I’ve been considering writing about the two year development reviews carried out by Health Visitors for quite some time. (In fact, The Toddler’s second birthday and her review were right around the time I first started blogging, six months ago.)
I have to admit at the start that there were no concerns raised at The Toddler’s review, which may make this seem an odd post. I hope people will see what I am getting at, even though I have no reason at all to be personally disgruntled (and I am not, I might add, despite what the pronoun jokes may suggest). It is just that, despite the unproblematic review we happened to have, I couldn’t help but feel that the process was pretty flawed and, in fact, kind of unnecessary.*
Now, I absolutely see the value in carrying out checks in order to try to pick up real problems in a child’s development (or families who may be struggling) early. That makes sense. There is a long gap between birth and school, and of course identifying any problems within that period could lead to better management and treatments for children.
My issue is not with the idea of reviewing children, it is with the method used. The checklists/questionnaires, the little tests, giving parents a score for their children. Does it really need to be done this way?
It seems to me that, where there are actually concerning developmental delays or behavioural issues, a trained professional should be able to identify that by simply watching the child during the meeting, and having a casual talk with parents. Is it necessary to be quizzing parents with what can feel like test questions? Keeping scores for two year olds? I’m sure there would be some children felt to be borderline as to whether there is cause for concern. But, presumably, some children are borderline on the scored system too. Those children could simply be monitored with further checks, surely? I would guess that is probably pretty much what happens anyway.
I wonder how accurate this scored system really is. A lot relies on reporting by the parents. Is it truthful? I am sure many people can work out the answer the Health Visitor is looking for – how many give that regardless? I expect I would be told in answer to this that the Health Visitor can get a reasonable idea if the parents are exaggerating the child’s progress from what they observe of the child. Indeed. So why don’t they just do that? Remove the pressure of making parents feel like they are being tested.
Aside from the accuracy of parents’ self reporting, there is the question of whether the little tasks and tests the toddlers are asked to complete at the review really serve any useful purpose. I have an example. One item The Toddler was marked down on was in the fine motor skills category, because she failed to thread beads on to a string for the Health Visitor. Now, I am not suggesting that The Toddler was capable of doing this. It may very well be that she could not do it; she had certainly never tried before. What interested me was that it was marked that she could not do it, and was therefore lacking in that aspect of fine motor skills, but the test did not actually show that. The test established that she did not do it, but not whether she could do it. You see, she had never tried before and she did not try then. She felt that there were more fun activities she could do with the beads and the string, and she entirely ignored the Health Visitor’s instructions. So was that a test of fine motor skills? Or was it a test of how willing toddlers are to follow instructions? This made me wonder. That happened to be the one thing The Toddler refused to comply with on the day, and it was not a big deal, but how many people’s children refuse to complete lots of the tests? We all know the answer to how willing toddlers are to follow instructions is not very. Do all children who don’t carry out the tasks get marked as lacking the skill being tested, regardless of whether that was demonstrated one way or the other?
Then there is the list itself, and the way it is scored. The checklist/questionnaire appears to represent a fairly arbitrary selection from the multitude of things a toddler might be able to do, as indeed you would expect if you tried to make a checklist to summarise the multitude of things a toddler might be able to do. Furthermore, there seemed to me little consistency between list items in terms of relative difficulty. For example, one item relates to combining two words together, another to using pronouns, rather than names, most of the time. I don’t consider those to be close to the same level of difficulty, or particularly likely to be seen at the same stage of development. To use The Toddler as an example, she was using two words together from about 20-21 months old. By the review at 24 months old, she was speaking in sentences of five-six words. At that time, she was using pronouns about 50% of the time and names the other 50% of the time (if anyone is interested, she was also therefore marked down in this area). By about 27 months, she was using pronouns nearly all the time. I do not dispute that some children may be using pronouns fully by two, though I think those children would be in a minority. However, I would expect any child who can properly use pronouns to also be able to speak in fairly complex sentences, far in advance of two word pairings. Therefore, if the checklist expects children to be able to use pronouns, should it not expect them to be able to speak in multi-word sentences too? This is why I say it is arbitrary and inconsistent. It is a very mixed selection of things most children could do at two years and things few would be able to. Which is okay in a sense, but makes it difficult to judge the meaning of the scoring. Even if the way the scores are viewed is designed to take account of the different levels of difficulty in the list items (dealt with further below), and even if it is not expected that an average child could do all of the tasks, it is hard to escape the impression given that the child was expected to be able to do all of the tasks.
What of situations where the child is able to perform tasks beyond those allowed for on the list. There is no provision for extra points for tasks the child could perform over and above those on the checklist. Whilst I am quite sure it is not the intention, I couldn’t help but feel that this creates an air of negativity. In effect, any area of ‘failure’ (even if it is for a task of a clearly higher level of difficulty than others) is highlighted by receiving zero points, but there is no corresponding system of crediting achievements over and above those listed. How then can you truly say you are assessing a child’s development? Surely you need to assess all areas where there has been progress, as well as areas where there may have been less progress? Is it really okay to highlight to potentially anxious parents that their child is not using pronouns (I am planning to really do this pronouns point to death) all the time (though probably most are not at two), but give no mention to how good their sentences are because that is not on the list? (For that matter, why are the pronouns (told you: to death) getting a mention at all? Is it likely that children not using pronouns at two are going to spend their life talking about themselves in the third person?)
Parents are subsequently given a copy of the checklist and the scores. There is no context to the scores, no explanation given. Perhaps the discrepancy in difficulty levels of the tasks is balanced by the way that the scores are viewed. So that, for example, 30/60 is actually the average score, and, say, 45/60 would be above average. Therefore, the points lost on items that would be clearly developmentally advanced do not prevent the child’s score from reflecting their appropriate level. I do not know if this is the case, though. Of course, the Health Visitor will have said if there is concern, no concern, the child performs above average, etc. However, I doubt that stops people from wondering about the score. Wondering if 35/60 is average? Low? Is 60/60 well above average? Or are the children supposed to get close to full marks? Who knows? Why give people scores without any context? What is the point?
Then there are the averages used to make these lists, to determine where points are given or taken away. Is any account taken of common differences between boys and girls, for example? Are different assessments used? Maybe, but I did not get the impression this was so. How would a single set of criteria based on the averaged development of two year olds allow for common gender differences? There are exceptions, of course, but boys tend to be very physical in their play and communication, girls much more vocal. If all children are being assessed against an averaged criteria, does this review tend to show a lot of boys as below average in language development, and many girls above average? Are more parents of boys therefore told there may be some language delay? I do not know if this is the case, but I do wonder. In truth, what is actually shown if you compare typical boys’ language to typical girls’ language is not developmental delays versus developmental advances, but simply developmental differences.
I should just say here, that I have no doubt that most Health Visitors actually administer these assessments in a sensible and pragmatic way. I am sure that they look beyond the scores in reaching their views on development. I am sure they recognise the limitations of the system, and issues such as developmental differences between genders as well. However, I don’t think that changes the fact that having scored lists creates comparison and competition. I don’t think it changes the fact that maybe, in ensuring that children are monitored and reviewed, we have gone just a little bit too far. A little bit too far into making everyone worry about and compare every little aspect of children’s development.
Of course, I am sure that these checklists/questionnaires, and the tasks set to the children, are not supposed to be referred to as tests. I am sure that the official line is that the scores aid the Health Visitors, and are nothing for parents to be concerned with. But this is my point: if you score them, people will always see them as a form of test or assessment. If you present people with scores, they will always worry, analyse and compare them. If we are not testing two year olds, why have the lists, tasks and test-like elements? And if we are testing two year olds, why on earth are we testing two year olds?
So, whilst there is clear value in identifying children with real difficulties, in order to provide the support needed at the earliest opportunity, I simply wonder if this is really the best way to be doing it. Is assessing two year olds against arbitrary criteria necessary? Is there a risk that this system is causing a disproportionate level of concern about minor developmental differences or delays, that are likely to even out of their own accord by school age? (Has anyone ever really needed to give thought to the percentage of pronoun use employed by a two year old??)
Does the mere act of providing parents with a checklist, a score for their children, risk causing unnecessary worry, putting pressure on parents and children, and fostering a culture of competitive parenting that is not healthy? We already carry out formal testing of very young children in schools. Social media is already full of competitive parents displaying rose tinted accounts of their children’s behaviour and achievements. There is enough anxiety for parents. There is enough pressure and competition. We do not need to be looking to highlight and record areas of ‘failure’ in two year olds, surely (and, indeed, I doubt that is the aim of the system, but it is implicit in the method used). We do not need to be comparing children to other children, let alone some invented ‘average’ child.
Perhaps most would not agree with me, but I would much rather see simple chats and observations carried out, with no lists and no scoring. Following which, any children about whom there is real cause for concern are referred for appropriate support, and everyone else is simply told there are no concerns and their child is doing fine. Not how fine their child is doing in comparison with other children. Not anything to worry about nor anything to brag about. Nothing about bloody pronouns.** Two year olds don’t care if they can say 50 more words than Susan next door. When children start school, no one can tell who walked at one and who was closer to two. Children develop at different rates. In most cases, can we not simply allow them to do so, and enjoy watching it happen?
**I am not as upset about the pronouns as it may appear, it just struck me as quite a good example of the possibly unnecessary elements of the process.)