Education of non-expert health care professionals regarding pediatric

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EDUCATION OF NON-EXPERT HEALTH CARE

PROFESSIONALS

REGARDING PEDIATRIC SEXUAL ASSAULT PROTOCOLS

Talia Goldberg

Jeremy Chad

Jennifer Keeler

BSTRACT

RATIONALE: Many health care professionals are unaware of evidence-based protocols

for management of pediatric sexual assault. This leads to redundant questioning and physical

examination. Health care workers must recognize red flags and know basic protocols for management.

OBJECTIVE: To create an educational resource for Chantel’s Place, the Peel Regional medical and

forensic clinic for domestic violence and sexual assault, that improves knowledge among non-expert

health care professionals regarding pediatric sexual assault protocols. METHODS: A seminar was

created using information gathered from manuscripts, clinician interviews, and case reviews. One

presentation was created for an interprofessionalhealth care audience and another was created for

emergency room staff

ESULTS

The interprofessional presentation was delivered once, and attained a positive response

from participants. 96% of attendees agreed the session achieved its learning objectives, and 93%

agreed the session was engaging and effective. Chantel’s Place staff believe the format is reproducible.

DISCUSSION: This feedback suggests this presentation format is an effective way to educate

health care professionals on pediatric sexual assault protocols. CONCLUSION: The creation of

a scalable educational resource for different health care audiences will allow Chantel’s Place to

promote evidence-based care and reduce emotional trauma for survivors of pediatric sexual assault.

EY WORDS

Sexual Assault

Sexual Abuse

Pediatrics

Interprofessional Health Care

Health Care

Education.

RATIONALE

The World Health Organization (WHO) estimates the global preva-

lence of pediatric sexual abuse to be 20% in girls and 5-10% in boys (World

Health Organization, 2006). The WHO defines pediatric sexual abuse as:

[...] the involvement of a child in sexual activity that he or she does not fully com-

prehend, is unable to give informed consent to, or for which the child is not develo-

BMSc - Faculty of Medicine, University of Toronto. 3359 Mississauga Road. Mississauga, Ontario, Canada L5L

1C6. 416-277-4546. talia.goldberg@mail.utoronto.ca

BESc, HBA - Faculty of Medicine, University of Toronto. 3359 Mississauga Road. Mississauga, Ontario, Ca-

nada. L5L 1C6. 647-633-5202. jeremy.chad@mail.utoronto.ca

RN(EC), BScN (Hons), NP, SANE. Chantel’s Place, Trillium Health Partners. 100 Queensway West. Mis-

sissauga, Ontario, Canada. L5B 1B8. 905-848-7580 ext. 2548. Jennifer.Keeler@trilliumhealthpartners.ca

http://doi.org/10.33027/2447-780X.2018.v4.n1.03.p25

GOLDBERG, T.; CHAD, J.; KEELER, J.

Revista do Instituto de Políticas Públicas de Marília, Marília, v.4, n.1, p. 25-34, Jan./Jun., 2018

pmentally prepared and cannot give consent, or that violates the laws or social taboos

of society. Child sexual abuse is evidenced by this activity between a child and an adult

or another child who by age or development is in a relationship of responsibility, trust

or power, the activity being intended to gratify or satisfy the needs of the other person.

(WORLD HEALTH ORGANIZATION, 1999, p. 15-16).

Pediatric sexual assault has the same definition, except that the perpe-

trator does not need to be in a relationship of responsibility, trust, or power over

the victim (THE SUSPECTED CHILD ABUSE & NEGLECT PROGRAM,

2003). Statistics Canada reports that sexual assault in youth and children is the

second most prevalent type of violence reported to police in that population, and

that it is 1.5 times more prevalent than the rate of sexual assault in young adults

(18 to 24). In 75% of cases, the perpetrators of this type of violence are someone

known to the child (STATISTICS CANADA, 2008). As reported by the Public

Health Agency of Canada, in 2008 there were 2,607 cases of substantiated sexual

abuse aged 15 and under in the population (PUBLIC HEALTH AGENCY OF

CANADA, 2010). Unfortunately, it is difficult to quantify the exact incidence

with certainty due to underreporting rates. In Canada, it is thought that only

12% of sexual assault cases in the general population are brought to the attention

of police (Statistics Canada, 2009). By extrapolating on the information above,

one could estimate that there were over 21,000 cases of pediatric sexual abuse

in Canada in 2008. Furthermore, this number only reflects substantiated cases.

Heppenstall-Heger et al. explained that when a potential case of sexual assault is

reported, there are usually no physical findings, and when there are, these findin-

gs tend to be nonspecific. It is common for there to be a delay between the occur-

rence of the assault and the time of patient presentation, by which point, injuries

have usually healed (HEPPENSTALL-HEGER et al., 2003). These reasons make

it very difficult to acquire concrete evidence of the event. Heppenstall-Heger et al.

found that in cases of acute sexual assault where injuries were observed, lasting

physical findings were present only 14.6% of the time (HEPPENSTALL-HE-

GER et al., 2003). Therefore, it is likely that the true annual incidence of pedia-

tric sexual abuse in Canada is well over the 21,000 listed above.

At Trillium Health Partners in Mississauga, Ontario, Canada, the acute

care of pediatric victims of sexual assault who present to the emergency room has

a defined protocol designed to provide the most effective care, both medically

and legally, to these individuals. Ideally, individuals should be referred in a timely

manner to Chantel’s Place, where a specially trained nurse provides one-on-one

care in a safe environment for these children. Chantel’s Place is one of 35 Ontario

hospital-based programs funded by the Ministry of Health and Long Term Care to

provide acute sexual assault and domestic violence services. Their mandate is to

serve individuals: ≥12 years of age who have been recently sexually assaulted (12

days); ≥16 years of age who have incurred recent physical injuries as a result of

domestic violence; and <12 years of age who disclose sexual abuse/assault. Here,

Education of non-expert health care professionals regarding pediatric

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they provide survivors of sexual assault and domestic violence with medical and

forensic assessment, prophylactic medication, safety planning, and social support

services. There is also a separate and private room to conduct interviews should

police involvement be required.

This service learning project focused on determinants of health sur-

rounding cases of pediatric sexual assault. According to the AFMC Primer on

Population Health, “traumatic experiences in early childhood shape personality

and have a lasting impact on how a person views his world, how he relates to

others, and how he interprets events” (The Association of Faculties of Medicine of

Canada, 2011, Ch. 2). A pediatric sexual assault encounter, therefore, will likely

have an effect on early childhood development. A 2014 study by Davidson and

Omar showed the long-term psychological impact that sexual assault encounters

can have on survivors. Higher rates of depression, post-traumatic stress disorder,

abnormal stress responses, drug use and self-harm have all been documented in

these children. Additionally, these individuals have shown that as they age, they

are more likely to enter into abusive relationships and demonstrate higher levels

of hospitalization and serious illnesses than age-matched populations (DAVID-

SON; OMAR, 2014). A World Health Organization report on sexual assault

explains that the medical history and forensic exam following a sexual assault can

further traumatize a survivor (WORLD HEALTH ORGANIZATION, 2003).

Chantel’s Place promotes the guidelines established by Adams et al. that state

that the history and forensic exam should only be performed by a trained clini-

cian who participates in annual continuing education (ADAMS et. al., 2007).

Chantel’s Place provides survivors across Peel Region with access to these trained

medical professionals.

There are additional concerns to consider for health care professionals

who encounter a victim of pediatric sexual assault. Poor history-taking skills can

actually destroy a patient’s case, as children are very suggestible. If questions are

asked the wrong way, then the child may provide the wrong answer, and those in-

correct answers may have implications in court. That mistake would be the fault

of the historian (THE SUSPECTED CHILD ABUSE & NEGLECT PRO-

GRAM, 2010). Additionally, health care professionals need to understand that

they have a legal obligation to report suspected cases of pediatric sexual assault to

the local Children’s Aid Society, regardless if the information is considered con-

fidential by professional standards (CHILD AND FAMILY SERVICES ACT,

1990). It is essential that professional health care workers who may come across

cases of pediatric sexual abuse and assault receive the education necessary to know

how to appropriately manage these situations.

OBJECTIVE

GOLDBERG, T.; CHAD, J.; KEELER, J.

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The objective of this service learning project was to create an educa-

tional resource for Chantel’s Place that could provide non-expert health care

professionals with the information they need in order to know their role and

responsibilities when a patient present with a potential case of pediatric sexual

assault. The goal was to create a resource that: (i)included the most salient infor-

mation for non-expert health care professionals regarding pediatric sexual assault

protocols; (ii) could be adapted easily for a variety of health care audiences; and

(iii)

could be delivered readily by Chantel’s Place staff. In doing so, we hoped to

improve health care professionals’ level of knowledge regarding this topic, which

should have positive benefits on childhood development for victims of pediatric

sexual assault.

METHODS

This project was completed in association with Chantel’s Place, the Peel

Regional medical and forensic clinic for domestic violence and sexual assault. It is

located within Trillium Health Partners in Mississauga, Ontario, Canada. Infor-

mation was gathered from manuscripts, published sexual assault guidelines and

manuals, and Statistics Canada. Additional information was obtained through

case review sessions with specially trained nurses from Chantel’s Place and the

Suspected Child Abuse & Neglect (SCAN) clinic at The Hospital for Sick Chil-

dren in Toronto, Ontario, Canada, and through interviews with front-line nurses

(n=4), social workers (n=2), and physicians (n=1). The above sources were analy-

zed for important legal details and common themes, and this information was

applied in a slideshow presentation format. Two presentations were created: one

for emergency room staff, and one for an interprofessionalhealth care audience.

The slideshow presentations contain information that was deemed as

being the most prudent and useful for a 40-60 minute educational seminar of

health care professionals. The first half of the presentation is built primarily as a

didactic form of teaching, with opportunities for audience participation via spo-

radic audience-directed multiple choice questions. The audience members were

given “clickers” that allowed them to electronically submit answers to questions

that were posed, and the overall answer distribution was displayed on screen. The

second half of the presentation involves case studieswith preset questions that are

designed to make seminar participants think deeper about the information they

have just learned in the first half of the seminar. The seminar participants are

separated into small groups for this part of the seminar, and seminar facilitators

float between 1-2 seminar groups to help guide discussion.

The following is an outline of the educational seminar:

1. Definitions

Pediatric Sexual Abuse

Education of non-expert health care professionals regarding pediatric

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Revista do Instituto de Políticas Públicas de Marília, Marília, v.4, n.1, p. 25-34, Jan./Jun., 2018

Pediatric Sexual Assault

Incidence and Prevalence

Relevance for all Health Care Professionals

Possible First Presentations

5. Continuum of Care

Cues and Red Flags

Physical signs

Emotional signs

Behavioral signs

Developmental signs

7. Taking a History

8. What Patients and Parents Want to Know

Case Studies

10.

Resources and Contacts

A sample case study with follow-up questions is included below: Nor-

ma is 16-years-old. This past Saturday she went to a friend’s house party. She has

known this friend for a couple of years. Norma brought her own alcohol and did

not drink anyone else’s alcohol that night. She did not realize how much she had

to drink, nor how late it was. The buses were no longer running and she did not

have money for a cab fare. Her friend told her she could stay over, so she did. In

the morning she found her clothing removed, and that her friend was in the bed

next to her, she believes she has been sexually assaulted. Today is Monday and she

at your office seeking support.

List the steps you would take.

What are your responsibilities in this scenario?

What kind of environment would be most helpful and supportive to

her at this time? And questions to ask that would be helpful?

What are your own beliefs and values?

What are some of the myths that come to mind from this scenario?

RESULTS

The interprofessional seminar was delivered once, and attained a posi-

tive response from participants. The didactic portion of the presentation ran for a

total time of 30 minutes with approximately 20 minutes of case-based discussion.

A post-session survey was administered to all attendees of the presentation and

GOLDBERG, T.; CHAD, J.; KEELER, J.

Revista do Instituto de Políticas Públicas de Marília, Marília, v.4, n.1, p. 25-34, Jan./Jun., 2018

28 responses were received. Of the 28 attendees who completed the post-session

survey, 96% agreed that the session achieved the stated learning objectives (Figure

1), and 93% agreed that the session was engaging and effective (Figure 2).

Figure 1

: Seminar Participant Evaluation of of Meeting Stated Learning Objectives

Figure 2

: Seminar Participant Evaluation of Seminar Effectiveness

The seminar was considered to be a success, with one participant saying,

“Great information. I felt like I learned the very basics of the things I should con-

sider in assault situations,” and another saying, “The information itself [was most

useful]. I didn’t know much of it beforehand.” A number of participants provided

some constructive criticism as well as suggestions for improvement. One parti-

cipant said “perhaps incorporate situations or real life examples to put a more

Education of non-expert health care professionals regarding pediatric

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realistic context on the session”. Another participant provided a comment for

improvement, suggesting “more clarification on different professions [interpro-

fessional healthcare] roles.” Finally, one participant proposed the use of a “Take

home Message” slide to help summarize the information provided.

Chantel’s Place staff have also agreed that the presentation format is

reproducible. Additionally, a presentation was created and approved by Chantel’s

Place staff designed for emergency room staff. The presentation was designed with

the same overall format and incorporated minor changes to gear the educa- tion to

an audience of people dealing with the more acute side of pediatric sexual

assault/abuse. This presentation has not yet been piloted on an audience.

DISCUSSION

The results show that participants drew important lessons from those

taught and emphasized, and that they appreciated the presentation’s clinical re-

levance. This strong, positive feedback suggests that this interactive presentation

format is an effective way to educate health care professionals on matters of ob-

vious clinical relevance. These presentations will allow Chantel’s Place to promote

its mandate and ensure pediatric survivors of sexual assault in Peel Region receive

high-quality, evidence-based care. With the appropriate management of pediatric

sexual assault and the widespread dissemination of this information, the goal is to

reduce the emotional trauma for pediatric survivors of sexual assault.

The interprofessional health care audience was selected because cases

of pediatric sexual assault can present in multiple settings. Children relate to

different health care professionals in different ways, and it is equally as possible

for a child to make a statement of abuse or assault to his or her physician, nurse,

occupational therapist, physiotherapist, dentist, social worker, personal support

worker, speech language pathologist, dietician, etc. In addition, cases of pediatric

sexual assault may often be discovered as a result of a child exhibiting signs and

symptoms of having been sexually assaulted, and not because the child makes an

explicit statement of assault. The health care professionals above all must have the

ability to recognize these signs and symptoms, because they may be the only health

care professional that the child sees for months (KELLOGG, 2005). The

emergency department was selected as another ideal audience for this seminar

because the emergency department represents a common location for children

to present after having been sexually assaulted (KELLOGG, 2005). For either

audience, appropriate management is essential and education of these protocols

can be targeted through the seminars that were created. Additional audiences that

can be targeted include primary care physicians, law enforcement officials, and

school teachers.

GOLDBERG, T.; CHAD, J.; KEELER, J.

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It is important to consider some of the limitations of this preliminary

work. This project is still in its early phases and the seminar has only been ad-

ministered once. It will be important to present the developed presentation to

emergency room staff and attain post-survey data from this group of individuals

to determine whether a similar response is seen. It must also be taken into con-

sideration how the long-term success of this presentation is to be monitored.

Though short-term success is being monitored by the post-seminar surveys, true

success will be dictated by the effect the seminars have on improving the way se-

minar participants manage cases of pediatric sexual assault. Some potential ways

of assessing long-term success include monitoring the rates of referral from Peel

Region emergency departments to Chantel’s Place, monitoring health outcomes of

Chantel’s Place patients who have been sexual assaulted, and asking Chantel’s

Place patients directly about their experiences with health care professionals (and

other related professionals such as law enforcement and school teachers) that

ultimately led to their referral to Chantel’s Place.

For Chantel’s Place, educational seminars were deemed as the first step

in improving care for pediatric patients of sexual assault and abuse. Chantel’s

Place can look to build on this work by creating other educational initiatives

that can be done in the community to ensure survivors of pediatric sexual assault

receive evidence-based care. One example of this future work is to create a marke-

ting campaign to educate citizens of Peel Region on the prevalence of pediatric

sexual assault in the community, the dangers of having a low reporting rate, and

the resources available to children and families in need. By empowering sexual

assault survivors and making them aware of Chantel’s Place and other resources

available to them in the community, it might improve survivors’ opportunities

to have access to these resources. Until now, survivors have relied on their health

care professionals’ knowledge that Chantel’s Place exists in order to get a referral;

if the survivors themselves are aware of Chantel’s Place, it could make a big diffe-

rence in the care they receive.

CONCLUSION

The educational seminar that was created over the course of this ser-

vice learning project will provide Chantel’s Place with a method of delivering

key information to non-expert health care professionals regarding management

of potential cases of pediatric sexual assault and abuse. The seminars have the

approval of Chantel’s Place staff, and have been used in practice on one occasion,

with overwhelmingly positive feedback. There are still numerous considerations

for measuring the long-term success of these seminars, and many other ways of

educating a diverse set of audiences have been postulated as well. Overall, there

is a hope that the continuing implementation of these seminars along with the

Education of non-expert health care professionals regarding pediatric

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creation of additional educational initiatives will result in better care and better

health outcomes for survivors of pediatric sexual assault and abuse.

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Submitted: 15/03/2018

Accepted: 25/07/2018

GOLDBERG, T.; CHAD, J.; KEELER, J.

Revista do Instituto de Políticas Públicas de Marília, Marília, v.4, n.1, p. 25-34, Jan./Jun., 2018

Education of non-expert health care professionals regarding pediatric

Artigos/Articlesw

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