As one policy to support the health of children, the Children and Families Agency has announced that all five-year-old children will be required to undergo a health check-up. The political party supporting this policy has made the announcement on its website where it was referred to as "Health Check-ups for Safe School Entrance of 5-year-olds."^*1

I have serious concerns about this policy. Readers may wonder why I am feeling such apprehension, so I would like to discuss the reasons below.

One reason for my concern is that I wonder if the early discovery of issues regarding children's behavior before starting school, which is the basic principle of the health examinations for five-year old children, actually helps children.

The advocates of health check-ups seem to hold the following views.

1. Health check-ups before entering school will allow early detection of behaviors that will cause future difficulties in school life and activities.
2. Specialists such as psychologists, child psychologists, etc. will diagnose such behavior and provide therapeutic education before the child starts school or recommend an appropriate school for the child.
3. Children who have shown improved behavior will begin school life smoothly, which will alleviate personal difficulties, parental concern, and strained work from the teachers.

If that is what will happen, let´s verify whether the hypothesis will work well in the current system. In cities and prefectures where it is a requirement, it calls for checking the behavior of approximately 900,000 five-year old children (2022).^*2 A behavioral examination of children cannot be completed in the short time period that is possible in physical examinations, cardiac screenings or visual examinations of other age groups. Even if a parent or guardian's check sheets for developmental activity are used, at the end, it is still necessary to observe the child´s activity and contact with others over a fixed period of time. Furthermore, in my experience, it takes at least 30 minutes (ideally, one hour) to diagnose a child with a developmental disability.

According to a survey by the Ministry of the Education, Culture, Sports, Science and Technology (MEXT), 8.8% of all children in Japan have a developmental disorder with behavioral characteristics.^*3 When a developmental disorder is suspected in a medical checkup of a five-year old, it is stipulated that the child should receive a secondary examination by specialists such as child psychiatrists. However, will it be possible to overcome the situation of extremely insufficient resources, in other words, a possible several-month wait for the first consultation? For example, even if the concept intended (early detection) is good, if the organization involved lacks the appropriate structure to realize it, implementing it as a system will only lead to confusion. On the website of a political party that supports health checkups for 5-year-old children, child psychiatrists are included in the list of specialists. That idea itself is valid, but in Japan, there are currently only 560 physicians in the field of child psychiatry. According to a survey by MEXT, 8.8% of all children may have a developmental disorder, so if the total number of 5-year-old children is 900,000, the number of cases to be found and diagnosed is 79,000 per year (900,000 x 8.8% = approximately 79,000 cases).

A single child psychiatrist will have to see about 130 five-year-old patients each year for a secondary examination, on top of the regular patients the doctor receives. As a matter of fact, many children with a developmental disorder are not only see by child psychiatrists, but also by pediatric neurologists, like myself. There are approximately 400 pediatric neurologists who actively diagnose developmental disorders. Even so, some physicians are very busy with clinical practice and patients must sometimes wait up to eight months for the first appointment. Can the large number of secondary examinations resulting from the 5-year-old health check-up really be handled by these already overburdened doctors? Even if the concept is good, without a solution to this sort of organizational problem, many parents of five-year old children, who are flagged as 'possibly having developmental disorders' as a result of the check-up, will have to live with anxiety and concern without being able to receive a specialist's diagnosis.

According to the website of the political party, under the present system of school entry consultation (optional), there is little time for sufficient consultation from the time of discovery to actual registration and attendance, and adequately handling matters is not possible. For this reason, it is considered good for all children to undergo a health check-up at the age of five. Most school entry consultation occurs around autumn, so they state that if the child has a check-up near his or her fifth birthday, there will be plenty of time before the student actually starts attending school.

Is Refusal to Attend School the Effect?

On this website, it is stated that if treatment or rehabilitation is provided to enable "early identification of the characteristics of development," it will be possible for many children to learn and study attending regular classes. Furthermore, it adds that "research indicates that municipalities that introduced a mandatory health checkup for five-year old children also saw a decline in school avoidance."

I searched for the research report and took a look at the content.^*4 It was the work of a local government organization in Kyushu that gathered results regarding five-year old children over a nine-year period. With the help of statistics, the physician who conducted the research clearly explained the significance of the decline in children who refuse to attend school. However, health checkups of five-year old children were not subject to statistical analysis, that is, the figures were not analyzed to identify the reason for the decline in school attendance, but the report concluded "the checkups of five-year old children reduced or lessened school avoidance," in other words, "a causal relation existed." They have not examined the possibility that the decrease in the number of children who refuse to attend school and providing health examinations to 5-year-old children, are unrelated concurrent occurrences.

In addition to this problem of statistical analysis, there is also a basic question: is it appropriate to judge the significance of five-year-old health check-up based only on the decline in school avoidance?

Are We Turning Away from Inclusive Education?

In this way, the policies are associated with a variety of problems, but my main concern lies elsewhere.

Now that the importance of inclusive education is recognized worldwide and supported by the many nations that have ratified the United Nations Convention on the Rights of Persons with Disabilities, inclusive education is advancing. However, in 2022, a UN commission of inquiry assessed Japan's progress in inclusive education and released a cautionary notice that "Japan is still conducting segregated education." Jonas Ruškus, then a member of the Committee on the Rights of Persons with Disabilities of the United Nations who was in charge of the report, expressed concern that regression in education was apparent and evident in Japan in the education of children with disabilities, "New laws and regulations have actually made education for children with disabilities more divisive and discriminatory by having children take medical examinations and then denying inclusive education based on the results."

Until recently, consultation regarding school attendance was optional, but it has become compulsory now in the form of a health checkup for 5-year-old children, and all children must undergo a medical checkup. As a result, it has come to promote select measures such as "anti-inclusive education" in the form of special needs classes and schools.

Even in the municipalities that claim school avoidance has declined, it is a fact that over a period of eight years, 56 five-year-old children were diagnosed with a developmental disorder of which 38 were placed in regular classes. In other words, 18 children (56 minus 38) were selected to attend special needs classes or special needs school. While it may be said that the number is hardly large, the required medical check-up for five-year-old children has become the door that leads to a segregated education.

The Ministry of Education, Culture, Sports, Science and Technology (MEXT) has placed special needs classes and special needs schools in districts as inclusive educational facilities. However, as can be recognized in the concerns of the United Nations experts committee, that is not compatible with international trends.

• *1 Komeito. Health Check-ups for Safe School Entrance of 5-year-olds. https://www.komei.or.jp/komeinews/p334598/
• *2 Statistics Bureau of Japan. Current Population Estimates as of October 1, 2022. https://www.stat.go.jp/english/data/jinsui/2022np/index.html
• *3 Ministry of Education, Culture, Sports, Science and Technology (MEXT), Survey Results of Students Who Attend Regular Classes and Require Special Educational Support (2022). https://www.mext.go.jp/content/20230524-mext-tokubetu01-000026255_01.pdf
• *4 Korematsu, S., Takano, T., & Izumi, T. (2016). Pre-school development and behavior screening with a consecutive support programs for 5-year-olds reduces the rate of school refusal. Brain & development, 38(4), 373-376. https://doi.org/10.1016/j.braindev.2015.09.012