by Ethan Schafer, Ph.D.
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.
Originally published in the 2005 September/October
issue of Camping Magazine. |
