Two Year Development Reviews: Do They Work?

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?

(*It should be noted, of course, that I can only base my observations and opinions on the way our review was conducted, which may not be the same as everyone’s experiences.
**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.)

19 comments

  1. This is a very timely post for me – I read it last night and my husband and I had just been chatting about the two year review (we’ve got ours next week). I welcome the HV service as one that supports families and children who may be struggling with aspects of life or complications and who would like or need extra support. That’s wonderful BUT I completely agree with you re the questionnaire, lists and scoring. I wonder how much it really does highlight any problems? I don’t know, I assume they have thought about it and there is a use. I hope it’s not just a government policy form ticking exercise. I’ll perhaps be able to offer a more involved comment after next week!

    • Silly Mummy says:

      Yes, I can very much see the good intentions in the HV service, and Sure Start and all of it. But I do have my doubts about how well it is really working in practice. Unfortunately, I think there is still a real tendency for these services to either not reach or alienate the people who need them the most, whilst probably contributing for everyone else to the overly neurotic and competitive atmosphere that parenting seems to have taken on these days (says the very neurotic but not particularly competitive mother!) Interested to know what you think of it when you’ve been! x

  2. Sarah says:

    I think your right in this. I never see it right to judge a child on wether they can thread beads or not on a piece of string, some may have never even tried like you said. My little girl loved drawing and could draw at cat by the age of two, but never had much interest in learning to ride along on her car and therefore could never really do it, it didn’t mean she was behind on that in my eyes its just that it wasn’t something she enjoyed doing. I also think that if she was sked to prove she could do something infront of a doctor she wouldn’t do it anyway. Luckily they don’t test things that way out here in Spain, she was accessed on her health and that’s it.

    • Silly Mummy says:

      That’s just it, isn’t it – how do you pick the few items on the list? What about all the other things they might do instead? How do you fit children into checklists and boxes when they are so different and develop so differently? Now you’ve mentioned Spain, I’m wondering what most other Western countries do – I’ll have to try to find out! Thanks for reading.

  3. Emily Davies says:

    My daughter recently turned 2.5 and we hadn’t had a 2yr check so I phoned to enquire. I was informed that children in our area born in March or April weren’t automatically offered one (presumably a cost cutting exercise?) but if I had concerns I could request one. This spoke volumes to me on the necessity of the check – either it’s necessary and all children get it, or it’s not that important. And if they feel it’s ok to just not give it to a chunk of kids and rely on parents voicing their concerns then it’s clearly not effective in the first place! I say scrap it for everyone and funnel the resources into something else that will pick up on and support children who are delayed.

  4. Jade Munro says:

    Ah jeez … our little one’s review is about 5 months away. I’m not keen on these reviews purely because each child develops at their own pace, this pace could span 12 months or so. I know my kid. She’s fine.
    Great piece, lovely. Really relevant to me.
    #Abitofeverything
    xx

    • Silly Mummy says:

      Yes, there is a massive variation in development between children, and I hate the idea that people get made to feel pressure over how their children develop, or that, even worse, the children themselves could pick up on pressure to perform a certain way. I agree that most people know if they need to worry about their kids or not, and their instinct is a better measure. Whilst I would guess that those who do need the extra help and will not self report, for whatever reasons, are probably also the ones who often fall through the nets of these checks, or who feel most alienated by them, anyway. Not the best way to target support where it is needed, I would say. Thanks for reading.

  5. John Adams says:

    Mmmmm, do they serve any purpose? Well I think development reviews probably do have their uses. A long term degenerative condition like muscular dystrophy might show up in a review. The other point is, who is being reviewed? Is the Health Visitor looking of signs of depression or other issues with the parent(s)? I bet some of that goes on. #ShareWithMe

  6. Lianne says:

    This is a great post! I work in Early Years and when these checks were bought in we all questioned them as ‘ snap shot questionnaires’, obv in Early Years we assess the children’s development based on long term observations rather than a 10 minute ‘tick box’ appointment as the 2 year check often is. BUT that said, it’s more about the needs of ‘paperwork’ more than anything, it’s about having something on file.
    Its a shame tho as it can make a parent worry, but as you correctly say, you cannot make a broad judgment of a childs development in a snap shot appointment. #pocolo

  7. Alice says:

    If you liked that, wait ’til you get to the completely arbitrary three year check, where they check the exact same stuff again, but without any obvious reference to the previous check. Utterly pointless.
    How the government loves a test! I found out what the tasks would be from a friend with a slightly older child whilst we were discussing the two year check over coffee. Out of interest, I went home and tried Jet on the tasks to see if he could do them. Then, to my shame, I showed him how to do the stuff he didn’t know how to do, so by the time of his check he did know how…
    I think I have been a part of this cynical over-reliance on testing education system we have in this ‘ere country for too long. If drawing dots, circles and lines is what you want to see, I will teach the kids to do that so they can jump through your hoops. That’s what happens when you impose tests onto children. We spend our energies teaching them to pass the tests instead of teaching them anything worth knowing.
    The idea of observing the child at play in an environment they feel comfortable in, with an adult they know is a much better one. How many children demonstrate that they can’t do things that they can in fact do, simply because they don’t feel at ease, or want to comply with instructions from a stranger?
    Apologies for this lengthy comment! In short, yeah – what you said!
    x Alice

  8. I had a foster child who did have some level of developmental delay. He had to have this test every 4 months. Every time the HV would ask him to put a ball in a cup. He never complied. He was always marked down on understanding of language even though I knew that he could understand simple commands and obey them. Eventually I realised that the problem might be that he just didn’t understand ‘cup’ as we usually referred to it as his ‘drink’. I sat down with him and practised putting the ball in the stupid cup. The next time he had the assessment, he aced the ball/cup think! I don’t normally train my foster children for the assessment as it’s important to get a true reflection of their capabilities bearing in mind that many of them are experiencing delay and haven’t always had all the input from health professionals in the past, but I don’t regret doing it on this occasion!

  9. I think this must be something that has come in in recent years as niether of my boys (to the best of my memory) has these checks(my youngest is 15).
    I agree with you though, a test like that for a two year old is fundamentally flawed. Understanding of instructions, willingness to carry out the tasks, shyness, etc can have a huge impact on the outcomes, so basically what are they measuring??
    Thanks for linking up, Tracey xx #abitofeverything

  10. Jenny says:

    I couldn’t agree more with this we just had our two year review with MM and it’ was a complete joke because she didn’t score on this or that or couldn’t draw a straight line or put beads on a necklace string. I agree with you. Thank you ever so much for linking up to Share With Me. I hope to see you again tomorrow for another great round up and hope you have been enjoying the blog hop. #sharewithme

  11. It’s very interesting to hear your view on this. I do not have good experiences with Health Visitors as they missed some very red flags at Ethan’s one year check which he should have been referred for. The same happened at his two year check. This list is quite new, they are now following the American way, and to be honest if this was used on Ethan, my non-verbal toddler might have been referred then too. So in a way I agree that children should be observed by trained experts as the Health Visitors missed Ethan’s autism but I know the expense of this it wouldn’t be possible. So if this scoring helps catch autism early I’m all for them. To be honest in regards to Little E I would be happy for her to have this test every few months. Perhaps they shouldn’t let us see the sore sheet or the questions as I found I didn’t want to or know how to answer them at Little E’s one year check.

    Thanks for linking up with Small Steps Amazing Achievements :0)
    x

  12. Fran says:

    Hi,
    I send my days developing systems. Yes I’m an IT geek. So please bear with this perspective.

    Imagine: the health visitor sees a child with developmental delay. She wants to request help for that child. That help will cost some bit of government money – so will be hard to get.

    The health visitor will need to provide “evidence” to get the help. The test score is that evidence. The health visitor couldn’t say “well he looked a bit funny”. That’s not the way people build systems.

    Ok, so why worry the parents with a score that is meaningless to them. simple: otherwise we’d all be cross that we didn’t see the score.

    Answer provide context and reassurance with the scores. We’ll see what my opinion of this is in 1 year and 3 months time – if it happens… 🙂

    • Fran says:

      sorry, further: the health visitor is a generalist. They might not spot certain things are wrong because people do tend to mask problems by not doing things they find difficult. So the test ensures that many areas are looked at by this visit and the Health visitor can report that there might be problems even if they’ve not got a clue what they are.

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