Checklist for Camp: Bug Spray, Sunscreen, Pills

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.”

Indeed, the Times reports, 20%  of children in sleep-away-camp take asthma and allergy drugs and “about a quarter of the children at camps are medicated for attention deficit disorder, psychiatric problems or mood disorders.” As one camp owner–who does not approve–states “This is the American standard of care now.”

The reporter does not even begin to question the commercial interests that have resulted in this medically inexplicable practice. Concern about this commercially driven health crisis now engulfing America’s children is diffused in this report which gives center stage to one of the staunchest promoters of psychotropic drugs for children:  Dr. David Fassler, a spokesman for the American Psychiatric Association as well as the American Academy of Child & Adolescent Psychiatry, who invariably reassures the public with unsupported claims:

“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.”

However, the cover story of the current issue of Harvard Magazine, “Psychiatry by Prescription: The Myth of Psychiatric Scientism,” by Ashley Pettus, offers much insight by opposing Harvard experts who offer opposing views about the nature and validity of the proliferation of psychiatric diagnoses.

“At the heart of a debate over epidemiological statistics are deep misgivings about the way psychiatry defines and measures mental illness. Despite major advances in the treatment of psychiatric symptoms in recent years, there are still no definitive clinical tests to determine whether someone has a given disorder or not.”

Among those quoted is Dr. Steve Hyman, Harvard University Provost, and Professor of Neurobiology at its Medical School, who served as Director of the National Institute of Mental Health (NIMH), and before that was the Director of Psychiatry Research at Massachusetts General Hospital. Dr. Hyman is a molecular biologist who has specialized in neurotransmitter action–thus, he knows how psychotropic drugs work.

When asked about the level of knowledge about psychiatric diagnoses Dr. Hyman responded:  “We have no equivalent of a blood-pressure cuff or blood test or brain scan that is diagnostic…The DSM IV [psychiatry’s diagnostic manual] has not given us validity…The proliferation of disorders in a single person,” he says, “suggests there is something wrong with the number of discrete diagnoses.”  See:  http://www.harvardmagazine.com/on-line/070647.html

By contrast, Dr. Fassler–who is no expert in the biology of the brain or drug mechanisms of action–invariably offers pharmaceutical industry marketing arguments. But such arguments are not credible;  they derive from pseudo-science:  “Dr. Fassler said that children with one behavior or mood disorder often “have a second or even a third diagnosis.” Dr. Fassler appears to confuse symptoms with diagnoses–underscoring the complete absence of science when children are diagnosed with multiple “disorders” for which they are prescribed multiple mind altering, damaging drugs.

The Times reporter glosses over the body of evidence showing that psychotropic drugs cause severe, debilitating adverse effects–both physical and metnal. They carry FDA-mandated black box warnings for scientific reasons. Instead, the Times merely notes that “some doctors, nurses, and camp directors are uneasy aboutr giving children so-called off-label drugs…”

Dr. Fassler is given ample opportunity to defend the current practice of prescribing psychotropic drugs for children off-label, whereas authoritative critics are not given an opportunity to lay out the harmful consequences of the practice.

By definition if a drug has not been approved for children, it means there is no evidence of its safety or efficacy. Thus, children who are prescribed drugs off-label are put at increased risks of harm. Dr. Fassler’s statement in defense of off-label prescribing–“that doesn’t mean they are inappropriate or unsafe.”– is not based on science and is, therefore, without merit.

The Times fails to report that off-label prescribing is highly lucrative for all the stakeholders involved. But whereas drug companies are legally restricted from promoting the use of drugs off-label, psychiatrists such as Dr. Fassler are not similarly restricted.  Thus, psychiatry’s leadership are serving as industry’s marketing foot soldiers by abandoning medicine’s oath:  “First, do no harm.”
Contact: Vera Hassner Sharav
veracare@ahrp.org

http://www.nytimes.com/2006/07/16/us/16camps.html?
THE NEW YORK TIMES
July 16, 2006
Checklist for Camp: Bug Spray. Sunscreen. Pills.
By JANE GROSS

BURLINGHAM, N.Y., July 15 — 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 Camp
Association, 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.

Copyright 2006 The New York Times Company

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