Reimagining our Approach to the Mental Health Crisis with Dr. Helen Egger | E. 85

Episode Introduction 

WARNING: This episode contains discussions on sensitive mental health topics that include depression, anxiety, and suicide among youth.

Helen explains Little Otter’s approach to mental healthcare for children, why mental health treatment hasn’t improved in ten years, and why it’s hard being a parent in America. She also describes how tantrums can be a ‘’mental health fever’’, emphasizes the need for a family focus in mental healthcare, and explains how telehealth provides access to care when 71% of counties don’t have a child psychiatrist.

Show Topics

• Mental health has deteriorated since the pandemic
• 50% of mental health disorders start before the age of 14
• Acknowledge the distressing impact of the mental health crisis
• A family focus improves mental health outcomes
• Tantrums aren’t just behavioral issues 
• The vital role of telemedicine in childhood mental health
• High quality work always wins out

10:25 Mental health has deteriorated since the pandemic

Helen explained how a mental health crisis impacts the whole family. 

‘’What I say about the child mental health crisis is that we were in a child mental health crisis before the pandemic, but it was made much worse by the pandemic and the stress of the pandemic. We’ve seen significant elevation in particularly anxiety, but also depression in kids. But this report, this white paper that I referenced that we produced was based on over 11,000 families coming to seek care at Little Otter. And when families come, they complete what we call the child and family mental health checkup, which I created. And the idea is we do checkups for height and weight and other variables, but we don’t have a way to check up on our child’s mental health or our family’s mental health, so when families come in, they complete this survey and they immediately get a report back. And the assessment looks at child mental health with separate developmentally appropriate sections for infants, toddlers, preschoolers, school age, and middle schoolers. Then we assess parent mental health, then we assess what we call family mental health, which is stress and the relationship between the parent and partner and the co-parenting relationship. That’s what we see all together. We think at Little Otter that we don’t just have a child mental health crisis, we have a parent mental health crisis. In our data, over half of the parents met clinical criteria for anxiety disorder and 1/3rd met criteria for depression.

13:27 50% of mental health disorders start before the age of 14 

Helen said children are affected by their environment and we cannot silo family members in treatment. 

‘’Because children are impacted by their environment, by their relationships. Another example, of course, is with younger children whose parents are depressed. We know so much about postpartum depression and the impact it has on the mom. And it has a huge impact on the child’s mental health. And it really impacts the quality of the parent-child relationship. Those are just two examples where we think to address this crisis where we have to innovate is not to silo the members of the family, carve them off and send them to different people, but there has to be an approach that’s thinking at the family level. And I truly think that is our first big innovation at Little Otter. And the second one is to say young children are suffering at the same rates as teens. Teens, it’s super important, absolutely critically important to meet the mental health needs of children. But again, if we’re going to make a dent in this crisis, we have to start as early as possible. 50% of adult mental health disorders start before the age of 14, but we put most of our effort and our dollars into older children and into adults, and we’re not focusing on where we can make a difference with early intervention and prevention. I’m so passionate about that, both where the industry should be focusing, but also educating parents so that they know the signs so they can advocate for what their children need and what they need.’’

15:30 Acknowledging the distressing impact of the mental health crisis

Helen said a cohesive, connected and relationship-based approach is essential in mental health care. 

‘’I think one thing is that older children show up in emergency rooms with suicidal ideation at higher rates. And those are very expensive interventions, so I think that’s one thing. Although the average age in our families, our kids we take care of for suicidal ideation is 10 years old. And we need to know that the second leading cause of death for children 10 to 14 is suicide. Again, it’s not something that only happens to teenagers. I also think that it’s somewhat more straightforward to provide mental health care to teenagers. And so at Little Otter, it’s not just that we see young children, we hire therapists who are experts in early childhood mental health. It’s its own area of specialization. And I think that many of the principles of our family mental health approach are embedded in the infant early childhood mental health field because you’re never thinking about a three-year-old separate from the parents, you’re with the child and with the parents. And so I personally think that approach should be applied across the lifespan. If you have a spouse who’s depressed, it’s impacting you in a huge way. And if you could be a part of that treatment to help understand and support your partner, I think treatments would be more effective. We’re really trying to bring that more cohesive and connected and relationship-based approach to all of mental health.’’

20:24 A family focus improves mental health outcomes

Helen said improving the mental health of children has a major impact of parental mental health too.

‘’It does. And I can tell you a very cool thing, which is in our outcome data, taking a cohort of over 200 kids who did treatment, 71% after 12 weeks went from the clinical to the nonclinical range. They had great impact. But we saw these were parents who we were not providing direct care for, we were just working with them in our Little Otter approach, that of the parents who had clinically significant anxiety at the start of their kids’ treatment, 67% were no longer in the clinical range. And for parents who had clinically significant depression at the start of treatment, 71% were no longer in the clinical range. Even just providing mental health care for children with this family focus, with this engagement with the parents with the acknowledgement of the impact on the whole family, we had a major impact on parent mental health, so we got us two for the price of one. And because we very rigorously have a measurement-based approach and track outcomes using the checkup but also other measures, we’re able to demonstrate that our care, even when it’s just focusing on the child, impacts and improves the mental health of parents and the mental health of the whole family.’’

25:46 Tantrums aren’t just behavioral issues

Helen explained that daily aggressive tantrums can indicate signs of a deeper problem. 

‘’But I’ll give you a good example from my work that I think brings it home, because it can seem abstract. Think about temper tantrums. Kids two to five have temper tantrums. In fact, 75% of two and three year olds will have had at least one tantrum last week. And it goes down a bit at four and five. And the thing about that is that is developmentally appropriate because young children are learning the capacity to manage their emotions, their big feelings, to manage behaviors when they have big feelings. And they’re not that good at it, and sometimes they just melt down. However, in my research I found that children who have tantrums nearly every day and who hit, bite, kick, or break something during a tantrum, those children are eight times more likely than children who don’t do that to having an impairing mental health disorder. But here’s the critical thing. People think about tantrums as a behavior problem. It’s as much connected to emotions. Children who have these aggressive frequent tantrums are at much higher rates of having an anxiety disorder, of having depression as well as ADHD or a behavior problem. That’s why I call daily aggressive tantrums a mental health fever. It’s a generalized sign that something might not be right. It doesn’t tell you what it is. You have to go and have an evaluation and look more deeply. But to me, that’s a useful knowledge that we can share with parents, right?…To say, “Here it is. It’s developmentally typical. But actually, this is not developmentally typical, and let’s look a little bit more deeply at it.”

32:31 The vital role of telemedicine in childhood mental health 

Helen said telehealth is on the only way to provide wider access to mental healthcare for children. 

‘’I think it’s a big question, can you do telemedicine in early childhood mental health? And the answer is yes. Again, science has shown that we can do that, and we’re obviously doing it at Little Otter. And that is so important. We are experts in delivering telehealth to young children. You don’t just plop a kid in front of a computer and expect them to talk like we’re talking. You put the computer on the floor, we use the whiteboards, we have toys. We’re very skilled at making it an engaging experience. But I think it’s critical to understand that it is the only way we are going to address the access problem. United States, 71% of the counties in the United States do not have one child psychiatrist. There are states in the upper Midwest who have zero child psychiatrists. Yes, we have to encourage more people to go in the field, et cetera. But that is not going to be the solution. We have to be able to bring our skills to families where they are, meaning in their home. And this is critically important when you think about the need for specialization. Perhaps you’re in an area that has some child mental health services but don’t have specialized early childhood services. But at Little Otter, because we’re 100% virtual, we can bring that expertise in. It could be early childhood mental health, but it also could be expertise in evidence-based treatment for obsessive compulsive disorder. It’s not just the early childhood. The mental health care that works is evidence-based care, not just random care. And parents, I think, need to seek that high quality care.’’

38:12 High quality work always wins out 

Helen said having a vision and being clear on your values and principles helps to succeed in the long-term. 

‘’…my experience has been, in the end, doing high quality work wins out. I’d say that was true in terms of the beginning of my scientific career when people doubted things. But if you do good science and you have the data to show it, you will be able to convince people. And so I think having just a very clear focus on what your values are and what are the key principles that you are focusing on I think really helps build for the longterm. And I think that’s the other thing. I think when we create new things, it takes a long time. And so I think it’s very important not just as a leader, but for inspiring the people who work with us to have five-year plans, to think through, okay, I want to be here. And how am I going to get there? And then to support people as they go through that. I think being able to have a vision for something that doesn’t exist and then be able to translate that and share that with others is one of the most amazing experiences that I’ve had the privilege of seeing that when you do that collaboratively… All of science, all of clinical work, this is collaborative work; doesn’t just come down to one person. But if you can create those collaborative teams with vision, you can make a huge difference. And I had that in my academic career, and now I’m having the privilege of having that experience in the digital health realm.’’

Show Links

Connect with Lisa Miller on LinkedIn

Connect with Jim Cagliostro on LinkedIn

Connect with Dr Helen Egger on LinkedIn

Check out VIE Healthcare and SpendMend 

You’ll also hear: 

A passion for mental health in children from birth to 6 years: Helen explains the motivation to launch Little Otter: ‘’…the earlier that we intervene, the better the outcome is for the kids.’’

No change in a decade – the urgent need to address the mental health crisis: ‘’We have a white paper that we just produced called Breaking the Silence: Meeting the Mental Health Needs of Young Children that I wrote. And in it, I look at the rates from when I started my career in the early, mid-2000s to now, 50% of children who need mental health services, only 50% get mental health services. That number was the same in 2013 as it is in 2023.’’

Mental health’s elephant in the room: ‘’The elephant in the room is something that’s the crisis of mental health as a whole, which is really how mental health is funded and the lack of parity of coverage for mental health care compared to coverage for other medical disorders.’’

Why it’s hard being a parent in America: ‘’We have not built a society that really focuses on maximizing the support for the youngest Americans or their parents so that …the typical parent is facing a lot of stresses that are going to impact their ability to support their children’s mental health.’’

The impact of the first five years lasts a lifetime: ‘’We know from brain science is that the period from birth to age five is where the architecture of the brain is really set down… What children experience in their relationships and their environments and what challenges they face at the mental health level, if those are not addressed, that is actually going to impact for a lifetime that child’s mental health….’’ 

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Episode Transcript 

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Dr. Egger (00:00): Even just providing mental health care for children with this family focus, with this engagement with the parents with the acknowledgement of the impact on the whole family, we had a major impact on parent mental health, so we got us two for the price of one. And because we very rigorously have a measurement-based approach and track outcomes using the checkup but also other measures, we’re able to demonstrate that our care, even when it’s just focusing on the child, impacts and improves the mental health of the parents and the mental health of the whole family. Introduction (00:25): Welcome to the Healthcare Leadership Experience Podcast, hosted by Lisa Miller and Jim Cagliostro. Lisa is the founder of VIE Healthcare Consulting and now Managing Director at SpendMend. Lisa and her team has generated over $1 billion in financial improvements for VIE’s clients since 1999. Since 2007, Jim has been a registered nurse working in critical care, perioperative services and outpatient settings at nationally recognized medical facilities across three states. You’ll hear conversations on relevant and trending topics in healthcare and much more. Now, here’s your hosts, Lisa and Jim. Jim (01:20): Hi, this is Jim Cagliostro, and you’re listening to the Healthcare Leadership Experience. Today’s guest is Dr. Helen Egger, co-founder and chief medical and scientific officer at Little Otter. Today I’m looking forward to discussing the re-imagining of our approach to the mental health crisis in America. So Dr. Egger, welcome, and thank you for joining us today. Dr. Egger (01:39): Thank you so much for having me. Jim (01:41): I always like to jump in right away and ask you to share a little bit about your story, how you got to where you are today, why you do what you do. Of course, I have to ask the origins of the name Little Otter. Dr. Helen Egger (01:52): Absolutely, absolutely. I am a child psychiatrist. I’m a research scientist. I’ve been a leader in academic medicine and also a leader in digital mental health. And before I joined Little Otter full-time two years ago, I was in academic medicine for 30 years. I was at Duke University for about 20 years. Dr. Egger (02:17): And my first love and, really, passion is early childhood mental health, and that’s the research career that I established, focusing on the mental health of children zero to six years old. And what has been really the hallmark at many points in my career is starting in an area that there isn’t a lot of information. I used to get jokes from people. What are you going to do, put babies on couches? And it’s like, no, no, that is not what we’re doing. Dr. Egger (02:48): But I had the privilege of leading a research group doing epidemiology, which is looking at the population level and creating the first structured interview to assess mental health symptoms in young kids. And that interview is now the international gold standard. It’s translated into 15 languages and really stirred research into asking the question, when should we worry about young children’s emotions and behaviors? Do mental health symptoms and disorders look the same in little kids as they do in older kids? And if not, in what way are they different? And so I did a series of large studies. And the answer in some ways really surprised all of us in the field, but has now been replicated many times. Children two to five years old have the same rate of impairing mental health disorders as older children and as adults. And that is mind blowing, right? Jim (03:52): It is. Dr. Egger (03:53): Because think little kids are just showing risks for problems, seeds for problems, but the truth is, unfortunately, that these children can experience dysregulated emotion, anxiety, depression, ADHD that’s really impacting their ability to develop fully. My life’s passion is to be able to bring this knowledge to people in the medical and mental health world, but also to parents so that we can identify problems because the earlier that we intervene, the better the outcome is for the kids. And so that’s that area. Then I also led the child division at Duke for six years, and then prior to joining, little Otter was chair of the Department of Child and Adolescent Psychiatry at NYU Langone in New York City. In those roles, really overseeing clinical services, but also what are the best practices, the most evidence-based interventions for children? Dr. Egger (04:58): And so the big question is, okay, why did you leave your endowed chair, tenure, being chair of a very big department to go found a digital health company? And the reason is… There are many reasons, but one of the main ones is being in the field for 30 years… And we’ve done amazing science, not just in early childhood mental health, but across kids zero to 18, knowing the challenges they face and having effective treatments, despite this, we are not moving the needle on children getting access to quality mental health care. We have a white paper that we just produced called Breaking the Silence: Meeting the Mental Health Needs of Young Children that I wrote. And in it, I look at the rates from when I started my career in the early, mid-2000s to now, 50% of children who need mental health services, only 50% get mental health services. That number was the same in 2013 as it is in 2023. Dr. Egger (06:10): And so I’ve really come to believe that, and this is why I moved into the area of digital health, we need new solutions and new approaches. And we need to be able to harness technology, data science, telehealth, and other approaches because what we’re doing now is just not working. And so that is the birth of Little Otter. Dr. Egger (06:32): And the reason I founded Little Otter with my daughter is that we really bring those two parts together. Obviously bring my clinical experience, my research experience, I also bring my experience as a mother of four children. And I have one child who has a brain illness called autoimmune encephalitis, so I have walked the walk of a parent with a child with significant mental health needs and know how hard, even despite my privilege, it is to get quality mental health care. But also knowing my kid’s alive because I was his mom, and that should be true for every kid. I bring that experience. And my daughter has an experience. She majored in computer science at UNC with product. She was at the tech company, Palantir, big data consulting company. Did projects all around the world, and then was recruited to the Chan Zuckerberg Initiative very early on when Mark and Priscilla founded it. And she built and led their infectious disease program. She has this experience of working with scientists and doctors to create products that can scale. And she was consulting with me about this idea and then finally said, “Oh, actually, I think I’m the person to do this with you.” And we raised a friend of the family round in 2020, and then when we raised our first seed round, I left academia to join Little Otter, and off we’ve been. Dr. Egger (08:03): And why Little Otter? we really wanted a name that was approachable and friendly. There’s so much stigma about mental health and also shame and what we want to be emphasizing, particularly because we focus on children birth to 14, that there’s something a positive mental health. It’s not just about mental health problems, this is about supporting our children in their mental health, in their emotional development, social development, behavioral development, so that they can thrive across all domains of their life. We really felt like having this name almost like a children’s book would really be approachable. The other thing is otters, particularly sea otters, actually represent our family-focused model. The parents, they take care of the baby for the first six months. And they’re very playful, they’re joyful, and so we really felt like Otters represented the best of what we were trying to give to families. Jim (09:04): That’s great. I like that. And it is wonderful. The first thing that stood out to me when I was looking through the website of Little Otter was the partnership between you and your daughter. I think that’s wonderful working together. You’re bringing your experience. You’re both bringing different skill sets. Growing up, I worked with my dad in his bike shop. And I know sometimes it would be difficult to work together, but you are both bringing a skillset to work together to advance. That- Dr. Egger (09:29): Absolutely. And that’s the thing. And we couldn’t either do it alone; we need each other. And people say, “Oh, how is it working with your mom? How’s it working with your daughter?” And this is not a joke. We both have done a lot of our own therapy and work, so we’re not bringing that to our business. We have a fantastic relationship. To me, it’s a dream come true. Jim (09:51): That’s great. I believe it. And it really stands out to me. I just want to point out what you brought up, the fact that… Was it 2013? Dr. Egger (09:57): Yes. Jim (09:58): The statistic about 50%. Dr. Egger (09:59): Yes. Jim (10:00): And the numbers haven’t changed, so like you said, something needs to be done differently. You’ve touched on this, I don’t know if there’s anything else you wanted to say about the current state of mental health today. We talk about it as a crisis. I know we have relatives, we have family, especially when it’s a child going through mental health issues or illness, it impacts the whole family. It is a crisis. But in terms of nationwide, how are we doing? Dr. Egger (10:25): Well we’re not doing well. What I say about the child mental health crisis is that we were in a child mental health crisis before the pandemic, but it was made much worse by the pandemic and the stress of the pandemic. We’ve seen significant elevation in particularly anxiety, but also depression in kids. Dr. Egger (10:46): But this report, this white paper that I referenced that we produced was based on over 11,000 families coming to seek care at Little Otter. And when families come, they complete what we call the child and family mental health checkup, which I created. And the idea is we do checkups for height and weight and other variables, but we don’t have a way to check up on our child’s mental health or our family’s mental health, so when families come in, they complete this survey, and they immediately get a report back. And the assessment looks at child mental health with separate developmentally-appropriate sections for infants, toddlers, preschoolers, school age, and middle schoolers. Dr. Egger (11:29): Then we assess parent mental health, then we assess what we call family mental health, which is stress and the relationship between the parent and partner and the co-parenting relationship. That’s what we see all together. We think at Little Otter that we don’t just have a child mental health crisis — we have a parent mental health crisis. In our data, over half of the parents met clinical criteria for anxiety disorder and a third met criteria for depression. Jim (12:02): Sorry to interrupt, but that’s for every child that you’re caring for. The family. Dr. Helen Egger (12:07): This is over 11,000 families who completed the checkup. What we know is that we have a child mental health crisis, we have a parent mental health crisis, and then that impacts the whole family in terms of stress; it impacts the relationships. And so our approach at Little Otter is, yes, we are a children’s mental health company, but that means we are really a family mental health company. Dr. Egger (12:33): And as I said from the beginning, we assess mental health across all these members of the family and their relationships with each other. And then our treatment plans, our interventions include child therapy and psychiatry, adult therapy and psychiatry, and we do parenting support and parent training, learning how to be a better parent, co-alignment between parents, and couples counseling, really acknowledging that all of these factors are going to be impacting the child’s mental health. You could think of an example of a child with significant anxiety. If that child every night has the parents screaming at each other because their relationship is highly conflicted, you’re really only going to make so much progress in cognitive behavioral therapy with that child, right? Jim (13:27): Sure, sure. Dr. Egger (13:27): Because children are impacted by their environment, by their relationships. Another example, of course, is with younger children whose parents are depressed. We know so much about postpartum depression and the impact it has on the mom. And it has a huge impact on the child’s mental health. And it really impacts the quality of the parent-child relationship. Those are just two examples where we think to address this crisis where we have to innovate is not to silo the members of the family, carve them off and send them to different people, but there has to be an approach that’s thinking at the family level. And I truly think that is our first big innovation at Little Otter. Dr. Egger (14:13): And the second one is to say young children are suffering at the same rates as teens. Teens, it’s super important, absolutely critically important to meet the mental health needs of children. But again, if we’re going to make a dent in this crisis, we have to start as early as possible. 50% of adult mental health disorders start before the age of 14, but we put most of our effort and our dollars into older children and into adults, and we’re not focusing on where we can make a difference with early intervention and prevention. I’m so passionate about that, both where the industry should be focusing, but also educating parents so that they know the signs so they can advocate for what their children need and what they need. Jim (15:08): I know we’re going to ask you about this later, but I really want to follow that line of thought in terms of I know it said on your website mental health support for the whole family, and you mentioned… I have my guesses, but why do you think so much emphasis and money and care is being placed in the older children and why the younger children are… I don’t want to say being neglected by what- Dr. Egger (15:30): Well, I think they are. I think one thing is that older children show up in emergency rooms with suicidal ideation at higher rates. And those are very expensive interventions, so I think that’s one thing. Although the average age in our families, our kids we take care of for suicidal ideation is 10 years old. And we need to know that the second leading cause of death for children 10 to 14 is suicide. Again, it’s not something that only happens to teenagers. Dr. Egger (16:04): I also think that it’s somewhat more straightforward to provide mental health care to teenagers. And so at Little Otter, it’s not just that we see young children, we hire therapists who are experts in early childhood mental health. It’s its own area of specialization. And I think that many of the principles of our family mental health approach are embedded in the infant early childhood mental health field because you’re never thinking about a three-year-old separate from the parents, you’re with the child and with the parents. And so I personally think that approach should be applied across the lifespan. If you have a spouse who’s depressed, it’s impacting you in a huge way. And if you could be a part of that treatment to help understand and support your partner, I think treatments would be more effective. We’re really trying to bring that more cohesive and connected and relationship-based approach to all of mental health. Dr. Egger (17:09): And there’s just a lack of knowledge that young children can experience mental health problems. And again, this is where why I left my job in academia. We have so much science that supports this; this is not a question. However, the knowledge just has not really permeated either into insurance companies or the industry, but also it’s not something that parents necessarily understand. There’s a big role for psycho education. That’s why child and family mental health checkup that I mentioned to you, we immediately give parents a report after they fill out the questionnaire. And it says in an area, is this concerning or typical? And then we give actionable advice. It’s very, very important that I think we should be doing universal screening to be able to identify children with problems. Dr. Egger (18:08): But then it’s, well, what do you do with this information? And you need to empower parents with this knowledge, and then say, “Okay, if it’s typical, here’s the ways you can support your child’s emotional development,” or that there are ways we can promote mental health. But if their child is in the concerning range, to say that, and say, “Okay, what are steps that you can take? What are the next steps to figure out whether this is something clinically significant and whether your child would benefit?” Dr. Egger (18:37): The elephant in the room is something that’s the crisis of mental health as a whole, which is really how mental health is funded and the lack of parity of coverage for mental health care compared to coverage for other medical disorders. And despite there having been a parity law over a decade ago, it really hasn’t had teeth. The Biden administration is now trying to give it more teeth, and I totally support that. But until we acknowledge that mental health disorders are disorders like diabetes or cardiovascular disease and that in fact often co-occur with very expensive chronic medical disorders, and that if we effectively treated mental health, we would reduce medical costs. But instead, there’s just been this division. And I think until that gets healed and there’s actual adequate reimbursement for mental health care, we are not going to see the changes that we need. Jim (19:48): Sure. I really appreciate, well, two things. I really appreciate the focus on family in all of this, in mental health for children. We see many of our listeners might have that in their family where a child is suffering from some sort of mental health issue. And it impacts the family so deeply across the board in terms of quality of life, everything, the care and the attention that’s needed. But then so often when we care for someone with a mental health disorder, health issue, we focus just on that individual, not recognizing a whole family’s being impacted. I love that your assessment and your care involves the whole family. Dr. Egger (20:24): It does. And I can tell you a very cool thing, which is in our outcome data, taking a cohort of over 200 kids who did treatment, 71% after 12 weeks went from the clinical to the nonclinical range. They had great impact. But we saw these were parents who we were not providing direct care for, we were just working with them in our Little Otter approach, that of the parents who had clinically significant anxiety at the start of their kids’ treatment, 67% were no longer in the clinical range. And for parents who had clinically significant depression at the start of treatment, 71% were no longer in the clinical range. Even just providing mental health care for children with this family focus, with this engagement with the parents with the acknowledgement of the impact on the whole family, we had a major impact on parent mental health, so we got us two for the price of one. And because we very rigorously have a measurement-based approach and track outcomes using the checkup but also other measures, we’re able to demonstrate that our care, even when it’s just focusing on the child, impacts and improves the mental health of parents and the mental health of the whole family. Jim (21:47): That’s amazing to hear. And we know there’s interaction between parent mental health and child mental health. I do want to ask, actually, to follow up with that, do you see in your experience, a lot of times where… And maybe we can’t know this, but the issue is starting with, okay, the child has something that they’re dealing with, and that then impacts the parents. Or a lot of times you see, well, there’s something before that even begins with the parents, and we’re just seeing it at the same time and it’s more complex as time goes on. Dr. Egger (22:16): I think both are true. I don’t think there’s one. I think what you said before is that it’s an interaction. It’s the same when we think about the fact that there are genetic risks for different mental health disorders, but that doesn’t mean that you are absolutely going to get that disorder, it means you have a risk for it. And then there are things that happen in your life, environmental impacts, your relationship, things that happen to you that might increase this risk and then result in you having the disorder. I think it really goes both ways. Dr. Egger (22:51): But in some ways, again, you want to pull back also about mental health, not just mental health problems. It’s hard being a parent in America, and the pandemic made being a parent even harder. We have such a lack of access to childcare, to maternity and paternity leave. We have not built a society that really focuses on maximizing the support for the youngest Americans or their parents so that even when there isn’t a distinct mental health disorder like anxiety or depression, parents, just the typical parent is facing a lot of stresses that are going to impact their ability to support their children’s mental health. Jim (23:39): Absolutely. If you’re just tuning in, you’re listening to the Healthcare Leadership Experience, and I’m your host, Jim Cagliostro. The show is sponsored by VIE Healthcare Consulting, a SpendMend company which provides leading edge financial and operational consulting for hospitals, healthcare institutions, and other providers of patient care. Since 1999, VIE has been a recognized leader in healthcare costs, hospital purchased services, healthcare benchmarking, supply chain management, and performance improvement. You can learn more about VIE Healthcare consulting at viehealthcare.com. Jim (24:13): I wanted to follow up, Helen, with this prevention. I know we talked a little bit about that previously. But patching or treating health issues, mental health issues at a younger age, I believe, is much more challenging than say, high school, adult in terms of… It’s hard enough to try to understand. I have a four-year-old, and even my seven-year-old, sometimes they struggle to express themselves or to really… And I think as a parent, my instinct is to say, “Well, it’s just a phase,” or, “They’ll grow out of it.” Prevention is huge, but also treating issues. We talk about that with heart disease, we talk about it with diabetes, why not mental health? Why is prevention so important? And why is treating at a young age crucial in this way? Dr. Egger (24:56): Yeah, absolutely. The reason early childhood mental health and prevention and early intervention is so important is these are the beginnings. This is the start. It is so typical, as a child psychiatrist, you see a kid who’s nine years old for ADHD, they already have lost many friends or having academic challenges, but they don’t get identified until age nine. And everyone in the history will tell you from the age of three, two, that this child had significant problems. I think the important thing to realize is we do… People who specialize in early childhood mental health, myself and the folks who are in this field, we are able to distinguish, again, I call it when to worry. And when is it in the range of typical? Dr. Egger (25:46): But I’ll give you a good example from my work that I think brings it home, because it can seem abstract. Think about temper tantrums. Kids two to five have temper tantrums. In fact, 75% of two and three year olds will have had at least one tantrum last week. And it goes down a bit at four and five. And the thing about that is that is developmentally appropriate because young children are learning the capacity to manage their emotions, their big feelings, to manage behaviors when they have big feelings. And they’re not that good at it, and sometimes they just melt down. However, in my research I found that children who have tantrums nearly every day and who hit, bite, kick, or break something during a tantrum, those children are eight times more likely than children who don’t do that to having an impairing mental health disorder. Dr. Egger (26:39): But here’s the critical thing. People think about tantrums as a behavior problem. It’s as much connected to emotions. Children who have these aggressive frequent tantrums are at much higher rates of having an anxiety disorder, of having depression as well as ADHD or a behavior problem. That’s why I call daily aggressive tantrums a mental health fever. It’s a generalized sign that something might not be right. It doesn’t tell you what it is. You have to go and have an evaluation and look more deeply. But to me, that’s a useful knowledge that we can share with parents, right? Jim (27:20): Sure. Dr. Egger (27:20): To say, “Here it is. It’s developmentally typical. But actually, this is not developmentally typical, and let’s look a little bit more deeply at it.” Dr. Egger (27:30): The other thing we know from brain science is that the period from birth to age five is where the architecture of the brain is really set down. Yes, there is growth and neuroplasticity actually throughout the lifespan, but it’s just exponential from zero to five. What children experience in their relationships and their environments and what challenges they face at the mental health level, if those are not addressed, that is actually going to impact for a lifetime that child’s mental health as well as actually impacts their physical health. This is critical because it prevents later problems, but also because the impact of those first five years of life really last a lifetime. Dr. Egger (28:18): And there’s huge, huge data on investment in early childhood mental health and social emotional development, and has a huge economic impact and payoff with producing healthier older children and healthier adults. And again, this science is irrefutable. This is not a question. That is why it’s just so important that we get the word out about how to deliver this care, but it’s also to acknowledge, look, we have an access to care crisis, not just the fact that we have high rates, but that it’s all care is not created equally. And what I feel like we should be talking about is access to quality care. And when it comes to early childhood mental health, it means access to care with people who are trained and specialized in delivering this care to children. It is not a one-size-fits-all solution. People who specialize in teenagers may not have the skillset to be able to work with a four-year-old. Jim (29:24): You talk about the access to quality care, I believe funding, sometimes it’s difficult. I believe one of the biggest challenges is we know the data is there, just like you shared, that early intervention, prevention, addressing these things at a younger age really does make a difference down the road. But I think because it’s such a long view, a big picture that it’s hard to really convince people, okay, we really need to invest in this. It really is something that we need to be focused on because we don’t see the results right away. Somebody needs a bypass in their heart. Okay, a few hours…- Dr. Egger (29:56): Right. Right. The return on investment I think that insurance companies look at is a one-year ROI. We can demonstrate, actually, the one year ROI of using services at Little Otter. But again, we need to demonstrate that. And I think what that reflects is this involves our society priorities because this really, I think, has to land in the seat of policymakers and our state and federal government. Which, actually, there are pockets of places that… California has invested in… They have a big birth to five initiative there. And so there are the grassroots efforts. And it really needs to be prioritized in funding at NIH, it needs to be prioritized in HHS, et cetera to really make a difference. Dr. Egger (30:53): And I do remain hopeful because I’ve been in the field of early childhood mental health for over three decades, and we’re so much farther than we were 30 years ago. Even though we haven’t really changed the access, et cetera, I see that we are making some progress. Jim (31:12): There is hope. Yeah. Dr. Egger (31:13): Yeah, there is hope. And even the fact that we’re really proud at Little Otter; we raised an A round in December of ’21, but as a female founded company, we’ve raised over $26 million. We’ve been able to convince investors that this is an unmet, huge need that it’s worth it to find solutions for. Jim (31:36): Yes. And so I know we’re running out of time, but I really want to spend some time on Little Otter prioritizes meeting families where they are. I want to talk about this role of technology. Can you really get into how the use of technology has become such a difference maker? Dr. Egger (31:53): Absolutely. Yeah. Jim (31:55): At least in terms of Little Otter… other places. Dr. Egger (31:56): Yeah. Well, I’ll start with our platform, our Little Otter platform. And I mentioned about the child and family mental health checkup, but we have a whole measurement and assessment approach that is interwoven into what we call the Little Otter way, our clinical care. And this impacts not only communication with families but are rigorously looking at quality assurance and outcomes. And that is really where we bring data science and immediate results to the table, to clinical decision-making and to supervision, et cetera. Dr. Egger (32:31): But number two is really the innovation in telemedicine. I think it’s a big question, can you do telemedicine in early childhood mental health? And the answer is yes. Again, science has shown that we can do that, and we’re obviously doing it at Little Otter. And that is so important. We are experts in delivering telehealth to young children. You don’t just plop a kid in front of a computer and expect them to talk like we’re talking. You put the computer on the floor, we use the whiteboards, we have toys. We’re very skilled at making it an engaging experience. Dr. Egger (33:07): But I think it’s critical to understand that it is the only way we are going to address the access problem. United States, 71% of the counties in the United States do not have one child psychiatrist. There are states in the upper Midwest who have zero child psychiatrists. Yes, we have to encourage more people to go in the field, et cetera. But that is not going to be the solution. We have to be able to bring our skills to families where they are, meaning in their home. Dr. Egger (33:39): And this is critically important when you think about the need for specialization. Perhaps you’re in an area that has some child mental health services but don’t have specialized early childhood services. But at Little Otter, because we’re 100% virtual, we can bring that expertise in. It could be early childhood mental health, but it also could be expertise in evidence-based treatment for obsessive compulsive disorder. It’s not just the early childhood. The mental health care that works is evidence-based care, not just random care. And parents, I think, need to seek that high quality care. Dr. Egger (34:19): And some people have preference for in-person, and I totally understand that. And I think people need to understand that virtual a lot enables us to bring this specialized high-quality care into your home. It’s definitely more convenient for families. We find a really great side effect is dads are much more involved in therapy because if you’re have one parent just taking the kid to therapy, it’s usually just going to be one parent and you’re maybe dragging your other little kids with you. But if you’re doing a Zoom session, multiple members of the family can join even if they’re not in the same space together. And so we also see significant benefit of being in people’s homes and be able to see the child’s room and their dog and to come up with plans that are consistent with the child’s life that they’re living. Dr. Egger (35:15): I think those are our biggest areas, but I think the third is design and approach. It gets back to Little Otter. We want the experience of being a Little Otter family as you interact with your tele sessions, but also with the app, with information that we share with you, with the data we share with you to be a positive, affirming experience. And that means that you need to focus on design and humans-centered design and user experience, and really making sure that you know who your customer are and that you’re designing an experience that will be positive for them and will make them not feel stigmatized, will make them feel supported, engaged, and joyful. Jim (35:56): I love what you’re saying that as you’re sharing about the telehealth, the involvement of both parents or of seeing, even observing the family in the home, but you also make me think of, we talk about white coat syndrome. Not just adults, but kids. When you go into a doctor’s office, it’s not home, so they might not behave in their normal way. When you see them at home, you can see a little bit more of the family interaction. I love that you said about seeing the room, the pets, how they’re interacting. Dr. Egger (36:22): Yeah, absolutely. Jim (36:22): That’s great. Dr. Egger (36:26): But again, you have to have people who are… We hire amazing therapists. The other thing I do want to say that’s different at Little Otter from some other digital health companies, all of our therapists are W-2 employees. We don’t refer people out. We don’t have contractors because we have a very clear approach to care that we train people in, that we do small group supervision, individual supervision, weekly case conference, rigorous quality control. We actually- Jim (36:54): That’s so valuable. Dr. Egger (36:55): … tape our sessions, so part of our QA is looking at the sessions for rapport with families. We’re not just doing chart review, we’re really looking at the therapeutic alliance and, again, what the experience is like. And so I think that’s another aspect is you really can’t have quality of care. Unfortunately, there’s a lot of mental health care that is not high quality. I feel like as a field, we need to really demand and expect, and I think consumers need to have enough knowledge to demand and get high quality care, not just whatever care they can get matched up to. Jim (37:36): That’s a great point, that’s a great point. And we are out of time. I feel like we could talk for another hour. Dr. Egger (37:41): Well, there’s so much to talk about. And as you can tell, this is my life’s work. I’m so passionate about trying to find new solutions. Jim (37:50): Well, and your passion comes through clearly. The impact that Little Otter is having, I believe, comes through clearly. And because this is the Healthcare Leadership Experience, we always like to ask if there’s any leadership lessons that have sustained you, that you have learned through your wide variety of work experiences. Anything that you’d like to leave our audience with, I’d love if you could share that with us. Dr. Egger (38:12): Yeah, thank you. Well, there are many, but one thing I would say is that my experience has been, in the end, doing high quality work wins out. I’d say that was true in terms of the beginning of my scientific career when people doubted things. But if you do good science and you have the data to show it, you will be able to convince people. And so I think having just a very clear focus on what your values are and what are the key principles that you are focusing on I think really helps build for the long term. Dr. Egger (38:49): And I think that’s the other thing. I think when we create new things, it takes a long time. And so I think it’s very important not just as a leader, but for inspiring the people who work with us to have five-year plans, to think through, okay, I want to be here. And how am I going to get there? And then to support people as they go through that. I think being able to have a vision for something that doesn’t exist and then be able to translate that and share that with others is one of the most amazing experiences that I’ve had the privilege of seeing that when you do that collaboratively… All of science, all of clinical work, this is collaborative work; doesn’t just come down to one person. But if you can create those collaborative teams with vision, you can make a huge difference. And I had that in my academic career, and now I’m having the privilege of having that experience in the digital health realm. Jim (39:47): Well said. Thank you, Helen. Thank you so much for being on the show today. And thank you to our listeners who spent time with us. If you have any questions about VIE Healthcare Consulting, a SpendMend company, or if you want to reach out to me or Lisa Miller, you can find us on LinkedIn. You can also find Helen on LinkedIn as well. We at SpendMend love helping hospitals save money and enhance the patient experience, and we’re hoping that the episode today gave you some new insights or ideas to consider and use in your career and your own healthcare organization. Dr. Egger, I did want to say, I forgot to mention littleotterhealth.com, correct? Dr. Egger (40:18): That’s right. Yep. Come visit us. Jim (40:21): Thank you so much. Dr. Egger (40:21): We’ve got great resources, and we’re providing care throughout the country. Jim (40:25): Thank you so much. Dr. Egger (40:26): Thank you. Speaker (40:28): Thanks for listening to The Healthcare Leadership Experience Podcast. We hope you’ve enjoyed this episode. If you’re interested in learning new strategies, best practices and ideas to utilize in your career and healthcare organization, check out our website at thehealthcareleadershipexperience.com. And, oh, yeah, don’t forget to rate and review us and be sure to join Lisa and Jim next time on The Healthcare Leadership Experience Podcast. Thanks again for listening.