Emotional Disorders and Psychotropic Medication

by Myra Pravda, RN, MSN

Many children come to day and resident camp with a variety of emotional disorders. The National Institute of Mental Health (NIMH) estimates that there are 12 million children under eighteen with a mental disorder. At least 3 to 5 percent of American school-age children suffer from attention deficit disorder (ADD) and attention deficit hyperactive disorder (ADHD).

Five percent of children with ADD/ADHD show signs of depression. A startling fact is that by the end of high school, one in four teens will have seriously considered suicide. The number of children being diagnosed with mental problems seems shocking but a recent NIMH survey revealed that as few as one in five kids with mental-health problems is receiving treatment of any kind. We will be seeing more children at camp with a variety of mental health problems and treatment plans.

The realization that a child’s behavior needs professional attention can be painful or frightening to parents who have tried everything to support their child. Many parents are reluctant to seek help fearing they will be blamed for the child’s problems and that their child may be inappropriately labeled. Once diagnosed, many treatment approaches are available, but finding the right combination that works for the child is often frustrating. Treatment approaches are psychotropic medication, family counseling, behavior modification, cognitive therapy, psychotherapy, or social-skills training. It is essential that camp directors and health care professionals work closely with the child’s parents, physician, and mental health worker to determine how the camp can best help the child have a successful camp experience.

In any given cabin or day-camp bunk you might have a child with ADD, one with ADHD, a child seeing a therapist for depression, a child with mood swings, a child on an herbal remedy for mild depression, and a child with an anxiety disorder. Many camp directors are baffled when parents tell them their child is taking medication for an emotional disorder. What are some of the emotional disorders and what are the psychotropic medications campers are bringing to camp?

Common Childhood Emotional Conditions

Attention Deficit Disorder — ADD is a persistent and frequent pattern of developmentally inappropriate inattention and impulsivity with or without hyperactivity (ADHD). These children have some positive traits: spontaneity, creativity, and the ability to lock on to and focus on certain tasks.

The symptoms that may present potential problems include trouble paying attention, inattention to details, losing items, being easily distracted, trouble listening, trouble following multiple adult commands, blurting out answers, impatience, fidgeting, talking too much, interrupting others, and having difficulty playing quietly.

Childhood Depression — Depression in school-aged and even pre-school children has been more recognized in recent years. Symptoms include frequent sadness, hopelessness, decreased interest in activities, social isolation, self-blame, somatic complaints (headache, abdominal pain, insomnia), difficulty with relationships, poor concentration, and thoughts or expressions of suicide or self-destructive behavior. Chronic depression is often associated with anorexia, weight loss, despondency, and suicidal thoughts. Depression may be masked by overactivity and aggressive, antisocial behavior.

Adolescent Depression — Mild depression occurs in up to 10 percent of high school students, moderate depression in 5 to 6 percent, and major depression in 1 to 2 percent. The symptoms are similar to childhood and adult depression but are modified by the circumstances in the adolescent’s life. Depressed adolescents may turn to alcohol or other drugs as a way to feel better.

Anxiety Disorders — Anxiety is expected to some degree and is normal at specific times in development. When anxieties become severe and begin to interfere with the daily activities of childhood, such as separating from parents, attending school, and making friends, the child may have an anxiety disorder. Some anxiety disorders are panic attacks, phobias, obsessive-compulsive disorder, and post-traumatic stress disorder.

Medication

Medication may be an effective part of the treatment program for many psychiatric disorders of childhood and adolescence. Today’s newer psychotropic drugs are considered safer and more effective than older medications. Psychotropic means, literally, "mind-turning" from psyche (mind) and trope (a turning). In Stedman’s Medical Dictionary (1987, Williams and Wilkins) it is defined as "affecting the mind, denoting drugs used in the treatment of mental illness" (p.623). They are used in clinical ways to modify mood, cognition, or behavior. Psychotropic drugs can be used either therapeutically or they can be illicit, recreational drugs.

We will be seeing more children at camp with a variety
of mental health problems and treatment plans.

Parents should know the medication their child is on, the benefits it should provide, the proper dose, and its unwanted side effects. Ask parents how long the child has been on the medication. If it is three months or longer, the dose most likely has been properly adjusted and any side effects have been discussed with the physician. Ask parents which unwanted side effects are observed in their child and what they do about it.

When a child comes to camp on medication, the parents need to be informed about the camp’s medication policies.

  • Require written instructions about all medication.

  • Have professional health staff review all medication information before any medication is given at camp.

  • All medication should be received in the original pharmacy containers.

  •  The camp health professional may need to talk to parents or physicians if instructions are unclear.

  • Many of the psychotropic medications received at camp are controlled substances and need to be counted and documented on arrival and departure of the camper or staff member. All medication management needs clear documentation.

Psychotropic Medications

Psychotropic medication can have serious side effects. Each medication has its own potential side effects.

Stimulant Medication — This medication is a useful part of the treatment for attention deficit hyperactivity disorder. Dexedrine (dextroamphetamine), Ritalin (methylphenidate), Cylert (pemoline), and Adderall are examples. Common side effects associated with stimulant drugs are insomnia, diminished appetite, anxiety, depression, and nervousness. These symptoms tend to normalize themselves within a few months. If the child is not eating well at camp, it is because they truly are not hungry. Ask what parents do at home. They may want to send a high-protein shake or recommend the child be offered a substantial snack in the evening when the medication is wearing off.

Serious side effects of stimulants: chest pain, irregular or fast heartbeat, skin rash, joint pain, fever or dry skin, psychotic-like mood or behavior, uncontrollable body movements (head, neck, arms, legs). Cylert may cause yellowing of eyes or skin (Teacher’s Drug Reference, p. 65).

Antidepressants — Antidepressants are used in the treatment of depression, school phobias, anxiety disorders, panic disorders, bedwetting, anorexia, bulimia, PMS, and ADHD. There are three classifications of antidepressants:

  • Tricyclic Antidepressant (TCAs): Elavil (amitriptyline), Endep (amitriptyline), Norpramin (desipramine), Pamelor (nortriphyline), Tofranil (imipramine). Serious side effects of Tricyclic Antidepressants (TCA’s): blurred vision or eye pain, confusion, hallucinations, irregular or rapid pounding heartbeat, seizures, muscle stiffness or spasm, tingling, pain or numbness in feet or hands, tremor, muscle twitches, difficulty urinating or loss of bladder control, yellowing of eyes or skin. Note: These drugs have significant potential for toxicity (Teacher’s Drug Reference, p. 199).

  • Selective Serotonin Reuptake Inhibitors (SSRIs): Luvox (fluvoxamine), Paxil (paroxetine), Prozac (fluoxetine), Zoloft (sertraline). Serious side effects of Selective Serotonin Reuptake Inhibitors (SSRIs): Agitation or restlessness, nausea, vomiting, dizziness, insomnia, palpitations, skin rash, hives, difficulty breathing, tingling or numbness, seizure. Prozac can also cause flu-like symptoms (Teacher’s Drug Reference, p. 201).

  • Atypical Antidepressants: Desyrel (trazadone), Ludiomil (maprotiline), Wellbutrin (bupropion), Effexor (veniafaxine). Serious side effects of atypical antidepressants:

  • --Wellbutrin — agitation, anxiety, restlessness, confusion, hallucinations, severe headache, difficulty breathing, palpitations, seizures.

  • --Ludiomil — difficulty breathing, eye pain, fainting spells, palpitations, fever or sweating, hallucinations, difficulty with bladder, muscle stiffness, skin rash, unusual swelling, muscle twitches or movement of the mouth, yellowing of skin or eyes, seizures.

  • --Desyrel — fainting spells, palpitations, fever and sweating, tremor or trembling, continuous painful erection (Teacher’s Drug Reference, p. 203)

Anti-Anxiety Medications (Benzodiazepines) — These medications are used to treat anxiety, phobic and panic disorders, seizures, and night terrors and induce muscle relaxation: Ativan (lorazepam), Klonopin (clonazepam), Xanax (alprazolam).

Antipsychotics (Neuroleptics) — Antipsychotics are used to treat psychotic patients with schizophrenia and acute mania. In the non-psychotropic patient they are used to treat Tourette’s or tic disorders: Haldol (haloperidol), Orap (pimozide), Stelazine (trifluoperazine), Thorazine (chlorpromazine), Risperdol (resperidone), Zyprexa (olanzapine).

The therapeutic effect of all medication needs to be evaluated at camp by the health care professional. One needs to be aware of the side effects of giving prescription medication with over the counter medication. For instance, combining stimulant medication with nasal decongestants can cause rapid pulse or high blood pressure. Many children with ADHD become cranky or more hyperactive on antihistamines, like Benadryl. Counselors need to be advised by the nurse of potential side effects they should look for.

All camps should have a prescription drug reference (PDR) and an over-the-counter (OTC) PDR. They may be obtained by asking the camp physician for the last year's edition when the doctor gets a new one. The camp pharmacy probably would be willing to save their old PDR and OTC PDR for the camp as well. There are many other medication resource books available in bookstores and nursing schools.

ADD/ADHD

In the camp setting, children who are on stimulants need to take their medication when it is prescribed to get the desired effect of reducing the behavioral and inattentive manifestations of ADD/ADHD. It is not the medication alone that brings on these desired changes. They don’t cure the disorder, only temporarily control the symptoms. The counseling staff needs to know how to help these campers with behavioral techniques and practical support. Parents and the child are great resources. Partner with them. They know what works at home and how the child copes with problems. Every diagnosed ADD/ADHD child in the school system has an Individualized Education Program (IEP).

The camp director or nurse may want to ask the parents for permission to obtain the IEP from the school. This information might help the camp and the camper with continuity of modifications recommended and used for the child in the school setting.

Children who suffer from ADHD usually have some social relationship difficulties. They may get into fights, disrupt activities, refuse to play fair, have temper tantrums, act impulsively, or withdraw to avoid frustration.

Children with ADD may have selective attention, might choose to "do their own thing," become easily distracted with scattered thoughts and ideas popping into their minds faster than they can keep up, they may be impulsive and act before they think, and may be hyperactive. These children often have low frustration levels, which makes it difficult to "be liked" by peers or make and keep friends. Each child is different. Some do well without medication for a time and others are miserable.

Drug Holidays

The "drug holiday" has become another source of confusion and concern to camp personnel. Some doctors recommend that children be taken off medication now and then to see if the child still needs it. This allows the family to assess the non-medicated child’s ability to use newly acquired behavioral, organizational, and cognitive skills.

Parents, physicians, and mental health workers 
need to be educated about the camp environment.

Another reason to take the child off medication is to allow nutritional and sleep patterns to normalize in order to prevent retardation in growth and development. Doctors often recommend temporarily stopping the drug during school breaks and summer vacations.

The following steps will be helpful in dealing with "drug holidays."

  • Discuss the holiday with parents.

  • Request permission to talk with the family physician about expectations of the child at your camp and the possible need for medication to be continued during this time.

  • Request that medication be sent along just in case it is needed. The parent and physician need to be contacted before the medication is resumed. The documentation as to why the medication was needed is very important.

Parents, physicians, and mental health workers need to be educated about the camp environment. Explain the camp’s daily routine and requirements placed on the child to dress himself, be on time to programs and meals, stay with a group, participate in camp activities, and the need to make choices. The child’s symptoms and the camp routine should be discussed before taking the child off medication at camp. Camp directors should address these issues prior to the beginning of camp.

Other Problems at Camp

In the camp setting, camp directors should be aware of the possibility of undiagnosed emotional problems surfacing. Any camper (or staff member) who attempts self-injury or makes threats of suicide, elicits violent behaviors, or severely withdraws from activities needs to be seen by a health care professional.

The camper’s parents also need to be contacted. This is the time when you need to utilize your health care team’s mental health clinic or medical clinic. Utilize your professional team to help answer any questions on emotional disorders and psychotropic medication.

Web Site Resources

American Academy of Child and Adolescent Psychiatry: www.aacap.org
Mental Health Information: www.mentalhealth.com
National Attention Deficit Disorder Association: www.add.org
American Psychiatric Association: www.psych.org

References
Agins, A. (1998). Teachers’ Drug Reference. Lancaster, PA: Technomic Publishing Co.
Associated Press (1999). Physical differences found in attention-deficit brains. The Cincinnati Enquirer, December 17,1999, A12.
Beers, M. and Berkow, R. Eds. (1999). The Merck Manual. Wightstation, NJ: Merck Research Laboratories.

Colin Herbst, A. (1999). What’s Wrong With Our Children? Parents, 74(9), 108-110,115.

Crowley, M. (1997). Do Kids Need Prozac? Newsweek October 20, 1997.
Ditter, B. (1994). Lifeline and Safety Nets. Newton Centre, MA: little fox productions.
Lishner, K.and Busch, K. (1994). Safe delivery of medications to children in summer camps. Pediatric Nursing, 20, 249-253.
Physicians’ Desk Reference, 52th edition, (1998). Montvale, NJ: Medical Economics Co.

 

Sears, W. and Thompson, L. (1998). The A.D.D. Book. New York, NY: Little, Brown and Company.

 

Myra Pravda, RN, MSN, is president of the Association of Camp Nurses, camp nurse at Camp Livingston in Ohio, and serves on the ACA Ohio board as complaint resolution chair and education committee member. Myra also coauthored the book Off to Camp, and has been a speaker at ACA and ACN educational events.

 

Originally published in the 2000 Winter issue of The CampLine.

 

It's important that all

It's important that all children feel welcomed and accepted at camp. Historically, camps are a place for children to discover themselves, who they are and what they want to be. Having worked with children who struggle with depression, certain camp activities and even service trips can be very beneficial to them. Find ways for them to make an individual difference. When they see their own value it's builds more self confidence and gives a positive self impression.