* Being a sick kid in the U.S. is always difficult. The worst part, for many of them, is the isolation from peers. Being a healthy school kid in the U.S. isn't always easy, either. Before you decide that a kid with school phobia is "a victim of secret sexual abuse" or has "attention deficit disorder" or whatever's the current fad in psychiatry, remember that today's schools are full of gangs, guns (in some communities, kids reportedly have to carry them just to travel safely to and from school; guns in the schools Arch. Ped. Adol. Med. 151: 360 & 555, 1997, Arch. Ped. Adol. Med. 153: 21, 1999, just before Columbine), bullies (suddenly discovered as a problem: Br. Med. J. 310: 274, 1995; Child Abuse & Negl. 22: 705, 1998; J. Child Psych. 39: 533, 1998; JAMA 285: 2094, 2001; Br. Med. J. 323: 480, 2001; kids who are crippled or otherwise different are singled out for torment), and a percentage of moronic-cruel teachers. Violent deaths at school: JAMA 275: 1729, 1996. The recent celebrated school shootings were by boys who had been bullied (Sci. Am. Sept. 1998; weakling Michael Carneal, who opened fire on a "prayer fellowship" in Kentucky, had been ridiculed, bullied and threatened by members of the group; one "Christian" responded to the boy's cry for help a few days earlier by threatening to beat him up: US News Dec. 15, 1997.) If you have ever gone hungry because your lunch money was stolen, or had your homework or art project maliciously destroyed, or been unable to use the bathroom because you would get roughed up, you can perhaps understand. The Left ("Let's spend a lot of somebody else's money for a course in conflict resolution!" "Differences must be tolerated and encouraged!" "Schools should be a place where values are clarified!"), despite their general interest in finding "victims", have always ignored the bullies. (There is zero evidence that "teaching conflict resolution", the current fad, does any good: Sci. Am. Sept. 1998). The Right ("D.A.R.E."; "I don't think they should teach ANY science until college"; "Schools should be a place where family values are taught") have always ignored the bullies. Doc: Pre-teen won't tell why he's afraid? Ask about shyness in the group shower. Public schools have long been dominated by politics and ideology, so that today, especially in poor communities, teachers have no incentive to teach well, and students have no (or negative) incentive to learn well. In the inner cities especially, longstanding attitudes about education have reduced the schools to mere day-care centers. Of course, this feeds into the cycle of non-achievement and hopelessness that shouldn't be part of any kid's life, but is. Sooner or later, somebody needs to claim "victim" status on a talk show or a sentencing hearing "because I was never forced to do homework as a kid, and now I'm stupid." In the area of science education alone, the impacts of both far-Right and far-Left have made the United States the laughing-stock of the world scientific and educational community. Today, there's even a bureaucratic procedure whenever a student bored into fidgeting because of hours of passive and rote learning gets "recommended for Ritalin therapy" by a teacher. (Ritalin, i.e., methylphenidate, is now known to work in the same way on anybody, whether or not they "have A.D.D."; it enables anybody to stay focused on a boring task, and present estimates are than 10% of U.S. grade-school boys are on the stuff: Br. Med. J. 312: 657, 1996.) I was in grammar school in the 1950s, and I remember left-handed kids being punished for writing with their left hands. That's how stupid and cruel it gets. Since then, I've watched most-if-not-all of our young people's problems blamed (more or less successively) on the international communist conspiracy, teaching evolution, non-conformity, food additives, "elitism", dyslexia and "minimal brain dysfunction", refined sugar, "secular humanism", attention-deficit disorder, all-pervasive-yet-imperceptible vicious racism, cow's milk, multicultural insensitivity, grading students instead of "focusing on building their self-esteem", not teaching radical Afrocentrism, multiple chemical sensitivities, and secret-forgotten sexual abuse. Simplistic (when not totally wrong), and proposed/attempted solutions (which are always part of somebody's political-economic agenda) are just as dumb. The 1990's mandate to remove asbestos from school buildings is now universally recognized as having been a colossal waste of money. And I think most educators today will tell you that today's entitlements for children with special needs have grown far in excess of what is reasonable, and interfere seriously with teaching reading, writing, and arithmetic to the healthy children. From the mid-1980's to just-recently, there was a monumentally stupid fad to ban (not just de-emphasize) the study of phonics and teach reading by word-recognition only (i.e., kids aren't allowed to sound-out words, but must guess what they are from context; this is an dumbing-down abuse of the "Whole Language" model, it clearly explains the sharp rise in U.S. illiteracy in the past ten years, and it finally was banned in California in early 1997; California was the center of the no-phonics fad, and the good citizens of the state were dismayed when it resulted in their children's reading scores plummeting to second-to-the-bottom in the US. I predicted the disaster in 1985. In 1998, even the National Research Council (Feds) came out with a statement that kids learn best if they learn phonics too. During the stupid fad, savvy parents bought phonics packages for home-teaching.) The fiasco in retrospect: Sci. Am. 286(3): 84, 2002. "Bilingual education", long a cornerstone of education in communities with many Hispanic members, is recognized today as having been another disaster. After "Saving Private Ryan", two different teens on two different occasions asked me, "Why were we never taught in school about D-day or what the second world war was fought about?" If it got covered at all, it's not sticking. The perennial desire is for "the schools to teach values", which, if they're not taught in the home and backed up by tough-love discipline, get nothing but lip service (and after-hours ridicule) from savvy children. As a country in which only 17% of us grown-ups say grace with our families at meals, only 33% show up at weekly services, but 80% of us want our children to be taught to pray the classroom, I'd say that we grown-ups are getting what we deserve when 12-year-old kids rob us at gunpoint. You may disagree. As a physician, you are educated to recognize bad science and emotionally-based foolishness. You may wish to take an interest in your local public schools.

Too many textbooks and discussions leave students free to make up their minds about things.

-- Mel Gabler, Texas "conservative" textbook critic

* Regrettably, concern with child abuse (sexual and otherwise) has become the preoccupation of the lunatic fringes (right, left), tending to discredit others who want to do something about this very serious problem. When we come to CNS, we'll discuss the "hypnotically-enhanced memories" fiasco of the 1988-1995 era, in which amateur and pseudo-professional psychotherapists convinced troubled people that their fathers or some other man had molested them bizarrely over many years, and hundreds of families were broken up, lives were ruined, men were sent to prison, and so forth. However, if an activist wants to "find" horrid, weird, secret abuse in a day care center, hypnosis isn't even required. Kids are extremely suggestible, and even "experts" are notoriously unable to agree as to whether a child's story of common-style sexual mistreatment is credible, and what's the future risk (i.e., it ain't a science, folks; Bull. Am. Acad. Psych. Law. 218: 281, 1993). In the contemporary witch-hunt, once one student makes one accusation, some community nut (on the lunatic fringe of the "Christian right", "New Age", "child protective advocacy", "feminist", and/or "recovery" movements) takes up the cause, the rest of the kids are told they are "in denial", and they get grilled repeatedly for months by "therapists" and prosecutors until they "remember". As any doctor knows, the best way to get the truth during an interview is to ask open-ended questions; activist "therapists" typically do just the opposite. Eventually, preposterous, constantly-changing stories emerge ("He slaughtered a giraffe in the kindergarten room" is typical), innocent people are put on trial, lives are ruined, and so forth (New Yorker 10/3/94). There have been over one hundred such trials, almost all of them extremely long and expensive. The prosecutors (who aren't always stupid) may realize it's all rubbish, but must continue the prosecutions for political reasons. The "therapists" always say "Believe the children! Believe the children! You are victimizing them again if you don't believe them!", never explaining why they don't believe the children originally when they say nothing happened. At least one acquitted defendant was murdered afterwards by a vigilante. The same kind of thing happened at the Salem Witch trials of 1692, where 20 people were put to death (19 hanged, one tortured to death) on the testimony of a group of children, ages 5-12. Case law, which is very sane, deals only with procedural stuff, and leaves the decision about the child's testamentary capacity to the judge (Supreme Court White vs. Illinois 1992, Coy vs. Iowa 1988). Children have enough problems with gangs, drugs, crime, and honest-to-goodness abuse (i.e., almost always in the home). We ought to stop coercing them into making up stories of abuse.

* "Family values!" is a positive-inferential term that means many things to many people. As politicians (liberal, conservative) make political capital by decrying Joe Camel and dirty pictures on the internet ("Protect our children! Protect our children!"), around two million kids silently leave home for the streets, or otherwise become homeless, each year (see, for example, Pub. Health. Rep. 108: 150, 1993). On any night, there are at least 100,000 kids living on the streets, separated from their families. Some are "runaways". Many are "throwaways". Most are something-in-between. Almost all are escaping intolerable family living situations (Hosp. Comm. Psych. 43: 155, 1992). Most support themselves on the "street economy" (MMWR 42: 873, Nov. 19, 1993) by panhandling, petty crime, the drug trade, and/or prostitution. (I use the "politically-incorrect" term without apology to the Left. The term "commercial sex work" implies a certain dignity and work-satisfaction that child prostitution doesn't possess. Child prostitution around the world: Lancet 359: 1417, 2002. A large minority of runaways, male and female, turn to prostitution; of course the "academic" literature refers to these kids as "sexually delinquent".) The Right talks about "protecting the family and the authority of parents" and offer no humane solutions whatsoever. (I note with hope the new emphasis of the conservative "Promise Keepers" on not being physically or verbally abusive with your family, while at the same time demanding decent behavior. Newt's orphanages sounded like the best idea so far to me -- ask me why, if you want.) The Left will usually suggest trendy-lucrative "drug, alcohol, and AIDS counseling" and some also offer their brand of political indoctrination. Actual effective help for these kids (who are mostly mistrustful, recalcitrant, and lacking in useful skills) comes from apolitical private individuals and agencies and mainstream religious organizations. There's plenty written about these kids; if you're going to do primary care and/or care about children, spend a few hours at a big medical school library and read up on the problem like I did. Runaways-throwaways tend to come from violent, abusive families in which kids are offered little opportunity for autonomy or individuation (gee whiz, Adolescence 28: 867, 1993). Adolescents are every bit as likely to be beaten by their parents as are younger kids; not surprisingly, these kids are mostly not paragons of virtue and social responsibility, and interestingly, people at protective services are likely to say that getting beaten is the teen's own fault (JAMA 270: 1850, 1993). Abusers typically say, "We / my partner / you spoiled the child." Examined in the cold light of reason, the decision by many girls to run away seems to be itself the result of clear thought and reflection: Adolescence 27: 387, 1992 (i.e., neither the far-Left nor the far-Right, despite all their talking, are willing to actually do anything to protect her from incest or whatever). Suspect incest when a parent (usually the father) is "overprotective" of a child, severely restricting outside activities; often these abusers are big on "family values" and right-wing anti-everything "spirituality". Not surprisingly, street teens are typically unable to read ("thank you, Today's Educational Establishment"), and those who can aren't much inclined to read things, in particular pamphlets on AIDS prevention (Pub. Health Rep., above, gee whiz Uncle Sam.) Government AIDS education projects for street kids seem like a total flop to this reviewer: MMWR 42: 873, 1993 for the statistics; Pub. Heath Rep. above agrees (gee whiz). An elaborate program based on "educational theory" intended to prevent kids from taking sexual risk was a total flop: Br. Med. J. 324: 1430, 2002; so was a massive intervention to educate girls not to get pregnant: Br. Med. J. 324: 1426, 2002 The current ideology in the child-protection business is "Don't break up the biological family; give everybody lots of counseling instead". ("Elisa Izquierdo syndrome"). That means more money for trendoid-counselors and of course less money spent overall; does it work well? Of course not. Adults who beat up children are not reasonable people interested in benefiting from psychotherapy. Children know it's a sham and become bitter. Some workers in the trenches, where it really matters, testify that the current system simply isn't reaching kids in need or doing what it's supposed to do: J. Adol. Health 12: 555 & 576, 1991. There is, of course, no real access to health care for runaway kids, for example, if they're HIV-positive (J. Adol. Health. 12: 504, 1991). One statistic I could not find is how many "sexually delinquent" street boys were thrown out of their homes for "being gay" in the first place (pseudo-conservatism strikes again! -- this is NOT what "family values" means to most of us), but this fiasco is extremely common (J. Adol. Health 12: 515, 1991; homosexual orientation is almost never a deliberate choice, a fact which is ignored by right-wing adults trying to make political capital at these kids' expense. A teenaged boy who believes he is gay often has a choice, particularly in a "conservative moral home", of being ridiculed and beaten regularly by his parents (J. Consult. Clin. Psych. 62: 261, 1994) and suiciding or running away: JAMA 275: 1354, 1996.) It is extremely difficult to provide effective social services for these kids, since they are pawns in the culture war (left vs. right: Child Welfare 73: 291, 1994). Fewer than half of adolescent male prostitutes have had normal sex with a woman (J. Adol. 14: 229, 1991). The pop wisdom that being molested sexually typically has major long-term pervasive adverse consequences is now being challenged (Psych. Bull. 124: 22, 1998) -- when the impact of a crazy home is controlled for, the effect of sexual abuse largely disappears. (This is the famous article that the US Congress unanimously "condemned"; common-sense told me the authors went too far in their rhetoric, even if their data is okay.) This is not to say that sexual contact between adults and children isn't wrong or that it should be treated lightly. It is also part of our world. According to the British, three-and-a-half million "sex tourists" go to the poor nations each year with the specific intent of having sex with children (Lancet 363: 542, 2004 -- Spain cracks down....) We'll briefly review childhood sexual abuse under "CNS", when we talk about the "repressed memories" fiasco of 1988-1995. Reading on victims and perpetrators of the real thing: Br. J. Psych. 169: 408, 1996. Sexual behavior in children includes a considerable amount of exploring, and not everybody agrees about how much of this is wholesome (Child Abuse & Neglect 22: 289, 1998). The current definition of "sexual abuse" seems to include simply getting flashed once, or shown dirty pictures once, or even showing it to an older kid who asked (Br. Med. J. 312: 1326, 1996); under these definitions, 10% of boys are sexually abused and 33% of girls are sexually abused, and these numbers seem to hold up internationally. (The horrendous adult misbehavior that most of us think of when we hear the words "sexual abuse" is far, far less common, thankfully.) Kids running away from insufferable homes are, of course, nothing new. If you haven't read "Huckleberry Finn" or the novels of Charles Dickens, do so sometime. In the poor nations, children are simply left even in the most atrocious situations (J. Urol. 160: 1116, 1999, young boys are returned to families that just cut their penises off); otherwise they would starve. In 2003 (Lancet 361: 1196, 2003) Brazil suddenly discovered that its huge number of homeless kids include child prostitutes and promised they will all stop being prostitutes by 2004.

* Nowadays, "Huckleberry Finn syndrome" refers to a person of substantial natural abilities but little direction or ambition, supposedly as a result of neglectful or abusive parents. The theme of the novel is that a child from a trash background is nevertheless wiser and morally superior to the "sivilized" folks who even he feels are his betters.

* Loathsome teenage ideas (racism of all varieties, silly-disgusting occultism, right-wing and left-wing demagoguery, proud do-nothing bitterness and bad-mouthed entitlement, live-fast-die-young, amoral pseudo-mysticism, and glorification of weird sex, death, and violence; have you visited your local music store lately?) are supposed to provide a focus for peer groups that are "a substitute for caring parents and other figures that these youngsters can look up to..." and so forth. They also deal directly and explicitly (though I'd say badly and foolishly) with issues that parents have learned not to speak about. I believe this is substantially correct [abstract 92376240; from Germany, where they talk more bluntly, I guess]. Kentucky teen vampire cult: Child Psych. Hum. Dev. 29: 209, 1999. Kids who commit genuine hate crimes don't belong to grown-up hate groups (Am. J. Psych. 160: 979, 2003).

* The neuropathology of attention deficit disorder, in which the kid can't concentrate or focus, is being worked out; the current work focuses on the caudate and its frontal lobe connections, which have to do with the ability to pay attention (Am. J. Psych. 151: 1791, 1994). It appears to be autosomal dominant with variable penetrance. One locus might be the dopamine transport gene DAT1 (Am. J. Hum. Genet. 56: 993, 1995); dopamine transport is inhibited by methylphenidate and amphetamine, which help attention deficit disorder. This writer believes this is a real entity (you can tell, because the kid can't focus on play: Br. Med. J. 311: 72, 1995), amenable to therapy with sympathomimetics (or try the few-foods approach: Arch. Dis. Child. 69: 564, 1993; JAMA 293: 1871, 1995). The writer also wonders what ever happened to kids who are disruptive simply because they are undisciplined, or unproductive because they lack guidance (no $ in diagnosing this, I guess, and somebody might get offended and boohoo to the judge). Tartrazine yellow, long considered an exacerbating factor by mothers and the tabloid press, might really make these kids worse: J. Ped. 125: 691, 1995. Before you diagnose "attention deficit disorder", I trust you'll rule out hearing problems, vision problems, lead poisoning, a chaotic home, and lack of discipline. Good luck. Likewise, by the mid-1990's, learning disability were diagnosed in 3 million U.S. kids, typically on the basis of academic performance staying below measured IQ. The kids then get special treatment. This writer believes learning disabilities are real, but wonders what happened to kids who are lazy, unmotivated, or unsupervised by their parents. Such kids, if they exist (ha ha) would meet the above criteria for "learning disabled", but there is no $ in diagnosing this, I guess, and somebody might get offended and boohoo to the judge. Even Science 267: 1896, 1995 is with your writer on this; in the years that followed, the literature started getting more sensible, and limiting the term "learning disability" to what we used to call "mental retardation" (Lancet 362: 811, 2003), affecting 1.5-2% of the population. We'll cover pervasive developmental defect ("autism", "Rain Man") under "CNS"; it's entirely a wiring problem and anyone who tells you otherwise is ignorant.

* As a family physician, you should see a teen who wishes to be seen without the parents' knowledge. Don't expect to get paid, Doc. Further, you're damned-if-you-do, damned-if-you-don't because of confidentiality issues (Curr. Op. Ped. 5: 395, 1993). Of course, if there's an anti-abortion tell-the-parents snitch-law in your state, and this applies to the teen's problem, you need to let the teen know. Your lecturer, who objects to abortion under most circumstances (and who recognizes and respects the fact that many people disagree with him), would take the anti-abortion militants more seriously if they also wanted to make contraception more available to teens -- some girls, especially in very bad neighborhoods, truly have no choice. Approach to the kid who is supposedly sexually abused: South. Med. J. 87: 1242, 1994.

* Shakespeare's "Romeo and Juliet" may have been spoiled for you as required reading in high school, and/or by parodies of the balcony scene and/or a bad (left-wing, right-wing) college "Western Civ" course. Think: The play's about godawful teenaged murder-suicide. (Juliet is 14, Romeo 16.) Shakespeare's plot-source was a warning to teenagers to obey their parents. The themes of the play, which were pretty-much new with Shakespeare and very radical in his time, are (1) young people ought to be allowed to marry for love, not just whoever their parents choose for them; (2) young people's tragedies likely result from their parents' stupidity and meanness; (3) love matures people, and gives dignity, meaning, and beauty even in the worst of circumstances. By the way, did you notice that Papa Capulet is an old guy ("past [his] dancing days", thirty years since he was "in a mask"), but Mama Capulet is was pregnant with Juliet at age 13 . In other words, she was the old lecher's forced child-bride and she is setting up the same thing for Juliet.