When 4-year-old Julian DiCarlo started preschool at The Primary School in East Palo Alto, his mother could understand only about half of what he said, owing to his speech delay. Before going to school, he would be panicked, scared, nervous and crying, his mother, Erica DiCarlo, said.

At the ambitious, tuition-free private school, he received targeted speech support, and at home his mother practiced speech with him. A year and half later, he's happy and proud of where he goes to school — and when he speaks, his mother can understand 90 percent of what he says.

"I can have a conversation with my son now," the mother of four said.

Julian is one of 243 children from East Palo Alto and Menlo Park's Belle Haven neighborhood enrolled at The Primary School, which is in its third year of operations. The O'Connor Street school has made waves for both its vision — which strives to integrate education and health care to better serve low-income children and families — and its famous founder, Priscilla Chan, a pediatrician and the wife of Facebook CEO Mark Zuckerberg.

Chan, who previously taught for a year at a private school and ran an after-school program, believed that providing education, health, dental, mental health and support services on one campus would dramatically improve outcomes for high-need children like Julian, whose mother also grew up in East Palo Alto but said she did not receive proper support at school for her own speech issues. She now works as a receptionist for Service Connect, a San Mateo County program that provides re-entry services to former inmates.

Her two older children, ages 11 and 9, started their education in the Ravenswood City School District, but they later transferred to the Woodside School District to get the support services they needed, she said.

When DiCarlo heard about The Primary School, before it opened, "I immediately told my husband, 'I wish my other two kids could be able to come to the school.' I automatically said, 'We needed this in the city of East Palo Alto.'"

The Primary School is part of an evolving educational ecosystem in East Palo Alto, with new charter schools arriving to meet community demand. About 2,400 students are currently enrolled in the K-8 Ravenswood City School District neighborhood schools, which are losing an increasing number of children to public charter and private schools in East Palo Alto and the surrounding area.

The city is now home to the K-12 public Aspire East Palo Alto Charter School and East Palo Alto Phoenix Academy; KIPP Valiant Community Prep, which opened in 2017 and plans to grow to include eighth grade. High schools include Eastside College Preparatory School, East Palo Alto Academy and public charter high school Oxford Day Academy, also opened in 2017.

Hundreds of other East Palo Alto families send their children to neighboring public school districts through the lottery-based Voluntary Transfer Program, or Tinsley program.

The Primary School, which plans to expand to include middle school, states its team is "fueled by the belief that the current model of school is too limited to close the achievement gap for our nation's most at risk children."

Chan chose to launch this model in a community that has historically struggled to provide high-quality education and where families are battling poverty, housing unaffordability, food insecurity, violence, immigration fears and other pressures. The Primary School seeks to address this "toxic stress" on young children and their ability to learn and engage at school.

"Existing education, health and social support systems are not set up to help the children most likely to experience trauma, which often goes untreated," Chan and Meredith Liu, co-founder and chief design officer of The Primary School, wrote in an opinion piece for CNN in 2017.

"This incredibly complex problem cannot be solved by tinkering at the edges. Instead, we have tried to build an entirely new system of care centered around a child's comprehensive needs."

Chan was not made available for an interview for this story. In a 2015 Facebook post announcing the school, she wrote that her own experience running an after-school program in a low-income housing project and working as a pediatrician in a public hospital demonstrated to her the need for "a better way of caring for and educating our children."

At a glance, The Primary School looks like any other elementary school: reading corners in classrooms, drawings tacked to walls, swings and play structures outside. But its structure is dramatically different. The school will admit children at or even before birth: Administrators make a concerted effort to recruit families in high need who might be unaware the school even exists. The school then provides services to parents during those early years and starts students full time at age 3, given that the majority of brain development happens in the first five years of life. DiCarlo's family had access to parent groups, school-readiness sessions and other programs before Julian started preschool in 2017.

A partnership with the nonprofit Ravenswood Family Health Center allows for on-site health and dental services, including dental, vision and asthma screenings. Students learn to brush their teeth at classroom sinks after they eat lunch every day.

Parents are deeply engaged with the school and are assigned coaches to make sure not only the students' but also the families' needs are met. Through the relationships the coaches develop with families, the school gains a holistic view of what's going on in a child's life. For example, a 3-year-old girl was arriving late at school due to instability at home, so the school helped the family find more stable housing, said Primary School CEO Courtney Garcia, who was hired last August.

"We get to think through the eyes of a child and the eyes of a family around what their experience can and should be in a school environment," said Zoe Duskin, who was hired as The Primary School's new principal last May.

"That opportunity to think beyond the conventional boundaries of what counts as school or what counts as pediatrics is just incredibly exciting work for me as an educator," Duskin said.

Duskin is The Primary School's third principal in as many years. A spokesperson for The Primary School attributed the leadership turnover to the fact that "building a new school (with an innovative new model) is hard work and not a fit for everyone."

Before opening The Primary School, Chan and the team spent a year talking to East Palo Alto families and organizations to understand what the community wanted in a new school. They recruited parents, including DiCarlo, to form an advisory group, which met once a week and gave input on everything from the schedule to the parent coaching program.

Through that effort, DiCarlo felt the school "let our voices (as parents) to be heard," rather than acting like well-financed outsiders who were telling the community what it needed — a familiar refrain for East Palo Alto.

It's a grassroots-level approach that may have come out of Chan and Zuckerberg's prior effort to radically change the education landscape: Their $100 million donation to reform public schools in Newark, New Jersey in 2010 was later criticized as a failed top-down initiative.

The tone of that reform effort — announced by Zuckerberg appearing with then Newark mayor Cory Booker and New Jersey governor Chris Christie before a cheering audience on the Oprah Winfrey Show — contrasts sharply with that of The Primary School, which has worked to focus on its families and stay under the radar, granting few press interviews (a communications manager was only hired last year).

The Primary School opened in August 2016 with 51 4-year-olds from East Palo Alto and Belle Haven. The school is now teaching its first class of first-graders and plans to grow an additional grade each year through eighth grade. The Primary School recently submitted plans to the city to expand to a site a few blocks away on Weeks Street.

Families can apply to The Primary School, but the school also actively recruits families, particularly through the Ravenswood Family Health Center. The school has a waitlist and admits students on a lottery basis when there aren't enough spaces available.

Rethinking health care

Just before the holidays, The Primary School students were in the midst of a health unit. In each classroom, students had transformed play areas into miniature dentist offices and hospital waiting rooms, hung hand-drawn posters on the walls classifying healthy and unhealthy foods and went on a field trip to the Ravenswood Family Health Center — all evidence of the school's effort to rethink primary care by making it a natural part of the school experience.

Last fall, the school focused on teeth and gum care because "poor oral health has a huge impact on a child's ability to attend and focus in school, and it is entirely preventable through basic everyday behavior changes," the school's 2017-18 annual report states. The school hosted a community night with dental practitioners and asked parents to set an oral health goal, such as cutting down on sugary snacks or brushing a child's teeth twice a day.

Students learned good tooth-brushing techniques in class and received free dental services from registered dental hygienists from Ravenswood Family Health Center who visit the school bimonthly to offer X-rays, cleaning and fluoride treatment, all optional services. This also means parents typically don't have to miss work to take children to appointments, unless a child is referred out to a clinic for extra care, like filling a cavity.

A few months ago, DiCarlo took her son Julian out of school for a dental appointment, which would be routine for children at most schools. He protested, she said, telling his mother, "They're supposed to come to school."

Asthma is the most common physical health problem among students at The Primary School and children in East Palo Alto more broadly, said Ravenswood Family Health Center pediatric nurse Sandra Nova, who works as a liaison between the clinic and school. Left untreated, asthma can affect a child's wellness and lead to absenteeism.

After a severe asthma attack, a child may need up to four to five days to recuperate, she said. A student could miss almost half a month of school because of two to three attacks.

"Typically asthma is addressed very reactively," Duskin said. "It's when they're too sick to go to school that they get seen by a doctor. We're trying to flip that model around and take a really proactive stance in noticing and designing action plans with kids and with families."

As such, The Primary School provides all students with monthly screenings, trains teachers to look for early symptoms and develops individualized action plans with affected students and their families. The action plans identify a student's asthma triggers, medications he or she is on and steps to take if he or she has an attack.

During peak asthma season in the winter and spring, a Ravenswood health fellow will check in with families once a month, often spending time educating parents about why medication is necessary and the implications of untreated asthma, Nova said.

In addition to asthma care and education, the school last year also provided all students with in-school vision screenings and followed up to ensure that parents of children who screened positively made appointments at their primary care clinic. As a result, 12 students got glasses for the first time.

Poor social-emotional health, not just physical health, is treated equally as a barrier to student learning at The Primary School. Like asthma, upheaval at home can cause a student to miss school and diminish their ability to focus at school. Developmental delays, including speech, as well as learning disabilities and behavior concerns are also common social-emotional issues Nova sees among students.

The school has a mental health provider on campus and last year adopted Conscious Discipline, a social-emotional curriculum in which teachers are trained to understand and respond to the brain states of children who have experienced trauma. Through it, teachers can identify when a behavioral issue might signify that a child is actually in a fight-or-flight survival state mentally — and then use that framework to build safety and trust for the student, said Garcia, the CEO.

"Rather than having a big behavior or a big emotion happen in the classroom and respond immediately with rewards or punishment, we instead want to come from an understanding of where a child is in their brain state and help them calm down and re-regulate," she said.

This approach was on display in a pre-kindergarten classroom on a recent morning, where lead teacher Vosa Cavu-Litman turned a read-aloud session with his young students into lessons on mindfulness and how to treat others.

Through the narrative of "Shubert's Helpful Day" — the main character is a bug who decides he'll be helpful to his peers no matter how they act — the class talked about naming emotions like anger and sadness. Before they could leave story time for a mid-morning snack, they had to answer questions like what to do to help their classmates feel safe or what to do if they feel angry during class. Suggestions from the 4-year-olds ranged from taking a deep breath to going to a safe space in the classroom (a pillow-filled corner with soft lighting).

"There's a lot of research that shows that kids don't learn well when they don't feel safe, when they don't feel that they're in trusting relationships with adults," Duskin said. "We also know that, when students have complex trauma histories, that feeling of safety and trust is much harder to establish because students have learned through experience that those things can be taken away quickly and that adults and their peers may not always be predictable. Creating structures through which we establish predictability, routine and trust really allows us to have that foundation of safety."

For teachers who are often frustrated by the limitations of traditional school boundaries, supporting students in this way is empowering, Duskin said.

Similarly, pediatricians become frustrated with the limitations they have in supporting young patients in need, only seeing them as newborns or when they're sick — unable to know how symptoms might be manifesting at school. Nova said she sees The Primary School as leveling the playing field for children who would otherwise start school at a disadvantage that would affect their life trajectories.

With the early intervention of The Primary School, "they can actually compete," Nova said. "It allows them a better chance to succeed eventually (not only) academically but also in communication with each other as a family."

Connecting family and school

The Primary School's parent coaches are perhaps the most unusual aspect of The Primary School model.

The DiCarlos' coach, Cristina Matthews, connected the family to housing, food and financial support resources, helping them fill out applications and navigate confusing bureaucracies. She reminded DiCarlo and her husband to attend school events and increased their participation in their son's education.

In their CNN opinion piece, Chan and Liu wrote, "Home life and environment are stronger predictors of academic and health outcomes than either formal education or health care."

So The Primary School parents attend a series of weekly groups when their children enroll and then are required to attend a monthly parent group after that, in addition to a monthly check-in with their coach. The seven full-time coaches often interact much more frequently with their families, a freedom that Matthews, whose background is in mental health, said allows them to build deeper relationships. The amount of time coaches spend with families each month varies and is driven by family need, school administrators said.

DiCarlo, from her own experience as a student in the Ravenswood City School District, understands the implications of a broken connection between home and school.

"I know how it feels to have homework and then you don't have the support at home because of either the language barrier or whatever it might be. I know how it feels going in the next day with your homework not completed — not because you didn't want to do it but (because) you need help and you didn't have that support at home," she said.

Replicating The Primary School model

It's hard not to be skeptical that what this privately funded school is working toward could be replicated within a conventional public school setting. But The Primary School leadership, many of whom came from public education, believe it's possible.

The school's long-term goal is to open three to five sites in the Bay Area (they're currently hiring for a new campus in Hayward), partner with early childhood providers and other school systems to share what they learn and then replicate it nationally. The school's leaders say they don't want The Primary School to be a "special" school and define "replicable" as sustainable through public funding. (The school declined to disclose its budget.)

As such, they made practical choices around the budget, teacher-student ratios and facilities to align with what a more traditional school would offer. The Primary School, for example, leases classrooms owned by the Ravenswood school district. Last year, the school analyzed public funding streams for education, health care and family support and set cost benchmarks towards which it is working. Leaders believe merging the education and health care systems will cut down on redundant services and close gaps in care.

Duskin, who was previously the founding principal of a public charter school in Washington, D.C., said replicating The Primary School model is not impossible, but "does require some transformation in how we think about the work of a school," particularly on the part of teachers and administrators to be open and responsive to feedback from parents and partner organizations.

"There's some humility there that's required for us as educators, but it's also where I think the work is becoming really interesting and promising," she said

The school's broader impact on students is not yet clear, at least publicly. School administrators said data on academic and social-emotional gains is not yet available, and they are "still learning about the long-term impact of our model."

But families like the DiCarlos say they are living out the benefits. Their youngest child, an 11-month-old girl, is already on The Primary School waitlist.