In September 2008, the New Zealand Government rolled out a new universal four year old health screen, the B4 School Check.  In addition to the general health, vision, hearing and dental checks traditionally conducted on kiwi kids, the B4 School Check includes a screening test for mental disorders, an initiative that arose out of a government plan for addressing conduct disorder in New Zealand children.

In the following year prescribing for 0-4 year olds in New Zealand increased over 140% while Ritalin extended release prescriptions for pre-schoolers doubled.

The lack of effectiveness and potential harm of pre-school mental health screening programmes is well established.  A randomized controlled trial of a public health and education screening program which included 4,797 four to five year old children found that at the end of the third school year, no differences were found between children who screened positive for disorders and received intervention and the “no intervention” groups using individual academic achievement, cognitive, and developmental tests.[1]

In its policy paper on the B4 School Check, the Ministry of Health acknowledges that “research does not support the use of mass screening for mental disorders in pre-schoolers” but does not explain why it is then proposing its introduction in NZ.

The mental health screen used in the new B4 School Check, the Strengths and Difficulties Questionnaire (SDQ), was developed by child psychiatrist and neurologist Dr Robert Goodman of the Institute of Psychiatry at King’s College in London.

This screening test has been introduced despite the Ministry of Health acknowledging that the test is “still being evaluated for predictive validity, reliability, sensitivity and specificity.”

Even if the test was valid elsewhere it would not be in New Zealand given that health professionals conducting the test are told by the Ministry that the scoring sheet being used in NZ “is based on the SDQ for older children, and the wording differs in three questions.” No explanation is provided as to why the scoring sheet for an older population has been substituted for the one designed for the pre-school test or how the wording differences affect validity.

Research shows the SDQ produces more false positives than false negatives, resulting in many children with no disorders being referred for diagnostic assessment[2] with false positive results affecting15% to 30% of children.

 So how does it work?

The SDQ involves the child’s parent and early childhood teacher completing a child behavior checklist. In the case of children who attend playcentre, the ‘teacher’ completing the questionnaire will be the parent of another child at the centre. The questions are of course highly subjective and likely to be influenced by recent events involving the child. Below is a link to the SDQ Questionnaire for 4-10 year olds.

SDQ_English(Austral)_pt4-10single

The child’s combined parent and teacher rating produces a result of normal, abnormal or borderline.

The vast majority of parents whose children undergo the B4 School Check have no idea their child is being screened for mental illness. This is as a result of a deliberate campaign of disinformation promulgated by our Ministry of Health.

In their pamphlet on the B4 School Check, the Ministry advises parents that the check “helps to make sure your child is healthy and can learn well at school” and “is a chance to discuss your child’s health and development with a nurse.” Parents are not told that rather than a discussion with a nurse, they are agreeing to participate in a structured and scored child behaviour checklist based on the American Psychiatric Association’s diagnostic manual for psychiatric disorders.

A separate pamphlet for teachers advises that he SDQ is a tool designed to get an overall picture of the child’s strengths and difficulties, is used to assess social and emotional development and is not used to diagnose or label children.

Health Professionals however are told that the B4 School Checks help capture children with “behavioural or mental health problems [which] may not be identified even if they are receiving regular health care.”

 The Ministry advised government in their paper on the B4School Check that “An increase in referrals to child and adolescent mental health services is likely to be one result of implementing the B4 School Check.” They advise those conducting the tests that referral of children for diagnostic evaluation will result in a diagnosis of:

• a mental health disorder
• behavioural issues; or
• normal behaviour

Research conducted in 2010 notes that the use of the SDQ includes evidence that is associated with increasing rates of clinician-rated diagnoses of child mental disorder across its full range.

So what is the truth? Is the SDQ a ‘school readiness check’ or a psychiatric screen?

Dr Goodman, the developer of the test and other researchers who use the test in clinical studies are clear that the test is not designed to assess health but to screen for mental disorders.  They make it clear that the SDQ is a test designed to identify how likely a particular child is to meet the diagnostic criteria for a range of psychiatric disorders.

The following are quotes from research papers by Dr Goodman and others on the use of the SDQ:

A computerised algorithm was developed to predict child psychiatric diagnoses on the basis of the symptom and impact scores derived from Strengths and Difficulties Questionnaires (SDQs) completed by parents, teachers and young people. The predictive algorithm generates “unlikely”, “possible” or “probable” ratings for four broad categories of disorder, namely conduct disorders, emotional disorders, hyperactivity disorders, and any psychiatric disorder. [3]

 A primary aim of both questionnaires is to identify children at high risk of psychiatric disorders and who therefore warrant further assessment.[4]

 This study supports the usefulness of the Strengths and Difficulties Questionnaire as an effective and efficient screener for child and adolescent mental health problems in the United States.[5]

 The reliability and validity of the SDQ make it a useful brief measure of the adjustment and psychopathology of children and adolescents.[6]

In respect to screening, Dr Goodman advises “In community samples, multi-informant SDQs (ie SDQs completed by both parents and teachers) can predict the presence of a psychiatric disorder with good specificity and moderate sensitivity.”

Contrary to assurances by the Ministry that the SDQ is not used for diagnostic labeling, the SDQ website advises that the screening test identifies symptoms and behaviours of the psychiatric  disorders and identifies disorders such as ADHD and Generalised Anxiety Disorder as defined by the DSM-IV and ICD-10.

The Ministry of Health goes beyond failing to inform parents and teachers of the purpose of the SDQ and the rights of parents to decline it, but actually instructs health professionals conducting the screen to withhold this information from parents. In its manual for health professionals the Ministry states the following:

Important: Do not use the words ‘borderline’ or ‘abnormal’ when communicating the results back to the parent. Use the terms ‘concerning’ to acknowledge parents’ concern. Avoid saying things like, ‘I need your permission to administer the SDQ’ or ‘Sorry for having to put you through this’ or ‘You don’t have to do this if you don’t want to’. These statements may engender a negative or fearful reaction in parents.

 Emphasise to parents and teachers that the SDQ’s purpose in relation to the B4 School Check is not to judge or label children, but to make sure the child has no problems that might hinder the child from learning and to get appropriate support and help for the child and their family/whanau if any problems are identified.

Parents may be intimidated by the SDQ or it may raise anxieties about their child. Introduce and discuss the SDQ in a way that minimises parental anxiety and reassures parents about the purpose of the questionnaire.

 The Ministry advises health professionals that a total difficulties score between 17 and 40 (an ‘abnormal’ or ‘concerning’ score) on either the Parent or Teacher questionnaire “identifies possible mental health disorders, socio-emotional issues or other developmental disorders affecting the child and their family/whanau.” Health professionals are told to “Refer a child with ‘concerning’ scores to a paediatrician, a child mental health specialist or the Child and Adolescent Mental Health Services, or Group Special Education (GSE), depending on the type of further evaluation and management the child needs.”

Interestingly, while the SDQ is promoted as a school readiness check, the results are not shared with the child’s school but sent to their doctor. The vision and hearing test results however are given to the child’s early education centre, kohanga reo, and/or school.

 In an official information act request, CASPER was advised that parents have the right to have their children screened for physical health while refusing the participate in the SDQ. Parents are however not told this before or during the B4 School Check. In our discussions with parents we are told that they agree to fill in the SDQ because they believe failure to do so will result in being unable to have their child’s hearing and vision tested.

The roll out of the B4 School Check occurred following a pilot programme, the results of which have not been published by the Ministry but which CASPER obtained under the Official Information Act. 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. The evaluators reported that parents stated that “these questions were not appropriate to the age group and were reluctant to label their child in the areas concerned.” Advice to the Ministry was that the SDQ should not be introduced but that if the Ministry chose to implement it, it should run a publicity campaign using a New Zealand celebrity to promote it in order to overcome parental resistance.

Remembering that the results of this test will remain on a child’s file for at least 10 years, what happens if a parent disagrees with the results or the assessment provided by the teacher?

In response to this question, the Ministry advises that it is unlikely the assessment will be removed from the child’s record. Apparently the usual course of action when a patient (or parent) believes that there has been a misdiagnosis or disagrees with information placed on the record by a health provider is that the information is not removed but that a note that the parent disagrees with it is placed on the file.

 So what results has screening NZ four year olds produced?

 Dr Pat Tuohy, the Ministry of Health’s Chief Advisor on Child and Youth Health advised in a press release on 23 Sept 2010 that the mean scores of four-year-old New Zealand children on the SDQ were comparable to those of preschoolers in Australia, the United Kingdom and the United States. He warned however, that the assessment raises some concerns about the higher rates of conduct problems seen in New Zealand preschoolers[7]

 Dr Tuohy presented the following data from the SQD at the Annual Conference of the Public Health Association of NZ held from 22-24 September 2010[8] which he claimed showed our children had higher rates of conduct disorder and difficulties relating to their peers than international averages.

	International comparisons
	NZ	Australia	Britain	USA
Total	7.3	8.2	8.6	7.4
Emotional	2.2	2.1	1.9	1.5
Conduct	2.5	1.5	1.6	1.4
Attention	3.2	3.1	3.6	3.2
Peer	2.1	1.6	1.4	1.3
Prosocial	8.4	8.3	8.6	8.4

In fact, Dr Tuohy’s claim that he was comparing NZ preschoolers with those in other countries is completely untrue. The US data he used is from 2001 and was taken from a random sample of 9,878 children aged 4-7. The British data was taken from a representative sample of 5,766 5-10 year olds. The Australian data was taken from a 2005 study involving a random sample of 910 children aged 7-17.

The average scores for populations that span age ranges of 3-10 years are not appropriate comparators for a population of NZ children who are all the same age and are far younger than those populations.

I have no doubt the goals of the interagency working group on conduct disorders have been met. The government has been provided with data showing that public funds should be invested in addressing New Zealand’s high rates of conduct disorder. The ‘infant mental health’ units and specialists in NZ hospitals have secured ongoing funding.

The results for our kids don’t look so great though. New Zealand pre-schoolers are being given stigmatising labels that will follow them through to their teenage years and affect the way parents, teachers and health professionals view and treat them and more and more children are being prescribed dangerous psychiatric drugs which are clinically proven to induce suicidality, violence, obesity, diabetes, cardiac arrest, impaired growth and infertility.

I sincerely doubt this is what parents expect from ‘child wellness checks’ in New Zealand.

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