school entry medical examination · the school entry medical examination 809 amongthe pictures...

Archives of Disease in Childhood, 1986, 61, 807-817

Personal practice

The school entry medical examinationK WHITMORE AND M BAX

Community Paediatric Research Unit, Charing Cross and Westminster Medical School, London

SUMMARY We describe our comprehensive examination of 5 year old school entrants. Theexamination includes a parental interview, measurements of growth and visual acuity, and anaudiometric sweep test all carried out by the school nurse and a paediatric examination andneurodevelopmental assessment carried out by the school doctor. The continuing need for suchan examination, at least in urban areas, is discussed and illustrated by some data from the NorthPaddington Primary School Study. We emphasise the practical use of the neurodevelopmentalassessment.

Until 1974 the medical inspections of schoolchildrenwere governed by statutory regulations that at onetime specified even the ages at which they were to becarried out. The value of such inspections was firstseriously questioned some 25 years ago when theregulations were amended, and in the 1960s thenature and conduct of routine periodic medicalinspections was a frequent topic in public healthjournals. Since the reorganisation of the NationalHealth Service (when the regulations were repealedand medical examinations of pupils ceased to beobligatory) articles on the routine examinations ofschoolchildren have rarely appeared in either publichealth or paediatric journals in the United King-dom. This is surprising, not only because 60% of theexaminations currently carried out by school doctorsare designated routine periodic medical examina-tions, which still involve over a million pupils (oneeighth of the school population), but also because in1984 all but one of the 201 district health authoritieswere\undertaking routine examinations of childrenwho were 'rising 5' and embarking on full timecompulsory education; one authority was reviewingits policy (C Haines. Personal communication.)One reason for this paucity of publications may be

the fact that at the same time that routine periodicmedical examinations were becoming discreditedchild health services were paying increasing atten-tion to the early identification of disabilities andhandicaps. Consequently, an extensive literaturehas been accumulating in a variety of journals on thedevelopmental screening of children during the

preschool years. The view has been expressed thatan examination of children at the age of 41/2 yearsshould be the final one in a preschool health careprogramme and replace the routine examination ofchildren on entry to school, and this has been theonly context in which reference to the latter hassometimes briefly appeared. Interestingly, only 18district health authorities have formally adopted theexamination at 41/2 years as the substitute for anexamination after entry to school.On the other hand, many paediatricians have

been showing an increasing interest in 'minimalbrain dysfunction', and school doctors are having tobe increasingly involved in learning and behaviourdisorders of children in school.' Papers dealingspecifically with the examination of young childrenin relation to the early detection and investigation oflearning disability are consequently more numerousthan those that describe a comprehensive examina-tion. When these papers have appeared they haveinvariably been in the context of a special studyrather than of everyday clinical practice.

In 1973 we published a brief report about a studywhere we comprehensively examined 5 year oldchildren in Isle of Wight schools.2 Subsequently, wereported on the method of our examination.3 Overthe last 10 years we have made a number ofmodifications to our original examination and nowuse almost all our research procedures daily in ourservice sessions in schools. We shall describe thesein more detail here before providing some generaldata that in our opinion confirm the need for every

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808 Whitmore and Bax

child on entry to an infant school to have acomprehensive examination by the school doctorand nurse. In another paper we present specific dataabout the neurodevelopmental items in ourexamination,4 which we believe justify their inclu-sion in a comprehensive entrant examination.The nurse carries out measurements of growth

and visual acuity and an audiometric sweep test andcompletes an interview with the parent. The doctorreviews the interview with the parent and carries outa paediatric examination and neurodevelopmentalassessment of the child.

The school nurse's role

Each child is weighed and measured, the readingsthen being checked against Tanner-Whitehousestandard age percentile charts* for height andweight attained. Weight is also checked againstheight percentile charts.5 In cases of children whoseheight is found to be below the third percentile forage the measurement is also checked against stan-dard height percentile charts that allow for theheight of the parents.6 Weighing machines (Avery)were available in all schools; these were regularlychecked by the authority's Weights and MeasuresDepartment. The children wore vest and pants.Heights were measured in bare feet using rulesattached to the wall; occasionally the rule wasattached to the weighing machine and if there wasdoubt about a reading this was repeated using aHarpenden portable Stadiometert.

Distant and near visual acuity is tested usingSheridan charts. The child's colour vision is alsochecked by the school nurse using the Guy'sSheridan-Gardner charts, though we are notourselves convinced of the educational need fordoing this as early as 5 years. The school nurse doesthese tests in school usually a day or two before thechild is examined in the presence of his parent. Shealso carries out a pure tone audiometric sweep testof all new entrants, if possible during their first termin school.When parent and child attend together as a rule it

is the nurse who will interview the parent, recordinginformation on a parent interview schedule. If forsome reason neither parent can attend the schoolmedical the nurse will visit the child's home tocollect this history. The doctor may well begin theneurodevelopmental examination of the child while

*Tanner-Whitehouse and Chin and Morris height and weight chartsare available from: Castlemead Publications, Swain's Mill, 4aCrane Mead, Ware, Herts SG12 9PY, England.tHarpenden Stadiometer is available from: Holtain Ltd, Crym-mych, Dyfed, UK.

this interview is going on in the same room, keepingan ear open to the parent's replies and of coursejudiciously joining in if it is appropriate. Theschedule provides information about the child'sbirth and medical history, his present health anddevelopment, and his accommodation and familyhistory. It also includes a slightly modified version ofthe Rutter Parental Behaviour Scale, which we useas a questionnaire and which can be rapidly re-viewed by the doctor and positive findings discussedwith the parents (it can also be scored for researchpurposes).

The school doctor's examination

The doctor's examination of the child is a combina-tion of a developmental, neurological, and paediat-ric examination. We describe the developmentaland neurological (neurodevelopmental) items firstbecause in practice the first thing we do with thechild is to look at some pictures. We shall completeour description of this part of the examinationbefore moving on to the physical examination,although in practice they constantly overlap. Wehave found that when the individual items arecarried out in the order shown in our aide-memoire(see Appendix) the examination progresses in a waythat is logical and effective clinically and enjoyablefor the child. Looking at pictures, chatting, and'playing games' helps to establish a good rapportwith the child so that cooperation is maximum. It isexceedingly rare for a 5 year old not to respond tothis approach, and the sequence we follow allows asmooth and gradual change from the child doingthings himself to his allowing things to be done tohim.The neurodevelopmental examination is princi-

pally a means of making some assessment ofthe efficiency of a child's perceptual-motor-com-munication performance in relation to his entry tofull time education. This is dependent upon a largenumber of overlapping component functions,involving a number of sensory perceptions andmotor organisations, but initially the neurodevelop-mental examination has to be confined to anassessment of movement, vision, hearing, speechand language, and overall ability to learn (generalintelligence). None of these can be tested strictly inisolation; it has to be deduced that function in thesefields is unimpaired from the child's response to abattery of tests. Several ready compiled batteriesalready exist in a commercial form-for example,the Denver Developmental Screening Test-but fora variety of reasons we have found these unsatisfac-tory for the neurodevelopmental examination ofentrants to school in this country, and we believe it



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is better that school doctors design their ownbattery, selecting from the very many tests that areavailable those that they personally find are easy toapply and allow a reasonably reliable assessment tobe made.An important consideration in selecting tests is

the equipment they require. It needs to be minimaland simple, at the same time enabling one to makean overall assessment of each aspect of a child'sfunctioning, which can then be recorded as normalor abnormal. Most tests contain very similar, oftenidentical, material, and it is their use and interpreta-tion that is important. We describe, therefore, insome detail some of the material that we use to showits objective rather than its superiority to other testmaterial. We use the following: the Reed HearingTest Card*, Renfrew Action Picturest, 12 colouredbricks, paper, and pencil.The Reed Test was designed as a test of hearing

for speech in which the child is asked to point to anamed picture, which is one of four on a card. Eightcards are provided in a hard back folder (12 x 4inches), which can stand on the table like an easel,allowing each card to be flipped over after use. It isnecessary to ensure that the child knows the namesof the objects to which he may be asked to pointbefore the hearing test, but we check this by usingthe cards as a picture vocabulary test; the pictureswe use are house, cup, bus, chicken, lamb, key,feet, sheep, tree, dog, cot, doll, and sock. We haveadded four tangible objects for the child to namethat do not appear on the cards (thumb, watch,pencil, and chair). The reader will readily note thatthese picture items could be provided from manyother sources-for example, Ladybird books. Afterasking the child to name the picture of the 'house' hecan be asked about three kinds of material used inbuilding one. He can also be asked to define certainpictures and objects identified in the vocabularytest-that is, house, cup, bus, key, knife, watch,pencil, and chair. Picture vocabulary, defining use,and naming materials are all standardised items thathelp in the assessment of ability. By the end of thesetests the doctor must be sure the child knows thenames of the objects on the cards to be used for thehearing test. We initially use only three cards for thispurpose-numbers 5, 6, and 7.We look at three elements of communication-the

semantic, the syntactical, and the transmissionsystem. The child's articulation of single words canbe checked during the picture vocabulary test.

*Reed Hearing Test Card is available from: The Royal NationalInstitute for the Deaf, 105 Gower St, London WCI, England.tRenfrew Action Picture is available from: Miss C E Renfrew,2a North Place, Old Headington, Oxford, England.

The school entry medical examination 809

Among the pictures we use routinely are some thatrequire articulation of the consonants 1, k, r, s, sh,and th (their selection is based on Ingram7 andMorley8). Articulation of words within sentencescan be heard during informal conversation with thechild throughout the examination and also in thestandard sentence the child is asked to repeat afterthe doctor has spoken it. A normal 5 year old childshould be able to repeat from memory a 10 syllablesentence; it is useful if this also contains the abovesix consonants.

Finally, to complete the assessment of speech andlanguage when the child has not talked freely we usethree Renfrew Action Pictures (numbers 6, 7, and 8)that depict in each instance a pair of linkedactivities. The child is required to construct agrammatically correct sentence that describes theactions depicted. For instance, one picture shows achild climbing a ladder against a house with a catclinging to the roof; one possible response would be'He's climbing the ladder to get the cat down'.Standardised scores of the syntax are supplied, andfrom a count of the number of items of informationthe child manages to convey on his own verbalinitiative and the number of grammatically correctforms he uses in doing so it is possible to obtain ascore of his expressive language. We used scores inour research study. We emphasise that the aim hereis to hear the child use a syntax relative to his age,and at times he will do so in spontaneous sentences.Usually, the child's actions, behaviour, and con-versation throughout the examination provide manyadditional opportunities to observe his understand-ing and use of the spoken word, which are aspectsalso of intelligence.We introduce the small 1 inch bricks by asking the

child if he can count, and then to do so to five whilewe place five bricks in a line on the table. Askinghim to count the bricks confirms that he has aconcept of number and not just a good memory. Thebricks are then used to check his understanding ofopposites (tall and short towers) and relative posi-tions in space-on, under, behind, beside, etc.These are simple practical reasoning tests and aresupplemented by construction and drawing tests thatare not only performance as opposed to verbal testsof intelligence but also equally useful in the assess-ment of eye-hand coordination (fine manipulation).There are a wide variety of such performance tests,some better standardised than others. For the 5 yearold entrant we use a timed (seven seconds) buildingof a three block bridge and an untimed building of asix block bridge from models and reproduction frommemory of two simple patterns with colouredbricks, one from memory after a demonstration andthe other without a demonstration.



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We then hand the child a pencil and ask him todraw in turn a circle, square, and triangle, copies ofwhich are placed in front of him one at a time-thatis, he is not shown how to draw these shapes. We usethe scoring criteria standardised by Terman andMerrill.9 From this task we note his hand perform-ance for drawing, the maturity of his pencil grip, andnot only his ability to distinguish and reproduce eachshape but also his executive skill in drawing them(motor precision).Moving away from the table, we next ask the child

to copy a series of movements that show arm-handcoordination. We have found that getting him tolightly pat the back of each hand quite quickly (12times in five seconds) and regularly and then toplace his arms and hands in four positions is a goodmethod. Items 5-8 from Berges-Lezine's imitationsof gesturesl are valuable tests that draw on severalcentral nervous system functions, including visualperception, concept of body image, muscle and jointsense, and motor organisation and control. Thesetests have been standardised and are simple yetinformative and fun for the child to do. We wouldemphasise at this point that throughout the ex-amination of a child's functioning we are concernednot only with his ability to achieve the end point butalso the manner in which he does so and the qualityof his performance.The traditional finger-nose test (in its several

versions) is widely used in neurological examinationand we have found it useful on some occasions. Ithas the added advantage that it moves the centreof attention to the face and paves the way for whatthe child may sometimes feel is the most submissivepart of the examination, requiring his willingness toopen his mouth wide. Once this has been achievedhe is seldom reluctant to undress for the restof the physical examination and the neurodevel-opmental tests involving the use of the lowerlimbs.

Examination of the head and face allows one toassess rapidly most of the cranial nerves. Afterobservation of the child's facies we observe and/orfeel for motor asymmetry when asking him to closehis eyes tightly, show his teeth, open his mouth, andmove his tongue around. While testing for motorimpersistence (mouth held open wide and tongueprotruded for 20 seconds) his dental health can beassessed. At this point too pupillary response tolight and the position of the light reflex can beobserved. We do not routinely use the cover test asthe importance of a latent squint seems to bedoubtful, and we have found an asymmetrical lightreflex, reduced visual acuity in one eye, andobservation of eye movements throughout the ex-amination (but especially when the child is carrying

out the neurodevelopmental tests previously de-scribed) are more reliable methods of detecting (orconfirming the mother's suspicions of) the presenceof an overt squint. Finally, we examine the ears withan auriscope.

In the absence of a history of illness or injuryphysical examination is subsequently confined toinspection of the skin, auscultation of heart andlungs for the presence of abnormal sounds, checkingfor hernias and in boys for undescended testicles,and looking at posture and limbs. We do notroutinely check the blood pressure, although thereare proponents of doing this as a routine, but we feelmore study is needed before it is adopted routinely.Similarly, testing for bacteriuria in girls is certainlyfeasible but at the time of the study it had not beenrecommended" until a non-radiological techniquefor detection of renal scarring had been developed(but see a recent comment'2).Muscle tone and power, and limb reflexes, can

readily be assessed at this stage when the child isrelaxed and no longer apprehensive about having tosee the doctor. We do not believe the plantarresponse is a useful routine test: most childrendislike it and in consequence its results may confusethe doctor more than assist him. On the smallerchild these tests-and indeed much of the paediatricexamination of the face, trunk, and limbs, can becarried out with the child sitting on the mother's lapor doctor's table. They are then lifted off for thecompletion of the neurodevelopmental tests (loco-motion) and palpation of the groin. We observe gaitas the child enters the room, but we also ask him towalk across the room for some specific reason; thecarrying out of an instruction distracts from theembarrassment some children have in parading infront of the doctor, as well as being another occasionfor observing intelligent responses. Walking heel-toe in a straight line and hopping on each leg havetheir own end point. For the child the examinationends with his returning to the table for a speechdiscrimination (Reed) test if this has not been doneat an earlier stage.The final note the doctor has to make is about the

child's behaviour. This is based, firstly, on theparent interview schedule, particularly the RutterScale, and the kind of relationship between parentand child that becomes apparent from the way theyreact to the situation/examination. Secondly, weobserve the child's behaviour towards ourselvesduring the examination, his attitudes towards par-ticipating in the tests, his level of motor activity, andhis attention span. Thirdly, the teacher will havesome observations to make about the child'sbehaviour in the classroom and how he gets on withother children.



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The nature of and need for an entrant examination

The special importance of a routine school entrantexamination stems from its educational context. It isthe youngest age after birth at which it is possible toensure that all children are seen, because educationis compulsory at 5, and it provides an opportunity tocarry out a comprehensive assessment in relation tothe child's introduction to formal teaching in a groupsituation. The examination that we carry out onlytakes 15 to 20 minutes. The importance of the child'sresponses has then to be assessed, and in the light ofthese conclusions the doctor has to advise bothparent and teacher that the child's health anddevelopment seem to be perfectly normal; alterna-tively, he has to alert the teacher and perhaps theunaware parent to the presence of problems ineither health or development and discuss with boththe implications of such problems for the child'seducation and care principally in school but also,when it may be relevant, at home. There are manyadvantages and few disadvantages in the parent andteacher both being present for the examination andsubsequent discussion. Because from inclination andtraining most doctors are so often more interested indisease and disorder it is important that we stresshow the whole procedure of the entrant examinationis as much concerned with the confirmation ofnormality and advice to both parent and teacherabout how this may be maintained and promoted asit is with the identification of abnormality and anynecessary action to deal with this.The school entrant examination is a form of

preventive health care applied to a specific popula-tion group and for this reason has often beenregarded as a screening procedure. 13 True, it makesuse of three screening procedures-that is, measure-ment of the growth and visual acuity and audiomet-ric sweep tests. There is, however, a crucial differ-ence between screening and assessment: screeningrequires only the observation and recording that thechild does or does not achieve at a given moment apredetermined, arbitrary threshold of performance;assessment requires an interpretation of his re-sponses and a clinical judgment as to the need forany action. The effectiveness of entrant medicalexaminations must not be gauged in terms of itsefficiency as a screening procedure.Assessment is relatively straightforward as re-

gards physical health, vision, and hearing, but it isnot quite so easy in respect of the results ofneurodevelopmental testing. The tests we haveselected can be scored on a three point scale fromwhich an overall neurodevelopmental score can becalculated by adding up the subscores obtained onfive groups of tests (Table 1). In everyday practice


Table 1 Tests contributing to the neurodevelopmentalscore (see Appendix)

Neurological score: Head circumferenceBerges-LezineFinger-noseMotor symmetry - eye

- faceMotor persistenceTongue movementsNystagmusCranial nervesSquintReflexes

Motor score:

Visual perceptionscore:

Speech andlanguage score:

Ability score:

Motor precision (quality of drawing skill)Pencil gripHand pattingFinger-noseGaitHeel-toe walkHopping

Squint,Visual acuityBuilding with bricksDrawing shapesBerges-Lezine

Picture vocabularyDefinitionsArticulation (words and sentences)Renfrew action pictures (information)

Picture vocabularyDefinitionsMaterialsSentence repetitionPractical reasoning itemsRenfrew action pictures (information)Building with bricksDrawing shapes

we have found it unnecessary to calculate any scoresas we are now familiar enough with the variouspatterns of response to reach a clinical decision as totheir importance. Elsewhere we show how suchclinical use of the tests can actually give a ratherbetter prediction of later learning difficulties thanthe neurodevelopmental score or its subscores can,probably because it can take into account thecontext and quality of the child's responses. Predic-tion, we hasten to add, is a tool of research and itsuse is not necessary in daily practice-nor advisableuntil such time as we have effective methods ofintervention.

It is often claimed that nowadays a comprehensiveexamination of every 5 year old child on entry toschool is a luxury that cannot be afforded and ifcarried out at all it should be done at the age of 41/2before the child starts school and by either thegeneral practitioner or the clinic doctor. We believethere are cogent arguments for this educationoriented examination to be done in school by thedoctor and nurse who will continue to providehealth care in the school and often be talking to



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teachers and parents. This provision of health carefor the child in relation to his functioning in school isall important. An interpretation of his neurodevelop-mental state to the teachers allows them to plan aneducational programme diagnostically suited to thatchild's abilities. We see this as just as important aresponsibility as, for instance, explaining the im-portance of a child's epilepsy, asthma, or diabetes.As for regarding the examination as a luxury, we

would point out that two thirds of schoolchildren inthis country live in inner city or suburban areaswhere a relatively high proportion of children aresocially disadvantaged and do not receive satisfac-tory health surveillance during their preschoolyears. Furthermore, such children are by and largemore than likely to have problems of one kind oranother on entry to school and to experiencedifficulty in their learning and behaviour duringtheir later school years. Our own studies in Padding-ton show how true this still is. In the 15 primaryschools in which we worked there were significantlygreater numbers of children from families of socialclasses 4 and 5, and 15% were socially disadvan-taged*. At least one third had no records ofassessments of health and development beforeentry, and of those for whom records were availabletwo out of five had not been examined since the ageof 2, and half of these had problems. Forty per centof all the children had problems on entry to schooland just as many still had problems by the age of 10(Tables 2 and 3). Only 6% of the children with aproblem at 5 had seen their general practitionerbecause of that problem during the previous 12months, and all nine had a physical health problem,including one boy with undescended testicles (out ofthree so diagnosed at the entrant examination) andone with a congenital heart disorder (out of five sodiagnosed on entry).

*This was a clinical opinion expressed by the doctor on the basis offamily size, overcrowding and lack of amenities at homc, maritaldiscord, the prescnce of serious illness to the family, and other suchinformation obtained at the entrant examination or from healthvisitors and social workers.

Table 2 Problems identified among 351 school entrantsin 1978

Problems Prevalence Prevalence Rates of socialof individual among all disadvantage inproblems (%) problems (%) school entrants

with problems (%)

Physical health 13 23 9Vision 8 14 28Hearing 8 14 18Speech and language 8 14 28Ability (intellectual) 14 26 14Behaviour 5 9 5()

Study group as a Rate for all Rate of socialwhole at 5 years problems disadvantage

40) 15

Table 3 Problems present among 230 childrenaged 10 years

Problem No of Prevalence (%)problems

Physical health(excluding dental disease) 24 10-4

Vision(excluding colour vision) 25 10-8

Hearing 4 1-7Speech and language 1 0-4Enuresis 5 2-2Reading 18 9-8*Learning 35 15-2Behaviour 20 8-7

Total No of children with problems 101/230 43-9

*Only 183 out of 230 children had a reading test.

We would agree that there are some children inevery infant school, and many children in mostschools in some places, whose health and develop-ment during the preschool years has been entirelysatisfactory and even documented as being so.Nevertheless, we believe that their parents shouldbe offered an interview with the school doctor andnurse and a decision not to give the child acomprehensive examination taken then on clinicalgrounds, rather than in advance as a matter ofadministrative policy.



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AppendixENTRANT MEDICAL EXAMINATION

NAME: School

Date of Birth: Age M / F S.M.O.

Date of first entry Date of examination:to Nursery / InfantSchool: Parent Present: Ma / Pa / No

MEASUREMENTS VISION

Height: cms. Age %-ile th. Without glasses R LWeight: kgs. Hgt. %-ile th. With glasses R LHead circumference: cms Near vision R LParent's height: Ma/Pa cms. Colour vision Pass / Fail

SUMMARY of ASSESSMENT

1.2.3.4.5.6.7.8.9.

10.11.

HealthNutritionVisionHearingSpeechLanguageAbilityManipulationLocomotionBehaviourSocialCircumstances

goodgoodnormalnormalnormalnormalnormalnormalnormalnormal

normal

poorpoorslight defectslight lossslight defectrestrictedlimitedrather clumsyrather clumsyminor problem

unhclpful

No action required / Referral required:

Other (specify):

unsatisfactoryunsatisfactoryimpairedimpaircdmarkcd defcctretardedretardeddyspraxicdyspraxicmajor problem

disadvantageous

to (use code)

See again



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Appendix-contd.

EXAMINATION

Naming and Defining Objects

Housc

House made of

Door made of

Window made of

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

Number answeredcorrectly:

(pass 2) /4

Yes

Yes

Yes

No

No

No

Number namedcorrectly:

(pass 16) 4

Number definedcorrectly:

(pass 5) 4

Ycs No

Yes

Yes

Yes

Hearing and Speech

Articulation (words)HearingAuditory discrimination

Auditory memoryArticulation (sentence)

Normal / Defect:Pass / FailPass / Fail

(Repeat sentencc "Susan can polish the red bicycle")Pass / FailNormal Defect:

(r - sh - th - s - I - k)

(r - sh - th - s - I - k)

Names

Yes No

Define by Use

Yes No

Materials:

Cup

Bus

Chicken

Laimb

Kcy

Fcet

Shccp

Tree

Dog

Cot

Doll

Sock

Knifc

Thumb

Watch

Pencil

Chair

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No



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Appendix-contd.

Language (Renfrew Action Pictures)

CARD 6

CARD 7

CARD 8

INFORMATION(pass 10)

GRAMMAR(pass 14)

Practical Reasoning

Compares 2 towersCounts to 5Counts 5 bricks

Construction and Drawing

Can build: 3 block bridge(7 secs)

6 block bridgeblock pattern II

Can draw: circlesquaretriangle

Motor precision: goodPencil grip: R

Hand-arm Co-ordination

yesyesyes

yes

yesyesyesyesyes

Lfairtripod

nonono

no

nonononono

- poor- awkward

Reasoning correct:(pass 3) /3

Performance correct:(pass 4) //

- other:-

Hand patting

Berges-Lezine

Finger-nose

Face and Head

Motor symmetry

Motor persistence

Tongue TremorDental

Upper respiratorytract

R on left fist regular12 in 5

secs.L on right fist regular

12 in 5secs.

5. | pass / fail 7. \ pass / fail6. I pass / fail 8. . pass / failpass deviation - R / L tremor

teeth-showingeyes-screwingmouth open 20 sec.tongue out 20 sec.

decayed, missing, filledgums healthyorthodontic problemnasal catarrhtonsils healthyglands enlarged

yesyesyesyesnonilyesnonoyesno

irregularfewer

irregularfewer

nosononoyesNumber:noyesyes: acuno: .-chronicyes:



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Appendix-contd.Eyes nvstagmus

movementssquint

Ears R - healthyv dullL - healthy / dull

Rest of body

nonormalno

I injected // injected /

yeslimitedves: treated

bulging / grommet Ibulging / grommct /

SkinHeart soundsBreath soundsUmbilieal herniaInguinal herniaTestesTrunk (inel. posture)

Arms (inel. shape. muscle tone)Legs (inel. shape. muscle tone)

Biceps

Braehio-radialis

Knee jerk

RLRLRL

Locomotion

walks with even pacesheel-toe walk steady

R steadyL steadv

can cannotunsteady cannotunsteady cannotunstcady cannot

Towards examiner

During examinationLevel of activityAttention span

forthcoming / guarded / non-cooperativeshy-warms up / shy / shy-cries

composed / petulant / difficult / clingingnormal / slow / fidgity / osver-activenormal / easily distracted / brief

Odd Clinical Note

wax obscurcswax obscures

Limbs

healthvnormalnormalaibsentabsentdownnormal

normalnormal

Reflexes

lesion:murmur:added:presentpresent: R / Lup: R / Labnormal:

abnormal:abnormal:

presentpresentpresentpresentpresentpresent

absentabsentabsentabsentabsentabsent

briskbriskbriskbriskbriskbrisk

Gait

Hopping

svm / asvm

sym / asym

sym / asym

Behaviour



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We thank Drs Sue Jenkins and Hilary Hart for their constructiveinterest during the preparation of this paper and our secretary,Lorraine Wilder, for her help in its presentation.

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4 Bax MCO, Whitmore K. The medical examination of childrenon entry to school: II the results and use of neurodevelopmentaltests. Dev Med Child Neurol. (In press.)

5 Chinn S, Morris RW. Standards of weight-to-height for Englishchildren aged 5.0 - 11.0 years. Ann Hum Biol 1980;7:457-71.

6 Tanner JM, Goldstein H, Whitehouse RH. Standards forchildren's height at ages 2-9 years allowing for height of parents.Arch Dis Child 1970;45:755-62.

7 Ingram TTS. Developmental disorders of speech. In:

Vinken PJ, Bruin W, eds. Handbook of clinical neurology.Vol 4. Amsterdam: North Holland, 1969:407.

8 Morley ME. The development and disorders of speech inchildhood. 2nd ed. Edinburgh: Livingstone, 1965.

9Terman LM, Merrill M. Stanford-Binet intelligence scale:manual for the third revision form L-M. London: Harrap, 1961.

'0 Berges J, Lezine I. The imitation of gestures. Clinics indevelopmental medicine no 18. London: The Spastics SocietyMedical Education and Information Unit associated with WmHeinemann Medical Books, 1965.Newcastle Covert Bacteriuria Research Group. Covert bac-teriuria in schoolgirls in Newcastle-upon-Tyne: a five-yearfollow-up. Arch Dis Child 1981;56:585-92.

12 Arneil GC. Urinary tract infection in children. Br Med J1985;290:1925-6.

13 Hall DMB. The child with a handicap. Oxford: BlackwellScientific Publications, 1984.

Correspondence to Dr M Bax, Community Paediatric ResearchUnit, The Charing Cross and Westminster Medical School, 52Vincent Square, London SWl.



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