By Janice Loschiavo, MA, RN

Luke sits alone on the bus headed to another new school. He hopes he can find his homeroom. He has not eaten since yesterday and has no money with him. Hungry and worried, he wonders. Can I get free lunch, does this school also have a lot of bullies, will they laugh at me, will my teachers be kind?? Luke is sure he will again be the dumbest in the class and will be put with the special education class (if his family doesn’t move again). His hands are shaking. He needs a cigarette. He is scared, lonely and absolutely miserable. Luke wishes he could go to sleep and not wake up. Luke is twelve years old today.

Who is the Marginalized Child?

Children are not the same. Today, we recognize that children know themselves when they are different. They may struggle with gender identity, a transient lifestyle, bullies, obesity, cultural diversity, violence in their homes, substance abuse, poverty, or mental/physical handicaps. These are the children who do not fit into our norm.

The marginalized child is shunned and denied involvement with peers. Delegated to the outer edge of social life, or margins, they have no hope of participating in a social life. Very often they have physical, racial or cultural traits which set them apart and make them unacceptable to the dominant or in group.

Usually, there is little or no positive, supportive relationships at home. This leads to further isolation and contributes to a sense of hopelessness.

Those who are marginalized, suffer from discrimination and subordination. With no control over their lives and no resources, they feel powerless.

These are the marginalized children of today.

The New School Environment

Today’s school environment has seen many changes. Since passage of the Individual with Disabilities and the American with Disabilities Acts school doors have been opened to many special needs students. However, not all have not opened their hearts to these children. It is the school nurse who can initiate a welcome into the school community, celebrate what makes each child unique and support their successes.

Schools are microcosms of the community. Problems that exist on the streets will manifest within the schools. Social conditions mirror that of the larger, outside world. Therefore, our solutions must be broader.

As educators we must stop and recognize that problems are not with just the one student, one family or one school. We are forced to look at a bigger picture. Today, due to this pandemic, we deal with a school presence which has lessened and children even more isolated. What risks threaten the school-age child? What children are at greatest danger of being marginalized? How can we recognize their problems quickly and provide the needed support?

Who is Marginalized?

A most basic need for all is to belong and be part of a group. No one should be denied this.

Once within the school boundaries, the nurse is responsible for the health and safety of all. The great majority of students will seldom enter your office. The children who are marginalized will find their way to you. They must be your priority. They are your class.

There are a number of children or groups that are traditionally excluded. They include children that suffer from:

1. Special Needs - Mental and Physical Disabilities

When we think of a child with special needs, we immediately assume they have some physical handicap. We kindly open doors, stand aside prepared to help. Mental illness is quite different. The student appears normal, therefore, we expect them to behave normally.

2. Morbid Obesity

Obesity is the fastest-growing epidemic with long and short term health consequences. This is probably the last remaining prejudice. One cannot get away with using a racial slur but calling a child a fat pig is acceptable.

3. Substance Abuse Issues

The opioid epidemic has caused many hardships and deaths. Vaping has also become a huge concern.

5. Bullies and their Victims

Comforting a child who has been bullied is a painful task. Comforting the child’s parent is worse. Learning of a child who has been a bullied victim that you were not aware of is the worst possible situation a school nurse could be in.

6. Child Abuse/Violence in the Home

Child abuse and violence at home continues to be major issues. The sooner it is halted, the greater the chance that the child will heal and the cycle will not be perpetuated.

7. Gender Identity

Sexuality is part of the normal development of every individual’s identity. Fear of being different is tantamount, especially during adolescence. We continue to see discrimination against homosexual, bisexual and transgender students.

8. Cultural /Racial Diversity

The United States remains a country of immigrants. We want our cultural/racially different students to retain the essence of who they are and display pride of their heritage.

9. Transient/ Unstable Lifestyle

Children who move frequently cannot establish and maintain friendships. Constant upheavals can be disruptive to normal development.

10. Poverty

Poverty does not permit a child to have traditional social experiences so important to development.

Effect of the COVID Pandemic on the Marginalized Child

The COVID-19 pandemic has highlighted the Marginalized Child. All children have suffered, but none more than the child who is already isolated. It has exacerbated a myriad of other issues including:

Loss of School Connections

School and the people within provide a safe refuge for the unhappy, neglected child. Many students form close bonds with teachers. Schools also are a primary source of food for those in need as well as emotional support.

Stress/ Increased Time at Home

It is difficult for many to be confined in one place for prolonged periods of time. The insecurity of the times has caused uncertainty as well as fear of illness and death.

Loss of Income

Many two parent-income homes have been reduced to one income or none. This places an increased burden of responsibility.

Academic Lag

It can be anticipated that all children will have some degree of academic loss. Virtual learning, no matter how well implemented, cannot replace in-person learning.

The School Nurse’s Role

Some nurses have chosen to move from the hospital into the school to continue their life-saving work. They believe more can be done to prevent illness and hospitalizations through education. Sadly, these nurses are not prepared for what faces them in this challenging new, environment.

With one foot in nursing and the other in education, the role is complex. The following strategies will be useful in supporting this challenge:

Remain informed

Reference only current, reliable, sources.

Teach

As the only health professional in the building, use every opportunity to educate administration, staff, parents, and students. Plan

Be an active member of the COVID team and other in-house intervention groups.

Triage

Implement all prevention levels:

Primary mask wearing, social distancing, handwashing, clean/ventilated rooms

Secondary pre-entrance screenings

Tertiary isolation room, return to school protocols, contact tracing

Assist the Marginalized Child

1. Calculate each child’s risk for marginalization relevant to the above ten factors.

2. Develop a plan to help each identified child.

3. Seek assistance from school team.

Suggestions

• Plan for the marginalized child’s entrance/reentrance into the school community.

• Arrange an orientation for the student and family.

• Upon enrollment, recommend the student attend a shorter day and have nurturing teacher.

• If warranted, assist in getting professional help for student and family.

• Implement a peer remediation group/buddy system.

• Speak frankly to parent and child and share your observations. Stress that you care.

• Have the student spend time with you. Lunch/recess is stressful for the marginalized student. Transition them into the lunchroom slowly.

Conclusion

My first Health Office was perfect.

Just off the main entrance. It was a large room furnished with a desk and a dozen chairs. A large folding table was available so students who needed to stay in for lunch for medical reasons could eat together in comfort.

Other students began coming for lunch: the student who had unrest at home, the newly enrolled child, one who was not getting along with peers, etc. Each found a place at the table and a warm welcome.

When time permitted I sat and joined the conversations. Teachers stopped in as well.

No one stayed very long in my lunch group. Once the cast came off, the new child made friends, the issues at home lessened - off they went, and others took their place. In a very short time, this table became a permanent main stay.

The Health Office was and still is the Heart of the School.

The school nurse has the opportunity to identify the child who is lost and provide a soft place for them to land. Seated around a table together, for at least part of the day, permits every child feel that they belong. Once accepted in a small group, they are more confident to find their place within the larger group.

No longer marginalized, they can learn, grow, and happily become a contributing member of the school community.

Janice Loschiavo, R.N., NJ-CSN is an Adjunct Instructor William Paterson University

Author Fast Facts for the School Nurse (Springer 2019)

School Nursing: The Essential Reference (Springer 8/20)