carey1

PRESENTATION TO TEXAS STATE BOARD OF EDUCATION. 11/1/00

By William B. Carey, M.D., of The Children's Hospital of Philadelphia

Introduction

There is a saying that complex situations always have simple solutions, and they are usually wrong. That is certainly true of the present crisis in children's behavior problems at home and at school. Our children's difficulties are complicated and there is no simple solution that fits all or even most of them.
I offer my congratulations to the Texas State Board of Education for trying to make some sense out of the complex issues of Attention-Deficit/Hyperactivity Disorder (ADHD) and the use of nervous system stimulants like methylphenidate (Ritalin). And I thank you for the honor of including me in your deliberations. My position is that I strive for the rational middle ground, which is neither a passive acceptance of the current popular views nor a promotion of any of the radically different theories of causes or solutions.
I am reminded of my most memorable previous visit to Texas in 1957, when I was invited to join the Army Medical Corps at Fort Sam Houston in San Antonio. The training included learning to crawl under live bullets without flinching, a valuable lesson for my later experience in professional life.
Who am I? I am a pediatrician from Philadelphia, who trained at the Harvard Medical School and the Children's Hospital of Philadelphia. Thirty-one years of my professional career were spent in primary care general pediatrics near Philadelphia, and the last eleven as a Clinical Professor of Pediatrics at the University of Pennsylvania and the Children's Hospital of Philadelphia teaching pediatric trainees at several levels about development and behavior. For over 30 years my chief research interest has been the normal temperament variations in children: what they are, and how they matter for parents and for children's health, behavior, and school performance. (I am also co-editor of all three editions of the leading textbook of developmental-behavioral pediatrics.)
What has drawn me to this controversial area of ADHD is the clear evidence that the present academic psychiatric establishment, although unquestionably the experts on major mental illness, are apparently unfamiliar with the broad range of normal behavior in children. They seem to have decided that certain annoying but normal behaviors are due to brain disorders. In my opinion, this confusion is largely responsible for the messy ADHD diagnosis prevailing today.
A clinical example will help to illustrate the sort of problems we are dealing with. A few days ago I saw in consultation at my office a five-year old boy, Steve, whose parents had been told by his preschool teacher that he had ADHD and should be treated with Ritalin. They wanted a second opinion. My review of his behavior revealed clearly that he is not overactive, not impulsive, and not distractible. He does have a challenging temperament, which includes traits of shyness, slow adaptability, and not as sunny a disposition as one might like. About 10% of normal children have this "spirited," challenging, or "difficult" behavioral style, which makes them hard for adults to manage, but it does not fit the existing criteria for ADHD and its presumed brain abnormality. Professional training in education (as well as medicine and psychology) has generally not included developing an appreciation of the wide range of normal behavior, with the result that any traits that a teacher or other caregiver does not like are in danger of being labeled an abnormality suitable for medication.
The basic facts
There does seem to be general agreement among well-informed professionals that 1-2% of the population of children are so pervasively overactive or inattentive that these qualities by themselves get in the way of normal living and make these children very hard for any caregivers to manage. For that small group medication may be a rational choice as part of a larger plan. But even for them it is generally unknown whether the symptoms come from abnormal brains or adverse environments. Such children come from various backgrounds such as families undergoing a variety of stresses, having themselves been born prematurely, exposed to illegal drugs during the pregnancy, or severely deprived in an eastern European orphanage.