Daring, Decade by Decade

Posted on Jan 19, 2012

Daring, Decade by Decade

William B. Carey ’45 is as relaxed and welcoming as a pediatrician should be. “Perhaps you’d be interested in how one person has had the good fortune of being able to create an interesting life for himself, and how he has managed to be active at it, still, at 84 years old,” says Bill. In Bill’s life, a key idea surfaces during his adolescence, and then evolves. Over time, this idea builds momentum and becomes an organizing force.

Bill Carey is a well-known, much-honored developmental and behavioral pediatrician. The fourth edition of his pediatrics textbook—Bill is the lead editor—was published in 2009. Residents in pediatrics at Children’s Hospital of Philadelphia encounter Bill as one of their mentors. He helps supervise the care these new doctors give to young patients and their families. Bill teaches them how to interview and counsel parents whose children are experiencing behavioral challenges.

Recounting the milestones in his life, Bill demarcates the formative experiences. First in his telling are those over which he had no control. Primary among them is the death of his father, when Bill was four and a half years old. When Bill was 15 years old—in Third Class at Milton, and until then, unaware of how his father had died—he inadvertently encountered the confirming information that his father had taken his own life. Confronting that, Bill plumbed the library books at Milton. “What is manic depressive disorder?” Bill looked for answers. “After my reading,” Bill says, “I was left with the impression that serious things like this might be prevented. It seemed that this is the kind of situation you can do something about. I was left without a father because of unfavorable environmental
circumstances. The thought stayed with me, although later evidence supported a major role for genetic influences in this particular condition.”

Bill remembers Milton as excellent, academically, and it allowed him to blossom. “With the surge of pubertal hormones,” he says, “and with Louis Andrews’s help, I went from a meek, flimsy kid to a bigger, stronger athlete. Milton wrestling had been undefeated for four years, at that point, and I, myself, was undefeated for two seasons.” Howard Abell also deserves accolades from Bill. Mr. Abell’s two-year course in the history of music has been of lifelong value, Bill
points out. “But at that time, Milton did little to help boys develop a sense of who they were, and what they should do with this outstanding education,” Bill says.

From the resident master on Forbes House’s third fl oor, however, Bill had “a unique experience of individual mentoring.” Robin McCoy, a classics faculty member who claimed proficiency in a dozen languages, chatted with everyone on the third floor. A cerebral character, Mr. McCoy “spent lots of time with me, and challenged me and some others to consider our plans for the future.” Having been successful in science and math, Bill had proposed a plan to become an engineer. Mr. McCoy pressed him to keep thinking. He urged Bill to apply the full scope of his abilities, to ask more of himself.

Mr. McCoy’s game-changing strategy turned out to be proffering an essential reading list. “He brought to me a great degree of diversity in my reading with
major works of literature. Plato’s Republic was a must-read, as was Gibbon’s Decline and Fall of the Roman Empire and some classics of Italian literature.” Later, as Bill set off for the Pacific in May 1945, “Mr. McCoy suggested that I read the basic works of Sigmund Freud,” Bill says. “This reading impressed upon me that people were a lot more interesting than machines.”

In December 1944, Bill’s family received word of his older brother Henry’s death at war. One month later, in January 1945, Milton graduated several 18-year-old seniors. Uncle Sam would not tolerate their waiting until a June graduation to go to war. Bill had to decide how to engage in the war. As they struggled with his brother’s death, Bill and his family weighed options, tried to assess the relative risks and benefits among limited strategies. With the hope of ultimately gaining a Naval commission, Bill entered the Merchant Marine rather than be drafted. Retrospectively, Bill labels this move as “his first major mistake.” Compared with his drafted classmates, Bill’s national service was longer; he was exposed to more danger; and the GI Bill of Rights did not apply to him. Further, because service in the Merchant Marine “counted for nothing except temporarily fulfilling your duty,” Bill was shipped, 12 years later, to an Army hospital in Arizona for two years after his pediatric residency, as an “obligatory volunteer.”

During his undergraduate years at Yale, various factors merged with Bill’s growing self-awareness, and netted a decision to pursue medicine at Harvard. Foregoing earlier considerations of neurology or psychiatry as specialty areas, Bill chose pediatrics. Three role models, who had all been his personal pediatrician, defined for him the range of possibility in the practice of pediatrics. Dr. Joseph Stokes chaired the medical department at Children’s Hospital of Philadelphia (CHOP) and helped lead some of the first effective demonstrations of preventing childhood viral diseases such as measles, hepatitis and paralytic polio. Dr. Charles Chapple at CHOP developed the Isolette, the first closed incubator for newborns. Finally, Clement Smith, ultimately of Harvard Medical School and Children’s Hospital, Boston, conducted investigations of the physiology of newborns, and became the “grandfather of modern neonatology,” according to Bill.

“Pediatrics, I discovered, would allow me a preventive role, and that’s what pushed me in that direction,” Bill says. After residency and his “obligatory voluntarism” in Arizona, Bill completed a one-year fellowship at CHOP in behavioral pediatrics, the first ever to be conducted in a department of pediatrics. The fellowship introduced him to the concept that became his research passion: differences in temperament—the largely inborn behavioral style variations that affect how we experience and respond to our environments.

A second “major mistake” put Bill off track for a time. He joined a multispecialty group practice in suburban Philadelphia. It was an “uncongenial practice,” Bill says. He was obligated to see as many patients as possible. He left, and began a more satisfying solo practice in the same town. The vision of combining an active clinical practice with valuable research began to define itself. “The idea that differences in children’s temperaments could affect their behavior, over time, had stayed with me,” Bill says.

During the 1950s, two ”gutsy researchers,” as Bill calls them, had proposed this idea as a research question and began rating infants on nine characteristics of temperament, including such traits as activity, adaptability, intensity, mood, distractibility and attention span. Stella Chess and Alex Thomas believed that the behavioral tendencies they were seeing were “born” into children. There had to be something innate that interacts with the environment and mediates the effects or alters the environment, they hypothesized. Their longitudinal study looked for correlations between traits of temperament and how a child fit into school, or made friends, or related at home.

Bill’s first temperament questionnaire, which sought observations about temperament from parents in his practice, was a “naïve attempt,” he says, “to develop a
psychological test instrument.” A talk Bill gave about his work at Temple University Graduate School surfaced a graduate student eager to work with Bill. Psychologist Sean McDevitt’s energy and interest in the subject, along with his skills, complemented Bill’s clinical experience and available test population. The two revised Bill’s original questionnaire and developed four others. Sean and Bill have been consistent research and publishing partners since. At the moment they are involved with preparing what Bill contends is his ninth and absolutely final book. It’s on behavioral assessment and management for pediatricians in primary care.

At first, this work on temperament drew strong negative reaction from traditional experts. At the time, colleagues in the field reviled the leading researchers and found them “hopelessly 19th century,” according to Bill. “They found me equally so.” The critics’ objected to accepting maternal observations of behavior as evidence. These “perceptions” were either “not real,” or “not adequate,” or both. “This attitude was a considerable obstacle,” Bill points out.

Reactions gradually became more positive, however, and momentum started to grow when Bill used his practice as a laboratory for child development information. “I was motivated by the idea that if parents could understand their children’s temperament—characteristics that we are all born with—then they could adapt their management of their children. You could figure out a better way of dealing with them and reduce bad mental health outcomes.”

Bill’s work on textbooks and research publications brought invitations from all over the world to speak. He addressed audiences across the United States and from Beijing to Melbourne, from Berlin to Buenos Aires. Bill was elected to the Institute of Medicine of the National Academy of Sciences, “an overwhelming experience for a pediatrician in private practice,” he says. He is also particularly gratified to have received an American Academy of Pediatrics’ Practice Award, signifying excellence in research while in practice; and the Academy’s C. Anderson Aldrich Award. The Aldrich Award recognizes significant contributions in the field of child development. Precursors to Bill are a prestigious lot, including doctors Benjamin Spock and T. Berry Brazelton.

The length of Bill’s career has meant witnessing an immense change in approaches to behavioral pediatrics. “Early on,” Bill relates, “everything you saw was ‘due to the environment.’ During the mainstream of my career, we started to correct that view by looking at temperament interacting with environmental factors. Today, far too many behavioral concerns are called brain disorders, although rarely is evidence established for that. We’ve gone from denial that anything is inborn, to the idea that innate temperament reacts with environmental realities, to the concept of a ‘defective’ brain. This latest approach too often takes normal behavior and pathologizes it.”

Throughout the years of his career—and still, as a teacher of young doctors in training—Bill’s driving motivation is the potential to help parents create the most effective family life for their children. His every effort is to help parents in purposeful, informed ways learn to prevent bad outcomes, and ensure robust, happy lives for their children.

CDE