The Assessor: An Interview with Dr. Cynthia Osborne

Cynthia Osborne has become one of the key people to whom the state of Texas turns when it wants a rigorous evaluation of one of its child protection and prevention programs.

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By Daniel Oppenheimer
Editor, Texas Health Journal


Over the course of her career at The University of Texas at Austin, Cynthia Osborne has established an extraordinary working relationship with the state of Texas. As Director of both the Center for Health and Social Policy and the Child and Family Research Partnership, Osborne has become one of the key people to whom state agencies turn when they want a rigorous evaluation of one of their child protection and prevention programs.

Osborne, who is also Associate Professor and Associate Dean for Academic Strategies at the LBJ School of Public Affairs, has conducted evaluations for the Texas Home Visiting Program, the largest home visiting program in the country; for critical child welfare programs of the Texas Department of Family and Protective Services; and for key child support programs of the Texas Office of the Attorney General.

Although some of her work is strictly retrospective, looking back at programs that have been completed, she also works in real time, conducting rapid cycle evaluations as programs are being implemented and iterated. The goal is that the feedback she and her colleagues are collecting and synthesizing will actually change, for the better, services being provided to the people of Texas.

We interviewed Osborne, on camera, at one of her offices at the LBJ School.

Texas Health Journal: How did you get into this line of work in the first place? Did you know from pretty early that you wanted to study social policy?

Cynthia Osborne: Not at all. When I first graduated from college, I worked as a research assistant for an economic consulting firm. I ran statistical analyses and they used that information for expert testimony and corporate litigation and things like that. It was interesting work, on its own terms, but I didn't have any sort of feeling that what I did made a difference.

During that period I started to just read all sorts of books, and one of the books I read was Jonathan Kozol’s Savage Inequalities, about conditions in America’s schools. It made a profound impression on me. I grew up in a working class family that was very stable and secure. I had a good education. I had good schools. Good home life. I was able to go to college, working my way through, without ever really reflecting on how unequal things were. I was pretty shut off from that reality. Reading that book was the first time that I thought deeply about the issue.

I started to read more and more, and to think more about the causes of inequality, as well as about potential solutions. I became convinced that the school system was key, was where the answer would be. If we could just make sure that every kid had a good education like I did, then all the problems would be solved. So at that point I decided to teach for a few years so I could figure out what's going on in the schools. Then maybe I’d take what I learned and bring it up to the more systematic level.

So that's what I did. I taught in a low-income school in California for a number of years. On about my second day there, though, I realized it's not just the schools. For so many of the kids I taught, there were things going on outside the school walls that made it very difficult for them to focus. When your dad is hauled off to jail, there is a shooting in your neighborhood, or there's a new person living in your household, it’s hard to focus on school. These are all things that my students would come and talk to me about. So rather than go into education, I decided I wanted to learn more about community poverty, social policy, and the family. And that's when I decided to go back to school and really study in those veins.

You’ve conducted a lot of evaluations and studies of a lot of different policies that seek to prevent maltreatment of children and improve services for families who are in the child protection system in one way or another. Is there a big picture insight that you’ve distilled from evaluating all these different aspects of the system?

There’s no one policy answer to these challenges. One thing I do know, which in a way is the flip side of what was obvious to me after working in the schools, is that for kids the single most important thing is that they have enough love, attachment, and resources devoted to them from the start. That’s not a policy answer. The policy arised when we seek to identify the things that prevent kids from being able to have those things, that prevent parents from being able to give those things to their children that they absolutely want to give, and then devise way to remove those obstacles.

Are there specific, evidence-based programs that have been shown to reduce maltreatment?

What really works, at the big picture level, is education and wages and resources. It’s these big macro policies that we know can make a difference for families, in either a positive or a negative direction. We saw during the last recession, for instance, that rates of maltreatment went up in families who had been solidly middle-class who were suddenly experiencing all the stressors of low-income status, like trying to find a job, losing health care, losing their home, and other things like that.

If you’re talking about specific interventions and programs, rather than macroeconomic forces, the truth is that we have not been able to demonstrate a connection between a specific intervention and a reduction in rates of child maltreatment across the board. And we may not be able to ever do that, even if we do see the rates come down over time. Such reductions are likely to be so incremental, and the result of so many factors, that it may be impossible to tie an outcome to a specific program. This has been the case, for instance, with the really dramatic reduction in teen pregnancy over the last few decades. We know that the rates have gone way down, and it is likely that various programs had something to do with it, but it is really difficult to connect one specific program to the reduction. With these big social problems, what we want to do is throw everything we can at them, and pay attention to evidence of efficacy where it’s available.

In the case of child protection and prevention, what we do know is that there are about 20 home visiting programs that have been demonstrated, through rigorous evaluation, to make a difference in things like school readiness, maternal and child health, social and emotional learning, and other indicators of well-being or health. That doesn’t mean we can just take an evidence-based program off the rack and assume it will automatically work in Texas, or in different regions of Texas. What has been shown to work in one context does not necessarily work in others. But if we are attentive to what the evidence base says, and are responsive and adaptive to what we learn once programs are deployed in the field, there is reason to believe that we can make a difference.

The challenges our families face are not going to be solved overnight. They’re not going to be solved with one silver bullet. There isn't one answer, which is why I think that the state's approach to this, which involves more systems-level work, is really important. They're not trying to just say there's a program for every problem and scale this program and everything will be fixed. They are working to understand how all of these issues are interconnected. And the more that we look at these really entrenched problems through that lens, I think the more successful we're going to be.

Can you give me an example of what this kind of systems-level approach might look like?

Sure. We’ve recently been brought on board to conduct an ongoing evaluation of a new home visiting program that has just been launched in Austin called Texas Family Connects. It’s based on a program that was piloted in Durham, North Carolina, and had real impact there. It’s similar to other home visiting programs that the state funds, where a nurse visits a family with a newborn to provide education, support, referrals, etc. What’s unique about this program, though, is that it is universal.

Every mom in the hospital who has a new baby, no matter if she is college educated or a teen mom, is greeted, welcomed, and congratulated on the new baby by a nurse from the program. The nurse then asks, “Can I come and visit with you in about three weeks just to give a little check in and see how you and the baby are doing?" Then she comes and visits with the family and does an extensive check, not just on health but also on all the other aspects of social and emotional well-being. Do you have childcare if you're going to work? Do you have transportation? They do screenings for mental health, depression, domestic violence, and so forth. They make sure that there's a safe place for the baby to sleep and that the mom understands what that means. And when they see that the mom has any unmet needs, they're able to provide a warm handoff between that mom and the resource in the community. So whether it is that the mom needs child care or a car seat, or to get signed up for food stamps or a mental health consultation, they can begin the process of connecting them to support.

What is beautiful, what makes this a truly systems level approach, is that for the universality to be possible the community has to align itself across a whole spectrum of services and support. The hospitals are involved. The gynecologists are involved. The pediatricians, the child care providers, the social support services, the city services. Everyone is watching and thinking: “Here's a family that's in our community. What do they need? How can we best support them?”

We work with the United Way of Greater Austin and Austin Public Health to facilitate a feedback loop from the families, so that it’s not just a one-way street. They’ll call back in four to six weeks after the first visit to their house to find out how it went, whether it was useful. “How'd it go when you said you needed this?” “How did it all go?" Then they’re able to say, "You know it was great. I really loved it.” Or, “There was a long wait list for the service they recommended and I couldn't get in." Or, "No one there spoke Spanish and I couldn’t access the services.” Or “There wasn’t a bus line that could get me there." So all that sort of feedback helps the community to think about changes in transportation, changes in training, changes in the types of services it provides or doesn’t. Over time we may get to see that we have way too many of one thing and not nearly enough of another, and shift the allocation of resources. And so we get to build the types of services for a community that they actually need.

This just launched in September, at St. David’s South. We're hoping that it's going to be expanded to the all across the community.

It sounds expensive.

The cost is about $500 per family, which isn’t that much per family but adds up as you scale. We have 17,000 babies born every year in Travis County, so to provide the service for the whole county would be expensive. But you have to ask what you’re getting for that expenditure. Not just a better start for the kids, and more support for the parents, but potentially savings in other areas. In Durham they did an analysis that found that for every $1 invested there were $3 in health care cost savings, a lot of which came from fewer visits to the ER. There were also fewer Child Protective Services investigations, after five years, of families that had participated in the program.

Why not just target it to the families that need it the most, or are at highest risk for certain kinds of problems?

The universal nature of the program isn’t just about catching everyone up in a dragnet so that the few people who really need acute help are caught as well. It helps us to understand that every new parent has challenges. When this program was piloted in Durham, they found that 94% of the moms who they visited needed something. Some just needed information, or a lactation consultant, or something concrete and limited like that. Others needed very acute intervention. Visiting everyone helps us to triage. They do a whole family assessment. It's not just of the newborn, or the mom. It's about mom and dad, and how they might be dealing with the infant in the context of their relationship, and their other kids, and how it is all going to work together. They do that assessment and are able to say, “You're a really good candidate for an intensive home visiting program. You're a great candidate for someone who needs to go to maybe one or two sessions just to make sure that you're comfortable with all this diaper changing or feeding or whatever's coming your way.” And so on.

There are programs that are much more intensive, and expensive, which would be difficult to make universal. This approach allows us to direct the parents who need those kinds of services into them, but also to provide other resources for everyone else. It becomes a resource for the whole community, and depends on the community in turn to support it and align with it. The hope, also, is that it builds overall strength and resilience in the community in ways that support everyone, including those with the most severe challenges.

What keeps you going? This is hard work. I mean that in two senses. It’s hard to work in the area of child protection, where some really awful things are happening. And it’s hard to work in the realm of social policy in general, where change is slow (if it happens at all).

I’m not working on the ground level, like the caseworkers are, where you’re interacting directly with families, and with children who have been maltreated. That’s the hardest job in the world. Even for them, however, it is not at all just bad outcomes. At an individual family level, there are folks who are able to get their feet underneath them, and the nurses and case workers and others who work with them are really making a difference in their lives

We hear those sorts of stories, and they are very rewarding. But from a researcher’s perspective, what's rewarding is when folks actually listen to what it is that we're saying. We go talk with the communities, talk with the frontline workers, and try to understand what's working, what's not working. We bring that information back to our clients, whether it's a state agency, a large nonprofit, or a local health department, and we say, “This is what we're hearing. This is what seems to be working, what's not working." And we help them to figure out how to be responsive to that information. Do you need different training? Is it better communication? Is it a different policy that needs to be put in place? Can we, through this process, actually help correct or improve some of the inefficiencies in the field. Can we close the gap between what we say that we're going to do and what is actually done at the very end of the line.

When changes are made in part because of the knowledge we’ve brought to the process, that's the really rewarding part of the job.  I'm a researcher. I'm not making any major difference in anyone's live. I realize that. But hopefully through small changes to policies and programs, over time, we are helping to make things a little bit better. That hope, and sometimes the evidence of that hope being realized, is what keeps me going.