Sunday, July 17, 2011

Welcome to BALTIMORE!

I grew up going into Baltimore to visit family, to go to the Inner Harbor, to take my sister to doctors appointments at Johns Hopkins, and to go to museums. I can remember driving through streets of what were surely at one time nice row homes that were starting to be boarded up. Row homes that were burned up, boarded up, falling down were a common site along one road we drove on to get to the hospital and to the inner harbor. Every time we went through, my mother would sigh.

“What is it?” either my sisters or I would ask from the backseat. “What’s wrong?”

“See those houses boarded up?” my mother would say. We would all look up from our games of tic-tac-toe and hangman and become solemn. “Those poor people,” my mother would say, locking the doors of the car.

“What?” we would ask. “What about the poor people? Do people live in those houses? Where did they go? Why do they look like that? What happened to that one? Why doesn’t that house have a roof? Why is that one falling apart? Where are the people?”

“They’re poor,” my mother would say. “Their houses got boarded up.”

“But why?”

“Because they couldn’t take care of them.”

“But who lives there?”

“Poor people.”

“But why did you lock the doors?”

“Because this area isn’t very safe.”

“But why isn’t it safe?”

“It just isn’t.” She would pause and we would nod, knowing that was all the answers we ever got, and likely all we would get this time as well. We stared out the window at a world we couldn’t imagine or understand, but that made us sad in a place deep in our hearts before turning back to our games.

Both sides of my family grew up in Baltimore. My mother’s parents lived there as children until they were married, and then came back later when my grandfather worked at Johns Hopkins. My father’s parents, and his entire family, have lived there forever and have never moved. They all started out downtown, and I grew up listening to stories of living on Lombard Street and going to the deli for corned beef. Stories about distant relatives living on Anne Street or Aliceanna Street or owning the shop off of Caroline Street near Orleans Street. The streets themselves are foreign to me, as they are to all my relatives at this point, but their names are as familiar to me as if I had grown up there. There are old family pictures in black and white of the old Baltimore—the way the city used to look when it was bustling and clean and beautiful. At least, that’s how it lives in the stories. It always sounds like a cultural hub: my grandfather grew up near the “Italian section” and the “Polish section” and tells stories of friends with last names like “Frank Spaghetti” or “Sam Spumoni” and “Earl Kozlowski.” The other side of my family is Jewish, so they tell stories of delis with corned beef and rye bread, pickles in huge barrels, and coddies. I really wish I could have seen the Baltimore they knew.

I went to college in Baltimore, but was far enough from the city that the woes of the city didn’t really affect me. During my 3 years of college, I volunteered at two different Baltimore City schools, which was where I got my first taste of what life in Baltimore was really like. It was there that I met children who talked about their incarcerated parents as though going to jail was as normal as going to the grocery store. One little boy told me excitedly that he had gone to visit his daddy in jail, and how his daddy was so nice because he bought him an orange soda from the vending machine. I worked and played with children who told me about the cockroaches and rats they saw in their kitchens, and how they made sure to save their milk from lunch because they would be hungry before bedtime because mommy didn’t buy food for dinner. I handed out notes afterschool about men who had been seen trying to pick up children in a silver car, warning parents to keep their children inside, and I entertained kids inside afterschool when we couldn’t go out to the playground because men in cars attempting to take pictures of children had been spotted repeatedly around the school. I talked to a 3rd grader whose 17-year-old brother had been shot, and I was at the school when a group of 5th grade boys left to walk home and then came running back because one of the boys was hit by a bus and killed. I was among the volunteers that saw the boys, heard the news, and then put on a happy face to play with his younger sister so she wouldn’t know until her parents came.

The billboards are something else I remember about driving into Baltimore. Haunting faces of children in black and white on signs reading: CHILD SEXUAL ABUSE. LEARN THE SIGNS. just weren’t something I saw in my still countrified little town of Frederick. Women with black eyes on billboards reading, “Well, he said he was sorry,” and one I swear I didn’t make up in my memory that says, “A woman is your friend. Don’t beat on her.” The “slogan” for Baltimore for a while, at least while I was in college, was BELIEVE. A black sign with white letters reading only the single word, I remember the irony of driving down streets like the ones pictured above with billboards reading BELIEVE everywhere. It was almost insulting as even I would wonder, “what the hell are we supposed to believe in?” (Some of the domestic violence billboards are still there, along with signs on buses and the metro that say: “Thou Shalt Not Kill. Exodus 20:13. Look it up” with a picture of something that looks like a knife and blood).

I went to a neuropsychology lecture last week, and the psychologist started his powerpoint with a big, “WELCOME TO BALTIMORE!” on the first slide. The next slide said, “There have only been 149 homicides…” and the next finished “…so far this year.” The homicide rate in Baltimore is number 4 in the country, and it makes the top 10 “most dangerous cities in America” list. In 2009, 21% of Baltimore city residents had income below the poverty line, and 10.8% lived with income 50% below the poverty line. 29.4% of children in Baltimore are living below the poverty line. I can’t remember the exact racial breakdown, but the city something like 68% African-American. It remains one of the most segregated cities in the US.

When I was living in Ohio, I worked in both Dayton and in Cincinnati. Working at the community mental health center in Dayton, I saw some people who were struggling financially. I had an elderly man walk to the clinic to see me because he didn’t have a car and didn’t have money for the bus, and it took him 5 hours to walk to the clinic. We saw people on a sliding scale, and by the end of my year there were able to accept Medicaid. I saw a couple rough kids, heard some difficult stories. In Cincinnati, I saw a very mixed group of clients. At the children’s hospital, we saw clients on Medicaid, but also saw clients with private insurance. I saw clients from well-off parts of Ohio, and also clients from the hills of Kentucky.

And now I have moved back to Baltimore, and I am working downtown in the middle of the city. Right smackdab in the middle of the mess. The clinic I work in accepts only clients on Medicaid (clients with private insurance go to another location). Some of the stories I am hearing are similar to the ones I heard in Ohio, but for the most part, the magnitude of the poverty is completely different. I have several clients who have been homeless in the past 6 months. I have several clients who are homeless or all but homeless now. Clients who were evicted from their homes, all of their belongings were put out on the street, and the doors were locked. By the time they got home, all of their belongings had been either stolen or broken and they had nowhere to go.

All of the children I see have developmental disabilities or, at the very least, developmental concerns and behavioral issues. I am seeing 17 year olds with high levels of lead per recent blood tests (likely due to lead in the pipes of wherever he’s living), and it is almost certainly the lead that has caused his developmental disability. I am seeing many children born to drug-addicted mothers who were born addicted and spent the first two weeks of their lives in the hospital detoxing. Now two years old, one of these children engages in almost constant, severe self-injury. I am seeing lots of kids in foster care, or kids who have been in foster care, or kids who are living with family members because their mother/father have been killed or are incarcerated. I have seen mothers that are illiterate, who bring their 17 year old daughters to the treatment session to help remember what I say, but the 17 year old dropped out of school in 9th grade, and she also can’t read. I had a mother who couldn’t concentrate on what I was telling her to do to decrease her child’s tantrums because she was so worried that I wouldn’t give her son a snack at the end of session. “Miss Laura, the other lady we saw, she gave him chips AND a juice box. She always gave him juice AND chips, and she was always real good to him. They’re always real good to us here. You can give him chips AND a juice box, right Miss Laura?” Part of me wonders: what if this kid is tantruming just because he’s hungry? What if all these problems are just due to the fact that the kid doesn’t get enough to eat? Part of me wonders: is she even here to get help with her kids behavior? Is she hearing anything I’m saying? Yes, I assure her, both verbally and nonverbally. Yes. I can be good to you, too.

I have learned to assess for barriers to treatment, and the barriers to treatment here are too many to name. Mom has a disability. Client is homeless. Mom is illiterate. Mom has 3 children with disabilities. Family has no transportation. Client is deaf and mom knows no sign language. Mom has post-traumatic stress disorder, or depression, or bipolar disorder, or borderline intellectual functioning.

In order for these families to come and see me, their child’s behaviors have to be pretty bad. Pretty disruptive. Pretty concerning. And they are: aggression, self-injury, tantrums, noncompliance, 8 year olds who aren’t toilet trained, and 6 year olds with no functional communication. They expect me to “fix” their child. They really think they can bring their child to me, and in one hour, maybe a couple sessions, I will work with the child and have him “get himself together.” But instead, I tell them that I will be giving THEM the tools to work with their child. “Special kids need parents with special tools to help them,” I say. “I don’t expect you to have those tools right now, but through our work together, we’ll figure out what those tools are. You have taken all the right steps so far to end up here, so that tells me you already know that you and your son need some help. You know your child better than anyone else, and you are his best helper. I’m going to give you some tools to try, and sometimes things are going to get worse before they get better. He’s going to be testing your patience even more than before. I’m going to be here to support you through that, and we’ll have to trouble shoot together. The important thing is you’re going to have to be really consistent. That’s how you’re going to see improvement. Let’s do it together.”

They nod. They tell me they understand. They tell me they’ll be consistent. They demonstrate time-out the way I explain it, and we set up behavior charts. I send them away with handouts and laminated picture cards and schedules and token economy charts with Spongebob or Justin Bieber or whatever that kid happens to like. And then they come
back, and I say, “how is his behavior?”

“It’s the same. He’s bad as ever.”

“Did you try the timeout we talked about?”

“Yep, I did that. It doesn’t work.”

“How many tantrums did he have this week?”

“It was constant. All the time.”

“And how many times did you use the timeout we talked about?”

“One time. It didn’t work.”

And we start again.

But then they tell me their stories and I don’t know how I expect them to be consistent. I don’t know how I can expect them to think about 3-step guided compliance and proper time-out procedures when they can’t read the handouts I gave them. When they don’t have a consistent place to live. When they are worried about how they’re going to feed their kids. When they are worried about their child’s safety. When they have 6 kids under the age of 6 in the house because their sister just moved in with them with her kids, and 6 kids in a 2 bedroom apartment is just too many.

So they leave, and I feel disheartened that I can’t help them…but the next week they come back. And they keep coming back. I know I must be doing something right, because they come back. At the very least, I guess, they like me, because they keep coming back to see me. They must feel like something is helping, because they are trying. They are coming. So we keep trying, and trying, and trying again.

The thing is, is that they do try. They are trying. They are giving this life their all, and it’s just too damn hard for any one person to navigate with the hand they’ve been dealt. So they try, and I try, and if we’re lucky, something will happen. I give their kids chips AND a juice box. I give them picture schedules and session notes in the simplest words I can manage. I praise them for trying. I give them bus tokens. I show them and tell them and practice with them, and have them show me, and tell me, and practice with me.

Then they leave, and I try to let them go before the next client comes through the door.


  1. Baby girl, this is hard, hard work. Make sure you get your chips AND your juice box too. Hugs.

  2. I missed this entry the first time. I applaud you, but sometimes I wonder how you can stand the misery of it all. I don't think I could. So overwhelming, so massively depressing. But I am glad someone is trying to help them.