Checklist for Camp: Bug Spray. Sunscreen. Pills.

By JANE GROSS
New York Times

July 16, 2006

BURLINGHAM, N.Y., July 15, 2006- The breakfast buffet at Camp Echo starts at a picnic table covered in gingham-patterned oil cloth. Here, children jostle for their morning medications: Zoloft for depression, Abilify for bipolar disorder, Guanfacine for twitchy eyes and a host of medications for attention deficit disorder.

A quick gulp of water, a greeting from the nurse, and the youngsters move on to the next table for orange juice, Special K and chocolate chip pancakes. The dispensing of pills and pancakes is over in minutes, all part of a typical day at a typical sleep-away camp in the Catskills.

The medication lines like the one at Camp Echo were unheard of a generation ago but have become fixtures at residential camps across the country. Between a quarter and half of the youngsters at any given summer camp take daily prescription medications, experts say. Allergy and asthma drugs top the list, but behavior management and psychiatric medications are now so common that nurses who dispense them no longer try to avoid stigma by pretending they are vitamins.

"All my best friends take something," said David Ehrenreich, 12, who has Tourette's syndrome yet feels at home here because boys with hyperactivity, mood disorders and facial tics line up just as he does for their daily "meds."

With campers far from home, family and pediatricians, the job of safely and efficiently dispensing medications falls to infirmaries and nurses whose stock in trade used to be calamine lotion and cough syrup. Three times a day, at mealtimes, is the norm, with some campers also requiring a sleep aid at bedtime to counteract the effect of their daytime medications.

"This is the American standard now," said Rodger Popkin, an owner of Blue Stars Camps in Hendersonville, N.C. "It's not limited by education level, race, socioeconomics, geography, gender or any of those filters."

Peg L. Smith, the chief executive officer of the American CampAssociation, a trade group with 2,600 member camps and three million campers, says about a quarter of the children at its camps are medicated for attention deficit disorder, psychiatric problems or mood disorders.

Many parents welcome the anonymity that comes when a lot of children take this, that or the other drug, so none stand out from the crowd.

"It's nobody's business who's taking what," said one parent of an Echo
camper whose child is medicated for A.D.D. and who asked not to be named for privacy reasons. "It could be an allergy pill. The way they do it now, he feels comfortable. He just goes up with everybody else, gets it and then carries on with his day."

Increasingly popular is a service offered by a private company called
CampMeds, which provides a summer's worth of prepackaged pills to 6,000 children at 100 camps. Its founder, Dana Godel, said 40 percent of the children regularly took one or more prescription medications, compared with 30 percent four years ago. Eight percent used attention deficit medications
last year; 5 percent took psychiatric drugs.

Borrowing technology developed for nursing homes, CampMeds distributes pills in shrink-wrapped packets marked with a name, date and time. Camp nurses simply tear each packet along the dotted line, sparing them the labor-intensive task of counting pills and reducing the risk of error and thus liability.

The proliferation of children on stimulants for attention deficit disorder, antidepressants or antipsychotic drugs - or on cocktails of all three - is not peculiar to the camp setting. Rather it is the extension of an increasingly common year-round regimen that has also had an impact on schools, although a lesser one, as most medicine is taken at home.

Exacting diagnoses and proper treatments enable some children to go to camp who otherwise could not function in that environment, said Dr. David Fassler, a child and adolescent psychiatrist and a professor at the University of Vermont College of Medicine. Dr. Fassler said that children with one behavioral or mood disorder often "have a second or even a third diagnosis." A child with A.D.D. may also be depressed and anxious, he said, a combination of symptoms that can make such children pariahs in the close quarters of a summer camp cabin without the proper combination of remedies.

Some camp owners question the trend, however. Mr. Popkin, the camp owner in North Carolina, is among them. "It's universal, and nobody really knows if it's appropriate or safe," he said.

And many experts say family doctors who do not have expertise in
psychopharmacology sometimes prescribe drugs for anxiety disorders and depression to children without rigorous evaluation, just as they do for adults.

"There is no doubt that kids are more medicated than they used to be," said Dr. Edward A. Walton, an assistant professor of pediatrics at the University of Michigan and an expert on camp medicine for the American Academy of Pediatrics. "And we know that the people prescribing these drugs are not that precise about diagnosis. So the percentage of kids on these meds is probably higher than it needs to be."

A few medicines growing in popularity, like Abilify and Risperdal, are used for a grab bag of mood disorders. But according to the Physicians' Desk Reference, the encyclopedia of prescription medications, they can have troublesome side effects in children and teenagers, including elevated blood sugar or the tendency toward heat exhaustion, which requires vigilance by counselors in long, hot days on the ball fields.

Some doctors, nurses and camp directors are uneasy about giving children so-called off-label drugs like Lexapro and Luvox. Such medications are used for depression and anxiety, and have been tested only on adults but can legally be prescribed to children. Clonidine is approved as a medication for high blood pressure but is routinely used for behavioral and emotional
problems in children.

"That doesn't mean they are inappropriate or unsafe," Dr. Fassler said,
adding that camp nurses should be able to call the physician when they have questions, but that not all parents welcome that.

Few camp directors risk discussions with parents about behavioral or psychiatric drugs. "We don't make these judgments for families," said Marla Coleman, an owner of Camp Echo and a past president of the American Camp Association.

Figuring out how to distribute all this medicine has taken some trial and
error, beginning with supervision by the nurses, who watch the children take their pills.

Some camps do it in the mess hall, citing informality to put campers at ease and the convenience of having everyone assembled in one place.

Other camps prefer the infirmary, to provide more privacy. Camp Pontiac in Copake, N.Y., built a special medication wing with its own entrance and a porch where campers wait their turn.

In Fishkill, N.Y., at a Fresh Air Fund camp for underprivileged children,
one nurse in the infirmary deals with bug bites and skinned knees and the other dispenses Strattera and Zoloft, the first for attention deficit
disorder and the second for depression, social anxiety or obsessive
compulsive disorder. Children at the camp take a comparable amount of medication for behavioral and psychological problems as their more
privileged counterparts, but more of them suffer from asthma and fewer from seasonal allergies.

The potential for drug interactions is compounded by the widespread use of allergy and asthma medications. Tofranil, an antidepressant for adults that is used for bed-wetting in children, is not recommended in combination with Allegra, for seasonal allergies, Advair, an asthma drug, or epinephrine, the
injectable antidote to deadly allergic reactions to bee stings, insect bites and certain foods, primarily peanuts.

Despite a tenfold increase in childhood allergies over the last decade, some camp doctors think daily medication is overused. The owners of Camp Pontiac, Ken and Rick Etra, brothers who are ear, nose and throat doctors, urge parents to forgo prescription remedies for seasonal allergies when occasional over-the-counter antihistamines are sufficient. Their summer camp does not overlap with the height of the pollen and grass season, the Etras say.

They also discourage bed-wetting medications, which can leave a youngster groggy. "They don't pee, but they're zombies," said Mimi Burcham, Pontiac's head nurse. Instead, camp directors train counselors to wake certain children at midnight for a trip to the bathroom and replace soiled linens with identical sheets to avoid embarrassment.

CampMeds charges $40 per child for any length of stay or for any regimen, a cost that most camps pass along to families. The Fresh Air Fund camps do not use CampMeds, but not because of cost, said Jenny Morgenthau, the fund's executive director. Rather, she said, many of the families are too disorganized - some in shelters or in prison - to do the preparatory paperwork.

So Fresh Air's campers arrive with unmarked bags and bottles that cannot be used under state regulations, and without some of their essential medicines. Susan Powers and Leticia Diaz, who run the infirmary at the girls' camp, are accustomed to children bringing their brother's expired asthma inhaler or their grandmother's sleeping pills in a perfume bottle. Sometimes the medications are missing because they have been sold on the street or used by adults, Ms. Powers and Ms. Diaz said. It takes a few days to unscramble.

The nurses at high-end camps have the opposite problem, with parents who try to involve themselves in all aspects of their children's lives. Some, for instance, may view photographs on the camp Web site, see their child is sunburned and call the camp director to ask for more diligent application of sunscreen. That mind-set may produce ceaseless efforts to help the child, but it has the potential to lead to overmedication, many camp owners and doctors say.

Ms. Burcham, a special-education nurse during the school year, said she often worried about her unfamiliarity with some of the drugs. She turns to the Physicians' Desk Reference for guidance, or sometimes calls her father, a psychiatrist.

Unpacking the shipment of medicine at Pontiac in mid-June, she tried to make sense of a packet from CampMeds for an 11-year-old who, for the first time, would be taking Concerta, for attention deficit disorder, along with Clonidine and Wellbutrin, both mood disorder drugs.

"I'm not a specialist, and that's very disturbing sometimes," Ms. Burcham said. "How do I know if we're really getting it right?"

Then she carefully placed the medications in a plastic bin marked with the camper's name.