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An olive-skinned boy with familiar doelike eyes and close-cropped hair perches on the stool in the corner of the examination room. Daniel is my 6-year-old patient for a well-child check, the third of the morning at the community clinic. He concentrates on his dirty tennis shoes but glances up when I enter the room. A generously proportioned African American woman accompanies him: his mom, I wonder. I introduce myself. “He’s been with me for a month,” she says. “I don’t know much about him.” Not his mom: foster care. I wonder what the story is. “But I think he has had trouble with asthma,” she continues. “He has an inhaler but no problems since he’s been with me.” She pulls folded papers from her large black purse. “Have you cared for children with asthma?” I ask. She nods. Daniel sits silently and continues to examine his sneakers. We talk about potential asthma triggers and the problem cough. The papers she has with her don’t say much about his medical history, only that he has no allergies. Has he been hospitalized for asthma? To the emergency department? Trouble with his ears? PE tubes? Tonsils out? She can’t answer my questions, and Daniel adds nothing. Exhaling, I vent my frustration; it’s not their fault. Quiet and obedient, Daniel responds to my questions. School—getting used to a new place. Wetting the bed—no. His favorite food—pizza. I ask him to climb up on the examination table; he shows good coordination. I peer in his ears with the otoscope; an old PE tube sits in the right canal. As I examine him and watch his reticent responses, I become convinced that I’ve inspected him before. “You seen me before?” I watch his sad, knowing eyes. He shrugs, raises his eyebrows, and picks at the paper on the examination table. I listen to his heart and lungs and ask him to blow my finger like he’s blowing a candle. He complies. He knows the routine. “No wheezes today.” I compliment Daniel and ask Foster Mom how things are going at home. “They reported problems, but he’s well-behaved for me. Plays well with my grandsons.” Her broad lips curve up as she gazes at Daniel. How many children has she nurtured? Probably dozens. I concentrate on Daniel. “Have you been in many foster homes?” “Lots.” He stares at his tennis shoes, swinging them against the examination table. They close with a Velcro strap. “Do you know what’s going on with his mom?” “Substance abuse and mental problems,” Foster Mom murmurs. Finishing up his examination, I check his genitals (circumcised) and talk about good touch and bad touch. I ask him to stand on the linoleum floor and touch his toes, and I check his spine for straightness. Then, I instruct him to imitate me: stand on his right foot and then his left. He follows. Neurons and synapses fire and connect in my brain. “Daniel, I know where I met you. Did you and your mom live at the shelter—the old big brick house?” He stares blankly, and then his expression shifts, like a cloud edging off the sun. His eyes widen. “The one with the winding stairs?” I nod and remember his mother. Weekly, I run a clinic at the local battered women’s shelter. Daniel and his mom stayed there for about a month, left, and returned several months later, only 6 months ago. I never saw her as a patient, so I didn’t know her story, only that she was committed to Daniel. I’d seen Daniel during their 2 different stays. Mom had the same doelike eyes; she was small framed and spoke English with a subtle Mexican accent, rolling her rs. Daniel was her pride and joy, and she kept detailed records in a pocket-size spiral notebook. Meticulous about Daniel’s ear infections and asthma, she’d arranged follow-up for him at the children’s hospital clinic when they moved out of the shelter. What had intervened in her mothering? Did she return to the abuser, her boyfriend or Daniel’s dad, and as a result, children’s services deemed her an unfit mother, failing to protect Daniel? Did she have an alcohol problem or drug addiction and start using again? Had she run out of her antidepressant or antianxiety medications and become unstable, another reason to deem her unfit? Had the system failed her? I have worked in the system long enough to know its imperfections. Everyone is well intentioned, but moms and kids fall through the cracks, lose health insurance, and cannot afford medications, despite my attempts to provide samples. They return to abusers because they cannot afford to live on their own or they want fathers for their kids. Daniel stands between his foster mom and me. I’ve taken his place on the stool. He examines his sneakers again. I wish there were answers in the stitching. My heart trembles as if a string is plucked. For a moment, I want to take him home, give him stability. I want to tell him that he has a dedicated mom who adores him, wants the best for him, and struggles to care for him. I want to see him in 5 years, 10 years, to remind him of this. If only I could wave a magic wand and assure him that his life will turn around—stable home, school, the love of healthy parents. I want to promise him that he will not grow up to be a drug addict, an abuser, repeating the patterns of his folks. Unfortunately, I cannot give him any guarantees; there is no insurance to protect him from these possibilities. At this moment, I can only assure Foster Mom and Daniel that today he is a healthy 6-year-old, and we will give him his kindergarten shots. Correspondence: Dr Zink, Department of Research, Olmsted Medical Center, 210 9th St SE, Rochester, MN 55904 (tzink@olmmed.org).
Archives of Pediatrics & Adolescent Medicine – American Medical Association
Published: Aug 1, 2005
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