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A descriptive study of a screening clinic for 3-year-olds Myers, Dorothy Rae 1978

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A DESCRIPTIVE STUDY OF A SCREENING C L I N I C FOR 3-YEAR-OLDS by DOROTHY RAE MYERS c. N., U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1 9 5 1. THESIS SUBMITTED I N PAR T I A L FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE I N NURSING i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l o f N u r s i n g ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA M a r c h , 1978 © D o r o t h y Rae M y e r s , 197 8 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a nd s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e Head o f my D e p a r t m e n t o r by h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f School /\Jur$)n The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 W e s b r o o k P l a c e V a n c o u v e r , C a n a d a V6T 1W5 i ABSTRACT A c o m m u n i t y h e a l t h u n i t i n a B r i t i s h C o l u m b i a s u b u r b e s t a b l i s h e d a s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s m o d e l l e d on s i m i l a r p r o g r a m s a l r e a d y o p e r a t i n g i n n e a r b y l o c a l i t i e s . The p u r p o s e o f t h e s t u d y was t o d e s c r i b e t h i s new s c r e e n i n g c l i n i c : t o r e p o r t on t h e p r o c e d u r e s e m p l o y e d , t h e p e r s o n n e l i n v o l v e d , t h e c h a r a c t e r i s t i c s o f t h e c l i e n t e l e , a n d t h e t y p e s , i n c i d e n c e , a nd d i s p o s i t i o n o f p r o b l e m s d e t e c t e d amongst t h e c h i l d r e n b r o u g h t t o t h e c l i n i c . The s t u d y p o p u l a t i o n c o n s i s t e d o f t h e 4 7 c h i l d r e n and t h e i r p a r e n t s who w e r e t h e c l i e n t s o f t h e c l i n i c d u r i n g i t s f i r s t t h r e e m o n t h s . The r e s e a r c h i n s t r u m e n t s w e r e o r i g i n a l q u e s t i o n n a i r e s and f o r m s d e v i s e d t o o b t a i n s o c i o l o g i c a l a n d h e a l t h h i s t o r y i n f o r m a t i o n . The f o r m s w e re c o m p l e t e d d u r i n g a home v i s i t and by a t e l e p h o n e i n t e r v i e w w i t h e a c h f a m i l y . The d a t a a r e a r r a n g e d i n f r e q u e n c y t a b l e s and p e r c e n t a g e s c a l c u l a t e d w h e r e a p p r o p r i a t e . A few v a r i a b l e s a r e c r o s s - t a b u l a t e d t o a d d d e s c r i p t i v e d e p t h t o t h e s t u d y . The f a m i l i e s i n t h e s t u d y w e r e f r o m t h e m i d d l e a nd u p p e r - m i d d l e c l a s s segment o f s o c i e t y . T hey h a d f r e q u e n t l y u s e d o t h e r h e a l t h r e s o u r c e s i n t h e c o m m u n i t y . The m o t h e r s ' m a i n c o n c e r n s w e r e a b o u t s p e e c h and l a n g u a g e d e v e l o p m e n t and b e h a v i o r p r o b l e m s o f t h e i r c h i l d r e n . T w e n t y - f o u r c h i l d r e n w e r e r e f e r r e d b y t h e c l i n i c s t a f f f o r 39 p r o b l e m s r e q u i r i n g r e t e s t i n g , f u r t h e r i n v e s t i g a t i o n , o r i n t e r v e n t i o n . T w e l v e o f t h e s e r e f e r r a l s w e r e f o r p r o b l e m s o f v i s i o n , 10 f o r b e h a v i o r , 6 f o r s p e e c h and l a n g u a g e , 3 e a c h f o r h e a r i n g , n u t r i t i o n , and d e n t a l h e a l t h , and 2 f o r p h y s i c a l d e v e l o p m e n t a l d e l a y . The c h i l d r e n c o o p e r a t e d e n t h u s i a s t i c a l l y i n t h e t e s t p r o c e d u r e s and t h e i r p a r e n t s f o u n d t h e c l i n i c t o be r e a s s u r i n g and a v a l u a b l e l e a r n i n g e x p e r i e n c e . The p a r e n t s w e r e w i l l i n g t o c o m p l y w i t h t h e r e f e r r a l s , b u t some d e l a y s i n t h e f o l l o w - u p p r o c e d u r e s w e re n o t e d , due t o t h e newness o f t h e c l i n i c . The s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s a p p e a r s t o be f i l l i n g a p r e v i o u s l y unmet n e e d i n t h e c o m m u n i t y . Community h e a l t h w o r k e r s i n v o l v e d i n p l a n n i n g a nd p r o m o t i n g new s e r v i c e s s h o u l d f i n d t h e d e t a i l e d d e s c r i p t i o n s o f t h e p r o c e d u r e s a nd o f t h e c l i e n t e l e o f t h e c l i n i c u s e f u l t o them. The e x t e n s i v e b i b l i o g r a p h y p r o v i d e s a b a c k g r o u n d o f p u b l i s h e d m a t e r i a l on t h e r a t i o n a l e and r e s u l t o f a v a r i e t y o f m e t h o d s o f s c r e e n i n g . C o m p a r i s o n w i t h s i m i l a r c l i n i c s i n o t h e r a r e a s w i l l be i m p o s s i b l e u n t i l t e r m i n o l o g y u s e d , t e s t p r o c e d u r e s e m p l o y e d , and m e t h o d s o f r e p o r t i n g r e s u l t s a r e s t a n d a r d i z e d . M e a n w h i l e , t h e c l i n i c s t a f f s h o u l d c o n t i n u e t o m a i n t a i n s t a t i s t i c a l e v i d e n c e o f t h e r e s u l t s o b t a i n e d and t o e v a l u a t e t h e p r o c e d u r e s u s e d i n i t s p r o g r a m . ( T h e s i s C h a i r m a n ) i i i TABLE OF CONTENTS Page LIST OF TABLES . v i i LIST OF PHOTOGRAPHIC PLATES v i i i ACKNOWLEDGMENTS i x Chapter I INTRODUCTION TO THE STUDY 1 D e f i n i t i o n of the Problem 2 Purpose of the Study . 2 S p e c i f i c Objectives of the Study 3 S i g n i f i c a n c e of the Study to Nursing 4 I I LITERATURE REVIEW 5 Developmental Theory 5 D e f i n i t i o n s of Screening 6 Rationale f o r Screening 8 Disease Screening 10 Developmental Screening . . 11 S p e c i f i c Problem Screening 12 Screening Procedures 16 Developmental Status . . . 17 V i s i o n 19 Hearing, Speech and Language 20 N u t r i t i o n a l Status 21 Dental Health 2 2 S o c i a l Adjustment 2 3 i v P a g e C h a p t e r P e r s o n n e l E m p l o y e d i n S c r e e n i n g P r o g r a m s 2 3 Age L e v e l s f o r P r e s c h o o l S c r e e n i n g 2 7 P a r t i c i p a n t s i n S c r e e n i n g P r o g r a m s 30 S o c i o e c o n o m i c S t a t u s 31 The " A t - R i s k " C o n c e p t 36 I n c i d e n c e o f H a n d i c a p p i n g C o n d i t i o n s . 38 Summary 44 I I I METHODOLOGY 46 The R e s e a r c h Q u e s t i o n 46 D e f i n i t i o n s 47 A s s u m p t i o n 48 L i m i t a t i o n s o f t h e S t u d y . 49 The R e s e a r c h P l a n 50 The A p p r o a c h 5 0 The S e t t i n g 50 The P e r s o n n e l 51 The P r o c e d u r e s 51 The S e l e c t i o n o f t h e S t u d y P o p u l a t i o n 62 The R e s e a r c h I n s t r u m e n t s 63 D a t a C o l l e c t i o n 64 D a t a A n a l y s i s . 65 Summary 65 I V ANALYSIS OF THE DATA . . 66 C h a r a c t e r i s t i c s o f t h e C h i l d r e n i n t h e S t u d y P o p u l a t i o n 6 7 V Page C h a p t e r C h a r a c t e r i s t i c s o f t h e P a r e n t s i n t h e S t u d y P o p u l a t i o n 69 F i n d i n g s o f t h e S c r e e n i n g C l i n i c 76 R e s p o n s e s o f t h e C h i l d r e n a n d P a r e n t s t o t h e C l i n i c E x p e r i e n c e . 78 C o m p l i a n c e o f t h e P a r e n t s t o R e f e r r a l s 80 A d d i t i o n a l F i n d i n g s 82 C r o s s - T a b u l a t i o n o f t h e D a t a 85 Summary 91 V DISCUSSION OF THE DATA . 93 The C h i l d r e n i n t h e S t u d y P o p u l a t i o n 9 3 The P a r e n t s i n t h e S t u d y P o p u l a t i o n 9 3 P a r e n t s ' C o n c e r n s f o r t h e i r C h i l d r e n ' s H e a l t h 95 P r e f e r r e d S o u r c e s f o r H e a l t h A d v i c e 95 F i n d i n g s o f t h e S c r e e n i n g C l i n i c 96 C o m p l i a n c e o f t h e P a r e n t s t o R e f e r r a l s 99 I m p l i c a t i o n s o f t h e P r e s e n t S t u d y 9 9 L i m i t a t i o n s a n d W e a k n e s s e s o f t h e P r e s e n t S t u d y 101 S u g g e s t i o n s f o r F u t u r e S t u d i e s 102 V I SUMMARY AND RECOMMENDATIONS 105 Summary o f t h e S t u d y 105 R e c o m m e n d a t i o n s 107 v i Page Chapter BIBLIOGRAPHY 110 APPENDICES 119 A Questionnaire No. 1 - P r e - c l i n i c Survey . . . 119 B Standard Health Department C l i e n t Record Form 123 C Data Summary Form . 125 D 3-Year-Old Screening C l i n i c Results Form . . 126 E Questionnaire No. 2 - P o s t - c l i n i c Survey . . 127 F Denver Developmental Screening Test Form . .130 G Anthropometric Charts 132 H N u t r i t i o n a l Status Questionnaire 134 I Speech Therapist's Questionnaire . 135 J Dental H y g i e n i s t ' s Findings 136 v i i LIST OF TABLES Page T a b l e I C h i l d r e n ' s B i r t h Rank and Number of 6 8 C h i l d r e n i n the F a m i l i e s i n the Study Population I I Levels of Educational Attainment of 71 Parents i n the Study Population I I I S o c i a l Class of the F a m i l i e s i n the 73 Study Population According to the Hollingshead Two Factor Index of S o c i a l P o s i t i o n IV Parents' Previous Use of Community 74 Health Resources f o r t h e i r C h i l d r e n V Parents' P r e f e r r e d Sources of Advice 77 (Weighted) VI Findings of the Screening C l i n i c 79 V I I Parents' Responses to the Screening 81 C l i n i c as a Learning Experience V I I I Compliance by the Parents to R e f e r r a l s 83 IX R e f e r r a l f o r Further I n v e s t i g a t i o n 86 versus Sex of C h i l d X Mothers' Concerns versus Reasons f o r 88 R e f e r r a l f o r Further I n v e s t i g a t i o n XI Previous Use of Health Resources versus 89 R e f e r r a l f o r Further I n v e s t i g a t i o n XII Number of C h i l d r e n Referred f o r Further 90 I n v e s t i g a t i o n versus S o c i a l Class of Family X I I I Previous Use of Health Resources versus 92 S o c i a l C l a s s of Family XIV Dental H y g i e n i s t ' s Findings f o r 38 C h i l d r e n 136 i n the Study Population (Appendix J) v . i i i LIST of PHOTOGRAPHIC PLATES Page P l a t e 1. From the Gross-motor Segment of the Denver Developmental Screening Test . . . . 53 2. Te s t i n g Depth Perception using the Titmus Stereo Test 54 3. Nurse Obtaining Height and Weight Measurements 56 4. Speech Therapist E v a l u a t i n g Consonant and Vowel Sounds 5 8 5. Dental H y g i e n i s t Examining the Mouth 60 6. At the Toy Table 61 i x ACKNOWLEDGEMENTS I w o u l d l i k e t o t h a n k t h e c h i l d r e n and p a r e n t s o f t h e s t u d y p o p u l a t i o n who j o i n e d me i n t h i s p r o j e c t s o e n t h u s i a s t i c a l l y a n d who g a v e s o g e n e r o u s l y o f t h e i r t i m e . I'm i n d e b t e d t o t h e many d e d i c a t e d p e o p l e who hav e w o r k e d w i t h y o u n g c h i l d r e n and who h a v e w r i t t e n a b o u t t h e r e s u l t s o f t h e i r w o r k . F o r t h e i r c o n t i n u i n g s u p p o r t a n d e n c o u r a g e m e n t , I'm most g r a t e f u l t o f a m i l y , f r i e n d s , c o l l e a g u e s , f a c u l t y a d v i s o r s , c l a s s m a t e s , l i b r a r i a n s , c o r r e s p o n d e n t s , and many o t h e r a s s o c i a t e s i n c o m m u n i t y h e a l t h a n d e d u c a t i o n . 1 C h a p t e r I INTRODUCTION TO THE STUDY T h i s s t u d y d e s c r i b e s a s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d c h i l d r e n e s t a b l i s h e d b y a c o m m u n i t y h e a l t h u n i t i n a B r i t i s h C o l u m b i a s u b u r b , and p r o f i l e s t h e s m a l l p o p u l a t i o n o f p a r e n t s a n d t h e i r c h i l d r e n who w e r e i t s f i r s t c l i e n t s . A l t h o u g h s i m i l a r s c r e e n i n g p r o g r a m s h a v e o p e r a t e d i n o t h e r a r e a s f o r a number o f y e a r s , t h e l i t e r a t u r e c o n t a i n s f ew s t u d i e s t h a t r e p o r t on t h e e f f e c t i v e n e s s o f t h e p r o g r a m s a s m e a s u r e d b y t h e c o m p r e h e n s i v e n e s s o f t h e i r c o v e r a g e o f c o m m u n i t y p o p u l a t i o n s , t h e i n c i d e n c e o f p r o b l e m s d e t e c t e d , o r t h e p r o p o r t i o n o f c l i e n t s who c o m p l y w i t h c l i n i c r e f e r r a l s . The c l i n i c d e s c r i b e d i n t h i s s t u d y i s s t a f f e d b y c o m m u n i t y h e a l t h n u r s e s , a s p e e c h t h e r a p i s t , and a d e n t a l h y g i e n i s t . I t o f f e r s a v a r i e t y o f s t a n d a r d s c r e e n i n g p r o c e d u r e s d e s i g n e d t o d e t e c t e x i s t i n g o r p o t e n t i a l h e a l t h p r o b l e m s and d e l a y s i n n o r m a l d e v e l o p m e n t . C h i l d r e n i n whom s u c h p r o b l e m s a r e d e t e c t e d a r e r e f e r r e d t o a p p r o p r i a t e h e a l t h p r o f e s s i o n a l s f o r f u r t h e r i n v e s t i g a t i o n and r e m e d i a l i n t e r v e n t i o n w h e r e i n d i c a t e d . S c r e e n i n g p r o g r a m s f o r p r e s c h o o l e r s a r e o f i n t e r e s t t o t h e a u t h o r b e c a u s e , a s a c o m m u n i t y h e a l t h n u r s e , s he ha s met many m o t h e r s who a r e c o n c e r n e d a b o u t w h e t h e r t h e i r c h i l d r e n a r e d e v e l o p i n g n o r m a l l y , and b e c a u s e i n h e r w o r k 2 i n s c h o o l s she f r e q u e n t l y e n c o u n t e r s c h i l d r e n who h a v e e n t e r e d t h e e d u c a t i o n a l s y s t e m h a n d i c a p p e d by u n d e t e c t e d s e n s o r y o r p h y s i c a l i m p a i r m e n t s . T h e r e i s an o b v i o u s n e e d f o r e a r l i e r d e t e c t i o n o f t h e s e h a n d i c a p p i n g c o n d i t i o n s so t h a t i n t e r v e n t i o n s c a n be u n d e r t a k e n w h i c h w i l l a l l o w t h e a f f e c t e d c h i l d r e n t o f u n c t i o n a t t h e i r o p t i m a l l e v e l . R o u t i n e s c r e e n i n g o f c h i l d r e n a t t h e age o f 3 a p p e a r s t o o f f e r hope t h a t many p o t e n t i a l l y h a n d i c a p p i n g c o n d i t i o n s c a n be d i s c o v e r e d a nd r e m e d i e d b e f o r e t h e c h i l d r e n e n t e r t h e s c h o o l s y s t e m . D e f i n i t i o n o f t h e P r o b l e m A s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s was e s t a b l i s h e d i n a B r i t i s h C o l u m b i a s u b u r b by a c o m m u n i t y h e a l t h u n i t . The o r g a n i z a t i o n o f t h e p r o g r a m and t h e p r o c e d u r e s e m p l o y e d w e r e m o d e l l e d o n p r o g r a m s a l r e a d y f u n c t i o n i n g i n n e a r b y l o c a l i t i e s . B e c a u s e no e v a l u a t i o n h a d b e e n done on t h e s e p r o g r a m s t o d e m o n s t r a t e v a l i d i t y o f t h e p r o c e d u r e s o r t h e e f f e c t i v e n e s s o f t h e c l i n i c s , p l a n n i n g f o r t h e new c l i n i c was b a s e d on a s s u m p t i o n and i m i t a t i o n . P u r p o s e o f t h e S t u d y The p u r p o s e o f t h e s t u d y was t o i n v e s t i g a t e and d e s c r i b e t h i s new s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s , and t o r e p o r t on t h e p r o c e d u r e s e m p l o y e d , t h e p e r s o n n e l i n v o l v e d , t h e c h a r a c t e r i s t i c s o f t h e c l i e n t e l e , a n d t h e t y p e s , 3 i n c i d e n c e a n d d i s p o s i t i o n o f p r o b l e m s d e t e c t e d . S p e c i f i c O b j e c t i v e s o f t h e S t u d y 1. To d e s c r i b e t h e o p e r a t i o n o f a s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s and t h e s p e c i f i c p r o c e d u r e s and p e r s o n n e l i n v o l v e d . 2. To d e s c r i b e t h e c h a r a c t e r i s t i c s o f t h e c h i l d r e n b r o u g h t t o t h e s c r e e n i n g c l i n i c . 3. To d e s c r i b e t h e c h a r a c t e r i s t i c s o f t h e p a r e n t s who make u s e o f t h e s c r e e n i n g c l i n i c , i n c l u d i n g t h e s o c i o e c o n o m i c s t a t u s o f t h e a t t e n d i n g f a m i l i e s , b a s e d on t h e p a r e n t s ' o c c u p a t i o n s and e d u c a t i o n . 4. To e l i c i t p a r e n t s ' p e r c e p t i o n s o f c u r r e n t and p o t e n t i a l h e a l t h o r b e h a v i o r a l p r o b l e m s o f t h e i r c h i l d r e n and t o i d e n t i f y t h e i r p r e f e r r e d s o u r c e s o f h e l p f o r t h e s e c o n c e r n s and t h e i r p r e v i o u s u s e o f c o m m u n i t y h e a l t h r e s o u r c e s . 5. To d e t e r m i n e t h e i n c i d e n c e and t y p e s o f p r o b l e m s d e t e c t e d by t h e c l i n i c s t a f f and t h e d i s t r i b u t i o n o f r e f e r r a l s o f t h e s e p r o b l e m s t o o t h e r h e a l t h p r o f e s s i o n a l s . 6. To d e t e r m i n e t h e s u b j e c t i v e r e s p o n s e s o f t h e c h i l d r e n and t h e i r p a r e n t s t o t h e c l i n i c e x p e r i e n c e . 7. To d e t e r m i n e t o w h a t e x t e n t p a r e n t s c o m p l y w i t h r e f e r r a l s a nd w i t h s u b s e q u e n t t h e r a p e u t i c p r o g r a m s . 8. To o b t a i n o t h e r i n f o r m a t i o n t h a t m i g h t h e l p t h e s p o n s o r i n g h e a l t h a g e n c y t o i m p r o v e and p r o m o t e t h i s new s e r v i c e . 4 S i g n i f i c a n c e o f t h e S t u d y t o N u r s i n g C o n t e m p o r a r y e d u c a t i o n a l p r o g r a m s a r e p r e p a r i n g n u r s e s t o u n d e r t a k e i n c r e a s i n g r e s p o n s i b i l i t y f o r h e a l t h s e r v i c e s i n t h e c o m m u n i t y . One way i n w h i c h n u r s e s a r e m e e t i n g t h i s new c h a l l e n g e i s by p l a n n i n g and o p e r a t i n g s c r e e n i n g p r o g r a m s f o r a p p a r e n t l y w e l l c h i l d r e n . S u c h p r o g r a m s a r e assumed t o be one way o f r e a c h i n g t h o s e c h i l d r e n who w o u l d b e n e f i t f r o m e a r l y r e m e d i a t i o n o f h i t h e r t o u n d e t e c t e d d i s a b i l i t i e s . H o wever, w i t h o u t k n o w l e d g e o f t h e segment o f t h e c o m m u n i t y w h i c h a c t u a l l y u t i l i z e s t h e s e r v i c e , t h e r e s u l t s t o be e x p e c t e d , and t h e b e n e f i t s d e r i v e d f r o m s u c h a p r o g r a m , t h e t r u e v a l u e t o t h e c o m m u n i t y o f t h i s n u r s i n g r o l e c a n n o t be d e t e r m i n e d . 5 C h a p t e r I I LITERATURE REVIEW The l i t e r a t u r e was r e v i e w e d f r o m s e v e r a l p e r s p e c t i v e s . B o o k s a nd a r t i c l e s w e r e r e v i e w e d on d e v e l o p m e n t a l t h e o r y ; d e f i n i t i o n s o f s c r e e n i n g ; t h e r a t i o n a l e f o r s c r e e n i n g p r o g r a m s ( b o t h f o r d i s e a s e and f o r d e v e l o p m e n t a l d e l a y ) ; v a r i o u s p r o c e d u r e s u s e d i n s c r e e n i n g p r o g r a m s t o a s s e s s d e v e l o p m e n t a l s t a t u s , v i s i o n , h e a r i n g , s p e e c h and l a n g u a g e d e v e l o p m e n t , n u t r i t i o n a l s t a t u s , d e n t a l h e a l t h , a n d s o c i a l a d j u s t m e n t ; t h e p r o f e s s i o n a l p e r s o n n e l e m p l o y e d i n v a r i o u s s c r e e n i n g p r o g r a m s ; t h e o p t i m a l age f o r s c r e e n i n g ; p a r t i c i p a t i o n i n s c r e e n i n g p r o g r a m s by v a r i o u s g r o u p s among t h e p o p u l a t i o n , i n t e r m s o f s o c i o e c o n o m i c f a c t o r s and o f t h e " a t - r i s k " c o n c e p t ; a n d t h e i n c i d e n c e o f p o t e n t i a l l y h a n d i c a p p i n g d i s o r d e r s d e t e c t e d b y s c r e e n i n g p r o g r a m s . D e v e l o p m e n t a l T h e o r y F o r m a l i z e d d e v e l o p m e n t a l t h e o r i e s o f c h i l d h o o d b e g a n w i t h t h e w o r k o f A r n o l d G e s e l l i n t h e U n i t e d S t a t e s and J e a n P i a g e t i n S w i t z e r l a n d i n t h e 1920s.; G e s e l l , a p e d i a t r i c i a n a t Y a l e U n i v e r s i t y , u s e d t h e c o n t r o l l e d o b s e r v a t i o n s o f c h i l d r e n i n h i s p i o n e e r i n g s t u d i e s ( G e s e l l and I l g , 1923) and d e v i s e d s c a l e s f o r t e s t i n g t h e c h i l d ' s d e v e l o p m e n t a l p r o g r e s s ( G e s e l l and A m a t r u d a , 1 9 4 7 ) . P i a g e t , 6 a p r o f e s s o r o f c h i l d p s y c h o l o g y a t t h e U n i v e r s i t y o f G e n e v a , d e v e l o p e d h i s t h e o r i e s p a r t l y a s t h e r e s u l t o f h i s d e t a i l e d and a n a l y t i c a l o b s e r v a t i o n s o f t h e b e h a v i o r o f h i s own t h r e e c h i l d r e n o v e r t h e f i r s t s e v e r a l y e a r s o f t h e i r l i v e s ( B e a r d , 1969, p. x i i ) . The d e v e l o p m e n t o f t h e c h i l d p r o c e e d s c o n t i n u o u s l y f r o m b i r t h , b u t i s c h a r a c t e r i z e d by s u d d e n and m a r k e d c h a n g e s i n c o m p l e x p a t t e r n s o f b e h a v i o r . Much o f d e v e l o p m e n t a l t h e o r y i s c o n c e r n e d w i t h t h e d e f i n i t i o n o f t h e d e v e l o p m e n t a l s t a g e s ( S u t t o n - S m i t h , 1 9 7 3 , p. 162) t h r o u g h w h i c h t h e c h i l d p a s s e s , and w i t h d e l i n e a t i n g t h e n o r m a l p a r a m e t e r s o f t h e / c h i l d ' s p r o g r e s s t h r o u g h t h e s e s t a g e s . V a r i o u s s c r e e n i n g p r o c e d u r e s h a v e b e e n d e v i s e d t o m e a s u r e t h e c h i l d ' s d e v e l o p m e n t s t a g e by s t a g e . O r d e r l y p r o g r e s s i s i m p o r t a n t ( G i n s b u r g a n d O p p e r , 1969 , p. 29) b e c a u s e c e r t a i n c a p a b i l i t i e s a r e m o s t e a s i l y a c q u i r e d d u r i n g s p e c i f i c d e f i n a b l e p e r i o d s i n c h i l d h o o d . A C o n f e r e n c e on C r i t i c a l P e r i o d s o f D e v e l o p m e n t i n New Y o r k i n 1961 ( H a v i g h u r s t , 1 9 7 2 , p. 6) p r o m u l g a t e d t h e t h e o r y o f t h e c r i t i c a l p e r i o d o r t h e t e a c h a b l e moment i n c h i l d h o o d . P s y c h o l o g i s t P a u l M u s s e n (196 3, p. 12) e x p l a i n s t h a t " t h e c h i l d who d o e s n o t l e a r n ( c e r t a i n t a s k s ) d u r i n g t h e s e p e r i o d s may h a v e g r e a t d i f f i c u l t y l e a r n i n g them l a t e r . " D e f i n i t i o n s o f S c r e e n i n g The C o n f e r e n c e on P r e v e n t i v e A s p e c t s o f C h r o n i c 7 D i s e a s e , s p o n s o r e d i n 1951 by t h e C o m m i s s i o n on C h r o n i c I l l n e s s , d e f i n e d s c r e e n i n g , a c c o r d i n g t o W i l s o n and J u n g n e r ( 1 9 6 8 , p. 1 1 ) , a s : t h e p r e s u m p t i v e i d e n t i f i c a t i o n o f u n r e c o g n i z e d d i s e a s e o r d e f e c t by t h e a p p l i c a t i o n o f t e s t s , e x a m i n a t i o n s , o r o t h e r p r o c e d u r e s w h i c h c a n be a p p l i e d q u i c k l y .... A s c r e e n i n g p r o g r a m i s n o t i n t e n d e d t o be d i a g n o s t i c . P e r s o n s w i t h p o s i t i v e o r s u s p i c i o u s f i n d i n g s m u s t be r e f e r r e d t o t h e i r p h y s i c i a n s f o r d i a g n o s i s and n e c e s s a r y t r e a t m e n t . The U.S. D e p a r t m e n t o f H e a l t h , E d u c a t i o n and W e l f a r e d e f i n e s s c r e e n i n g ( T e r r e l l , 1 9 7 4 , p. 10) a s : t h e u s e o f q u i c k , s i m p l e p r o c e d u r e s w h i c h c a n be c a r r i e d o u t w i t h l a r g e g r o u p s o f p e o p l e t o s o r t o u t a p p a r e n t l y w e l l p e r s o n s f r o m t h o s e who h a v e a d i s e a s e o r a b n o r m a l i t y and t o i d e n t i f y t h o s e i n n e e d o f more d e f i n i t i v e s t u d y . Thomas McKeown, P r o f e s s o r o f S o c i a l M e d i c i n e a t t h e U n i v e r s i t y o f B i r m i n g h a m , d e f i n e s p r e s c r i p t i v e s c r e e n i n g (McKeown, 196 8, p. 6) a s : i n v e s t i g a t i o n w h i c h h a s a s i t s p r i m a r y a i m n e i t h e r r e s e a r c h n o r t h e p r o t e c t i o n o f p u b l i c h e a l t h , b u t a d i r e c t c o n t r i - b u t i o n t o t h e h e a l t h o f i n d i v i d u a l s . C l i n i c a l p s y c h o l o g i s t Ken L e s s l e r a r g u e s ( 1 9 7 2 , p. 101) f o r a b r o a d d e f i n i t i o n o f s c r e e n i n g , one w h i c h goes, b e y o n d p h y s i c a l h e a l t h p r o b l e m s t o encompass any p r o c e s s o r c o n d i t i o n w h i c h may be d e t r i m e n t a l t o t h e c h i l d ' s g r o w t h 8 and p o s i t i v e d e v e l o p m e n t . He p r o p o s e s (p. 193) t h i s d e f i n i t i o n o f s c r e e n i n g : The a c q u i r i n g o f p r e l i m i n a r y i n f o r m a t i o n a b o u t c h a r a c t e r i s t i c s w h i c h may be s i g n i f i c a n t t o t h e h e a l t h , e d u c a t i o n , o r w e l l - b e i n g o f t h e i n d i v i d u a l a n d w h i c h a r e r e l e v a n t t o h i s l i f e t a s k s . M u r i e l U p r i c h a r d ( 1 9 7 2 , p. 30) makes t h e d i s t i n c t i o n b e t w e e n " m e d i c a l c a r e " a n d " h e a l t h c a r e " , t h e l a t t e r b e i n g " t h e e f f o r t t o a s s i s t e a c h i n d i v i d u a l t o a c h i e v e h i s opt i m u m l e v e l o f w e l l n e s s . " S c r e e n i n g i s one way t o p r o m o t e w h a t K i r s t e n Weber ( 1 9 7 2 , p. 138) d e f i n e s a s " h i g h - l e v e l w e l l n e s s " by s e e k i n g o u t t h o s e i n d i v i d u a l s i n t h e g e n e r a l p o p u l a t i o n whose p o t e n t i a l f o r t h i s s t a t e o f w e l l n e s s may be i m p a i r e d . R a t i o n a l e f o r S c r e e n i n g I n a b r o a d s e n s e , s c r e e n i n g h a s . b e e n e x p l a i n e d a s p a r t o f a g e n e r a l t r e n d away f r o m " c o m p l a i n t m e d i c i n e " t o w h a t c o u l d be c a l l e d " m a i n t e n a n c e m e d i c i n e " , i n w h i c h a h e a l t h t e am c o n t i n u o u s l y e n d e a v o r s t o p r o t e c t a n d m a i n t a i n t h e h e a l t h o f t h e p o p u l a t i o n f o r w h i c h i t i s r e s p o n s i b l e ( K a p r i o , 1 9 6 8, p. 3 4 5 ) . "Once we move f r o m l o o k i n g f o r c o m m u n i c a b l e d i s e a s e s t o l o o k i n g f o r c h r o n i c c o n d i t i o n s o r d e v e l o p m e n t a l p r o b l e m s , " s a y s L e s s l e r ( 1 9 7 2 , p. 1 9 3 ) , "we c a n no l o n g e r e a s i l y s e p a r a t e t h e s i c k f r o m t h e w e l l . " N o r s h o u l d t h i s be a 9 p r i m e c o n c e r n . " I t i s more i m p o r t a n t t o g a i n i n f o r m a t i o n and u n d e r s t a n d i n g a b o u t p r o b l e m s o f g r o w t h and d e v e l o p m e n t and t h e h a n d i c a p p i n g c o n d i t i o n s o f c h i l d h o o d . " S u c h i n f o r m a t i o n , he n o t e s (p. 1 9 5 ) , i s more i m p o r t a n t d u r i n g t h e c h i l d ' s e a r l i e s t y e a r s t h a n a f t e r h i s l i f e p a t t e r n s h a v e b e e n e s t a b l i s h e d . L e s s l e r . i n s i s t s t h a t t h e i n f o r m a t i o n o b t a i n e d by s c r e e n i n g m u s t h a v e r e l e v a n c e t o t h e c h i l d ' s p a r t i c u l a r l i f e s i t u a t i o n . "A c o n d i t i o n o r c h a r a c t e r i s t i c w h i c h may be a d a p t i v e f o r one p e r s o n , i n one s e t o f c i r c u m s t a n c e s , and a t a g i v e n p o i n t i n h i s l i f e , may be p r o b l e m a t i c f o r a n o t h e r p e r s o n a t a d i f f e r e n t t i m e , o r i n a d i f f e r e n t c u l t u r a l m i l i e u " ( p . 1 9 3 ) . I n C a n a d a , t h e H a l l - D e n n i s R e p o r t ( 1 9 6 8 , p..80) s u g g e s t e d a c o o r d i n a t e d h e a l t h a n d e d u c a t i o n a l s e r v i c e t o s e r v e p a r e n t s i n t h e c r i t i c a l p r e s c h o o l d e v e l o p m e n t a l p e r i o d o f t h e i r c h i l d r e n ' s l i v e s when, i t s a i d , a g r e a t d e a l c a n be d one t o " i d e n t i f y a nd a l l e v i a t e c h a r a c t e r i s t i c s a nd c o n d i t i o n s t h a t a r e p o t e n t i a l l y d e t r i m e n t a l t o t h e c h i l d ' s l a t e r d e v e l o p m e n t . " The CELDIC R e p o r t ( S h a n n o n , 1 9 7 0 , p.. 164) m e n t i o n s t h e n e e d " t o p r o v i d e f o r c o n t i n u i n g c a r e d u r i n g t h e p r e s c h o o l p e r i o d i n o r d e r t h a t e a r l y d e t e c t i o n o f d i f f i c u l t i e s i n d e v e l o p m e n t w o u l d a l l o w f o r p r o m p t r e m e d i a t i o n . " The r e p o r t d e s c r i b e d t h e i n c i d e n c e o f e m o t i o n a l a n d l e a r n i n g d i s o r d e r s among C a n a d i a n c h i l d r e n a s o f e p i d e m i c p r o p o r t i o n s , and e s t i m a t e d t h a t one m i l l i o n 10 c h i l d r e n w e r e i n n e e d o f i n t e g r a t e d p r o f e s s i o n a l s e r v i c e s ( p . 5 9 ) . I n "A New P e r s p e c t i v e on t h e H e a l t h o f C a n a d i a n s " , H e a l t h M i n i s t e r M a r c L a l o n d e ( 1 9 7 4 , p. 61) s t a t e s t h a t 5 t o 10 p e r c e n t o f C a n a d i a n s c h o o l c h i l d r e n h a v e an e m o t i o n a l o r l e a r n i n g d i s o r d e r t h a t s h o u l d r e c e i v e p r o f e s s i o n a l c a r e . D i s e a s e S c r e e n i n g . The s c o p e o f a s c r e e n i n g p r o g r a m may r a n g e f r o m d e t e r m i n a t i o n o f t h e i n c i d e n c e o f a s p e c i f i c d i s e a s e e n t i t y s u c h a s u r i n a r y t r a c t i n f e c t i o n w i t h i n a l i m i t e d p o p u l a t i o n ( C o n s t a b l e , 1 9 7 5 , p. 1 7 2 ) , t o a t t e m p t s t o e s t i m a t e t h e l e v e l o f t h e g e n e r a l h e a l t h o f an e n t i r e n a t i o n ( G o l d s m i t h , 1 9 7 2 , p. 2 1 4 ) . I n r e c e n t y e a r s t h e c o n c e p t o f m u l t i p l e s c r e e n i n g h a s come t o t h e f o r e . M u l t i p l e s c r e e n i n g i n v o l v e s t h e a d m i n i s t r a t i o n o f a b a t t e r y o f s t a n d a r d i z e d t e s t s t o a p o p u l a t i o n w i t h t h e a i m o f d e t e c t i n g e x i s t i n g o r p o t e n t i a l d i s e a s e o r d i s a b i l i t y a t l o w c o s t t h r o u g h e f f i c i e n t u s e o f p e r s o n n e l a n d f a c i l i t i e s . The c o n c e p t i s n o t u n i v e r s a l l y a c c e p t e d . S m i l l i e , f o r e x a m p l e , i n a 1952 p a p e r ( p . 256) d e c l a r e d t h a t M u l t i p l e s c r e e n i n g ( i s ) i n f e r i o r m e d i c i n e , p o o r m e d i c i n e , s l i p s h o d , s h o r t - c u t m e d i c i n e a n d , f u r t h e r m o r e , p o o r p u b l i c h e a l t h . 11 Developmental Screening. The aim of any screening program i s to detect the t a r g e t abnormality at an e a r l y stage, when i t i s most l i k e l y to be s u s c e p t i b l e to remediation. This a p p l i e s to developmental delays as w e l l as to disease e n t i t i e s . The work of the developmental t h e o r i s t s has l e d to the c r e a t i o n of t e s t s which can be used w i t h some confidence t o detect delays i n development which, i f unrecognized, could s e r i o u s l y handicap the c h i l d i n l a t e r school and s o c i a l s i t u a t i o n s . There i s general agreement among authors who have w r i t t e n on the subject of developmental progress t h a t many p o t e n t i a l l y handicapping c o n d i t i o n s can be detected before the c h i l d reaches school age, but o f t e n t h i s i s not done. Wintle et a l , i n a B r i t i s h study ( 1 9 7 2 , p. 327) found t h a t 87 percent of a l l defects detected i n school medical examinations were p r e v i o u s l y unknown to the general p r a c t i t i o n e r or to the d i s t r i c t nurse. The Lancet ( 1 9 7 5 , p. 784) says t h a t between 10 and 20 percent of c h i l d r e n i n B r i t a i n s t i l l reach school age w i t h d e f e c t s , o f t e n t r e a t a b l e ones, t h a t have gone undetected. In a review of American screening programs, Rogolsky ( 1 9 6 8 - 6 9 , p. 18) r e p o r t s that about 40 percent of a l l kindergarten c h i l d r e n have problems which can s e r i o u s l y i n t e r f e r e w i t h t h e i r l e a r n i n g or adjustment i n the e a r l y primary-school years. Bower (19 69, p. 11) comments that 12 f a i l u r e t o f u n c t i o n i n s c h o o l i s n o t t a n t a m o u n t t o f a i l u r e i n l i f e b u t i t comes p e r i l o u s l y c l o s e i n t h i s d a y a n d a g e . Does d e v e l o p m e n t a l a s s e s s m e n t a c t u a l l y d e t e c t t r e a t a b l e c o n d i t i o n s ? M a c K e i t h ( 1 9 7 5 , p. 3 2 8 ) , r e p o r t i n g on B r i t i s h e x p e r i e n c e , s a y s t h a t c h i l d r e n w i t h c e r e b r a l p a l s y u s e d t o a r r i v e f o r t r e a t m e n t a t an a v e r a g e age o f 2 1/2 y e a r s . H o w e v e r , he s a y s , i n an a r e a w h e r e u n i v e r s a l p e r i o d i c d e v e l o p m e n t a l a s s e s s m e n t h a s b e e n done f o r s e v e r a l y e a r s , 90 p e r c e n t o f c e r e b r a l p a l s i e d c h i l d r e n now e n t e r t r e a t m e n t d u r i n g t h e i r f i r s t y e a r o f l i f e . D a v i s ( 1 9 7 5 , p. 105) c o n s i d e r s t h a t e f f e c t i v e p r e s c h o o l s c r e e n i n g s h o u l d be a b l e t o d e t e c t v i r t u a l l y a l l c o n g e n i t a l a b n o r m a l i t i e s . S p e c i f i c P r o b l e m S c r e e n i n g . The r a t i o n a l e f o r d i s e a s e o r d e v e l o p m e n t a l s c r e e n i n g may f o c u s on some s p e c i f i c a r e a s o f c o n c e r n . 1. V i s i o n : The i m p o r t a n c e o f e f f e c t i v e v i s u a l f u n c t i o n i n g t o a c h i l d ' s n o r m a l d e v e l o p m e n t i s s e l f - e v i d e n t . I f a y o u n g c h i l d c a n n o t d e v e l o p n o r m a l b i n o c u l a r v i s i o n b e c a u s e o f i n e q u a l i t y o f r e f r a c t i o n o r a s q u i n t , t h e v i s i o n i n t h e a f f e c t e d e y e i s s u p p r e s s e d t o p r e v e n t t h e c o n f u s i o n c a u s e d by a b l u r r e d image o r d i p l o p i a , w r i t e s P e r k i n s ( 1 9 6 8 , p. 2 5 3 ) . 13 I f suppression i s allowed to p e r s i s t , a permanent amblyopia w i l l f o l l o w and, once e s t a b l i s h e d , i s extremely d i f f i c u l t to t r e a t . . . . Most squints s t a r t between the ages of 2 and 4, and i f they are not detected and t r e a t e d before the f i r s t school examination, amblyopia w i l l be w e l l e s t a b l i s h e d . I t has been estimated t h a t approximately 1 percent of the population i s v i r t u a l l y one-eyed as a r e s u l t of amblyopia. In a review of ophthalmological s e r v i c e s i n the Northampton area, Ingram (1973, p. 279) reported t h a t n e a r l y 50 percent of the c h i l d r e n w i t h squint were over the age of 7 when f i r s t detected. By t h i s age, there i s no r e a l hope of improvement w i t h treatment. 2. Hearing, Speech and Language: The a b i l i t y to hear c l e a r l y has a s i g n i f i c a n t bearing on the c h i l d ' s development of language and, t h e r e f o r e , s o c i a l s k i l l s : "Hearing i s the s o c i a l sense" (Psychology Today, 1970, p. 271). F e l l e n d o r f (1975, p. 211) considers that Detection of hearing l o s s , e s p e c i a l l y i n view of the i m p l i c a t i o n s of undetected hearing l o s s w i t h regard to a c h i l d ' s language and speech development, should be one of the p u b l i c h e a l t h agencies' major r e s p o n s i b i l i t i e s . A developmental d i s a b i l i t y a f f e c t i n g the development of language occurs i n 1 of every 170 c h i l d r e n , according to Schwartz and Murphy (1975, p. 722). They preclude " s e l f - r e c o v e r y " as a f u n c t i o n of i n c r e a s i n g age, and s t a t e 14 (p. 717) : E a r l y d e t e c t i o n o f d e v e l o p m e n t a l l a n g u a g e d i s a b i l i t i e s may be e x p e c t e d t o m a x i m i z e t h e e f f e c t i v e - n e s s o f r e m e d i a l p r o g r a m s a n d m i n i m i z e r e s i d u a l e f f e c t s on c o m m u n i c a t i o n . B r i c k e r a nd B r i c k e r ( 1 9 7 4 , p. 454) a r g u e f o r e a r l y s p e e c h t r a i n i n g , s t a t i n g t h a t " p a r t i c u l a r e r r o r s become more c o n s i s t e n t a nd p e r s i s t e n t w i t h a g e . " S t u t t e r i n g i s an a f f l i c t i o n o f 1 p e r c e n t o f t h e p o p u l a t i o n , a nd t h e t h e r a p y i s p r e v e n t i v e ( B r u c e , 19 72, p. 2 4 ) . 3. N u t r i t i o n a l S t a t u s : The N u t r i t i o n C a n a d a S u r v e y o f 1970-72 r e v e a l e d d e f i c i e n c i e s i n i n t a k e o f v a r i o u s n u t r i e n t s by a s u r p r i s i n g number o f C a n a d i a n c h i l d r e n . F o r e x a m p l e , o f t h o s e c h i l d r e n u n d e r 4 y e a r s o f age i n t h e g e n e r a l ( i . e . , n o n - i n d i g e n o u s ) p o p u l a t i o n , more t h a n 60 p e r c e n t w e r e n o t c o n s u m i n g a d e q u a t e amounts o f p o t e n t i a l V i t a m i n D, 44 p e r c e n t w e r e d e f i c i e n t i n i r o n i n t a k e , and 26 p e r c e n t l a c k e d s u f f i c i e n t c a l c i u m i n t h e i r d i e t s ( N u t r i t i o n C a n a d a , 1 9 7 3 , T a b l e 5-3) . R e p o r t i n g on t h e N u t r i t i o n C a n a d a S u r v e y , n u t r i t i o n c o n s u l t a n t Z . I . S a b r y ( 1 9 7 4 , p. 343) p r o p o s e d t h e d e v e l o p m e n t o f s y s t e m s f o r m o n i t o r i n g t h e n u t r i t i o n a l h e a l t h o f C a n a d i a n s i n o r d e r t o d e t e c t p r o b l e m s e a r l y and t o e n a b l e t h e i n i t i a t i o n o f c o r r e c t i v e m e a s u r e s . 15 (The v a l i d i t y o f t h e N u t r i t i o n C a n a d a f i n d i n g s h a s b e e n q u e s t i o n e d b y P e t t ( 1 9 7 5 , p. 1 6 5 ) , among o t h e r s . P e t t c o n t e n d s t h a t t h e s u r v e y d a t a " c a n n o t p o s s i b l y be u s e d t o r e p r e s e n t t h e p o p u l a t i o n o f C a n a d a " , s i n c e o n l y 46 p e r c e n t o f N u t r i t i o n C a n a d a ' s s a m p l e a c t u a l l y c o m p l e t e d t h e s u r v e y . ) 4. D e n t a l H e a l t h : T h r e e o u t o f f i v e C a n a d i a n c h i l d r e n h a v e d e n t a l c a r i e s by t h e age o f 3 y e a r s ; by t h e e a r l y s c h o o l y e a r s t h e f i g u r e h a s r i s e n t o n i n e o u t o f t e n ( D e n t a l H e a l t h D i v i s i o n , 1970, p. 2 0 ) . I n a p a p e r e v a l u a t i n g t h e e f f e c t i v e n e s s o f a d e n t a l p r o g r a m f o r 3 - y e a r - o l d s , G r a y e t a l ( 1 9 7 0 , p. 192) d e c l a r e t h a t "To a c h i e v e good d e n t a l h e a l t h w i t h m i n i m a l p r e m a t u r e p r i m a r y - t o o t h l o s s , G r a d e I c h i l d r e n ( s i c ) s h o u l d be u n d e r t h e r e g u l a r c a r e o f a d e n t i s t by t h e age o f 3 y e a r s . " I n a n e a r l i e r a r t i c l e ( 1 9 6 8 , p. 202) G r a y e x p l a i n s t h a t t h e i d e a f o r t h e p r o g r a m , w h i c h i n v o l v e d s e n d i n g b i r t h d a y - c a r d o f f e r s o f f r e e d e n t a l c h e c k u p s t o 3 - y e a r - o l d s , o r i g i n a t e d i n C a l i f o r n i a a nd was t r i e d i n t h e I n t e r i o r o f B r i t i s h C o l u m b i a b e c a u s e i t h a d b e e n f o u n d t h e r e t o o t h a t " d e n t a l p u b l i c h e a l t h p r o g r a m s b e g i n n i n g a t s c h o o l e n t r a n c e a r e t o o l a t e . " 5. S o c i a l A d j u s t m e n t : F a m i l y d y n a m i c s may be a s o u r c e o f l e a r n i n g p r o b l e m s , w r i t e M c D o n a l d and S o e f f i n g ( 1 9 7 1 , p. 6 8 1 ) , a n d 16 i n t e l l e c t u a l d e v e l o p m e n t may be i n f l u e n c e d b y f a m i l y s o c i a l p a t t e r n s s u c h a s t h e n a t u r e o f t h e m o t h e r - c h i l d o r c h i l d - s i b l i n g i n t e r a c t i o n . A B o s t o n s t u d y r e p o r t e d by P r a t t ( 1 9 7 3 , p. 76) f o u n d t h a t r e s t r i c t i v e p a r e n t s who demanded c o n f o r m i t y and o b e d i e n c e i n t h e i r c h i l d r e n f a i l e d i n a c h i e v i n g l o n g - t e r m s o c i a l i z a t i o n o b j e c t i v e s b e c a u s e t h e " c h i l d r e n f a i l t o d e v e l o p t h e i r own i n t e r n a l c a p a c i t i e s f o r s e l f - c o r r e c t i o n . " C o n v e r s e l y ( p . 6 8 ) , g r a n t i n g o f autonomy f o s t e r s c o m p e t e n c y and a c t i v e c o p i n g b e h a v i o r i n c h i l d r e n o f w h i c h one i m p o r t a n t e x p r e s s i o n i s s o u n d h e a l t h b e h a v i o r . Shaw (19 74, p. 69 6) s a y s t h a t c o n t e m p o r a r y m o t h e r s , i f t h e y a r e t o g a i n c o n f i d e n c e i n t h e i r r o l e , r e q u i r e p r o f e s s i o n a l p r o g r a m s w h i c h s u p p l y t h e i n f o r m a t i o n on c h i l d d e v e l o p m e n t and a s s i s t a n c e i n c h i l d r e a r i n g o n c e p r o v i d e d by t h e e x t e n d e d f a m i l y . S c r e e n i n g P r o c e d u r e s S c r e e n i n g p r o g r a m s f o r p r e s c h o o l e r s h a v e t a k e n a v a r i e t y o f f o r m s a s t h e y h a v e d e v e l o p e d i n d i f f e r e n t r e g i o n s , i n r e s p o n s e t o l o c a l t r a d i t i o n s , n e e d s and c a p a b i l i t i e s . Some i n c l u d e c o m p l e t e p h y s i c a l e x a m i n a t i o n s by p e d i a t r i c i a n s ; o t h e r s r e l y on r e l a t i v e l y s i m p l e t e s t s , o f t e n p e r f o r m e d by v o l u n t e e r s u n d e r p r o f e s s i o n a l s u p e r v i s i T y p i c a l l y a s c r e e n i n g p r o g r a m e n c o m p a s s e s some p r o c e d u r e t o a s s e s s d e v e l o p m e n t a l l e v e l s ; t e s t s f o r v i s i o n and h e a r i n g ; a d e n t a l e x a m i n a t i o n ; a n d an a s s e s s m e n t o f t h e c h i l d ' s n u t r i t i o n a l s t a t u s . L e s s l e r ' s d e f i n i t i o n o f s c r e e n i n g ( 1 9 7 2 , p. 193) f a i r l y d e s c r i b e s t h e p r o g r a m i n o p e r a t i o n a t t h e c l i n i c u n d e r s t u d y i n t h i s p a p e r . R a t h e r t h a n f o c u s s i n g s o l e l y o n t h e t r a d i t i o n a l h e a l t h / i l l n e s s d i c h o t o m y , t h i s c l i n i c s e e k s t o i d e n t i f y p h y s i c a l , s o c i a l o r e m o t i o n a l s t a t e s t h a t m i g h t i n h i b i t t h e c h i l d ' s a t t a i n i n g " h i g h - l e v e l w e l l n e s s . " L i k e many o t h e r c l i n i c s r e p o r t e d i n t h e l i t e r a t u r e , t h i s one s e e k s t o a s s e s s c h i l d r e n i n t e r m s o f d e v e l o p m e n t a l s t a t u s ( i n c l u d i n g p e r s o n a l / s o c i a l and l a n g u a g e s k i l l s ) , h e a r i n g , v i s i o n , n u t r i t i o n , a n d d e n t a l h e a l t h . D e v e l o p m e n t a l S t a t u s . I n L e n n a r t K o h l e r ' s p i l o t p r o j e c t o f s c r e e n i n g S w e d i s h 4 - y e a r - o l d s , m e n t a l d e v e l o p m e n t and s o c i a l a d a p t a t i o n w e r e a s s e s s e d b y a p s y c h o l o g i s t who o b s e r v e d t h e c h i l d r e n i n g r o u p s o f f o u r o r f i v e . T h i s was f o l l o w e d b y an i n t e r v i e w w i t h e a c h o f t h e p a r e n t s ( K o h l e r , 1 9 7 3 , p. 1 3 ) . T h i s . p r o c e d u r e a p p e a r s t o h a v e b e e n d e v i s e d s p e c i f i c a l l y f o r t h i s s t u d y . I n B r i t a i n , t h e S t y c a r D e v e l o p m e n t a l S e q u e n c e s h a v e b e e n a v a i l a b l e s i h . e e 1960. T h e s e s c h e d u l e s w e r e d e v e l o p e d 18 by p e d i a t r i c i a n M a r y D. S h e r i d a n o v e r a p e r i o d o f 35 y e a r s i n an a t t e m p t t o p e r f e c t an a s s e s s m e n t t o o l s p e c i f i c a l l y r e l a t e d t o B r i t i s h c h i l d r e n ( S h e r i d a n , 1 9 7 5 , p. 1) . I n t h e U n i t e d S t a t e s a n d C a n a d a , t h e m o s t common a s s e s s m e n t t o o l i s t h e D e n v e r D e v e l o p m e n t a l S c r e e n i n g T e s t (DDST), d e v e l o p e d b y F r a n k e n b u r g a n d Dodds ( 1 9 6 7 ) . T h i s t e s t p r o v i d e s a p r a c t i c a l m e t h o d o f s c r e e n i n g f o r e v i d e n c e o f s l o w d e v e l o p m e n t i n i n f a n t s a n d p r e s c h o o l c h i l d r e n . I t c o v e r s f o u r f u n c t i o n s : p e r s o n a l / s o c i a l , f i n e m o t o r / a d a p t i v e , l a n g u a g e , and g r o s s m o t o r . The p e r f o r m a n c e o f t h e c h i l d i s r a t e d on a t e s t f o r m ( A p p e n d i x E, p.127) on w h i c h 105 t a s k s a r e a r r a y e d i n t h e f o u r s e c t o r s a c r o s s t h e age r a n g e f r o m b i r t h t o 6 y e a r s . Norms a r e g i v e n f o r t h e a g e s a t w h i c h 25, 50, 7 5 , and 90 p e r c e n t o f t h e c h i l d r e n i n t h e o r i g i n a l t e s t s a m p l e p a s s e d e a c h t e s t i t e m . A m a n u a l ( F r a n k e n b u r g e t a l , 1970) p r o v i d e s i n s t r u c t i o n s f o r a d m i n i s t e r i n g a n d s c o r i n g t h e t e s t s . A l t h o u g h t h e t e s t was o r i g i n a l l y s t a n d a r d i z e d on a s a m p l e o f 1,06 3 p r e s u m a b l y n o r m a l c h i l d r e n whose f a m i l i e s r e f l e c t e d t h e o c c u p a t i o n a l a n d r a c i o - e t h n i c c h a r a c t e r i s t i c s o f t h e p o p u l a t i o n o f D e n v e r , C o l o r a d o , i n t h e 1960s,,: i t ha s p r o v e n t o be w i d e l y a p p l i c a b l e i n o t h e r c o n t e x t s . F o r e x a m p l e , D r . F r e d e r i c k A. N o r t h , f o r m e r d i r e c t o r o f t h e U.S. Head S t a r t p r o g r a m , f o u n d t h e DDST t o be r e l i a b l e a n d v a l i d . He recommends u s i n g t h e p a r e n t - r e p o r t e d 19 i t e m s o f t h e DDST t o i d e n t i f y t h e l a r g e m a j o r i t y o f c l e a r l y n o r m a l c h i l d r e n , and a p p l y i n g t h e f u l l DDST p r o c e d u r e t o t h e r e m a i n i n g m i n o r i t y ( N o r t h , 1 974, p. 6 3 3 ) . I n C a n a d a , t h e DDST was made an i n t e g r a l p a r t o f t h e E t o b i c o k e s c r e e n i n g p r o g r a m b e c a u s e i t " i s e a s i l y a d m i n i s t e r e d a n d i s c o n d u c i v e t o h e a l t h s c r e e n i n g a n d a n t i c i p a t o r y g u i d a n c e " ( K i r s t i n e , 1 9 7 4 , p. 1 2 ) . The DDST h a s b e e n u s e d i n an A l b e r t a s c r e e n i n g p r o g r a m (Edmonton, 19 7 6 ) , a n d i n a number o f p r o g r a m s i n B r i t i s h C o l u m b i a ( T h o r e s a n d P h i l i o n , 1 9 7 2 ; W o l f , 1976; B u r n a b y , 1 9 7 6 ) . B a r n e s a n d S t a r k ( 1 9 7 5 , p. 3 6 4 ) , i n a B r i t i s h C o l u m b i a s t u d y u n d e r t a k e n s p e c i f i c a l l y t o d e t e r m i n e w h e t h e r l o c a l norms w e r e n e e d e d , f o u n d t h a t t h e DDST c a n v a l i d l y be u s e d o n a r u r a l a n d s e m i - r u r a l C a n a d i a n p o p u l a t i o n . V i s i o n . A number o f t e c h n i q u e s h a v e b e e n d e v i s e d t o o v e r c o m e t h e d i f f i c u l t y o f t e s t i n g t h e v i s i o n o f v e r y y o u n g c h i l d r e n . I n Sweden, f o r e x a m p l e , K o h l e r (197 3, p. 16) c o m b i n e d a v i s u a l a c u i t y t e s t , a c o v e r t e s t , a n d a t e s t o f b i n o c u l a r v i s i o n , none o f w h i c h r e q u i r e d t h e c h i l d t o be a b l e t o i d e n t i f y l e t t e r s . He f o u n d t h e s e t e s t s e a s y a n d q u i c k t o c a r r y o u t , and f o l l o w - u p s t u d i e s showed t h a t no c h i l d r e n w i t h f u n c t i o n a l s t r a b i s m u s o r a m b l y o p i a had p a s s e d t h e s c r e e n i n g t e s t s . T h o r e s and P h i l i o n ( 1 9 7 2 , p. 269) u s e d a g e s t a l t t e c h n i q u e f o r v i s u a l s c r e e n i n g . T h i s was d e v e l o p e d f r o m 20 t h e S t y c a r m e t h o d b u t s u b s t i t u t e d s i m p l e g e o m e t r i c s h a p e s f o r S h e r i d a n ' s l e t t e r s a n d t o y s . T h e y f e l t t h i s t o be s u p e r i o r t o t h e more t r a d i t i o n a l random-E t e s t , w h i c h t h e y f e l t c o n f u s e d some c h i l d r e n . The E t o b i c o k e s t u d y u s e d t h e S n e l l e n i l l i t e r a t e - E c h a r t and G o o d - l i t e e q u i p m e n t ( K i r s t i n e , 1 9 7 4 , p. 1 1 ) . The B u r n a b y p r o g r a m ( B u r n a b y , 19 76) r e l i e s on an e y e - m u s c l e b a l a n c e t e s t . N o r t h c o n s i d e r s ( 1 9 7 4 , p. 632) t h a t t h e S n e l l e n c h a r t c a n be u s e d s u c c e s s f u l l y on most c h i l d r e n p a s t t h e age o f 3 o r 4. B u t he s a y s i t s h o u l d amaze and c h a g r i n us a l l t o r e a l i z e t h a t a f t e r d e c a d e s o f r o u t i n e v i s i o n s c r e e n i n g f o r m i l l i o n s o f c h i l d r e n , a l m o s t n o t h i n g i s known a b o u t t h e r e l i a b i l i t y o r v a l i d i t y o f t h e t e c h n i q u e o f s c r e e n i n g f o r v i s u a l a c u i t y . . . . N o n e t h e l e s s , s c r e e n i n g 'makes s e n s e . ' H e a r i n g , S p e e c h and L a n g u a g e . A c h i l d ' s h e a r i n g and l a n g u a g e d e v e l o p m e n t c a n be m o n i t o r e d , t h r o u g h t h e c h i l d ' s e a r l i e s t y e a r s , b y means o f p a r e n t - a n s w e r e d q u e s t i o n n a i r e s , a c c o r d i n g t o N o r t h ( 1 9 7 4 , p. 6 3 2 ) . A f t e r t h e age o f 3 o r 4, he s a y s , t e s t i n g b y means o f a p u r e - t o n e a u d i o m e t e r i s f e a s i b l e . T h i s t e c h n i q u e was e m p l o y e d i n t h e S w e d i s h h e a l t h - c o n t r o l s t u d y o f 4 - y e a r - o l d s ( K o h l e r , 1 9 7 3 , p. 1 7 ) ; i n t h e E t o b i c o k e n u r s i n g a s s e s s m e n t p r o j e c t ( K i r s t i n e , 197-4, p. 1 1 ) ; and i n t h e V a n c o u v e r I s l a n d p r e s c h o o l p r o g r a m ( T h o r e s a nd P h i l i o n , 1 9 72, p. 2 6 9 ) . F o r y o u n g e r c h i l d r e n , " p l a y a u d i o m e t r y " may be u s e d , a s i n t h e S t y c a r s e q u e n c e s ( S h e r i d a n , 1 9 7 5 , p. 6 7 ) , and a t t h e H a l i f a x H e a r i n g a n d S p e e c h C l i n i c ( S o r t i n i , 1 9 6 4 , p. 7 1 ) . I n B r i t i s h C o l u m b i a , two a p p r o a c h e s a r e t a k e n t o t h e t e s t i n g o f h e a r i n g . Some s c r e e n i n g p r o g r a m s ( W o l f , 1976) u s e c o n v e n t i o n a l a u d i o m e t r y ; o t h e r s , s u c h a s t h a t o f t h e B u r n a b y H e a l t h D e p a r t m e n t (19 7 6 ) , u s e t h e l a n g u a g e - r e l a t e d i t e m s f r o m t h e DDST a s an i n d i r e c t m e a s u r e o f t h e c h i l d ' s h e a r i n g a b i l i t y . N u t r i t i o n a l S t a t u s . W e i g h t a nd h e i g h t m e a s u r e m e n t s c o n s t i t u t e one r o u g h a s s e s s m e n t o f a c h i l d ' s n u t r i t i o n a l s t a t u s . A d m i t t e d l y t h e a s s e s s m e n t i s i m p e r f e c t a n d i n d i r e c t , b u t N o r t h (.1974, p. 633) b e l i e v e s t h a t g r o w t h m e a s u r e m e n t s a r e s o r e a s s u r i n g t o p a r e n t s t h a t t h e y c a n p r o b a b l y be j u s t i f i e d on t h a t g r o u n d a l o n e . H o w e v e r , a n y i n t e r p r e t a t i o n d e p e n d s on c o m p a r i n g t h e c h i l d ' s m e a s u r e m e n t s w i t h h i s own p r e v i o u s r e c o r d s , o r w i t h a g e - a p p r o p r i a t e norms. The C h i l d r e n ' s M e d i c a l C e n t e r o f B o s t o n h a s d e v i s e d an a n t h r o p o m e t r i c c h a r t w h i c h i s commonly u s e d f o r t h i s p u r p o s e i n B r i t i s h C o l u m b i a ( A p p e n d i x G, p. 132 ) . O v e r n u t r i t i o n l e a d i n g t o o b e s i t y may be a more s e r i o u s p r o b l e m i n o u r a f f l u e n t C a n a d i a n p o p u l a t i o n t h a n u n d e r n u t r i t i o n . Many w r i t e r s a g r e e t h a t o b e s i t y b e g i n s e a r l y i n c h i l d h o o d , a l t h o u g h o v e r - f e e d i n g i s n o t t h e o n l y c a u s e . 22 O v e r n u t r i t i o n p e r s e c a n n o t and s h o u l d n o t be s i n g l e d o u t a s t h e o n l y f a c t o r i n t h e h i g h i n c i d e n c e o f o b e s i t y among i n f a n t s and c h i l d r e n , w r i t e s p e d i a t r i c i a n D o n a l d E. H i l l ( 1 9 7 5 , p. 5 9 ) . H o w e v e r , f e e d i n g p r a c t i c e s e s t a b l i s h e d i n c h i l d h o o d a r e d i f f i c u l t , i f n o t i m p o s s i b l e , t o a l t e r , a nd l i k e l y p l a y a r o l e i n t h e h i g h i n c i d e n c e o f o b e s i t y . . . . We s h o u l d l o o k f o r ways o f i d e n t i f y i n g t h e s e i n d i v i d u a l s a t an e a r l i e r a g e . . . . We n e e d t o i d e n t i f y t h e s e i n f a n t s and c h i l d r e n whose g r o w t h - p a t t e r n i s a b n o r m a l and e x a m i n e b o t h t h e p a t t e r n and amount o f f o o d i n t a k e i n o r d e r t o r e d u c e t h e l i k e l i h o o d o f l i f e t i m e o b e s i t y . D e n t a l H e a l t h . A d e t a i l e d d e n t a l e x a m i n a t i o n and d e n t a l - h e a l t h c o u n s e l l i n g s e s s i o n w e r e i n c l u d e d i n t h e S w e d i s h h e a l t h - c o n t r o l p r o g r a m ( K o h l e r , 1 9 7 3 , p. 1 7 ) . K o h l e r f o u n d a h i g h i n c i d e n c e o f c a r i e s i n h i s s t u d y p o p u l a t i o n and c o n c l u d e d t h a t a p r o g r a m o f p r e v e n t i o n s h o u l d be i n t r o d u c e d a t a v e r y e a r l y a g e : "The age o f 4 i s f a r t o o l a t e " ( p . 2 6 ) . N o r t h ( 1 9 7 4 , p. 635) c o n s i d e r s t h a t " D e n t a l c a r i e s a r e s o p r e v a l e n t t h a t a l l c h i l d r e n o v e r age 3 s h o u l d be c o u n s e l l e d t o o b t a i n r o u t i n e d e n t a l e v a l u a t i o n and p r e v e n t i v e c a r e . " I n t h e E t o b i c o k e n u r s i n g a s s e s s m e n t p r o j e c t ( K i r s t i n e , 1 9 7 4 , p. 2 1 ) , d e n t a l s c r e e n i n g was i n c l u d e d as p a r t o f t h e t o t a l p h y s i c a l a s s e s s m e n t o f t h e c h i l d r e n . D e n t a l s c r e e n i n g i s a l s o i n c l u d e d i n t h e s c r e e n i n g p r o g r a m c o n d u c t e d by t h e R i c h m o n d H e a l t h D e p a r t m e n t ( W i l s o n , 1 9 7 6 ) . I t was o m i t t e d f r o m t h e C e n t r a l V a n c o u v e r I s l a n d p r e s c h o o l s c r e e n i n g p r o g r a m b e c a u s e , a c c o r d i n g t o T h o r e s a n d P h i l i o n ( 1 9 7 4 , p. 3 8 6 ) , "we w e r e u n a b l e t o t a c k l e i t . " S o c i a l A d j u s t m e n t . As p r e v i o u s l y d i s c u s s e d , t h e DDST a s s e s s e s some a s p e c t s o f t h e c h i l d ' s p e r s o n a l / s o c i a l f u n c t i o n i n g . P e r c e i v i n g t h e p a r e n t - c h i l d r e l a t i o n s h i p a s a c a u s a t i v e f a c t o r i n d e v e l o p m e n t a l d i f f i c u l t i e s , C o k i n e t a l ( 1 9 7 1 , p. 504) i n i t i a t e d a teamwork a p p r o a c h i n one c l i n i c : t h e d o c t o r and t h e s o c i a l w o r k e r g r e e t e d t h e p a r e n t s t o g e t h e r b e f o r e t h e c h i l d ' s e x a m i n a t i o n , and t h e i n d i c a t e d r e m e d i a l i n t e r v e n t i o n s , p h y s i c a l o r s o c i a l , w e r e j o i n t l y p l a n n e d . P e r s o n n e l E m p l o y e d i n S c r e e n i n g P r o g r a m s I n s u r v e y i n g t h e l i t e r a t u r e on s c r e e n i n g p r o g r a m s , t h e t y p e s o f p e r s o n n e l who p e r f o r m t h e a s s e s s m e n t t a s k s w e r e c o n s i d e r e d . The p r o c e d u r e s p e r f o r m e d a n d t h e r e l a t i v e emphases p l a c e d on v a r i o u s a s p e c t s o f t h e a s s e s s m e n t may be d e t e r m i n e d by t h e m i x o f p r o f e s s i o n a l w o r k e r s i n v o l v e d i n s u c h a p r o g r a m . L e s s l e r ( 1 9 7 3 , p. 657) a r g u e s f o r a b r o a d a p p r o a c h t o s c r e e n i n g . He w r i t e s : Too o f t e n s c r e e n i n g p r o g r a m s a r e e n c a p s u l a t e d by p r o f e s s i o n a l b o u n d a r y - s e t t i n g . E d u c a t o r s l o o k a t c o g n i t i v e d e v e l o p m e n t a n d ' s c h o o l r e a d i n e s s . ' 24 Mental h e a l t h s p e c i a l i s t s look f o r be h a v i o r a l or emotional problems.... P h y s i c i a n s search f o r d e v i a t i o n s of p h y s i c a l growth.... Each alone, however, misses the whole c h i l d w hile l o o k i n g at him piecemeal. In the Swedish h e a l t h - c o n t r o l model the assessment team c o n s i s t e d of Kohler (a p e d i a t r i c i a n ) , a p s y c h o l o g i s t , a d e n t i s t , a r e g i s t e r e d nurse and a p e d i a t r i c nurse (Kohler, 1973, p. 8). A d e t a i l e d p h y s i c a l examination of each c h i l d by the p e d i a t r i c i a n was an i n t e g r a l p a r t of the study; because the r e s u l t s were so sparse Kohler questions the ne c e s s i t y of t h i s type of examination (p. 24) and suggests d e l e g a t i n g the i n i t i a l h e a l t h a p p r a i s a l because "nurses with t r a i n i n g and experience of c h i l d r e n should make the best examiners" (p. 8). In B r i t a i n , by c o n t r a s t , C u r t i s Jenkins b e l i e v e s that screening should be done by p h y s i c i a n s as a p a r t of general p r a c t i c e . "The doctor should c a r r y out the e n t i r e examination, and delegate none of i t to other workers", he says (1975, p. 95). MacKeith (1975, p. 328) says, however, t h a t p a r t s of the developmental assessment can be c a r r i e d out by a i d e s , or h e a l t h v i s i t o r s i n the home, but t h i s "needs to be under the constant s u p e r v i s i o n of experienced medical doctors." Wintle et a l (1972, p. 328), reviewing the r e s u l t s of school medical examinations i n an i n t e g r a t e d B r i t i s h 25 p r a c t i c e , f o u n d t h a t f o u r o u t o f f i v e p r e v i o u s l y unknown d e f e c t s c o u l d h a v e b e e n d e t e c t e d by a s u i t a b l y t r a i n e d n u r s e . I n a C a r d i f f s t u d y o f t h e u s e o f t h e D e n v e r D e v e l o p m e n t a l S c r e e n i n g T e s t , B r y a n t e t a l ( 1 9 7 3 , p. 39) c o n c l u d e d t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e b e t w e e n t h e t e s t r e s u l t s o b t a i n e d by d o c t o r s and t h o s e o b t a i n e d by h e a l t h v i s i t o r s . A n u n s i g n e d L a n c e t a r t i c l e ( 1 9 7 5 , p. 7 8 5 ) , r e v i e w i n g B r i t i s h e x p e r i e n c e w i t h d e v e l o p m e n t a l a s s e s s m e n t , s u g g e s t s t h a t " w e l l - i n s t r u c t e d p a r a m e d i c a l p e r s o n n e l may w e l l do a more s k i l f u l a s s e s s m e n t t h a n a h a r a s s e d o r h a l f - h e a r t e d d o c t o r . " I n c r e a s i n g l y i n t h e U n i t e d S t a t e s c h i l d a s s e s s m e n t h a s b e e n d e l e g a t e d t o p e d i a t r i c n u r s e p r a c t i t i o n e r s . M c A t e e and S i l v e r ( 1 9 7 4 , p. 579) s a y t h a t s u r v e y s and e v a l u a t i o n s t u d i e s o f t h e . U n i v e r s i t y o f C o l o r a d o p e d i a t r i c n u r s e p r a c t i t i o n e r p r o g r a m h a v e shown t h a t t h e s e p r a c t i t i o n e r s and p e d i a t r i c i a n s a g r e e c l o s e l y i n t h e i r a s s e s s m e n t o f t h e h e a l t h s t a t u s o f c h i l d r e n . T e r r e l l ( 1 9 7 4 , p. 11) d e s c r i b e s a p r o g r a m o f E a r l y a nd P e r i o d i c S c r e e n i n g , D i a g n o s i s and T r e a t m e n t (EPSDT) o f f e r e d t o U.S. c h i l d r e n e l i g i b l e f o r M e d i c a i d b e n e f i t s . The c l i n i c on w h i c h she f o c u s s e s i s s t a f f e d by t h r e e p u b l i c h e a l t h n u r s e s and a p e d i a t r i c n u r s e p r a c t i t i o n e r . S p e c i a l l y t r a i n e d c o m m u n i t y h e a l t h n u r s e s p e r f o r m e d 26 t h e a s s e s s m e n t p r o c e d u r e s on t h e c h i l d r e n i n t h e E t o b i c o k e s t u d y ( K i r s t i n e , 1974, p. 2 0 ) . T h e r e was no o b j e c t i v e a s s e s s m e n t o f t h e i r p e r f o r m a n c e . I n E d m onton, c o m m u n i t y h e a l t h n u r s e s p e r f o r m r o u t i n e p r e s c h o o l a s s e s s m e n t p r o c e d u r e s and d i r e c t h e a l t h a i d e s who a r e r e s p o n s i b l e f o r s c r e e n i n g h e a r i n g , s p e e c h and v i s i o n ( Edmonton, 1 9 7 6 ) . The V a n c o u v e r I s l a n d p r e s c h o o l s c r e e n i n g p r o g r a m d e s c r i b e d by T h o r e s and P h i l i o n ( 1 9 7 2 , p. 269) was c o n d u c t e d l a r g e l y b y t r a i n e d v o l u n t e e r s u n d e r t h e s u p e r v i s i o n o f p u b l i c h e a l t h n u r s e s and a p h y s i c i a n . I n c o n t e m p o r a r y B r i t i s h C o l u m b i a p r a c t i c e , . s c r e e n i n g p r o g r a m s f o r p r e s c h o o l e r s a r e d i r e c t e d by c o m m u n i t y h e a l t h n u r s e s and u t i l i z e a v a r i e t y o f o t h e r h e a l t h p e r s o n n e l . The F r a s e r V a l l e y p r o g r a m , d e s c r i b e d by W o l f ( 1 9 7 6 ) , f o r e x a m p l e , e m p l o y s h e a l t h a i d e s t o p e r f o r m a u d i o m e t r i c e x a m i n a t i o n s and n u r s e - v o l u n t e e r s t o p e r f o r m v i s i o n t e s t s . I n B u r n a b y , c o m m u n i t y h e a l t h n u r s e s t eam w i t h a n u t r i t i o n i s t a n d a s p e e c h t h e r a p i s t who i s t r a i n e d i n a u d i o m e t r y ( B u r n a b y , 1 9 7 6 ) . I n R i c h m o n d , t h e a s s e s s m e n t team i s composed o f c o m m u n i t y h e a l t h n u r s e s , a r e g i s t e r e d n u r s e t r a i n e d i n h e a r i n g and s p e e c h e v a l u a t i o n , a d e n t a l h y g i e n i s t and an o r t h o p t i s t ( W i l s o n , 1976) . From h e r r e v i e w o f o t h e r s 1 s t u d i e s o f p r e v e n t i v e h e a l t h b e h a v i o r s , P e n d e r ( 1 9 7 5 , p. 388) c o n c l u d e d t h a t " t h e c o m p e t e n c e t h e p u b l i c a t t r i b u t e s t o t h e n u r s e w i l l ... 27 a f f e c t t h e i r r e s p o n s i v e n e s s t o h e r s u g g e s t i o n s . . . . " A c c o r d i n g t o a T o r o n t o , s t u d y ( C a n a d i a n P r e s s , 1 9 7 6 ) , one segment o f t h e p u b l i c i s n o t s e e k i n g a s s i s t a n c e i n c h i l d c a r e f r o m t h e c o m m u n i t y h e a l t h n u r s e . The l o w - i n c o m e m o t h e r s s u r v e y e d s a i d t h a t when t h e y n e e d e d h e l p f o r t h e i r c h i l d r e n , t h e y t u r n e d f i r s t t o a d o c t o r , s e c o n d t o a t e a c h e r , t h i r d t o a c o u n s e l l o r , a n d f o u r t h t o t h e i r h u s b a n d s . P u b l i c c o n f i d e n c e i n n u r s e s p r e s u m a b l y w i l l be e n h a n c e d b y d e v e l o p m e n t s i n C a n a d i a n n u r s i n g e d u c a t i o n f o l l o w i n g t h e r e c o m m e n d a t i o n s o f t h e C o m m i t t e e on N u r s e P r a c t i t i o n e r s ( B o u d r e a u , 1 972, pp. 1 3 - 1 4 ) . C a n a d i a n u n i v e r s i t i e s h a v e b egun t o o f f e r e x p a n d e d - r o l e n u r s i n g p r o g r a m s ( H u r d , 1 9 72; K e r g i n e t a l , 1973) whose g r a d u a t e s s h o u l d e x h i b i t a h i g h d e g r e e o f c o m p e t e n c e i n d e v e l o p m e n t a l a s s e s s m e n t s k i l l s , among o t h e r s . A l l f i n a l - y e a r n u r s i n g s t u d e n t s e n r o l l e d i n t h e c o m m u n i t y h e a l t h n u r s i n g c o u r s e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a a r e p r e p a r e d t o c a r r y o u t p h y s i c a l a p p r a i s a l s a n d d e v e l o p m e n t a l t e s t s o f y o u n g c h i l d r e n ( C a w s t o n , 1 9 7 2 , p. 6 7 ) . Age L e v e l s f o r P r e s c h o o l S c r e e n i n g The a p p r o p r i a t e age l e v e l f o r s c r e e n i n g f o r d e v e l o p m e n t a l d e l a y s a n d h a n d i c a p p i n g c o n d i t i o n s o f c h i l d - h o o d h a s b e e n a m a t t e r o f c o n s i d e r a b l e c o n t r o v e r s y . W h i l e i t i s g e n e r a l l y c o n c e d e d ( G a l l a g h e r , 1 9 7 3 , p. 687; B e n s o n and B e a t t i e , 1 964, p. 378; S h e r i d a n , 1 9 7 5 , p. 1) t h a t age 28 6, o r s c h o o l e n t r a n c e , i s t o o l a t e f o r many r e m e d i a l i n t e r v e n t i o n s t o be f u l l y e f f e c t i v e , many t e s t s c a n n o t be p e r f o r m e d u n t i l t h e s u b j e c t i s o l d en o u g h t o c o o p e r a t e . T h e r e f o r e t h e o p t i m a l age f o r s c r e e n i n g becomes s u b j e c t t o c o m p r o m i s e . " I n a d e v e l o p m e n t a l s e n s e , " s a i d A r n o l d G e s e l l ( 1 9 2 3 , p. 253) , t h e c h i l d i s i n d e e d a p r e t t y w e l l - f i n i s h e d p r o d u c t when h i s s i x t h - y e a r m o l a r s b e g i n t o e r u p t . The p r e - s c h o o l y e a r s a r e i n c o m p a r a b l y t h e p e r i o d o f m o s t r a p i d a n d m o s t f u n d a m e n t a l g r o w t h . . . . L a t e r w o r k h a s c o n f i r m e d G e s e l l ' s f i n d i n g s . B l o o m h a s w r i t t e n ( 1 9 6 4 , p. 57) t h a t b y t h e t i m e a c h i l d r e a c h e s t h e age o f 4, h i s b a s i c i n t e l l i g e n c e and p e r s o n a l i t y s t r u c t u r e h a v e b e e n f o r m e d . P s y c h o l o g i s t B u r t o n W h i t e , h e a d o f t h e H a r v a r d P r e s c h o o l P r o j e c t , b e l i e v e s t h a t t h e d e v e l o p i n g a n d l e a r n i n g c a p a b i l i t i e s t h a t w i l l s e e a c h i l d t h r o u g h t h e r e s t o f h i s l i f e a r e s e t by t h e age o f 2 ( W h i t e , 1 9 7 5, p. 4 ) . F u r t h e r , t h e d e g r e e o f f l e x i b i l i t y a n d t h e c a p a c i t y f o r c h a n g e t h a t humans h a v e d e c l i n e s w i t h a g e , a n d t o a l t e r p e r s o n a l i t y p a t t e r n s o r s o c i a l a t t i t u d e s a f t e r age 3 i s v e r y d i f f i c u l t ( p . 2 5 7 ) . K o h l e r a g r e e s , i n a r e p o r t ( 1 9 7 3 , p p . 6-7) on t h e e l a b o r a t e p i l o t s t u d y f o r a S w e d i s h h e a l t h - c o n t r o l p r o g r a m w h i c h he d i r e c t e d , t h a t " t h e e a r l i e r a d i s a b i l i t y i s d e t e c t e d a n d t h e e a r l i e r s u i t a b l e t r e a t m e n t c a n be i n s t i t u t e d , t h e b e t t e r r e s u l t s may be e x p e c t e d . " 29 However, he says, i n order to detect minor handicaps i n some f i e l d s , the cooperation of the c h i l d i s of great importance. He and h i s colleagues t h e r e f o r e chose the age of 4 as " t h i s age was presumed to be the e a r l i e s t at which s p e c i f i c mass screening t e s t s , i n v o l v i n g a great deal of cooperation, could be used on the m a j o r i t y of the c h i l d r e n . " This age, however, proved to be too l a t e f o r e f f e c t i v e prevention of de n t a l c a r i e s ; two out of three of Kohler's 4-year-olds already s u f f e r e d from c a r i e s (p. 26). Canadian programs have a l s o encountered d i f f i c u l t y i n e s t a b l i s h i n g an optimal age f o r screening of preschoolers. The Etobicoke Community Health Department i n Ontario chose 3-to-4-year-olds f o r the nursing assessment p r o j e c t reported by M y r t l e K i r s t i n e (19 74, p. 12), apparently because they were conveniently e n r o l l e d i n j u n i o r kindergarten c l a s s e s i n the t a r g e t community. In Edmonton, A l b e r t a , the L o c a l Board of Health o f f e r s screening s e r v i c e s to a l l c h i l d r e n over the age of 4 1/2 who attend a kindergarten or day care centre, and to some younger c h i l d r e n i d e n t i f i e d by preschool teachers or nurses as warranting h e a l t h or developmental assessment (Edmonton, 19 76). Thores and P h i l i o n (1972, p. 269), r e p o r t i n g on the preschool screening program on Vancouver I s l a n d , chose 4 as the age f o r screening. " I d e a l l y , " they s a i d , " t h i s should be done even e a r l i e r , but i t was f e l t t hat the 30 a p p l i c a t i o n o f a l a r g e - s c a l e p r o g r a m much e a r l i e r t h a n t h i s age was n o t p r a c t i c a l f o r u s i n i t i a l l y . " I n B r i t i s h C o l u m b i a , r e c e n t d e v e l o p m e n t a l s c r e e n i n g p r o g r a m s h a v e f o c u s s e d on 3 - y e a r - o l d s ( B u r n a b y , 19 76; W i l s o n , 1976; W o l f , 1 9 7 6 ) . P a r t i c i p a n t s i n S c r e e n i n g P r o g r a m s The u l t i m a t e o b j e c t i v e o f a n y s c r e e n i n g p r o g r a m f o r p r e s c h o o l e r s , a n d o f t h e n e c e s s a r y f o l l o w - u p and r e m e d i a t i o n w h i c h s h o u l d f l o w f r o m i t , i s t h e m a x i m i z a t i o n o f t h e c h a n c e s o f a l l c h i l d r e n t o s u c c e e d i n s c h o o l and i n l i f e . T h a t t h i s g o a l i s n o t b e i n g met i s e v i d e n t f r o m t h e l i t e r a t u r e . N o r t h ( 1 9 7 0 , p. 7 0 0 ) , r e p o r t i n g on t h e U.S. Head S t a r t e x p e r i e n c e , s a y s t h a t a c e n t r a l p r o b l e m o f a l l h e a l t h p r o g r a m s h a s b e e n t o a s s u r e t h a t e v e r y c h i l d o b t a i n s t h e n e c e s s a r y s c r e e n i n g t e s t s , e x a m i n a t i o n s , and p r e v e n t i v e m e a s u r e s and t h a t e v e r y c h i l d who n e e d s t r e a t m e n t a c t u a l l y r e c e i v e s i t . He a d d s : P r o g r a m s h a v e o n l y r a r e l y s u c c e e d e d i n a c h i e v i n g t h e 100 p e r c e n t c o v e r a g e w h i c h i s t h e o n l y t r u e s t a n d a r d o f s u c c e s s . E v e n K o h l e r ' s h i g h l y o r g a n i z e d S w e d i s h h e a l t h - c o n t r o l p i l o t p r o j e c t a c h i e v e d s l i g h t l y l e s s ' (95.1 p e r c e n t ) t h a n N o r t h ' s i d e a l s t a n d a r d , i n s p i t e o f s t r e n u o u s e f f o r t s t o r e a c h a l l p a r e n t s i n h i s s t u d y p o p u l a t i o n . L i k e many o t h e r w o r k e r s , K o h l e r f o u n d (19 7 3 , p. 12) t h a t n o n - p a r t i c i p a t i n g f a m i l i e s h a d a somewhat p o o r e r s o c i o e c o n o m i c b a c k g r o u n d t h a n p a r t i c i p a n t s , and t h a t t h e i r n e e d f o r a d v i c e a n d s u p p o r t was g r e a t e r t h a n t h a t o f o t h e r f a m i l i e s . S i m i l a r l y The L a n c e t ( 1 9 7 5 , p. 784) n o t e s t h a t i n B r i t a i n "a b i g p r o b l e m i s t h a t p a r e n t s o f t h e c h i l d m o s t i n n e e d may n o t s e e k t h e s e r v i c e s o f f e r e d . " The r e s u l t , i t s a y s , i s t h a t 10 t o 20 p e r c e n t o f B r i t i s h c h i l d r e n e n t e r s c h o o l w i t h u n d e t e c t e d d e f e c t s , many o f w h i c h c o u l d h a v e b e e n t r e a t e d e a r l i e r h a d t h e i r p a r e n t s t a k e n a d v a n t a g e o f a v a i l a b l e s c r e e n i n g a n d t r e a t m e n t s e r v i c e s . I n Sweden, W a l l a c e r e p o r t s i n a c o m p a r a t i v e s t u d y ( 1 9 7 5 , p. 4) 69 p e r c e n t o f a l l c h i l d r e n a g e d 2 t o 7 v i s i t c h i l d w e l f a r e c e n t r e s w h i c h p r o v i d e s c r e e n i n g a n d h e a l t h a s s e s s m e n t among o t h e r s e r v i c e s . I n c o n t r a s t , s h e n o t e s , o n l y 20.7 p e r c e n t o f c h i l d r e n a g e d 2 t o 5 i n E n g l a n d and W a l e s v i s i t e d s i m i l a r c e n t r e s . I n t h e U n i t e d S t a t e s , B r i n t o n ( 1 9 7 2 , p. 47) s a y s t h e d e s i r e d g o a l o f h e a l t h s u p e r v i s i o n o f a l l c h i l d r e n o f t h e l o w e r s o c i o e c o n o m i c c l a s s e s i s n o t b e i n g met i n s p i t e o f an i n c r e a s e d e m p h a s i s o n p r e v e n t i v e h e a l t h s e r v i c e s . S o c i o e c o n o m i c S t a t u s . B i r c h and Gussow ( 1 9 7 0 , p p . 4 - 5 ) , who n o t e a s t r o n g c o r r e l a t i o n b e t w e e n p o v e r t y and m e m b e r s h i p i n n o n - w h i t e m i n o r i t i e s i n t h e U.S., c o n s i d e r i t b e y o n d a r g u m e n t t h a t c h i l d r e n b u r d e n e d by t h i s d o u b l e h a n d i c a p do l e s s w e l l i n s c h o o l t h a n t h e i r more p r i v i l e g e d f e l l o w s . T hey s e e a r e l a t i o n s h i p , a l s o , b e t w e e n p h y s i c a l w e l l - b e i n g and s c h o o l s u c c e s s ( p . 7 ) . N o r t h ( 1 9 7 0 , p. 698) n o t e s t h a t " t h e a c t u a l i n c i d e n c e o f c e r t a i n h e a l t h p r o b l e m s ... i s h i g h e r i n p o o r c h i l d r e n . " S i m i l a r l y , K o h l e r ( 1 9 7 3 , p. 25) f o u n d t h a t " c h i l d r e n f r o m l o w e r s o c i o e c o n o m i c g r o u p s r a n a p a r t i c u l a r r i s k o f h a v i n g i m p o r t a n t h e a l t h p r o b l e m s . " I n t h e i r s t u d y o f k i n d e r g a r t e n c h i l d r e n i n t h r e e B r i t i s h C o l u m b i a a r e a s , T o n k i n e t a l ( 1 9 7 3 , p. 954) f o u n d t h a t " p o o r s c h o o l p e r f o r m a n c e seemed t o be a l i a b i l i t y o f l o w s o c i o e c o n o m i c s t a t u s . " D e s p i t e t h e i r g r e a t e r n e e d , p o o r p e o p l e a p p a r e n t l y do n o t f u l l y u t i l i z e a v a i l a b l e p r e v e n t i v e h e a l t h s e r v i c e s . M a i s e l w r i t e s ( 1 9 7 5 , p. 377) t h a t s p e c i a l p r o g r a m s a i m e d a t n e e d y g r o u p s h a v e b e e n r e v e a l e d a s s t o p g a p m e a s u r e s w h i c h a c t u a l l y p e r p e t u a t e a s y s t e m o f u n e q u a l h e a l t h c a r e . " S i m p l y o f f e r i n g h e a l t h c a r e t o t h e p o o r o r n e a r p o o r i s no g u a r a n t e e t h a t p e o p l e w i l l a v a i l t h e m s e l v e s o f i t o r u t i l i z e i t p r o p e r l y . " I n a u s e f u l r e v i e w a r t i c l e , R o s e n s t o c k ( 1 9 6 6 , p. 96) s a y s t h a t s t u d i e s h a v e shown t h a t p r e v e n t i v e and d e t e c t i o n s e r v i c e s a r e u s e d m a i n l y by y o u n g , w h i t e , r e l a t i v e l y a f f l u e n t a nd w e l l - e d u c a t e d women. S t e e l e a nd McBroom ( 1 9 7 2 , p. 384) f o u n d t h a t " h e a l t h b e h a v i o r i s i n p a r t a 33 f u n c t i o n o f i n c o m e " a n d t h a t " p e r s o n s o f h i g h e r s o c i o e c o n o m i c s t a t u s w e r e more l i k e l y t o e ngage i n p r e v e n t i v e h e a l t h a c t i o n s . " P e n d e r ( 1 9 7 5 , p. 385) a l s o s a y s t h a t s t u d i e s h a v e shown t h a t t h o s e who u s e p r e v e n t i v e h e a l t h s e r v i c e s t e n d t o be w h i t e , m a r r i e d women who h a v e g r a d u a t e d f r o m c o l l e g e , a r e i n t h e m i d d l e - t o - h i g h - i n c o m e g r o u p s , and a r e members o f s m a l l f a m i l i e s . G r e e n f o u n d ( 1 9 7 0 , p. 95) t h a t t h e m o t h e r ' s e d u c a t i o n was t h e v a r i a b l e t h a t c o r r e l a t e d m o s t h i g h l y w i t h a f a m i l y ' s p r e v e n t i v e h e a l t h b e h a v i o r . Income and e d u c a t i o n , he r e p o r t s , a r e e s s e n t i a l l y e q u i v a l e n t i n t h e i r r e l a t i o n s h i p t o h e a l t h b e h a v i o r . S t e e l e a n d McBroom ( 1 9 7 2 , p. 391) f o u n d t h a t r e c e n t e x p e r i e n c e w i t h i l l n e s s g e n e r a l l y h e i g h t e n s t h e l i k e l i h o o d t h a t p e r s o n s o f u p p e r s o c i o e c o n o m i c s t a t u s w i l l e n g a g e i n p r e v e n t i v e h e a l t h b e h a v i o r ; f o r t h o s e i n t h e l o w e r g r o u p i n g s , i t d e c r e a s e s , t h e l i k e l i h o o d . Among t h e h a r d - t o - r e a c h p o p u l a t i o n , G r e e n ( 1 9 7 0 , p. 88) f o u n d t h a t l a r g e f a m i l i e s i n h i b i t t h e m o t h e r ' s e x - p o s u r e t o s o c i a l i n f l u e n c e s t h a t m i g h t o t h e r w i s e i m p r o v e h e r c h a n c e s o f u s i n g p r e v e n t i v e h e a l t h s e r v i c e s . C h e r r y a n d Kuba ( 1 9 7 1 , p. 572) f o u n d i n a C h i c a g o s t u d y t h a t t h e t r a d i t i o n a l a s s u m p t i o n t h a t " p a r e n t s a r e by d e f i n i t i o n m a t u r e a d u l t s who w i l l p r o t e c t t h e i r o f f s p r i n g " was n o t n e c e s s a r i l y t r u e . T h e r e a r e p a r e n t s who c a n n o t assume t h e i r s o c i a l r e s p o n s i b i l i t i e s ; t h e s e p a r e n t s "must 34 be p u r s u e d , u n d e r s t o o d , a nd t o l e r a t e d " i f t h e y a r e t o be e f f e c t i v e l y i n v o l v e d i n p r e v e n t i v e h e a l t h s e r v i c e s t o t h e b e n e f i t o f t h e i r c h i l d r e n . I f s o c i o e c o n o m i c s t a t u s i s an i n d i c a t o r o f h e a l t h b e h a v i o r , some way must be d e v i s e d t o s t r a t i f y a s t u d y p o p u l a t i o n . K o h l e r w r i t e s ( 1 9 7 3 , p. 9 ) : The i n f l u e n c e o f t h e s o c i a l e n v i r o n m e n t u p o n g r o w t h a n d d e v e l o p m e n t , h e a l t h a n d d i s e a s e h a s b e e n c o n f i r m e d i n many s t u d i e s and i s now common k n o w l e d g e . T h e r e f o r e , i n a s t u d y o f c h i l d h e a l t h i t i s n e c e s s a r y t o i n c l u d e some k i n d o f d e s c r i p t i o n o f t h e way o f l i f e o f t h e c h i l d r e n and t h e i r f a m i l i e s . The Two F a c t o r I n d e x o f S o c i a l P o s i t i o n was d e v e l o p e d by Y a l e U n i v e r s i t y s o c i o l o g i s t A u g u s t H o l l i n g s h e a d t o meet t h e n e e d f o r a p r o c e d u r e t o e s t i m a t e t h e p o s i t i o n t h a t i n d i v i d u a l s o c c u p y i n t h e s t a t u s s t r u c t u r e o f s o c i e t y ( H o l l i n g s h e a d , 1 9 5 7 , p. 2 ) . O c c u p a t i o n a nd e d u c a t i o n a r e t h e two f a c t o r s u s e d by H o l l i n g s h e a d i n d e t e r m i n i n g s o c i a l p o s i t i o n . The o c c u p a t i o n a l f a c t o r i s d e r i v e d f r o m a s c a l e w h i c h c l a s s i f i e s j o b s i n t o s e v e n c a t e g o r i e s : C a t e g o r y 1: h i g h e r e x e c u t i v e s , m a j o r p r o f e s s i o n a l s a n d m a j o r e m p l o y e r s ; C a t e g o r y 2: l e s s e r e x e c u t i v e s , l e s s e r p r o f e s s i o n a l s and l e s s e r e m p l o y e r s ; C a t e g o r y 3: a d m i n i s t r a t o r s , m i n o r p r o f e s s i o n a l s and m i n o r e m p l o y e r s ; C a t e g o r y 4: t e c h n i c i a n s , c l e r i c a l and s a l e s w o r k e r s and s e l f - e m p l o y e d ; C a t e g o r y 5: s k i l l e d m a n u a l e m p l o y e e s ; C a t e g o r y 6: s e m i - s k i l l e d e m p l o y e e s ; a nd C a t e g o r y 7: u n s k i l l e d e m p l o y e e s . 35 The e d u c a t i o n a l f a c t o r i s d e r i v e d f r o m a s c a l e d i v i d e d i n t o s e v e n p o s i t i o n s : C a t e g o r y 1: g r a d u a t e p r o f e s s i o n a l t r a i n i n g ; C a t e g o r y 2: u n i v e r s i t y g r a d u a t i o n ; C a t e g o r y 3: p a r t i a l c o l l e g e t r a i n i n g ; C a t e g o r y 4: h i g h s c h o o l g r a d u a t i o n ; C a t e g o r y 5: p a r t i a l h i g h s c h o o l ; C a t e g o r y 6: j u n i o r h i g h s c h o o l c o m p l e t i o n ; and C a t e g o r y 7: l e s s t h a n s e v e n y e a r s o f s c h o o l . The o c c u p a t i o n a l f a c t o r i s g i v e n a h e a v i e r w e i g h t t h a n t h e e d u c a t i o n a l f a c t o r (7:4) t o o b t a i n t h e I n d e x o f S o c i a l P o s i t i o n S c o r e f o r a n i n d i v i d u a l . T h e s e s c o r e s a r e r a n g e d i n t o S o c i a l C l a s s e s I , I I , I I I , I V , and V ( H o l l i n g s h e a d , 1957, p. 1 0 ) . The d e v e l o p m e n t o f t h e I n d e x o f S o c i a l P o s i t i o n u s i n g t h e o c c u p a t i o n a l s c a l e , t h e e d u c a t i o n a l s c a l e and a r e s i d e n t i a l s c a l e , and t h e v a l i d a t i o n o f t h e I n d e x , a r e d i s c u s s e d b y H o l l i n g s h e a d and R e d l i c h ( 1 9 5 8 , pp. 3 8 7 - 4 0 7 ) . The o c c u p a t i o n a l s c a l e i s a m o d i f i c a t i o n o f A l b a E d w a r d s ' s y s t e m u s e d b y t h e U n i t e d S t a t e s C e n s u s B u r e a u ( M y e r s and B e a n , 1 9 6 8 , p. 2 3 5 ) . I n t h e r e p o r t o f t h e N a t i o n a l C h i l d D e v e l o p m e n t S t u d y i n B r i t a i n , t h e a u t h o r s ( D a v i e e t a l , 1 9 7 2 , p. 2) b o r r o w e d f r o m t h e R e g i s t r a r G e n e r a l ' s c l a s s i f i c a t i o n o f f a t h e r s ' o c c u p a t i o n s f o r c e n s u s p u r p o s e s , i n o r d e r t o s t r a t i f y t h e p o p u l a t i o n f r o m S o c i a l C l a s s I t o S o c i a l C l a s s V. I n t h i s schema, S o c i a l C l a s s I c o n s i s t s o f h i g h e r p r o f e s s i o n a l s w i t h h i g h e d u c a t i o n a l q u a l i f i c a t i o n s . S o c i a l C l a s s I I c o n s i s t s o f o t h e r p r o f e s s i o n a l s and m a n a g e r s . S o c i a l C l a s s I I I ( non-manual) c o n s i s t s o f a l l o t h e r n o n - m a n u a l w o r k e r s a n d S o c i a l C l a s s I I I (manual) o f s k i l l e d m a n u a l w o r k e r s . S o c i a l C l a s s I V c o n s i s t s o f s e m i - s k i l l e d m a n u a l w o r k e r s and S o c i a l C l a s s V c o n s i s t s o f u n s k i l l e d m a n u a l w o r k e r s . 36 F a m i l i e s w i t h no f a t h e r o r m a l e h e a d o f h o u s e h o l d w ere c o n s i d e r e d u n c l a s s i f i a b l e . The " A t - R i s k " C o n c e p t . A l t h o u g h N o r t h a nd K o h l e r a i m f o r u n i v e r s a l c o v e r a g e i n s c r e e n i n g p r o g r a m s , some o t h e r w o r k e r s h a v e f e l t t h a t a t t e n t i o n s h o u l d be c o n c e n t r a t e d on t h o s e c h i l d r e n m o s t l i k e l y t o s u f f e r f r o m d e f e c t s o r d e v e l o p m e n t a l d e l a y s . The c o n c e p t o f a r e g i s t e r o f c h i l d r e n " a t - r i s k " was i n t r o d u c e d i n B r i t a i n b y R.L. L i n d o n (1961) a n d M a r y S h e r i d a n ( 1 9 6 2 ) . The Edmonton L o c a l B o a r d o f H e a l t h (1976) m a i n t a i n s s u r v e i l l a n c e o f c h i l d r e n on i t s a t - r i s k r e g i s t e r u n t i l t h e age o f 3. F o r i t s n u r s i n g a s s e s s m e n t p r o j e c t , t h e E t o b i c o k e Community H e a l t h D e p a r t m e n t c h o s e a p o p u l a t i o n f r o m p r e d o m i n a n t l y l o w e r - i n c o m e u r b a n a r e a s ( K i r s t i n e , 1 9 7 4 , p. 1 2 ) . How e v e r , K o h l e r w r i t e s ( 1 9 7 3 , p. 7) t h a t c l i n i c a l l y s e l e c t i n g c h i l d r e n who a r e c o n s i d e r e d t o be e s p e c i a l l y l i a b l e t o d e v e l o p h a n d i c a p s and k e e p i n g them u n d e r c l o s e s u r v e i l l a n c e p r o d u c e s d i s a p p o i n t i n g r e s u l t s . He f o u n d t h e r i s k g r o u p s i n c l u d e d o n l y a p o r t i o n o f t h e c h i l d r e n who h a d s u b s e q u e n t h a n d i c a p s , a n d i n c l u d e d too. many n o r m a l c h i l d r e n . B e n s o n ( 1 9 6 9 , p. 145) c o n c u r s w i t h t h i s a s s e s s m e n t . H i s e v a l u a t i o n o f t h e a t - r i s k r e g i s t e r s w h i c h h a d b e e n e s t a b l i s h e d i n some h e a l t h u n i t s i n B r i t i s h C o l u m b i a c o n c l u d e d t h a t a v e r y h i g h p e r c e n t a g e o f a l l c h i l d r e n i n e v i t a b l y h a d t o be p l a c e d on s u c h a r e g i s t r y i f a p o t e n t i a l ' a t - r i s k ' c o n d i t i o n w e r e n o t t o be m i s s e d , a nd t h i s made t h e c o n c e p t u n w o r k a b l e . 37 In B r i t a i n , C u r t i s Jenkins found (1975, p. 94) that " i n some areas o v e r - e n t h u s i a s t i c a p p l i c a t i o n of the r u l e s has placed more than h a l f the newborns on the ' a t - r i s k ' r e g i s t e r . " In the s p e c i f i c case of strabismus, Kornder et a l (1974, p. 213) found that although there i s a p o s i t i v e r e l a t i o n s h i p between a f a m i l y h i s t o r y of v i s u a l problems and the diagnosis of strabismus, there i s no c l e a r - c u t i n d i c a t i o n of a group e s p e c i a l l y at r i s k which could be s e l e c t e d i n order to streamline a program.of preschool v i s i o n screening. Many authors are agreed t h a t there i s l i t t l e p o i n t i n screening c h i l d r e n unless personnel, f a c i l i t i e s and procedures e x i s t to provide help to those.who are found to need i t . The discovery of h e a l t h problems or defects i s of no i n t e r e s t whatsoever i f there e x i s t no ways or means of t r e a t i n g or a l l e v i a t i n g these c o n d i t i o n s , w r i t e s Kohler (1973, p. 8). "Detection of defects should not be encouraged unless there are resources f o r follow-up diagnosis and treatment," says an unsigned a r t i c l e i n The Lancet (1975, p. 786). North emphasizes (1970, p. 699) that a program "must be w i l l i n g to do whatever i s necessary to assure treatment and follow-up." For L e s s l e r (1972, pp. 194-5), a 'screening program' does something about the problems t h a t have been 38 i d e n t i f i e d . . . . I t i s a c r u e l h o a x t o g a i n i n f o r m a t i o n a b o u t a c h i l d and t h e n do n o t h i n g w i t h i t . I n c i d e n c e o f H a n d i c a p p i n g C o n d i t i o n s I n t h e l a s t few d e c a d e s s o c i a l and m e d i c a l c h a n g e s h a v e made i t p o s s i b l e f o r h e a l t h w o r k e r s t o d e v o t e l e s s t i m e and a t t e n t i o n t o t h e g r o s s c h i l d - h a z a r d s o f e a r l i e r g e n e r a t i o n s and c o r r e s p o n d i n g l y more t o t h e l e s s o b v i o u s h i n d r a n c e s t o n o r m a l p h y s i c a l , i n t e l l e c t u a l a nd s o c i a l d e v e l o p m e n t . W r i t e s V a n c o u v e r p e d i a t r i c i a n J o h n U. C r i c h t o n ( 1 9 7 5 , p. 3 7 9 ) , i n an e x p l o r a t i o n o f t h e " b o r d e r l a n d " b e t w e e n m e d i c i n e and e d u c a t i o n : One o f t h e m a n i f e s t a t i o n s o f t h e c h a n g i n g p r i o r i t i e s o f m e d i c a l p r a c t i c e i s t h e i n v o l v e m e n t o f p h y s i c i a n s i n t h e f i e l d o f l e a r n i n g d i s o r d e r s . L i k e l y t h i s h a s a r i s e n p a r t l y b e c a u s e w i t h i n t h e l a s t 20 y e a r s o r so c o n t r o l o f m o s t a c u t e d i s e a s e s o f c h i l d h o o d h a s b e e n a c h i e v e d . D o c t o r s , t h e r e f o r e , h a v e b e e n a b l e t o d e v o t e more t i m e t o s u b t l y h a n d i c a p p i n g c o n d i t i o n s , w h i c h f o r m e r l y w e r e t h e p r o v i n c e o f s p e c i a l i s t n e u r o l o g i s t s o r w h i c h w e r e c o m p l e t e l y i g n o r e d by t h e p r o f e s s i o n a t l a r g e . The CELDIC R e p o r t ( S h a n n o n , 1970., p. 59) , d e s c r i b i n g a n e x h a u s t i v e s t u d y o f t h e n e e d s o f C a n a d i a n c h i l d r e n w i t h e m o t i o n a l a n d l e a r n i n g d i s o r d e r s , s t a t e s t h a t b e t w e e n 2 and 3 p e r c e n t o f c h i l d r e n r e q u i r e f u l l - t i m e s p e c i a l e d u c a t i o n a l placements and estimates t h a t a f u r t h e r 8 to 12 percent of c h i l d r e n need a d d i t i o n a l p r o f e s s i o n a l i n t e r v e n t i o n s to a s s i s t them w i t h t h e i r emotional, b e h a v i o r a l or l e a r n i n g d i s a b i l i t i e s . When one examines the incidence of handicapping c o n d i t i o n s revealed by screening programs reported i n the l i t e r a t u r e , i t i s f u t i l e to attempt to make comparisons without f i r s t c o n s i d e r i n g socioeconomic d i f f e r e n c e s among the populations screened, the ages of the s u b j e c t s , the screening procedures employed, and the o b j e c t i v e s of the various programs. In h i s Swedish study, Kohler (1973, p. 23) found th a t 15 percent of the 4-year-olds examined had " f u n c t i o n a l l y important h e a l t h problems." This category excluded d e n t a l and p o t e n t i a l p s y c h o l o g i c a l and educational h e a l t h problems. In s p e c i f i c areas Kohler reported (p. 19) the f o l l o w i n g i n cidences: Dental problems 65.4 percent V i s u a l problems 12.5 percent Hearing problems 3.9 percent Not a l l of these were considered " f u n c t i o n a l l y important h e a l t h problems." In a review of s e v e r a l American screening programs, L e s s l e r (1973, p. 657) found the f o l l o w i n g ranges reported i n s p e c i f i c problem areas: 40 D e n t a l p r o b l e m s 80 - 90 p e r c e n t V i s i o n p r o b l e m s 7.4 p e r c e n t V i s u a l p e r c e p t i o n 3 6 - 6 9 p e r c e n t H e a r i n g 1.5- 3 p e r c e n t L a n g u a g e 1 6 . 3 - 25 p e r c e n t M e n t a l h e a l t h 2 - 10 p e r c e n t The d i f f i c u l t y o f c o m p a r i n g r e s u l t s f r o m s c r e e n i n g p r o g r a m s r e p o r t e d i n t h e l i t e r a t u r e i s i l l u s t r a t e d b y t h e d a t a c i t e d i n t h i s s e c t i o n . The u s e o f a v a r i e t y o f s c r e e n i n g p r o c e d u r e s , and t h e u s e o f d i f f e r e n t t e r m i n o l o g y t o d e s c r i b e p o s s i b l y s i m i l a r c o n d i t i o n s , makes c o n f i d e n t c o m p a r i s o n i m p o s s i b l e . Many a u t h o r s u s e s u c h v a g u e t e r m s a s " m e n t a l h e a l t h " p r o b l e m s o r " b e h a v i o r a l o r e m o t i o n a l d i s o r d e r s " ; o r " v i s i o n " , " v i s u a l p e r c e p t i o n " o r " p e r c e p t u a l " p r o b l e m s . L e s s l e r ( 1 9 7 2 , p. 196) r e c o g n i z e s t h i s p r o b l e m . He s a y s , f o r e x a m p l e , t h a t t h e r e i s l i t t l e a g r e e m e n t on w h a t c o n s t i t u t e s a t r e a t a b l e l a n g u a g e p r o b l e m and w h a t t h e d i s t r i b u t i o n o f l a n g u a g e p r o b l e m s may b e . Y e t m o s t p e o p l e a g r e e t h a t l a n g u a g e d i f f i c u l t i e s a r e among t h e m o s t d e v a s t a t i n g t o a c h i l d ' s l i f e . I n a p r e - k i n d e r g a r t e n s c r e e n i n g p r o b j e c t i n W e l l e s l e y , M a s s a c h u s e t t s , a i m e d a t e a r l y i d e n t i f i c a t i o n o f c h i l d r e n w i t h p o t e n t i a l l e a r n i n g d i s a b i l i t i e s , p r o j e c t d i r e c t o r G e r t r u d W y a t t ( 1 9 7 0 , p. 6) r e c o r d e d t h e s e f i n d i n g s : B e h a v i o r a n d e m o t i o n a l d i s o r d e r s 10.8 p e r c e n t S p e e c h a n d l a n g u a g e d i s o r d e r s 7.0 p e r c e n t P o s s i b l e h e a r i n g p r o b l e m s 3.0 p e r c e n t M a r k e d l y p o o r m o t o r c o o r d i n a t i o n 1.9 p e r c e n t M e n t a l r e t a r d a t i o n , p r e v i o u s l y known 1.2 p e r c e n t M u l t i p l e p r o b l e m s 5.7 p e r c e n t 41 ( L a n g u a g e , r e s t l e s s n e s s , h y p e r a c t i v i t y , s h o r t a t t e n t i o n s p a n , p o o r m o t o r c o o r d i n a t i o n ) V i s u a l p r o b l e m s ( P e r c e n t a g e n o t r e c o r d e d b e c a u s e a l l c a s e s a l r e a d y u n d e r t r e a t m e n t ) I n a much e a r l i e r p a p e r on t h e N a t i o n a l H e a l t h S u r v e y i n t h e U n i t e d S t a t e s i n t h e l a t e 1 9 5 0 s , E l e a n o r H u n t o f t h e C h i l d r e n ' s B u r e a u r e p o r t e d ( 1 9 5 9 , p. 21) t h e f o l l o w i n g c l a s s i f i c a t i o n s o f i m p a i r m e n t i n 4.1 p e r c e n t o f a l l c h i l d r e n u n d e r 15: 2 p e r c e n t o f f i r s t - g r a d e p u p i l s h a d p r e v i o u s l y unknown p a t h o l o g i c c o n d i t i o n s , e v e n a f t e r e x t e n s i v e h e a l t h e x a m i n a t i o n s ; t h e s e w e r e m a i n l y a c u t e i n f e c t i o n s . T h i s p a u c i t y o f r e s u l t s f r o m t r a d i t i o n a l s c h o o l m e d i c a l e x a m i n a t i o n s was a l s o r e c o g n i z e d b y t h e B r i t i s h C o l u m b i a H e a l t h D e p a r t m e n t i n 1 9 6 1 . A c c o r d i n g t o B e n s o n (1 9 6 4 , p. 3 7 6 ) , a r e v i e w o f t h e p r e v i o u s 21 y e a r s ' r e c o r d s showed t h a t o n l y a b o u t 15 p e r c e n t o f t h e c h i l d r e n e x a m i n e d h a d p r o b l e m s , and t h a t m o s t o f t h e s e w e r e a l r e a d y u n d e r a d e q u a t e c a r e . I n a c h a n g e o f d e p a r t m e n t a l p o l i c y , t h e t r a d i t i o n a l u n i v e r s a l s c h o o l e x a m i n a t i o n was a b a n d o n e d and c h i l d r e n w e r e t h e r e a f t e r e x a m i n e d by a d o c t o r o n l y on O r t h o p e d i c 36 p e r c e n t 26 p e r c e n t 15 p e r c e n t 8 p e r c e n t S p e e c h H e a r i n g V i s i o n M e y e r s t e i n ( 1 9 6 9 , p 1920) f o u n d t h a t f e w e r t h a n r e f e r r a l a f t e r s c r e e n i n g b y a s c h o o l n u r s e . The y i e l d o f c a s e s was a b o u t t h e same u n d e r t h e new s y s t e m , B e n s o n f o u n d (p. 3 7 8 ) . I n a n a r r o w - f o c u s s t u d y o f s t r a b i s m u s i n i n f a n t s , K o r n d e r e t a l ( 1 9 7 4 , p. 208) f o u n d an i n c i d e n c e o f 3.2 p e r c e n t o f m a n i f e s t s t r a b i s m u s among t h e 1,074 c h i l d r e n b o r n d u r i n g 1967-68 i n t h e B o u n d a r y H e a l t h U n i t a r e a o f B r i t i s h C o l u m b i a . I n a f u r t h e r s t u d y o f 2,619 f i r s t - g r a d e p u p i l s , t h e same a u t h o r s f o u n d ( p . 212) t h a t 4.5 p e r c e n t h a d m a n i f e s t s t r a b i s m u s . T h e y c o n s i d e r e d t h i s s h o u l d be r e g a r d e d a s t h e minimum i n c i d e n c e a s some c a s e s m i g h t h a v e b e e n m i s s e d by t h e p r o j e c t team. I n t h e E t o b i c o k e s t u d y ( K i r s t i n e , 1 974, p. 30) o f 283 k i n d e r g a r t e n c h i l d r e n , 103 o r 36.4 p e r c e n t w e r e i n i t i a l l y r e f e r r e d b y t h e s c r e e n i n g t e a m t o c o m m u n i t y h e a l t h n u r s e s f o r f o l l o w - u p . A f t e r r e - s c r e e n i n g , t h e n u r s e s i d e n t i f i e d t h e f o l l o w i n g n e e d s : B e h a v i o r a l / e m o t i o n a l n e e d s 2 5.3 p e r c e n t S p e e c h ( e x c l u d i n g l a n g u a g e b a r r i e r ) 14.7 p e r c e n t D e v e l o p m e n t a l 12.0 p e r c e n t N u t r i t i o n ( o b e s i t y a n d u n d e r w e i g h t ) 9.3 p e r c e n t S o c i a l a n d s c h o o l a d j u s t m e n t 6.7 p e r c e n t D e n t a l 2.7 p e r c e n t On t h i s r e - e x a m i n a t i o n , t h e c o m m u n i t y h e a l t h n u r s e s d e t e c t e d a t o t a l o f 75 n e e d s among 55 o f t h e 103 r e f e r r e d c h i l d r e n , who r e p r e s e n t e d 18.7 p e r c e n t o f t h e 2 83 c h i l d r e n i n i t i a l l y s c r e e n e d . I n t h e i r s t u d y o f p r e s c h o o l e r s on c e n t r a l V a n c o u v e r 43 I s l a n d , T h o r e s and P h i l i o n ( 1 9 7 2 , p. 270) r e p o r t e d t h e f o l l o w i n g f i n d i n g s as t h e r e s u l t o f s c r e e n i n g w i t h t h e D e n v e r D e v e l o p m e n t a l S c r e e n i n g T e s t , h e a r i n g a n d v i s i o n t e s t s : L a n g u a g e d e l a y 9.2 p e r c e n t F i n e - m o t o r / a d a p t i v e d e l a y 4.0 p e r c e n t P e r s o n a l / s o c i a l d e l a y 3.5 p e r c e n t G r o s s - m o t o r d e l a y 2.9 p e r c e n t H e a r i n g p r o b l e m s 6.4 p e r c e n t V i s i o n p r o b l e m s 3.5 p e r c e n t The o r i g i n a l s c r e e n i n g was done b y n o n - p r o f e s s i o n a l v o l u n t e e r s , A f t e r r e - s c r e e n i n g o f c h i l d r e n w i t h s u s p i c i o u s f i n d i n g s b y p u b l i c h e a l t h n u r s e s , T h o r e s a n d P h i l i o n r e p o r t e d ( 1 9 7 4 , p. 386) t h e f o l l o w i n g r a t e s o f r e f e r r a l : H e a r i n g p r o b l e m s 4.0 p e r c e n t V i s i o n p r o b l e m s 1.8 p e r c e n t G e n e r a l h e a l t h d e v e l o p m e n t 1.1 p e r c e n t I n t h e 1974 a n n u a l r e p o r t o f t h e B u r n a b y H e a l t h D e p a r t m e n t ( p . 1 5 ) , t h e C h i l d H e a l t h S e r v i c e s i n c l u d e d t h e f o l l o w i n g d a t a on t h e o p e r a t i o n o f t h e i r s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s : Number o f c l i n i c s h e l d 13 Number a t t e n d i n g 12 3 Number o f d e f e c t s n o t e d 86 Number r e f e r r e d t o f o l l o w - u p 9 9 A l a t e r r e p o r t ( B u r n a b y , 1976) r e v e a l s t h a t o f 216 c h i l d r e n s e e n a t t h e s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s , 124 o r 57.4 p e r c e n t w e r e r e f e r r e d f o r f o l l o w - u p f o r t h e s e r e a s o n s : 44 D e n t a l H e a r i n g S p e e c h V i s i o n 12 p e r c e n t 11.6 p e r c e n t 11.1 p e r c e n t 8.8 p e r c e n t 5.1 p e r c e n t 4.6 p e r c e n t 2.3 p e r c e n t 1.8 p e r c e n t D e v e l o p m e n t a l d e l a y N u t r i t i o n M o t h e r O t h e r ( u n s p e c i f i e d ) S c h o o l s u r v e y s c o n d u c t e d i n S a s k a t c h e w a n and B r i t i s h C o l u m b i a h a v e r e v e a l e d t h a t " t h e number o f b o y s w i t h l e a r n i n g d i s a b i l i t i e s i s g r e a t e r t h a n t h e number o f g i r l s " ( S h a n n o n , 1969 , p. 5 8 ) . T h i s h i g h e r i n c i d e n c e o f l e a r n i n g d i s a b i l i t i e s i n b o y s i s r e p o r t e d i n s u r v e y s t h r o u g h o u t t h e E n g l i s h - s p e a k i n g w o r l d , a c c o r d i n g t o H a c k n e y ( 1 9 6 9 , p. 1 9 ) . R u t t e r a n d T i z a r d ( 1 9 7 0 , p. 53) s t a t e t h a t i t was n o t e d t h a t a l l c o n d i t i o n s i n v o l v i n g a m a r k e d d e l a y i n t h e d e v e l o p m e n t o f a n o r m a l f u n c t i o n ( e . g . , s p e e c h ) w e r e a s s o c i a t e d w i t h a m a l e p r e p o n d e r a n c e . The p h y s i c a l m a t u r a t i o n o f b o y s i s much s l o w e r t h a n g i r l s f r o m b e f o r e b i r t h t o a d u l t h o o d ... p e r h a p s t h r o u g h t h e s l o w d e v e l o p m e n t o f c e r t a i n p a r t s o f t h e b r a i n . The K i r s t i n e s t u d y ( 1 9 7 4 , p. 33) r e p o r t e d an e q u a l number o f b o y s and g i r l s r e f e r r e d f o r f o l l o w - u p . The b o y s h a d more s p e e c h p r o b l e m s a nd t h e g i r l s h a d more n u t r i t i o n a l n e e d s and s o c i a l a d j u s t m e n t p r o b l e m s . The d e v e l o p m e n t a l t h e o r y o f c h i l d h o o d h a s p r o v i d e d a f o u n d a t i o n f o r new m e t h o d s o f h e a l t h p r o m o t i o n a n d t h e p r e v e n t i o n and d e t e c t i o n o f d i s a b i l i t y i n t h e p r e s c h o o l Summary p o p u l a t i o n . E v e r y s c r e e n i n g p r o g r a m i s u n i q u e i n i t s o b j e c t i v e s , i n t h e s k i l l s o f t h e w o r k e r s i n v o l v e d , i n t h e p r o c e d u r e s e m p l o y e d , and i n t h e segment o f t h e p o p u l a t i o n u n d e r s t u d y . The c h i l d r e n m o s t " a t r i s k " a r e l i k e l y t o be members o f f a m i l i e s who a r e l e a s t l i k e l y t o u s e a v a i l a b l e h e a l t h r e s o u r c e s . E d u c a t i o n a l l y q u a l i f i e d n u r s e s a r e i n c r e a s i n g l y r e s p o n s i b l e f o r a b r o a d e r r o l e i n d e v e l o p m e n t a l a s s e s s m e n t s c r e e n i n g p r o g r a m s . The a c t u a l i n c i d e n c e o f h a n d i c a p p i n g c o n d i t i o n s i n c h i l d r e n i s d i f f i c u l t t o e s t i m a t e b e c a u s e o f t h e u s e o f v a g u e t e r m i n o l o g y , t h e v a r i e d s k i l l l e v e l s o f t h e e x a m i n e r s , and t h e p a u c i t y o f f o l l o w - u p s t u d i e s r e p o r t e d i n t h e l i t e r a t u r e . C h a p t e r I I I 46 METHODOLOGY T h i s c h a p t e r s e t s o u t t h e r e s e a r c h q u e s t i o n ; d e f i n i t i o n s , a s s u m p t i o n s a n d l i m i t a t i o n s o f t h e s t u d y ; a n d t h e r e s e a r c h p l a n , i n c l u d i n g d e t a i l e d d e s c r i p t i o n s o f t h e a p p r o a c h t a k e n by t h e r e s e a r c h e r , t h e s e t t i n g a n d p r o c e d u r e s o f t h e c l i n i c u n d e r s t u d y , t h e s e l e c t i o n o f t h e s t u d y p o p u l a t i o n , t h e r e s e a r c h i n s t r u m e n t s , t h e means o f d a t a c o l l e c t i o n , and t h e me t h o d o f d a t a a n a l y s i s . The R e s e a r c h Q u e s t i o n The q u e s t i o n t o be a n s w e r e d i n t h i s p a p e r i s : "How d o e s a n e w l y e s t a b l i s h e d s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s f u n c t i o n a n d w h a t r e s u l t s d o e s i t p r o d u c e ? " T h i s q u e s t i o n w i l l be a n s w e r e d i n t e r m s o f t h e mode o f o p e r a t i o n o f t h e c l i n i c , t h e p e r s o n n e l and p r o c e d u r e s e m p l o y e d , t h e c h a r a c t e r i s t i c s o f t h e c h i l d r e n a n d t h e i r p a r e n t s who a t t e n d t h e c l i n i c , t h e number a n d t y p e s o f r e f e r r a b l e p r o b l e m s o b s e r v e d b y t h e c l i n i c s t a f f , t h e d i s t r i b u t i o n o f r e f e r r a l s , t h e d e g r e e o f c o m p l i a n c e w i t h r e f e r r a l s , a n d t h e s u b j e c t i v e r e s p o n s e s o f t h e c h i l d r e n and t h e i r p a r e n t s t o t h e c l i n i c e x p e r i e n c e . 47 D e f i n i t i o n s The f o l l o w i n g t e r m s a r e d e f i n e d f o r t h e p u r p o s e s o f t h i s s t u d y : S c r e e n i n g means t h e u s e o f r e l a t i v e l y s i m p l e and e c o n o m i c a l p r o c e d u r e s t o d e t e c t e x i s t i n g o r p o t e n t i a l d i s o r d e r i n a p p a r e n t l y w e l l p e r s o n s . S c r e e n i n g c l i n i c means a f a c i l i t y e s t a b l i s h e d i n a B r i t i s h C o l u m b i a s u b u r b w h e r e p a r e n t s may b r i n g t h e i r c h i l d r e n , b y a p p o i n t m e n t , f o r d e v e l o p m e n t a l , s e n s o r y a nd d e n t a l s c r e e n i n g . C h i l d d e v e l o p m e n t means t h e o r d e r l y p r o g r e s s i o n o f a c h i l d t h r o u g h t h e s t a g e s o f d e v e l o p m e n t d e l i n e a t e d b y d e v e l o p m e n t a l t h e o r i s t s . D e v e l o p m e n t a l a s s e s s m e n t means t h e a p p r a i s a l by t r a i n e d p r o f e s s i o n a l s o f t h e n o r m a l i t y o r o t h e r w i s e o f t h e c h i l d ' s d e v e l o p m e n t a l p r o g r e s s . P r o b l e m means any c o n d i t i o n w h i c h may a c t u a l l y o r p o t e n t i a l l y impede a c h i l d ' s p h y s i c a l , c o g n i t i v e o r s o c i a l d e v e l o p m e n t . A p r o b l e m may be a h a n d i c a p , d e v e l o p m e n t a l d e l a y , p h y s i c a l o r s e n s o r y i m p a i r m e n t , p h y s i c a l o r i n t e l - l e c t u a l d e f e c t , d i s e a s e , d i s o r d e r , d i s a b i l i t y , d y s f u n c t i o n , o r o t h e r a b n o r m a l i t y . Community means t h e g e o g r a p h i c a r e a , s e r v e d by t h e h e a l t h d e p a r t m e n t t h a t s p o n s o r s t h i s s c r e e n i n g c l i n i c , o r t h e p o p u l a t i o n o f t h a t a r e a . 48 C ommunity h e a l t h n u r s e means a n u r s e who h a s h a d u n i v e r s i t y o r p o s t - b a s i c t r a i n i n g i n n u r s i n g i n t h e c o m m u n i t y , and who i s e m p l o y e d by t h e a g e n c y s p o n s o r i n g t h i s c l i n i c . S t u d y p o p u l a t i o n means t h e p a r e n t s a n d c h i l d r e n who a t t e n d e d t h e s c r e e n i n g c l i n i c d u r i n g i t s f i r s t t h r e e m o n t h s o f o p e r a t i o n . P a r e n t means t h e m o t h e r , f a t h e r , g r a n d p a r e n t , g u a r d i a n o r o t h e r a d u l t r e s p o n s i b l e f o r a c h i l d a t t e n d i n g t h e c l i n i c . C o m p l i a n c e means t h e v o l u n t a r y a c c e p t a n c e by t h e p a r e n t o f a r e f e r r a l by t h e c l i n i c s t a f f t o a n o t h e r h e a l t h r e s o u r c e , and a c t i o n t o i m p l e m e n t t h a t r e f e r r a l . H e a l t h r e s o u r c e means any h e a l t h p r o f e s s i o n a l o r h e a l t h o r s o c i a l a g e n c y t o w h i c h a p a r e n t may be r e f e r r e d f o r d e f i n i t i v e d i a g n o s i s o f a c h i l d ' s p r o b l e m a n d / o r f o r t h e r a p e u t i c i n t e r v e n t i o n . I n t e r v e n t i o n means any a c t i o n d e s i g n e d t o a m e l i o r a t e , a l l e v i a t e o r remedy a p r o b l e m . B r e a s t - f e d i n f a n t i s an i n f a n t whose p r i m a r y s o u r c e o f n o u r i s h m e n t u n t i l t h e age o f t h r e e m onths i s b r e a s t m i l k . B o t t l e - f e d i n f a n t i s an i n f a n t who i s f e d a t t h e b r e a s t f o r l e s s t h a n t h r e e m o n t h s a f t e r b i r t h o r whose p r i m a r y s o u r c e o f n o u r i s h m e n t d u r i n g t h a t p e r i o d i s a b o t t l e d f o r m u l a . A s s u m p t i o n I t was assumed t h a t t h e f i n d i n g s o f t h e s i x c o m m u n i t y h e a l t h n u r s e s a n d t h e two s p e e c h t h e r a p i s t s who t o o k p a r t i n t h e c l i n i c s e s s i o n s u n d e r s t u d y , and whose s k i l l l e v e l s w e r e n o t e v a l u a t e d , w e r e a t a u n i f o r m s t a n d a r d . L i m i t a t i o n s o f t h e S t u d y T h i s s t u d y i s l i m i t e d b y t h e f o l l o w i n g f a c t o r s : 1. The s t u d y p o p u l a t i o n c o n s i s t s o f a s e l f - s e l e c t e d g r o u p o f p a r e n t s a n d c h i l d r e n e n g a g i n g v o l u n t a r i l y i n p r e v e n t i v e h e a l t h b e h a v i o r . 2. The s t u d y was r e s t r i c t e d t o a t i m e f r a m e o f t h r e e months w h i c h was t h e i n i t i a l p e r i o d o f o p e r a t i o n o f t h e c l i n i c . 3. The a s s e s s m e n t p r o c e d u r e s a nd t h e i r s p e c i f i c a p p l i c a t i o n s i n t h e c l i n i c may be u n i q u e . 4. No e v a l u a t i o n h a s b e e n a t t e m p t e d o f e i t h e r t h e a s s e s s m e n t p r o c e d u r e s o r o f t h e s k i l l s o f t h e c l i n i c p e r s o n n e l . 5. F o r two p a r e n t s i t was i m p o s s i b l e t o a r r a n g e a home v i s i t b e f o r e t h e c l i n i c a p p o i n t m e n t d a t e , s o q u e s t i o n n a i r e h o . 1 was l e f t i n t h e i r m a i l b o x e s a nd c o m p l e t e d b y them w i t h o u t p e r s o n a l e x p l i c a t i o n b y t h e r e s e a r c h e r . 6. D a t a on d e n t a l h e a l t h w e r e c o m p i l e d s e p a r a t e l y b y t h e d e n t a l h y g i e n i s t a n d s h e d i d n o t a t t e n d t h e f i r s t c l i n i c s e s s i o n . 50 The R e s e a r c h P l a n The r e s e a r c h p l a n w i l l be d e s c r i b e d i n t e r m s o f t h e a p p r o a c h , t h e s e t t i n g f o r t h e c l i n i c , t h e p e r s o n n e l and p r o c e d u r e s e m p l o y e d a t t h e c l i n i c w i t h p h o t o g r a p h i c i l l u s t r a t i o n s , t h e s e l e c t i o n o f t h e s t u d y p o p u l a t i o n , t h e r e s e a r c h i n s t r u m e n t s , and d a t a c o l l e c t i o n and d a t a a n a l y s i s . The A p p r o a c h . A l l p a r e n t s a t t e n d i n g t h e s e s s i o n s o f t h e s c r e e n i n g c l i n i c u n d e r s t u d y w e r e a s k e d t o c o m p l e t e a q u e s t i o n n a i r e b e f o r e t h e i r v i s i t s t o t h e c l i n i c , a n d t o p a r t i c i p a t e i n a t e l e p h o n e i n t e r v i e w some t i m e a f t e r w a r d s . The i n f o r m a t i o n a c q u i r e d i n t h i s way was a ugmented by t h e f i n d i n g s o f t h e s c r e e n i n g p e r s o n n e l and by o t h e r d a t a a v a i l a b l e f r o m t h e s p o n s o r i n g a g e n c y . The d a t a w e r e e n t e r e d i n t o a c o m p u t e r a n d s u b m i t t e d t o s t a t i s t i c a l a n a l y s i s . The S e t t i n g . The s c r e e n i n g c l i n i c d e s c r i b e d i n t h i s s t u d y was e s t a b l i s h e d by a h e a l t h d e p a r t m e n t i n a s u b u r b a n l o c a t i o n i n B r i t i s h C o l u m b i a i n J a n u a r y , 1976. The c l i n i c i s c e n t r a l l y l o c a t e d i n a r e n t e d c h u r c h h a l l , b u t r e m o v e d f r o m m a j o r b u s r o u t e s . The c l i n i c o r i g i n a l l y s c h e d u l e d s c r e e n i n g a p p o i n t m e n t s f o r t e n c h i l d r e n on t h e t h i r d F r i d a y m o r n i n g o f e a c h m o n t h , b u t t h e o v e r w h e l m i n g r e s p o n s e t o t h e i n i t i a l a n n o u n c e m e n t o f t h e p r o g r a m n e c e s s i t a t e d s c h e d u l i n g a s e c o n d c l i n i c on t h e f i r s t F r i d a y o f e a c h m o n t h . F r i d a y m o r n i n g was c h o s e n f o r t h e c l i n i c s b e c a u s e t h e a c c o m m o d a t i o n 51 was a v a i l a b l e and s t a f f could be freed from other commitments on t h a t day. The Personnel. Each c l i n i c i s s t a f f e d by three community h e a l t h nurses who are t r a i n e d to administer the Denver Developmental Screening Test (DDST), to use v i s i o n assessment t o o l s , and to counsel parents on n u t r i t i o n . Each parent r e c e i v e s pamphlets on v a r i o u s aspects of h e a l t h maintenance from.the charge nurse. A speech t h e r a p i s t assesses c h i l d r e n i n speech and language development and f o r p o s s i b l e hearing impairment. She suggests to parents ways of promoting speech and language s k i l l s . A d e n t a l h y g i e n i s t screens c h i l d r e n f o r d e n t a l defects and teaches parents and c h i l d r e n r o u t i n e s f o r maintaining optimal o r a l hygiene. The Procedures. One nurse administers the p e r s o n a l / s o c i a l , fine-motor/adaptive, and gross-motor segments at the c h i l d ' s age l e v e l of the DDST (Appendix F, p.130 ). In the p e r s o n a l / s o c i a l segment, the parent i s asked i f the c h i l d can independently perform c e r t a i n t a s k s : washing and d r y i n g hands, p u t t i n g on c l o t h i n g , h e l p i n g i n household r o u t i n e s . The c h i l d i s asked to button up a sweater or coat, and his/ h e r independence i s f u r t h e r t e s t e d by a b r i e f separation from the parent. The fine-motor/adaptive segment i n v o l v e s p e n c i l - a n d - paper ta s k s : i m i t a t i n g the drawing of a v e r t i c a l l i n e , copying a c i r c l e , a c r o s s , and a square, and drawing a person. The c h i l d i s asked to p i c k the longer of two l i n e s (Appendix F, p.130) i n three t r i a l s . B u i l d i n g a tower of e i g h t , one-inch wooden cubes, and i m i t a t i n g the b u i l d i n g of a bridge w i t h three of these cubes completes t h i s segment f o r the c h i l d . The parent i s asked i f the c h i l d can pedal a t r i c y c l e to begin the gross-motor segment. Then the c h i l d i s asked to broad-jump over the t e s t form (Plate 1, p. 53). The c h i l d i s timed from f i v e to ten seconds while balancing on one f o o t , and then i s asked to hop on one f o o t . A heel-to-toe walk along a s t r a i g h t l i n e f o l l o w s , and the segment concludes w i t h the c h i l d attempting to catch a bounced tennis b a l l . The second nurse performs a v i s i o n assessment on each c h i l d . This i n c l u d e s t e s t s f o r c o l o r - b l i n d n e s s , depth percept i o n , v i s u a l a c u i t y , muscle r o t a t i o n , the cover t e s t , and e l i c i t i n g a b r i e f h i s t o r y of f a m i l y eye problems from the parent because of the f a m i l i a l . n a t u r e of strabismus. The Colour V i s i o n Test P l a t e s f o r the I n f a n t s (Matsubara, 195 7) are used to t e s t f o r c o l o r - b l i n d n e s s . * These p l a t e s d i s p l a y animal f i g u r e s which most c h i l d r e n can q u i c k l y i d e n t i f y . Depth perception i s t e s t e d using the Titmus Stereo Test (Plate 2, p. 54). The c h i l d wears *This t e s t was l a t e r d i scontinued as i n v a l i d . P l a t e 1. From the Gross-motor Segment of the Denver Developmental Screening T e s t 54 P l a t e 2. T e s t i n g D e p t h P e r c e p t i o n u s i n g t h e T i t m u s S t e r e o T e s t 55 p o l a r o i d glasses and i s asked to "pinch the t i p of the wing" of the house f l y , and i s asked "which of the animals i s coming out to meet you?" i n the animal p l a t e s . V i s u a l a c u i t y i s t e s t e d using Henry F. A l l e n ' s Preschool V i s i o n Test. P i c t u r e s of f a m i l i a r o bjects are shown to the c h i l d , and w i t h eyes a l t e r n a t e l y occluded, the c h i l d i s asked to name the o b j e c t which the examiner d i s p l a y s while backing away from the c h i l d to a distance of 20 f e e t . A comparison of the v i s u a l a c u i t y of the c h i l d ' s two eyes i s considered more important than the absolute values obtained. Muscle balance i s tes t e d by the cover/uncover t e s t , n o t i n g any movement of the uncovered eye, and by the l i g h t r e f l e x t e s t , using a f l a s h l i g h t and noting the r e f l e c t i o n i n the p u p i l s . Muscle r o t a t i o n i s assessed by t e s t i n g through the s i x c a r d i n a l f i e l d s of gaze and m i d l i n e convergence (Bates, 1974, p. 3 4 ) . The procedures are explained and an opportunity i s given f o r the parent to express any concerns about the c h i l d ' s v i s i o n . The t h i r d nurse weighs and measures the c h i l d ( P l a t e 3, p. 56) and then p l o t s these f i n d i n g s on the anthropometric chart (Appendix G, p. 1 3 2 ) . D i s c u s s i o n of the c h i l d ' s n u t r i t i o n a l status i s based on these measurements and the answers to questions on a d i e t form (Appendix H, p.134) which was p r e v i o u s l y mailed to and completed by the parent. This form was devised by the c l i n i c s t a f f s p e c i f i c a l l y f o r the 3-year-old c l i n i c . IT 56 P l a t e 3 . N u r s e O b t a i n i n g H e i g h t and W e i g h t M e a s u r e m e n t s 57 The s p e e c h t h e r a p i s t c o m p l e t e s t h e l a n g u a g e segment o f t h e DDST. She a s k s t h e c h i l d i t s f i r s t and l a s t names and t e s t s f o r t h e c h i l d ' s c o m p r e h e n s i o n o f " c o l d " , " t i r e d " , a n d " h u n g r y " . By p l a c i n g b l o c k s , t h e c h i l d d e m o n s t r a t e s i t s c o m p r e h e n s i o n o f t h e m e a n i n g s o f t h e p r e p o s i t i o n s " o n " , " u n d e r " , " i n f r o n t " , a n d " b e h i n d " . C o l o r r e c o g n i t i o n i s t e s t e d by a s k i n g t h e c h i l d t o make c h o i c e s f r o m a b r i g h t a s s o r t m e n t o f r e d , b l u e , y e l l o w , g r e e n , and o r a n g e b l o c k s , and t h e t h e r a p i s t a t t e m p t s t o e l i c i t t h e antonyms o f " h o t " , "woman", and " b i g " b y a s k i n g t h e c h i l d t o c o m p l e t e s h o r t s e n t e n c e s . The c h i l d i s a s k e d t o d e f i n e a " b a l l " , " l a k e " , " d e s k " , " h o u s e " , " b a n a n a " , " c u r t a i n " , " c e i l i n g " , " h e d g e " , and "pavement", a n d t h e c o m p o s i t i o n o f a s p o o n , a s h o e , a n d a d o o r . The u s e o f p l u r a l s i s n o t e d . U s i n g p i c t u r e t e s t c a r d s ( P l a t e 4, p. 5 8 ) , t h e s p e e c h t h e r a p i s t n e x t e v a l u a t e s t h e c h i l d ' s c o n s o n a n t a nd v o w e l s o u n d s a n d d e t e r m i n e s a t o t a l s o u n d s c o r e on t h e A r i z o n a A r t i c u l a t i o n P r o f i c i e n c y S c a l e ( F u d a l a , 1 9 7 2 ) . The AAPS t o t a l s c o r e s a r e a v e r a g e d f o r c h i l d r e n a g e d 3 t o 11 y e a r s . The t e s t i s i n t e r p r e t e d t o t h e p a r e n t . To a s s e s s t h e c h i l d ' s h e a r i n g , t h e t h e r a p i s t a s k s t h e p a r e n t a s e r i e s o f q u e s t i o n s f r o m a f o r m d e s i g n e d s p e c i f i c a l l y f o r t h e s c r e e n i n g c l i n i c ( A p p e n d i x I , p . 1 3 5 ) . The q u e s t i o n s r e l a t e t o t h e c h i l d ' s r e s p o n s e b e h a v i o r a t home, l i s t e n i n g h a b i t s , a n d a n y h i s t o r y o f e a r i n f e c t i o n s . The d e n t a l h y g i e n i s t e x a m i n e s t h e c h i l d ' s t e e t h P l a t e 4. S p e e c h T h e r a p i s t E v a l u a t i n g C o n s o n a n t and V o w e l Sounds 59 and mouth f o r a n y p r o b l e m s o f o c c l u s i o n , b i t e , t h e t o n g u e , and c a r i e s ( P l a t e 5, p. 6 0 ) . She d e s c r i b e s : t o t h e p a r e n t w h a t t o o t h d e c a y i s , and d e m o n s t r a t e s on a d e n t u r e m o d e l how c a r i e s c a n be p r e v e n t e d by g ood b r u s h i n g h a b i t s . She d i s c u s s e s t h e e f f e c t s o f thumb s u c k i n g , b l a n k e t s u c k i n g , and t o n g u e t h r u s t i n g on t h e t e e t h . The h y g i e n i s t a d v i s e s on t h e a d m i n i s t r a t i o n o f f l u o r i d e d r o p s a n d s u g g e s t s f l u o r i d e p a i n t i n g o f t h e c h i l d ' s t e e t h , s i n c e t h e a r e a ' s w a t e r s u p p l y i s n o t f l u o r i d a t e d . She c o n c l u d e s h e r i n t e r v i e w w i t h a d i s c u s s i o n o f t h e i m p o r t a n c e o f g o o d d i e t a r y h a b i t s t o d e n t a l h e a l t h and s u g g e s t s n u t r i t i o n a l s n a c k s f o r home and p l a y s c h o o l t h a t w i l l n o t be d a m a g i n g t o t o o t h e n a m e l . A p a c k a g e o f l i t e r a t u r e g i v e n t o t h e p a r e n t i n c l u d e s Up t h e Y e a r s f r o m One t o S i x and C a n a d a ' s F o o d G u i d e f r o m H e a l t h and W e l f a r e C a n a d a , a s s o r t e d p a m p h l e t s on n u t r i t i o n and c h i l d h e a l t h p u b l i s h e d by p r i v a t e c o m p a n i e s a s p r o m o t i o n - a l m a t e r i a l , and s n a c k s u g g e s t i o n s and r e c i p e s h e e t s f r o m t h e s p o n s o r i n g h e a l t h d e p a r t m e n t . No p s y c h o l o g i c a l t e s t s a r e e m p l o y e d , b u t t h e n u r s e s o b s e r v e t h e p a r e n t - c h i l d i n t e r a c t i o n s and t h e c h i l d ' s a d j u s t m e n t t o t h e t e s t i n g p r o c e d u r e s . The c h i l d r e n a r e a l s o o b s e r v e d a t a t o y t a b l e ( P l a t e 6, p. 6 1 ) . w h e r e t h e y may p l a y i f t i m e p e r m i t s b e t w e e n v i s i t s t o t e s t i n g s t a t i o n s . S i b l i n g s a r e d i s c o u r a g e d f r o m a t t e n d i n g t h e s c r e e n i n g c l i n i c , b u t i f t h e y a r r i v e w i t h a b r o t h e r o r s i s t e r , t h e i r a t t e n t i o n 60 P l a t e 5 . D e n t a l H y g i e n i s t E x a m i n i n g t h e M o u t h 61 P l a t e 6. A t t h e Toy T a b l e can be d i v e r t e d to the toy t a b l e . F i v e c l i n i c appointments are scheduled at 9:00 a.m. and f i v e at 10:30 a.m., each c h i l d being a l l o t t e d 15 minutes at each of the f i v e screening s t a t i o n s . I f a problem i s observed i n the c h i l d , or a r e - t e s t i s i n d i c a t e d , the parent i s t o l d she w i l l be contacted by the community h e a l t h nurse i n her area. The S e l e c t i o n of the Study Po p u l a t i o n . A f t e r the establishment of the c l i n i c was announced, parents phoned the h e a l t h department to place t h e i r names on a w a i t i n g l i s t f o r appointments. When phoned back by the a s s i s t a n t supervisor to be given an appointment time, the parents were asked i f they were w i l l i n g to p a r t i c i p a t e i n a study to be undertaken by a nursing student. The supervisor made i t c l e a r that u n w i l l i n g n e s s to p a r t i c i p a t e would not p r e j u d i c e the parents' r i g h t to attend the c l i n i c . Parents who agreed to p a r t i c i p a t e were t o l d that the student would contact them to arrange an i n t e r v i e w i n t h e i r home. This procedure was c a r r i e d out f o r the f i r s t f i v e c l i n i c s essions. A l l parents scheduled to attend these sessions agreed to cooperate i n the study.* Three c l i n i c appointments were broken because of i l l n e s s of the c h i l d r e n ; these c h i l d r e n and t h e i r parents were e l i m i n a t e d from the study. The t o t a l study p o p u l a t i o n , t h e r e f o r e , numbers 4 7 c h i l d r e n and 4 7 parents. *A11 c h i l d r e n attending the screening sessions were accompanied by t h e i r mothers. 63 The Research Instruments. Questionnaire no. 1 (Appendix A, p. 119) was designed by the researcher to e l i c i t i n f o r m a t i o n on the c h i l d ' s previous use of h e a l t h resources, p a r e n t a l concerns about p o s s i b l e problems, the parent's p r e f e r r e d sources of guidance on p h y s i c a l and b e h a v i o r a l problems, the age of the mother and education of both parents, and how the parent learned about and got to the c l i n i c . This questionnaire^was pre- t e s t e d on a group of ten parents who attended a s i m i l a r screening c l i n i c i n another urban l o c a l i t y . As a r e s u l t of the p r e - t e s t , the format of the o r i g i n a l q u estionnaire was a l t e r e d and one question was e l i m i n a t e d as i r r e l e v a n t . Explanatory notes were added to reduce the need f o r explanation by the i n t e r v i e w e r . Supplementary inform a t i o n was drawn from the standard h e a l t h department c l i e n t record form (Appendix B, p.12 3), which had been completed before the c l i n i c appointment. Permission to inc o r p o r a t e t h i s a d d i t i o n a l i n f o r m a t i o n i n t o the study had been obtained from h e a l t h department a d m i n i s t r a t o r s . This supplementary inform a t i o n was entered on the data summary form (Appendix C, p. 125), a l s o devised by the researcher. A c l i n i c r e s u l t s form (Appendix D, p. 126) was designed by the researcher to enable c l i n i c personnel to record the number and types of problems detected, whether or not these problems had been p r e v i o u s l y known, and the h e a l t h resources to which r e f e r r a l s were made. 64 Questionnaire no. 2 (Appendix E, p. 12 7) was devised by the researcher as an o u t l i n e f o r a follow-up i n t e r v i e w w i t h each parent. Because of the s u b j e c t i v e nature of t h i s q u e s t i o n n a i r e , i t was n e i t h e r p r e - t e s t e d nor modified. To preserve c o n f i d e n t i a l i t y , a code number was used to i d e n t i f y each f a m i l y on both q u e s t i o n n a i r e s , the data summary form and the c l i n i c r e s u l t s form. Data C o l l e c t i o n . The researcher v i s i t e d the home of each of the p a r t i c i p a t i n g parents to complete que s t i o n n a i r e no. 1 and to answer any questions they might have about t h e i r forthcoming c l i n i c v i s i t . During t h i s inverview each parent was asked f o r permission to use a d d i t i o n a l i n f o r m a t i o n p r e v i o u s l y recorded by the h e a l t h department. In a l l cases permission was granted. The researcher then l a t e r completed the data summary form. A c l i n i c s t a f f conference was held immediately a f t e r each c l i n i c to share t e s t r e s u l t s and observations on each c h i l d , to decide appropriate r e f e r r a l s , i f any, and to i n i t i a t e r e f e r r a l procedures. The c l i n i c r e s u l t s form was completed at t h i s conference. Approximately one month a f t e r e a c h . c l i n i c s e s s i o n , the researcher conducted a telephone follow-up i n t e r v i e w with each of the p a r t i c i p a t i n g parents. The purpose of t h i s i n t e r v i e w was to obta i n information on compliance w i t h r e f e r r a l s and to e l i c i t the parents' and c h i l d r e n ' s s u b j e c t i v e r e a c t i o n s to the c l i n i c experience. 65 The c o d e numbers f o r e a c h f a m i l y u s e d on t h e f o u r f o r m s e n a b l e d t h e r e s e a r c h e r a n d t h e c l i n i c s t a f f t o m a i n t a i n a c c u r a t e r e c o r d s on a l l p a r t i c i p a n t s w h i l e p r e s e r v i n g t h e c o n f i d e n t i a l i t y o f t h e i n f o r m a t i o n r e c o r d e d . A l l p a r t i c i p a n t s w e r e i n f o r m e d t h a t a summary o f t h e f i n d i n g s w o u l d be made a v a i l a b l e t o them on r e q u e s t u p o n c o m p l e t i o n o f t h e s t u d y . D a t a A n a l y s i s . The d a t a w e re t r a n s f e r r e d t o H o l l e r i t h c a r d s a n d r e a d i n t o s t o r a g e i n t h e UBC C o m p u t i n g C e n t r e . The l i b r a r y p r o g r a m , UBC MVTAB, was u s e d t o p r o d u c e f r e q u e n c y and p e r c e n t a g e t a b l e s o f a l l v a r i a b l e s . S e l e c t e d s e t s o f v a r i a b l e s w e r e c r o s s - t a b u l a t e d a n d s u b j e c t e d t o C h i - s q u a r e t e s t s f o r i n d e p e n d e n c e . Summary C e r t a i n t e r m s a r e u n i q u e l y d e f i n e d f o r t h i s s t u d y , one a s s u m p t i o n i s made, a n d t h e s t u d y l i m i t a t i o n s a r e l i s t e d f o l l o w i n g t h e r e s e a r c h q u e s t i o n . A d e s c r i p t i o n i s p r o v i d e d o f t h e s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s u n d e r s t u d y . D e t a i l s o f t h e s e t t i n g , t h e p e r s o n n e l i n v o l v e d , a n d t h e p r o c e d u r e s e m p l o y e d a r e i l l u s t r a t e d w i t h p h o t o g r a p h i c p l a t e s . The method t o s e l e c t t h e s t u d y p o p u l a t i o n , t o u s e t h e r e s e a r c h i n s t r u m e n t s , a n d t o f a c i l i t a t e d a t a c o l l e c t i o n and d a t a a n a l y s i s i s d i s c u s s e d . 66 C h a p t e r I V ANALYSIS OF THE DATA The d a t a c o l l e c t e d f r o m t h e d a t a summary f o r m , q u e s t i o n n a i r e no. 1, t h e c l i n i c r e s u l t s f o r m , and q u e s t i o n n a i r e no. 2 w e re a m a l g a m a t e d a n d , w h e r e a p p r o p r i a t e , a r r a n g e d i n f r e q u e n c y t a b l e s and d e s c r i b e d i n p e r c e n t a g e s . S e l e c t e d s e t s o f v a r i a b l e s w e r e c r o s s - t a b u l a t e d f o r p o s s i b l e r e l a t i o n s h i p s . The c h i l d r e n i n t h e s t u d y p o p u l a t i o n a r e c h a r a c t e r i z e d i n t e r m s o f s e x , b i r t h p l a c e , b i r t h r a n k , number i n f a m i l y , a g e , b i r t h w e i g h t , a n d i m m u n i z a t i o n s t a t u s . The p a r e n t s o f t h e c h i l d r e n a r e d e s c r i b e d i n t e r m s o f t h e m o t h e r ' s i n f a n t f e e d i n g p r a c t i c e , m o t h e r ' s a g e , m o t h e r ' s o c c u p a t i o n a n d f a t h e r ' s o c c u p a t i o n , t h e e d u c a t i o n a l a t t a i n m e n t s o f m o t h e r s and f a t h e r s , and t h e i r s o c i o e c o n o m i c s t a t u s . The p a r e n t s ' r e s p o n s e s t o q u e s t i o n s a b o u t p r e v i o u s u s e o f h e a l t h r e s o u r c e s and t h e i r c u r r e n t c o n c e r n s a b o u t h e a l t h o r b e h a v i o r a l p r o b l e m s o f t h e i r c h i l d r e n a r e o u t l i n e d . T h e i r p r e f e r r e d s o u r c e s o f h e l p f o r t h e s e c o n c e r n s a r e i d e n t i f i e d . The f i n d i n g s o f t h e c l i n i c s c r e e n i n g team a r e s u m m a r i z e d i n t e r m s o f t h e numbers and t y p e s o f p r o b l e m s o b s e r v e d and t h e d i s t r i b u t i o n o f r e f e r r a l s t o o t h e r h e a l t h p r o f e s s i o n a l s . The s u b j e c t i v e r e s p o n s e s o f t h e c h i l d r e n and t h e i r p a r e n t s t o t h e c l i n i c e x p e r i e n c e a r e r e p o r t e d , as a r e t h e p a r e n t s ' c o m p l i a n c e o r n o n - c o m p l i a n c e w i t h t h e c l i n i c t eam's r e f e r r a l s a n d t h e i n i t i a t i o n o f i n t e r v e n t i o n w h e r e n e c e s s a r y . A l s o o u t l i n e d a r e t h e p a r e n t s ' r e s p o n s e s t o p u b l i c i t y a b o u t t h e c l i n i c , t h e i r means o f t r a n s p o r t a t i o n t o t h e c l i n i c , and t h e i r e v a l u a t i o n o f t h e u s e f u l n e s s o f t h e s c r e e n i n g p r o g r a m . C h a r a c t e r i s t i c s o f t h e C h i l d r e n i n t h e S t u d y P o p u l a t i o n I n f o r m a t i o n f r o m t h e d a t a summary f o r m ( A p p e n d i x C, p.125) r e v e a l e d i n f o r m a t i o n a b o u t t h e 47 c h i l d r e n i n t h e s t u d y . T w e n t y - f i v e o f t h e c h i l d r e n a r e g i r l s , 22 a r e b o y s . The G r e a t e r V a n c o u v e r r e g i o n was t h e b i r t h p l a c e f o r 35 o f t h e c h i l d r e n , 4 w ere b o r n i n o t h e r r e g i o n s o f C a n a d a , and 8 c h i l d r e n w e r e b o r n a b r o a d (5 i n t h e U n i t e d K i n g d o m and 3 i n E a s t A f r i c a ) . F i f t e e n o f t h e c h i l d r e n i n t h e s t u d y p o p u l a t i o n w e r e f i r s t - b o r n , 22 w e r e t h e s e c o n d c h i l d r e n i n t h e i r f a m i l i e s , 9 w e re t h i r d c h i l d r e n , a n d 1 p a r t i c i p a n t was t h e f o u r t h c h i l d . Two o f t h e 47 c h i l d r e n w e r e " o n l y " c h i l d r e n , 31 c h i l d r e n h a d 1 b r o t h e r o r s i s t e r , 13 c h i l d r e n h a d 2 b r o t h e r s o r s i s t e r s , and 1 c h i l d h a d 3 s i b l i n g s . T h e s e c h a r a c t e r i s t i c s a r e s u m m a r i z e d i n T a b l e I ( p . 6 8 ) . A l l o f t h e c h i l d r e n w e r e b e t w e e n 4 4 and 4 8 months o l d a t t h e t i m e o f t h e s t u d y . T w e n t y - e i g h t , o r 6 0 p e r c e n t , o f t h e c h i l d r e n w e r e w i t h i n two months o f t h e i r 4 t h b i r t h d a y . 68 T a b l e I C h i l d r e n ' s B i r t h Rank and Number o f C h i l d r e n i n t h e F a m i l i e s i n t h e S t u d y P o p u l a t i o n B i r t h Rank Number o f C h i l d r e n o f C h i l d i n F a m i l y T o t a l s P e r c e n t a g e i n S t u d y 1 2 3 4 1 s t 2 13 15 31.9 2nd 18 4 22 46.8 3 r d 9 9 19.2 4 t h 1 1 2.1 T o t a l s 2 31 13 1 47 P e r c e n t a g e 4.2 66.0 27.7 2.1 100.0 69 A l l o f t h e c h i l d r e n w e i g h e d b e t w e e n 2.5 and 3.9 k i l o g r a m s a t b i r t h , w i t h i n t h e n o r m a l r a n g e . T h i r t y - s e v e n , o r 79 p e r c e n t , w e i g h e d i n t h e r a n g e b e t w e e n 3.0 and 3.9 k i l o g r a m s . F o r t y - two o f t h e c h i l d r e n h a d r e c e i v e d t h e c o r r e c t d o s a g e s o f a l l t h e i m m u n i z i n g a g e n t s recommended by t h e p r o v i n c i a l h e a l t h d e p a r t m e n t f o r c h i l d r e n o f t h e i r a g e . O n l y 5 o f t h e c h i l d r e n w e r e d e f i c i e n t i n i m m u n i z a t i o n . C h a r a c t e r i s t i c s o f t h e P a r e n t s i n t h e S t u d y P o p u l a t i o n I n i n f a n t f e e d i n g p r a c t i c e , 17 o f t h e m o t h e r s i n t h e s t u d y had b r e a s t - f e d t h e i r i n f a n t a n d 30 h a d f e d t h e i r i n f a n t a b o t t l e d f o r m u l a . A l l o f t h e m o t h e r s w e r e b e t w e e n 25 and 40 y e a r s o l d , 23 o f t h em, o r 39 p e r c e n t , b e i n g 30 t o 34 y e a r s o l d . T h i r t y - s i x o f t h e m o t h e r s d e s c r i b e d t h e m s e l v e s a s h o u s e w i v e s ( i . e . , f u l l - t i m e h o m e m a k e r s ) , 9 h e l d s t e a d y p a r t - t i m e j o b s i n t h e c o m m u n i t y , and 2 had f u l l - t i m e p o s i t i o n s . A l l o f t h e 47 f a t h e r s o f t h e c h i l d r e n i n t h e s t u d y p o p u l a t i o n w e r e e m p l o y e d f u l l - t i m e . E l e v e n , o r 2 3 p e r c e n t , o f t h e f a t h e r s ' o c c u p a t i o n s w e r e i n C a t e g o r y 1 o f H o l l i n g s h e a d ' s o c c u p a t i o n a l s c a l e ( H o l l i n g s h e a d , 1 9 5 7 , p. 3 ) . T h i s c a t e g o r y i n c l u d e s u n i v e r s i t y p r o f e s s o r s , m e d i c a l d o c t o r s , and t o p b u s i n e s s e x e c u t i v e s . A n o t h e r 11 f a t h e r s w e r e i n C a t e g o r y 2 p o s i t i o n s : b a n k m a n a g e r s and l a r g e b u s i n e s s e m p l o y e r s . Ten f a t h e r s , o r 21 p e r c e n t , w e r e i n C a t e g o r y 3: a d m i n i s t r a t o r s and o w n e r s o f s m a l l e r b u s i n e s s c o n c e r n s . A n o t h e r 10 f a t h e r s w e r e i n C a t e g o r y 4: s a l e s m e n , t e c h n i c i a n s , a n d s e l f - e m p l o y e d 70 t r a d e s m e n o r s m a l l s t o r e o w n e r s . T h r e e f a t h e r s , o r 6 p e r c e n t , w e r e s k i l l e d m a n u a l w o r k e r s ( C a t e g o r y 5) and 2 f a t h e r s , o r 4 p e r c e n t , w e r e s e m i - s k i l l e d e m p l o y e e s ( C a t e g o r y 6 ) . None o f t h e 94 p a r e n t s i n t h e s t u d y p o p u l a t i o n h a d l e s s t h a n a . G r a d e 9 e d u c a t i o n . T h i r t e e n o f t h e f a t h e r s and 1 m o t h e r h a d a u n i v e r s i t y d e g r e e ; 11 f a t h e r s and 14 m o t h e r s h a d c o m p l e t e d some u n i v e r s i t y c o u r s e s b u t h a d n o t o b t a i n e d a d e g r e e ; 9 f a t h e r s a n d 8 m o t h e r s h ad c o m p l e t e d t e c h n i c a l o r v o c a t i o n a l p r o g r a m s ; 2 f a t h e r s a n d 3 m o t h e r s h ad c o m p l e t e d a b u s i n e s s s c h o o l p r o g r a m ; 10 f a t h e r s a n d 16 m o t h e r s h a d c o m p l e t e d G r a d e 12 o r i t s e q u i v a l e n t b u t h a d . n o t h a d p o s t - s e c o n d a r y e d u c a t i o n ; and 2 o f t h e f a t h e r s a n d 5 o f t h e m o t h e r s h a d e n d e d t h e i r f o r m a l e d u c a t i o n b e t w e e n G r a d e s 9 and 11. The e d u c a t i o n a l a t t a i n m e n t s o f t h e p a r e n t s a r e s u m m a r i z e d i n T a b l e I I (p. 7 1 ) . I t was d e c i d e d t o a t t e m p t t o e s t i m a t e t h e s o c i a l p o s i t i o n o f e a c h o f t h e 47 f a m i l i e s i n t h e s t u d y p o p u l a t i o n , u s i n g t h e f a t h e r ' s e d u c a t i o n a n d o c c u p a t i o n a s t h e k e y v a r i a b l e s , a c c o r d i n g t o t h e H o l l i n g s h e a d Two F a c t o r I n d e x o f S o c i a l P o s i t i o n . T h i s made i t n e c e s s a r y t o r e - c a t e g o r i z e t h e e d u c a t i o n a l l e v e l s o f t h e f a t h e r s , a s r e p o r t e d b y t h e m o t h e r s , t o c o i n c i d e w i t h t h e c a t e g o r i e s o f t h e H o l l i n g s h e a d e d u c a t i o n a l s c a l e . ( 1 9 5 7 , p. 9 ) . A s o c i a l - c l a s s s c o r e f o r e a c h f a m i l y was t h e n c o m p u t e d a c c o r d i n g t o t h e H o l l i n g s h e a d m e t h o d , and 10 o f t h e f a m i l i e s w e r e f o u n d t o be i n S o c i a l C l a s s I , 10 i n S o c i a l C l a s s I I , 71 T a b l e I I L e v e l s o f E d u c a t i o n a l A t t a i n m e n t o f P a r e n t s i n t h e S t u d y P o p u l a t i o n U n i v e r s i t y d e g r e e Some u n i v e r s i t y T e c h n i c a l / v o c a t i o n a l B u s i n e s s s c h o o l G r a d e 12 G r a d e 9 - 1 1 T o t a l s F a t h e r Number P e r c e n t a g e 13 27.7 11 23.4 9 19.1 2 4.2 10 21.3 2 4.2 47 100.0 M o t h e r Number P e r c e n t a g e 1 2.1 14 29.8 8 17.0 3 6.4 16 34.0 5 10.6 47 100.0 72 19 i n S o c i a l C l a s s I I I , 7 i n S o c i a l C l a s s I V , and 1 i n S o c i a l C l a s s V. T h e s e d a t a a r e d i s p l a y e d i n T a b l e I I I , p. 73. P r e v i o u s Use o f H e a l t h R e s o u r c e s . T w e n t y o f t h e m o t h e r s i n t h e s t u d y p o p u l a t i o n , o r 4 3 p e r c e n t , h a d a t t e n d e d c o m m u n i t y p r e n a t a l c l a s s e s w h i l e t h e y w e r e c a r r y i n g t h e c h i l d i n c l u d e d i n t h e s t u d y . F i v e h a d a t t e n d e d p r e n a t a l c l a s s e s d u r i n g a p r e v i o u s p r e g n a n c y and 22 h a d n e v e r a t t e n d e d a p r e n a t a l c l a s s . ( T h i s l a s t g r o u p i n c l u d e d 2 m o t h e r s o f a d o p t e d c h i l d r e n i n c l u d e d i n t h e s t u d y . ) The m o t h e r s w e r e a s k e d t o r e c a l l t h e i r p r e v i o u s u s e o f c o m m u n i t y h e a l t h r e s o u r c e s f o r t h e i r c h i l d r e n . F o r 38 o f t h e m o t h e r s , o r 81 p e r c e n t , t h e r e s o u r c e m o s t f r e q u e n t l y u s e d was t h e g e n e r a l p r a c t i t i o n e r . T w e n t y - f i v e o f t h e c h i l d r e n , o r 53 p e r c e n t , h a d v i s i t e d a g e n e r a l p r a c t i t i o n e r w i t h i n t h e s i x m onths p r e c e d i n g t h e a d m i n i s t r a t i o n o f t h e q u e s t i o n n a i r e . The s e c o n d - m o s t - f r e q u e n t l y - u s e d r e s o u r c e was t h e w e l l - b a b y c l i n i c , w h i c h h a d b e e n v i s i t e d b y 2 2 , o r 47 p e r c e n t , o f t h e m o t h e r s . The m o t h e r s ' r e s p o n s e s a r e shown i n d e t a i l i n T a b l e I V , p. 74. B e f o r e t h e c l i n i c v i s i t , 26 o f t h e c h i l d r e n , o r 55 p e r c e n t , h a d r e c e i v e d p r o f e s s i o n a l t r e a t m e n t f o r t o n s i l l i t i s , e a r i n f e c t i o n , o r an o r t h o p e d i c p r o b l e m . F o u r c h i l d r e n h a d b e e n t r e a t e d f o r a l l e r g i e s , 3 f o r a s t h m a , 2 f o r e c z e m a , 2 f o r a v i s i o n p r o b l e m , and 2 f o r g a s t r o r - i n t e s t i n a l 73 T a b l e I I I S o c i a l C l a s s o f t h e F a m i l i e s i n t h e S t u d y P o p u l a t i o n A c c o r d i n g t o t h e H o l l i n g s h e a d Two F a c t o r I n d e x o f S o c i a l P o s i t i o n Number o f F a m i l i e s P e r c e n t a g e C l a s s I 10 21.3 C l a s s I I 10 21.3 C l a s s I I I 19 40.4 C l a s s I V 7 14.9 C l a s s V 1 2.1 T o t a l s 47 100.0 74 T a b l e I V P a r e n t s ' P r e v i o u s Use o f Community H e a l t h R e s o u r c e s f o r t h e i r C h i l d r e n R e s o u r c e Rank- 1 - O r d e r e d F r e q u e n c y o f 2 3 4 5 Use 6 T o t a l D e n t a l c l i n i c 0 1 7 4 3 0 15 D e n t i s t 1 12 10 1 0 1 25 E m e r g e n c y w a r d 0 4 10 7 4 1 26 G e n e r a l p r a c t i t i o n e r 38 2 2 0 1 0 43 P e d i a t r i c i a n 6 1 2 5 0 1 15 W e l l - b a b y c l i n i c 2 22 6 2 1 0 33 O t h e r : O p h t h a l m o l o g i s t 0 1 0 1 0 0 2 S p e e c h t h e r a p i s t 0 0 1 0 0 0 1 U r o l o g i s t 0 1 0 0 0 0 1 T o t a l s 47 44 38 20 9 3 d i s o r d e r s . O t h e r r e p o r t e d p r o b l e m s o f p h y s i c a l h e a l t h w e r e c y s t i t i s , b r o n c h i t i s , w h o o p i n g c o u g h , and a t u m o r r e q u i r i n g s u r g i c a l e x c i s i o n . One m o t h e r h a d s o u g h t p r o f e s s i o n a l h e l p i n d e a l i n g w i t h h e r c h i l d ' s t e m p e r t a n t r u m s and 1 c h i l d h a d r e c e i v e d s p e e c h t h e r a p y . E i g h t o f t h e c h i l d r e n h ad r e c e i v e d d e n t a l t r e a t m e n t . S i x t e e n o f t h e m o t h e r s , o r 34 p e r c e n t , i n d i c a t e d t h a t t h e i r c h i l d r e n h a d n e v e r r e c e i v e d p r o f e s s i o n a l t r e a t m e n t . P a r e n t s ' P r e s e n t C o n c e r n s . T w e n t y - f i v e o f t h e m o t h e r s , o r 5 3 p e r c e n t , i n d i c a t e d t h a t t h e y h a d no c u r r e n t c o n c e r n s a b o u t t h e i r c h i l d r e n ' s d e v e l o p m e n t , e v e n t h o u g h t h e y w e r e e a g e r f o r them t o a t t e n d t h e s c r e e n i n g c l i n i c . E l e v e n m o t h e r s t h o u g h t t h e i r c h i l d m i g h t h a v e a p r o b l e m i n s p e e c h o r l a n g u a g e d e v e l o p m e n t , 7 w e r e c o n c e r n e d a b o u t b e h a v i o r , 3 w e r e c o n c e r n e d a b o u t d e n t a l h e a l t h , 2 w e re c o n c e r n e d a b o u t h e a r i n g , 2 h a d c o n c e r n s a b o u t n u t r i t i o n , and 2 w e r e c o n c e r n e d a b o u t t h e i r c h i l d ' s v i s i o n . -These numbers e x c e e d 22 b e c a u s e some m o t h e r s w e r e c o n c e r n e d a b o u t more t h a n a s i n g l e p o t e n t i a l p r o b l e m . T h e s e c o n c e r n s a r e d e t a i l e d i n T a b l e X, p. 88. P a r e n t s ' P r e f e r r e d S o u r c e s o f A d v i c e . When s e e k i n g a d v i c e a b o u t p h y s i c a l p r o b l e m s o f t h e i r c h i l d r e n , 2 9 o f t h e m o t h e r s , o r 62 p e r c e n t , t u r n e d f i r s t t o t h e i r g e n e r a l p r a c t i t i o n e r . F o r a d v i c e on b e h a v i o r a l p r o b l e m s , 21 o f t h e m o t h e r s , o r 45 p e r c e n t , p r e f e r r e d t o d i s c u s s t h e i r c o n c e r n s w i t h t h e i r s p o u s e . No m o t h e r i d e n t i f i e d t h e c o m m u n i t y h e a l t h n u r s e a s h e r f i r s t - c h o i c e a d v i s o r i n e i t h e r c a t e g o r y . T a b l e V, p. 77, d e t a i l s t h e m o t h e r s ' p r e f e r e n c e s . T h e s e p r e f e r e n c e s w e r e w e i g h t e d f o r c l a r i t y i n t h e t a b l e . F i n d i n g s o f t h e S c r e e n i n g C l i n i c The c l i n i c s t a f f a d j u d g e d 23 o f t h e c h i l d r e n i n t h e s t u d y p o p u l a t i o n t o be p r o b l e m - f r e e a n d r e f e r r e d 24 c h i l d r e n t o a p p r o p r i a t e h e a l t h p r o f e s s i o n a l s o r a g e n c i e s f o r f u r t h e r i n v e s t i g a t i o n o f a t o t a l o f 39 p r o b l e m s , o f w h i c h 11 had b e e n p r e v i o u s l y known t o t h e p a r e n t s . T h i r t e e n o f t h e r e f e r r e d c h i l d r e n e a c h had a s i n g l e p r o b l e m and 11 had two o r t h r e e p r o b l e m s e a c h . Of t h e 39 p r o b l e m s n o t e d a t t h e c l i n i c , 12 were r e l a t e d t o v i s i o n , 3 t o h e a r i n g , 6 t o s p e e c h o r l a n g u a g e d e v e l o p m e n t , 2 t o p h y s i c a l d e v e l o p m e n t , 8 t o s o c i a l a d j u s t m e n t , 3 t o n u t r i t i o n , 3 t o d e n t a l h e a l t h , a n d 2 w e r e p r o b l e m s o f p a r e n t - c h i l d r e l a t i o n s h i p s . N i n e t e e n o f t h e 2 4 c h i l d r e n w e r e r e f e r r e d t o t h e f a m i l y ' s l o c a l c o m m u n i t y h e a l t h n u r s e , 1 c h i l d was r e f e r r e d t o t h e n u r s e a n d t h e s p e e c h t h e r a p i s t , 1 c h i l d was r e f e r r e d t o t h e g e n e r a l p r a c t i t i o n e r and t h e s p e e c h t h e r a p i s t , 2 c h i l d r e n w e r e r e f e r r e d t o t h e g e n e r a l p r a c t i t i o n e r , a n d 1 c h i l d was r e f e r r e d t o t h e s p e e c h t h e r a p i s t . No r e f e r r a l s f o r i m m u n i z a t i o n w e r e made by t h e c l i n i c s t a f f . H o wever, t h e r e s e a r c h e r r e f e r r e d t h e 5 c h i l d r e n who 77 T a b l e V P a r e n t s ' P r e f e r r e d S o u r c e s o f A d v i c e ( W e i g h t e d ) * S o u r c e F o r P h y s i c a l P r o b l e m s F o r B e h a v i o r a l P r o b l e m s C h i l d - c a r e book 1.79 2.00 Community h e a l t h n u r s e .23 .43 D r u g g i s t .19 N o t a p p l i c a b l e F r i e n d o r n e i g h b o r .59 1.62 G e n e r a l p r a c t i t i o n e r 5.59 3.45 • H u s b a n d 1.19 3.59 P e d i a t r i c i a n 1.38 1.21 O t h e r r e l a t i v e .75 . 70 No one .00 .15 * The m o t h e r s w e r e a s k e d t o r a n k - o r d e r t h e i r p r e f e r r e d s o u r c e s o f a d v i c e . T h e s e c h o i c e s w e r e w e i g h t e d b y a l l o t t i n g 7 p o i n t s f o r 1 s t c h o i c e , 6 p o i n t s f o r 2nd c h o i c e , 5 p o i n t s f o r 3 r d c h o i c e , 4 p o i n t s f o r 4 t h c h o i c e , 3 p o i n t s f o r 5 t h c h o i c e , 2 p o i n t s f o r 6 t h c h o i c e , and 1 p o i n t f o r 7 t h o r 8 t h c h o i c e , a nd d i v i d i n g t h e sum f o r e a c h s o u r c e o f a d v i c e b y 47, t h e t o t a l number o f p a r t i c i p a n t s . 78 were d e f i c i e n t i n i m m u n i z a t i o n s t a t u s t o t h e i r d o c t o r s o r t o t h e n e a r e s t c h i l d h e a l t h c e n t r e . W i t h one e x c e p t i o n , a l l o f t h e s e c h i l d r e n w e r e r e c e n t a r r i v a l s t o t h e l o c a l a r e a and a l l w e r e p a r t i a l l y i m m u n i z e d . The d a t a on t h e p r o b l e m s o f t h e c h i l d r e n r e f e r r e d by t h e c l i n i c s t a f f a r e t a b u l a t e d i n T a b l e V I , p. 79. I n a d d i t i o n t o t h e 39 p r o b l e m s r e f e r r e d , t h e d e n t a l h y g i e n i s t d e t e c t e d 3 d e n t a l p r o b l e m s w h i c h w e r e n o t r e p o r t e d a s r e f e r r a l s on t h e c l i n i c r e s u l t s f o r m ( A p p e n d i x D, p . 1 2 6 ) . I t i s n o t known i f t h e s e c h i l d r e n w e r e s u b s e q u e n t l y s e e n by a d e n t i s t . A l s o , a s p r e v i o u s l y s t a t e d i n t h e s t u d y l i m i t a t i o n s , t h e d e n t a l h y g i e n i s t d i d n o t e x a m i n e 9 o f t h e c h i l d r e n i n t h e s t u d y p o p u l a t i o n . F o r t h e s e r e a s o n s , t h e f i n d i n g s o f t h e d e n t a l h y g i e n i s t f o r t h e 38 c h i l d r e n i n t h e s t u d y p o p u l a t i o n t h a t she e x a m i n e d a r e r e p o r t e d s e p a r a t e l y i n T a b l e X I V ( A p p e n d i x J , p . 1 3 6 ) . T h i r t y - o n e o f t h o s e c h i l d r e n , o r 82 p e r c e n t , w e r e c a r i e s - f r e e . R e s p o n s e s o f t h e C h i l d r e n and P a r e n t s t o t h e C l i n i c E x p e r i e n c e M o t h e r s o f 41 o f t h e 47 c h i l d r e n r e p o r t e d t h a t t h e i r c h i l d c o o p e r a t e d w e l l o r e n t h u s i a s t i c a l l y i n t h e t e s t p r o c e d u r e s . T h r e e m o t h e r s s a i d t h e i r c h i l d was c o n f u s e d , 1 c h i l d was s a i d t o be f r i g h t e n e d , a nd 2 c h i l d r e n d i d n o t c o o p e r a t e . M o t h e r s o f 2 c h i l d r e n r e p o r t e d t h a t t h e v i s i o n t e s t i n g p r o c e d u r e d i s t r e s s e d t h e c h i l d . T w e n t y - n i n e o f t h e m o t h e r s r e p o r t e d l e a r n i n g s o m e t h i n g 79 T a b l e V I F i n d i n g s o f t h e S c r e e n i n g C l i n i c P e r c e n t a g e P e r c e n t a g e o f o f R e a s o n f o r R e f e r r a l New Known T o t a l P r o b l e m s (N=39) C h i l d r e n (N=47)* V i s i o n 8 4 12 30. 8 25.6 H e a r i n g 1 2 3 7.7 6.4 S p e e c h o r l a n g u a g e 4 2 6 15.4 12. 8 P h y s i c a l o r d e v e l o p m e n t a l d e l a y 2 0 2 5.1 4.2 S o c i a l a d j u s t m e n t d e l a y 6 2 8 20.5 17.0 N u t r i t i o n 3 0 3 7.7 6.4 D e n t a l 3 0 3 •7.7 6.4 P a r e n t - c h i l d r e l a t i o n s h i p s 1 1 2 5.1 4.2 T o t a l s 28 11 39 100. 0 C h i l d r e n r e f e r r e d 24 51.1 C h i l d r e n n o t r e f e r r e d 23 48.9 T o t a l s 47 100.0 * The sum o f t h e s e p e r c e n t a g e s w o u l d be g r e a t e r t h a n t h e p e r c e n t a g e o f c h i l d r e n r e f e r r e d ( 5 1 . 1 p e r c e n t ) b e c a u s e some c h i l d r e n w e r e r e f e r r e d f o r more t h a n one p r o b l e m . 80 new a b o u t one o r more a s p e c t s o f t h e i r c h i l d ' s h e a l t h a nd d e v e l o p m e n t by t a k i n g t h e c h i l d t o t h e s c r e e n i n g c l i n i c . S p e e c h o r l a n g u a g e d e v e l o p m e n t was m e n t i o n e d by 16 o f t h e s e m o t h e r s , 8 l e a r n e d a b o u t p h y s i c a l d e v e l o p m e n t , 7 l e a r n e d a b o u t n u t r i t i o n , 6 l e a r n e d a b o u t s o c i a l a d j u s t m e n t , 6 l e a r n e d a b o u t d e n t a l h y g i e n e , a n d 3 l e a r n e d a b o u t v i s i o n . T h i s number (46) e x c e e d s t h e number o f m o t h e r s r e p o r t i n g (29) b e c a u s e some m e n t i o n e d two o r more a s p e c t s a s b e i n g new t o them. T a b l e V I I , p. 8 1 , s u m m a r i z e s t h e s e d a t a . F o r t y - f o u r o f t h e m o t h e r s q u e r i e d f o u n d t h e c l i n i c e x p e r i e n c e t o be u s e f u l a nd r e a s s u r i n g t o them as a p a r e n t , 2 m o t h e r s s t a t e d an o p p o s i t e v i e w , a n d 1 m o t h e r had no o p i n i o n . S i x o f t h e m o t h e r s t h o u g h t t h e c l i n i c h a d d e t e c t e d a p r o b l e m t h a t c o u l d h a v e a d v e r s e l y a f f e c t e d t h e c h i l d l a t e r i n s c h o o l h a d i t p r o c e e d e d u n t r e a t e d . O t h e r p o p u l a r a s p e c t s o f t h e c l i n i c w e r e t h e t o y c e n t r e f o r t h e c h i l d r e n a nd t h e d e v e l o p m e n t a l l i t e r a t u r e g i v e n o u t . The m o s t f r e q u e n t c o m p l a i n t was t h a t t h e t e s t i n g s e s s i o n was t o o l o n g f o r t h e c h i l d r e n a nd a few m o t h e r s c o m p l a i n e d a b o u t t h e l a c k o f f e e d b a c k a f t e r t h e c l i n i c v i s i t . O n l y 2 m o t h e r s h a d c o m p l a i n t s a b o u t t h e s t a f f and t h e t e s t p r o c e d u r e s . C o m p l i a n c e o f t h e P a r e n t s t o R e f e r r a l s T w e n t y - s i x r e f e r r a l s w e r e made f o r 24 c h i l d r e n f o r f u r t h e r i n v e s t i g a t i o n a nd p o s s i b l e i n t e r v e n t i o n i n a t o t a l 81 T a b l e V I I P a r e n t s ' R e s p o n s e s t o t h e S c r e e n i n g C l i n i c a s a L e a r n i n g E x p e r i e n c e R e s p o n s e Number P e r c e n t a g e N o t a l e a r n i n g e x p e r i e n c e A l e a r n i n g e x p e r i e n c e 18 29 38.3 61.7 T o t a l s 47 100.0 P a r e n t s l e a r n e d a b o u t : V i s i o n 3 6.4 S p e e c h o r l a n g u a g e 16 34.0 P h y s i c a l d e v e l o p m e n t 8 17.0 S o c i a l a d j u s t m e n t .6 12. 8 N u t r i t i o n 7 14.9 D e n t a l h e a l t h 6 12. 8 * The r e p o r t e d number o f i t e m s l e a r n e d a b o u t (46) - e x c e e d s t h e number o f p a r e n t s who f o u n d t h e c l i n i c a l e a r n i n g e x p e r i e n c e (29) b e c a u s e some p a r e n t s m e n t i o n e d h a v i n g l e a r n e d a b o u t more t h a n one a s p e c t o f t h e i r c h i l d ' s h e a l t h o r d e v e l o p m e n t . 82 o f 39 p r o b l e m s . A t t h e t i m e o f t h e p o s t - c l i n i c s u r v e y , 18 o f t h e r e f e r r a l s h a d b e e n k e p t . I n o n l y two i n s t a n c e s d i d t h e r e f e r r e d - t o h e a l t h p r o f e s s i o n a l n o t c o n c u r w i t h t h e c l i n i c n u r s e s ' r e a s o n f o r r e f e r r a l . E i g h t o f t h e r e f e r r e d c h i l d r e n w e r e u n d e r g o i n g f u r t h e r t e s t i n g o r t r e a t m e n t . F o r t h e r e m a i n i n g 8 c h i l d r e n , no f u r t h e r t e s t i n g o r t r e a t m e n t h a d y e t b e g u n . Of t h e r e m a i n i n g 8 m o t h e r s who h a d n o t y e t c o m p l i e d w i t h t h e r e f e r r a l , 7 w e r e w a i t i n g t o be c o n t a c t e d by t h e c o m m u n i t y h e a l t h n u r s e i n t h e i r a r e a and 1 p r e f e r r e d t o t a k e h e r c h i l d t o t h e f a m i l y p h y s i c i a n f o r r e t e s t i n g . T a b l e V I I I , p. 83, s u m m a r i z e s t h e s e d a t a . A d d i t i o n a l F i n d i n g s The p r e - c l i n i c a nd p o s t - c l i n i c q u e s t i o n n a i r e s a l s o e l i c i t e d i n f o r m a t i o n on how t h e p a r e n t s l e a r n e d a b o u t and g o t t o t h e c l i n i c , t h e i r a s s e s s m e n t o f i t s u s e f u l n e s s , and some g e n e r a l comments. P u b l i c i t y . T w e n t y - t h r e e o f t h e 47 m o t h e r s a t t e n d i n g t h e c l i n i c l e a r n e d a b o u t t h e s e r v i c e f r o m i t e m s i n s e r t e d i n S c h o o l P a r e n t B u l l e t i n s b r o u g h t home by o l d e r c h i l d r e n . N i n e p a r e n t s r e a d a b o u t t h e c l i n i c on a P l a y S c h o o l n o t i c e b o a r d . O t h e r s o u r c e s o f i n f o r m a t i o n w e r e a n o t i c e i n t h e H e a l t h U n i t o f f i c e , a f r i e n d o r n e i g h b o r , an i t e m i n t h e l o c a l n e w s p a p e r , t h e c o m m u n i t y h e a l t h n u r s e , and a f a m i l y - l i f e 83 T a b l e V I I I C o m p l i a n c e by t h e P a r e n t s t o R e f e r r a l s R e f e r r e d - t o H e a l t h P r o f e s s i o n a l Community S p e e c h H e a l t h N u r s e D o c t o r T h e r a p i s t Number o f c h i l d r e n r e f e r r e d 20 3 3 C o m p l i a n c e t o r e f e r r a l s 13 2 3 N o n - c o m p l i a n c e 7 1 0 C o n c u r r e n c e w i t h r e a s o n s 12 1 3 f o r r e f e r r a l N o n - c o n c u r r e n c e 1 1 0 I n t e r v e n t i o n b e g u n 4 1 3 NB: D a t a r e p o r t e d a t t h e t i m e o f t h e p o s t - c l i n i c s u r v e y ( a p p r o x i m a t e l y one m onth a f t e r t h e c l i n i c v i s i t ) . 84 e d u c a t i o n p a m p h l e t . T r a n s p o r t a t i o n . F o r t y - t w o o f t h e m o t h e r s d r o v e t h e m s e l v e s t o t h e c l i n i c i n t h e f a m i l y c a r . O n l y 3 came by b u s , 1 w a l k e d , a n d 1 t o o k a t a x i . U s e f u l n e s s . F o r t y - s i x o f t h e m o t h e r s f e l t t h e c l i n i c t o be a v e r y u s e f u l c o m m u n i t y s e r v i c e and w o u l d recommend i t t o t h e i r f r i e n d s . One m o t h e r s a i d she had no o p i n i o n a b o u t i t s u s e f u l n e s s o r r e c o m m e n d i n g t h e s e r v i c e . Comments o f t h e P a r e n t s . T h r e e o u t o f f o u r o f t h e p a r e n t s ' s p o n t a n e o u s comments w e r e f a v o r a b l e t o w a r d s t h e c l i n i c . A l m o s t h a l f o f t h e s e f o c u s s e d on t h e c l i n i c a s a l e a r n i n g e x p e r i e n c e . O t h e r f a v o r a b l e comments i n c l u d e d s u c h s t a t e m e n t s a s : " A l l c h i l d r e n s h o u l d be t e s t e d " ; "The f a m i l y d o c t o r d o e s n ' t know en o u g h a b o u t d e v e l o p m e n t " ; " ( T h e c h i l d ) e n j o y e d b e i n g t h e c e n t r e o f a t t e n t i o n " ; " U s e f u l f o r a n s w e r i n g ' l i t t l e ' p r o b l e m s " ; " I t s h o u l d be done e v e r y two y e a r s " . The m o s t f r e q u e n t c a u s e o f c r i t i c i s m o r u n f a v o r a b l e comments was t h e l e n g t h o f t h e c l i n i c s e s s i o n (75 m i n u t e s ) . Many o f t h e m o t h e r s c o m p l a i n e d o f h a v i n g to. w a i t f o r t h e i r c h i l d ' s t u r n i n t h e t e s t i n g p r o c e d u r e s , and t h e i r c h i l d r e n became t i r e d , , h u n g r y , r e s t l e s s , o r b o r e d . Some o f t h e t e s t p r o c e d u r e s w e r e d e s c r i b e d a s c o n f u s i n g , f r i g h t e n i n g , 85 i n a d e q u a t e , o r u n n e c e s s a r y . S i x m o t h e r s w e r e d i s a p p o i n t e d t h a t t h e y h a d n o t h a d an o p p o r t u n i t y t o d i s c u s s t h e i r c h i l d ' s p r o b l e m s i n d e t a i l w i t h t h e c l i n i c n u r s e s , and t h r e e comments w e r e made a b o u t t h e s t a f f b e i n g r u s h e d , l a c k i n g r a p p o r t w i t h t h e c h i l d r e n , a n d n o t b e i n g s u f f i c i e n t l y s t r i c t w i t h t h e c h i l d r e n . C r o s s - T a b u l a t i o n o f t h e D a t a Some o f t h e v a r i a b l e s p r e v i o u s l y d e s c r i b e d w e r e c r o s s - t a b u l a t e d i n c o n t i n g e n c y t a b l e s t o l e n d d e p t h t o t h e d e s c r i p t i o n o f t h e s t u d y p o p u l a t i o n . R e f e r r a l f o r F u r t h e r I n v e s t i g a t i o n v e r s u s Sex o f C h i l d . Of t h e 2 4 c h i l d r e n who w e r e r e f e r r e d b y t h e c l i n i c s t a f f t o o t h e r h e a l t h p r o f e s s i o n a l s f o r f u r t h e r i n v e s t i g a t i o n , 13 w e r e m a l e a nd 11 f e m a l e . Of t h e 2 3 c h i l d r e n who w e r e a d j u d g e d f r e e o f p r o b l e m s r e q u i r i n g r e f e r r a l , 9 w e r e m a l e and 14 f e m a l e . The p r e p o n d e r a n c e o f m a l e s i n t h e r e f e r r e d g r o u p i s n o t s i g n i f i c a n t a t t h e .05 l e v e l . (See T a b l e I X , p.86.) P a r e n t s ' C o n c e r n s v e r s u s R e a s o n s f o r R e f e r r a l f o r F u r t h e r I n v e s t i g a t i o n . Of t h e 25 c h i l d r e n whose m o t h e r s e x p r e s s e d no c o n c e r n s , 16 w e r e a d j u d g e d by t h e c l i n i c s t a f f t o be f r e e o f p r o b l e m s . The r e m a i n i n g 9 c h i l d r e n w e r e r e f e r r e d t o o t h e r h e a l t h p r o f e s s i o n a l s f o r i n v e s t i g a t i o n o f one o r more p r o b l e m s w h i c h h a d n o t b e e n a p p a r e n t t o t h e i r m o t h e r s . 86 T a b l e I X R e f e r r a l f o r F u r t h e r I n v e s t i g a t i o n v e r s u s Sex o f C h i l d R e f e r r e d f o r f u r t h e r i n v e s t i g a t i o n N o t r e f e r r e d T o t a l s P e r c e n t a g e s Sex o f C h i l d M a l e f e m a l e 13 9 11 14 22 25 46.8 53.2 T o t a l P e r c e n t a g e 24 23 51.1 49.9 47 100.0 C h i - s q u a r e = 1.108; D e g r e e s o f f r e e d o m = 1 D i f f e r e n c e n o t s i g n i f i c a n t a t .05 l e v e l 87 Of t h e 22 c h i l d r e n whose m o t h e r s e x p r e s s e d some c o n c e r n s , 9 w e r e r e f e r r e d f o r i n v e s t i g a t i o n o f t h e p r o b l e m t h a t h a d c a u s e d t h e c o n c e r n . F i v e o f t h e s e c h i l d r e n w e r e a l s o r e f e r r e d f o r i n v e s t i g a t i o n o f a d d i t i o n a l p r o b l e m s , a b o u t w h i c h t h e m o t h e r s h a d n o t e x p r e s s e d c o n c e r n s . S i x c h i l d r e n whose m o t h e r s h a d e x p r e s s e d c o n c e r n s w e r e r e f e r r e d f o r p r o b l e m s o t h e r t h a n t h o s e t h a t h a d g i v e n r i s e t o t h e i r m o t h e r s ' c o n c e r n s . S e v e n c h i l d r e n whose m o t h e r s e x p r e s s e d c o n c e r n s w e re c o n s i d e r e d b y t h e c l i n i c s t a f f t o be f r e e o f p r o b l e m s r e q u i r i n g f u r t h e r i n v e s t i g a t i o n . (See T a b l e X, p. 88.) P r e v i o u s Use o f H e a l t h R e s o u r c e s v e r s u s R e f e r r a l f o r F u r t h e r I n v e s t i g a t i o n . A c o m p a r i s o n was made b e t w e e n t h e p r e v i o u s u s e o f h e a l t h r e s o u r c e s a mongst t h e r e f e r r e d g r o u p o f c h i l d r e n a n d t h e n o n - r e f e r r e d g r o u p . I n t h e r e f e r r e d g r o u p , an a v e r a g e o f 4.1 h e a l t h r e s o u r c e s h a d b e e n p r e v i o u s l y a t t e n d e d . The n o n - r e f e r r e d c h i l d r e n h a d a t t e n d e d an a v e r a g e o f 3.8 h e a l t h r e s o u r c e s p r e v i o u s l y . (See T a b l e X I , p. 89.) R e f e r r a l f o r F u r t h e r I n v e s t i g a t i o n v e r s u s S o c i a l C l a s s o f F a m i l y . Of t h e 24 r e f e r r e d c h i l d r e n , 3 w e r e f r o m f a m i l i e s i n C l a s s I , 7 w e r e i n C l a s s I I , 9 w e r e i n C l a s s I I I , 4 w e r e i n C l a s s I V , and 1 was i n C l a s s V. Of t h e 23 n o n - r e f e r r e d c h i l d r e n , 7 w e r e i n C l a s s I , 3 w e r e i n C l a s s I I , 10 w e r e i n C l a s s I I I , and 3 w e r e i n C l a s s I V . (See T a b l e X I I , p. 90.) 88 Table X Mothers' Concerns versus Reasons f o r R e f e r r a l f o r Further I n v e s t i g a t i o n Concerns of Number of 2 2 Mothers Problems Referred Reason Number Reasons f o r R e f e r r a l Not D H N P B S V Referred Dental (D) 4 Hearing (H) 2 N u t r i t i o n 2 (N) P h y s i c a l 0 (P) Behavior 7 (B) Speech (S) Visxon (V) 16 3 2 0 14 1* 1 1 2 1 1 0 2 0 4* 2 2 4* 4 Subtotals 34 27 Mothers Not Concerned 25 12 16' To t a l s 39 2 10 6 12 23 Cases of p a r e n t / s t a f f concurrence (*) Cases of p a r e n t / s t a f f non-concurrence 26 36 (NB: For purposes of t h i s t a b l e , problems of parent/ c h i l d r e l a t i o n s h i p s and delays i n s o c i a l adjustment have been combined i n the s i n g l e category, Behavior.) 89 Table XI Previous Use of Health Resources versus R e f e r r a l f o r Further I n v e s t i g a t i o n Health Resources Used Referred Group (N=24) Non-Referred Group (N=23) For Parents: P r e n a t a l c l a s s e s 11 14 For C h i l d r e n : Dental c l i n i c 7 8 D e n t i s t 15 10 Emergency ward 13 13 General p r a c t i t i o n e r 22 21 P e d i a t r i c i a n 9 6 Well-baby c l i n i c 19 14 Other: Ophthalmologist 1 1 Speech t h e r a p i s t 0 1 U r o l o g i s t 1 0 T o t a l s 98 88 Average per c h i l d 4.1 3. 90 T a b l e X I I Number o f C h i l d r e n R e f e r r e d f o r F u r t h e r I n v e s t i g a t i o n v e r s u s S o c i a l C l a s s o f F a m i l y S o c i a l C l a s s o f F a m i l y I I I I I I I V V T o t a l s R e f e r r e d 3 7 9 4 1 24 N o t r e f e r r e d 7 3 10 3 0 23 T o t a l s 10 10 19 7 1 47 91 P r e v i o u s Use o f H e a l t h R e s o u r c e s v e r s u s S o c i a l C l a s s o f F a m i l y . The m o t h e r s i n t h e s t u d y p o p u l a t i o n w e r e a s k e d t o i d e n t i f y t h e i r p r e v i o u s u s e o f p r e n a t a l c l a s s e s and t h e f o l l o w i n g h e a l t h r e s o u r c e s f o r t h e i r c h i l d r e n : d e n t a l c l i n i c , d e n t i s t , e m e r g e n c y d e p a r t m e n t , g e n e r a l p r a c t i t i o n e r , p e d i a t r i c i a n , w e l l - b a b y c l i n i c , o r o t h e r h e a l t h p r o f e s s i o n a l o r a g e n c y . The m o t h e r s ' d e s i g n a t i o n s w e r e t o t a l l e d a nd a v e r a g e s c o m p u t e d by S o c i a l C l a s s o f e a c h f a m i l y . The a v e r a g e number o f h e a l t h r e s o u r c e s p r e v i o u s l y u s e d w e r e : 4.3 f o r C l a s s I , 4.7 f o r C l a s s I I , 3.8 f o r C l a s s I I I , 2.9 f o r C l a s s I V , a n d 3.0 f o r t h e . C l a s s V m o t h e r . (See T a b l e X I I I , p. 92.) Summary The c h i l d r e n a n d t h e i r p a r e n t s i n t h e s t u d y p o p u l a t i o n a r e c h a r a c t e r i z e d by t h e i n f o r m a t i o n o b t a i n e d w i t h t h e r e s e a r c h i n s t r u m e n t s . S e l e c t e d d a t a w e re a r r a n g e d i n f r e q u e n c y t a b l e s and p e r c e n t a g e s c a l c u l a t e d w h e r e s u i t a b l e . The f a m i l i e s w e r e c a t e g o r i z e d a c c o r d i n g t o t h e H o l l i n g s h e a d Two F a c t o r I n d e x o f S o c i a l P o s i t i o n . The p r e v i o u s u s e o f c o m m u n i t y h e a l t h r e s o u r c e s , c u r r e n t c o n c e r n s , p r e f e r r e d s o u r c e s o f a d v i c e , and t h e m o t h e r s ' r e s p o n s e s t o t h e c l i n i c e x p e r i e n c e a r e t a b u l a t e d . S e l e c t e d v a r i a b l e s w e r e c r o s s - t a b u l a t e d t o a d d d e s c r i p t i v e d e p t h t o t h e s t u d y . T e s t s f o r d e p e n d e n c e o f t h e v a r i a b l e s w e r e n e g a t i v e . 92 T a b l e X I I I P r e v i o u s Use o f H e a l t h R e s o u r c e s v e r s u s S o c i a l C l a s s o f F a m i l y S o c i a l C l a s s o f F a m i l y P e r c e n t a g e H e a l t h R e s o u r c e s o f F a m i l i e s U s e d I I I I I I I V V T o t a l s (N=47) F o r P a r e n t s : P r e n a t a l c l a s s e s 6 7 9 3 0 25 53.2 F o r C h i l d r e n : D e n t a l C l i n i c 6 3 5 1 0 15 3 1 . 9 D e n t i s t 4 6 12 2 1 25 53. 2 E m e r g e n c y w a r d 6 6 12 2 0 26 55 . 3 G e n e r a l p r a c t i t i o n e r 9 8 18 7 1 43 9 1 . 5 P e d i a t r i c i a n 3 7 4 1 0 15 31. 9 W e l l - b a b y c l i n i c 9 8 11 4 1 33 70. 2 O t h e r : O p h t h a l m o l o g i s t 0 2 0 0 0 2 4. 2 S p e e c h t h e r a p i s t 0 0 1 0 0 1 2. 1 U r o l o g i s t 0 0 1 0 0 1 2. 1 T o t a l s 43 47 73 20 3 186 Number o f f a m i l i e s b y s o c i a l c l a s s 10 10 19 7 1 47 100. 0 A v e r a g e number o f r e s o u r c e s u s e d p e r f a m i l y 4.3 4.7 3.8 2.9 3.0 4.0 93 C h a p t e r V DISCUSSION OF THE DATA The d a t a w i l l be e x a m i n e d i n t h e l i g h t o f p r e v i o u s , s t u d i e s r e p o r t e d i n t h e l i t e r a t u r e . The i m p l i c a t i o n s o f t h e f i n d i n g s o f t h e p r e s e n t s t u d y , i t s l i m i t a t i o n s a n d w e a k n e s s e s , w i l l be d i s c u s s e d a n d s u g g e s t i o n s made f o r f u t u r e s t u d i e s . The C h i l d r e n i n t h e S t u d y P o p u l a t i o n The t y p i c a l c h i l d i n t h e s t u d y was o f n o r m a l w e i g h t a t b i r t h , h a d r e c e i v e d a l l recommended i m m u n i z a t i o n s , h a d a l r e a d y b e e n t r e a t e d f o r one o r more h e a l t h p r o b l e m s , b u t was e s s e n t i a l l y h e a l t h y a t t h e t i m e o f a s s e s s m e n t . The c h i l d was t h r e e m onths s h o r t o f h i s / h e r 4 t h b i r t h d a y , b u t was a b l e t o c o o p e r a t e w e l l i n t h e t e s t i n g p r o c e d u r e s . T h i s a p p e a r s t o b e l i e t h e b e l i e f o f K o h l e r (1973) and T h o r e s a n d P h i l i o n (1972) who f e l t t h a t 4 y e a r s was t h e e a r l i e s t age a t w h i c h c h i l d r e n c o u l d c o o p e r a t e s u f f i c i e n t l y t o make s c r e e n i n g p r a c t i c a b l e . A m a j o r i t y o f t h e c h i l d r e n w e r e b o r n i n t h e l o c a l a r e a , and n e a r l y a l l h a d one o r more s i b l i n g s . The P a r e n t s i n t h e S t u d y P o p u l a t i o n The p a r e n t s who a t t e n d e d t h e new s c r e e n i n g c l i n i c i n i t s i n i t i a l p h a s e w e r e t y p i c a l l y f r o m t h e m i d d l e and 94 u p p e r - m i d d l e c l a s s segment o f t h e c o m m u n i t y . The f a t h e r i s e m p l o y e d , i n a m e d i u m - t o - h i g h - s t a t u s o c c u p a t i o n . He h a s h a d a t l e a s t some u n i v e r s i t y e d u c a t i o n . The mean l e v e l o f e d u c a t i o n o f t h e f a t h e r s i n t h e s t u d y was. 13.6 y e a r s . The com m u n i t y mean l e v e l o f e d u c a t i o n f o r e m p l o y e d m a l e s i s 10.4 y e a r s ( L i o y , 1 9 7 5 , p. 1 2 2 ) . The m o t h e r s i n t h e s t u d y a r e a l m o s t a l l f u l l - t i m e homemakers, a g e d 30 t o 34 y e a r s . The mean l e v e l o f e d u c a t i o n o f t h e m o t h e r s was 12.5 y e a r s , h i g h e r t h a n t h e mean l e v e l o f 10.6 y e a r s f o r f e m a l e s i n t h e l a b o r f o r c e ( L i o y , 1 9 7 4 , p. 1 2 2 ) . The f a m i l i e s a l m o s t a l l owned a t l e a s t one c a r and h a v e a h i s t o r y o f f r e q u e n t u s e o f o t h e r h e a l t h r e s o u r c e s i n t h e c o m m u n i t y . The a v e r a g e f a m i l y i n t h e s t u d y numbered 4.3 p e o p l e , c o m p a r e d t o t h e c o m m u n i t y a v e r a g e o f 3.8 p e o p l e p e r f a m i l y h o u s e h o l d ( L i o y , 1 9 7 5 , p. 1 6 4 ) . T h i s p r o f i l e o f t h e t y p i c a l f a m i l y i n t h e s t u d y p o p u l a t i o n c o i n c i d e s g e n e r a l l y w i t h many o f t h e s t u d i e s m e n t i o n e d i n C h a p t e r I I . R o s e n s t o c k ( 1 9 6 6 ) , G r e e n ( 1 9 7 0 ) , and S t e e l e and McBroom. (1972) s a y t h a t t h e r e l a t i v e l y a f f l u e n t a n d w e l l - e d u c a t e d segment o f t h e c o m m u n i t y h a v e a c o n s i s t e n t p a t t e r n o f h e a l t h b e h a v i o r a n d more o f t e n u s e co m m u n i t y h e a l t h r e s o u r c e s . C h i l d r e n o f p a r e n t s i n t h e l o w e r s o c i o e c o n o m i c s t r a t a w e r e u n d e r - r e p r e s e n t e d i n t h e s t u d y p o p u l a t i o n . I t i s s u c h c h i l d r e n , a c c o r d i n g t o N o r t h ( 1 9 7 0 ) , K o h l e r ( 1 9 7 3 ) , and T o n k i n e t a l ( 1 9 7 3 ) , who a r e most l i k e l y t o h a v e i m p o r t a n t 95 h e a l t h p r o b l e m s t h a t m i g h t be d e t e c t e d by t h e new s c r e e n i n g s e r v i c e . P a r e n t s ' C o n c e r n s f o r t h e i r C h i l d r e n ' s H e a l t h S h e r i d a n ( 1 9 7 3 , p. 16) h a s c o n c l u d e d t h a t i f a m o t h e r s u s p e c t s t h a t h e r c h i l d h a s some d e v e l o p m e n t a l d e f i c i e n c y , s h e i s l i k e l y t o be r i g h t . T h i s c o n c l u s i o n was n o t b o r n e o u t by t h e p r e s e n t s t u d y . A c o m p a r i s o n o f t h e m o t h e r s ' c o n c e r n s w i t h t h e f i n d i n g s o f t h e c l i n i c s t a f f ( i . e . , r e a s o n s f o r r e f e r r a l ) shows t h a t i n 26 i n s t a n c e s t h e c l i n i c s t a f f c o n c u r r e d w i t h t h e m o t h e r s e i t h e r i n t h e r e a s o n s f o r t h e i r c o n c e r n s , o r i n t h e i r l a c k o f c o n c e r n , and i n 36 i n s t a n c e s t h e c l i n i c s t a f f d i d n o t c o n c u r w i t h t h e m o t h e r s . I t may be t h a t i n many i n s t a n c e s t h e m o t h e r i s p r o p e r l y c o n c e r n e d a b o u t h e r c h i l d ' s d e v e l o p m e n t , b u t c a n n o t a c c u r a t e l y i d e n t i f y t h e p r o b l e m a r e a . F o r e x a m p l e , o f 16 c h i l d r e n whose m o t h e r s e x p r e s s e d c o n c e r n a b o u t t h e i r s p e e c h d e v e l o p m e n t , o n l y 4 w e r e r e f e r r e d f o r f u r t h e r s p e e c h i n v e s t i g a t i o n b u t 10 w e r e r e f e r r e d f o r . i n v e s t i g a t i o n o f o t h e r p r o b l e m s . P r e f e r r e d S o u r c e s f o r H e a l t h A d v i c e The l i t e r a t u r e was v e r y s p a r s e i n r e p o r t i n g p r e f e r r e d s o u r c e s o f a d v i c e f o r m o t h e r s a b o u t t h e i r c h i l d r e n ' s h e a l t h and b e h a v i o r p r o b l e m s . The s i n g l e s t u d y m e n t i o n e d i n t h e l i t e r a t u r e r e v i e w ( C a n a d i a n P r e s s , 1976) r e p o r t e d t h a t among a g r o u p o f l o w - i n c o m e women i n T o r o n t o , t h e p h y s i c i a n was t h e p r e f e r r e d s o u r c e o f h e l p f o r p r o b l e m s o f t h e i r c h i l d r e n , w i t h t h e h u s b a n d i n f o u r t h p l a c e . I n my s t u d y , t h e g e n e r a l p r a c t i t i o n e r was t h e o v e r w h e l m i n g f a v o r i t e f o r a d v i c e on p h y s i c a l p r o b l e m s , w i t h t h e h u s b a n d i n f o u r t h p l a c e , b u t f o r b e h a v i o r a l p r o b l e m s t h e h u s b a n d was t h e p r e f e r r e d s o u r c e o f a d v i c e , c l o s e l y f o l l o w e d b y t h e g e n e r a l p r a c t i t i o n e r . T h i s a p p e a r s t o r e v e a l a c l o s e s h a r i n g o f c h i l d - r e a r i n g r e s p o n s i b i l i t i e s among t h e p a r e n t s . I n n e i t h e r s t u d y d i d t h e c o m m u n i t y h e a l t h n u r s e a p p e a r a s a s i g n i f i c a n t s o u r c e o f a d v i c e . F i n d i n g s o f t h e S c r e e n i n g C l i n i c I n t h e p r e s e n t s t u d y , 51 p e r c e n t o f t h e c h i l d r e n s c r e e n e d w e r e r e f e r r e d f o r f u r t h e r i n v e s t i g a t i o n . F o r r e a s o n s s e t o u t i n C h a p t e r I V , i t i s d i f f i c u l t t o make a d i r e c t c o m p a r i s o n o f t h i s o v e r a l l r e f e r r a l r a t e w i t h many o f t h e p r e v i o u s s t u d i e s e x a m i n e d . The m o s t s i m i l a r p r o g r a m m e n t i o n e d i n t h e l i t e r a t u r e r e v i e w was t h a t o f t h e B u r n a b y H e a l t h D e p a r t m e n t , i n w h i c h 57.4 p e r c e n t o f t h e c h i l d r e n s c r e e n e d w e re r e f e r r e d f o r f o l l o w - u p i n v e s t i g a t i o n ( B u r n a b y , 1 9 7 6 ) . T h i s c o m p a r e s t o t h e 36.4 p e r c e n t r e f e r r a l r a t e o f t h e E t o b i c o k e s t u d y ( K i r s t i n e , 1 9 7 4 ) . Of t h e r e a s o n s f o r r e f e r r a l i n t h e p r e s e n t s t u d y , 97 v i s i o n was t h e m o s t common. I t a c c o u n t e d f o r 26 p e r c e n t o f t h e c h i l d r e n r e f e r r e d . T h i s c o m p a r e s t o 12.5 p e r c e n t i n t h e K o h l e r (19 73) s t u d y , t h e 3.5 p e r c e n t r e p o r t e d b y T h o r e s a nd P h i l i o n ( 1 9 7 2 ) , a n d t h e 8.8 p e r c e n t r e p o r t e d i n t h e B u r n a b y (19 76) s t u d y . The s e c o n d m o s t common r e a s o n f o r r e f e r r a l i n t h e p r e s e n t s t u d y was b e h a v i o r a l p r o b l e m s . T h i s a c c o u n t e d f o r 21 p e r c e n t o f t h e c h i l d r e n r e f e r r e d ( i n c l u d i n g s o c i a l a d j u s t m e n t d e l a y and p r o b l e m s o f p a r e n t / c h i l d r e l a t i o n s h i p s ) . T h i s c o m p a r e s w i t h K i r s t i n e ( 1 9 7 4 ) , who r e p o r t e d 25.3 p e r c e n t o f t h e n e e d s o f t h e c h i l d r e n s c r e e n e d w e r e i n t h e a r e a o f b e h a v i o r a l p r o b l e m s . I n t h e W e l l e s l e y s t u d y , W y a t t ( 1 9 7 0 ) . r e p o r t e d t h a t 10.8 p e r c e n t o f t h e c h i l d r e n s c r e e n e d h a d b e h a v i o r a l a n d e m o t i o n a l d i s o r d e r s . I n h i s r e v i e w o f a number o f U.S. s c r e e n i n g p r o g r a m s , L e s s l e r (1973) r e p o r t e d a r a n g e o f 2 t o 10 p e r c e n t o f m e n t a l h e a l t h p r o b l e m s . S p e e c h a nd l a n g u a g e p r o b l e m s w e r e t h e t h i r d m o s t common r e a s o n f o r r e f e r r a l i n t h e p r e s e n t s t u d y . T h e s e a c c o u n t e d f o r 13 p e r c e n t o f t h e c h i l d r e n r e f e r r e d . I n h i s r e v i e w L e s s l e r (1973) f o u n d a r a n g e o f 16.3 t o 25 p e r c e n t o f l a n g u a g e p r o b l e m s . W y a t t (1970) r e p o r t e d a 7 p e r c e n t i n c i d e n c e o f s p e e c h a n d l a n g u a g e p r o b l e m s . K i r s t i n e (1974) f o u n d t h a t 14.7 p e r c e n t o f t h e n e e d s d e t e c t e d i n h e r s t u d y r e l a t e d t o s p e e c h . I n t h e B u r n a b y (1976) s t u d y , s p e e c h a c c o u n t e d f o r 11.1 p e r c e n t o f t h e c h i l d r e n r e f e r r e d . The f i n d i n g i n t h e p r e s e n t s t u d y o f 6.4 p e r c e n t o f t h e 98 c h i l d r e n r e f e r r e d f o r h e a r i n g p r o b l e m s e x a c t l y e q u a l s t h e f i g u r e r e p o r t e d by T h o r e s and P h i l i o n (1972) . K o h l e r (1973) r e p o r t e d 3.9 p e r c e n t o f h e a r i n g p r o b l e m s . . The B u r n a b y (1976) s t u d y f o u n d 11.6 p e r c e n t h e a r i n g p r o b l e m s . I n t h e p r e s e n t s t u d y 6.4 p e r c e n t o f t h e c h i l d r e n w e r e r e f e r r e d f o r i n v e s t i g a t i o n o f n u t r i t i o n a l p r o b l e m s . K i r s t i n e (19 74) r e p o r t e d 9.3 p e r c e n t o f t h e n e e d s d e t e c t e d w e r e i n t h e a r e a o f n u t r i t i o n . B u r n a b y (19 76) r e p o r t e d 4.6 p e r c e n t o f c h i l d r e n r e f e r r e d f o r n u t r i t i o n a l r e a s o n s . P r o b l e m s o f d e l a y i n p h y s i c a l d e v e l o p m e n t w e r e t h e r e a s o n f o r r e f e r r a l o f 4.2 p e r c e n t o f t h e c h i l d r e n i n t h e p r e s e n t s t u d y . B u r n a b y (1976) r e p o r t e d r e f e r r i n g 5.1 p e r c e n t o f t h e c h i l d r e n s c r e e n e d f o r i n v e s t i g a t i o n o f " d e v e l o p m e n t a l d e l a y . " W y a t t (1970) r e p o r t e d 1.9 p e r c e n t o f c h i l d r e n i n h e r s t u d y h a d " m a r k e d l y p o o r m o t o r c o o r d i n a t i o n . " T h o r e s and P h i l i o n (1972) r e p o r t e d f i n e - m o t o r o r g r o s s - m o t o r d e l a y i n a t o t a l o f 6.9 p e r c e n t o f t h e c h i l d r e n i n t h e i r s t u d y . A s t a r t l i n g f i n d i n g o f t h e p r e s e n t s t u d y , a s c o m p a r e d w i t h p r e v i o u s s t u d i e s , was t h e r e l a t i v e l y l o w r a t e o f d e n t a l d i s e a s e among c h i l d r e n f r o m an a r e a whose w a t e r s u p p l y i s n o t f l u o r i d a t e d . Of t h e 38 c h i l d r e n f o r whom d e n t a l e x a m i n a t i o n r e c o r d s a r e c o m p l e t e , o n l y 7 ( o r 18.4 p e r c e n t ) showed s i g n s o f c a r i e s . T h i s i s i n s h a r p c o n t r a s t t o K o h l e r 1 s f i n d i n g o f 65.4 p e r c e n t o f S w e d i s h c h i l d r e n w i t h d e n t a l p r o b l e m s , L e s s l e r ' s 1973 r e v i e w w h i c h f o u n d i n c i d e n c e s o f 80 t o 90 p e r c e n t o f d e n t a l p r o b l e m s i n v a r i o u s U.S. s c r e e n i n g p r o g r a m s , and t h e 6 0 p e r c e n t i n c i d e n c e o f c a r i e s r e p o r t e d f o r C a n a d a a s a w h o l e ( D e n t a l H e a l t h 99 D i v i s i o n , 1 9 7 0 ) . A number o f a u t h o r s ( R u t t e r a nd T i z a r d , 197 0; S h a n n o n , 1970; H a c k n e y , 1969) h a v e f o u n d a h i g h e r i n c i d e n c e o f d e v e l o p m e n t a l d e l a y among b o y s t h a n among g i r l s . I n t h e p r e s e n t s t u d y , 13 o f t h e 24 c h i l d r e n r e f e r r e d f o r f u r t h e r i n v e s t i g a t i o n w e r e b o y s and 11 w e r e g i r l s . The d i f f e r e n c e i n t h i s c a s e i s n o t s t a t i s t i c a l l y s i g n i f i c a n t . C o m p l i a n c e o f t h e P a r e n t s t o R e f e r r a l s The r a t e o f c o m p l i a n c e w i t h r e f e r r a l s o f t h e c h i l d r e n t o o t h e r h e a l t h p r o f e s s i o n a l s was v e r y h i g h . T h i s was t o be e x p e c t e d : g o o d f a c i l i t i e s e x i s t i n t h e c o m m u n i t y f o r f o l l o w - u p p r o c e d u r e s a nd u n i v e r s a l m e d i c a l c a r e i n s u r a n c e e l i m i n a t e s a n y c o s t c o n c e r n f a c t o r . The r e a s o n f o r t h e d e l a y i n t h e m o t h e r s b e i n g c o n t a c t e d b y t h e c o m m u n i t y h e a l t h n u r s e i n t h e i r a r e a c a n be e x p l a i n e d b y t h e newness o f t h e c l i n i c and t h e f a c t t h a t f i r m f o l l o w - u p p r o c e d u r e s h a d n o t y e t b e e n e s t a b l i s h e d . I m p l i c a t i o n s o f t h e P r e s e n t S t u d y I t seems c l e a r t h a t t h e new s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s i s m e e t i n g a p r e v i o u s l y u n f i l l e d n e e d i n t h e c o m m u n i t y . D e s p i t e t h e a d v a n t a g e s o f s u p e r i o r home and f a m i l y b a c k g r o u n d s , c o n s c i e n t i o u s and i n t e l l i g e n t p a r e n t s , and p r e v i o u s u s e o f an a r r a y o f h e a l t h s e r v i c e s , h a l f o f t h e c h i l d r e n w e r e f o u n d t o h a v e . p o s s i b l e d e f e c t s o r d e v e l o p m e n t a l d e l a y s w a r r a n t i n g f u r t h e r i n v e s t i g a t i o n . T i m e l y d e t e c t i o n and i n t e r v e n t i o n p r e s u m a b l y w i l l a m e l i o r a t e many o f t h e s e 100 p r o b l e m s . The p a r e n t s a l s o b e n e f i t e d p s y c h o l o g i c a l l y f r o m t h e c l i n i c e x p e r i e n c e ; a l l b u t t h r e e o f t h o s e who a t t e n d e d f e l t r e a s s u r e d b y i t a n d f o u n d i t u s e f u l . T hey a p p a r e n t l y f e l t a n e e d f o r s u p p o r t i n t h e i r p a r e n t i n g r o l e a n d f o u n d i t a t t h e c l i n i c . The f i n d i n g s o f t h e c l i n i c a p p e a r t o c a s t d o u b t o n the; p h i l o s o p h y o f c o n c e n t r a t i n g h e a l t h r e s o u r c e s o n a p r e s u m e d " a t - r i s k " p o p u l a t i o n . None o f t h e c h i l d r e n i n t h e s t u d y p o p u l a t i o n w o u l d h a v e b e e n c o n s i d e r e d t o be e s p e c i a l l y " a t r i s k " , y e t many o f them h a d n e e d f o r f u r t h e r s e r v i c e f r o m h e a l t h p r o f e s s i o n a l s . A t t h e same t i m e , t h e c l i n i c i s n o t a t t r a c t i n g many c h i l d r e n who may g e n u i n e l y f a c e a h i g h e r r i s k o f d i s o r d e r t h a n i t s p r e s e n t p o p u l a t i o n . I t i s w e l l r e c o g n i z e d ( N o r t h , 1970, G r e e n , 1 9 7 0 , K o h l e r , 1973) t h a t l o w e r s o c i o e c o n o m i c s t a t u s i m p l i e s a p r o p o r t i o n a t e l y h i g h e r r a t e - o f d e v e l o p m e n t a l , s o c i a l a n d e d u c a t i o n a l p r o b l e m s . The s t u d y p o p u l a t i o n , h o w e v e r , was c o n s p i c u o u s l y d r a w n f r o m t h e m i d d l e a n d u p p e r - m i d d l e c l a s s e s . T h i s s t u d y a l s o makes i t c l e a r t h a t , e v e n among t h e w e l l - e d u c a t e d a n d h e a l t h - c o n s c i o u s p o p u l a t i o n , t h e c o m m u n i t y h e a l t h n u r s e h a s a r e m a r k a b l y l o w p r o f i l e . A l t h o u g h t h e p a r e n t s e x p r e s s e d c o n f i d e n c e i n t h e c o m p e t e n c e o f t h e c l i n i c n u r s e s a n d t h e v a l i d i t y o f t h e i r t e s t p r o c e d u r e s , a n d m o s t ha d p r e v i o u s l y a t t e n d e d a w e l l - b a b y c l i n i c , t h e y d i d n o t r e g a r d t h e n u r s e a s a s i g n i f i c a n t s o u r c e o f a d v i c e f o r e i t h e r t h e 101 p h y s i c a l o r b e h a v i o r a l p r o b l e m s o f t h e i r c h i l d r e n . L i m i t a t i o n s a n d W e a k n e s s e s o f t h e P r e s e n t S t u d y A s d i s c u s s e d e a r l i e r , t h i s s t u d y was l i m i t e d b y t h e f a c t t h a t t h e s t u d y p o p u l a t i o n c o n s i s t e d o f a s e l f - s e l e c t e d g r o u p o f f a m i l i e s ; t h e s t u d y was r e s t r i c t e d t o t h e i n i t i a l t h r e e months o f t h e c l i n i c ' s o p e r a t i o n ; t h e c o m b i n a t i o n o f a s s e s s m e n t p r o c e d u r e s a n d t h e i r s p e c i f i c a p p l i c a t i o n s i n t h e c l i n i c may be u n i q u e ; n e i t h e r t h e a s s e s s m e n t p r o c e d u r e s n o r t h e s k i l l s o f t h e c l i n i c p e r s o n n e l w e r e e v a l u a t e d ; a n d t h e d e n t a l h e a l t h d a t a w e r e n o t f u l l y i n t e g r a t e d w i t h t h e o t h e r c l i n i c r e s u l t s . The newness o f t h e c l i n i c may h a v e a t t r a c t e d an u n r e p r e s e n t a t i v e c l i e n t e l e . Women who p r i d e t h e m s e l v e s on b e i n g "good m o t h e r s " m i g h t be more w i l l i n g t h a n o t h e r s , o r m i g h t e v e n f e e l c o m p e l l e d , t o t r y a new s e r v i c e t h a t o f f e r s some p r o s p e c t o f b e n e f i t i n g t h e i r c h i l d r e n o r r e i n f o r c i n g t h e i r c o n f i d e n c e i n t h e m s e l v e s i n t h e i r " m o t h e r i n g " r o l e . Some o f t h e a s s e s s m e n t p r o c e d u r e s w e r e new t o t h e c l i n i c s t a f f , s o a l l o w a n c e must be made f o r e r r o r i n a p p l i c a t i o n a n d i n t e r p r e t a t i o n o f t h e p r o c e d u r e s and t h e r e s u l t s . F u r t h e r , c r i t e r i a f o r r e f e r r a l w e r e n o t w e l l e s t a b l i s h e d a t t h i s e a r l y s t a g e . The c o m m u n i t y h e a l t h n u r s e s o f t h e s p o n s o r i n g a g e n c y who w e r e n o t d i r e c t l y i n v o l v e d i n t h e c l i n i c o p e r a t i o n w e re u n f a m i l i a r w i t h e x p e c t e d f o l l o w - u p r o u t i n e s . 102 Some of the weaknesses of the design and execution of the study must be a t t r i b u t e d to the inexperience of the researcher. The s p e c i f i c o b j e c t i v e s of the study were probably u n r e a l i s t i c a l l y broad. The survey instruments could have been improved w i t h more thorough p r e - t e s t i n g . The form i n which some of the data was gathered made subsequent a n a l y s i s u n n e c e s s a r i l y d i f f i c u l t . The content of the instruments could have been more narrowly focussed on the s p e c i f i c o b j e c t i v e s of the study, and some overlap and r e p e t i t i o n could have been avoided. Suggestions f o r Future Studies A number of p o s s i b i l i t i e s f o r fu t u r e s t u d i e s suggest themselves. As a minimum, the c l i n i c s t a f f should continue to maintain records of i t s f i n d i n g s i n a systematic and standardized way to permit long-term measurement of the need f o r i t s s e r v i c e s and to enable p r e d i c t i o n s to be made about unmet h e a l t h needs i n the community. Another obvious need i s a study of the r e s u l t s of i n i t i a l r e f e r r a l . In most cases c h i l d r e n were r e f e r r e d to the community h e a l t h nurse; i n some cases t h i s was simply because of s u s p i c i o u s or incomplete r e s u l t s of the i n i t i a l a p p l i c a t i o n of the c l i n i c ' s assessment procedures. The c l i n i c r e s u l t s must be considered incomplete without knowledge of whether the nurse subsequently judged the c h i l d 103 to be problem-free, continued s u r v e i l l a n c e or i n i t i a t e d i n t e r v e n t i o n s , or r e f e r r e d the c h i l d to some other h e a l t h p r o f e s s i o n a l f o r more d e f i n i t i v e i n v e s t i g a t i o n and p o s s i b l e treatment. In the longer term, i t would be u s e f u l to i n v e s t i g a t e the e f f e c t i v e n e s s of i n t e r v e n t i o n i n those c h i l d r e n f o r whom i t was deemed necessary. Such a study could be done a f t e r a lapse of perhaps a year, or repeated at s u i t a b l e i n t e r v a l s . Once the c h i l d r e n screened by the c l i n i c begin to enter the school system, i t would be p o s s i b l e to compare them with a c o n t r o l group of peers who had not had the b e n e f i t of the c l i n i c ' s s e r v i c e s . This presumably would provide more d e f i n i t i v e i n f o r m a t i o n on the value of a s e r v i c e based on concepts of developmental theory. An e v a l u a t i o n of the s k i l l l e v e l s of the personnel of the screening c l i n i c could be a fu t u r e study. This could be done by comparing the assessments made by one c l i n i c nurse to those of another, or by comparing t h e i r f i n d i n g s w i t h those of more s p e c i a l i z e d personnel. This could help to modify a concern f o r u n d e r - r e f e r r i n g or o v e r - r e f e r r i n g c h i l d r e n . Another f u t u r e on-going study that suggests i t s e l f i s an e v a l u a t i o n of the assessment procedures employed by the c l i n i c . Are the procedures r e l i a b l e and v a l i d ? Are they e f f i c i e n t ? Do some procedures overlap? Are b e t t e r techniques a v a i l a b l e ? The c l i n i c s t a f f should c o n t i n u a l l y 104 c o n s i d e r t h e s e q u e s t i o n s . L i a i s o n w i t h a g e n c i e s p r o v i d i n g a s i m i l a r s c r e e n i n g s e r v i c e i n a d j o i n i n g m u n i c i p a l i t i e s c o u l d a n s w e r some o f t h e s e q u e s t i o n s a n d e v e n t u a l l y make r e s u l t c o m p a r i s o n s p o s s i b l e . F i n a l l y , t h e r e i s a n e e d f o r more d e t a i l e d d e l i n e a t i o n o f t h e c l i n i c p o p u l a t i o n i n s o c i o e c o n o m i c t e r m s t o f i n d o u t i f t h e c l i n i c p o p u l a t i o n r e p r e s e n t s t h e c o m m u n i t y . I f i t d o e s n o t , a s t h i s s t u d y h a s r e v e a l e d , a s u r v e y o f e l i g i b l e n o n - u s e r s o f t h e s e r v i c e s h o u l d be a t t e m p t e d t o d e t e r m i n e why t h e y do n o t u s e i t and how t h e s e r v i c e c o u l d be made more a c c e s s i b l e a n d a t t r a c t i v e t o them. 105 C h a p t e r V I SUMMARY AND RECOMMENDATIONS A b r i e f d e s c r i p t i o n o f t h e p u r p o s e o f t h e s t u d y , t h e l i t e r a t u r e r e v i e w , t h e r e s e a r c h m e t h o d o l o g y e m p l o y e d , t h e f i n d i n g s o f t h e c l i n i c and o t h e r d a t a a c q u i r e d b y t h e r e s e a r c h e r i n t h e c o u r s e o f t h e s t u d y a r e s u m m a r i z e d i n t h i s c h a p t e r , a n d r e c o m m e n d a t i o n s a r e p r e s e n t e d . Summary o f t h e S t u d y A s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d c h i l d r e n was e s t a b l i s h e d by a h e a l t h d e p a r t m e n t i n a B r i t i s h C o l u m b i a s u b u r b , b a s e d . o n s i m i l a r p r o g r a m s a l r e a d y f u n c t i o n i n g i n n e a r b y m u n i c i p a l i t i e s . The e f f e c t i v e n e s s a n d v a l i d i t y o f t h e s e p r o g r a m s h a d n o t b e e n e v a l u a t e d b e f o r e t h e o p e n i n g o f t h e new c l i n i c . The p u r p o s e o f t h i s s t u d y was t o i n v e s t i g a t e and d e s c r i b e t h i s s c r e e n i n g c l i n i c , t o r e p o r t on t h e p r o c e d u r e s e m p l o y e d , t h e p e r s o n n e l i n v o l v e d , t h e c h a r a c t e r i s t i c s o f t h e c l i e n t e l e , a n d t h e r e s u l t s o b t a i n e d . The l i t e r a t u r e was r e v i e w e d f r o m s e v e r a l p e r s p e c t i v e s : t h e d e v e l o p m e n t a l t h e o r y o f c h i l d h o o d , t h e r a t i o n a l e f o r s c r e e n i n g p r o g r a m s , t h e o p t i m a l age o f t h e s u b j e c t s t o be s c r e e n e d , t h e v a r i o u s t e s t p r o c e d u r e s e m p l o y e d i n s c r e e n i n g p r o g r a m s a nd t h e i r v a l i d i t y , t h e p e r s o n n e l i n v o l v e d i n s c r e e n i n g p r o g r a m s , and t h a t segment o f t h e p o p u l a t i o n who 106 a v a i l t h e m s e l v e s o f p r e v e n t i v e h e a l t h r e s o u r c e s . R e p o r t e d i n c i d e n c e s o f h a n d i c a p p i n g c o n d i t i o n s i n c h i l d r e n p r o v e d d i f f i c u l t t o i n t e r p r e t b e c a u s e o f t h e i d i o s y n c r a t i c n a t u r e o f e a c h p r o g r a m ; i . e . , v a r i a t i o n s i n t h e a g e s o f t h e s u b j e c t s s c r e e n e d , t h e u s e o f n o n - s t a n d a r d a nd o b f u s c a t i n g t e r m i n o l o g y , d i f f e r e n c e s i n q u a l i f i c a t i o n s and s k i l l l e v e l s o f t h e p e r s o n n e l i n v o l v e d , a n d t h e d e a r t h o f f o l l o w - u p s t u d i e s . The p o p u l a t i o n i n v o l v e d i n t h e p r e s e n t s t u d y a r e t h e 4 7 c h i l d r e n a n d t h e i r p a r e n t s who w e r e t h e c l i e n t s o f t h e s c r e e n i n g c l i n i c f o r 3 - y e a r - o l d s d u r i n g i t s f i r s t t h r e e months o f o p e r a t i o n . The c h i l d r e n w e r e s c r e e n e d by a team o f t h r e e c o m m u n i t y h e a l t h n u r s e s , a s p e e c h t h e r a p i s t , and a d e n t a l h y g i e n i s t . The s c r e e n i n g r o u t i n e s w e re d e s i g n e d t o a s s e s s d e v e l o p m e n t a l l e v e l , v i s i o n , h e a r i n g , s p e e c h a nd l a n g u a g e , n u t r i t i o n a l s t a t u s , a n d d e n t a l h e a l t h . P h o t o g r a p h s a r e p r o v i d e d t o i l l u s t r a t e t h e s e p r o c e d u r e s . The d a t a on t h e s t u d y p o p u l a t i o n w e r e o b t a i n e d f r o m t h e h e a l t h d e p a r t m e n t ' s c l i e n t r e c o r d s a nd f r o m two o r i g i n a l q u e s t i o n n a i r e s a n d a c l i n i c r e s u l t s f o r m d e s i g n e d b y t h e r e s e a r c h e r . The d a t a w e r e c o d e d t o e n s u r e c o n f i d e n t i a l i t y a n d w e r e m a c h i n e - t a b u l a t e d a nd a n a l y z e d , p r o d u c i n g f r e q u e n c y and p e r c e n t a g e t a b l e s f o r s e l e c t e d v a r i a b l e s . A few v a r i a b l e s w e r e c r o s s - t a b u l a t e d t o add d e s c r i p t i v e d e p t h t o t h e s t u d y . T a b l e s a r e u s e d t o d i s p l a y t h e s e l e c t e d v a r i a b l e s . The q u e s t i o n n a i r e s and o t h e r f o r m s d e v i s e d f o r t h e s t u d y , and t h e f o r m s u s e d b y t h e c l i n i c s t a f f , a r e i n c l u d e d i n a p p e n d i c e s . 107 The s t u d y r e v e a l e d t h a t t h e i n i t i a l c l i e n t e l e o f t h e new c l i n i c was d r a w n p r e d o m i n a n t l y f r o m t h e h i g h e r s o c i o e c o n o m i c s t r a t a o f t h e c o m m u n i t y . M o s t o f t h e c h i l d r e n h a d b e e n e x p o s e d t o an a r r a y o f c o m m u n i t y h e a l t h r e s o u r c e s . N o n e t h e l e s s , 51 p e r c e n t o f them w e r e f o u n d by t h e c l i n i c s t a f f t o h a v e p r o b l e m s r e q u i r i n g f u r t h e r i n v e s t i g a t i o n and p o s s i b l e i n t e r v e n t i o n . The commonest r e a s o n s f o r r e f e r r a l w e r e p r o b l e m s r e l a t e d t o v i s i o n , b e h a v i o r , and s p e e c h and l a n g u a g e . The t r u e i n c i d e n c e o f t h e s e and o t h e r p r o b l e m s c a n n o t be c o n f i r m e d w i t h o u t a f o l l o w - u p s t u d y a s p r o p o s e d i n t h e s u g g e s t i o n s f o r f u t u r e s t u d i e s . R e c o m m e n d a t i o n s The f i r s t r e c o m m e n d a t i o n a r i s i n g f r o m t h i s s t u d y i s t h a t a l l p a r e n t s a t t e n d i n g t h e s c r e e n i n g c l i n i c r e c e i v e a f o l l o w - u p t e l e p h o n e c a l l o r home v i s i t t o d i s c u s s t h e r e s u l t s o f t h e t e s t i n g p r o c e d u r e s . T h i s s t u d y h a s shown t h a t t h e new s c r e e n i n g c l i n i c i s n o t r e a c h i n g a l l o f i t s p o t e n t i a l c l i e n t e l e , a nd t h e p a r t o f t h e c o m m u n i t y t h a t i s n o t u s i n g i t s s e r v i c e s may c o n t a i n t h o s e c h i l d r e n m o s t a t r i s k o f h a n d i c a p p i n g c o n d i t i o n s . T h e r e f o r e , a d d i t i o n a l m e a s u r e s a r e n e e d e d t o p r o m o t e more w i d e s p r e a d u s e o f t h i s f a c i l i t y . C l i n i c s e s s i o n s m i g h t be h e l d i n t h e e v e n i n g t o e n a b l e p a r e n t s i n t h e w o r k f o r c e t o a t t e n d . The l o c a t i o n o f t h e c l i n i c c o u l d be r o t a t e d i n n e i g h b o r h o o d s , p e r h a p s u s i n g u n o c c u p i e d s c h o o l r o o m s , t o 108 e l i m i n a t e t r a n s p o r t a t i o n p r o b l e m s f o r some p a r e n t s . S c r e e n i n g p r o c e d u r e s c o u l d be c o n d u c t e d i n Day C a r e a n d P l a y S c h o o l s e t t i n g s . A n o t h e r r e c o m m e n d a t i o n t h a t c o u l d e n s u r e t h e m o s t e f f i c i e n t u s e o f t h e s c r e e n i n g c l i n i c i s t h e m a i l i n g o f a d e v e l o p m e n t a l q u e s t i o n n a i r e t o e l i g i b l e p a r e n t s i n t h e c o m m u n i t y . T h o s e c h i l d r e n whose p a r e n t s r e p o r t e d s u s p i c i o u s f i n d i n g s w o u l d be g i v e n a p r i o r i t y t o a t t e n d t h e c l i n i c . B e c a u s e o f t h e many c o n c e r n s t h e m o t h e r s h a d a b o u t p r o b l e m s o f b e h a v i o r a n d t h e many r e f e r r a l s made f o r t h a t r e a s o n , t h e c l i n i c s t a f f c o u l d u s e f u l l y be augmen t e d b y a n o t h e r n u r s e , o r a c h i l d p s y c h o l o g i s t , g i v e n t i m e t o d i s c u s s t h e s e c o n c e r n s . The e x c h a n g e o f i n f o r m a t i o n among d e v e l o p m e n t a l s c r e e n i n g c l i n i c s i n B r i t i s h C o l u m b i a i s i n a d e q u a t e . I t i s recommended t h a t t e r m i n o l o g y u s e d a nd m e t h o d s o f r e p o r t i n g be s t a n d a r d i z e d t o f a c i l i t a t e i n f o r m a t i o n - s h a r i n g a n d t h e c o m p i l a t i o n o f s t a t i s t i c a l d a t a . S h a r p h a s w r i t t e n P r e v e n t i v e m e d i c i n e i s c o m p l e t e l y d e p e n d e n t upon p r o d u c i n g s t a t i s t i c a l e v i d e n c e o f i t s s u c c e s s . No g r a t e f u l p a t i e n t s , r e l i e v e d o f t h e i r symptoms, s i n g i t s p r a i s e s . The g r e a t e r t h e s u c c e s s i n p r e v e n t i o n t h e l e s s l i k e l y w i l l t h e r e be p u b l i c a p p r e c i a t i o n , b e c a u s e i t i s t a k e n f o r g r a n t e d . ( S h a r p and K e e n , 196 8, p. 9) . F i n a l l y , c o m m u n i t y h e a l t h n u r s e s n e e d t o p r o m o t e t h e i r s e r v i c e s i n t h e c o m m u n i t y more a c t i v e l y . T h i s s t u d y h a s , 109 r e v e a l e d t h a t t h e p a r e n t s i n t h e c o m m u n i t y h a v e a n e e d f o r t h e i r s e r v i c e s a nd n u r s e s h a v e t h e s k i l l s t o r e s p o n d t o t h a t n e e d . 110 BIBLIOGRAPHY B a r n e s , K e i t h E. and S t a r k , A n n e t t e . "The D e n v e r D e v e l o p m e n t a l S c r e e n i n g T e s t : A N o r m a t i v e S t u d y . " A m e r i c a n J o u r n a l o f P u b l i c H e a l t h , V o l . 6 5 , No. 4, A p r i l 1 9 7 5 , pp. 3 6 3 - 369. B a t e s , B a r b a r a . A G u i d e t o P h y s i c a l E x a m i n a t i o n . P h i l a d e l p h i a , J . B . L i p p i n c o t t C o., 1974. B e a r d , R u t h M. An O u t l i n e o f P i a g e t ' s D e v e l o p m e n t a l P s y c h o l o g y f o r S t u d e n t s and T e a c h e r s . New Y o r k , The New A m e r i c a n L i b r a r y , 1 972. B e n s o n , K . I . G . "The P r e - S c h o o l C h i l d — ' F o r g e t - M e - N o t 1 . " C a n a d i a n J o u r n a l o f P u b l i c H e a l t h , V o l . 6 0 , No. 4, A p r i l 1 9 6 9 , pp. 1 4 1 - 1 4 6 . B e n s o n , K.I.G. and B e a t t i e , A l i c e . "A New A p p r o a c h t o t h e S c h o o l H e a l t h P r o g r a m . " C a n a d i a n J o u r n a l o f P u b l i c H e a l t h , V o l . 5 5 , No. 9, S e p t e m b e r 196 4, pp.. 3 7 1-379. B i r c h , H e r b e r t G. a n d Gussow, J o a n D. D i s a d v a n t a g e d C h i l d r e n : H e a l t h , N u t r i t i o n a n d S c h o o l F a i l u r e . New Y o r k , H a r c o u r t , B r a c e & W o r l d , I n c . , 1970. B l o o m , B e n j a m i n S. S t a b i l i t y a n d Change i n Human C h a r a c t e r i s t i c s . New Y o r k , J o h n W i l e y and S o n s , I n c . , 1964. B o u d r e a u , Thomas J . , C h a i r m a n . R e p o r t o f t h e C o m m i t t e e on N u r s e P r a c t i t i o n e r s . O t t a w a , H e a l t h and W e l f a r e C a n a d a , 1972. B ower, E.M. E a r l y I d e n t i f i c a t i o n o f E m o t i o n a l l y H a n d i c a p p e d C h i l d r e n i n S c h o o l . S p r i n g f i e l d , 1 1 1 . , C h a r l e s C. Thomas, 1969. B r i c k e r , W.A. a n d B r i c k e r , D.D. "An E a r l y L a n g u a g e T r a i n i n g S t r a t e g y . " L a n g u a g e P e r s p e c t i v e s : A c q u i s i t i o n , R e t a r d a t i o n , and I n t e r v e n t i o n , e d . R.L. S c h i e f e l b u s c h a nd L . L . L l o y d . B a l t i m o r e , MD., U n i v e r s i t y P a r k P r e s s , 1974, p p . 4 31-468. B r i n t o n , D.M. " H e a l t h C e n t e r M i l i e u : I n t e r a c t i o n o f N u r s e s and Low-Income F a m i l i e s . " N u r s i n g R e s e a r c h , V o l . 2 1 , N o . l , J a n u a r y - F e b r u a r y 1972, p p . 46-52. B r u c e , C y n t h i a B. "An I n t r o d u c t i o n t o S t u t t e r i n g . " C a n a d i a n N u r s e , V o l . 68, No. 8, A u g u s t 1 9 7 2 , pp. 24-26. 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" C a n a d i a n J o u r n a l o f P u b l i c H e a l t h , V o l . 6 3 , No. 1, J a n u a r y - F e b r u a r y 1 9 7 2 , pp. 67-68. C h e r r y , B . J . and K u b y , A.M. " O b s t a c l e s t o t h e D e l i v e r y o f M e d i c a l C a r e t o C h i l d r e n o f N e g l e c t i n g P a r e n t s . " A m e r i c a n J o u r n a l o f P u b l i c H e a l t h , V o l . 6 1 , No. 3, M a r c h 1 9 7 1 , pp. 5 6 8 - 5 7 3 . C o k i n , M., C o l l i g a n , E. and F e r r e r , R. " H e l p i n g P a r e n t s i n a P e d i a t r i c C l i n i c . " C h i l d W e l f a r e , V o l . L, No. 9, November 1 9 7 1 , pp. 5 0 4 - 5 0 9 . C o n s t a b l e , P . J . " U r i n a r y I n f e c t i o n . " S c r e e n i n g i n G e n e r a l P r a c t i c e , e d . C.R. H a r t . E d i n b u r g h , C h u r c h i l l L i v i n g s t o n e ( M e d i c a l D i v i s i o n o f Longman G r o u p L t d . ) , 1 9 7 5 , p p . 163 - 1 7 6 . C r i c h t o n , J.U. " V e n t u r e t o t h e E x t e r i o r : D o c t o r s i n t h e B o r d e r l a n d B e t w e e n M e d i c i n e and E d u c a t i o n . " B r i t i s h C o l u m b i a M e d i c a l J o u r n a l , V o l . 1 7 , No. 1 1 , November 19 7 5 , p p . 3 7 9 - 3 8 1 . C u r t i s J e n k i n s , G.H. "The P r e - S c h o o l C h i l d . " S c r e e n i n g i n G e n e r a l P r a c t i c e , e d . C.R. H a r t . E d i n b u r g h , C h u r c h i l l L i v i n g s t o n e ( M e d i c a l D i v i s i o n o f Longman G r o u p L t d . ) , 1 9 7 5 , p p . 91-100. D a v i e , R., B u t l e r , N e v i l l e , a n d G o l d s t e i n , H a r v e y . S t u d i e s i n C h i l d D e v e l o p m e n t . L o n d o n , Longman G r o u p L t d . , 1972. D a v i s , R. H a r v a r d . "The S c h o o l C h i l d . " S c r e e n i n g i n G e n e r a l P r a c t i c e , e d . C.R. H a r t . 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"A P r e s c h o o l S c r e e n i n g P r o g r a m on C e n t r a l V a n c o u v e r I s l a n d : A Two-Year F o l l o w - Up." C a n a d i a n J o u r n a l o f P u b l i c H e a l t h , V o l . 6 5 , No. 5, S e p t e m b e r - O c t o b e r 197 4 , pp. 383-387. T i t m u s S t e r e o T e s t s . P e t e r s b u r g , V a . , T i t m u s , O p t i c a l Co., I n c . T o n k i n , R o g e r S., R o b i n s o n , G e o f f r e y C. and K i n n i s , C l a i r e . "A S t u d y o f K i n d e r g a r t e n C h i l d r e n i n T h r e e S o c i o e c o n o m i c A r e a s o f B r i t i s h C o l u m b i a . " H e a l t h S e r v i c e s R e p o r t s , V o l . 88, No. 10, December 1 9 7 3 , pp. 9 4 7 - 9 5 5 . U p r i c h a r d , M u r i e l . "The E d u c a t i o n o f N u r s e s . " C a n a d i a n N u r s e , V o l . 6 8 , No. 6, J u n e 19 7 2 , pp. 30-36. 118 V a n c o u v e r H e a l t h D e p a r t m e n t . H e a l t h 1975 ( A n n u a l R e p o r t ) . V a n c o u v e r , B.C., M e t r o p o l i t a n H e a l t h S e r v i c e s . W a l l a c e , H.M. "The R o l e o f M a t e r n a l and C h i l d H e a l t h i n a N a t i o n a l H e a l t h S e r v i c e . " C h i l d r e n T o d a y , V o l . 4, M a r c h - A p r i l 1 9 7 5 , pp. 2-6. Weber, K i r s t e n . " C u r r e n t C o n c e p t s i n Community H e a l t h N u r s i n g a n d T h e i r I m p l i c a t i o n s f o r t h e S e c o n d a r y S c h o o l H e a l t h S e r v i c e s i n B r i t i s h C o l u m b i a . " C a n a d i a n J o u r n a l o f P u b l i c H e a l t h , V o l . 6 3 , No. 2, M a r c h - A p r i l 1 9 7 2 , pp. 1 3 7 - 1 4 2 . W h i t e , B u r t o n L. The F i r s t T h r e e Y e a r s o f L i f e . E n g l e w o o d C l i f f s , N . J . , P r e n t i c e - H a l l , I n c . , 1975.. W i l s o n , B e v e r l e y . D e s c r i p t i o n o f t h e R i c h m o n d , B.C., 3 - Y e a r - O l d S c r e e n i n g C l i n i c . P e r s o n a l c o m m u n i c a t i o n , May 25, 1976. W i l s o n , J.M.G. and J u n g n e r , G. P r i n c i p l e s and P r a c t i c e o f S c r e e n i n g f o r D i s e a s e . G e n e v a , W o r l d H e a l t h O r g a n i z a t i o n , 1968. W i n t l e , C . J . , C l a y , S. and D a v i s , R.H. "The S c h o o l M e d i c a l E x a m i n a t i o n i n an I n t e g r a t e d G r o u p P r a c t i c e . " J o u r n a l o f t h e R o y a l C o l l e g e o f G e n e r a l P r a c t i t i o n e r s , V o l . 22, No. 118, May 1 9 7 2 , pp. 327-329. W o l f , D o r e e n . U n p u b l i s h e d L e c t u r e . P u b l i c H e a l t h N u r s i n g I n s t i t u t e , E s s o n d a l e , B.C., M a r c h 2, 1976. W y a t t , G e r t r u d . E a r l y I d e n t i f i c a t i o n o f C h i l d r e n - w i t h P o t e n t i a l L e a r n i n g D i s a b i l i t i e s : R e p o r t o f T i t l e V I P r o j e c t , 19 6 8- 69. W e l l e s l e y ( M a s s a c h u s e t t s ) P u b l i c S c h o o l s , 1970. 120 I How d i d you hear about t h i s c l i n i c ? ( ) Community Health Nurse ( ) Day Care Centre n o t i c e ( ) F r i e n d or neighbor ( ) Newspaper n o t i c e ( ) Play School n o t i c e ( ). School Parent b u l l e t i n ( ). Other (Please s p e c i f y ) II How d i d you get to the c l i n i c ? ( ) Bus ( ) Family car ( ) Friend's car ( ) Walked ( ) Other (Please s p e c i f y ) I I I Has your c h i l d ever been to one or more of these h e a l t h resources? ( I f more than one category i s app- l i c a b l e , please rank i n order of frequency of v i s i t s , w i t h 1 as the most f r e q u e n t l y attended.) ( ) Dental C l i n i c ( ) D e n t i s t ( ) Emergency Department ( ) General P r a c t i t i o n e r ( ) P e d i a t r i c i a n ( ) Well-Baby C l i n i c ( ) Other h e a l t h - c a r e agency (Please s p e c i f y ) ( ) None of these IV Approximately when, i f ever, d i d 1-6 6-12 More than your c h i l d l a s t v i s i t each of these? mos. mos. 1 year Never ago ago ago Dental C l i n i c ( ) ( ) ( ) ( ) D e n t i s t ( ) ( ) ( ) • ( ) Emergency Department ( ) ( ) ( ) ( ) General P r a c t i t i o n e r ( ) ( ) ( ) ( ) P e d i a t r i c i a n ' ( ) ( ) ( ) ( ) Well-Baby C l i n i c ( ) ( ) ( ) ( ) Other h e a l t h - c a r e agency ( ) ( ) ( ) ( ) (Please s p e c i f y ) 121 Has your c h i l d been t r e a t e d f o r a problem i n one or more of the areas l i s t e d at r i g h t ? ( ,) Dental h e a l t h ( ) Hearing ( ) N u t r i t i o n ( ) P h y s i c a l h e a l t h (Please s p e c i f y ) ( ) Behavior (Please s p e c i f y ) ( ) Speech or language ( ) V i s i o n ( ) Other (Please s p e c i f y ) ( ) None of the above VI Do you t h i n k your c h i l d might have a problem i n one or more of these aspects o f development? ( ) Dental h e a l t h ( ) Hearing ( ) N u t r i t i o n ( ) P h y s i c a l h e a l t h (Please s p e c i f y ) ( ) Behavior (Please s p e c i f y ) ( ) Speech or language ( ) V i s i o n ( ) Other (Please s p e c i f y ) ( ) None of the above Note t o Questions V and V I : " P h y s i c a l h e a l t h " problems might i n c l u d e such things as ear i n f e c t i o n s , surgery, pneumonia, a l l e r g i e s , poor c o - o r d i n a t i o n , e t c . "Behavior" problems might i n c l u d e such t h i n g s as temper tantrums, disobedience, f i g h t i n g , bed-wetting, e t c . VII Who would you turn to f o r advice ( ) Child-care book i f your c h i l d became i l l with a fever, ( ) Community Health Nurse an unusual rash, a severe c o l d , etc.? ( ) Druggist (Please indicate f i r s t choice with 1, ( ) Friend or neighbor second choice with 2, etc.) ( ) General P r a c t i t i o n e r ( ) Husband (or wife) ( ) P e d i a t r i c i a n ( ) Relative (mother, s i s t e r , aunt, etc.) ( ) No one VIII Who would you turn to f o r advice ( ) Child-care book i f your c h i l d became d i f f i c u l t to ( ) Community Health Nurse manage because of problems at the ( ) Friend or neighbor table, with t o i l e t - t r a i n i n g , ( ) General P r a c t i t i o n e r disobedience, etc.? ... ( ) Husband (or wife) (Please indicate f i r s t choice with 1, ( ) P e d i a t r i c i a n second choice with 2, etc.) ( ) Rela t i v e (mother, s i s t e r , aunt, etc.) ( ) No one IX Which age-bracket are you now in? ( ) 19 or under ( ) 20 to 24 ( ) 25 to 29 ( ) 30 to 34 ( ) 35 to 39 f ) 40 or over Father Mother X What l e v e l of formal education ( ) ( ) U n i v e r s i t y degree have you and your spouse ( ) ( ) Some u n i v e r s i t y completed to date? ( ) ( ) Technical or vocat- ional program ( ) ( ) Business school ( ) ( ) Grade 12 ( ) ( ) Grade 9-11 ( ) ( ) Grade 8 ( ) Other (Please specify) ( ) Other (Please specify) H 1 7 3 - M L H-70 NAME Sex Surname BIRTHDATE Given name BIRTHPLACE Pre-S MH CAS TB CASE TB CON. RHC Day Month Year FATHER'S NAME MOTHER'S NAME OCCUPATION OCCUPATION No. of children in family BUS. PHONE BUS. PHONE W 1 ( ii_r\ ________ — • 1—•—— HISTORY: Give dates IMMUNIZATION DATES: COMMUNICABLE DISEASE OTHER ILLNESSES Date and Dose Date Chicken Pox Allergies, Skin D.P.T. Small- pox P.T. N.T. Oral Polio Meas- les Other Measles Allergies, Resp. 1. Mumps Convulsive Disorders 2. Rubella Accidents 3. Scarlet Fever Operations 4 . Whooping Cough Other 5. 6. Infectious Diarrhoea Staph. Infection Tuberculin Test Date Dose Result TU BCG Vacc'n Other Hearing at 6 months TU Date TU > w a o H X ro 5. 2. Year C.H. Center or Kdgten. Unit Home Address Phone to NAME Birth Date Birth Wt. Family Doctor MOTHER INFANT OR PRESCHOOL Prenatal Supervision from Prenatal Classes attended: Month Total number of pregnancies: Illnesses during pregnancy: Condition at birth: Feeding History: Behaviour: Delivery: Postpartum fcllow-up: Remarks: Siblings: Birth Year Name Birth.Year Date Wt. Age Feeding NOTES Literature & Surname APPENDIX C 125 DATA SUMMARY FORM D a t e P a t i e n t N o . 01 02 03 04 05 06 07 08 09 10 S BP FO MO R PN BW F d g . I A g e S e x - 1 i s m a l e , 2 i s f e m a l e . B i r t h P l a c e - 1 i s G r e a t e r V a n c o u v e r , 2 i s e l s e w h e r e i n C a n a d a , 3 i s a n y w h e r e e l s e . F a t h e r ' s O c c u p a t i o n ) r _ ? a c c o r d i n g t o H o l l i n g s h e a d ' s s c a l e M o t h e r ' s O c c u p a t i o n ) a n d 8 f o r f u l l - t i m e h o u s e w i f e Rank - 1 i s o n l y c h i l d , 2 / 3 i s 2nd o f 3 c h i l d r e n , e t c . P r e n a t a l - 0 i f n e v e r a t t e n d e d c l a s s e s , 1 i f d i d a t t e n d , 2 i f a t t e n d e d d u r i n g p r e v i o u s p r e g n a n c y . B i r t h W e i g h t - E x a c t w e i g h t t o b e r e c o r d e d ( i n t e r v a l s t o b e u s e d i n a n a l y s i s ) . F e e d i n g - 1 f o r b r e a s t , 2 f o r b o t t l e . I m m u n i z a t i o n S t a t u s - 1 i f a l l i m m u n i z a t i o n s up t o d a t e , 2 i f n e e d s f u r t h e r i m m u n i z i n g , 3 i f n e v e r i m m u n i z e d . A g e - R e c o r d e d i n m o n t h s . 126 APPENDIX D Health Department 3-Year-Old Screening Clinic Date No. Attending 2 3 4 5 6 7 8 9 10 Patient Referral Record: Patient No. Problem No. Previously known? Referred to: 1 t 3 A 5 6 7 8 9 10 APPENDIX K 127 UBC GRADUATE STUDENT RESEARCH STUDY Q u e s t i o n n a i r e No. 2 on a Community H e a l t h D e p a r t m e n t ' s 3 - Y e a r - 0 1 d S c r e e n i n g C l i n i c (To be a d m i n i s t e r e d by t h e r e s e a r c h e r by t e l e p h o n e ) D a t e Code No. 1 How d i d y o u r c h i l d r e a c t t o t h e e x p e r i e n c e o f b e i n g t e s t e d a t t h e c l i n i c ? ( ) F r i g h t e n e d ( ) C o n f u s e d ( ) C o o p e r a t e d w e l l ( ) C o o p e r a t e d e n t h u s i a s t i c a l l y ( ) O t h e r ( S p e c i f y ) 2 Was any a s p e c t o f t h e e x p e r i e n c e p a r t i c u l a r l y d i s t r e s s i n g t o y o u r c h i l d ? ( ) No ( ) Y e s ( S p e c i f y ) D i d y o u l e a r n a n y t h i n g a b o u t t h e s t a t e o f y o u r c h i l d ' s h e a l t h and d e v e l o p m e n t t h a t y o u d i d n ' t know b e f o r e ? ( ) No ( ) Y e s ( S p e c i f y ) D i d t h e r e s u l t s o f y o u r c h i l d ' s s c r e e n i n g g i v e y o u r e a s s u r a n c e ? ( ) No ( ) Y e s ( ) C a n ' t s a y Do y o u t h i n k t h a t t a k i n g y o u r c h i l d t o t h e c l i n i c was u s e f u l t o y o u a s a p a r e n t ? ( ) No ( ) Y e s ( ) No o p i n i o n Do y o u f e e l t h a t t h e c l i n i c h a s h e l p e d t o d e t e c t any p r o b l e m s t h a t m i g h t l a t e r h a v e a f f e c t e d y o u r c h i l d ' s p e r f o r m a n c e i n s c h o o l ? ( ) No ( ) Y e s ( ) C a n ' t s a y 128 7 What d i d y o u l i k e o r d i s l i k e a b o u t t h e c l i n i c ? Time o f d a y Day o f week L o c a t i o n P e r s o n n e l T e s t i n g t e c h n i q u e O t h e r L i k e d D i s l i k e d No O p i n i o n ) ( S p e c i f y ) ( ) ( ) ( ) ( S p e c i f y ) D i d t h e c l i n i c s t a f f i m p r e s s y o u a s : ( ) ( ) ( ) C o m p e t e n t I n c o m p e t e n t O t h e r ( S p e c i f y ) ( ) No o p i n i o n D i d t h e t e s t p r o c e d u r e s a p p e a r t o y o u t o S c i e n t i f i c U n s c i e n t i f i c O t h e r be ( ) ( ) ( ) ( ) No o p i n i o n ( S p e c i f y ) 10 Our r e c o r d s show t h a t y o u r c h i l d was r e f e r r e d b y t h e c l i n i c t o t h e f o l l o w i n g a g e n c y / a g e n c i e s : A g e n c y A g e n c y A g e n c y A D i d y o u t a k e y o u r c h i l d t o A g e n c y A g e n c y A g e n c y 1 2 3 ( ) ( ) ( ) No No No ( ) ( ) ( ) Y e s Y e s Y e s B ( I f a n s w e r t o any o f t h e a b o v e i s Y e s , c o n t i n u e w i t h B; i f No, s k i p t o D.) D i d t h e a g e n c y / a g e n c i e s t o w h i c h y o u w e r e r e f e r r e d a g r e e w i t h t h e c l i n i c n u r s e s ' r e a s o n s f o r r e f e r r i n g y o u ? A g e n c y A g e n c y A g e n c y 1 2 3 ( ) ( ) ( ) No No No ( ) ( ) ( ) Y e s Y e s Y e s Has any t e s t i n g o r t r e a t m e n t o f y o u r c h i l d b e e n s t a r t e d by t h e a g e n c y / a g e n c i e s ? A g e n c y 1 A g e n c y 2 A g e n c y 3 ( ) ( ) ( ) No No No ( ) ( ) ( ) Y e s Y e s Y e s 129 D I f y o u d i d n o t t a k e y o u r c h i l d t o t h e r e f e r r e d - t o a g e n c y / a g e n c i e s , c o u l d y o u p l e a s e t e l l me why? A g e n c y 1 A g e n c y 2 A g e n c y 3 11 Do y o u t h i n k t h e 3 - Y e a r - 0 1 d S c r e e n i n g C l i n i c i s a u s e f u l s e r v i c e f o r y o u r P u b l i c H e a l t h D e p a r t m e n t t o p r o v i d e ? ( ) No ( ) Y e s ( ) No o p i n i o n 12 W o u l d y o u recommend t h e c l i n i c t o y o u r f r i e n d s ? ( ) No ( ) Y e s ( ) N o t s u r e 13 W o u l d y o u c a r e t o make a n y a d d i t i o n a l comments a b o u t t h e c l i n i c o r i t s s e r v i c e ? PREVIOUSLY COPYRIGHTED MATERIAL, LEAVES 130-131, IN APPENDIX E, NOT MICROFILMED, DENVER DEVELOPMENTAL SCREENING TEST © 1969, WILLIAM K.v FRANKENBURG, M.D, and JOSIAH B, DODDS, PHD, UNIVERSITY OF COLORADO MEDICAL CENTER, DENVER, COLORADO, U.S.A. M O N T H S 1 2 14 15 16 17 18 19 20 21 22 23 24 YEARS Vh 3 3Vi _ 5 S'/i « I I I REGARDS FACE SMILES RESPONS I vaY INITIALLY SHY WITH STRANGERS 1 IMITATES HOUSEWORK PUTS O N CLOTHING PLAYS PAT-A-CAKE SMILES S P O N T A N E O U S L Y * 1 0 0 % pass at birth I I FEEDS SELF CRACKERS RESISTS TOY PULL 5 0 % PLAYS PEEK-A-BOO WORKS FOR TOY O U T OF REACH PLAYS BALL WITH EXAMINER INDICATES W A N T S (NOT CRY) DRINKS FROM CUP USES S P O O N , SPILLING LITTLE WASHES & DRIES H A N D S BUTTONS UP HELPS IN HOUSE - SIMPLE TASKS REMOVES G A R M E N T DRESSES WITH SUPl SEPARATES F R O M RVISION lAOTHER EASILY PLAYS INTERACTIVE G A M E S e.g., T A G I I I I I I 1 I I I I ES WITHOUT SUPERVISION I I I I 1 I I 1 I FOLLOWS T O MIDLINE | _ S _ l _ l • * EQUAL M O V E M E N T S FOLLOWS PAST MIDLINE GRASPS RATTLE SIT, L O O K S FOR Y A R N REGARDS RAISIN SIT, TAKES 2 CUBES SCRIBBLES SPONTANEOUSLY TOWER O F 2 CUBES REACHES FOR OBJECT B A N G S 2 CUBES HELD IN H A N D S TOWER O F 4 CUBES IMITATES BRIDGE COPIES • DEMONSTR. TOWER O F 8 CUBES FOLLOWS 180 H A N D S TOGETHER RAKES RAISIN ATTAINS PASSES CUBE H A N D T O H A N D NEAT PINCER GRASP O F RAISIN IMITATES VERTICAL LINE WITHIN 30 M A N 3 PARTS THUMB-FINGER GRASP DUMPS RAISIN FROM BOTTLE-SPONT DUMPS RAISIN FROM BOTTLE-DEMONSTR I I I I I I I I I 3 W O R D S OTHER T H A N M A M A , D A D A I I I DRAWS M A N 6 PARTS KS LONGER LINE JOMPREHENDS O L D , IRED, H U N G R Y / 2 COMPREHENDS PREPOSITIONS/3 I I I I RESPONDS T O BELL VOCALIZES - N O T CRYING D A D A OR M A M A , NONSPECIF IC TURNS T O VOICE COMBINES 2 DIFFERENT W O R D S D A D A OR M A M A , SPECIFIC POINTS T O 1 N A M E D BODY PART N A M E S 1 PICTURE E L i IMITATES SPEECH S O U N D S M C O G N I Z E S COLC RS/3o f 4 ANA I DGIES F O L L O W S DIRECTIONS/2 of 3 OPPOSITE t 2 of 3 USES PLURALS DEFINES W O R D S / 6 of 9 I I I I I I I 1 — I - STANDS MOMENTARILY WALKS HOLDING O N FURNITURE STANDS A L O N E WELL GIVES 1ST & LAST N A M E I I I I I I COMPOS IT ION O F / 3 of 3 I I I I I I , STO LIFTS 1 HEAD STO HEAD UP . BEAR S O M E WEIGHT O N LEGS PULL T O SIT N O HEAD L A G KICKS BALL F O R W A R D T H R O W S BALL O V E R H A N D BALANCE O N 10 S E C O N D S / 2 F O O T If 3 HOPS O N 1 F O O T STO HEAD UP 9 0 " SITS WITHOUT SUPPORT B A L A N C E O N 1 F O O T 1 S E C O N D C A T T H E S BAL[ B O U N C E D / 2 o f 3 STO CHEST UP A R M SUPPORT SIT - HEAD STEADY STANDS HOLDING O N PULLS SELF T O S T A N D STOOPS & RECOVERS WALKS WELL JUMPS IN PLACE PEDALS TRICYCLE E GETS T O SITTING WALKS BACKWARDS B R O A D JUMP WALKS UP STEPS 5 SEC: BALANCE O N 1 F O O T O N D S / 2 of 3 T O E W A L K / 2 of 3 B A C K W A R D HEEL - T O E / 2 of 3 1 2 M O N T H S 14 15 16 17 18 19 20 21 22 23 24 2V4 3 YEARS DIRECTIONS DATE NAME BIRTHDATE HOSP. NO. 1. 2. 3. k. 5- 6. Try to get c h i l d to smile by smiling, t a l k i n g or waving to him. Do not touch him. When c h i l d i s playing with toy, p u l l i t away from him. Pass i f he r e s i s t s . Child does not have to "be able to t i e shoes or button i n the back. Move yarn.slowly i n an arc from one side to the other, about 6" above child's face. Pass i f eyes follow 90° to midline. (Past midline; 180°) Pass i f c h i l d grasps r a t t l e when i t i s touched to the backs or t i p s of fingers. Pass i f chil d continues to look where yarn disappeared, or t r i e s to see where i t went. Yarn should be dropped, quickly from sight from tester's hand without arm movement. Pass i f c h i l d picks up r a i s i n with any part of thumb and. a finger. Pass i f c h i l d picks up r a i s i n with the ends of thumb and index finger using an over hand approach. 9. Pass any en- closed form. F a i l continuous round motions. 10. Which li n e i s longer? (Not bigger.) Turn paper upside down and repeat. (3/3 or 5/6) 11. Pass any crossing l i n e s . 12. Have c h i l d copy f i r s t . I f f a i l e d , demonstrate When giving items 9, 11 and 12, do not name the forms. Do not demonstrate 9 and 11. 13- When scoring, each pair (2 arms, 2 legs, -etc.) counts as one part. Ik. Point to picture and have child, name i t . (No credit i s given for sounds only.) 15. 16. 17. 18. 19. 20. 21. 22. 23. 2k. 25. 26. 27. 28. DATE •Tell c h i l d to: Give block to Mommie; put block on table; put block on f l o o r . Pass 2 of 3- (Do not help c h i l d by pointing, moving head or eyes.) Ask c h i l d : What do you do when you are cold? ..hungry? ..tired? Pass 2 of 3- T e l l c h i l d to: Put block on table; under table; i n front of chair, behind chair. Pass 3 of k. (Do not help c h i l d by pointing, moving head or eyes.) Ask c h i l d : I f f i r e i s hot, ice i s ?; Mother i s a woman, Dad i s a ?; a horse i s b i g , a mouse i s ?. Pass 2 of 3- Ask c h i l d : What i s a b a l l ? ..lake? ..desk? ..house? ..banana? ..curtain? ..ceiling? ..hedge? ..pavement? Pass i f defined i n terms of use, shape, what i t i s made of or general category (such as banana i s f r u i t , not just yellow). Pass 6 of 9- Ask c h i l d : What i s a spoon made of? ..a shoe made of? ..a d.oor made of? (No other objects may be substituted.) Pass 3 of 3- When placed on stomach, c h i l d l i f t s chest off table with support of forearms and/or hands. When c h i l d i s on back, grasp his hands and p u l l him to s i t t i n g . Pass i f head does not hang back. Child may use w a l l or r a i l only, not person. May not crawl. Child, must throw b a l l overhand 3 feet to within arm's reach of tester. Child must perform standing broad jump over width of test sheet. (8-1/2 inches) T e l l c h i l d to walk forward, ccOocOCfcOGO-^- heel within 1 inch of toe. Tester may demonstrate. Child must walk k consecutive steps, 2 out of 3 t r i a l s . Bounce b a l l to c h i l d who should stand 3 feet away from tester. C h i l d must catch b a l l with hands, not arms, 2 out of 3 t r i a l s . T e l l c h i l d to walk backward, ^ - C O c Q c O C O toe within 1 inch of heel. Tester may demonstrate. Child must walk k consecutive steps, 2 out of 3 t r i a l s . AND BEHAVIORAL OBSERVATIONS (how child, feels at time of test, r e l a t i o n to tester, attention span, verbal behavior, self-confidence, etc , ) : 157. 10-70 D i s t r i b u t e d as a s e r v i c e by M e ad Johnson L a b o r a t o r i e s M O N T H S 1 2 3 SMILES RESPONSIVELY SMILES S P O N T A N E O U S L Y REG- FACE 'ARDS : INITIALLY SHY WITH S T R A N G E R S 14 15 16 17 18 19 20 21 22 23 24 YEARS 2Vi 3 5 5'A 6 ——!•—• IMITATES H O U S E W O R K PUTS O N C L O T H I N G PLAYS P A T - A - C A K E USES S P O O N , SPILLING LITTLE BU * 100% pass at birth FEEDS SELF CRACKERS RESISTS T O Y PULL 50% p mmm PLAYS P E E K - A - B O O W O R K S FOR T O Y O U T O F R E A C H PLAYS BALL WITH EXAMINER INDICATES W A N T S ( N O T CRY) DRINKS F R O M C U P W A S H E S & DRIES H A N D S F O L L O W S T O MIDLINE III I ! • — M l " EQUAL M O V E M E N T S F O L L O W S PAST MIDLINE G R A S P S RATTLE SIT, L O O K S FOR Y A R N REGARDS RAISIN SIT, TAKES 2 CUBES HELPS IN H O U S E - SIMPLE TASKS R E M O V E S G A R M E N T I I I I I I DRESSES WITH SUPERVISION 1 • • • • • • • • H H SEPARATES F R O M MOTHER EASILY PLAYS INTERACTIVE G A M E S e.g., T A G DRESSES WITHOUT SUPERVISION I 1 I I I I I I I I i I I I I I SCRIBBLES S P O N T A N E O U S L Y T O W E R O F 2 CUBES REACHES FOR OBJECT B A N G S 2 CUBES HELD IN H A N D S COPIES O T O W E R O F 4 CUBES IMITATES BRIDGE COPIES • IMITATES • D E M O N S T R . T O W E R O F 8 C U B E S F O L L O W S 180 H A N D S TOGETHER RAKES RAISIN ATTAINS PASSES CUBE H A N D T O H A N D N E A T PINCER G R A S P O F RAISIN IMITATES VERTICAL LINE WITHIN 30' THUMB-FINGER G R A S P DUMPS RAISIN F R O M BOTTLE-SPONT. DUMPS RAISIN F R O M BOTTLE -DEMONSTR I I I I I I I I I I I D R A W S M A N 3 PARTS PICKS L O N G E R LINE 3 O F 3 D R A W S M A N 6 PARTS I I I I I I I I 1 [ I I RESPONDS T O BELL VOCALIZES - N O T CRYING D A D A OR M A M A , NONSPECIF IC TURNS T O VOICE 3 W O R D S OTHER T H A N M A M A , D A D A C O M B I N E S 2 DIFFERENT W O R D S D A D A OR M A M A , SPECIFIC E POINTS T O 1 N A M E D BODY PART S Q U E A L S N A M E S 1 PICTURE IMITATES SPEECH S O U N D S F O L L O W S DIRECTIONS/2 of 3 USES PLURALS C O M P R E H E N D S C O L D , TIRED, H U N G R Y /2 of 3 C O M P R E H E N D S PREPOSITIONS/3 of 4 R E C O G N I Z E S C O L O R S /3 of 4 OPPOSITE A N A L O G I E S 2 of 3 DEFINES W O R D S / 6 of 9 GIVES 1ST & LAST N A M E I I I I I I I I I I I C O M P O S I T I O N OF/3 of 3 I I I I I I I I I I I I S T O LIFTS STO HEAD UP 45* BEAR S O M E WEIGHT O N L E G S PULL T O SIT N O HEAD L A G S T A N D S MOMENTARILY W A L K S H O L D I N G O N FURNITURE KICKS BALL F O R W A R D T H R O W S BALL O V E R H A N D B A L A N C E O N 1 F O O T 10 S E C O N D S / 2 of 3 H O P S O N 1 F O O T S T O HEAD UP 9 0 ° S T O CHEST UP A R M SUPPORT SIT - HEAD STEADY • SITS WITHOUT SUPPORT  S T A N D S H O L D I N G O N PULLS SELF T O S T A N D S T A N D S A L O N E WELL S T O O P S & RECOVERS W A L K S WELL W A L K S B A C K W A R D S B A L A N C E O N 1 F O O T 1 S E C O N D JUMPS IN PLACE PEDALS TRICYCLE C A T C H E S B O U N C E D BALL/2 of 3 HEEL T O T O E W A I K /2 of 3 B A C K W A R D HEEL - T O E/2 of 3 W A L K S UP STEPS B A L A N C E O N 1 F O O T 5 S E C O N D S / 2 of 3 to co CO II \ I, n m <"Z —i SO -n n 5 u m Z ° co CO Z o 5 z i 3 v FT § 0 V z z < m O rn < m o 2 n * 3 z o DIRECTIONS DATE NAME BIRTHDATE HOSP. NO. 131 Try to get c h i l d to smile "by smiling, t a l k i n g or waving to him. Do not touch him. When child, i s playing with toy, p u l l i t away from him. Pass i f he r e s i s t s . Child does not have to be able to t i e shoes or button i n the back. Move yarn slowly i n an arc from one side to the other, about 6" above child's face. Pass i f eyes follow 90° to midline. (Past midline; 180°) Pass i f c h i l d grasps r a t t l e when i t i s touched to the backs or t i p s of fingers. Pass i f c h i l d continues to look where yarn disappeared or t r i e s to see where i t went. Yarn should be dropped, quickly from sight from tester's hand without arm movement. Pass i f c h i l d picks up r a i s i n with any part of thumb and a finger. Pass i f c h i l d picks up r a i s i n with the ends of thumb and index finger using an over hand, approach. Pass any en- closed form. F a i l continuous round, motions. When giving items 10. Which li n e i s longer? (Not bigger.) Turn paper upsid.e down and repeat. (3/3 or 5/6) 11. Pass any crossing l i n e s . 12. Have c h i l d copy f i r s t . I f f a i l e d , demonstrate 11 and 12, do not name the forms. Do not demonstrate 9 a n ( i H- 13- When scoring, each pair (2 arms, 2 legs, etc.) counts as one part. lk. Point to picture and. have chil d name i t . (No credit i s given for sounds only.) 15- 16. 17- 18. 19- 20. 21. 22. 23. 2h. 25. 26. 27. 28. DATE span T e l l c h i l d to: Give block to Mommie; put block on table; put block on f l o o r . Pass 2 of 3- (Do not help c h i l d by pointing, moving head or eyes.) Ask c h i l d : What do you do when you are cold? ..hungry? ..tired? Pass 2 of 3- T e l l c h i l d to: Put block on table; under table; i n front of chair, behind chair. Pass 3 of h. (Do not help c h i l d by pointing, moving head or eyes.) Ask c h i l d : I f f i r e i s hot, ice i s ?; Mother i s a woman, Dad i s a ?; a horse i s b i g , a mouse i s ?. Pass 2 of 3. Ask c h i l d : What i s a b a l l ? ..lake? ..desk? ..house? ..banana? ..curtain? ..ceiling? ..hedge? ..pavement? Pass i f defined i n terms of use, shape, what i t i s made of or general category (such as banana i s f r u i t , not just yellow). Pass 6 of 9- Ask c h i l d : What i s a spoon made of? ..a shoe made of? ..a door made of? (No other objects may be substituted.) Pass 3 of 3- When placed on stomach, c h i l d l i f t s chest off table with support of forearms and/or hands. When c h i l d i s on back, grasp his hands and p u l l him to s i t t i n g . Pass i f head does not hang back. Child may use w a l l or r a i l only, not person. May not crawl. Child must throw b a l l overhand 3 feet to within arm's reach of tester. Child must perform standing broad jump over width of test sheet. (8-1/2 inches) T e l l child, to walk forward, c O a O o o c o - i V heel within 1 inch of toe. Tester may demonstrate. Child must walk k consecutive steps, 2 out of 3 t r i a l s . Bounce b a l l to c h i l d who should stand 3 feet away from tester. C h i l d must catch b a l l with hands, not arms, 2 out of 3 t r i a l s . T e l l c h i l d to walk backward, < - a O c o O C O toe within 1 inch of heel. Tester may demonstrate. Child must walk k consecutive steps, 2 out of 3 t r i a l s . AND BEHAVIORAL OBSERVATIONS (how c h i l d feels at time of test, r e l a t i o n to tester, attention , verbal behavior, self-confidence, etc , ) : 157. 10-70 D i s t r i b u t e d as a s e r v i c e by M ead Jo h n s o n L a b o r a t o r i e s   APPENDIX H 134 N u t r i t i o n a l S tatus Q u e s t i o n n a i r e NAME: ; DATE: 1. Frequency o f e a t i n g : times/day. 2. C h i l d ' s a p p e t i t e : Good ( ); F a i r ( ); Poor ( ); V a r i a b l e ( ). 3. Best meal of the day: B r e a k f a s t ( ); Lunch ( ); Supper ( ). 4. C h i l d e a t s : alone ( ); w i t h f a m i l y ( ). Average V a r i e t y Adequate and Amounts YES NO 5. Kinds of Foods per 24 Hours ( O f f i c e use) M i l k ( i n c l u d e m i l k used i n soups, puddings, etc.) Cheese Yogurt Vitamin C F r u i t s Vegetables C e r e a l s and bread whole g r a i n s , e n r i c h e d r e f i n e d Meat/Fish/Poultry/Eggs Legumes/Peanut B u t t e r Sweets (sugar, d e s s e r t s , beverages, c a n d i e s , cookies) 6. Is Vitamin D added to the milk you purchase? Yes ( ) No ( ) 7. Are F l u o r i d e supplements used? Yes ( ) No ( ) 8. Are Vit a m i n supplements used? Yes ( ) No ( ) Brand_ 9. Are M i n e r a l supplements used? Yes ( ) No ( ) Brand 10. L i s t foods c h i l d does not e a t . 11. P a r t i c u l a r comments a t t h i s time. 135 APPENDIX I S p e e c h T h e r a p i s t ' s Q u e s t i o n n a i r e HEARING SCREENING — 3-YEAR-OLD C L I N I C 1) Does y o u r c h i l d r e s p o n d t o h i s name b e i n g c a l l e d ? (a) i n t h e same room - Y e s No (b) i n a n o t h e r room - Y e s No (c) o u t s i d e a t p l a y - Y e s No (d) when awakened - Y e s No 2) Does y o u r c h i l d a s k y o u t o r e p e a t y o u r s t a t e m e n t s a n d / o r q u e s t i o n s ? Y e s No ( i . e . , I b e g y o u r p a r d o n ? What? Eh?) 3) Does y o u r c h i l d l i s t e n t o T V / r a d i o w i t h l o w / m e d i u m / h i g h v o l u m e ? 4) Does y o u r c h i l d r e s p o n d t o i n s t r u c t i o n s ? Y e s No 5) D i d .your c h i l d r e a d i l y r e s p o n d t o i n s t r u c t i o n f o r v i s i o n t e s t i n g ? Y e s No 6) Have y o u e v e r q u e s t i o n e d y o u r c h i l d ' s h e a r i n g a b i l i t y ? Y e s No 7) Has y o u r c h i l d e v e r h a d e a r i n f e c t i o n s ? Y e s No l e f t e a r - r i g h t e a r - r e c e i v e d t r e a t m e n t w i t h a n t i b i o t i c s ! 8) Do y o u t h i n k a u d i o m e t r i c t e s t i n g i s i n d i c a t e d ? Y e s No 136 APPENDIX J T a b l e X I V D e n t a l H y g i e n i s t ' s F i n d i n g s f o r 38 C h i l d r e n i n t h e S t u d y P o p u l a t i o n F i n d i n g s Number P e r c e n t a g e (N=38) C a r i e s - f r e e 31 81.6 Have f a m i l y d e n t i s t 21 55.3 Had a t t e n d e d d e n t a l c l i n i c 10 26. 3 P r e v i o u s l y t r e a t e d 5 13.2 M o u t h h a b i t s n o t e d : - Thumb s u c k e r 8 21.0 Tongue t h r u s t e r 1 2.6 B l a n k e t s u c k e r 1 2.6 S o o t h e r u s e r 1 2.6 R e f e r r e d t o n u r s e f o r f u r t h e r c o u n s e l l i n g 2 5.3 R e f e r r e d t o d e n t a l c l i n i c 4 10.5 R e f e r r e d f o r t r e a t m e n t : F o r v i s i b l e d e c a y 3 7.9 F o r c r o s s - b i t e 2 5.3 F o r t o n g u e - t i e 1 2.6 T o t a l r e f e r r a l s 10 26. 3

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