine (this would be the only way she would be allowed to come back to camp) and they would not have to worry about her cutting herself. The head counselor had this group discussion with their counselor present (and with Sarah not present). The girls were also asked if they had ever known anyone else who had cut themselves, partly as a way to see if there was any other fallout from Sarah’s revelation. Sarah did return to camp after being seen by a mental health professional, who later began on-going therapy with Sarah after camp but who thought Sarah was not in danger of cutting at camp. (Camp, for Sarah, was respite from the stresses of her life at home, so there was no urge to cut at camp.) Sarah willingly agreed to a ‘‘contract’’ about not cutting and talking to a trusted adult if she ever felt the urge or if she just needed to talk about private matters. She ended the summer happily and came back to camp for several successive summers. Level of consultation There are many levels of consulting to summer camps. First there is consultation about an individual camper who may have medication or behavior issues, which may require a combination of education, assessment of the camp’s ability to manage the child’s behavior, and assessment of the child’s ‘‘readiness’’ for camp. There may be consultation before camp to assess whether the child is ready or to ascertain what would need to be in place in terms of agreements, behavioral strategies, and personnel for a child to be successful in any given program. There is a deeper level, on-going consultation in which the consultant develops a more long-term relationship with the director and other personnel. In such arrangements, although it is the director who may be ‘‘paying the bill,’’ any consultant, to be effective, must win over the people who actually execute the program and supervise the campers. In a world of
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greater anxiety on the part of parents, the trend is toward more consultation in deeper, long-term relationships, in which the overall health of the camp culture and program can be developed and shaped into an ever-improving, healthy experience for camper, staff, and parents alike.
Summary An increased need for consultation to summer camps from the allied health/mental health fields is seen as a result of several factors. A wider range of camp options appealing to a broader audience has made camp available to more children, including camps for special populations, such as children who have diabetes, asthma, oncologic conditions, and Crohn’s disease. There also has been an increase in awareness and expertise in the diagnosis of childhood disorders, such as attention deficit hyperactive disorder, obsessive compulsive disorder, attachment disorder, Asperger’s syndrome, and childhood-onset bipolar illness. As more children are put on psychotropic and other medications, more children come to camp with medication side effects or requirements that camp professionals need help preparing for and understanding. Camps have multiple clients, including the identified camper, the camper’s parents, the staff, and the camp community as a whole. Special consideration needs to be given to the community aspect of camp, as a child’s behavior will undoubtedly affect other campers around her as well as the confidence level of the staff. Reactions to medications or exhibition of certain behaviors will have an impact on the community overall, and a critical part of the consultation may be the need to address the reactions of other campers or staff. Key information necessary to providing adequate consultation include such things as duration of the camp session, whether it is a day or resident program, the overall competence of the staff, including staff in the health center, and particular demands of the camp program. How long a child may require to tolerate certain conditions may have a significant impact on the consultation given. Using examples of typical consultations, specific steps were covered in ascertaining proper information and creating a plan in response to each.
References [1] Koplewicz HS. It’s nobody’s fault: new hope and help for difficult children and their parents. New York: Times Books, Random House; 1996. [2] Nicodemus T. Camp through the decades. Available at: http://www.acacamps.org/campmag/ cm037decades.php. Accessed July 27, 2007. [3] Mogel W. The blessing of a skinned knee. New York: Peguin Books; 2001.