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4 screening and detecting problems
Formal screening
4.1 Screening is the use of formal tests or examination
procedures on a population basis to identify those who are
apparently well, but who may have a disease or defect, so
that they can be referred for a definitive diagnostic test.
Some defects can only be detected by health professionals
if a search is made or through the use of specific
screening tests.
4.2 The
UK National Screening Committee (
NSC) was established in 1996 to advise
the Department of Health and the devolved administrations
in Scotland, Wales and Northern Ireland on all aspects of
screening policy. In forming its proposals, the
NSC draws on the latest research
evidence and the skills of specially convened
multi-disciplinary expert groups, which always include
patient and service user involvement. The
NSC assesses proposed new screening
programmes against a set of internationally agreed
criteria. In 1996, the
NHS was instructed not to introduce any
new screening programmes until they had been reviewed by
the
NSC. The
NSC has endorsed the recommendations in
Hall 4.
4.3
Hall 4 found that much existing screening activity
did not meet the criteria for screening tests, yet cogent
arguments were often made for their continued usefulness in
the evaluation and care of apparently healthy children.
4.4 Whilst screening has the potential to save lives or
improve quality of life through early diagnosis of serious
conditions, the process is not 100% accurate - in any
screening programme, there are some false positive results
(wrongly reported as having the condition) and false
negative results (wrongly reported as not having the
condition). Screening can reduce the risk of developing a
condition or its complications, but it cannot guarantee
protection. Parents should be made aware of the benefits
and limitations of screening tests so that they can make
informed decisions about whether to participate. Patient
information leaflets on screening are already produced by
and available from
NHS Health Scotland. Parents should also
be provided with information, including sources of support,
following diagnosis.
4.5 Staff should always know when, where and how to
refer a child whose screening test result gives cause for
concern. The route of referral will depend on the
particular condition and local protocols. Early detection
has implications for other aspects of the child's care,
including diagnostic and treatment facilities. Planning and
monitoring of screening programmes must take into account
the implications for these other services.
4.6 Children's services professionals across a range of
settings should also be clear about sources of advice and
referral protocols when they suspect that a child may have
a problem which requires health assessment.
Hearing screening
4.7 In line with national guidance from the
UK National Screening Committee and
HDL(2001)51
53, all
NHS Boards are expected to have
introduced Universal Newborn Hearing Screening (
UNHS) in 2005.
4.8 In line with the recommendations made in
Hall 4, once
UNHS is in place, universal distraction
testing at 7-9 months should be abandoned. The National
Newborn Hearing Screening Implementation Group has
recommended that universal distraction testing should be
discontinued once
UNHS has been in place for one full
year. The Group has already recommended increased vigilance
amongst professionals in relation to risk groups such as
children who have suffered from meningitis, received
ototoxic drugs (i.e. those which may damage the hearing
mechanism), children with middle ear disease and children
with developmental disorders which may mimic hearing loss
or be associated with hearing loss.
4.9 If the school entry hearing sweep test is currently
in place, this should continue whilst further evidence
about its effectiveness is collected and evaluated. No
further routine hearing testing should be undertaken.
Similarly, no new hearing screening programmes should be
introduced until further evidence is available.
4.10 Audiology services must be able to respond to the
concerns of referrers and parents promptly.
NHS Boards should therefore review the
local arrangements for access to paediatric audiology
services and staff training to ensure efficient referral
and testing for children with suspected hearing loss.
Audiological assessment and follow up should be arranged
automatically for any child who:
- Has had bacterial meningitis.
- Has had prolonged treatment with ototoxic
drugs.
- Has had a severe head injury.
- Is experiencing learning, behavioural or speech and
language difficulties.
4.11
NHS Boards should ensure co-ordination
of the local paediatric audiology programme, including
screening, training, audit and monitoring.
Vision screening
4.12 All children should be screened by an orthoptist in
their pre-school year, between the ages of four and five
years, removing the need for vision testing on school
entry. This reflects recommendations by the
UK National Screening Committee and
Hall 4, and is already being implemented in some
areas using a database to manage orthoptist screening in
pre-school centres, health centres and primary schools to
maximise coverage and accessibility.
4.13 Until an orthoptist pre-school vision screening
programme is in place, children's visual acuity should be
tested on school entry by an orthoptist, or through a
programme which is supervised by an orthoptist or an
optometrist. The evidence for screening in secondary school
remains inconclusive. On that basis, if screening on a
single occasion is already in place, it should continue,
but more frequent screening should cease, and no new vision
screening should be introduced in secondary school.
4.14 There is little evidence of the benefits of
screening for colour vision defects and no attempt should
be made to screen for colour vision defects in primary
school. If screening is already in place for adolescents,
it should continue, but no new colour vision screening
should be introduced. Adolescents whose career planning
might be affected by a colour vision impairment should be
advised to visit an optometrist for expert advice and
assessment. Children and young people who are found to have
a colour vision defect should be advised that this may be
an important issue in relation to certain career
choices.
4.15 Arrangements should be made for any child
undergoing assessment for educational under achievement or
other school problems to have a visual acuity check. Vision
screening should also be undertaken in schools for children
with hearing impairment.
4.16 One person in each
NHS Board area should be designated to
take overall responsibility for monitoring vision screening
programmes.
Screening for postnatal depression
4.17 The universal child health surveillance programme
offers a clear opportunity to detect those at high risk,
and those who have developed symptoms and signs of a mental
health problem.
4.18 Guidance on the identification and treatment of
postnatal depression and perinatal mental illness has
already been published in
MEL(1999)27 and in the
Framework for Mental Health Services in Scotland54. This suggests that detection of postnatal depression
may be done in the course of a routine assessment interview
or by using the 10-item self-report Edinburgh Postnatal
Depression Scale
55. Although
Hall 4 reiterates the advice of the National
Screening Committee that screening for postnatal depression
should not be routinely offered at present, the National
Screening Committee has advised that, whilst the Edinburgh
Postnatal Depression Scale (
EPDS) should not be used as a screening
tool, it may be used as a checklist as part of a mood
assessment for postnatal mothers, alongside professional
judgement and clinical interview. The
SIGN guideline on postnatal depression
56 suggests that the
EPDS should be used at approximately six
weeks and three months following delivery and should be
administered by trained health visitors or other health
professionals.
4.19 Perinatal and Postnatal depression services are
being expanded across Scotland.
Screening for obesity
4.20
Hall 4 advises that where there is concern that a
child may be overweight, his/her height and weight should
be measured and the body mass index (
BMI) calculated and recorded. It also
recommends that health professionals should offer support
to children and families who want to control their weight.
However,
Hall 4 recommends against use of
BMI for universal screening until there
is consensus about the effectiveness of intervention
programmes.
4.21 During the consultation on draft guidance, some
argued that height and weight should be measured and
BMI recorded more regularly than
Hall 4 advises.
Hall 4 advises against regular universal height
and weight measurement as this takes up valuable
practitioner time and there is little evidence of proven
benefit in terms of outcome.
4.22 However,
Hall 4 does recognise that population trends in
BMI might be useful for monitoring the
impact of public health interventions and recommends that
measurement of height and weight should be made at or
around the time of school entry and measurements stored so
that
BMI can be calculated and used as a
public health indicator. In Scotland, height and weight
data have also been collected (though not consistently) for
a number of years at P7 (age 10/11) and S3 (age 13/14). In
order to ensure continued study of longitudinal trends,
universal recording of height, weight and
BMI should continue at P7, but only on a
periodic basis, every three years. This will be triggered
through the Child Health Surveillance School System and
will commence in academic year 2007/08. Where it is in
place, recording of height, weight and
BMI at S3 should discontinue. This is
reflected in
Annex 1. Arrangements for
identifying and monitoring obesity in children and young
people will be kept under review.
4.23 Public health strategies to prevent obesity are
reflected in the Health Promotion section of this
guidance.
Developmental disorders and
disabilities
4.24 Although routine developmental screening
examinations may detect extreme variations from normal
development, most disabilities and disorders are found by
other means. They are often identified by examination in
the period immediately after birth. They are often also
detected by a child's parents or family, or professionals
who are in regular contact with the child, by close
observation and follow up of children at risk, or noted
opportunistically when a child presents to health services
for other reasons. Development is a continuum and it is
sometimes difficult to separate 'normal' from 'abnormal'
presentation at any precise age.
4.25 Evidence suggests that formal universal screening
for developmental delay and disorder, speech and language
delay, autism and co-ordination disorder makes little
contribution to the detection of serious impairments, and
it is not, therefore, recommended.
Hall 4 found that developmental screening
programmes also performed poorly when tested against the
National Screening Committee criteria.
4.26 The detection of problems is discussed further in
the following two sections on surveillance in the early
years and in school-age children and young people.
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