Exclusive Interview with Dr. Harold Koplewicz, CEO, Child Mind Institute
Transcribed by Marissa Schain
Education Update caught up with Dr. Harold Koplewicz, president of the Child Mind Institute, to discuss the latest issues in children’s mental health care and what makes the Institute an unusual center.
Dr. Pola Rosen (PR): What is the mission of The Child Mind Institute?
Dr. Harold Koplewicz (HK): We’re a relatively young organization. We just celebrated our first anniversary. We have a very big mission. Our mission is transform mental health care for the world’s children to fulfill their full potential. In this country alone we have 50 million children who have a real psychiatric disorder and less than half of them get help. We want to change the way we deliver the care, how we identify these kids who have these problems, and we want to improve the treatments. We want to improve the treatments that are out there and also find new treatments so that kids can really do well at work, which is school, at love, which is most of the time with their family, and at play which is hobbies or sports, or activities with their friends. What every parent wants for their child is to have full lives.
PR: How do you plan to do identification?
HK: Diagnosis in child mental health is still being done the old fashioned way, which is taking a history. In medicine, history taking is clearly the most important instrument we have. If you’re speaking to a man in his 50s who has pain in his chest that is radiating down his left arm, you are concerned it might be some heart attack, some kind of myocardial infarction; the muscle of the heart is not getting the right blood supply. There are many ways we can test the hypothesis because we have instruments that can take pictures of the heart. We have ways of looking inside the heart. We are getting there with the brain and what we are looking for is a new way of making these diagnoses.
We started the Healthy Grain Network. It’s the idea of taking 10,000 kids and putting them into a functional MRI, which is different than a structural MRI. It is an imaging machine that can tell you how the brain is functioning. We have figured out that if you let a child stay at rest, the brains of kids who have ADHD [attention deficit hyperactivity disorder], or have autism or have anxiety, the brain talks to itself differently than a typical child. When the brain is at rest, we can see some real differences. If we can get thousands of kids across the world, to lie in a machine and get these kinds of pictures, this would be the equivalent of what the growth charts are like when you go to a pediatrician. We need to do that to the brain. Then we have to find a group of kids who have disorders and see how their brain development is different in the development than typical kids.
PR: Will this change the face of mental health care?
HK: This is truly going to be a game changer in many ways. We are trying to encourage our scientists to break down asylums. Traditionally you would have a scientist at Columbia, or someone from Harvard who wouldn’t share their data until they had published it. We want a group of scientists who are part of our scientific research council from ten different institutions with expertise from many different areas to be able to collaborate with each other and to be able to put their data online even before they use it, so we can speed up the process.
In many ways child psychiatric disorders is the last frontier. If you think about heart disease, 30 years ago people, who had a heart attack, became cardio cripples. If they survived they were never the same. Today with stents, with new medication, with bi-pass surgery, we can really change the world.
We haven’t been able to do that yet with psychiatry. We also know that 75 percent of serious psychiatric illness occurs before the age of 24, 50 percent before the age of 14.
The biggest bang for the buck that we can get is finding treatments that will work on kids early.
PR: Will there be financial benefits for the nation if you treat symptoms and illness early?
HK: I think truly while child psychiatric illness is misunderstood; there are many myths about it. It doesn’t really make a difference what your political affiliation is. This is good for our nation.
Whether you are a liberal who cares desperately about the good of children’s lives, mental health is good for our children. They’ll do better in school, more likely to graduate, less likely to drop out and get involved in illegal activities.
If you’re a fiscal conservative, it is good for us to find more solutions for good mental health for our kids. Because if you do stay in school and you do graduate your chances of paying taxes and becoming a contributor to society are much greater than if you find school so frustrating because you can’t sit still in school, or you’re too anxious to attend, and frankly becoming someone who takes from society than someone who is able to contribute.
PR: In re MRIs: Will that research and those tools be able to tell us that a child has ADHD or has autistic tendencies? Will those MRI’s be able to differentiate between some of the diagnoses we have out there now?
KH: The Holy Grail has always been the blood tests. If you have a cough and you are hacking away and it bothers you tremendously and you go to the doctor, before he even takes a chest x-ray, if you have a fever and a cough and he takes a blood test, we can tell whether or not you have a virus or a bacterial infection. If you have a virus, we can tell the patient, “drink plenty of fluids and stay in bed, you will live longer than the virus.” If it’s a bacterial infection, there are specific antibiotics you can take and have to take to make sure it doesn’t get worse.
You’re not going to be able to get that specific blood test. But what we will be able to get are biomarkers. If we can be able to tell the difference between the brain of a child who is typical versus the brain of a child with autism tendencies on the Asperger and Autism spectrum versus the brain of a child with ADHD, that becomes the confirmation of a diagnoses. That in itself would be very reassuring for parents. One of the hardest things that parents have is A) accepting their child has one of these disorder and B) the treatment.
Very rarely has there been more controversy than the idea of medication for psychiatric disorders. Instead of embracing them and saying that we have a wonderful group of medications that can help children sit and focus…many people in the public think that’s cheating or that’s teaching children to use drugs. The facts on this are completely against that. In fact they say we know that kids that are adequately medicated for ADHD early are less likely to use drugs later. Kids that are properly medicated for depression are less likely to self-medicate later.
The truth is that psychiatric illness in children is not only common but it’s quite treatable and children who have these disorders can go on to live normal lives if they get the treatment they deserve.
PR: Are you planning outreach programs in schools?
HK: More importantly than local schools, like Willy Sutton said, the reason he robbed banks is that’s where the money is, and the reason we work in schools, is simply that’s where the kids are. Teachers know children better than anybody else. If you talk to a group of parents who have three children, their sample size is three. If a good teacher has 25 kids in her class every year of third grade and she has been teaching for ten years, she knows 250 eight-year-olds; she’s going to tell you a lot.
More importantly today because of all the budget cuts, many schools are eliminating special education or exclusion programs so teachers more than ever really have to have skills in classroom behavior and classroom management. And if they can’t do that, they end up spending so much time on the child who’s making the most amount of noise and the other kids end up suffering. School is supposed to be a place of learning, not a place of psychiatric treatment. Teachers have to have these kinds of skills.
We’re now working on a pilot program for Teach for America. We’re working on a program with the Board of Education here in New York City to see if we can establish programs that can be replicated across the nation. One of them, which I think is most interesting, is a program called Parent Child Interaction Therapy. We work with kids who are disruptive and are off task. That program was started by a group of people at the University of Florida. We are becoming the largest training site in PCIT. We train parents about what behaviors they should ignore, what behaviors they should actually stop, and what behaviors they should praise. If your kid is doing lots of things that you don’t like, when they do something that you do like, you tend not to praise it and you tend to ignore it and that’s not good. And we train parents about these skills, we evaluate the child by observation, sometimes we go to school and observe then, and then we give the parents a receiver they put in their ear. Either through a one-way mirror or through a camera, we are able to tell parents when they should ignore things, what they should praise, and if they’re not praising enough and to stop behavior that is really disruptive. It works fast in 6 to 10 sessions.
Now we are transforming that teacher interaction therapy. We ask them to take the most difficult child they’re having difficulty managing out of the class and to work with that child in front of us. We give them skills to work with the most difficult child in praising them, in ignoring certain behaviors and stopping certain behaviors, [and] they can generalize those skills for the whole class.
A good example of that would be if one child is constantly raising their hand and the other children in the class don’t raise their hand. If you constantly call on the child who raises their hand, the other children won’t answer. They will give up. If you ignore the child who is raising their hand, then that child will stop raising his hand also. What’s a young teacher to do? We teach that teacher to slap that hand and say “That’s a good hand! I like that hand, can you show me some other hands?”
And so it’s not the question or the answer we’re looking for, it’s the behavior of raising your hand. We’re trying to teach teachers that just by changing some of their behaviors, they can get more of their kids to raise their hands and then figure out if the kids are giving the right answer or not.
If you think about the traditional way of psychotherapy, we used to play with children on the floor and hope we would get a better understanding of what the child is thinking or feeling. Unfortunately many times the child would behave very well on the one-to-one and you wouldn’t be able to generalize in the outside world. What we’re planning is we’re wiring our new center. It’s going to consist of over 23,000 square feet of space. If you treat a child intensely, if the child has terrible OCD, they can fly to New York, they can stay in a hotel with their parents, the can get 3 to 5 hours of intensive exposure and response prevention and medication. And they go home, and how do we see them? We use Skype and they get a booster session a week later so they don’t have to come 100,000 miles. That’s what I mean by transforming the mental health care of our children. How do we change the delivery and how do we train you? Most importantly parents need to know more. Our Web site, which will launch in November, will be the destination of noncommercial interaction that will give scientific sound information about mental health. Not only from the Child Mind Institute personnel and faulty, but from Columbia [University], Harvard, UCLA, the experts in the world on our Web site.
PR: What would you say is the prevalent mental illness among children today in this country?
HK: There are two, I think it depends on the age. In very young children, it’s disruptive disorders. About 5 percent of the population has ADHD. We can show you differences on MRIs versus a group of typical kids. These are children who are clearly more inattentive, more impulsive, and more hyperactive than a child their age. Unfortunately it’s a lifetime illness. It doesn’t mean you can’t pay attention, it means you lose your attention span very quickly when it becomes boring for you.
The other common illness which I think is minimized by the public is anxiety disorders. Anxiety is something we all experience. But in anxiety disorder…it lasts longer than two weeks. It’s a set of illogical worries that we can’t shake and affects our behavior. It happens between 6 percent of the population between the ages of 7 and 16 at any time. That’s a conservative estimate. Very often these kids don’t come to see a child psychologist or a mental health professional and they end up in a pediatrician’s office because they have headaches or stomach aches. We can’t find the organic cause but their stomach ache and their headache is still real because it’s caused by their anxiety or this misfiring of the amygdale. Unfortunately this often is mislabeled or minimized with the hope that children will outgrow it but unfortunately kids will either treat it themselves or they will limit their lives.
The good news is that there are so many psychosocial interventions that work. Children who are selectively mute who have a form of social anxiety will not speak to strangers. They will only talk to mom and dad. With intensive behavioral therapy, within 5 days, you can get those children to relax and [speak well]. We call it the brain buddies program to do it in a fun way and to make parents feel less shameful or guilty that they’ve done something.
PR: Is there a national program that you admire that would serve as a paradigm for the nation?
HK: I think one of the reasons we decided to start the Child Mind Institute, after spending 12 years at NYU…is that typically what happens is that these programs are always a “PS” [post script]. At Child’s Hospital, they were always terrific at taking care of childhood cancer, at diabetes or seizures, but it’s always a post script. When you think about mental health and when you think about psychiatry, child psychiatry is always the afterthought. It became clear to us that the same way St. Jude’s truly tackled childhood leukemia, we needed to create an institution that is exclusively dedicated to transforming child mental health care. If we don’t have that, then unfortunately whenever there is a cutback, or whenever there are financial problems, there is always something that may appear to be more life threatening or more important.
Since this is in many ways the last frontier, the brain is, in my opinion, the most exciting way to do exploration. But if you think about the bang for the buck … there is just a tremendous amount of potential. And clearly everyone realizes that if you turn around a child that was going to drop out and stays in school, or a child that was literally so unable to focus or was unable to calm themselves down to attend school, you could really make a difference. Kids who have separation anxiety or school phobia are significantly more likely to have panic attacks.
Unfortunately we’re the only place that clearly cares about child mental health in a way that’s exclusive. Not to say that other things aren’t important but we think this is the most important thing we have to offer the nation. #
