Aura M. Obando, MD, FAAP
September 19, 2016
I recently saw an eleven-year-old girl who was particularly anxious about the first day of school. During the visit, she shyly disclosed that she’d been having accidents on the way to school during the previous school year. The bus driver was unable to stop when she reported the need to urinate during the commute, which took over an hour each way because the homeless shelter where she currently lives is not in the community where she attends school.
I provide outreach medical care in motels for homeless families with the support of a multidisciplinary team at the Boston Health Care for the Homeless Program. As a physician caring for homeless families, I have to consider in each medical visit how a myriad of social barriers impact my patients’ health and well-being, from transportation challenges to food insecurity to the effects of living in a shelter or hotel room.
School-aged children add another layer of complexity; homelessness makes having a “normal” school experience unattainable.
When a family becomes homeless in Massachusetts, they are sheltered wherever there is an opening. The federal McKinney-Vento law provides funding to school districts to help minimize disruptions in school attendance, allowing students to continue their education at their current school or transfer to the district where they’re being sheltered. Many families opt to keep children enrolled in their “home” district, which can mean extraordinarily long bus rides, late arrivals and missed school breakfasts—all of which can reduce students’ attention span and ability to learn. In the shelters where I see patients, lengthy commutes are extremely common, with some patients reporting up to two hours on a school van or bus each morning and afternoon.
"National data shows that homeless students experience higher rates of school mobility, absenteeism, and lower graduation rates when compared to non-homeless peers."
Despite the McKinney-Vento law, homeless children miss a great deal of school. National data shows that homeless students experience higher rates of school mobility, absenteeism, and lower graduation rates when compared to non-homeless peers. Homeless children also have four times the rate of developmental delays and twice the rate of learning disabilities as housed children, making educational interruptions particularly detrimental.
Our team cared for a refugee family from East Africa whose two adolescent boys arrived considerably behind their peers because of the language barrier and the quality of schooling in the refugee camp where they lived for many years before coming to the United States. They’d been making great progress in an English as a Second Language program in their school, but then were sheltered in a town 15 miles away. When they first became homeless, their parents came into our shelter-based clinic deeply concerned that their children were not in school. Days went by, multiple emails were sent, and calls were made to the district to advocate for these children’s transportation to be set up so they could return to school. Finally, after an email to the state homeless education coordinator, the boys were able to return to school after missing a total of four weeks. Transportation considerations for a child with special needs, such as requiring a mobility device like a wheelchair or accompaniment by a monitor, are even more complicated, and these children are at even higher risk for delays in transportation arrangements.
Adolescents seem to struggle most with the emotional and social challenges of homelessness. Shelters and hotels do not usually have quiet study spaces conducive to reading and learning, for example. Food insecurity is pervasive in my patient population, and my rapidly-growing adolescents tend to report frequent hunger. Adolescents in particular become self-conscious when the school bus drops them off in front of hotels and shelters. They also are unable to participate in normal activities like having friends over. Extracurricular activities can provide stability, a sense of belonging and improve opportunities for employment and a college education, but it can be difficult for homeless children to participate in sports teams, clubs and special events like dances with added transportation and cost considerations.
"For those patients struggling with homelessness or housing insecurity, it is imperative to understand how housing status impacts their school experience and educational prospects."
I met Louise in a shelter for homeless youth last spring, and while she was struggling with depression, she was otherwise on a promising track. I was struck by her tenacious spirit and drive, and humbled that she had been living in a shelter for months, without the support of her family and with very limited financial means, and yet she was still about to graduate high school with plans (and a scholarship!) to attend a four-year college. She mentioned in passing that she would have to attend her prom in jeans as she had no other clothes and hoped people would not tease her for it. I sent an email to my team that afternoon, with the hope that someone might have a dress in her size to pass on. That email was forwarded and posted on social media, and the next day, we were inundated with offers of prom dresses, flowers, assistance with hair and make-up, and more.
Louise’s story, which she gave me permission to share, inspired so many to try create a “normal” high school experience for someone who had been through so many struggles. In the end, Louise was gifted a personal stylist experience at a large department store in addition to a new dress. She chose a beautiful gown in glimmering shades of blue and purple. I happened to be in the shelter clinic on the day of the prom and was able to see her in her full regalia, with her beaming smile, and overflowing excitement. She was so elated that she seemed to float right off the ground. Although our intervention was completely non-medical in this case, I know that helping her have this prom experience, along with the kind donations from others, shielded her from yet another trauma of homelessness.
The providers on my outreach team feel fortunate to be able to help in the way we do. These children’s needs are often so profound that every single patient encounter yields a success story, even if small. Each fall, my outreach medical care team looks forward to what we have come to love as backpack distribution season. We get to hand out brand new backpacks filled with school supplies at our homeless shelter and motel-based clinics to all the children on site. There is nothing more heart-warming than the excited grin of a child opening their brand new backpack. In that moment, housing status no longer matters.
As pediatricians, we have the unique responsibility to advocate for our most vulnerable patients. The AAP advocates for policies and programs like rapid re-housing and vouchers that aim to reduce family homelessness and is supporting a major expansion in funding that would eliminate family homelessness but there is more that can be done at the practice level. For those patients struggling with homelessness or housing insecurity, it is imperative to understand how housing status impacts their school experience and educational prospects. It is only then that we can take steps at the individual and policy level to do what we can to protect children from the negative impact homelessness can have on their education.
Aura M. Obando, MD, FAAP, a member of the American Academy of Pediatrics Council on Community Pediatrics, is an Instructor of Medicine at Harvard Medical School and on staff at Massachusetts General Hospital. An internist and pediatrician, she provides shelter-based care for homeless families in the Greater Boston area with the Boston Health Care for the Homeless Program.