In this episode of The Committed Innovator, McKinsey innovation leader Erik Roth speaks with the founder, president, and medical director of the Child Mind Institute in New York City, Dr. Harold Koplewicz. At a time of increasing concerns globally about child and adolescent mental health, the organization is working to use advanced imaging technologies and AI to help revolutionize diagnosis and treatment of psychiatric illness and psychological and learning disorders. This is an edited transcript of their discussion. You can listen to the full episode on your preferred podcast platform.
Erik Roth, McKinsey: Welcome back to another episode of The Committed Innovator. We are so pleased to welcome Dr. Harold Koplewicz to the program today. Dr. Koplewicz is the president and medical director of the Child Mind Institute in New York City, an organization he founded over ten years ago that’s dedicated to transforming mental healthcare for children globally. Dr. Koplewicz, tell us about the Child Mind Institute.
Harold Koplewicz, The Child Mind Institute: We are an independent nonprofit with a very big mission, which is to transform the lives of children and adolescents who struggle with mental health or learning disorders. We do that by looking at care, science, and education.
Erik Roth: Usually every great innovation starts with a valuable problem to solve. What problem is the Child Mind Institute solving and why is no one else doing so?
Harold Koplewicz: The scope and seriousness of the problem being left unsolved have been something the world has had trouble wrapping its arms around. The most common illnesses of childhood and adolescence are mental health disorders. In the United States alone, one out of five kids will struggle with one of these disorders, which means that everyone knows and loves one of these kids. And yet, 70 percent of counties in the United States do not have a single childhood or adolescent psychiatrist. Even more upsetting is the fact that it takes, on average, eight years from the onset of symptoms of a behavioral or emotional disorder for a child to get seen by a clinician.
Because of a lack of resources, the problem with stigma, and the misconceptions and distortions about how real, common, and treatable these disorders are, we now have what is truly an epidemic of childhood and adolescent mental health problems, which have only been made worse by COVID-19.
Erik Roth: What was the inspiration that led you to start the institute?
Harold Koplewicz: I had been a child and adolescent psychiatrist for over 40 years, and have been very fortunate to have served a number of the larger child and adolescent psychiatry organizations in the United States. Typically these psychiatry departments are financially costly for medical centers, and because child psychiatry is a cost center, the ability to innovate is limited. The focus is usually limited to “See patients, train the next generation of child psychiatrists, and do some research that hopefully is federally funded.” Working to lift the stigma or educate parents and pediatricians to promote early intervention isn’t really possible within that focus. So we had to think out of the box if we’re going to take on this very important problem.
Erik Roth: It sounds like what you’re saying is that you believe the system is effectively failing our children in many ways if it’s not equipped to identify and treat these common disorders.
Harold Koplewicz: You’re 100 percent right. Also, we don’t have enough providers, we lack people who understand what evidence-based care is, and we don’t have parents, educators, or even pediatricians who are able to recognize the signs and symptoms of these disorders, which are always easier to treat when the symptoms are newer than when they’re chronic. On top of that, the child mental health system has always been two or three steps behind the rest of medicine. For example, one of the major things we don’t have in child mental health or child psychiatry is an objective test. In other areas of medicine, we have blood tests, X-rays, or genetic tests to identify objectively when a child has one disorder versus another. We do not have that in child and adolescent mental health.
Erik Roth: You mentioned evidence-based care. What is that?
Harold Koplewicz: Historically in the United States we have been overwhelmingly influenced by the work of Sigmund and Anna Freud, who did their work in the 1930s and 1940s. They put forward the idea that there’s an unconscious. So adults are really talking to themselves when they’re dreaming, and so those dreams are very important. They believed the psychiatrist should listen to patients’ accounts of those dreams to understand how an adult patient could be more intimate, ambitious, and productive in life. That type of treatment was meant for adult patients who are depressed or anxious or who have eating disorders. It’s the same treatment for all those disorders.
Today that field of thought has moved to more evidence-based care: behavioral therapy, cognitive behavioral therapy, and dialectical behavioral therapy. When we do psychoanalytic therapy on kids, we interpret their play, rather than their dreams. And again, it’s the same approach whether the child has ADHD, adolescent depression, or separation anxiety.
Although there have been dramatic advances in recent years in talk therapy and what we think really works, it’s impossible to have one treatment modality that works for multiple diseases. And it’s impossible to determine the right treatment modality without the right diagnosis. Without a diagnosis, you can’t have treatment. This again is where the science needs to move forward—we need diagnostic tools for child and adolescent mental health. This is our focus at the Child Mind Institute.
That’s what we need. That’s the breakthrough we’re looking for—a test that can tell us this kid has ADHD and this kid has depression and this kid has anxiety disorder. And maybe the intervention is a pill, or it’s psychosocial, but just think how relieving it will be for a parent to hear that there’s a definitive, objective test before they go on the treatment journey.
Erik Roth: With that as your problem to solve, how did you think about structuring the institute?
Harold Koplewicz: I spent a lot of time looking at other models of healthcare innovation. I’ve always been struck by the fact that childhood cancer, which affects about 15,000 kids a year in the United States, versus 17 million kids who have a mental health disorder, has always gotten more respect and certainly more funding and rigorous research than something as common and real and sometimes as lethal as mental health disorders.
One of the first models I visited was St. Jude Children’s Research Hospital in Memphis, Tennessee. The organization is independent and nonprofit, they only have 73 beds, and yet they have thousands of people doing research and clinical care. If you don’t have insurance, they’ll treat you for free. They’re a real machine that has helped change the way Americans think about childhood cancer. Because the organization is independent, they were able to put a laser focus on pediatric leukemia, and they changed the outcomes. It used to be 94 kids out of 100 who would die. Today it’s four out of 100. That kind of model seemed to be something worth exploring.
I also spent time with the people at [The] Michael J. Fox [Foundation], who have changed the way we think about Parkinson’s, and also with the people at Autism Speaks, which started with a set of grandparents who changed the way America thinks about autism and fundraised to produce more research. We thought that if we built on those models, we could tackle child mental health disorders and learning disorders.
That was the first step. We wanted to provide treatment that was more innovative, looking at improvement over time, determining the different desired outcomes for different diagnoses—not just a kid coming for talk therapy the same time every week regardless of whether improvement was occurring.
Erik Roth: Talk about how the fundraising side works for the Child Mind Institute, given that it relies in large part on public perceptions. The categories of illnesses you treat are often difficult to identify, and there is stigma to work through, even though, as you said, everybody probably knows somebody with a child who is suffering.
Harold Koplewicz: One of our first partnerships that made a significant difference was with Bloomingdale’s. Every Christmas they advertise that for each teddy bear they sell, they give $5 to a charity. The fact that they were willing to let us be a recipient charity in our first year was exceptionally important. We didn’t sell out the teddy bears that year, though, so I told Bloomingdale’s I would buy all the remaining ones because I didn’t want them to leave us. The CEO at the time, Michael Gould, to his credit, stuck with us. He put us in their catalog and gave us a store window at Christmastime and spoke about us—“We’re so proud that we’re partners with the Child Mind Institute.” Then the next CEO, Tony Spring, added on by deciding to offer customers the option to round up their change to support the Child Mind Institute between Thanksgiving and New Year’s. He did that again in May for Mental Health Awareness Month. And when the current CEO, Olivier Bron, came on, he vowed to continue this support, saying, in essence, “We want to lean even deeper into this partnership because we think the work you’re doing really does help parents because it helps their kids.”
It was important that a brand so much bigger and better known than us was willing to partner. And by the way, that was very courageous. No other national brand was embracing children’s mental health or even mental health, for that matter. That was an important accomplishment in the very beginning.
Erik Roth: Let’s shift to the delivery of care. You mentioned early on that it’s multifaceted in the sense that you need to educate educators and parents and a whole variety of different constituents around a particular child. What strategies does the Child Mind Institute use to touch all of those different, important stakeholders?
Harold Koplewicz: The fact that we have to do that is what makes child mental health different from something like cancer, where, as we said, the disease presents itself. Even before COVID-19, we had a very large school and community program to train mental health professionals in schools, educate teachers and pediatricians, and run many parent education programs. Our goal was to make our first line of defense much smarter and better at identifying children with issues as early as possible.
Then when COVID-19 came, we had to figure out how to take this to scale when schools are closed. How do we help these kids get back to school after being out of school? How do we make them more resilient? Or how do we show them they have the resilience to be able to do this?
I’ve always thought about the fact that when I was in school, we didn’t have physical fitness as a requirement until President Kennedy started the Presidential Fitness Test. So we came up with Healthy Minds, Thriving Kids, a program to help teachers teach kids critical mental health and coping skills.
The eight essentials of innovation
Erik Roth: You’re both a clinician and an entrepreneur in the sense that you’re delivering care still to this day and you’re building this organization. How do you balance the two?
Harold Koplewicz: I have to tell you, I would become a child and adolescent psychiatrist in a New York minute all over again. A lot of my colleagues who are in different fields of medicine have retired or want to retire and feel too controlled by managed care. But I have the ability to change the trajectory of a child’s life if I can get the diagnosis right and get them on the right treatment so that their lives are much fuller and more productive. I continue to see those patients. Also, the kids make it very hard for you to become too pretentious or arrogant because they call you out as soon as you tell them anything that doesn’t smell like the truth.
I spend the rest of my week doing clinical administration, a tremendous amount of fundraising, and working on a lot of partnerships. The fact that I work with governors is not something a typical child and adolescent psychiatrist would do. If I was at a big academic center that’s a $2 billion or $3 billion enterprise, they would not want me doing these things, and would tell me to stay in my lane. But I see these activities as being part of the larger picture. My lane is child and adolescent mental health, and working with governors is part of what I do. We are working with a number of states on how to do statewide collaborations to start looking at mental health skills before a child ever becomes ill.
I’m still optimistic that we can tackle these sets of disorders. I’m old enough to remember when I went to Sunday school that they threw all of us into the back of a station wagon and there weren’t any seats there, let alone seat belts. And I was around before AIDS was called AIDS, when it was called GRID, gay-related immunodeficiency, and men were dying left and right and we seemed stuck. Robust science has changed outcomes in so many areas like these, so I am very optimistic we can do that for child and adolescent mental health. I just think it needs innovation, and people who do open science to share the results so that we accelerate discovery. It means you have to figure out new partnerships with people you didn’t think were your partners. Pediatricians make sense, of course, but governors are really essential.
Erik Roth: Where do you think the breakthrough might come from? Is it in the data and the next generation of technology? Will generative AI or other analytics find something that hasn’t been discovered yet?
Harold Koplewicz: We believe it will. Our chief science officer, Michael Milham, helped start our initiative called the Healthy Brain Network, which has built an open database of more than 7,600 children that contains MRIs of their brains, EEGs, and other data. We have so much data that we haven’t even analyzed all of yet, so the fact that we now have AI and that it’s an open database will most likely accelerate the research.
For example, just by looking at MRIs we can tell you the difference between 100 kids with ADHD and 100 kids with autism and 100 kids who have both ADHD and autism. But we still can’t tell you just by looking at one scan what a kid has. And that’s the holy grail. We are looking to develop something like the strep throat test—you take the strep test, and either you have it or you don’t, and if you do, you take an antibiotic and it disappears. That’s what we need. That’s the breakthrough we’re looking for—a test that can tell us this kid has ADHD and this kid has depression and this kid has anxiety disorder. And maybe the intervention is a pill, or it’s psychosocial, but just think how relieving it will be for a parent to hear that there’s a definitive, objective test before they go on the treatment journey.
Erik Roth: One of your goals is to help reduce stigma around mental health challenges. How is that going? What is stopping us as society from tackling the children’s mental health crisis?
Harold Koplewicz: COVID-19 has been a driver of both the problem and the discussion about the problem. Because so many school-age children suffered so much during the lockdowns and this has been an ongoing issue since then, most everyone is willing to talk about their kids’ mental health. But we are still fighting the larger problem of getting broader society to focus on children’s mental health as a problem that affects us all. I think there are a few reasons for this. One is funding for research. For example, the National Institutes of Health (NIH) gives the National Institute of Mental Health (NIMH) about $1.5 billion a year to do research. Out of that, the National Institute of Mental Health decides how much it wants to spend on what type of research, which can include areas such as Alzheimer’s or schizophrenia or depression. Typically about only $240 million of that money goes to child and adolescent mental health disorders. Considering that 75 percent of all mental health disorders occur before the age of 24, and that 50 precent of them occur before the age of 14, I think child and adolescent mental health should get at least half of that $1.5 billion the NIH allocates to NIMH.
I also think the lack of funding research is tied to kids being unable to vote. In that sense, Alzheimer’s is definitely going to trump ADHD, even though ADHD puts you at risk for going to jail, using substances, teen pregnancy, increased car accidents, more divorce, et cetera. And consider that depression puts you at higher risk for suicide, suicidal behavior, more aches and pains, and higher doctor bills when you get older. Also, as a society we’re quick to label kids as lazy, crazy, and stupid, or to blame their problems on bad parenting, instead of recognizing how real these child and adolescent mental disorders are.
Erik Roth: The way the healthcare system is set up doesn’t focus much on prevention as perhaps it should in these types of cases.
Harold Koplewicz: I don’t think there’s any prevention. I think we’re getting better with some things, such as understanding the risks of obesity. We all know now that secondary cigarette smoke is bad for children. And we we put seat belts on them because car accidents are the leading cause of death for young people. Except for the Healthy Minds, Thriving Kids program we have going in two states, we don’t do prevention for child and adolescent mental health. And yet mental health problems affect 20 or 30 percent of the population. Mental health fitness is just not part of our dialog yet. It’s getting better—the fact that [the actor] Emma Stone talks about her anxiety, that [California Governor] Gavin Newsom talks about his dyslexia is good, but we’re not there yet.
Erik Roth: Do you want to share a success story from the Child Mind Institute?
Harold Koplewicz: One case that comes to mind immediately is of a young person who is about to start at one of the more prestigious music schools, about four years later than one would normally start college. The patient had lots of behavioral symptoms as a child, including being disobedient, oppositional, and defiant. He was misdiagnosed several times, and sent as a preadolescent to a residential treatment program. Some of his treatment seemed to make some sense given his behavior—being in a treatment setting with lots of rules and regulations, and having consequences for behaviors. One way or another he came to see me, and through both paper-and-pencil testing and clinical evaluation we were able to determine that the patient has a form of autism, which had been overlooked. The treatment has been slow, involving medication for certain symptoms that make it difficult for the patient to focus, and an educational system that can recognize how he learns and understand the symptoms that interfered with functioning.
It has been a long haul. But he is now able to enter a highly competitive college program where he will be studying music composition. I think the real change for him is getting the right diagnosis, which allowed a more personalized treatment that was more effective. Just today he showed me what his new apartment looks like. The fact that this young person is living independently and will finally start college can’t be more gratifying.
Erik Roth: How many children has the Child Mind Institute treated since its inception?
Harold Koplewicz: Our direct care has reached kids from 49 states and the District of Columbia, as well as from 45 nations. More than 25,000 children have come to see us. Our research programs and school and community programs have reached over two million kids. Our Healthy Minds, Thriving Kids program reaches 73,000 educators, and they in turn have done work with 1.8 million kids. We are working to expand that; we are training teachers and pediatricians in child mental health basics so they can recognize when a kid is in trouble. This year we’re teaching psychologists and child psychiatrists evidence-based interventions. What are the things we know work? And how can we get a kid in and out of the office as fast as possible? There are so many better things a kid can do besides seeing a doctor. If we can make sure their symptoms are decreasing, they’re functioning, then I’d rather they take ballet class, play baseball, hang out with their friends.
Erik Roth: What are your goals for the future of the Child Mind Institute?
Harold Koplewicz: I am really focused on making the Child Mind Institute more financially sustainable, and on becoming a gold-standard provider. Should there be a way to certify that a clinician has the necessary training to provide evidence-based care, and if so, do we have a role in that? We’re looking carefully at what we do and figuring out what is absolutely essential to our mission. How do we make sure that we will win, that we will be successful? I’m optimistic because I think there’s an inflection point right now—something has happened. I think it’s because of COVID-19 that people are willing to talk about child and adolescent mental health. It’s not only Bloomingdale’s that is talking to us; there are another 15 or 20 nationwide corporations that are willing to talk to us at the Child Mind Institute and potentially help us get the word out about how real, common, and treatable these disorders are.
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