ADD and drug holidays.

The summer camp experience is a challenging one, with potential to greatly influence a camper. At camp, a child begins to learn about life without Mom and Dad. The camper participates in new experiences and develops crucial social skills. Due to close quarters and intense social interaction at camp, children with Attention Deficit Disorder, with or without hyperactivity, may be at a greater risk of having unsuccessful camp experiences.

Logistics

The camp setting presents a unique challenge to children with ADD. The logistics of the experience demand a great deal of attention to task. While campers do not go from classroom to classroom, they do follow a schedule of six to eight activity periods per day, each with its own rules and requirements. Instead of learning and using the mathematical times tables, for example, campers learn how to follow the rules of the soccer game or the directions for an arts and crafts project. Campers travel with cabin mates as they rotate from activity to activity across the camp grounds. Children who are "easily distracted by extraneous stimuli," "have difficulty following instructions," and "often do not seem to listen to what is being said," have difficulty arriving at the activities and participating fully once there.

Social skills

The social aspects of the camp experience often prove to be even more troublesome for a child with ADD than the logistical demands of the schedule. At sleep-away camps, 12 or 13 campers live together for two or four weeks at a time in one cabin. Personal boundaries and possessions are extremely important within each cabin. Campers have their own beds, dresser of drawers, and closet space. This area becomes highly personalized, and is crucial to each camper's sense of security in this new environment. When violations of a person's space or belongings occur, reaction is immediate and often emotional.

The trespass into a peer's area and use of a peer's belongings without permission are primary causes of tension in cabins. In all situations, prompt resolution of each conflict is crucial. With swift and appropriate intervention by the counselor, the campers involved can express their feelings, make any needed apologies, and go on about their business. With repeated offenses, however, resolution becomes more difficult. Even the most astute counselor cannot always prevent the sequelae of repeated intrusions, especially when a child has offended cabin mates. The invading child runs the risk of acquiring a label and being ostracized by other campers in the cabin. At this stage, the counselor should involve other resources, such as the unit leader, camp director, camp doctor, and, most importantly, the child's parents.

"Sustaining attention in tasks or play activities," and "awaiting one's turn in games or group situations," can also be difficult for a child with ADD. Difficulty sustaining attention on the ball field, for example, can lead to mistakes that foster angry feelings and harsh words. The negative outcomes of not being able to await one's proper turn range from name-calling to pushing to actual fighting. Whether lining up to go to a meal, picking up the day's mail, or selecting the batting order at the ball game, taking turns is a crucial aspect of the camp experience. If the same situations occur repeatedly, the campers and counselors will eventually reach a limit, beyond which a troublesome child's stay at camp is in jeopardy.

Understanding, preparation, communication

The keys to a positive camp experience, for both parents and children, are understanding, preparation, and communication. All three go hand in hand. Open communication between the child's physician, the camp staff, the potential camper, and appropriate family members is crucial to providing an adequate understanding of the camp environment and the situation at hand.

* The physician must be aware of the family's decision to send the child to camp.

* The camp staff must learn strategies to deal successfully with campers who exhibit ADD behaviors.

* The physician, family, and camp staff must all realize the importance of the summer camp experience itself.

* Parents need to understand the complexities of camp when first considering sending a child to camp.

Drug holidays

Some people believe medications used to treat ADD should not be given on weekends, holidays, or during the summer. These periods of no medication, often referred to as drug holidays, are instituted to minimize the medicine's real and potential side effects.

The most common medication used to treat attention deficit disorders is methylphenidate (Ritalin). Possible side effects of the medicine include loss of appetite, difficulty sleeping, headache, increased heart rate, irritability, and growth impairment. Side effects which may occur tend to resolve spontaneously upon stopping the medicine, and many will gradually lessen in severity with continued use of the medicine.

No matter how well intended, the idea of automatically stopping a child's medication every weekend, during school vacation, or at camp is too simplistic. Physicians should evaluate stopping the medication the same way they decide to begin it: through an analysis of the risks versus the benefits. If a child's non-medicated behavior puts at risk that child's ability to function in a group, then it may be better for the child to continue taking medication at camp.

Each child reacts to ADD differently. Depending on the particular areas of difficulty, a child may be capable of a successful camp experience without medicine.

Ideally, the decision to take a drug holiday will be made jointly by the family and the physician, with appropriate input from the camp staff and the child, well in advance of the camp session.

The following steps are important when a child with ADD will, indeed, go on a drug holiday at camp:

* Before camp begins, parents inform appropriate staff (typically a counselor and an administrator) that the child is on a drug holiday.

* Parents share information concerning the specific nature of the child's problem as well as coping strategies.

* Parents leave a supply of the camper's medication, along with parents' and personal doctor's phone numbers, at the camp health center.

* Camp staff working with the camper call the parents at the first sign of any problem. In that phone call, the decision is made whether or not to consult the camper's physician about restarting the medicine.

The summer camp experience can be one of the most beautiful, influential, enjoyable, educational, and rewarding experiences a child will ever have. Every child deserves the chance to make the absolute most of this wonderful opportunity. The goal, therefore, is not to eliminate drug holidays, but to ensure that the decision to withhold medication is examined carefully. Parental understanding of the camp environment, early preparation, and communication between the child's physician and appropriate camp staff is essential.

References

Committee on Children with Disabilities, Committee on Drugs. (1987, November.) "Medication for children with an attention deficit disorder." Pediatrics, 80(5),758-760.

"Methylphenidate revisited." (1988, May 6.) The Medical Letter on Drugs and Therapeutics, 30(765),51-52.

Morgan, Andrew M. (1986, October.) "Use of stimulant medication in children." American Family Physician, 38(4),197 202.

Munoz-Millan, Robinson J., & Casteel, C. Richard. (1989, July.) "ADHD: recent literature." Hospital and Community Psychiatry, 40(7), 699-707.

RELATED ARTICLE: Typical characteristics of a child with Attention Deficit Disorder

* fidgets, squirms, is restless

* has difficulty remaining seated when required

* is easily distracted by extraneous stimuli

* has difficulty awaiting his/her turn

* difficulty following instructions

* difficulty sustaining attention in task or play

* often shifts from one unfinished activity to another

* has difficulty playing quietly

* often talks excessively

* often interrupts/intrudes on others

* often does not seem to listen

* often loses things necessary for tasks or activities

* often engages in physically dangerous activities without considering possible consequences.

According to the Diagnostic and Statistics Manual, version III, revised.

Steven H. Crossman is a medical student at the Medical College of Virginia in Richmond. He has been involved with ACA as a staff member of Camp Airy in Thurmont, Md. for more than six years.