[Edit: Some of my views expressed in this post, have now changed, please see the post here for clarification.]
At the age of four – prior to starting school – every child in New Zealand is meant to have a “B4 School Check.” The B4 School Check is a 45 minute interview (though the actual time seems to vary a lot) designed to identify any problems the child has, that may affect their learning at school. This includes health, vision and hearing checks. But it also includes an increasingly controversial check for the child’s “strengths and difficulties” (the SDQ, Strengths and Difficulties Questionnaire). A growing number of people are concerned that the SDQ is a stealthy and unhealthy, check for mental health.
The SDQ has two parts to it: the questionnaire filled out by the parent (SDQ-P), and the questionnaire filled out by the “teacher” (SQD-T). (Though what and who counts as a “teacher” is reasonably broad, and can include other parents at a play-centre.) Officially, the SDQ is not used to diagnose or label a child; it is meant to identify concerns and determine whether a referral to a specialist might be required.
On the surface this all looks fine, but how the health checks are being conducted and the actual outcome of the heath checks – specifically of the SDQ – have raised concerns. Whether those concerns are over-reactions, misunderstandings, or evidence of out-dated attitudes towards “mental health” issues, is what I want to consider in this and my next post.
First off, the outcome of these health checks, in relation to the SDQ: They were introduced in 2008 (after a pilot run if 2007 to see how well they performed). There was a “140 per cent increase in antidepressant prescriptions for 0 to 4-year-olds between 2009 and 2010, and an average 10 per cent increase in mood-stabilising drug prescriptions in the last five years for children aged five and over.”
Whether we should be concerned about those increases or not (here is just one example of someone very concerned about it), depends on whether these checks are picking up conditions that were present and previously un dealt-with, or whether they were prescriptions for conditions that don’t exist: If the checks are picking up on genuine conditions that need treatment, and the appropriate treatment is being put in place, then I think that’s cause for celebration rather than alarm; a child and their family are receiving much-needed help.
There are some who are at all times – regardless of genuine conditions – against the medication of young children in this manner. That is an important argument, but it can’t be wrapped up in a critique of the B4 School Checks: If your view is that medicating children with condition X is always harmful, then you can’t get angry at a Check which identifies a child as having condition X; the accurate target would be “the preferred treatment” for all children with that condition, ie not just the ones identified thanks to a B4 School Check.
The concerned writer I linked to above, adds that the ineffectiveness of interventions after preschool checks, has been well established; but she links to a 1987 study to support the point. I would have thought it particularly unconvincing to use a 20-year-old study, which used a different check and different treatments than are currently used with the children concerned, to reach the conclusion that the current B4 School Check – and the then following interventions – are pointless or harmful. The writer even states later in their piece that the government has used a Check based on the current DSM and ICD, both of which – I point out – were actually published well after 1987. I would have thought updated checks and treatments would suggest the need to use updated studies.
As I mentioned earlier, the government did run a pilot program for the B4 School Check, the year before it was widely introduced. The government shares some positive parental feedback from that trial, in the information it provides to teachers about the SDQ. Including very high levels of parental confidence and satisfaction in the checks (see the download to the right on this page, under “FAQ…”). This of course doesn’t tell us about the accuracy and effectiveness of the outcomes from the Checks (and would have struggled to do so, I expect, after only one year).
Furthermore, not all parental feedback was actually positive, some was quite critical. For example, “The pilot showed strong resistance from parents to the rating scale used, the applicability of the questionnaire and specific questions about lying, cheating and stealing.” It appears that these parental concerns were not made publicly available, they only came to light after an Official Information Act request.
There is concern about the number of false-positives that arise from a B4 School check. The writer of the critical piece again points out that there are a high number of false positives, whereby children are sent along for diagnostic assessment despite having no condition (based on a 2000 study in England, of the SDQ). However, again, surely this would only be really concerning if those false positives were then inaccurately diagnosed and then given inappropriate treatment? If what is happening is children are being identified with potential problems that turn out to not be an actual condition, then doesn’t it mean the B4 school checks are doing what they set out to do? That is, identifying potential problems and allowing professionals to then follow-up to determine if a causative condition actually exists?
This makes me weary of the use of the term “false positives” in this context: A “false positive” result from a B4 School Check would be “there is something here that is concerning” when in reality there is not something concerning. The B4 School Check is not a diagnostic instrument, and neither is it used or intended as such. If it was being used to diagnose a condition which later turned out to be false, then the term “false positive” would surely be more accurate.
Of course there do remain other issues around these “false positives” (even once we distinguish that the B4 School Check is not a diagnosing instrument). That is the time, stress, and money involved in determining that a child does not have a condition, after the B4 Check identifies a potential issue. I do think this is a valid and important concern, and part of the reason why you wouldn’t want the B4 School Check to be casting such a wide net.
There are also concerns about the findings of a B4 Check remaining on the child’s records for 10 years, and the impact this in itself might have on the way the child is dealt with by educators and other professionals. However, as long as it is understood that the B4 School Check is not a diagnostic instrument, I think much of that concern is ameliorated. It does though again argue in favour of having a more precise or targeted Check. Which brings me to what I think is another important concern about these B4 School Checks:
They are not compulsory. A parent can choose too, to only take part in the hearing and vision checks (for instance) and not do the SDQ part. But neither of these points – that the entire thing is not compulsory and that a parent can choose to only take part in a portion of it – are emphasized for parents. Many parents apparently think and thought they were compulsory.
When I was informed that my eldest (my autistic son) was of the age that he should have a B4 School Check, it was via a form that arrived in the mail. The form made it very clear that I could choose not to have the Check done. When I didn’t return the form, they did follow-up with a phone call to remind me about the Check. I told them my son was already “in the system;” that he had already gone through full health checks, and had a confirmed diagnosis. This seemed to satisfy them and they thereafter left me alone.
Even though I knew I didn’t have to do the Check, and didn’t want to do the Check, I did feel an uncomfortable amount of pressure to do so anyway, both via the form and during the follow-up phone call; like I was a negligent parent should I choose not to take part. It was very clear from the phone call that I was expected to justify why I wouldn’t take part in the Check, which seems to move the Checks away from their supposedly “completely voluntary” nature.
Indeed, notes made available by the Government to educators, tells them to strongly encourage parents to take part and to reassure parents so they will take part, rather than a focus on – say – informing parents more so about what the Check tests for and the parents’ unhindered right to refuse the B4 School Check.
There is one final and important aspect of the B4 School Check that I want to address, but this post is already very long, so I’m going to split that off into a “Part Two.” In Part Two I intend to discuss issues around the public’s perceptions of “mental health” issues that arise from the B4 School Checks. In particular, I’ll be looking at the public’s evident concerns about the stigma of diagnoses which arise from the B4 School Check outcomes, and the public’s perception of “epidemics” like autism that can supposedly arise from such Checks. I’ll also be considering the way in which the public has responded to the idea of checking young children at all for such conditions.
Relevant and Useful links:
- “Ministry ‘hides test’s real purpose'”(stuff.co.nz, June 24th 2012)
- “Universal Psychiatric Screening for NZ Pre-Schoolers” (Bradshaw, March 15th, 2012)
- “The mental health of New Zealand preschool children. Strengths and Difficulties questionnaire at 4-5 years” (pdf, Ministry of Health).
- One of many public discussions by New Zealanders on the B4 School Check, on TradeMe (only viewable by TradeMe members though)
- Ministry of Health’s “B4 School Check” webpage