


Dr. Koplewicz is married and is the father of three sons.

Q.What is the most common psychological disorder of childhood and adolescence?

A. Attention deficit disorder. It's somewhere between 3 to 5 percent of the population. That translates into millions of children. I think that the next highest group consists of some of the anxiety disorders such as separation anxiety disorder, which translates into school phobia. Also very common now is obsessive-compulsive disorder, which occurs in as much as 1 out of 100 children.

Q.Are those increasing?

No. I think the identification of these disorders is much improved, and because of that we're hearing a lot more about them. But if we think back to our elementary school days, there were kids who couldn't sit still. We called them bad boys. There were girls who were very quiet in school, and we thought that they were stupid. If you took the time to really get to know them, they were incredibly bright, but they were nervous wrecks.

I think that in the past decade the diagnoses have gotten better, and I think that it's amazing that certain books have helped us. Judy Rappaport's "The Boy Who Couldn't Stop Washing," about obsessive-compulsive disorder, brought this disorder out of the closet to the point where we've destigmatized it.

That's one of the reasons why I wrote my book. I was hoping that it would destigmatize and change people's attitudes to understand that their kids are not bad and that it's not bad parents that cause psychiatric illness.

Q. Do you agree with a professor emeritus of biology at Harvard, Dr. Ruth Hubbard, who wrote in her book "Exploding the Gene Myth" that placing too great an importance on genes may neglect environmental, social and economic factors?

A. She's absolutely right. It can be a copout to say that if it's in the genes that there's nothing we can do about it. While we know that it may not be anyone's fault, there's certainly the responsibility to do something about the kid's problem. That's where environment and parenting can exacerbate the problem or help us to diminish the problem.

We know that an enriched school program that addresses the kids' deficits and assets is a big help. You can't underestimate all of the environmental and psychosocial interventions that can play into this.

Q. Do you engage the parents in the child's therapy?

A. I think the parents are essential. But that doesn't mean that kids aren't allowed their privacy. They should be able to tell things to their psychiatrist without the fear that he'll share every confidence with the parents. Kids also have to know that their parents are a part of the solution.

Q. How do medications like Ritalin and Prozac help children?

A. What really strikes me is that years ago, when I was in pediatrics and a child came in with a red throat, I would prescribe antibiotics. We never looked at the culture. We decided by the response whether or not the child needed it. We gave medicine out all the time, and no one called it "drugs."

Now, when I give medicine to a child because of behavioral symptoms, it seems there is a bias against this. Just because the symptoms are behavioral doesn't mean it's within the child's or the parents' control. It isn't the parents' fault and it's not the child's fault. And if it's not their fault, then to deny them medicine, I think, is unfair.

People worry that these are chemical straitjackets that are not getting to the root of the problem. They say the child has a disorder because the parents got divorced or were neglectful. But there's no evidence that divorce or working moms cause psychiatric illness. That may have an effect on children, but they don't cause psychiatric problems.

q. Why is it believed that Ritalin has become a recreational drug?

A. It's unbelievable how that happened. Ritalin doesn't cause euphoria. Amphetamines cause you to become euphoric. If I gave someone a tablet of Dexedrine, pure speed, not only would they have more attention, but their mood would lift and they would feel somewhat expansive and grandiose.

Ritalin makes you feel more focused and less distracted from noise, but it doesn't give you a rise. It's not a great illicit drug, but now it's got a name. I honestly believe that will pass because it doesn't give you that sensation.

Q. Why are more boys than girls given diagnoses of attention deficit disorder?

A. I think there are more boys in general who have psychiatric illness. If you look at the kids under the age of 12 in this clinic the overwhelming majority of these are boys who are suffering from everything from obsessive-compulsive disorder to disruptive disorders and conduct problems. But when you hit the age of 12 you have a lot more girls with trouble such as depression and anxiety.

I think there are definitely gender differences. Maybe when girls get attention deficit disorder without the hyperactivity, we tend not to pick up on it, because they don't make noise and they're not disruptive.

The other issue is that brain changes go on during adolescence that clearly must have some effect on girls. I think there are societal reasons, brain differences and a difference in the way a disorder can present itself in a girl versus a boy.

Q. Do you think it would be better for psychiatrists instead of pediatricians to prescribe Ritalin?

A. I think the diagnostic evaluation of a child who one suspects of psychiatric, behavioral or emotional problems should be done by a child and adolescent psychiatrist. There's a certain expertise that we have in the diagnosis of these disorders. Also, by the nature of the practice pediatricians see kids for very brief periods of time.

You hear that so many children receive medicine after a teacher makes a complaint, and no child psychologist or child and adolescent psychiatrist has seen the child. There's more than one reason why someone could be hyperactive. There's definitely more than one reason why someone could be inattentive.

Q. What do you think of the statements in "The Myth of ADDS" by Dr. Thomas Armstrong that many children are medicated for school-related problems, that those children are processing information differently, that they are bored by the slow pace and that their symptoms disappear on vacations?

A. I think that if we took the average kid who had ADHD back in the past they wouldn't go to school. In the 1890's you would apprentice this kid out to a farmer, and he'd make a fence or ride a horse. He'd have a lot of novel experiences, and that would make him feel better. But we're not going to teach him how to read, and we'd certainly have trouble giving him math skills, because he'd be moving around so much.

These kids do well when you put them in front of a video screen or when you put them in front of a television. But that's a different kind of attention. If you have a dramatic superhistrionic type of teacher in a small class, that teacher will hold the attention of these children.

In school it's the child's requirement to force his attention up, even though it might not be all that novel or seductive or arousing. The child is still forced to watch the teacher write on the board. It's very easy to say that the teacher isn't good enough. But that's not the case. There are 25 kids in the class, and the teacher has to teach. It's impossible to keep the kid aroused all the time. The kid has to have self-arousal, also.

Q. What about the side effects of medications like Ritalin?

A. A very important part of using medicine to help kids with brain disorders, I think, is educating the parents. The majority of medications have nuisance side effects and very few serious side effects. Most of the nuisance side effects go away with time. They can keep kids from taking the medicine, because if the child constantly has a dry mouth or if he is having trouble falling asleep or if he is losing his appetite, the child will say, "The pills don't make me feel good."

Kids who take Prozac very frequently seem to feel energized or have some kind of disinhibition. If that happens we clearly are not going to give them the medicine at nighttime.

Q. What do you think of dietary approaches like the Feingold diet?

A. The fact is that the Feingold diet has never been tested in a controlled way. While you have lots of parents giving testimonials, to date we haven't been able to prove that it's better than a placebo.

So one would say if it doesn't hurt them, how can it be harmful? It will be another failure for the child. It can be costly for the family and it takes a lot of energy.

That also goes for biofeedback. There's a huge amount of Long Island hospitals that do biofeedback with kids who have ADHD, saying that it will lower the dose of Ritalin. It seems to be very irresponsible. Without any proof that this is true, parents are spending hundreds of dollars on these treatments, taking their kids out of school or out of after-school activities to go there, and I think that has a cost.

The same thing could be said about psychotherapy. Everyone thinks it has no adverse symptoms. I beg to differ. While psychosocial interventions are important, psychotherapy should only have its place when it has efficacy.

Q. Are there any physical tests that can indicate whether a child has a psychiatric disorder?

A. No. Right now we still don't have a blood test or a brain scan to tell us if a child has something as common as depression or attention deficit disorder.

Q. What is your greatest challenge as a child and adolescent psychiatrist?

A. I think it's when I have to tell parents that their child has a disorder that has a poor prognosis. The other part is when I have to tell parents who can't hear that anything is wrong with their child. When I give them the bad news, they want to kill the messenger.

The most frustrating part is when I tell someone that there are a lot of things that we can do, but the idea that their child might have to take a pill makes them so defensive. That's when I feel like a terrible failure. They've left the office because they don't like the news and they're going to try to find someone who will tell them what they want to hear. Meanwhile the child is not going to succeed and is going to suffer in school.

I think the biggest challenge is getting parents not to feel guilty and to focus on the child's problem -- and not their own reactions to it.

Photo: Dr. Harold Koplewicz at Schneider Children's Hospital. (VicDeLucia/The New York Times)