SCHOOL HEALTH CLINIC
LOOKING BEYOND THE TUMMY ACHE
Last year,
a George Middle School student died from inhaling butane. In another incident, four boys burned
their legs with a fungicidal spray, hoping to scar their bodies to deepen their bond of friendship.
And a play called Secrets, based on true stories of young AIDS victims, raised many
questions from students during a Q&A session.
Drug use, self-mutilation, unprotected sex: These are among the grim but critical issues
dealt with at George's health center, one of the first two school-based clinics in Portland middle schools.
After the butane death, the school's crisis team worked one-on-one with students who were troubled by
the tragedy. The boys who turned up at the clinic with ulcerated legs received counseling in identifying
healthier ways to bond. After the Kaiser-sponsored AIDS play, students swarmed the clinic asking for
HIV screenings.
"Kids have to know the risks that are out there," says Principal Jane Arkes. "These are
not little-kid things. These are life-and-death issues."
Based on its 10-year experience operating clinics in Portland high schools, the Multnomah
County Health Department knew that the risky behaviors that threaten high schoolers' health typically
begin in middle school, says community health nurse Lori Koch. Last year, the county set up the
city's first middle school clinics at George and Portsmouth middle schools. The schools are located
in the St. John's neighborhood, an economically and culturally diverse area in North Portland where
health-care services are scarce.
"One-third of the population here in St. Johns has not graduated high school," says
Koch, who works full time coordinating services at the clinic. The neighborhood has the city's
highest percentage of people over age 25 without a high school
diploma, according to data from
Portland Public Schools and Metro. "You have a very high population of parents who are
undereducated, underemployed, and, therefore, underinsured."
Sniffles and sore throats, headaches and lice, immunizations and sports physicals are the routine
reasons kids come to the clinic. But when a student shows up again and again, clinic staff look behind
the ailment of the day.
"After you've seen a tummy ache two or three times or a headache two or three times,
you know something else is going on," says Koch. "We're able to talk to them and route them into
some form of help."
Denise Chuckovich, who manages school-based health centers in Multnomah County, says:
"What's really happening is that students are checking the place out—Is this a safe place?"
Alcoholism and sexual abuse—problems that often crop up in struggling families—are
common in St. Johns, according to Koch. Kids in alcoholic or abusive homes frequently visit the clinic
with minor complaints.
"We see them for the sore throat, the earache, the sprained ankle, the period cramps," says
Koch, who works with a full-time mental health consultant, a half-time pediatric nurse practitioner, and a
senior office assistant. "They usually present with fairly small things. By the third visit, we do a
risk assessment, where we look at everything." The thorough checkup provides a full picture of the person,
including where they live, what their lifestyle is like, substance use, sexual history, medical history, and
psychosocial history. "We identify risks and then work on a care plan around those risky
behaviors," Koch says.
A care plan can include individual, group, and family counseling, as well as referral to outside
agencies. A key clinic goal, Koch says, is keeping kids in class. For example, a child with an upset
stomach may be reacting to a stressful situation at home. Before the clinic was established, the student
would report to the office; if the school nurse wasn't in, the student often was sent home. Now, Koch
says, clinic staff can diagnose and treat the illness and its underlying causes, while keeping the child
in school and then returning her to class.
Kids can't get condoms or birth control at the clinic. But they can get information, counseling,
and exams for family planning and sexually transmitted diseases (STDs).
"Eighty-five percent of the family planning counseling I do is on abstinence," says Koch.
"Our focus is not talking about birth control. It's talking about choices. It's talking about what you
want to do with your life, what your goals are, and how early sexual involvement changes that."
If students want birth control or condoms, they are directed to county clinics outside the
school. By law, kids don't need parents' permission to get family-planning counseling, birth-control
devices, or treatment for STDs. Clinic staff strongly encourage students to involve their parents. But
kids often are reluctant or unable to discuss the subject at home. Parents, too, sometimes shy away from
the topic, Koch points out.
"The beauty of it is that many of the kids who have not been able to talk to their parents
about sexual issues have a safe place to come and get information," Koch says.
Except for family-planning and STD services, students need parental permission to access medical
or mental health services at the clinic. About 80 percent of George students have permission to use the
clinic—a percentage that Koch expects to increase when non-English speaking parents begin receiving permission
forms in their own language. The county, Koch says, is working on translations.
The angry objections some Portlanders raised when the first school-based clinics opened
in Portland in 1985 have given way to strong community and parental support, says Chuckovich. "Once
we get in and start delivering services, people see what a valuable resource it is," she notes.
In a typical month, about 250 students—half the student body—visit the clinic. Many
go in more than once. Services and prescriptions are free, although Medicaid and families' insurance
companies sometimes are billed, says Koch.
Sexuality issues are only one small piece of the clinic's work. Less than 10 percent of the
services provided at George relate to family planning, Chuckovich says. "We really want to look
at the whole picture of what's going on with that person and respect them as a person," she
stresses. "They feel very comfortable here."
—Lee Sherman Caudell
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