At Broad Acres Elementary, educators say the school's busy health-care center is a necessity for many sick or trouble children.
The wall clock in the school health center ticks by 8:30 a.m., but the new family never shows. Nurse Ladys Lux gazes out a nearby window with narrowed eyes, as if searching for her missing patients in the knots of dark-haired children scurrying across the schoolyard through a biting, mid-December wind. "Normally, we don't schedule physicals when the families first get here because so many don't stay," Lux says. "But we did this time when we saw this family had other problems."
The petite woman's voice trails off as she turns away from the window and reaches for the phone on the reception desk. The family she speaks of is headed by a poor, single immigrant mother from El Salvador who recently moved into the surrounding neighborhood with her five children. One of the youngsters has spina bifida, a congenital disability that can require extensive medical care. It's unlikely that any of the children have received much in the way of medical care during their young lives, Lux says, but that will change now that they're here, at Broad Acres Elementary School. They will now have access to a pediatrician, a nurse practitioner, a nurse technician, a psychiatrist, a psychologist, therapists, and, of course, Lux herself.
The Broad Acres clinic is one of 1,500 school-based health centers nationwide that bring a wide range of medical, nutritional, and mental-health care to millions of students and their families. The centers, the first of which sprang up in the early 1970s in Dallas and St. Paul, Minn., provide an important safety net for children and adolescents—particularly the more than 10 million today who lack health insurance, according to the Washington-based Center for Health and Health Care in Schools.
For the community served by Broad Acres Elementary, Lux is more than a school nurse—she's a lifeline. The school, though located in Maryland's Montgomery County, a wealthy suburb of the nation's capital packed with medical specialists, high-tech hospitals, and busy doctors' practices, is at the heart of an unofficial village of squat, brick apartment buildings isolated from the world around it by class, language, and culture. Inside the buildings, it's typical for two or more families to share a two-bedroom unit, adding to the stress the occupants already face each day as they juggle multiple low-wage jobs in hotels, restaurants, and landscaping and construction companies—work that may be there one day, gone the next. Few of the working parents have cars, and some don't even have telephones.
The school itself has the dubious distinction of being the 140,000-student Montgomery County district's neediest; nearly 94 percent of its 500 pupils receive free or reduced-price lunches. Spanish is the dominant language spoken in the community, followed by Vietnamese, and nearly 30 percent of the students are enrolled in remedial English. Broad Acres' student-mobility rate also hovers around 30 percent.
Assoua rests with a warm towel over her eyes as treatment for an
As such, the health center has the full support of Principal Jody Leleck, who is working to raise her school's academic standing in today's world of high-stakes testing. "You can't understand the stress children suffer in a high-poverty environment," she says, "and that stress manifests itself in so many ways. If we didn't have [the health center], my full-time job would be social services, and we'd never get to the learning piece."
In short, many of the heads of households here lack the money, time, language skills, and education to deal with an expensive and complex U.S. health-care system. The sheaf of paperwork required for medical assistance alone is enough to drive many of the parents away, Lux says, even when they have help, even when the forms are in Spanish.
Lux, a native of Ecuador who is fluent in both Spanish and English, has already cleared that hurdle with the Salvadoran family, a process that can take considerable time—minutes and hours that are not reimbursable under any public or private insurance plans. So, she is determined to track down at least the three children enrolled at the school to bring them in for physical examinations by a nurse or doctor.
"Who knows what we'll find," she says, a worried frown creasing her brow.
Lux's concern for the new students is based in part on the experience that her patients' health problems are sometimes not as simple as they seem at first glance. On a recent weekday morning, an overweight boy in a T-shirt sits hunchbacked, knocking his heels against the metal side of the examination table while the health center's nurse practitioner, Cara Soifer, peers into his ears with a light. The 9-year-old has been a frequent visitor to the health center in the past. His complaint this morning is an earache, and he winces when the nurse touches his left ear. But it's the extra pounds the boy is carrying that most concerns Soifer.
"You have a lot of fluid in your ears," she tells him. "Unfortunately, the kind of ear pain you have won't be helped by medicine. You need to move around and drink more water."
Soifer, who doesn't appear to carry a pound of extra weight herself, begins to quiz the boy about his weekend.
"What did you do?"
Played video games, the 3rd grader mumbles.
"What did you drink?"
"Did you go outside at all?"
He shakes his head.
As in schools nationwide, a growing number of children at Broad Acres Elementary are overweight. The nurses here say it's the result of inactivity and eating too much of the wrong foods. "That's a real problem in this school because the kids only have gym class once a week, and there are very few after-school activities that are physical," Soifer says. "And all they drink is soda and juice."
The nurse practitioner stands silently for a moment eyeing the boy before her with a hand over her mouth, as if considering her words carefully before she speaks. "You really need to take a break from the [video games] to at least stretch," she counsels him. Soifer's patient refuses to meet her eye, but she is persistent, asking whether there are any physical activities he likes, such as playing outdoors with a soccer ball. The boy seems to pull inside himself, hanging his head to avoid the nurse's gaze and picking at his hands.
Soifer lets him off the hook and wraps up the session. "Well, I guess it's cold outside, so it's hard to go out with a ball right now. But you need to drink," she says, "And water, not soda. It will help thin out that snot that's backing up into your ears."
She gives the boy Tylenol and sends him back to class. As she watches him shuffle back down the hallway that connects the health center to the main school building, Soifer shakes her head and raises a tissue to her own runny nose.
"He doesn't get enough activity, but it's not going to change," she says, sinking into one of the waiting-area chairs with a mug of hot tea. "His father is overweight, he's being raised by a babysitter, and it's difficult to make them understand that this is a serious problem."
But, like other students here, the boy and his family have struggles beyond their weight. Soifer nods toward the suite of offices that houses the therapists and social workers who make up the other half of the Broad Acres health center. "They've worked with the family a lot," she says.
Marta Contreras, a full-time mental-health therapist at Broad Acres, believes that the health of the mind and the body are inextricably linked, a philosophy reflected in the close working relationship between her program, called Linkages to Learning, and the health room. "You can't look at the physical without looking at the mental health," she says.
A tiny woman with a mane of thick, curly black hair, Contreras leads a busy 14-person staff that includes a part-time psychologist, therapists, social workers, five interns from area universities, and a psychiatrist who comes twice a month to write and adjust prescriptions for children with conditions such as attention deficit hyperactivity disorder or anxiety. Linkages to Learning also offers English-language and computer instruction for parents, seminars on pressing health topics, nutrition counseling for families, and other services.
The mental-health staff itself posted 746 sessions during the last budget year, seeing a total of 32 clients, many of them in need of ongoing treatment for problems such as mood disorders and ADHD. "These families are under a lot of pressure," Contreras says simply.
And the referrals keep coming.
A kindergartner with a heart-shaped face beneath a heavy fringe of black bangs comes into the health center on a recent winter morning with her mother, who looks weary with her own hair pulled back from her face in an untidy ponytail. Her daughter, on the other hand, grins broadly at Soifer and even giggles as Lux translates the nurse practitioner's questions into Spanish for the mother, and then relays the answers to Soifer in English. The 5-year- old's complaint is a stomachache, accompanied by ear pain. Soifer does find an infection in one of the girl's ears, but the nurse's questions reveal that she suspects a potentially deeper problem.
Jocelyn and mother
Juni Lopez, recent immigrants from El Salvador, listen to
Principal Jody Leleck, while nurse practitioner Cara Soifer and
Lux confer behind them.
The girl is bordering on what the nurses here call "frequent flier" status, meaning she's been to the health center a lot lately. The frequent fliers aren't necessarily the children who come here for treatment of chronic illnesses—the 45 asthmatics, the two diabetics, or the handful of others with either liver conditions, ADHD, allergies, or seizures. Instead, these students tend to trot in regularly with complaints of runny noses, stomachaches, headaches, and other mild symptoms that can't be traced to any underlying physical cause.
"Tell me what's been going on at home," Soifer urges the mother. Lux translates the question, and the mother turns to Lux and launches into a lengthy explanation in Spanish. "She says that even though [her daughter] sleeps all night, she is complaining in the morning that she's tired," Lux says. "Every day, she asks if the next day is going to be school. She wakes her up early, but she doesn't want to get up. She says she doesn't want to go to school."
In the next few minutes, Soifer learns that the pupil is performing well in her classes and has friends. The mother guides the daughter through the same wake-up routine every morning, and the girl seems to be fine when she arrives at school, where an older sister also attends classes. Yet her complaints of sickness arise in the evenings and mornings during the school week and disappear over the weekends.
The nurses conclude that she misses her mother and suffers anxiety when she knows they'll be separated. Soifer decides to write a referral for the pair to speak with one of the therapists on the Linkages to Learning staff. "When I first got here, I felt like I had to ration out the referrals to the school guidance counselor and Linkages," Soifer said. "Now I don't hesitate."
The 5-year-old boy on the exam table is not answering Dr. Phyllis Harris' questions—at least not the first time she asks them. "Do your ears hurt?" she asks.
"Are you coughing at all?"
Again, the kindergartner, dressed in tattered jeans and a red shirt several times too large for his tiny frame, says nothing. He simply squirms beneath the pediatrician's searching hands.
"How's school?" Dr. Harris asks. And again: "How's school?"
"Fine," he says, perking up the second time she asks him.
"Have you been having trouble hearing?" she asks loudly.
"Yeah," he replies, smiling up at the doctor.
The boy's visit with Harris on a recent Wednesday afternoon is a follow-up appointment. Two weeks ago, he came into the health center seriously ill with a double ear infection, bronchitis, and a fever. Both ears are still infected. The boy says he finished the antibiotic prescribed at his last visit, but the doctor says it's hard to tell.
A tall, thin woman with dark-rimmed glasses perched on her nose, Dr. Harris recounts a day early in the school year when the boy came into the health center wheezing, a sign of asthma. His mother insisted he'd never been treated for asthma before. But he was clearly familiar with the medicine dispensers for asthma when he was in here, the doctor says, and the mother ended up changing her mind when pressed by the health center staff.
school nurse Ladys Lux comforts kindergartner Christopher
Estrada, who has asthma. The Montgomery County, Md., school is
located in a lower-income neighborhood where access to
health-care services is limited.
"Now I'm worried about how well he'll do in school if he can't hear," Dr. Harris says. "We're not sure how reliable his mother is for proper administration of his medicine, and we have difficulty reaching her because she has no telephone. He appears to be dosing himself."
Fortunately, the boy is an exception, the doctor adds. "Most of the parents here are very involved," she says, "and they're very comfortable coming here."
The doctor's positive assessment of the community is one expressed by every member of the health center staff. "The parents here are very proud," Lux says. "They want what's best for their children."
As for the new students who missed their appointments, Lux learns after several phone calls that two of the three children enrolled at Broad Acres were home sick the day of their scheduled physicals.
"We will have to try again, maybe after the holidays," she says, tucking a thermometer into the mouth of a little girl who was the school's first case of flu this year. "We need to get them in here."
Vol. 23, Issue 21, Pages 26-29Published in Print: February 4, 2004, as Health-Care Hub