SEM examinations: routine and selective
| Author | Intervention | Study | Subjects | Findings and conclusions | Comments |
|---|---|---|---|---|---|
| RCTs | |||||
| Wadsworth5 |
Type of SEM: routine and selective Routine: questionnaire sent to all parents plus examination of preschool records. Height, weight, hearing, and vision screened by nurse SEM by SMO—details not specified Selective: all children seen by school nurse for screening of hearing, vision, height, and weight Selection by class review.2-150 Selection criteria include: parent request; child on protection register; preschool medical records incomplete/missing; known medical condition needing clarification; SEN | Randomised controlled trial: 106 primary schools (2223 school entrants) were randomly allocated within locality boundaries (defined by the coverage of a single SMO) to an intervention (selective) and a control (routine) group The same school doctor examined both groups of children |
Routine: 1208 primary school entrants Selective: 1015 primary school entrants | 69% of children seen in selective schools Selection for SEM did not identify the same number or type of problems as the routine screening examination Children with significant speech, and behaviour problems were identified at follow up one year later who had not been selected for a SEM examination The selective SEM consumed 23% more time | • Schools rather than pupils randomised • No data on comparability of intervention and control groups • Schools not described • Screening tests and conditions not clearly defined • Condition not reported by need for identification; newly defined; or need for action • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Comparative studies | |||||
| Jessen et al 6 |
Type of SEM: routine and selective Routine: parent questionnaire, height, weight, vision and hearing screening by school nurse. Physical, neurodevelopmental, and behavioural screening by doctor Selective: selection based on review of preschool notes, parental questionnaire, and class review. Selection criteria include: parent request; child on protection register; preschool medical records incomplete/missing; known medical condition needing clarification; SEN | Comparative observational study Schools matched by high levels of socioeconomic deprivation and health problems The same school doctor examined both groups of children |
Routine: 117 primary school entrants Selective: 171 primary school entrants | 73% of children seen in selective schools Important and previously undetected problems are picked up by both types of SEM Selective assessment, following class review, picked up significant problems better, especially behavioural and social | • Screening tests and conditions not clearly defined • Conditions not reported by need for identification; new problems • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Donnelly and Powell7 |
Type of SEM: routine and selective Routine: health questionnaire to parents. Height, weight, and vision screening by school nurse. Hearing screening by audiologist. Physical, neurodevelopmental, and behavioural screening by doctor Selective: all children seen by school nurse for screening of hearing, vision, height, and weight. Selection by class review. Criteria for selection include: information from preschool checks and medical history; parental questionnaire | Comparative observational study Schools matched by Jarman index The same school doctor examined both groups of children |
Routine: 259 primary school entrants Selective: 194 primary school entrants | 49% of children seen in selective schools The selection rate was much higher in schools with a high Jarman index Selection did not have a great effect on referrals or recalls The time saved by the doctor with a selective system depends on the numbers of children selected and the time taken by the nurse | • No comparison of groups • Screening tests, uptake rate and conditions not clearly defined • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Prospective observational studies | |||||
| Bax and Whitmore9 |
Type of SEM: routine Routine: health questionnaire to parents. Hearing, vision, height, and weight screening by school nurse. Neurodevelopmental, medical, and behavioural screening by doctor | Prospective observational study | 351 primary school entrants | High neurodevelopmental score is a good predictor of referral to a school psychologist during infant school years, which predicts later learning difficulties. It is important for SEMs to include a neurodevelopmental examination | • Screening test not defined • Uptake rate not defined • Condition not reported by need for identification; new problems; action taken • No referral/recall criteria defined |
| Broomfield and Tew16 |
Type of SEM:selective Selective: height, weight, vision, and simple coordination screening by school nurse. Hearing screening by audiometrician Selection by class review. Selection criteria include : information from preschool records; parental questionnaire; results of screening | Prospective observational study | 774 primary school entrants | Number of new conditions identified at SEM are relatively few SEMs should be reserved for children who have missed preschool screening and those with special needs A selective system can be as effective in identifying problems as a routine SEM 35% of children seen by doctor for SEM | • School not described • Screening tests, uptake rate and conditions not clearly defined • Conditions not reported by need for identification • Referral and recall criteria not defined • No follow up after referral • No follow up of whole cohort |
| Houghton et al 17 |
Type of SEM:selective Selective: all children seen by school nurse for screening of hearing, vision, height, and weight. Selection criteria include: incomplete immunisation; absence of previous developmental assessments; known/ suspected physical, developmental, or social problems | Prospective observational study | 82 primary school entrants | Majority of problems at school entry are detected by nurse screening tests—SEM adds very little Selection based on previous examination and availability of records does not identify children at particular risk | • Do not know what percentage of children were seen by the doctor for a SEM • School not described • Screening tests, uptake rate, and conditions not clearly defined • Conditions not reported by need for identification or action taken • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Leff12 |
Type of SEM: selective Selective: all children seen at school entry have been referred for review following a comprehensive examination carried out on all children at 4 years by both doctor and nurse. Other criteria for selection: request from parent/teacher/other professionals; new to area | Prospective observational study | 237 school entrants | 10% of children referred to specialist for first time 30% of children had a known difficulty 13% of children had physical health problems which were monitored at school | • Do not know what percentage of children were eligible for a SEM —no denominator • Screening tests and conditions not clearly defined • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Ni Bhrolchain4 |
Type of SEM: routine Routine: all children seen by school nurse for hearing test (Sweep test), vision tests (linear Snellen chart and letter matching card. Occlusion by Albupore tape), family and immunisation history, monitoring of weight and height. Physical examination by doctor, including neurodevelopmental tests and immunisation; advice to parents about health concerns | Prospective observational study | 269 primary school entrants | 76 problems per 100 children seen 75% of problems first identified at school entry Selective SEM may be more expensive than routine SEM | • Population not defined • School not described • Screening tests, uptake rate, and conditions not clearly defined • Conditions not reported by need for identification, number of new problems, or action taken • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Ni Bhrolchain and Shribman19 |
Type of SEM:selective Selective: all children seen by school nurse for screening of hearing, vision, height, and weight. Selection carried out by school nurse. Criteria for selection : parent questionnaire; medical history; absence of three year check | Prospective observational study | 3700 primary school entrants | 57% of children seen by a doctor for a SEM Tracer method2-151 is useful to assess the effectiveness of selective SEM This method of selection successfully detects children with problems | • School not described • Screening tests and conditions not clearly defined • Condition not reported by need for identification or action taken • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Varley15 |
Type of SEM:routine Questionnaire sent to all parents plus examination of preschool records. All children seen by the school doctor and nurse | Prospective observational study | 747 primary school entrants | 46% of children had one or more health problems 50% of problems newly diagnosed at SEM 71% of new problems needed treatment SEMs are essential for all children in the district and SEMs are not justified | • School not described • Screening tests, uptake rate and conditions not clearly defined • Condition not reported by need for identification or new problems • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Retrospective observational studies | |||||
| Donnelly and Powell8 |
Type of SEM: routine As above for routine group | Audit of three years of SEMs | 6165 records of primary school entrants | The morbidity rate for 1990–93 increased from 30–37% The number of behaviour problems increased by 388%, coordination and motor problems continue to be identified at rate of 6% per annum and unidentified undescended testes at rate of 0.4% in 1992/3 It is important to check the health and development of children in their first year of school | • School not described • Retrospective recording of data • Screening tests and conditions not clearly defined • Conditions not reported by need for identification or number of new problems • Referral and recall criteria not defined • No follow up after referral • No follow up of whole cohort |
| Elliot et al 18 |
Type of SEM:routine Routine: no details regarding content of examination | Retrospective audit | 10% random sample of 1127 primary school entrants | Selection criteria based on the absence of a three year health check and/or parental or nurse concern, would have failed to identify 217 of the 491 children with new problems, some of which were serious | • School not described • Retrospective recording of data • Screening tests, uptake rate and conditions not clearly defined • Conditions not reported by need for identification, number of new problems, or action taken • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Kennedy11 |
Type of SEM: routine All children — height, weight, vision by school nurse. Hearing by educational audiologist. Physical examination by school doctor — no routine neurodevelopmental examination | Retrospective observational study | 1048 primary school entrants | 62% of new problems already known about by at least one professional Most new problems could have been found by screening tests not involving doctors Little is being achieved by SEMs and a change is long overdue | • School not described • Retrospective recording of data • Screening tests, uptake rate, and conditions not clearly defined • Conditions not reported by need for identification • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| O’Callaghan and Colver10 |
Type of SEM:selective Selective: all children seen by school nurse for screening of hearing, vision, height, and weight. Selection by class review. Criteria for selection include: records of preschool surveillance missing/incomplete; request by parent/teacher/ professional; SENs; clarification of known medical condition | Retrospective observational study | 494 primary school entrants from 10 schools | 96% of children seen The ‘routine’ SEM is an outdated concept and that its abolition would allow more time for more important aspects of educational medicine | • Schools not described • Retrospective recording of data • Screening tests, uptake rate, and conditions not clearly defined • Condition not reported by need for identification; new problems; action taken • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Richman and Miles13 |
Type of SEM:selective Selective: all children interviewed by school nurse and screened for height, weight, hearing and vision defects. Selection by class review. Selection criteria include: review of preschool records by doctor and nurse; incomplete immunisation | Prospective observational study | 52 primary school entrants | 33% of children seen by doctor for SEM 20 children (38%) had a total of 24 health problems of which five problems were already known and a further two problems were being treated There is no longer a place for routine SEMs for all children at school entry | • School not described • Retrospective recording of data • Screening tests and conditions not clearly defined • Conditions not reported by need for identification or action taken • Referral criteria and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
| Smith et al 14 |
Type of SEM:routine Questionnaire sent to all parents. Height, weight, and audiometric screening by school nurse. Physical examination, neurodevelopmental and speech assessment by school doctor | Retrospective observational study | 1000 medical records of school entrants | Once known medical problems and those screened for by the school nurse were excluded only 17 problems requiring treatment were discovered Routine screening by a nurse followed up by selective SEM by the school doctor, is efficient and effective | • School not described • Retrospective recording of data • Screening tests, uptake rate, and conditions not clearly defined • Conditions not reported by need for identification • Referral and recall criteria not clearly defined • No follow up after referral • No follow up of whole cohort |
↵2-150 Class review is one of the methods used to select children for a SEM examination. The school medical officer (SMO), school nurse, teachers and other relevant professionals, for example speech therapist and school psychologist, are all involved in making a decision concerning which children need to be seen for a SEM examination. In the absence of a formal class review, concerns raised by teachers, parents or other professionals are taken into account in the selection process.
↵2-151 The Tracer method is a means of evaluating the quality of health care delivery. The Tracer conditions selected must be relatively common, easily defined, amenable to medical intevention, serious enough to need treatment, and non-medical influences on course must be known (Ni Bhrolchain, 1993).
SEN=special educational needs.