At a day care center in Reservoir Hill, the terrible reality of AIDS intrudes upon the pleasant ebb and flow of childhood.
From counting to coloring, lessons at this Head Start center for children affected by human immunodeficiency virus, or HIV, are routine preschool fare. But staff members know that extra doses attention, whether of medicine or of hugs, may be needed.
"The kids have days when they come in with real, real hurts," says teacher Mildred Thomas.
The center, run by the Baltimore City Head Start Program in collaboration with the Chesapeake AIDS Foundation, is free to children ages 2 1/2 to 5 whose families are affected by the virus that causes acquired immune deficiency syndrome, or AIDS.
A second center, in East Baltimore, serves children from infancy to 3 years. And a third, also for infants, is scheduled to open this week.
Together the three centers will be able to accommodate 70 youngsters.
Some of the children who attend are HIV-positive; some already have AIDS; and some are not sick themselves but come from families devastated by HIV.
About half the youngsters are cared for by foster parents or extended families: The real parents are dead, too sick to provide care -- or simply unwilling to do so.
There are about 150 HIV-positive children under 12 in the Baltimore area, according to the city health department. Since 1981, 174 Maryland children in this age group -- a total of 15 last year -- have been diagnosed with full-blown AIDS. The great majority of Marylanders with AIDS live in the city.
About 25 percent of all babies born to HIV-positive women are infected with the virus. And by the year 2000, as many as 126,000 children and adolescents nationwide may be motherless because of the disease, according to the Orphan Project, a New York research group.
Many of the families using the Baltimore centers are extremely worried about confidentiality. "There's a real fear among the parents of some one finding out" that HIV affects the household, says Clare Siegel, coordinator of the Head Start HIV project.
Outside the program, some parents haven't even told friends and family. But it is the policy of the centers that each pupil learn the medical truth, as gently as possible.
"When the parents come in, we discuss the issue openly. We talk about guardians, wills and so on," says Ms. Siegel.
But most of the children are too young to understand fully. "They have had blood taken; they may go to the doctor a lot -- but they think everyone does this," she says.
A dozen years ago, doctors thought HIV-positive children would not live very long. "We were told the kids were going to die; the 2-year-olds weren't going to get into Head Start; they weren't going to go to first grade," says Ms. Siegel.
But new treatments have increased the average life span of these children to 8 to 10 years. And there's greater hope for future babies. The number of HIV-positive infants born to infected mothers can be reduced by two-thirds if the women are treated with the drug AZT during pregnancy, according to a new study.
Infected women increasing
Meanwhile, the number of women infected with HIV is increasing steadily. "Last year, there was a 31 percent increase of infection among women in childbearing years [nationally] and a 32 percent increase in the children," says Dr. Peter Vink, acting director of the pediatric AIDS division at the University of Maryland at Baltimore.
In many ways, the Reservoir Hill center is like any other preschool: When the children turn 6 years old, most go to regular first-grade classes.
Still, the goal is to offer these children extra support without making any of them feel odd or singled out. Because they come from such varied circumstances, the pupils have different emotional needs.
One child, for example, has no symptoms of infection though she is HIV-positive. However, she is extremely insecure, says her foster mother, Elaine Williams, a former city schoolteacher.
In January, this 4-year-old was placed with Ms. Williams. The little girl's new "family" includes two other foster children: a 3-year-old girl who is very ill with AIDS but attends day care when she is well enough, and a 14-month-old boy born addicted to cocaine. He is healthy now and may attend the new day care center, Ms. Williams says.
She sends her foster children to day care to meet friends and to learn. "I don't have any idea how long [they] will be with me," she says. "But I don't think they should be deprived of anything. Not of anything."
At the end of every school day, the 4-year-old gets anxious. While still with her real mother, the girl was dropped at nursery school one day and never picked up, says Ms. Williams. "I try never to be late to pick her up at school. She has a huge fear of being [abandoned]."
Though the centers are licensed to care for 70 youngsters, daily attendance is erratic. Occasionally a child is hospitalized for weeks. Others miss one or two days a week. Sometimes it is the child who is too sick too come; sometimes the parent.
If a child misses a day, staffers call home or pay visits to the hospital.
"Many of the women we serve are still actively using drugs or are too ill to care for a child. In many ways, this is a respite program for moms or other care-givers," Ms. Siegel says.
Toys washed daily
The Head Start HIV centers take extra steps to guard against infection. Toys, for example, are washed every day. Staff members wear gloves and use disinfectants when blood or other body fluids are present.
Teachers have permission to administer medicines; a nurse can give drugs intravenously, if need be.
All parents are informed immediately if one of the pupils gets the sniffles or other symptoms because even common childhood ailments could be devastating to a child who has a weakened immune system.
As they perform their routine jobs -- serving snacks, leading exercises, reciting the days of the week -- the teachers are watchful.
"One little boy has constant stomach pains. Is it side effects from medicine? Is it because he is truly ill? Is it grief because he has lost his mother?" says Janice MacKenzie, who has worked at the Reservoir Hill center for nearly a year.
And the teachers understand the rage and confusion felt by many of the children. Sometimes it erupts when a biological parent comes to visit a child who has been placed in foster care.
"The child will tell her mother, 'No, you are not my mother. I don't have a mother,' " says Ms. MacKenzie.
But sometimes, says Ms. MacKenzie, her own understanding gives way to grief.
"You see a child, and you can tell they are coming to their end. You can see this. And they are very small, and you cannot really understand."