ADHD & MAM, Part II

By Elizabeth Levine

Physicians are becoming more dependent on using psychotropic medications in the treatment of Attention Deficit Disorder (ADD) and Hyperactivity Attention Deficit Disorder (ADHD). There are many medications presently out on the market and although the Food & Drug Administration has not approved many for use in children, they continue to be prescribed.

Physicians use a combination method of treatment to include medication therapy, relaxation techniques as well as weekly/monthly sessions for follow-up.

Once the diagnosis has been established, and the medication prescribed, the child can live a normal life with parental guidance, love, caring and a solid structural base. These children need a lot of structure and do best with recurrent routines.

Some children may only need to take one medication, while others need a combination of the mood altering medications in order to provide them with a sufficient level for day-to-day experiences. Many children with ADD/ADHD need a clear set of boundaries. This is especially important when the child is removed from their home environment to attend a sleep-away camp.

Diagnosis
There are many ways to assist a camper in having a successful summer. I will include some of the challenges in having a camper with the diagnosis of ADD/ADHD, on medications and some ways of assuring that the camper has a successful summer.

Nursing staff and counselors must assure that the camper take the prescribed medications on schedule. Taking medications at erratic times may not provide the adequate levels for the medication to be effective.

Some medications like Ritalin can last from four to eight hours, but can be quite individual and unreliable, while other medications such as Strattera or Concerta have a longer duration. Camp nurses have always had to worry about the uninterrupted continuation of medications during camp.

I have witnessed campers being sent home for acting out. This is very sad for all involved and sends a message of failure to those campers; however, these campers cannot be allowed to stay if they are being disruptive, violent or non-compliant about camp activities/regimens.

Camp nurses' concerns increase when the medication is about to run out and the pharmacy cannot refill the prescription because they are classified as controlled substances.

In the past, the camp relied on the parent to visit the physician to obtain a new order for the medications, fill the prescription at their local pharmacy and ship the medication overnight to the camp's health care center/infirmary. This takes great skill, coordination, and continuous parental support to ensure there will be an ample amount of medication left for the camper.

It is every parent's fear that his or her child may be asked to go home during a camp session for an inability to adapt to the routine.

Two years ago, Dana Godel, founder and director of CampMeds, and former camp nurse, identified a growing need for provision of medication during the camp experience. CampMeds has been able to overcome this particular challenge because they receive all the prescriptions in advance and take responsibility for the medications arriving to camp in a timely manner. They not only arrive on time, but also individually sealed in packets for easier dispensation.

Of 8,690 prescriptions servicing 65 camps for the months of June and July 2004, 19% (1,651) were prescriptions written for medications prescribed for ADD/ADHD. Of the 1,651 prescriptions, the following are the percentage breakdown of meds ordered for ADD/ADHD: Concerta-45%, Adderall-26%, Straterra-19%, Ritalin-7%, and Vitamins/supplements-3%.

Many times I have seen the parents leave the decision of taking the medication up to the camper. When this is requested by the parent, it is very important for the medical staff to inquire about what telltale signs are red flags for that child.

This allowance is usually given to older campers who know themselves and can determine when they have reached their limit. They must posses the ability to approach the nurse and request the medication.

However, for those younger in age, a camp nurse usually has to track down the campers that do not readily go to the nurses for medication administration. These children can become disruptive and even at times abusive if they do not receive their medications in a timely manner.

Boundaries
Another challenge for all involved when overseeing the care of a child with an ADD/ADHD diagnosis is to consistently find ways to speak positively about the camper. This is sometimes difficult for new counselors to do when the child is being disruptive and not obeying the rules of camp.

Counselors must be oriented to positive strategy techniques and should be trained not to complain about the things that the campers have done or not done... this is especially important when they are around other campers.

They must be especially sure to praise the child and give positive feed back as this boosts morale and self-esteem. Remember, they do not mean to be disruptive; many times, they cannot help it.

Encourage the child to alert their counselor when something is bothering them so that you can try to correct a concern before it becomes a problem. Set standards and add structure and routine to every day activities.

Some ideas for structure and routine include: Making lists that include times and events and posting the list near the child's living area in the bunk; color-coding sports equipment, toiletries, etc. for easy recognition (this will avoid what I call dilly-dallying and assist to maintain focus); and list and post morning and night rituals.

It is very important to be firm and consistent, but with empathy set clear-cut rules and consequences, and do not give a series of directions. Break the directions up into short parts and give them one at a time. Insist that the child complete a task and do not let the child avoid a task by continuous actions such as talking, acting, etc. These are the child's subtle ways of manipulating the environment.

Do not ask these children, "Would you like to," instead say, "We are going to... now." Sit or stand next to the child when it is necessary to keep him/her in control, and when speaking with them always be sure that you are looking into their eyes, otherwise, they may not be listening to you.

Always reward them with kind words of praise for their appropriate behavior. These children need much encouragement and affection. They are easily discouraged because of their repeated unsuccessful attempts. Their counselors and sports specialists must give those responsibilities and tasks that are attainable so they can experience success.

Camps provide a caring, nurturing environment for all children and although there are many specialty camps for children with an array of physical and behavioral disorders, many children with ADD/ADHD can be mainstreamed into a residential summer camp.

Lines of communication must remain open between the camp's director, administrative staff, counselors, medical staff and parents for true success. These children learn self-control from their therapists and parents; at camp, they are provided the environment to learn self-confidence. They will ultimately live life with that confidence that comes from an inherent knowledge that they can achieve anything they set out to do!

"All you need in this life is ignorance and confidence; then success is sure."
--Mark Twain

Elizabeth A. Levine is a pediatric case management coordinator at Jackson Memorial Hospital in Miami, and a nursing doctoral student at Barry University in Miami Shores, Fla. Elizabeth has been a camp nurse every summer in North Carolina for the past four years and in Massachusetts the summer of 2000. She has been a nurse for 16 years.