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The intermediate school medical inspection
THE INTERMEDIATE SCHOOL MEDICAL INSPECTION By J. S T U A R T
HORNER,
M.B., CH.B.,D.P.H.,D.I.I-L
Deputy Principal School Med&'al Officer, County Borough of Croydon formerly Deputy Principal School Medical Officer, County Borough of Dewsbury Trm need for some modification of existing methods of .school medical inspection has been widely recognized in recent years. Several vxperiments have been conducted to determine the most suitable and effective form of medical inspection(The Medical Officer 1961) and these have been encot-raged by the Ministry of Education (C.M.O. Ministry of Education, 1958). A preliminary investigation in Dewsbury (Horner 1962) showed that the introduction of a screening procedure reduced the number of inspections whilst the number of children who were discovered to require medical treatment was increased. An enlarged experiment was designed, therefore, to determine whether this screening technique could satisfactorily replace the general medical inspection of all children at 11 years. A description of the experiment and the results which .were obtained may be of some general interest. METHODS
AND
MAT.ERIAL
Tile Screening Procedure A detailed questionnaire was prepared and forwarded to the parents of all children who would normally have received an intermediate school medical inspection. The question sheet Consisted of a comprehensive previous medical history of the child including an immunization history, enquiries concerning certain family illnesses and a series of twenty questions about specific complaints suffered by the child. An opportunity was given for the parent to insist upon a medical inspection without stating the reason for such a request. The school nledical record card (10M) and the completed questionnaire were then inspected by the deputy principal school medical officer who decided whether the child should be allocated to the experimental group or to the control group. Under the proposed procedure only those children in the "experimental group" would normally be presented for examination although, on this occasion, all children were given a routine school medical inspection. The medical officer who conducted the examination was not advised of the group to which the child belonged so that a form of blind experiment was cffected. No opportunity was given for the school health visitor or the head teacher to suggest names of children who were in special need of a medical examination although this would seem to be an essential adjunct to selection on the basis of a questionnaire. 291
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Whe,~ the medic:il cxamin:llions h:ld been complclcd lhe children were again ~!ivided inlo the two gr!~lips so th~ll conll~:lrisons could be made bclwcen those chihh'cn who had i~rcviou.,/.'ly been considered I~ be healthy and those who wollld have required ,m cxalninalion llll¢icr ,'1 sciccliVC procedure. A total of 830 cl,,ildrcn wel'c cli/:,,iblc ibr school ri~tcdical inspccliola :lnd 799 qucslionn~lires were rcltlrncd. The nuwtl~cr of l~upils who were aclu:illy examined wa~ 791 so lhlll ~,lllc :lbsenice rate w:!s 4"7 per cent. The nuinber of abscnlces was greilicl" :in~loiigsl lhe exl)erimcnt:tl group. Since all those who f:iilcd to return :l qucsiionnairc wcrc :nilonliltically placed in the cxperillieill:il calcgory, the group probal)ly includes niost ~)1"lhose p:ircills who had least inlcresl in the hcallla of their children :tlld who may not lmvc presclllcd lhcnl for nlcdiclll insl)CClion, In ~lddilion, those childrcll who :ire lllosl ill riced o1" ex~imin:ilion are also nlorc likely to be.:lbscnt from school on lhe day it is due to bc conducted.
M~'thods of Assessment 'Fhc mimbcr of childrcri who were allocated to e:lch group was rccordcd, togclhcr with the reason for ii~iclutling each child in the experimental category. In Ibis w~ly the reductioll in lhe llunll~er of examinations which would l~}llow the introduction of a selective inspection could bc determined. The reason for lhe examination was depe~lden[ on those syml~lOmS which the school medical ollicer considered 1o bc important. In gener:ii, every child who demonstrated a positive symptom was examined although the large number of parents who claimed that their child w~is "nervous" (Table V) prcventcd the attainment of this ide:ll in :all cases. Many ,
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it is designed to assisl. Taylor (1961) has slated that one of the major justificafions for ;t routine me(lloyd inspection is that the mothers wish it. He had obtained his intbrmation from those mothers who had attended when their children were examined. Such obserwtlions arc subject to bias, however, since molhcrs who have made an effort to attend a medical examination---often at some personal inconvenience--are unlikely to inform the doctor that they consider the whole procedure to be a waste of time. The number of parents who atlend lhe school medical inspection is likely to provide a more realistic assessment of parental approval. The preliminary survey revealed a much higher attendance rate by parents than in any of the previous six years, but ~t was not possible to use this index during,, the present experiment since all the children were examined at a normal routine school medical inspection. It has been suggestcd that parents who are most conscious of their child's health will complete the questionnaire more thoroughly and are also more likely to attend for medical examination. The attendance of parents in the experimental group did not differ signiiicantly fi'om that in the control group so that this determinalion could be used to measure the degree of pa~rental approval after a selective procedure has been introduced. The selcclion procedure was dependent upon the provision of adequate information for each child. The number of questionnaires which were completed satisfactorily was used to assess the co-operation which could reasonably be expected from the parents. THE
RESULTS
Children Allocated to the Experimental Group A total of 830 children were eligible for a school medical inspection and the number of those who were allocated to the experimental group has been recorded in Table I. Although atl the pupils subsequently received a school medical inspection, only the experimental group would have required a medical examination if a selective procedure had been used. The sex differences are not significant. Reasons for Selection The reason for allocating each child to the experimental group has been recorded in Table II. It is not surprising that, in a northern industrial town, the most frequent cause should be regular chest complications following an upper respiratotay tract infection. Unsatisfactory school progress was an important reason for selection since the possibility that medical conditions were responsible for poor educational attainments should always be considered. Any child whose questionnaire was very incomplete was automatically selected even though positive symptoms had not been admitted. Similarly children who failed to return their questionnaire were also selected and a small number of pupils were allocated to the experimental group because their previous school health record
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HEALTH
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I
Number of children eligible for medical inspection
Experimental group
Examination rate using selection procedu're
Control group
BOYS
420
187
44.5 Yo
233
GIRLS
410
181
44.1 ~o
229
TOTAL
830
368
44-3 ~o
462
TABLE II REASONS FOR SELECTION Reason for Examination
BOYS
GIRLS
TOTAL
. . .
34 38 18 14 18 13 13 11 10 8 7 3
44 23 20 22 14 18 13 13 6 5 2 1
78 61 38 36 32 31 26 24 16 13 9 4
. . . . . . . . . . . . . . . . . . . . .
187
18 t
368
Chest colds . . . . . . . . . . . . . . . Parental request . . . . . . . . . . . . Unsatisfactory school progress ......... Recurrent sore throats ............ History o f a running ear ............ Questionnaire not returned . . . . . . . . . . . . History o f joint pains . . . . . . . . . . . . Enuresis . . . .... . . . . . . . . . . . . Morning cough . . . . . . . . . . . . Previous medical history ............ Incomplete questionnaire ............ Nervous symptoms . . . . . . . . . . . . Total
DEFECTS
DETECTED
. . . . . .
. . . . . . . .
TABLE III DURING MEDICAL
INSPECTION
(Excluding Defective Vision and Dental Defects) Experimental Control group Total group ~
No.
Standard
~
Error (diff.)
No.
~o
No.
Defects referred for investigation
38
11.2
15
3.3
53
6.7
1.8
Defects requiring treatment
35
10,3
23
5.1
58
7.3
1.9
Defects requiring observation
151
44.4
94
20.8
245
31.0
i 0"5
Total defects
224
65,9
132
29.3
356
45.0
i 1.3
Number of children examined
340
--
451
--
791
--
INTERMEDIATE
DEFECTS
Category or Code Number 4 6 7 I0 I1 12 13 14 Other Total R T O
SCHOOL
MEDICAL
INSPECTION
TABLE !V NOT PREVIOUSLY RECORDED SCHOOL HEALTH SERVICE
T y p e o f defect
BY THE
Experimental Control group group (340 (45 ! c h i l d r e n ) children)
Skin defects . . . . . . ..... . . . . E a r diseases and h e a r i n g defects ... N o s e a n d t h r o a t defects . . . . . . . . . H e a r t defects . . . . . . . . . . . . L u n g disease . . . . . . . . . . . . H e r n i a a n d genital defects ...... Orthopaedic c o n d i t i o n s . . . . . . . . . N e r v o u s system ......... Miscellaneous . . . . . . . . . . . .
295
Total (79 i children)
20 33 35 4
13 I1 26 2
33 44 61 6
8 6 29 14 36
2 7 36 3 18
10 13 65 17 54
. . . . . . . . . . . . . . . . . .
185
118
303
Defects r e q u i r i n g investigation . . . . . . Defects r e q u i r i n g t r e a t m e n t ...... Defects r e q u i r i n g o b s e r v a t i o n ......
33 24 128
13 20 85
46 44 213
COMPLETION
TABLE V OF Q U E S T I O N N A I R E S
History Completed on the Questiomlaire V a c c i n a t i o n state ... . H i s t o r y o f infectious disease P r e v i o u s significant illness in Occupation of Father . Occupation of Mother . Significant family history . R e c o r d o f siblings . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . the child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Defects recorded on the questionnaire (a) Previous defects J o i n t pains . . . . . . . . . . . . . . . Asthma . . . . . . . . . . . . . . . . . . R u n n i n g Ears . . . . . . . . . . . . . . .
BOYS
99.1 Yo 99,1 Y/o 97-5yo 96..8 ~o 96"5 ~o 92"4Yo 91 "0~o
GIILLS T O T A L
42 8 35
(b) Physical defects P o o r appet ite . . . . . . . . . . . . . . . 19 R e c u r r e n t sore throats . . . . . . . . . . . . 25 Morning cough . . . . . . . . . . . . . . . 19 F r e q u e n t chest colds . . . . . . . . . . . . 63 (c) Mental attd Psychological deflects . . . . . . . . . Nightmares . . . . . . . . . . . . . . . 16 Enuresis . . . . . . 15 N e r v o u s child o r "liighly s t r u n g " ...... 72 Abnormal behaviour ............ 12 U n s a t i s f a c t o r y s c h o o l progress ......... 31 S e p a r a t i o n f r o m m o t h e r in e a r l y c h i l d h o o d ... 2t Name of Family Doctor provided . . . . . . . . . . . . . . . .
46 6 35
88 14 70
1I'0 1-8 8,8
28 33 12 66
47 58 31 129
5"9 7-3 3.9 16"I
8 24 16 31 86 158 11 23 24 55 22 43 . . . . .
3,0 3.9 19"8 2.9 6"9 5.4 96-9~
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suggested that a full medical examination was desirable. Where multiple reasons for selection were present on the questionnaire, the one which was considered to be most important by the deputy principal school medical officer has been recorded in the table.
Defects detected during Medical blspection The total number of defects (excluding defcctive vision and dental defects) which were reported by the school medical officers is shown in Table HI. The defects were divided imo those which were referred for further investigation, those which requir0d or were already receiving treatment and finally those which required observation. The incidence of defects in all three categories is greater in the experimental group and the differences are all statistically significant. An analysis of defects discovered for the first time at this medical inspection showed a similar trend although in the category "defects requiring treatment" the difl;zrence was not sufficient to be statistically significant. Tile subdivision of these primary defects according to the system of the body has been recorded in Table IV. It should be remembered that all the defccts in the control group column of this table would escape detection by a selective form of medical inspection.
Completion of the Questionnaires 31 questionnaires (3.7 per cent.) were not returned and a further 9 were so incomplete that the child was automatically allocated to the experimental group. The percentage of completed answers to the questions is shown in Table V, together with a record of the number of defects reported on the questionnaire. DISCUSSION
Several experimental forms of medical inspection have been introduced in recent years. Douglas et alii (1961) have described a much improved system for the entrant examination which seeks to integrate the G.P. into the preventive aspects of school heahh care. There is considerable justification for examining every child at school entry and for developing the scope of this examination. In Hampshire during 1958, it was discovered that over half of the defects found in children when first starting school were unknown to their parents or if known were not being treated. The number of new defects discovered at the intermediate medical inspection is usuatly smaller and various forms of selective procedure have been developed to exclude some of the healthy children who would otherwise receive an examination. At present one defect requiring treatnzent is discovered for every nine completed medical inspections when defects of"~.,i.~ionare excluded
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(C.M.O. Ministry of Education 1962). In Dewsbury the ratio of defects discovered to children e~amined at the intermediate medical inspection is even lower than th~:; composite figure (P.S.M.O., Dewsbury C.B. 1961). The relatively small number of defects discovered by the inspection of large numbers of children does suggest that a preliminary selection procedure could be useful. In this way a more generous allowance of time could be given to those children who are most in r,eed of a medical examination. It has been noted by Witlmell et alii (1961) that a screening procedure allows the school medical officer to devote more time to the children and also makes the actual examination more stimulating. Jackson (1961) has stressed the importance of providing an adequate amount of time for each inspection and he has reported that a much greater number of defects were discovered by a more comprehensive medical examination. In view of the present bias towards treatment rather than prevention within the N.H.S., it seems doubtful whether the allocation of a really satisfactory amount of additional time for all school medical inspections is practicable unless some form of preliminary selection is also introduced. Any modification of the routine medical inspection must ensure that the periodic vision testing of all children is maintained. It is defective vision which the School Health Service detects most readily and most efficiently. Almost 40 per cent. of all defects requiring treatment which are reported by the service can be allocated to this category (C.M.O. Ministry of Education 1962). In Dewsbury, the school health visitor tests the vision of all children who are eligible for an intermediate medical inspection and this procedure should be continued after the introduction of a selective form of examination. Bacon (1961) has emphasized that defective vision is the condition which in frequency a n d importance stands out from all others as the one which would escape detection by a selection procedure and he has concluded that frequent testing of vision is essential for all schoolchildren. The major criticism of a selective form of inspection concerns the possibility of overlooking a serious defect amongst the children who are not examined, This experiment has shown the extent to which such a criticism is justifiable at an intermediate inspection. 38 potentially treatable defects could have escaped detection in the absence of a routine medical exanlination (Table HI). The categories of these defects were : ~ Orthop,,cdic Ears and hearing Speech defects Cardiac nmrmur O t h c r defccts
... ... ,.. .,. ...
8 6 3 I 3
Skin defects ...... Tonsils ...... U n d e s c e n d e d testicles Habit spasm ......
8 5 3 1
The cardiac murmur had already been discovered so tllat Otis defect would not have been overlooked. Similarly the hearing and speech defects could have been detected by routine audionletry and reports from the teaching staffwithout
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the necessity for a medical examination. Two of the boys ~]tn undescended testicles subsequently required surgical treatment and five of the orthopaedic defects received treatment from a specialist. It must be admitted that a selective form of medical examination will not reveal all the children who require treatment. Whilst it has been stated that a symptomless cardiac murmur in the intermediate age group can be ignored (C.M.O. Ministry of Education 1960) there are evidently other defects which, although they may not reveal themselves to the parents or teachers, still warrant investigation. The analysis of defects not previously discovered by the School Health Service showed that +he majority were amongst the experimental group. "The selection procedure appears to have been very successful with the exception of postural defects, enlarged tonsils and genital abnormalities. In these categories an important number of defects were discovered in the control group and these would have escaped detection by a selective form of medical examination. It might be supposed that this objection could be largely discounted in view of the fact that for most of the defects observation was preferred to active treatment. It is difficult to ignore such a large number of defects, however, since individual doctors differ in the standards which they adopt for allocating children to each category. Indeed Henderson (1957) has suggested that national records of defects should combine those requiring treatment and those requiring observation. If this view is accepted then the number of defects which would remain undetected by a selective form of examination is appreciably increased (Table IV). It is clear from this experiment that selection methods based upon a questionnaire will not reveal all the children who are suffering from a physical defect. Nothing less than an inspection of every pupil is likely to be completely effective. A full school medical examination is probably unnecessary ~br this purpose since observation of the child by the school medical officer would be sufficient to exclude skin and postural defects. In some areas this is achieved by visiting the school during a physical education lesson. The procedure which is adopted will depend upon local circumstances but it should present an opportunity for examining the genitalia in boys. The questionnaires were completed very satisfactorily and the general information which became available to the Department in this way was greatly increased. Barasi and Cartwright (1957) noted that the majority of questions were answered in 95 per cent. of cases and this experiment has produced similar results. Douglas et alii (1961) have emphasized the value of a detailed questionnaire. The information which was provided would seem to be a sufficient basis for selection. It is interesting that nervous symptoms have been reported so frequently. Almost o n e in every five children is stated to be nervous and although this question is rather vague, it is surprising that such a high percentage of parents should consider the symptom to be worthy of comment. Previous experience
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had suggested that the term "enuresis" should be carefully defined so that parents were asked to state whether their child had wet the bed three times during the previous month. The incidence is rather higher than that recorded by Cust (1958) although he used a definition of ten wet nights in any one month. The proportion of nervous symptoms amongst the group of children who have been separated from their mother for a month or longer during the first five years of life, is greater than amongst the remaining children. The numbers involved are, however, too small to justify statistically reliable conclusions. CONCLUSIONS
It is concluded that some modification of the intermediate school medical inspection is desirable in order to avoid the examination of large numbers of healthy children and to permit a more detailed assessment of some pupils. In this enquiry the largest proportion of defects has occurred in the experimental group so that selection by means of a questionnaire would be effective and generally reliable. A number of important defects would have been missed by the exemption of certain children from an examination. It is concluded that routine tests of vision and hearing together with a physical inspection by the school medical officer are necessary for every child if all defects are to be discovered. A detailed medical examination could then be restricted to children whose parents reporlcd positive symptoms. This would permit a more thorough elucidation of psychological disturbances which form the largest group of defects revealed by the questionnaires. The relatively short period of time available for the medical inspection of every schoolchild often precludes an adequate investigation of such symptoms. It is concluded from this experiment that approximately half of the children in t h e intermedate age group would be presented for a complete medical examination. The percentage of non-returned questionnaires was very small and the answers were satisfactorily completed so that they provided a sound basis for selection. These observations suggest that parents would co-operate with the modified procedure which has been proposed for the intermediate school medical inspection. SUMMARY
Questionnaires were issued to the parents of all children eligible for an intermediate medical inspection. Consequent upon the results obtained the pupils were allocated to two groups; the experimental group were considered to require a medical examination and the remainder were assumed to be healthy. All the children were subsequently examined a n d the experience of the two groups was compared. Criteria of assessment have been stated and the results have been described in detail. It is concluded that a complete medical examination could be restricted to those children who have been selected by means of a questionnaire, provided
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that tests of vision and hearing are retained for all pupils at the age of 11 years. A brief observation of every child is desirable in order to discover all significant defects. ACKNOWLEDGMENTS I should fike to thank Dr. T. W. Robson, Principal School Medical Officer, Dewsbury C.B. for permission to conduct this experiment and to publish the results obtained. I am most grateful to Dr. M. D. Warren for his helpful advice and criticism. My thanks are also due to Mrs. B. Martin for her assistance in the preparation of the paper and Miss B. M. Penrice who prepared most of the data used in the tables. REFERENCES B A CO N, L. J. (1961). Developments in periodic medical inspection of schoolchildren. J. Royal Society Health. 81, pp. 322-327. B A R A S*I, F., a n d C A R T W P . I G H T , A. (1957). Med. Off., 97, p. 63. C H rE F M E D XC A L O F F I C E R. Ministry o f Education (1958). The Health of the Schoolchild t956 a~d :~957, p. 77. C H I E F M ~ D I C A L 0 V F I C E R, Ministry o f Education (1960) The Health o f the Schoolchild 1958 and 1959, pp. 62-69. CHIEF MEDICAL O F F I C E R , Ministry of Education (1962.) The Health o f the Schoolchild. t960 and 1961, Appendix D, Table VIII. C u s T, G. (1958). Nocturnal Enuresis. Med. Off., 100, p. 252. D O U G L A S , J., E D G A R , W., A T K I N S O N , V. H., C R A W F O R D , W. E. D., M A C C u L LO H, G. T., and L A v E R I C K, R. C. (1961). School Medical Inspections and the Family Doctor. Med. Off., 105, pp. 351-355. H o R N ER, J. S. (1962). The Intermediate School Medical Inspection. Appendix to the Annual Report u p o n the School H e a l t h Service 1961, Principal School Medical Officer, Dewsbury County B o r o u g h Council. J A C K S O N, T. F. M. (196t). A Comprehensive School Medical Examination. Med. Off., 106, pp. 317-320. L E E, J. A. H. (1958). T h e effectiveness o f Routine E x a m i n a t i o n o f Schoolchildren. Brit. Med. J., I, pp. 573-576. Experiments in School Inspections. The Medical Officer (1961), 105, p. 114. PRINCIPAL S C H O O L M E D I C A L O F F I C E R , C o u n t y Borough of Dewsbury (1961). Annual Report upon tile School ltealth Service 1960. p. 5. P R I N C i P A L S c H O O L M r O I C A L O F F I C E R, C o u n t y o f Hampshire (1959). Annual Report for the year 1958, p. 6. T A Y L O R, G. B. (1961). The Routine Medical Inspection. Med. Off., 105, p. 48. W I T H N E L L, A. (1958). The Value of the R o u t i n e School Medical Examination. Med. Off.,
99, pp. 31-36. W I T H N E L L , A . , B R I G G s,B., H AR GR EA VE S, I., and S H A W, M. K . (I961). A Nonroutine scheme o f Medical Inspection for J u n i o r Schools. Men: Off., 106, pp. 320-322.
HORNER,
M.B., CH.B.,D.P.H.,D.I.I-L
Deputy Principal School Med&'al Officer, County Borough of Croydon formerly Deputy Principal School Medical Officer, County Borough of Dewsbury Trm need for some modification of existing methods of .school medical inspection has been widely recognized in recent years. Several vxperiments have been conducted to determine the most suitable and effective form of medical inspection(The Medical Officer 1961) and these have been encot-raged by the Ministry of Education (C.M.O. Ministry of Education, 1958). A preliminary investigation in Dewsbury (Horner 1962) showed that the introduction of a screening procedure reduced the number of inspections whilst the number of children who were discovered to require medical treatment was increased. An enlarged experiment was designed, therefore, to determine whether this screening technique could satisfactorily replace the general medical inspection of all children at 11 years. A description of the experiment and the results which .were obtained may be of some general interest. METHODS
AND
MAT.ERIAL
Tile Screening Procedure A detailed questionnaire was prepared and forwarded to the parents of all children who would normally have received an intermediate school medical inspection. The question sheet Consisted of a comprehensive previous medical history of the child including an immunization history, enquiries concerning certain family illnesses and a series of twenty questions about specific complaints suffered by the child. An opportunity was given for the parent to insist upon a medical inspection without stating the reason for such a request. The school nledical record card (10M) and the completed questionnaire were then inspected by the deputy principal school medical officer who decided whether the child should be allocated to the experimental group or to the control group. Under the proposed procedure only those children in the "experimental group" would normally be presented for examination although, on this occasion, all children were given a routine school medical inspection. The medical officer who conducted the examination was not advised of the group to which the child belonged so that a form of blind experiment was cffected. No opportunity was given for the school health visitor or the head teacher to suggest names of children who were in special need of a medical examination although this would seem to be an essential adjunct to selection on the basis of a questionnaire. 291
202
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Whe,~ the medic:il cxamin:llions h:ld been complclcd lhe children were again ~!ivided inlo the two gr!~lips so th~ll conll~:lrisons could be made bclwcen those chihh'cn who had i~rcviou.,/.'ly been considered I~ be healthy and those who wollld have required ,m cxalninalion llll¢icr ,'1 sciccliVC procedure. A total of 830 cl,,ildrcn wel'c cli/:,,iblc ibr school ri~tcdical inspccliola :lnd 799 qucslionn~lires were rcltlrncd. The nuwtl~cr of l~upils who were aclu:illy examined wa~ 791 so lhlll ~,lllc :lbsenice rate w:!s 4"7 per cent. The nuinber of abscnlces was greilicl" :in~loiigsl lhe exl)erimcnt:tl group. Since all those who f:iilcd to return :l qucsiionnairc wcrc :nilonliltically placed in the cxperillieill:il calcgory, the group probal)ly includes niost ~)1"lhose p:ircills who had least inlcresl in the hcallla of their children :tlld who may not lmvc presclllcd lhcnl for nlcdiclll insl)CClion, In ~lddilion, those childrcll who :ire lllosl ill riced o1" ex~imin:ilion are also nlorc likely to be.:lbscnt from school on lhe day it is due to bc conducted.
M~'thods of Assessment 'Fhc mimbcr of childrcri who were allocated to e:lch group was rccordcd, togclhcr with the reason for ii~iclutling each child in the experimental category. In Ibis w~ly the reductioll in lhe llunll~er of examinations which would l~}llow the introduction of a selective inspection could bc determined. The reason for lhe examination was depe~lden[ on those syml~lOmS which the school medical ollicer considered 1o bc important. In gener:ii, every child who demonstrated a positive symptom was examined although the large number of parents who claimed that their child w~is "nervous" (Table V) prcventcd the attainment of this ide:ll in :all cases. Many ,
INTI~RMI~.DIATI~
S(~IIO01.
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293
it is designed to assisl. Taylor (1961) has slated that one of the major justificafions for ;t routine me(lloyd inspection is that the mothers wish it. He had obtained his intbrmation from those mothers who had attended when their children were examined. Such obserwtlions arc subject to bias, however, since molhcrs who have made an effort to attend a medical examination---often at some personal inconvenience--are unlikely to inform the doctor that they consider the whole procedure to be a waste of time. The number of parents who atlend lhe school medical inspection is likely to provide a more realistic assessment of parental approval. The preliminary survey revealed a much higher attendance rate by parents than in any of the previous six years, but ~t was not possible to use this index during,, the present experiment since all the children were examined at a normal routine school medical inspection. It has been suggestcd that parents who are most conscious of their child's health will complete the questionnaire more thoroughly and are also more likely to attend for medical examination. The attendance of parents in the experimental group did not differ signiiicantly fi'om that in the control group so that this determinalion could be used to measure the degree of pa~rental approval after a selective procedure has been introduced. The selcclion procedure was dependent upon the provision of adequate information for each child. The number of questionnaires which were completed satisfactorily was used to assess the co-operation which could reasonably be expected from the parents. THE
RESULTS
Children Allocated to the Experimental Group A total of 830 children were eligible for a school medical inspection and the number of those who were allocated to the experimental group has been recorded in Table I. Although atl the pupils subsequently received a school medical inspection, only the experimental group would have required a medical examination if a selective procedure had been used. The sex differences are not significant. Reasons for Selection The reason for allocating each child to the experimental group has been recorded in Table II. It is not surprising that, in a northern industrial town, the most frequent cause should be regular chest complications following an upper respiratotay tract infection. Unsatisfactory school progress was an important reason for selection since the possibility that medical conditions were responsible for poor educational attainments should always be considered. Any child whose questionnaire was very incomplete was automatically selected even though positive symptoms had not been admitted. Similarly children who failed to return their questionnaire were also selected and a small number of pupils were allocated to the experimental group because their previous school health record
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I
Number of children eligible for medical inspection
Experimental group
Examination rate using selection procedu're
Control group
BOYS
420
187
44.5 Yo
233
GIRLS
410
181
44.1 ~o
229
TOTAL
830
368
44-3 ~o
462
TABLE II REASONS FOR SELECTION Reason for Examination
BOYS
GIRLS
TOTAL
. . .
34 38 18 14 18 13 13 11 10 8 7 3
44 23 20 22 14 18 13 13 6 5 2 1
78 61 38 36 32 31 26 24 16 13 9 4
. . . . . . . . . . . . . . . . . . . . .
187
18 t
368
Chest colds . . . . . . . . . . . . . . . Parental request . . . . . . . . . . . . Unsatisfactory school progress ......... Recurrent sore throats ............ History o f a running ear ............ Questionnaire not returned . . . . . . . . . . . . History o f joint pains . . . . . . . . . . . . Enuresis . . . .... . . . . . . . . . . . . Morning cough . . . . . . . . . . . . Previous medical history ............ Incomplete questionnaire ............ Nervous symptoms . . . . . . . . . . . . Total
DEFECTS
DETECTED
. . . . . .
. . . . . . . .
TABLE III DURING MEDICAL
INSPECTION
(Excluding Defective Vision and Dental Defects) Experimental Control group Total group ~
No.
Standard
~
Error (diff.)
No.
~o
No.
Defects referred for investigation
38
11.2
15
3.3
53
6.7
1.8
Defects requiring treatment
35
10,3
23
5.1
58
7.3
1.9
Defects requiring observation
151
44.4
94
20.8
245
31.0
i 0"5
Total defects
224
65,9
132
29.3
356
45.0
i 1.3
Number of children examined
340
--
451
--
791
--
INTERMEDIATE
DEFECTS
Category or Code Number 4 6 7 I0 I1 12 13 14 Other Total R T O
SCHOOL
MEDICAL
INSPECTION
TABLE !V NOT PREVIOUSLY RECORDED SCHOOL HEALTH SERVICE
T y p e o f defect
BY THE
Experimental Control group group (340 (45 ! c h i l d r e n ) children)
Skin defects . . . . . . ..... . . . . E a r diseases and h e a r i n g defects ... N o s e a n d t h r o a t defects . . . . . . . . . H e a r t defects . . . . . . . . . . . . L u n g disease . . . . . . . . . . . . H e r n i a a n d genital defects ...... Orthopaedic c o n d i t i o n s . . . . . . . . . N e r v o u s system ......... Miscellaneous . . . . . . . . . . . .
295
Total (79 i children)
20 33 35 4
13 I1 26 2
33 44 61 6
8 6 29 14 36
2 7 36 3 18
10 13 65 17 54
. . . . . . . . . . . . . . . . . .
185
118
303
Defects r e q u i r i n g investigation . . . . . . Defects r e q u i r i n g t r e a t m e n t ...... Defects r e q u i r i n g o b s e r v a t i o n ......
33 24 128
13 20 85
46 44 213
COMPLETION
TABLE V OF Q U E S T I O N N A I R E S
History Completed on the Questiomlaire V a c c i n a t i o n state ... . H i s t o r y o f infectious disease P r e v i o u s significant illness in Occupation of Father . Occupation of Mother . Significant family history . R e c o r d o f siblings . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . the child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Defects recorded on the questionnaire (a) Previous defects J o i n t pains . . . . . . . . . . . . . . . Asthma . . . . . . . . . . . . . . . . . . R u n n i n g Ears . . . . . . . . . . . . . . .
BOYS
99.1 Yo 99,1 Y/o 97-5yo 96..8 ~o 96"5 ~o 92"4Yo 91 "0~o
GIILLS T O T A L
42 8 35
(b) Physical defects P o o r appet ite . . . . . . . . . . . . . . . 19 R e c u r r e n t sore throats . . . . . . . . . . . . 25 Morning cough . . . . . . . . . . . . . . . 19 F r e q u e n t chest colds . . . . . . . . . . . . 63 (c) Mental attd Psychological deflects . . . . . . . . . Nightmares . . . . . . . . . . . . . . . 16 Enuresis . . . . . . 15 N e r v o u s child o r "liighly s t r u n g " ...... 72 Abnormal behaviour ............ 12 U n s a t i s f a c t o r y s c h o o l progress ......... 31 S e p a r a t i o n f r o m m o t h e r in e a r l y c h i l d h o o d ... 2t Name of Family Doctor provided . . . . . . . . . . . . . . . .
46 6 35
88 14 70
1I'0 1-8 8,8
28 33 12 66
47 58 31 129
5"9 7-3 3.9 16"I
8 24 16 31 86 158 11 23 24 55 22 43 . . . . .
3,0 3.9 19"8 2.9 6"9 5.4 96-9~
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suggested that a full medical examination was desirable. Where multiple reasons for selection were present on the questionnaire, the one which was considered to be most important by the deputy principal school medical officer has been recorded in the table.
Defects detected during Medical blspection The total number of defects (excluding defcctive vision and dental defects) which were reported by the school medical officers is shown in Table HI. The defects were divided imo those which were referred for further investigation, those which requir0d or were already receiving treatment and finally those which required observation. The incidence of defects in all three categories is greater in the experimental group and the differences are all statistically significant. An analysis of defects discovered for the first time at this medical inspection showed a similar trend although in the category "defects requiring treatment" the difl;zrence was not sufficient to be statistically significant. Tile subdivision of these primary defects according to the system of the body has been recorded in Table IV. It should be remembered that all the defccts in the control group column of this table would escape detection by a selective form of medical inspection.
Completion of the Questionnaires 31 questionnaires (3.7 per cent.) were not returned and a further 9 were so incomplete that the child was automatically allocated to the experimental group. The percentage of completed answers to the questions is shown in Table V, together with a record of the number of defects reported on the questionnaire. DISCUSSION
Several experimental forms of medical inspection have been introduced in recent years. Douglas et alii (1961) have described a much improved system for the entrant examination which seeks to integrate the G.P. into the preventive aspects of school heahh care. There is considerable justification for examining every child at school entry and for developing the scope of this examination. In Hampshire during 1958, it was discovered that over half of the defects found in children when first starting school were unknown to their parents or if known were not being treated. The number of new defects discovered at the intermediate medical inspection is usuatly smaller and various forms of selective procedure have been developed to exclude some of the healthy children who would otherwise receive an examination. At present one defect requiring treatnzent is discovered for every nine completed medical inspections when defects of"~.,i.~ionare excluded
INTERMEDIATE
SCHOOL
MEDICAL
INSPECTION
297
(C.M.O. Ministry of Education 1962). In Dewsbury the ratio of defects discovered to children e~amined at the intermediate medical inspection is even lower than th~:; composite figure (P.S.M.O., Dewsbury C.B. 1961). The relatively small number of defects discovered by the inspection of large numbers of children does suggest that a preliminary selection procedure could be useful. In this way a more generous allowance of time could be given to those children who are most in r,eed of a medical examination. It has been noted by Witlmell et alii (1961) that a screening procedure allows the school medical officer to devote more time to the children and also makes the actual examination more stimulating. Jackson (1961) has stressed the importance of providing an adequate amount of time for each inspection and he has reported that a much greater number of defects were discovered by a more comprehensive medical examination. In view of the present bias towards treatment rather than prevention within the N.H.S., it seems doubtful whether the allocation of a really satisfactory amount of additional time for all school medical inspections is practicable unless some form of preliminary selection is also introduced. Any modification of the routine medical inspection must ensure that the periodic vision testing of all children is maintained. It is defective vision which the School Health Service detects most readily and most efficiently. Almost 40 per cent. of all defects requiring treatment which are reported by the service can be allocated to this category (C.M.O. Ministry of Education 1962). In Dewsbury, the school health visitor tests the vision of all children who are eligible for an intermediate medical inspection and this procedure should be continued after the introduction of a selective form of examination. Bacon (1961) has emphasized that defective vision is the condition which in frequency a n d importance stands out from all others as the one which would escape detection by a selection procedure and he has concluded that frequent testing of vision is essential for all schoolchildren. The major criticism of a selective form of inspection concerns the possibility of overlooking a serious defect amongst the children who are not examined, This experiment has shown the extent to which such a criticism is justifiable at an intermediate inspection. 38 potentially treatable defects could have escaped detection in the absence of a routine medical exanlination (Table HI). The categories of these defects were : ~ Orthop,,cdic Ears and hearing Speech defects Cardiac nmrmur O t h c r defccts
... ... ,.. .,. ...
8 6 3 I 3
Skin defects ...... Tonsils ...... U n d e s c e n d e d testicles Habit spasm ......
8 5 3 1
The cardiac murmur had already been discovered so tllat Otis defect would not have been overlooked. Similarly the hearing and speech defects could have been detected by routine audionletry and reports from the teaching staffwithout
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the necessity for a medical examination. Two of the boys ~]tn undescended testicles subsequently required surgical treatment and five of the orthopaedic defects received treatment from a specialist. It must be admitted that a selective form of medical examination will not reveal all the children who require treatment. Whilst it has been stated that a symptomless cardiac murmur in the intermediate age group can be ignored (C.M.O. Ministry of Education 1960) there are evidently other defects which, although they may not reveal themselves to the parents or teachers, still warrant investigation. The analysis of defects not previously discovered by the School Health Service showed that +he majority were amongst the experimental group. "The selection procedure appears to have been very successful with the exception of postural defects, enlarged tonsils and genital abnormalities. In these categories an important number of defects were discovered in the control group and these would have escaped detection by a selective form of medical examination. It might be supposed that this objection could be largely discounted in view of the fact that for most of the defects observation was preferred to active treatment. It is difficult to ignore such a large number of defects, however, since individual doctors differ in the standards which they adopt for allocating children to each category. Indeed Henderson (1957) has suggested that national records of defects should combine those requiring treatment and those requiring observation. If this view is accepted then the number of defects which would remain undetected by a selective form of examination is appreciably increased (Table IV). It is clear from this experiment that selection methods based upon a questionnaire will not reveal all the children who are suffering from a physical defect. Nothing less than an inspection of every pupil is likely to be completely effective. A full school medical examination is probably unnecessary ~br this purpose since observation of the child by the school medical officer would be sufficient to exclude skin and postural defects. In some areas this is achieved by visiting the school during a physical education lesson. The procedure which is adopted will depend upon local circumstances but it should present an opportunity for examining the genitalia in boys. The questionnaires were completed very satisfactorily and the general information which became available to the Department in this way was greatly increased. Barasi and Cartwright (1957) noted that the majority of questions were answered in 95 per cent. of cases and this experiment has produced similar results. Douglas et alii (1961) have emphasized the value of a detailed questionnaire. The information which was provided would seem to be a sufficient basis for selection. It is interesting that nervous symptoms have been reported so frequently. Almost o n e in every five children is stated to be nervous and although this question is rather vague, it is surprising that such a high percentage of parents should consider the symptom to be worthy of comment. Previous experience
INTERMEDIATE
SCHOOL
MEDICAL
INSPECTION
299
had suggested that the term "enuresis" should be carefully defined so that parents were asked to state whether their child had wet the bed three times during the previous month. The incidence is rather higher than that recorded by Cust (1958) although he used a definition of ten wet nights in any one month. The proportion of nervous symptoms amongst the group of children who have been separated from their mother for a month or longer during the first five years of life, is greater than amongst the remaining children. The numbers involved are, however, too small to justify statistically reliable conclusions. CONCLUSIONS
It is concluded that some modification of the intermediate school medical inspection is desirable in order to avoid the examination of large numbers of healthy children and to permit a more detailed assessment of some pupils. In this enquiry the largest proportion of defects has occurred in the experimental group so that selection by means of a questionnaire would be effective and generally reliable. A number of important defects would have been missed by the exemption of certain children from an examination. It is concluded that routine tests of vision and hearing together with a physical inspection by the school medical officer are necessary for every child if all defects are to be discovered. A detailed medical examination could then be restricted to children whose parents reporlcd positive symptoms. This would permit a more thorough elucidation of psychological disturbances which form the largest group of defects revealed by the questionnaires. The relatively short period of time available for the medical inspection of every schoolchild often precludes an adequate investigation of such symptoms. It is concluded from this experiment that approximately half of the children in t h e intermedate age group would be presented for a complete medical examination. The percentage of non-returned questionnaires was very small and the answers were satisfactorily completed so that they provided a sound basis for selection. These observations suggest that parents would co-operate with the modified procedure which has been proposed for the intermediate school medical inspection. SUMMARY
Questionnaires were issued to the parents of all children eligible for an intermediate medical inspection. Consequent upon the results obtained the pupils were allocated to two groups; the experimental group were considered to require a medical examination and the remainder were assumed to be healthy. All the children were subsequently examined a n d the experience of the two groups was compared. Criteria of assessment have been stated and the results have been described in detail. It is concluded that a complete medical examination could be restricted to those children who have been selected by means of a questionnaire, provided
300
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that tests of vision and hearing are retained for all pupils at the age of 11 years. A brief observation of every child is desirable in order to discover all significant defects. ACKNOWLEDGMENTS I should fike to thank Dr. T. W. Robson, Principal School Medical Officer, Dewsbury C.B. for permission to conduct this experiment and to publish the results obtained. I am most grateful to Dr. M. D. Warren for his helpful advice and criticism. My thanks are also due to Mrs. B. Martin for her assistance in the preparation of the paper and Miss B. M. Penrice who prepared most of the data used in the tables. REFERENCES B A CO N, L. J. (1961). Developments in periodic medical inspection of schoolchildren. J. Royal Society Health. 81, pp. 322-327. B A R A S*I, F., a n d C A R T W P . I G H T , A. (1957). Med. Off., 97, p. 63. C H rE F M E D XC A L O F F I C E R. Ministry o f Education (1958). The Health of the Schoolchild t956 a~d :~957, p. 77. C H I E F M ~ D I C A L 0 V F I C E R, Ministry o f Education (1960) The Health o f the Schoolchild 1958 and 1959, pp. 62-69. CHIEF MEDICAL O F F I C E R , Ministry of Education (1962.) The Health o f the Schoolchild. t960 and 1961, Appendix D, Table VIII. C u s T, G. (1958). Nocturnal Enuresis. Med. Off., 100, p. 252. D O U G L A S , J., E D G A R , W., A T K I N S O N , V. H., C R A W F O R D , W. E. D., M A C C u L LO H, G. T., and L A v E R I C K, R. C. (1961). School Medical Inspections and the Family Doctor. Med. Off., 105, pp. 351-355. H o R N ER, J. S. (1962). The Intermediate School Medical Inspection. Appendix to the Annual Report u p o n the School H e a l t h Service 1961, Principal School Medical Officer, Dewsbury County B o r o u g h Council. J A C K S O N, T. F. M. (196t). A Comprehensive School Medical Examination. Med. Off., 106, pp. 317-320. L E E, J. A. H. (1958). T h e effectiveness o f Routine E x a m i n a t i o n o f Schoolchildren. Brit. Med. J., I, pp. 573-576. Experiments in School Inspections. The Medical Officer (1961), 105, p. 114. PRINCIPAL S C H O O L M E D I C A L O F F I C E R , C o u n t y Borough of Dewsbury (1961). Annual Report upon tile School ltealth Service 1960. p. 5. P R I N C i P A L S c H O O L M r O I C A L O F F I C E R, C o u n t y o f Hampshire (1959). Annual Report for the year 1958, p. 6. T A Y L O R, G. B. (1961). The Routine Medical Inspection. Med. Off., 105, p. 48. W I T H N E L L, A. (1958). The Value of the R o u t i n e School Medical Examination. Med. Off.,
99, pp. 31-36. W I T H N E L L , A . , B R I G G s,B., H AR GR EA VE S, I., and S H A W, M. K . (I961). A Nonroutine scheme o f Medical Inspection for J u n i o r Schools. Men: Off., 106, pp. 320-322.