CHECKLIST FOR CAMP - BUG SPRAY - SUNSCREEN - PILLS

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.