Little Otter’s Rebecca Egger on making mental health care accessible to all

For Rebecca Egger, the CEO and co-founder of Little Otter, a mental health service designed for children, digital transformation will play a crucial role in scaling healthcare. That approach is already being rewarded and recognized – Rebecca was recently named on Inc Magazine’s influential Female Founders 100 list for 2021.

Rebecca has a background in astrophysics and computer science and spent many of her formative years looking at gamma-ray bursts and supernovas, but eventually, eager to get into software and product design, she moved to San Francisco.

In 2017, she started working as a product lead at the Chan Zuckerberg Initiative, building their infectious disease program and IDseq, an open-source online platform to spot movement of diseases across borders, the emergence of new illnesses, or the spread of drug-resistant strains.

In June 2020, in the midst of the pandemic, Rebecca and her mother — child psychiatrist and scientist Dr. Helen Egger — launched Little Otter. The company means a great deal to both of them. In a heartfelt testimony, Rebecca recalls how her little brother came down with a rare autoimmune brain disorder back in 2008. Despite her mother’s experience and prestige as a tenured faculty member at a major medical center, she felt the mental health systems weren’t putting the family at the center of their care, dismissing a lot of her insights and concerns. Little Otter and its family-first approach, they believe, is the antithesis of that.

In this episode, we sat down with Rebecca to talk about her mission to make mental health care scalable and accessible for all, and how the pandemic and technology are radically changing the way we think about mental health care.

Here are some of our favorite takeaways from the conversation:

1. It’s all about the family setting

According to the National Research Council and Institute of Medicine, one in five children has a mental, emotional, or behavioral disorder, and about 80 percent of them do not receive the mental health care they need. For Rebecca, this is unacceptable — and it calls for a completely new approach. Children live with their families, and so, taking care of a child’s mental health means taking the whole family environment into account.

We designed Little Otter to be a kind of family-first, in-your-home model. You don’t know when issues are going to come up. They don’t happen on a schedule. One day things are fine, and the next day, there’s a meltdown. Many of our families text videos of a tantrum to their provider and are like, “How was I supposed to handle this?” … How do you make sure you’re providing support that actually works with a family that’s not just seeing someone in an isolated environment?

2. Scale and accessibility are key

One of the reasons Rebecca couldn’t see herself as an academic is because academic research all too often stays inside a laboratory. For her, this is one of the most pressing issues of our time. How can you develop the technology while making sure it really gets to the people who need it the most and has an actual impact on their lives?

It’s so interesting because medicine, in some ways, is very, very advanced, right? In some pockets of it, incredible things are being done. But what I experienced at [the Chan Zuckerberg Initiative] and also with Little Otter is that it’s available to very few. There’s amazing research and work getting done, and there’s this amazing technology and AI, but the hard part is to actually make that accessible and scalable and get it in the hands of people who really, really need it.

3. You need both automation and human interaction

AI and automation will inevitably play a big part in scaling healthcare and making it accessible for everyone who needs it. New digital, data-forward, and automated solutions will be cheaper, more efficient, and available around the clock. But as Rebecca points out, you can’t really replace human therapists and doctors. There will always have to be a balance.

How much of human interaction can actually be replaced? In some cases, an AI therapist or AI counselor can support certain issues, but in many cases, therapy works because it’s about connecting with another person. It’s a long-term relationship. (…) There’s always going to be instances where people will have to go to a doctor’s office.

Caught your interest? We’ve gathered a list of articles, videos, and podcasts you can check out:

• Back to school mental health toolkit
• 12 tips for sending kids back to school amid COVID-19
• Interview with Little Otter CEO Rebecca Egger
• Cliniko founder Joel Friedlaender on bringing digital transformation to healthcare

This is Scale, Intercom’s podcast series on driving business growth through customer relationships. If you enjoy the conversation and don’t want to miss future episodes, just hit subscribe on iTunes, stream on Spotify, or grab the RSS feed in your player of choice. You can also read the full transcript of the interview, which has been lightly edited for clarity, below.

Liam Geraghty: Rebecca, we are delighted to welcome you to the show today. To kick things off, could you tell us a little bit about yourself and your background?

Rebecca Egger: I’m the co-founder and CEO of the digital health company Little Otter, and I have a background in computer science, physics, product design, and graphic design. Before, I was leading the infectious disease program at the Chan Zuckerberg Initiative, which was very, very relevant work. Before that, I was at Palantir and at a few startups doing various things. All of that work gave me a lot of experience to build Little Otter.

Liam: For sure. Little Otter, which you co-founded last year in the middle of a pandemic, of all things. Could you explain what Little Otter is?

Rebecca: Little Otter is a digital mental health company for families with children 0–12 years old. We provide assessments and mental health care, telemental health care to families and children. We match them to the right types of support and provide parent coaching, therapy, couples counseling, or psychiatry services as needed, evidence-based care, fully digital.

Taking the plunge with telemedicine

Liam: Was it a big challenge starting a company in the middle of a pandemic?

Rebecca: Yeah. I had decided to do Little Otter before the pandemic even started to emerge. I had already decided to leave my position at the Chan Zuckerberg Initiative. I felt like it was time. I founded this company with my mom, Dr. Helen Egger, and this is something that we had been talking about for a very, very long time.

A year or two years before we really took the plunge, I was kind of helping her in a consulting capacity to think about how she could build a company and what that would look like. And about a year into doing all the research and support for her, after building out the business model, doing user interviews, realizing the market, and just started deeply caring about this, I was like, “Wait, I want to do this.”

“If the pandemic hadn’t happened, I might have been convinced we had to do brick and mortar when, in reality, this was the way we needed to go”

The most interesting thing is that we always wanted to be fully telemedicine. We never wanted brick-and-mortar locations. In February 2020, when I started to fundraise for our pre-seed round, I was met with a lot of questions around that. So, actually, the pandemic just accelerated us being able to really do what we had wanted to do in the first place. I think it was a good lesson for me as a CEO. If the pandemic hadn’t happened, I might have been convinced we had to do brick and mortar when, in reality, this was the way we needed to go.

Liam: How has it been going so far?

Rebecca: It’s been incredible. I mean, building a company during this time is very interesting. Because we’re running a full telemedicine service and we have a fully remote team, because we’ve set it up to be remote-first, it’s been great to build a team that way. Also, there’s just massive amounts of need. I think our biggest issue right now, and I talk about this all the time, is that there’s so much need and awareness emerging in this space, so how do we prioritize and effectively support the families most efficiently and grow our product without sacrificing quality?

Liam: How do you go about doing that? How do you go about trying to address the kids’ mental health epidemic?

“When you’re looking at a four-year-old who’s having a tantrum, they can’t tell you, ‘I’m depressed.’ They express their feelings in different ways”

Rebecca: The first issue with the mental health epidemic is that families — caregivers, but also pediatricians and teachers — don’t have the tools to identify if issues are existent, especially with younger children. That is really where Dr. Egger, my mom’s experience, comes in. When you’re looking at a four-year-old who’s having a tantrum, they can’t tell you, “I’m depressed.” They express their feelings in different ways. Even though they have mental health disorders at the same rates as adults, it’s very hard to identify what’s going on.

We also know that early intervention matters. We’re first addressing the problem by creating better ways to make it really, really easy for families to sign up for our product and get immediate feedback to say, “Should I worry? Is this something that I need to get parent coaching for, or is this a serious problem that might need therapy and medication?”

Gamma rays and supernovas

Liam: One of the things I kind of wanted to talk to you about was your journey to this point, from tech entrepreneur to mental health children’s startup founder. Before we kind of get to this point where we are now, I really wanted to ask you about one of the earliest things you did because I personally find it so fascinating that you were a part of an astrophysics research team focused on gamma-ray bursts and the PROMPT telescope network in Chile. What was that like?

Rebecca: I’m going to kind of start my journey a little bit earlier and give credit where credit is due. I grew up in North Carolina and was lucky enough to go to the North Carolina School of Science and Math, a completely free magnet boarding school for juniors and seniors that has an amazing science program. They even had a telescope there. That was really where I was able to take very advanced classes, and I fell in love with physics and was able to just take every physics class that I could imagine.

“You’re also dealing with the world’s coolest problems, right? What existed before us, and what is going to exist after?”

When I entered and went into UNC, I thought I was going to live my life in a telescope. I was going to write papers because it’s the coolest, right? What I realized while working on this is that the reason I was so interested in it is actually it had a lot of the same elements of software – bear with me, I promise this makes sense – where it’s a very visual science, right? It’s about analyzing images and looking at data, but you’re really taking pictures, and I was really into graphic design. Then there’s also the element of computer science, statistics, programming. And you’re also dealing with the world’s coolest problems, right? What existed before us, and what is going to exist after?

Anyway, I was lucky enough to join this amazing research team, which is still one of the best research teams at UNC, and their big work was in gamma-ray bursts, recording some of the earliest things that we’ve ever been able to record in the universe. They sponsored a group of telescopes, the PROMPT telescopes in Chile, and those can be used and rented out by other groups, but the minute they sense a gamma-ray burst, everything stops and it just focuses on them.

“I realized I really didn’t want to do academia. I felt like physics was just kind of limiting”

Liam: I just keep thinking about all these very sci-fi movies where you kind of see people huddled around in these rooms, waiting for that signal to come through, and then it’s like panic stations. Is that anything like that?

Rebecca: It’s a hundred percent like that. We would get alerts because you don’t know when they’re going to happen, right? It would be completely random. The coolest thing was that when I was a sophomore in college, on my laptop, I could log into these telescopes and take pictures of these crazy supernova remnants. It was just a way to impress people.

I loved it and the people on the team were amazing, but the reason I didn’t continue doing that is I realized I really didn’t want to do academia. I felt like physics was just kind of limiting. I wanted to do a more creative thing. The reason I ended up doing computer science and graphic design was that I wanted to stay in my position in the lab. I wanted to do a major that could let me still do relevant work but wasn’t as focused on physics. So I ended up doing computer science and ended up publishing a paper with them and working there throughout my years at UNC.

The rush of a startup

Liam: Wow. So after that, you worked with a registered creative co and then launched a one-person consulting business, Egger Designs. What were those early days like?

Rebecca: I don’t know who your listeners are, but this is just a huge lesson in finding advocates and people who believe in you. The reason I started doing design was that one of my very close friends was running for student body president at UNC and was like, “Hey, you actually can do design. Let me pay you for a logo.” Then I started my own freelance business, and then, of course, he was the first investor in Little Otter when I announced it. It was a nice way to show that people support you from the very beginning.

“I feel like my entire career has been a lot of cold emails leading to a lot of opportunities”

I kind of just built up doing a lot of design work, became really self-taught, and then went to registered creative and became a web designer. And then, I really, really wanted to get into software and product design, so I ended up joining a startup and coming to San Francisco.

Liam: How did you find the startup experience or the startup life?

Rebecca: I mean, I loved it. I feel like my entire career has been a lot of cold emails leading to a lot of opportunities. What ended up happening is I had a computer science degree, I could do design, I had just graduated from UNC, and I had some friends in San Francisco who were like, “You should probably come out here. You should probably join a startup. People are looking for people who can code.”

My friend convinced me. I literally went on AngelList and just sent cold emails to every company that I thought looked cool. I said, “I’m going to be in San Francisco for a week. This is my experience,” slept on my friend’s couch, and by the end of that week, I had four offers, because now what I know as a startup founder is that you are desperate and you need people who are ambitious and will just get shit done.

It was really exciting for me. I quit my job and just moved out to San Francisco. I loved being part of a startup. Probably the reason I love doing Little Otter is that the most exciting time is when you’re trying to figure out, “How am I going to make this thing work? How do you take nothing and make something that people love?”

Making something helpful

Liam: So that kind of brings us to the Chan Zuckerberg Initiative. For anyone who doesn’t know, it was founded in 2015 by Priscilla Chan and Mark Zuckerberg to help solve some of society’s toughest challenges, like eradicating disease and improving education. Rebecca, you joined as a product and program lead in the area of infectious disease. How did that come about, and what was it like?

Rebecca: You kind of missed about two and a half years at Palantir, which were also very, very formative, and I would also say the biggest “throw you in a fire, learn how to be successful.” My time at Palantir was amazing, but I was traveling a lot, a lot, a lot, and I really wanted to find some stability and work on one project for a longer set of time.

“They were some of the most brilliant engineers I’ve ever worked with, and they were like, ‘Make something that people want that is helpful'”

The Chan Zuckerberg Initiative, I’ll call it CZI, had just started, and they were hiring their first product managers, so I started as a product manager. Once again, the stars massively aligned where I obviously wanted to also get back to my roots in science. They were starting the science initiative, and I still really missed working with scientists, missed my lab at UNC, et cetera.

When I joined, I was the second product manager in the science initiative, and they were like, “Hey, we gave some money to the Chan Zuckerberg Biohub,” which is this amazing group of scientists. “We want to do something with them. Figure it out.” Which to me was like a dream come true. They were some of the most brilliant engineers I’ve ever worked with, amazing scientists, and they were like, “Make something that people want that is helpful.” That’s how we ended up building the infectious disease program while I was there.

Liam: As you say, you’re working on this tool to help scientists kind of better understand diseases. I believe that’s something very close to your own heart, from a piece I read, and your own family with your brother’s experience. I was wondering if you might be able to tell us a little bit about his story.

“As my mom says, ‘My son is alive because I am his mother,’ and every parent should have that”

Rebecca: Yeah. It’s also very, very relevant to Little Otter. I think that it’s the catalyst for why my mom also wanted to start a Little Otter and really changed kind of our trajectory as a family. My little brother, when he was 13, was diagnosed with autoimmune encephalitis. It shows up as psychosis.

At the time, my mom was head of child psychiatry at Duke and had done a bunch of grants with the neuroscience folk, and she knew that it was not a psychiatric issue. It really seemed like something else was going on. But even with her experience as a doctor and her experience in the institution, there was so much distrust in her. Luckily, we had the privilege and experience to advocate for my brother’s care, but most families are not that lucky. As my mom says, which I think is true, “My son is alive because I am his mother,” and every parent should have that.

A new dawn of healthcare transformation

Liam: At this point where tech is transforming the provision of healthcare in so many ways, and it’s funny that just a few years ago, all the talk was of like keyhole surgery, but now we’ve moved on from that to artificial intelligence and 3D printing and even robot-assisted surgery. I just wanted to get your sense of this and where we are right now with all of that.

Rebecca: I think it’s so interesting because medicine, in some ways, is very, very advanced, right? In some pockets of it, incredible things are being done. But what I experienced at CZI and also with Little Otter is that it’s available to very few. There’s amazing research and work getting done, and there’s this amazing technology and AI, but the hard part is to actually make that accessible and scalable and get it in the hands of people who really, really need it. This is just my personal philosophy, and I think it’s the reason why I couldn’t be myself be an academic. I love thinking and I love that scientists exist, but I believe it doesn’t really matter until people really get it and feel the effects of it. And it’s so hard to do that.

“How do we make sure that this work done in a laboratory setting is available to other people?”

For example, my mom has done some of the only studies on artificial intelligence to diagnose and identify autism in young children. She created the first research kit app with Apple to do this machine-learning way to look at videos of young children. She created a lab called The Wonder Lab to create these assessment tools for families while she was at NYU, which this incredible, incredible work, but the average person doesn’t even know that’s possible. How do we make sure that this work done in a laboratory setting is available to other people?

Once again, with my work at CZI, the product that I developed ended up identifying the first strains of COVID in Bangladesh and in Cambodia. That was because that technology existed, but it only existed in labs in the US. It’s awesome that it exists there, but it’s not actually helping the people where the disease is emerging. My answer to all of that is that this work is amazing and needs to be happening, but I think that people need to be figuring out how do we make it accessible and available to really impact people’s lives.

Liam: What you mentioned earlier about your experience with Little Otter, COVID has obviously accelerated things in this space. What has the impact been and what are the changed expectations amongst patients? Is there a gulf between what patients expect and what is or can be provided?

“In terms of mental health care, the conversation has changed. Families are able to talk about it more”

Rebecca: I think even before COVID, we were entering a new era where, say, millennials were more comfortable with telemedicine and were seeing the benefits of it. I also think there’s more of an expectation. If someone doesn’t have a way that I can email them, I’m probably not going to work with them. I don’t pick up the phone that often. I think that those expectations have already been put into place.

In terms of mental health care, the conversation has changed. Families are able to talk about it more. This always existed, but the stigma is decreasing. The message we’re getting from families is that they’re excited to embrace a new way of supporting their families and translating all of the work that has already been done in the adult mental health space and making it available for children.

Balancing tech with human interaction

Liam: For sure. I’m wondering what you see as the big challenges companies are facing to virtual healthcare as data is leveraged to improve services. Is that going to be tricky, do you think?

Rebecca: Well, I think this is an important question, especially for mental health care, and it goes back to your previous question about AI services. How much of human interaction can actually be replaced? And how much do we want the human touch to be replaced? In some cases, an AI therapist or an AI counselor can support certain issues, but in many cases, therapy works because it’s about connecting with another person. It’s a long-term relationship.

“There’s always going to be instances where people will have to go to a doctor’s office or meet with a person”

The benefit is that, for a large number of services, we can increase access by making things more automated, by leveraging data, by improving efficiency, and that’s a big thing that we’re doing at Little Otter. But you also have to recognize that there are always going to be instances where people will have to go to a doctor’s office or meet with a person.

The downside is that, well, we’re one of the few digital mental health companies that was actually founded by a doctor. What I worry about is as things get more and more pervasive in this space and more people enter it, people already don’t know what good versus bad mental health care is, right? It’s hard to tell and it only works if it’s done properly and scientifically. I think that’s a big question we’re going to have to grapple with.

“You don’t know when issues are going to come up. They don’t happen on a schedule. One day, things are fine, and the next day, there’s a meltdown”

Liam: In this space, we hear a lot about the benefits for older people who live alone, having a doctor regularly checking in via video consultation. We read and see a lot about that. But what about children? How can telehealth services support families’ mental wellness?

Rebecca: That’s really why we designed Little Otter to be a kind of family-first, in-your-home model. Just like with elder care, you don’t know when issues are going to come up. They don’t happen on a schedule. One day things are fine, and the next day, there’s a meltdown. How do you make it so it’s more of an asynchronous, on-demand service? Many of our families text videos of a tantrum to their provider and are like, “How was I supposed to handle this?” That is a much better way of getting care than, “Well, I hope you take notes. You’re going to come to my office in a week, and we’ll talk about it.” And you can also see people’s homes. It’s like, how do you make sure you’re providing support that actually works with a family that’s not just seeing someone in this isolated environment? That isn’t a realistic expectation.

A revolution in mental health care

Liam: What’s next? Have you any big plans or projects for 2021?

Rebecca: We’re building Little Otter to be the go-to mental health service for families under the age of 12 everywhere. We want to change the way people think about mental health. We want families and children to identify issues earlier, we want people to be proud that they were Little Otter kids or part of our membership. I know that’s what every CEO says, but I think we’re entering a really new wave and have a huge opportunity. What if we had a generation that had access to mental health care earlier? How would that change the world in the next 10 to 15 years?

So we’re building that, which is an incredible challenge and fun. And then, in the next year, even in the next month, we’re really focused on back to school and this transition after the past year. There’s so much uncertainty, so how do we create a service that kind of embraces this moment and meets families where they are while also thinking long-term? Because hopefully, we’ll be getting out of this. How do we meet the moment and also provide care that can scale and be sustainable? So yeah, a lot of building, a lot of awareness. I just hope that we can reach as many families as you need us.

“We want to change the way people think about mental health”

Liam: It sounds great. Lastly, then, where can our listeners go to keep up with you on your work?

Rebecca: I’m on Twitter, @RebeccaEgger, obviously on LinkedIn as well, and Little Otter is on LinkedIn, and then you can learn more about Little Otter at littleotterhealth.com. We have tons and tons of resources for parents. We have a free tantrum screen for kids two to six to help identify if tantrums are normal or something you should worry about. We’ll be releasing our back to school mental health toolkit in two weeks and we’ll be making a lot of announcements about that. We’re on Instagram and Twitter and Facebook and everything.

Liam: Brilliant. Well, Rebecca, it’s been great to talk to you. Thanks so much.

Rebecca: I really appreciate it. Thank you.