Can You Hear Me Now?

Can You Hear Me Now?
A look at what happens when quiet health problems go undetected in students. by Lory Hough
Joanna Belcher, Ed.M.’08, wasn’t surprised when Diego’s mother came to the elementary school in Compton, Calif., where she was working as a reading and language arts teacher, to talk about her son. For the past two years, the single mother had been meeting with Belcher to discuss work habits and homework for Diego, a fourth-grader, and for her older son, Edgar. At the time, Belcher was driving the two boys on Saturdays to a gifted program while the mother worked. The previous year, she helped them pick a middle school for Edgar.
“I wasn’t surprised when she came to me because I had a great relationship with this mother,” says Belcher, now a student in the School Leadership Program.
What shocked her was what Diego’s mother had to say: At home she was repeating comments to her son and suspected he had a hearing problem. After getting a referral from the nurse’s aide at school, finding a local clinic, and helping the mother, who spoke Spanish, translate her concerns to the specialist, Belcher discovered that the mother was right. Diego had almost no hearing in one ear.
“I’m ashamed to say that I didn’t notice his hearing loss. He was a very bright student who aced almost every assignment and loved to participate in class,” Belcher says. “When she brought the subject to my attention, I thought about small indicators, like him asking me to repeat questions frequently, that I hadn’t associated with possible hearing loss.”
Diego is actually one of the lucky ones: As a fourth grader, he was still doing well academically in spite of his hearing problem. But what would have happened if the problem had gone unnoticed for another year? For five years? Like many kids, his grades might have started to slip or his attention in class may have waned — and no one would likely have connected the dots. Hearing problems like Diego’s are just one of the many undetected “quiet” troubles, as Lecturer Rick Weissbourd, Ed.D.’87, calls them, that some students bring to school every day, particularly students in low-income communities. They come hungry, sleep deprived, and unable to see the blackboard. Some are stressed, depressed, and anxious about their safety.
On their own, these troubles, whether physical or psychological, are just that: troubling. No one wants a child suffering through class with a massive toothache. But what’s even more worrisome is the fact that for some students, these quiet troubles, when left unchecked, can spiral into bigger health and learning problems that can severely impact their ability to do well in school.
An undetected vision problem, for example, makes it hard for a first- or second-grader to read, Weissbourd says. “Reading failure is one of the prime pathways into special education, and once you get into special ed, it’s hard to get out,” he says, noting that an estimated 25 percent of students in urban schools have undetected vision problems. “Deal with the vision problem so that you don’t have to put the kid into special education. I don’t want to overstate this — most kids in special education do not have undetected vision problems — but it is a factor.”
Antonia Orfield writes in Eyes for Learning that schools in only 32 states mandate annual eye exams; even when given, the exams focus primarily on the ability to see far. In most states, parental follow-up is not required. Students miss the vision test because many families, especially in urban areas, move frequently. Kids also lose glasses, and Medicaid can take months to replace them. With 85 percent of school activities being visual, once students fall behind, it can be hard to catch up. One study found that 80 percent of juvenile delinquents doing poorly in school had vision problems.
Nutrition is another quiet trouble. Research shows that weight affects attendance. A study published last August in the journal Obesity found that obese and overweight fourth- to sixth-graders in nine schools missed more days each year than underweight and “normal” students — 12.2 for obese, 10.9 for overweight, 10.1 for normal, and 7.5 for underweight.
Students also miss days when they’re not eating enough, a problem that often impacts concentration. President Harry Truman tried to address this decades ago when he signed the National School Lunch Act in 1946, guaranteeing a free school lunch to children in need. Twenty years later, the breakfast program was added. Unfortunately, “kids are still coming to school hungry,” says Weissbourd. In the United States, an estimated 11 million children live in homes where people have to skip meals or eat less in order to make ends meet. Even when breakfast is provided at school, time constraints often push students through the meal, or if they’re on a late bus, they miss it altogether. When Belcher was working in Washington, D.C., many of her students came to school so hungry that they complained about head- and stomachaches. She started handing out granola bars and other snacks. She would also make bag lunches for students to take home for the weekend.
Why are these quiet troubles going unnoticed or untreated? For starters, as Weissbourd discovered in a study he did with Caroline Watts, Ed.M.’87, Ed.D.’93, and Lecturer Terrence Tivnan, M.A.T.’70, Ed.D.’80, the very nature of quiet issues makes them difficult, if not impossible, for overextended teachers and other educators to detect or measure. Caretaking is an example. Many students supervise siblings and tend to sick parents, which can lead to less sleep and added stress. Other students are being cared for by elderly relatives whose own health situations make it difficult to fully care for children.
Quiet issues also get drowned out by “louder” issues. Aggressive and challenging kids often become the focus of attention in school. These kids, Weissbourd explains in his book, The Vulnerable Child, can “operate like brushfires in a classroom, igniting other children and engulfing the energies of their teachers. They require constant vigilance: they are always in the center of their teachers’ radar screens.”
As a result, quiet kids and their problems get overlooked. Belcher says that her experience with Diego, a star student, made it painfully clear how easily this happens.
“Teachers may not notice quiet problems with students who work very hard and aren’t behavior problems,” she says. “During my first two years of teaching in California, I had 33 students in my class. Although I built wonderful relationships with my students’ families, the ‘squeaky wheel gets the oil’ concept definitely applied much of the time.”
Noticing quiet problems is just one hurdle, says Lesley Ryan, Ed.M.’01, a former teacher at the Lee Academy in Boston (a pilot school that Weissbourd helped start) who now oversees new teachers at four public schools in the city. Better preparing educators to handle quiet troubles is another.
“Without proper training for these issues and without someone to help you deal with them, then as a teacher, you don’t always know what to do,” she says. “If a child isn’t doing well, many times the first thing you do is start a psychiatric evaluation. No one thinks to ask: Does this kid need glasses? It would be a lot easier to get a vision screening and find a donor for glasses than go through a whole psych evaluation.”
Charissa Saenz, Ed.M.’04, an English teacher at a rural high school in El Paso, Texas, says her formal education as a teacher focused more on academics and pedagogical theories. “When these issues were brought up, it was usually in the context of classroom management and student buy-in rather than how to deal with quiet issues in terms of resolution, administration, and school policy,” she says. That puts a lot of pressure on teachers.
“Personally, I am overwhelmed by the frequency and severity of these issues and often feel inadequate as an educator when it comes to dealing with them,” she says. “I speak for myself, but I’m sure that many educators would agree with me when I say that the burden rests on us when it comes to dealing with these quiet issues; any outside help or support is a rare commodity.”
Administrators and district officials, she says, are often more focused on more public troubles. “High-stakes testing and perfect attendance are frequently discussed during faculty meetings or teacher in-services,” she says, “while the quiet issues are rarely, if ever, brought to the surface.”
The problem is that schools can only take on so much alone, says Watts, director of Children’s Hospital Neighborhood Partnerships in Boston.
“It’s not fair to say that schools can take over these services if we don’t give them the resources they need,” she says. Her program, which is funded by grants, private donors, and some partner contributions, is trying to help with one resource that is sorely lacking in most schools: good mental health services. The program sends clinicians and social workers into Boston Public Schools to help children and families at risk before serious mental and emotional disorders emerge. It also trains school staff to identify and respond to signs of distress. Watts says the program started in 2002 when it became clear that schools in the city badly needed help. Research showed that 16 percent of Boston high school students had contemplated suicide, and 12 percent made a suicide attempt. At the time, the wait for outpatient mental health services had increased by about 200 percent.
One of the contributing factors is trauma — a louder issue that often gets expressed quietly. “Kids are living in unsafe neighborhoods or homes,” says Watts. “If they’re living in a home with domestic violence, this is a child who is probably sleep deprived because he or she is hypervigilant. That’s not a quiet problem, that’s a huge problem.”
Belcher remembers one student who was about two years behind in skill level. At the time, her primary caregiver, her grandmother, died, and then her father was shot and killed by police. The school didn’t have a counselor, so Belcher did what she could: she bought the student a journal.
“Her writing contained detailed descriptions of violent acts and her feelings,” she says. “As a teacher, it was so frustrating for me to see a child in so much turmoil and not have any professional resources with which to connect her at school to help her get through this time.”
Getting to know students at that level is one way to discover quiet issues. Getting caregivers involved can also help, says Lecturer Jackie Zeller, a psychologist who also works with the Children’s Hospital Neighborhood Partnership.
“When caregivers feel that they can trust their children’s teachers, they are more likely to reveal familial challenges and more personal information that might be impacting their children’s progress at school,” she says. “Children are embedded in multiple contexts, and undeniably the home is one of the most important of those contexts. If we do not include parents and caregivers in our conversations, we are missing important partners for our students’ successful development.”
Hearing problems...are just one of the many undetected “quiet” troubles, as Lecturer Rick Weissbourd, Ed.D.’87, calls them, that some students bring to school every day, particularly students in low-income communities. They come hungry, sleep deprived, and unable to see the blackboard. Some are stressed, depressed, and anxious about their safety.More often than not, says Liz Aybar, Ed.M.’02, principal of P.S. 1 Charter School in Denver, caregivers want to be involved.
“I get frustrated when I hear the assumption that low-income parents don’t care,” she says. “I do not find that to be true. Most families in our school, across the board, tell us it is critical for their child to be in school and to do well. There can be circumstances where they’re working two or three jobs and they can’t be there, but our parents wholeheartedly advocate for their children’s education and want to be partners with us.”
At Codman Academy, a small charter school that Meg Campbell, C.A.S.’97, started in a neighborhood health center in Boston, the staff gets families involved from day one at the initial “intake” session by asking lots of questions: What were years one through three like for the student? How much TV does the family watch? What time do they go to sleep?
“We try to make everything transparent,” Campbell says, “and engage parents in a meaningful way.”
Sometimes, though, caregivers are also affected by quiet problems, particularly depression. It is estimated that between 10 and 20 percent of all parents suffer from acute or severe depression, says Weissbourd. Another 30 to 60 percent of lowincome parents suffer from milder forms of depression. Studies show that children learn best in language-rich environments where parents are reading and asking questions — something that is harder for depressed parents to muster on a daily basis.
“It’s a huge issue. It takes a lot more effort for a depressed parent to help with homework or read to their children,” he says. “Many do incredibly well despite being depressed, but it’s a whole lot harder.”
Not having health insurance also makes it harder for families to stay on top of quiet troubles. Although some states offer comprehensive insurance programs for the poorest kids, many states are struggling with funding these programs as they face the worst deficits they’ve seen in years.
“When families do not have access to health insurance, they often must wait until health problems become more severe, or they go to overwhelmed clinics where they may not see the same doctor consistently, affecting the doctor’s understanding of their medical history,” says Belcher.
Untreated dental problems are a prime example. For the first time in 40 years, according to the National Center for Health Statistics, the number of cavities in preschool-age children is on the rise. The news is even worse for poor kids. About one-third of all children living below the poverty level did not have a recent dental visit in 2005, compared with less than one-fifth of children with higher incomes. Poor dental care leads to pain and tooth loss, which can lead to high levels of absenteeism, the inability to concentrate, and in some cases, poor speech development. In 2006, the School of Dentistry at the University of Michigan surveyed 4,000 kindergarten and elementary students. A toothache kept 20 percent of them up at night and 3 percent home from school. Nearly 20 percent said discomfort made it hard to pay attention in class.
“Kids come to you holding their mouths. What are you supposed to do?” Ryan says. “Even if you send them home, if a kid doesn’t have insurance, nothing is going to get fixed. It’s another one of those problems that spirals. If you don’t have insurance, you don’t get cleanings, which leads to decay, which leads to pain, and then you can’t focus on your work.”
Although a lack of insurance is usually linked to poverty, Weissbourd stresses that many poor kids do not have problems and “lots of people do well despite the problems” that come from being poor. In addition, many quiet issues, such as sleep deprivation, cut across economic lines. A 1998 survey of more than 3,000 high school students from a variety of schools found that students who reported getting Cs, Ds, and Fs in school went to bed about 40 minutes later than students who reported getting As and Bs. Other factors contributing to sleep deprivation include being anxious and going to bed with the TV on. Early school start times have also been blamed. (Some schools, like Codman Academy, have responded by starting later.)
What more can be done? Prevention, most say, is critical. Schools need to form local partnerships with dental schools and mental health centers. With parents, they need to hold mattress and eyeglass drives. They need to better train teachers. They also need to better observe students.
In Denver, Aybar pairs each of her students with an advisor. They meet every day to see how the student is doing. Parents and guardians also meet with the advisors several times a year and become part of a support team that is pulled together if a problem — quiet or loud — is suspected. At Codman Academy, if a student has his or her head down on the desk, they are sent to the reflection room and asked to fill out a sheet that helps them think about their actions. Staff members meet weekly to review the sheets.
What more can be done? Prevention, most say, is critical. Schools need to form local partnerships with dental schools and mental health centers. With parents, they need to hold mattress and eyeglass drives. They need to better train teachers. They also need to better observe students.“We’ll look at the data and we’ll notice that student X was in reflection three times. One of us will go talk to that student,” Campbell says. “Something is usually going on in their lives. Our assumption is that you want to be here learning, so we have to figure out what’s getting in the way of that.”
Becoming data-driven around quiet issues is a must for schools these days, says Weissbourd. Too often, he says, schools do the minimum when it comes to these issues — a one-time workshop on proper nutrition, for example, that is attended by the same small group of parents. “We should try a different approach. Let’s try to be systematic,” he says. For example, “It’s important for schools to keep track of how many kids are coming to school sleep deprived. If a third of kids are consistently tired, the school should try several strategies and track whether they can bring that percentage down.”
Most schools, however, are not set up to think about students this way, says Watts. Instead, they divvy up the tasks.
“We tend to compartmentalize: grades are the teacher’s responsibility, feelings are the counselor’s,” Watts says. “We need to think about the whole child, the whole classroom, the whole school, and leverage our strengths.”
Schools also have to commit to making quiet issues a priority, says Ryan.
“It takes the school to be rigorous about issues like this,” she says. “They need to say to kids, ‘Hey, you need to wear your glasses,’ and then have parents stay on them. Kids lose glasses all the time. As a teacher, I’ve actually taken away kids’ glasses when they leave school when I know they have a pair at home, that way I know they’ll have them the next morning.”
For Campbell, making the rules clear also helps. This year, the school’s board voted to make dental exams mandatory for students. Those without coverage will be seen at the adjoining health center. Their handbook also says that students who need glasses have to wear them. “We’re not afraid,” Campbell says, “to be grownups.”