Child Adolesc Psychiatric Clin N Am

16 (2007) 807–816

Consulting to Summer Camps

Bob Ditter, Med, LCSW72 Montgomery Street, Boston, MA 02116, USA

This summer, approximately 10 million children and 1 million adults willgo to a camp program of some kind.1 As the number of children going tocamp has grown (the American Camp Association estimates that the num-ber of children going to camp in 2007 will be between 1% and 3% higherthan 2006), so has the need for qualified, focused, competent consultationto camp professionals. In addition to increased enrollment, several factorshave increased the need for consultation to children’s summer camps fromthe allied health professions. First, the overall awareness and diagnosis ofchildhood disorders and syndromes have expanded greatly in the last 15years. Some of these disorders, such as bipolar illness in children, Asperger’ssyndrome, and childhood autism, only recently have been understood morefully [1]. The number of children going to camp with a diagnosis has in-creased in concert with this new awareness. Likewise, with advances inthe use of psychotropic and other medications in children, more childrenare marching off to camp on drugs whose side effects and efficacy mostcamp professionals do not understand fully.2

Another factor feeding the increased need for consultation to summercamps is the increased availability of camp programs to general and specialneeds populations. Camps currently represent a broad range of programs,including local city or town recreation department day programs, elaboratemulti-week day camps, day and resident sports clinics and camps, 1- and2-week resident camps operated by agencies and foundations (eg, Girl

E-mail address: bobditter1@aol.com1 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 � 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 forspecial populations, such as persons who have diabetes, muscular dystro-phy, Crohn’s disease and colitis, children’s oncology camps, and burnscamp, to name a few. Longer term, private, independent camps with generaland specialized programming, such as horseback riding, wilderness tripping,sailing, and water sports, also are in operation. With camp within reach ofso many more childrendincluding children with special needs who beforethe late 1980s could not be served in a camp programdit is no surprisethat camp professionals are encountering more behaviors with which theyneed help.

One other significant factor in the landscape of children’s summer campsdeals with camp professionals themselves. Camp started as an outgrowth ofschool, beginning with the Gunnery Camp in the mid-nineteenth century.The Gunnery Camp is considered the first organized American camp. Fred-erick W. Gunn and his wife, Abigail, operated a home school for boys inWashington, Connecticut. In the summer of 1861, they took the wholeschool on a 2-week trip into the woods. The class hiked to their destinationand then set up a campsite. The students spent their time boating, fishing,trapping, and practicing camp crafts. The trip was so successful that theGunns continued the tradition for 12 years [2].

What began as an expedition and a way to get children out into the wil-derness soon grew into a movement. New Englanddwith Maine, Vermont,and Upstate New York taking the leaddbecame the site of sophisticatedcamps for children that emphasized camp crafts, community living, andvalues education. Many of these camps were an extension of school, allow-ing children to get out into the fresh air and learn in a more experientialway. As a result, most camp professionals were educators, not mental healthpractitioners 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 keep-ing with this trend, most camp directors were athletes or teachers. Even asthe emphasis in camping more recently has been placed on the emotionaland social growth of campers through small group living, there has been lit-tle change in the backgrounds of the folks running those programs. Manycamp professionals still lack formal training in child development, child psy-chology, or social work; most have backgrounds in education, recreation,business, or physical education. Most camp directors also have multipleduties 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 deepunderstanding 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 oversightand competent supervision of their children. In reaction to the horrors ofnightly news reports, replete with child abductions, school shootings, child

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abuse cases, and other instances of violence, many parents have become in-creasingly anxious about their children’s safety3 and have demanded a moresophisticated level of expertise at camp regarding their children’s emotionalwell-being. In response, many camps have either retained the services ofa mental health professional at camp, just as they have a camp nurse or phy-sician at camp, or they have such an individual ‘‘on call.’’ The practice ofhaving a social worker or psychologist on call or at camp for part of thesummer undoubtedly will grow as parents come to expect a higher levelof expertise and service with regard to their children.

Who is the client?

One of the most important questions in consulting is knowing who yourclient is. Although a consultant may be called by the camp director, it is usu-ally because of the behavior of a particular camper. Is the camper the clientor is the director? The parents of the camper are, after all, paying the campbill and are not only responsible for the health and well-being of their childbut also are entitled to consent to any intervention involving an allied healthprofessional before it occurs. Although a consultant may educate a directoror other camp employee in some general sense about the behavior of thechild and may even give general suggestions, it is unwise and unethical foran outside consultant to actually interview or interact directly with a camperwithout 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 be-havior and may need some direction or pointers about how best to deal withor contain that child’s behavior. The other campers are also undoubtedly af-fected by the behavior of every child in their group.

So who is the client? This question is not unlike the one faced by the childmental health worker who is called by parents who have their own set ofconcerns but whose reality may be different from that of the child or ofthe school professionals who have their other interests at stake. My answerto 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 ownneeds and then the well-being of the overall camp. As in the case of the childmental health professional who practices from a community-based

3 Dr. Mogel [3] asserts that parents’ anxiety about their children’s well-being in an uncer-

tain world has led to an overprotective, overinvolved style of parenting.4 Consultants should not expect camp professionals to always know to follow this proto-

col, 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 ben-efactor of the larger community), knowing how to speak to all the constit-uents in the life of the child has benefits to the overall life experience of thatchild. At camp, knowing how to educate a camp director, give pointers tothe attending counselors responsible for the child’s care at camp, and reas-sure parents and give them additional resources is an important componentto a consultation. There may be times, for example, when a consultant musthelp a director establish guidelines for keeping a child or sending a childhome. Each member of the camp communitydthe director, counselor,camper, and the camper’s parentsdneeds help with this decision in differentways. The director needs sound guidelines; the counselors need understand-ing and a way of explaining the events to the other children; the camperneeds help with the sense of failure; and parents need reassurance andmay need additional resources for their child in the aftermath of his orher departure.

Salient facts

When consulting with camps, certain specific facts about the programmay have significant bearing on the type of information or advice given.From my experience, I have identified five important factors that havea bearing on the kind of advice or consultation I offer a camp.

Whether the camp is a day or resident (sleep-away) camp. Certain behav-iors or medications that can be managed in a day program, in which thechild returns home every night, cannot be managed in a resident programsimply because they are too volatile or need greater parental or adult super-vision than can be guaranteed in a resident program. Likewise, there may bechildren who fare better away from their community. Having the benefit ofthe ‘‘fresh start’’ would favor a resident camp program and indicate againsta local day program.

The duration of the program. Some behaviors or medications can be man-aged for a week but not for 3 or 4 weeks. Knowing how long a child will beinvolved in the program may have a significant impact on whether the childcan participate in the program at all or for some abbreviated time. Alongthese lines, I have often suggested that a child shorten his or her stay atcamp if it means leaving after a relatively successful stay rather than over-stay 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 itpromising for a child to be involved, whereas a more rigorous, less flexibleprogram would be inadvisable. For example, a child who has bipolar illnessmay be able to manage wood shop, arts and crafts, and some field and watersports but not an intensive wilderness tripping program or a more exclusivesports program in which hydration and fatigue might make it dangerous forthe 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 whohas diabetes, routinely takes his or her own blood sugar measurements, andadministers his or her own insulin and is enrolled in a general camp programmay need a private place to perform that routine and be provided the oppor-tunity to report regularly to his or her parents while being properly super-vised by a trusted adult at camp. A child on lithium treatment for bipolarillness may need an adult to monitor his or her activity level, fatigue, andhydration, alternately making sure that the child is getting the necessaryrest and water and communicating frequently with parents and watchingfor the early warning signs of overactivity that the child may not see orwish 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, ser-vice, and care. One of the ‘‘jobs’’ of a good consultant in a case like this is todetermine 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 so-phisticated understanding of a certain disorder or behavior, whether as aninformed parent or as part of their out-of-camp profession, can make a dif-ference as to whether a youngster can be maintained in a particular campprogram. My experience is that the level of expertise among camp profes-sionals varies widely, especially because there is no recognized training pro-gram for camp directors. It is their personal experience, or the personalexperience of their staff, that comes into play. For example, one camp I con-sulted to had a camp nurse whose own son had severe attention deficit hy-peractive disorder. She had taken it upon herself to become highly informedabout attention deficit hyperactive disorder and was much more able to helpsupervise and advise the staff and implement specific suggestions I hadmade, which I would not have offered had someone with her caliber of un-derstanding not been available. This nurse was, in a sense, my ‘‘on the in-side’’ ally. Determining who has what expertise or experience can helpdetermine not only whether a specific child can be managed but also whethermore complex suggestions can be implemented successfully.

Group living and the community factor

There is one aspect of camp that permeates all types of camps, whetherday or resident, long- or short-term, that needs consideration when consul-ting to summer camps. All camps operate with children in groups, whichare, in effect, small communities. This approach means that not only doesa child’s behavior affect everyone else in the group but also that the groupaffects the child’s behavior. For a child to be successful at camp, he or shemust be successful in the group to a certain degree. What follows are twodifferent examples.

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Case 1

Several years ago I was consulting to a co-ed resident camp with a 7-weekprogram when the behavior of a 12-year-old girl was brought to my atten-tion. 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 madea good adjustment to camp. Approximately 1 week after the start of camp,Josie began evidencing some bizarre behavior. First, she wandered awayfrom the other girls and talked to herself during cabin clean-up and resthour. Eventually it came to the attention of counselors that she was collect-ing dead insects and had constructed an ‘‘insect cemetery’’ next to her cabinda development that made her wary cabin mates even more skeptical of herbehavior. It came out that she had begun writing in other girls’ journalsthings such as, ‘‘You will die!’’ The last straw was when she was caughtplacing a sanitary napkin that she had taken from one of her counselor’sbelongings onto another campers bed after saturating it with red ink froma magic marker. By that time her bunk mates were entirely afraid of herunpredictable and off-putting behavior. After speaking to her parents andchecking with the health center, it came out that Josie had started takingProzac approximately 3 weeks before the start of camp, which would havemeant that she was on week 5 of her treatment. I strongly recommendedthat Josie leave camp with her parents, get a consultation from a qualifiedchild psychiatrist, and not return unless the camp could get a clean bill ofhealth from that professional. The director of the girls’ unit to which Josiebelonged felt that Josie could not return to camp and be successful be-cause the other girls had been so put off by her behavior that she wasafraid 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 resistantto removing their daughter from this prestigious camp for fear of the impactit would have on her reputation at camp and in her community, where manychildren at this camp lived.) After seeing the girl for two or three separatesessions back home, the psychiatrist concluded that she had been havinga 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 keepingher out of camp.

Although medically correctdthe girl did return to camp and her bizarrebehavior did stopdwhat the psychiatrist failed to understand and failed toaddress was the communal aspect of camp life. What the counselors and theunit director needed to bring this girl back into her cabin were some sugges-tionsdworked out with the parents’ consentdabout how to explain herprevious behavior to her cabin mates. Without such a plausible explanation,simple enough and credible enough for the other girls to understand, Josiesimply 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 thisupon Josie’s parents, who needed to work together with the camp and thepsychiatrist to arrive at something that would be acceptable to them andbe credible to the other girls, Josie’s summer had a less happy endingthan might have been possible. She was simply marginalized and isolatedby the other girls, and no amount of coaxing or talking seemed to changethis until approximately the last week of camp. Even so, Josie never returnedand the opportunity was lost.

Case 2

The second example involved a 13-year-old boy, ‘‘Mike,’’ who was diag-nosed with bipolar illness and came to camp on lithium. To take lithiumsafely, the boy needed to have access to extra water and had to be monitoredclosely so he would not become overheated or overtired. Either of these twoconditions resulted in extended agitated outbursts and made his behaviorchallenging to manage. The camp agreed to take the boy on, partly becausehis counselor was a mature, responsible individual who was up for the task.Once again, however, the communal nature of camp life was not taken intoconsideration. The other boys could not help but notice the extra attentionMike received from his counselor and the extra rest periods he took, thetimes 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 truthabout his bipolar illness for fear of Mike being stigmatized, the other boyshad no way to make sense of what seemed to them like special attention.The consultant, who was Mike’s therapist at home, conferred with thecamp about the possibility of Mike attending and did an excellent job pre-paring the camp for the physical requirements of Mike’s condition. The con-sultant failed to understand, however, that Mike would be living andplaying in a small group in which his behavior would be scrutinized byhis peers. The health of his friendships suffered as a result of poor or inad-equate advice given to the parents (allowing them to insist that the otherboys be told ‘‘nothing’’) and the lack of preparedness of the camp for deal-ing with the social ‘‘fallout.’’ Once again, consultants must consider thatchildren at camp live, work, play, and relate in a community in which theirbehavior impacts others and in which their ‘‘success’’ may depend as muchon 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 develop-ment, medicine, or child psychology, one of the main roles consultants playwith camp professionals is that of educator. Behaviors such as cutting, eat-ing disorders, attention deficit hyperactive disorder, obsessive compulsivedisorder, 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 campprofessionals about the myths and realities of these behaviors and thenhelp directors create ways to determine whether children who present withthese behaviors can be maintained at camp and, if so, develop the agree-ments, protocols, or stipulations necessary for the child and the othercampers to have a safe and successful experience.

Case 1

One example involves cutting behavior. While visiting a co-ed residentcamp a few years ago, I was approached by the head counselor of theteen girls. She told me that one of her counselors had come to her withsome concerns about a 13-year-old female camper, ‘‘Sarah.’’ Sarah evidentlytold some of her cabin mates that she been cutting herself at home, that shehad done so for approximately 3 months before coming to camp, and thather parents ‘‘didn’t know.’’ One of the girls who heard Sarah’s story becameupset and secretly approached her counselor, who then came to the headcounselor, who came to me. (This manner of information transfer is typicalat camp. There are even times when a camper swears peers or a counselor tosecrecy, only to reveal a ‘‘secret’’ that is a bombshell that the listener did notcount on and does not know how to respond to or handle.)

The head counselor was concerned because she was afraid Sarah was atrisk for killing herself and she wanted some help knowing what to do. Myfirst task was to take the head counselor with me to the director and deter-mine a response. My second task was to educate the director and the headcounselor about cutting behavior, including information that although it isself-injurious behavior, it is not suicidal. The motive for much cutting be-havior in teens, I explained, is to gain a sense of control in a world in whichthey typically feel grossly out of control. As counterintuitive as that mightseem, cutters often talk about a sense of calm they gain by focusing on theirpain. Although not a behavior to be left unsubstantiated and managed,most cutting is not life-threatening. My goal was to lessen the anxiety ofthe head counselor as a prelude to developing a plan.

The next step was to have the head counselor discretely check the story ofthe upset camper who had informed her counselor. This was an attempt toget as much information as possible before calling Sarah’s parents. Even ifSarah was inventing this story, such fabrication might indicate that Sarahmight be troubled in a way that warranted attention. Her parents were pre-dictably incredulous and disbelieving. First, they refused to admit that theirdaughter could be so distraught as to do such a thing. Maybe more impor-tantly, they were sure that such behavior could never go unnoticed by them.I suggested to the parents that either way, whether Sarah was telling thetruth or fabricating, the camp had an obligation to tell them and it madesense to speak to her about it. (They were not sure about because, to quotethem, ‘‘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, thecamp needed assurance from Sarah that she would stop saying these thingsto other campers (and that if she did need to talk to someone about it, shecould speak to any adult on staff she trusted). If her story were true, thecamp needed Sarah to agree not to engage in such behavior while atcamp and agree that she and her parents would have a plan for Sarah totalk to a professional about it.

The upshot was that not only did Sarah confess that her story was true butalso she revealed scars on her upper arm (above her sleeve) from times she hadcutwhile at home before camp.Her parents, still incredulous, were told to takeSarah fromcamp to get her evaluated by anoutside professional, and the othergirls were reassured that Sarah would be fine and that she was getting the helpshe needed. (There was no taking back what Sarah had revealed to them, sodamage control was needed.) The girls in Sarah’s cabin also were asked notto talk to other campers about it out of respect for Sarah’s privacy. Theywere also told that if she came back to camp, they could be sure that shewas fine (this would be the only way she would be allowed to come back tocamp) and they would not have to worry about her cutting herself. Thehead counselor had this group discussion with their counselor present (andwith Sarah not present). The girls were also asked if they had ever known any-one else who had cut themselves, partly as a way to see if there was any otherfallout from Sarah’s revelation. Sarah did return to camp after being seen byamental health professional, who later began on-going therapy with Sarah af-ter camp but who thought Sarahwas not in danger of cutting at camp. (Camp,for Sarah, was respite from the stresses of her life at home, so therewas no urgeto cut at camp.) Sarah willingly agreed to a ‘‘contract’’ about not cutting andtalking to a trusted adult if she ever felt the urge or if she just needed to talkabout private matters. She ended the summer happily and came back tocamp for several successive summers.

Level of consultation

There are many levels of consulting to summer camps. First there is con-sultation about an individual camper who may have medication or behaviorissues, which may require a combination of education, assessment of thecamp’s ability to manage the child’s behavior, and assessment of the child’s‘‘readiness’’ for camp. There may be consultation before camp to assesswhether the child is ready or to ascertain what would need to be in placein terms of agreements, behavioral strategies, and personnel for a child tobe successful in any given program.

There is a deeper level, on-going consultation in which the consultantdevelops a more long-term relationship with the director and other person-nel. In such arrangements, although it is the director who may be ‘‘payingthe bill,’’ any consultant, to be effective, must win over the people whoactually 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 consultationin deeper, long-term relationships, in which the overall health of the campculture 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 alliedhealth/mental health fields is seen as a result of several factors. A widerrange of camp options appealing to a broader audience has made campavailable to more children, including camps for special populations, suchas children who have diabetes, asthma, oncologic conditions, and Crohn’sdisease. There also has been an increase in awareness and expertise in thediagnosis of childhood disorders, such as attention deficit hyperactive disor-der, obsessive compulsive disorder, attachment disorder, Asperger’s syn-drome, and childhood-onset bipolar illness. As more children are put onpsychotropic and other medications, more children come to camp with med-ication side effects or requirements that camp professionals need help pre-paring for and understanding.

Camps have multiple clients, including the identified camper, thecamper’s parents, the staff, and the camp community as a whole. Specialconsideration needs to be given to the community aspect of camp, asa child’s behavior will undoubtedly affect other campers around her aswell as the confidence level of the staff. Reactions to medications or exhibi-tion of certain behaviors will have an impact on the community overall, anda critical part of the consultation may be the need to address the reactions ofother campers or staff.

Key information necessary to providing adequate consultation includesuch things as duration of the camp session, whether it is a day or residentprogram, the overall competence of the staff, including staff in the healthcenter, and particular demands of the camp program. How long a childmay require to tolerate certain conditions may have a significant impacton the consultation given. Using examples of typical consultations, specificsteps were covered in ascertaining proper information and creating a plan inresponse 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.