What's Going On?

Are you finding youth more complicated and challenging to work with? Did you know that today one in five youth ages ten to twenty-four years is diagnosed with a defined mental health problem causing at least mild impairment, and another 7 to 10 percent experience significant functional impairment (Department of Health and Human Services 1999)? Suicide is the third leading cause of death among youth ages five to twenty-four years and is directly associated with mood disorders, and substance abuse remains at epidemic proportions (Evans and Foa 2008; Department of Health and Human Services 1999). Girls are diagnosed with eating disorders more often and earlier in their lives, and a reported one in 150 youth are now diagnosed with an autism disorder each year (Evans and Foa 2008).

Are these problems on the rise? Changes in how mental health problems are defined over time make comparisons difficult. However, many experts agree that due to complex reasons including increased exposure to dangerous environments and sociopolitical factors that make life more stressful, mental health disorders in youth are on the rise (Evans and Foa 2008). Regardless of why this is the case, it is safe to assume that more campers are going to step off of the buses with concerning mental health issues at camp this summer.

All youth face psychological problems at some point in their life time, whether or not they are assigned a diagnosis and receive treatment. While information is more available now than ever before, the field of childhood mental health remains bewildering for non-clinicians. Where do camp professionals turn to for better understanding of these serious issues?

Debunking Child and Adolescent Mental Health

The American Psychiatric Association has a classification system that trained professionals use for diagnosing mental health problems (American Psychiatric Association 2000). Many identified disorders share symptoms, and nearly half of those diagnosed with a mental health disorder meet criteria for two or more disorders (National Institute of Mental Health 2008). According to the diagnostic system, mental health labels or descriptors such as autism, depression, or anxiety are applied only when an individual experiences a known cluster of symptoms that cause significant functional impairment and distress over a specified period of time (American Psychiatric Association 2000).

Accurate and thoughtful diagnosis and assessment of youth is critical, as diagnoses are often used to make life-changing decisions and tend to "follow" youth past the time that they are useful or relevant. For that reason, it is best that applying diagnostic labels or using them to describe a camper be left to trained professionals, tempting though it may be for us to make assumptions based upon our own experiences or things we hear in the popular literature about mental health problems.

There are a number of identified disorders that first begin in infancy or childhood (birth through eighteen years). Some of these problems resolve naturally and others continue into adulthood. The childhood diagnoses delineated by the American Psychiatric Association include learning disorders and mental retardation, autism spectrum disorders, attention deficit and disruptive behavior disorders, attachment disorders, eating disorders, and separation anxiety disorder. Experts increasingly recognize that youth also experience disorders once thought to occur only in adults including anxiety, depression, bipolar disorder, obsessive compulsive disorder, schizophrenia, gender identity disorders and eating disorders (National Institute of Mental Health 2008).

Camps have very limited time to gain an understanding of any given camper, particularly ones that are having difficulties. This challenges a camp's confidence and success in managing mental health problems. When a problem arises, camps need to have the skills to manage it or seek help from someone who can. Most camps do not have the luxury of hiring a mental health professional, yet more expertise seems necessary in order to address the complex problems youth face today.

So, What Now?

The good news is that camps can increase their capacity to serve children appropriately and effectively with mental health problems. By building capacity to handle youth with a variety of abilities and challenges, we are enriching the camp experience for all. There are skill sets that camps can either strengthen or develop to handle mental health problems better. These include understanding child development, recognizing signs of distress, gaining prior knowledge, developing effective staff training and behavior management plans, and determining and communicating essential functions to camp staff, prospective parents, and campers.

Understanding Child Development 
It is important to distinguish mental health problems from developmental "phases." All youth experience periods of behavioral and emotional disregulation as they reach toward expected developmental benchmarks. Mental health professionals make this distinction in part by assessing how long a behavior or symptom has been present (duration), how strong or persistent the symptom is (intensity) and how often it occurs (frequency). Behaviors or emotions that are abnormally high in duration, intensity and frequency at any specified developmental level and are reducing the ability to function effectively may indicate a mental health problem and not merely a developmental phase. Mental health problems tend to linger and escalate without treatment, while developmental challenges resolve more spontaneously and respond better to the typical things adults do to support youth development.

A familiar example for camps is homesickness. It is expected that young children or those with no experience being away from home may temporarily experience "symptoms" at camp such as sleep disturbances, sadness, and loss of appetite, social withdrawal, and difficulty engaging in activities (Thurber and Walton 2007). When older youth experience these symptoms beyond the time it would be considered "normal," they may be experiencing a problem in need of clinical attention. Almost all behaviors youth demonstrate can and should be assessed along these developmental lines before conclusions are made about psychopathology. Childhood in and of itself is not a mental health disorder, though it can seem that way at times!

Recognizing Significant Signs of Distress
It is common for people to experience stress in new situations. However, the presence of distress may mean that something more serious is occurring. Signs of distress to be aware of include sleep and eating disturbances, extreme anger and irritability, prolonged sadness, tearfulness or withdrawal, rapid mood swings, suicidal talk, extreme agitation or anger, marked changes in energy level or interests, and overly aggressive or sexualized behaviors.

There is also a range of very unusual and rare behaviors that only occur in the course of a defined mental health diagnosis or mental health emergency and require immediate medical attention. These include visual or auditory hallucinations, paranoia, self injury, odd or jumbled language, suicide attempts (attempting it, not just thinking about it), reckless behavior, self injury such as head banging and cutting, or other behaviors that are odd or markedly out of the societal norm.

Gaining Prior Knowledge
Camps need to know their campers and staff as well as possible in advance, since problems frequently arrive unannounced. By asking the right questions ahead of time, camps have a better chance of preparing for potential problems. Many camps collect developmental information on their camper applications such as school performance, typical responses to changes and transitions, ability to get along with other children, and challenging behaviors. You might want to ask parents if the child has experienced any significant changes or stresses at home in school during the past year. Sometimes an open-ended question such as "what, if anything, concerns you about your child?" can elicit information relevant to how the child will adjust at camp.

If camps choose to admit a camper or counselor with an identified mental health disorder, it is also prudent to gain some understanding of that disorder and its treatment ahead of time. One should never predict or presume anything about an individual on the basis of a diagnosis alone, as diagnoses can be inaccurate and incomplete, and it is never certain how any one will respond to the unique camp situation (Ditter 2007). There are well-respected, user-friendly, and timely sources on mental illness on the Internet, some of which are listed at the end of this article. The American Camp Association (ACA) also provides helpful links and resources in the Education portal of its Web site (www. ACAcamps.org). Urge parents of campers with a diagnosed mental health problem to provide you with as much information as possible. Emphasize that providing accurate and complete information is critical to their child's safety and success at camp. Mental health professionals who have treated a camper may be willing to provide you with a one-page summary of evaluation findings and recommendations that might prove useful. In general, you will want to know about major symptoms, medication's purpose and side effects, what special help the child needs, how symptoms are managed, and how behavioral issues are typically handled.

Effective Staff Training and Behavior Management Plans
All youth (campers and counselors) arrive at camp with a cadre of behaviors and coping strategies. Camp represents a unique context in which old strategies are applied to new situations with varying degrees of success. Further, camp is a testing ground for new behavioral strategies and social roles (Cohen and Carlson 2007). To complicate things further, the people most often handling children at camp (counselors) are at a turbulent developmental stage themselves (Erceg 2007). As a result, it is critical for camps to invest time in developing effective staff training and behavior management plans.

Camp staff should learn the basics of child development, developmental challenges, and child-interaction skills. Training should be designed so that the content is easily and quickly learned and applied. Camps should develop a culture that encourages team work and collaboration. Counselors who are not afraid to ask questions and seek help will ultimately be more successful with their campers (Cohen and Carlson 2007).

Good behavior management policies include clear rules and structure, well defined acceptable and unacceptable behaviors, systems of praise and reinforcement, and named strategies for handling behavioral or emotional problem that have proven effective in the past. Staff, parents, and campers should be aware of the camp's behavior management expectations, policies and procedures prior to enrollment. Camps should have trained and highly visible staff that are equipped to and charged with handling camper issues that are out of the norm.

Determining and Communicating Essential Functions
Camps need to assess their essential functions for both campers and staff (Erceg 2007). Essential functions are qualities or skills required by campers or staff to be successful in your program. For example, it may be essential that all participants in your program can walk or toilet independently. There may also be essential functions with regard to mental health issues. In examining the needs produced by various childhood mental health problems, you may conclude that your program lacks the structure or local expertise needed to provide appropriate or effective programming for some or all of them. Make sure prospective campers and staff know what to expect by describing what a typical day at camp is like within the promotional and application materials. The better the program is described ahead of time, the better the chance that all participants will successfully meet the program's essential functions.

Tough Decisions
To what length should camps go to handle mental health problems? When the interventions that fall within your level of expertise have continually failed and community safety is at risk, it is probably time to end the relationship and refer the family on to other resources. It is very difficult to manage a mental health problem that was either not anticipated or reaches crisis level. Camps that are prepared in the ways previously described have a better chance of handling tough issues well. Also, deciding the limits of your expertise before you even accept applications will reduce the emotional turmoil and stress involved in sending a camper or staff member home when that need arises.

Who Can Help?

Camp is a unique child context with unique goals. While not all mental health professionals have camp experience, a growing number are interested in expanding their practices to camps. If possible, camps should contract with one or more local mental health professionals with solid reputations who could become an "on call" resource for the camp. Consultants should be degreed and licensed mental health professionals who specialize in children, teens, and families. Some things a consultant can help with include teaching development or behavior management during staff orientation, teaching camps about special populations of children, developing behavior and wellness policies and procedures, and providing guidance and support when needs arise during the summer. Consultants can also help camps assess their essential functions and assist in the process of sending a child home (Ditter 2007; Cohen and Carlson 2007).

A Call to Arms

Increasing your camp's capacity to accommodate youth with mental health challenges addresses ACA's 2008 20/20 Vision of vastly increasing the numbers of children benefiting from camp by the year 2020, and ACA's 2009 The Power of the Experience, by making the camp experience richer and more accessible to all participants. We know that camp is important and beneficial to most children. While including youth with mental health problems can be painful, frustrating and difficult, there is also great joy and satisfaction in witnessing how diversity deepens teamwork, tightens bonds within the community, and helps everyone to grow. Our hope is that armed with desire, awareness and skills, camps will no longer see mental health problems as a threat will confidently offer their programs to youth who arguably need it the most.

Web Resources
National Mental Health Information Center
Autism Society of America
National Attention Deficit Disorder Association
National Institute of Mental health
Child and Adolescent Bipolar Foundation
Child Trauma Institute
Hallowell Center for Cognitive and Emotional Health
Mental Health America


Evans, A.L. and Foa, E.F. et al. (2008). Treating and preventing adolescent mental health disorders: What we know and what we don't know. Annenberg Foundation Trust at Sunnylands and Oxford University Press, www.amhitreatingpreventing.oup.com. Accessed 10/20/08.
Department of Health and Human Services: A report of the Surgeon General. (1999). Bethesda MD: NIMH, www.surgeongeneral.gov. Accessed 10/20/08.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR). (2000). Washington D.C.: American Psychiatric Association, 2000.
National Institute of Mental Health, www.nimh. nih.gov/health/statistics/index.shtml. Page last reviewed 9/08.
Thurber, C.A. and Walton, E.A. (2007). Preventing and Treating Homesickness. McAuliffe-Fogarty, A. and Carlson, K.P. Guest Editors. Summer Camp Programs. Child and Adolescent Psychiatric Clinics, Vol 16 (4), 843-858. Philadelphia: Elsevier.
Ditter, B. (2007). Consulting to Summer Camps. A. McAuliffe-Fogarty and K.P. Carlson, Guest Editors. Summer Camp Programs. Child and Adolescent Psychiatric Clinics, Vol 16 (4), 807-816. Philadelphia: Elsevier.
Cohen A. and Carlson, K.P. (2007). Developing Positive Behavior at Camp: Contain-Discuss- Plan. McAuliffe-Fogarty, A. and Carlson, K.P. Guest Editors. Summer Camp Programs. Child and Adolescent Psychiatric Clinics, Vol. 16 (4),859-874. Philadelphia: Elsevier.
Erceg, LE (April 2007). Essential functions of campers: A familiar concept gets new application. In L. Ridder's (chair). Camp Nurse Symposium. Symposium conducted at the Association of Camp Nurses Educational Conference, St. Charles, IL.

Karen P. Carlson, Ph.D., is a practicing clinical psychologist and a lecturer in the Yale University Child Study Center. For the past fifteen years she has served as consulting psychologist at The Hole in the Wall Gang Camp® in Ashford, Connecticut. The Hole in the Wall Gang Camp, in collaboration with its associated camps in the United States and abroad, provides children with cancer and other serious illnesses and conditions a camp experience of highest quality while extending year-round support to their families and health care providers.

Originally published in the 2009 January/February issue of Camping Magazine.