SUMMARY The incidence of sensory or language abnormalities and the factors influencing the clinical medical officers' decisions to refer children who failed developmental tests were studied. There were 1259 children examined and referrals for vision, hearing, and language assessment were made for 39(3.1%), 75(6.0%), and 27(2.1%), respectively. About 80% of these problems, however, were not known to the child health services when the children were 3-5 years old, mainly because children had moved to the district after the age of 3-5, and did not attend the 3-5 year screening clinics. Referrals formed only a small percentage of children who failed a test (11-0% failed vision, 19.5% hearing, and 24-6% language assessments). For vision and hearing the most important reason for the discrepancy was the clinical medical officers' wish to reassess children who failed the test before referring them. For the language test the clinical medical officer's often believed that the screening did not reflect the child's skills, which suggests that language screening as currently used in the district is not effective. Evaluation of the examination has highlighted the need to review the tests being used.A school entry medical examination takes place in most district health authorities.' 2 This is currently the only scheduled examination of primary school children and is a last chance to identify systematically undetected health problems that could affect the child's educational performance,2 4 although some would support regular screening (for example, for vision) during school years.5 It has been claimed that between 10 and 20% of children in Britain reach school with defects that should have been detected earlier.6 There is also a suspicion that examiners who identify a preschool child who has failed a test do not always take the required action. There is, however, little factual information to support these opinions, and explanations of why this might occur have not been established.In West Lambeth Health Authority a precoded questionnaire recording the main examination results and referral details of those children whose school entry medical assessment was unsatisfactory has been used since 1984. Information about preschool examinations has been entered on to computer. We were therefore able to check whether those sensory or physical health problems identified in the school entry examination were previously known, and if not what the possible reasons were. We also explored the reasons why clinical medical officers did not refer children for further investigations when they failed tests according to pre-established thresholds. Subjects and methodsChildren attending the 42 primary schools covered by the West Lambeth Health Authority are routinely examined between the ages of 5-0 and 5.5 years.
Referrals from preschool medical examinations were followed up for two years to assess attendance rate, waiting time for appointment, appropriateness of the referral, the diagnosis and management of the condition. Altogether 184 children were referrals for ophthalmology, 285 The joint working party on child health surveillance was sceptical of the effectiveness of many of the scheduled prescribed examinations in Britain and recommended research to evaluate the current components of the programme.' The group was particularly critical of the assessment of squint by non-specialised personnel, visual acuity before school age, universal hearing screening after 10 months until school entry, and systematic assessment of language problems. In West Lambeth Health Authority an audit programme was carried out to assess whether the child examination schedule provided by clinics was operating efficiently. We were concerned to describe the actions which took place after a child was identified as having a sight, hearing, or language problem. Areas of ascertainment were the level of attendance to the specialist services, waiting time for appointment, the appropriateness of the referral, the diagnosis, and treatment of the referred children and the compliance with the prescribed treatment. No formal audit of these services has been carried out previously in Britain. The study should be relevant to health districts-with multiethnic inner city area characteristics. Subjects and methodsAll the children aged under 4-5 years of age referred to speech therapy, audiology, or ophthalmology as a result of a scheduled examination were flagged and followed up for a two year period from August 1986. A general information document was completed by the referring clinical medical officer or health visitor and three specific documents relating to each specialty were designed to be completed by the research assistant (AR) based on information obtained from the notes and directly from the specialists. The data were recorded on a precoded form for each child at six, 12, and 24 months after referral or at discharge if this occurred before the follow up dates.The general information document based on the examination by the clinical medical officer or health visitor recorded date of birth and sex, area of concern, specialty to which the child was referred, and whether the referral was initiated by the doctor or health visitor. The clinical medical officers used scheduled examination tests for assessment. For hearing they used the distraction test at 7 months, the Stycar 6 toy test at age 2 years, and the Stycar 7 toy test at age 3-5 years. The receptive and expressive language was examined using a modification of the tests used in the Hounslow study2 and approved by Reynell. Vision
Returns of scheduled school entry examinations, from 838 primary school children in West Lambeth Health Authority, were analysed to assess the possible association of a child's home language background, age, sex, behaviour, and examiner with the results of the developmental examination. To allow for variation in social characteristics between participating schools, a ward index of deprivation based on the 1981 census was assigned to all the children in the schools of each ward. Variables representing development were most consistently associated with the child's behaviour during the examination and with the examiner. A child's home language background was associated only with the auditory memory test. The child's ability to concentrate during the test situation was closely related to his performance. With respect to the examiners, it is suggested that community health services need to consider schemes of ongoing in-service training and careful calibration of the tests.
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