Camp counselor Annie Artiga stood in a gymnasium on a rainy morning, jotting down marks on a clipboard as she watched her 10 charges play kickball.
She was not keeping score. She was recording points based on each child's behavior, increasing one's tally for good sportsmanship, subtracting points for another when the girl could not remember the number of outs in the game. The children all have diagnosed behavioral disorders, most with attention deficit hyperactivity, others with a form of autism.
The camp -- the University of Alabama at Birmingham's six-week Summer Treatment Program -- is one of a growing number of programs nationwide that provide intense behavioral therapy for children in a summer day camp setting.
"It addresses a lot of important areas of daily life," said camp director Bart Hodgens, a clinical psychologist at UAB's Sparks Center. "The children are developing social skills, problem-solving skills, academic skills, and we also spend a lot of time on recreation."
According to the National Institute of Mental Health, ADHD affects an estimated 3 percent to 5 percent of school-age children nationwide. Symptoms include impulsiveness, hyperactivity and inattention, and the disorder often impairs the children's ability to function in multiple settings -- including home, school and in relationships with peers.
UAB's highly detailed program addresses those impairments by guiding the 24 enrolled children through a strict schedule of sports, academics and art classes. Before and after each session, staff members lead the children in a discussion about rules for the games, classroom and camp life.
Children receive points for correct answers and maintaining eye contact, among other behaviors. Those points earn the children rewards, such as permission to participate in weekly field trips.
The entire program follows a manual designed by William E. Pelham Jr., professor of psychology, pediatrics and psychiatry at the State University of New York at Buffalo. The comprehensive psycho-social therapy is based on the concept that medication is simply a quick fix for children with such disorders -- and does nothing, in the long run, without behavior modification.
"People are becoming increasingly aware that even though medication is what's tried with most ADHD kids, medication alone is not a sufficient long-term treatment," Pelham said. "There's a lot of data showing that parents don't like to medicate their kids."
Pelham said the demand for his manual -- which includes more than 400 pages of intricate instructions -- has increased significantly since he developed the program in the early 1980s. He estimated that there are about 100 programs across the country -- including the camp at UAB -- that use a version of his plan.
According to ADHD experts, such behavioral therapy programs have proved effective in repeated studies.
"The behavioral interventions, when combined with medication, are really what we consider to be the standard of care," said Russell A. Barkley, a research professor of psychiatry at SUNY Upstate Medical University in Syracuse.
"We often recommend that they be combined," said Barkley, who has written nearly 20 books on ADHD and treatment options. "Many children obviously succeed with medication alone, but the medication doesn't address all of their difficulties."
He praised Pelham's camp and similar programs but said "practical or logistical" problems could limit their growth.
"It has to be in a place where graduate students or advanced undergraduates are available, because they provide very inexpensive labor," Barkley said. "They gain training from the program at very little pay, and the program benefits from having highly educated people who are very motivated."
He said the camps "aren't going to pop up like McDonald's on any given street corner, because the resources needed to keep them affordable are limited."
Even at UAB's university-based program -- with graduate and undergraduate staff members -- the program costs $2,800 for each child -- a sum usually paid by the families. Parents and staff said they hope that camps will eventually lower their price or that insurance companies will pay for the programs.
"I'd like to see more of these kind of camps . . . and have them be more financially within reach," said Vicki Norris, of Birmingham, whose 9-year-old son, William, is returning to the UAB camp for a second year.
She said she hoped for "some type of insurance payment for them, because it makes such a difference in their lives."
Pelham said he modified his treatment program in Buffalo this year to experiment with making the camp more cost-effective, such as cutting the program to four weeks and assigning more children to each staff member.
"Because of the financial problems, we're trying to figure out: How non-intensive can we be?" Pelham said.
But Pelham said that he also hoped for insurance assistance, insisting that companies should more readily offer payment for behavioral therapy as well as medication -- giving parents options without forcing them to "bankrupt themselves."
Norris said she found the camp's points-and-rewards system so effective that she adopted it at home.
"I was actually able to adapt the points system for daily use, and it absolutely changed the way the whole school year went," Norris said.
She said her son had been medicated before starting the camp, but it was the program that became "a life-changing experience for him."
"It gave him back a world of confidence -- helped him develop better techniques for meeting people and approaching people."