Abstract
Child sexual abuse (CSA) is a pervasive public health problem. If left undetected, CSA can result in immediate and long-term health problems, which can be mitigated through early identification. Schools are an ideal environment to implement screening measures, and school nurses (SN) are uniquely poised to intervene and respond early. The aim of this review was to systematically examine and synthesize the international evidence related to screening for early identification of CSA in schools. Themes emerging from the analysis were SN behaviors relative to screening, potential instruments or approaches for screening, and SN and school professionals’ beliefs about CSA screening practices. This review found little evidence that CSA screening is occurring in schools. However, SNs are aware that screening falls within their scope of practice and many SNs feel they should be screening for it. A constant proactive approach by SNs is necessary to improve early identification and subsequent intervention.
Keywords
Background
Child sexual abuse (CSA) is a pervasive public health problem that is preventable, often silent, and affects 1 in 4 girls and 1 in 13 boys (Centers for Disease Control and Prevention [CDC], 2020). If left undetected, the physical and psychological trauma CSA causes can result in immediate and long-term health problems (Hall & Hall, 2011; Jordan et al., 2017; National Center for Victims of Crime, 2020). Early identification can mitigate the negative health consequences associated with CSA by leading to an opportunity for intervention and treatment of youth victims before long-term consequences ensue (Chandran et al., 2020).
Since the United States (US) Congress enacted the Child Abuse Prevention and Treatment Act (CAPTA) in 1974, CSA has been illegal in all 50 states and requires mandatory reporting when suspected by specified professional groups, including nurses (Brown & Gallagher, 2014; GovTrack.us, 2022). Despite mandatory reporting efforts, CSA remains an underreported, underrecognized, and significant health problem that affects communities in the US and beyond (CDC, 2020; Chandran et al., 2020; Liu & Vaughn, 2019; World Health Organization [WHO], 2017). Instruments or questions that screen for a history of CSA or abuse-related symptoms (e.g., post-traumatic stress disorder [PTSD], depression, anxiety, and sexualized behaviors) are recommended for use in primary care settings (Hanson & Adams, 2016; Hanson & Wallis, 2018; Hoft & Haddad, 2017; Hornor, 2013; Sabella, 2016).
School systems are an ideal environment to implement CSA screening measures aimed at early identification, and school nurses (SN) are uniquely poised to intervene and respond early, increasing the likelihood that victimized youth are identified (American Academy of Pediatrics Council on School Health, 2016; Grace et al., 2012; National Association of School Nurses [NASN], 2018). Nevertheless, outside of mandatory reporting laws, how schools and SNs are used as a resource for early CSA identification is not fully understood.
Child sexual abuse is recognized by law as a form of child maltreatment. It involves any completed or attempted (non-completed) sexual act, sexual contact with, or exploitation, including sex trafficking and commercial sexual exploitation of children (CSEC) aged 17 or younger (Leeb et al., 2008; Office of Juvenile Justice and Delinquency Prevention, 2020; Rape Abuse and Incest National Network, 2020). It is a crime that often goes underreported or not reported, resulting in the difficulty of obtaining exact estimate data (CDC, 2020). For example, the National Center for Victims of Crime (2020) research indicates that 1 in 5 girls and 1 in 20 boys are victims of CSA. The CDC (2020) reports that CSA victimization occurs in 1 in 4 girls and 1 in 13 boys. Estimates also vary based on the country, definition, type of CSA studied, the extent of coverage, and the quality of the data (Singh et al., 2014). The WHO reports that 18% of girls and 8% of boys worldwide have experienced sexual abuse (WHO, 2017). Child sexual abuse is a universal, preventable phenomenon occurring in all ages, socioeconomic classes, and nearly all countries (CDC, 2020; Krug et al., 2002; Singh et al., 2014).
Research indicates adults with a history of CSA experience psychological and physical problems including anxiety, depression, obesity, headaches, aggression, suicide attempts, PTSD, and self-destructive behaviors, to name only a few (Johnson, 2004; Knisely et al., 2000; WHO, 2020; Wilson, 2010). Molnar et al. (2001) examined the relationship between CSA and subsequent psychiatric disorders in adults and found that the severity of symptoms the adult experienced negatively correlates with the age of abuse. Thus, the younger the individual experiencing CSA, the higher the risk that the individual will experience more physical and psychological symptoms later in life requiring treatment. The Molnar et al. (2001) study findings demonstrate that identification should take place early in the life of CSA victims to facilitate mitigating the development of long-term negative health consequences that require arduous treatment. Furthermore, research indicates that many persons who experience CSA do not ever disclose their victimization during childhood or do so in adulthood after health issues have surfaced (Hanson & Adams, 2016; Hornor, 2013).
In addition, children are developing cognitively and emotionally and may lack language and comprehension of sexual abuse experiences impeding their ability to express in words their sexual abuse to an adult, such as a SN (Pearce, 2011). It is a reality that the SN is caring for victims of CSA who have not yet disclosed, making screening even more crucial to the future health of youth victims. Findings associated with research conducted among adult survivors of CSA who concurrently experience physical and psychological consequences underscores the gravity of early recognition of CSA while victims are still in their youth.
Health promotion in the community setting entails three levels of prevention: primary, secondary, and tertiary. Primary prevention includes education before a problem ensues, secondary prevention includes screening for early problem identification, and tertiary prevention includes rehabilitation after problem identification and treatment. Schools and school health clinics facilitate efforts to address all three levels of community health prevention (Rector, 2018). The passage of CAPTA led to a wealth of theoretical and empirical work focusing on the primary prevention of CSA in the community (US Department of Health and Human Services Child Bureau, 2014). These programs utilize SNs and school counselors to deliver CSA prevention content to raise community awareness of the problem (Barron et al., 2015; Davis & Gidycz, 2000; Ogunfowokan & Fajemilehin, 2012). However, prevention programs do not contain a screening component (Sekhar et al., 2018). Research to date has demonstrated the prevalence of CSA education prevention programs (i.e., primary), as well as the need for some form of medical treatment after CSA has occurred (i.e., tertiary) but little is known about existing research on CSA screening in schools (i.e., secondary), consistent with other forms of abuse screening of youth in schools. Determining the current state of the science for screening can bridge primary and tertiary levels of prevention by providing evidence-based insight about CSA prevention interventions at the secondary level.
School nurses are community health nurses whose role includes the prevention, early identification, intervention, and treatment of child maltreatment of all types, including CSA (American Academy of Pediatrics Council On School Health, 2016; NASN, 2018). The SN can provide both individual and population health, and care coordination between the school and community-based health professionals (Rector, 2018). SNs also perform other screening protocols and refer for potential health issues such as vision, hearing, scoliosis, acanthosis nigricans, mental health, and nutrition (NASN, 2020). Additionally, prevention research speaks to the need for CSA screening in schools (Hampton & Lieggi, 2020; Harding et al., 2019; Hoft & Haddad, 2017). Findings from this review could be used to inform future intervention research to assist SNs and other school professionals in screening students for CSA victimization.
Problem Identification
The NASN posits the vital role SNs play in early identification, assessment, intervention, and reporting of youth suspected of maltreatment as being critical to the physical and emotional well-being and academic success of students (NASN, 2016, 2018). At the same time, the US Preventive Services Task Force (USPSTF) has determined “insufficient evidence” exists for or against recommending specific interventions to identify CSA in health care settings (USPSTF, 2018). However, the USPSTF did find evidence to support that once abuse has been assessed, interventions can reduce the harm to youth (Hornor, 2013; USPSTF, 2018). That said, there are compelling reasons to encourage some type of screening as a routine aspect of SN care.
First, on an average school day, the SN cares for 43.5 students or 6.5 students per hour (Bergren, 2016) compared to physicians who care for an average of 20.2 patients per day (The Physicans Foundation, 2018). Second, according to the NASNs Framework for 21st Century School Nursing Practice, the burden of CSA identification and intervention are within the scope of SN practice (NASN, 2016). Although research that estimates the number of youths who simultaneously attend school while CSA specifically is occurring was not found during this review, there is literature that supports varying estimates of students attending school experiencing other forms of defined abuses that include sexual abuse in nature, such as human trafficking (Fraley & Aronowitz, 2021). Additionally, anecdotally one can surmise that many youths experiencing CSA are also students attending school. Thus, a missed opportunity for early identification of victimized students can be avoided by implementation of proactive CSA screening intervention practices.
Review Aim and Research Questions
The aim of this integrative review is to systematically examine and synthesize the international evidence related to screening for early identification of CSA in school settings.
Research questions specifically examined include (1) are there established screening practices for CSA utilized in schools? (2) how does CSA screening occur in schools? and (3) what are the barriers and facilitators surrounding the issue of CSA screening in school?
Method
Design
Whittemore and Knafl’s (2005) systematic methodology for conducting an integrative review was used as a framework to guide this review by following the five steps associated with the model: (a) problem identification, (b) literature search, (c) data evaluation, (d) data analysis, and (e) presentation of results. An essential attribute of this methodology is that it allows diverse research methods, including experimental and non-experimental empirical study types and theoretical literature, for consideration in the review. Since there is little known about CSA screening in schools, this comprehensive model is well-suited for application in this review. The Quality Assessment Tool for Studies of Diverse Designs (QATSDD) (Sirriyeh et al., 2012) was used to appraise studies. Like Whittemore and Knafl's model (2005), the QATSDD appraises diverse study designs.
Literature Search
Assessment of the published research literature related to CSA and screening in schools involved the help of an experienced health science librarian using five electronic databases chosen for their scope and relevance to nursing: (a) PubMed, (b) ERIC, (c) CINAHL, (d) Scopus, and (e) APA PsycInfo. The CINAHL nursing database produced the most results of all the databases searched, and ERIC the least. Additional search strategies employed scanning reference lists (i.e., hand search) and forward citation searching using the Google Scholar search engine. A brief gray literature search included assessing the NASN website to explore whether a screening tool specific to CSA is housed within their list of available screening tool kits.
Including the terms “screening” OR “identification” OR “assessment” in the search yielded few results so more general terms that encompassed the three identified review concepts (i.e., population affected, types of CSA, and school setting variations) were added. Search terms focusing specifically on the concepts facilitated the literature search by using Boolean operators and data-specific MeSH terms. The search included the following terms: “child” OR “adolescent” OR “youth” OR “adolescence” OR “minors” AND “child sexual abuse” OR “sex trafficking” OR “commercial sexual exploitation of children” OR “CSEC” OR “human trafficking” OR “prostitution” OR “sex work” AND “school nurse” OR “school health nurse” OR “school health nursing” OR “school health.” Additionally, the search years for the review were 1974 to 2020 to capture any potential literature after Congress passed the CAPTA legislation in 1974. The first author also hand-searched the reference lists of the final ten review articles regarding CSA screening in schools and confirmed that no articles were overlooked.
Inclusion criteria for abstracts were: (a) primary research, (b) peer-reviewed, (c) available in English, (d) studies conducted in the US and beyond, (e) published between 1974–2020, (f) study focusing on identification, or screening, or detection, or assessment, or awareness, or recognizing, or seeing CSA among youth attending schools, and (g) study conducted with SNs, students, or other professionals within the school system (e.g., teachers, counselors, stakeholders, or administrators). Child sexual abuse is a form of child maltreatment (WHO, 2020); therefore, studies that included child maltreatment were deemed essential and considered for review. Exclusion criteria were (a) non-English studies, (b) homeschooled youth, (c) online/remote learners, (d) studies containing samples obtained from hospitals or community-based health centers, and (e) studies that evaluate or implement CSA prevention strategies including programs in schools.
Studies were stored and organized using Endnote citation manager software (Clarivate, 2020). Once articles were uploaded and organized into Endnote, they were copied and transferred into Covidence software (Covidence, 2020) for literature reviews to begin the abstract screening process.
There were 395 articles identified during electronic database searching and 16 identified during a hand search of reference lists totaling 411 articles. Of these, software removed 140 duplicates leaving 271 articles for abstract screening. Application of inclusion and exclusion criteria during abstract screening resulted in 177 excluded articles, leaving 94 remaining for full-text review, after which, 10 of the 94 articles met the review aims. Figure 1 is the PRISMA flow diagram.
PRISMA 2009 flow diagram.
Data Evaluation
Critical Appraisal Tool
The QATSDD (Sirriyeh et al., 2012) appraisal tool was used for this review. It contains 16-items rated on a 4-point scale, (0 = not at all, 1 = very slightly, 2 = moderately, and 3 = complete). Evaluating the quality of each study occurs by awarding a score for each item, then summing the score to obtain a total numeric score and expressing the total as a percentage. If there was a question about whether an item fully encompassed the criteria associated with one of the scaled areas, choosing the lower score minimized error and ensured equity (Sirriyeh et al., 2012). Table 1 includes quality scores. Percentage scores of each study ranged from 52.1% to 91.6%, with an average score of 72.9%. Since little is known about the phenomenon, all studies were kept in the review to help shape scientific knowledge. Overall, appraisal of evidence from all studies indicates that very little intervention work exists, most of the data is qualitative, and quantitative designs have primarily been descriptive.
QATSDD Item Scoring Calculation for Each Study Reviewed.
Note: N/A indicates Not Applicable.
Data Analysis
During the initial data analysis stage, studies were grouped according to research design (i.e., quantitative, qualitative, and mixed methods) and read multiple times noting areas that contained critical statements relevant to the review aim. To assist with data interpretation, extracted data from individual studies were placed into a data matrix to visualize patterns and relationships between studies (see Table 2). During the data comparison phase, a constant comparative and iterative analysis assisted with identification of commonalities, patterns, and relationships (Whittemore & Knafl, 2005), resulting in the development of themes based on similar characteristics of findings noted in each study.
Data Matrix.
Initial extraction of findings was conducted by one author using a continual comparison approach, whereby, themes were compared to each other and to the original studies to ensure thematic categories accurately reflected study findings. Themes were reviewed, revised, and confirmed by a study co-author. During conclusion drawing and theme development, the authors sought to address the review aim to describe what is known internationally about CSA screening in schools.
Results
The final ten studies include four quantitative (Ribeiro et al., 2015; Saewyc et al., 2003; Sundler et al., 2019; Zolotor et al., 2009), four qualitative (Fraley & Aronowitz, 2021; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Sekhar et al., 2018), and two mixed methods (Fraley et al., 2018; McGurk et al., 1993). Of the ten studies, three were conducted in Sweden, five in the US, one in Brazil, and one was a multi-national pilot study conducted in Iceland, Russia, India, and Columbia. Studies were conducted in countries where diverse health care systems exist that vary in organization, yet the one commonality is that all of them have a structured school system.
All ten studies were relevant to addressing any form of CSA among students attending school. Of the four quantitative, two used a descriptive cross-sectional design (Ribeiro et al., 2015; Sundler et al., 2019), one conducted a secondary data analysis using an existing data set (Saewyc et al., 2003), and one was an international pilot study using a population-based survey (Zolotor et al., 2009). The qualitative studies utilized informant interviews, either focus groups or individual. Both mixed methods studies used a sequential explanatory design using a survey to collect data first, followed by interviews with informants (Fraley et al., 2018; McGurk et al., 1993). Not all study settings were within a school environment, and study samples varied between SNs, students, survivors of sex trafficking, and school stakeholders. Four studies explicitly included a sample of SNs (Fraley et al., 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Sundler et al., 2019). Two study samples included not only SNs but also survivors of sex trafficking (Fraley & Aronowitz, 2021) and school stakeholders (e.g., school administrators/counselors, doctors, parents, educational staff) (Sekhar et al., 2018). Study samples that included SNs, sex trafficking survivors, and school stakeholders occurred in diverse settings such as school nurse conference locations (Fraley & Aronowitz, 2021; Sundler et al., 2019), a trafficking survivor retreat (Fraley & Aronowitz, 2021), a university setting (Kraft & Eriksson, 2015), and conference spaces (Sekhar et al., 2018). Additionally, three studies included a sample of students ranging in age from 11–17, and these were the only studies conducted specifically in the school setting (McGurk et al., 1993; Ribeiro et al., 2015; Zolotor et al., 2009). However, Saewyc et al. (2003) conducted a secondary data analysis using a large data set of survey outcomes obtained from students in the school setting across two time points (e.g., 1992, 1998). Among the studies included in this review, none had a sample of youth under the age of 11.
The purpose of the studies conducted with SNs was to explore their attitude and awareness, as well as how they detect, identify, suspect, support, and address youth at risk for or currently experiencing CSA (Fraley & Aronowitz, 2021; Fraley, Aronowitz, & Jones, 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Sundler et al., 2019). The purpose of studies conducted with student samples was to either determine CSA prevalence using instruments administered anonymously (Ribeiro et al., 2015; Zolotor et al., 2009), or to determine the nature and scope of CSA among students identifying as CSA victims in the school clinic setting (McGurk et al., 1993). Of the ten studies, one stands out as the only study whose purpose was explicitly to understand SNs and school stakeholder perspectives regarding screening for CSA in schools (Sekhar et al., 2018). In other words, the remaining studies did not articulate CSA screening as the study purpose. Instead, screening emerged as a topic of discussion within the study's context.
Following data analysis, three central themes related to screening emerged across studies: SN behaviors relative to screening, potential instruments or approaches for screening, and SN and school professionals’ beliefs about screening practices. Themes are presented here in descending order of frequency, with the most common theme being SN behaviors relative to screening, followed by potential instruments or approaches for screening, and lastly, SN and school professionals’ beliefs about CSA screening practices.
School Nurse Behaviors Relative to Screening
School nurses exhibit a range of behaviors relative to screening that can serve as barriers or facilitators to screening students for CSA. Studies conducted with samples of SNs indicate that many times SNs see the red flags associated with CSA but are unsure how best to respond or, better yet, how best to screen those students suspected to be experiencing abuse (Fraley & Aronowitz, 2021; Fraley, Aronowitz, & Jones, 2018; Kraft & Eriksson, 2015; Saewyc et al., 2003). The power of intuition plays a prominent role in the SNs’ ability to see the behaviors exhibited by students that indicate abuse may be occurring (Fraley & Aronowitz, 2021; Kraft & Eriksson, 2015). Outcomes from several studies with SNs reveal that often they know something is not right with a student but fail to act on the intuition for a variety of reasons such as avoidance, mislabeling, and fear (Fraley & Aronowitz, 2021; Fraley, Aronowitz, & Jones, 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Sundler et al., 2019). Behaviors associated with the SNs’ failure to act lead to underreporting of CSA, which is an evidence-based issue discussed in several studies (Kraft & Eriksson, 2015; Sekhar et al., 2018; Sundler et al., 2019). Although there are many implications associated with CSA mandated reporting failures, if the SN suspects it, they must report it. One study found that of the SNs surveyed, 14% had a student admit CSA in the past year, and of these only 8% were reported by the SN (Sundler et al., 2019). On the contrary, outcomes from one study hold promise for SNs. Using a grounded theory approach, Fraley and Aronowitz (2021) found that SNs can adjust their ability to see signs of abuse by recognizing how these students may present in school settings and learning how to assess, screen, and refer. At the same time, Kraft et al. (2017) refer to the ability of SNs to see youth experiencing CSA as “from blind eye to eye opener” (p. 136).
Studies with SNs found that mislabeling of symptoms or situations demonstrated by youth is a typical behavior exhibited by SNs, which can inhibit their decision to screen. For example, in Sweden and the US, students experiencing CSA frequent the SN clinic with somatic complaints. Unfortunately, many times SNs mislabel these complaints attributing them to other causes such as behavioral issues instead of seeing and exploring the actual underlying cause of the frequent visits (Fraley & Aronowitz, 2021; Fraley, Aronowitz, & Jones, 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Sundler et al., 2019). Situations can also be mislabeled by SNs. For example, a student may present with complaints of being up all night working and the SN fails to inquire as to why a teenager would be working all night (Fraley & Aronowitz, 2021). One study suggests that when youth present with multiple somatic complaints, the SN should keep in their mind the question, “Can this be caused by abuse?” (Sundler et al., 2019, p. 5).
Avoidance is a behavior in SNs that was observed in three articles (Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Sundler et al., 2019). Kraft and Eriksson (2015) conducted a Swedish study to explore how SNs detect child maltreatment and, much to their astonishment, noted that the SNs hardly mentioned CSA during focus group interviews. Kraft et al. (2017) conducted a follow-up study explicitly to learn SN perspectives on detecting CSA and avoidance was determined to be the core concept that permeated all other themes. Outcomes from the Sundler et al. (2019) study indicate that when SNs avoid addressing CSA, it can affect their ability to identify students who may be experiencing it. Reasons for SN avoidance include ambivalence toward the phenomenon, arousal of strong emotions, and belief that the disclosure process is complicated (Kraft et al., 2017). Other SN characteristics and beliefs could also play into avoidance of addressing the issue, such as a lack of knowledge about CSA and risk factors, concern over consequences of reporting, inability to see behind the symptoms, a lack of nursing experience, lack of support from school administration, and a need for improving the health dialogue with students suspected of abuse (Fraley & Aronowitz, 2021; Fraley, Aronowitz, & Jones, 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Sundler et al., 2019). Avoidance behaviors can lead to SN discouragement from implementation of screening interventions.
Potential Instruments or Approaches for Screening
Existing research conducted in schools related to the identification of CSA has been collected from anonymous and non-anonymous participants. Research related to the identification of CSA anonymously was primarily to determine prevalence using the school setting as an access point to large populations of adolescents (Ribeiro et al., 2015; Saewyc et al., 2003; Zolotor et al., 2009). Whereas a study with non-anonymous participants utilized the school health clinic to access students for participation (McGurk et al., 1993).
Two international studies used the same instrument to conduct anonymous prevalence research for abuse on a self-report survey administered in the school setting (Ribeiro et al., 2015; Zolotor et al., 2009). The instrument, called the ISPCAN Child Abuse Screening Tool-Child version (ICAST-C) is a population-based, multilingual survey instrument containing 82 screener questions regarding potentially victimizing experiences at home, school, or work (e.g., physical, sexual, psychological, and neglect abuse), followed by queries for frequency and perpetrator (Zolotor et al., 2009, p. 835). The sample sizes of the Zolotor et al. (2009) and Ribeiro et al. (2015) studies were 571 and 288, respectively. In both studies, the ICAST-C experienced low rates of missing data indicating that students responded to most questions about abuse. Results from both studies indicate that, when administered anonymously, the ICAST-C identifies high rates of child victimization in all domains (Ribeiro et al., 2015; Zolotor et al., 2009).
Saewyc et al. (2003) conducted a secondary data analysis to determine the prevalence of CSA from data gathered from an extensive population-based survey called the Minnesota Student Survey (MSS), which measures health and risk behaviors, including sexual abuse (e.g., incest and non-familial). A large sample of anonymous ninth and twelfth-grade students were administered the MSS across two-time points in 1992 (n = 77,374) and 1998 (81, 247). Incest and non-familial sexual abuse were reported by boys and girls in 9th and 12th grade, and among students of all ethnic groups. Results suggest that 1 in 10 students in the state of Minnesota have a history of sexual abuse. The prevalence for abuse was similar for both grades in 1998, which may mean that sexual abuse occurs before 9th grade (Saewyc et al., 2003). Although missing data was not discussed in the article, Saewyc et al. (2003) discusses the efficacy of research related to high respondent response rates on anonymous population-based surveys.
Research from non-anonymous participants suggests that school health clinics provide opportunities for early identification of CSA. One dated but essential study utilized the SN and school health clinic to conduct their study with non-anonymous student participants attending a large public high school in the US (McGurk et al., 1993). After obtaining parental permission to participate, McGurk et al. (1993) administered a self-report health survey to participants who presented to the school health clinic for care unrelated to CSA. Students who responded yes to questions about sexual abuse (n = 20) met with the SN, who made a report to the Department of Child Services. Next, participants engaged in an in-depth interview with a clinical psychology intern using a semi-structured questionnaire. Upon completing the interview, 10 of the 20 participants agreed to participate in school-based counseling services (e.g., individual or group). Results showed that participants in the study were ready to acknowledge their sexual abuse when asked a direct question on a self-report survey. In addition, participants verbalized that counseling sessions were beneficial in helping them to realize that as victims of CSA, they were not alone. Study findings suggest that schools containing a health clinic staffed with a SN and counseling staff may provide an opportunity for CSA identification and intervention (McGurk et al., 1993).
SNs in Sweden use a tool called a health dialogue as an intervention with students to inform SNs about a student's overall health and lifestyle (Golsater et al., 2011). In all three of the studies conducted in Sweden, SNs discuss tailoring the health dialogue to better assist them with using the tool to facilitate screening and dialoguing with students suspected to be experiencing CSA (Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Sundler et al., 2019). The discussion centers around revising the health dialogue tool to incorporate CSA questions to help SNs navigate difficult conversations, read between the lines, and assess verbal and non-verbal expressions.
School Nurse and School Professional Beliefs About CSA Screening Practices
A consensus among all articles is the belief that schools are an ideal setting to conduct research and screening for the early identification of all forms of CSA. Several studies state screening is the key to early identification and referral of CSA victimization (Fraley et al., 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Saewyc et al., 2003; Sekhar et al., 2018). Equally important is that education and health promotion stakeholders identified the SN to be the most equipped professional to perform the screening (McGurk et al., 1993; Saewyc et al., 2003; Sekhar et al., 2018). At the same time, SNs believe that screening for CSA falls within their purview and that they should be screening for CSA (Fraley et al., 2018; Kraft et al., 2017; Saewyc et al., 2003; Sekhar et al., 2018; Sundler et al., 2019). Fraley et al. (2018) found that 32% of SN participants felt they should be screening for commercial sexual exploitation, a form of CSA. They also believed that barriers to screening included large student bodies, time constraints, and lack of funding to promote prevention.
A direct aspect of screening is the willingness of the child to disclose CSA. Unfortunately, beliefs regarding disclosure of CSA and how best to facilitate this are conflicting, with some studies suggesting that disclosure can occur by asking the child directly (Kraft et al., 2017; McGurk et al., 1993; Ribeiro et al., 2015; Zolotor et al., 2009). For instance, Sundler et al. (2019) discovered that 42% of SNs had a child admit to them that they were experiencing CSA, and of these 37% made a mandatory report. Additionally, McGurk et al. (1993) found that of the 22 participants who reported CSA, 20 agreed to participate in the study. On the contrary, Sekhar et al. (2018) found that informant beliefs about screening discussed during focus groups were that instead of asking students directly, there should be opportunities for disclosure provided to students. Sekhar et al. (2018) identified three themes: early screening is preferred (e.g., kindergarten), a concern about confidentiality in the school clinic, and refinement of the screening process starting with routine education on safe touches and defining normal.
Discussion
The aim of this review was to examine the research literature on screening for CSA in schools; however, this review found little evidence that CSA screening is occurring in schools. In addition, there is a paucity of research that truly addresses screening for CSA in schools. This review finding is congruent with current research on the effectiveness of CSA screening practices in primary care settings, which is also limited (Hanson & Adams, 2016; Hanson & Wallis, 2018; Hornor, 2013). Research that does exist focuses on measuring CSA prevalence in the school setting and the attitudes and beliefs of nurses and other stakeholders. Screening for CSA is discussed as a recommendation; something that should be occurring to facilitate early identification and subsequent referral/reporting (Fraley et al., 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; McGurk et al., 1993; Saewyc et al., 2003). Moreover, Kraft and Eriksson (2015, p. 354), Sekhar et al. (2018, p. 160), and Saewyc et al. (2003, p. 270) state that screening should be occurring in schools and that it is the key to early identification. However, there is no evidence to show that screening is occurring as a standard of practice. There is also limited robust intervention research. The research primarily describes SNs and stakeholders’ understanding of factors related to early CSA identification, and screening emerges as a plausible intervention.
Some instruments used to determine prevalence hold promise for modification to be used as screening tools by SNs. For example, the ICAST-C self-report survey instrument and youth risk surveys (e.g., the MSS) have the potential for translation for use by SNs to assist with individual screening when victimization is suspected (Saewyc et al., 2003; Zolotor et al., 2009). Furthermore, researchers conducting studies with students in schools to gather data anonymously suggest the viability of using the school setting to assist with determining the scope and prevalence of the CSA problem, which is a critical first step in calculating accurate estimates of child victimization (Ribeiro et al., 2015; Saewyc et al., 2003; Zolotor et al., 2009). Anonymous self-report instruments could be implemented as a first measure to determine the problem's prevalence. Without accurate estimate data, implementing measures that facilitate health interventions for child victims becomes a challenge. Thus, the benefit of obtaining CSA prevalence data is twofold. First, on a larger scale, prevalence data can be used to set local and national priorities and garner support for program and policy development aimed at child protection (Zolotor et al., 2009, p. 834). Moreover, in countries with no prevalence data, anonymous surveys administered in schools can provide much-needed information about the CSA problem, as was the case in the Ribeiro et al. (2015) study conducted in Brazil. Second, on a smaller scale, although CSA is known to exist, prevalence data can be used to substantiate the implementation of screening measures for CSA in schools. While at the same time, raising SN awareness and knowledge and provide SNs with a deeper understanding of the problem's reality (Saewyc et al., 2003).
Overwhelmingly, SNs in the US and Sweden are aware that screening for CSA falls within their scope of practice and many SNs feel they should be screening for it. Screening for other health issues for early detection of problems is something that SNs already incorporate into their daily practice (NASN, 2016). Nevertheless, outcomes from this review indicate that screening for CSA in the traditional sense remains a topic of discussion with little action to initiate screening interventions, or training on how to screen, in the school setting (Fraley et al., 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017; Saewyc et al., 2003; Sekhar et al., 2018). To that end, Sweden has made strides toward screening interventions to determine student health and wellness status by using a health dialogue tool. Research using a health dialogue tool advocates its usefulness in identifying where health issues may exist and facilitating the SNs ability to dialogue with students about these issues (Golsater et al., 2011). At the same time, Swedish SNs discuss that the tool requires revisions to include CSA content (Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017). The health dialogue tool may hold promise as a potential tool that can be modified to assist SNs with screening efforts.
Overcoming SNs behaviors related to screening is of primary importance. Avoidance is one of the largest barriers to addressing the CSA issue. Therefore, prevention should include educational interventions for SNs to recognize risks and signs of youth victimization. For instance, training SNs to see the red flags and acting on their intuition (Fraley & Aronowitz, 2021; Fraley, Aronowitz, & Jones, 2018; Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017). Moreover, findings from this review affirm the frequency of CSA mandatory reporting failure, which raises the question as to whether SNs understand the legal implications associated with, and how nurses are protected in, mandated reporting. Educating and training SNs first about CSA risks, signs of abuse, how to screen, and clarification about what constitutes mandatory reporting can provide them with confidence in their ability to detect CSA before they feel empowered to implement screening measures.
During the focused search of the literature on screening for CSA, it became apparent that screening is a term used interchangeably with assessment, identification, and detection creating an ambiguity around how the term screening is applied in the CSA research. Therefore, the importance of discerning screening as an actual intervention used to determine potential CSA versus as part of the nursing process made the action of reviewing the full text of articles imperative.
Future research should focus on learning the feasibility of screening, establishing what a screening tool for SNs might look like, and potentially setting guidelines for screening practices. Also, among the studies included in this review, none had a sample of youth under the age of 11, which may indicate a gap in the science that surrounds CSA and early identification and screening in schools specifically among students attending elementary school. Additionally, outcomes from intervention work can assist with designing and implementing an explicit screening tool for SNs.
Limitations
This review is limited because terms are not well defined, and this ambiguity can lead to confusion about the meaning of terms associated with how screening is described in the literature. For example, although CSA screening is an intervention and necessary for identification, the terms identification, assessment, and detection are used interchangeably with screening in the research. Additionally, CSA screening as an intervention in schools was difficult to find in the literature because screening tends to be something discussed during the research study in lieu of being a variable under study. Given the latter, there is a possibility that some additional information may exist about screening in schools. Last, the first author conducted the initial literature review; therefore, the chance for bias is present.
Recommendations for School Nurses
Research suggests the school health setting is an ideal environment for CSA screening by SNs (Fraley et al., 2018; McGurk et al., 1993; Saewyc et al., 2003; Sekhar et al., 2018). A strong argument supporting the need for school CSA screening lies in the research suggesting that long-term health consequences experienced by adult survivors could have been mitigated by early identification in youth. Hence, SNs can impact early identification and intervention through the implementation of screening practices as a routine aspect of care for all students.
School nurses are aware that screening is within their scope of practice, that their role is central to early CSA identification, and that they are obligated to report anytime CSA is suspected, however, CSA remains underreported and does not occur consistently among SNs (CDC, 2020; Sundler et al., 2019). School nurses should ensure they are knowledgeable about the many forms of CSA, risk factors associated with CSA, their own beliefs and behaviors about CSA, and what symptoms and complaints students experiencing CSA may present with when they seek care in the school health clinic. Opportunities for continuing education should be encouraged by school administrators and should include a screening component (Sekhar et al., 2018). A proactive and systematic approach to responding to suspected CSA is necessary to improve early identification and subsequent intervention for youth.
Implications from this review shed light on the need for a tested and validated screening tool for use by SNs that can not only assist with identification but can also facilitate navigating difficult conversations with suspected students (Fraley et al., 2018; Kraft & Eriksson, 2015; Sekhar et al., 2018). There are child maltreatment and CSA screening instruments that exist and can be modified to meet the specific needs of SNs. One example is the health dialogue currently used by SNs in Sweden (Kraft & Eriksson, 2015; Kraft, Rahm, & Eriksson, 2017). In a recent phenomenology study conducted with Swedish SNs, findings corroborate the benefit of using a health dialogue in promoting positive health and learning, especially when coupled with a health questionnaire (Kostenius, 2021). The use of a tool such as the health dialogue can facilitate a more proactive and systematic approach to early identification of CSA, as well as other issues that impact the health and wellbeing of youth. Overall, the lack of an evidence-based screening tool for use by SNs in the school setting does not provide a rationale for avoiding the CSA problem, nor does it negate the nurse's obligation to act. Instead, it makes the urgency of responding to the issue even more significant.
Conclusion
This review provides insight into the crime of CSA and the role of schools and SNs to assist in early identification, which includes screening practices. Findings from this review indicate that the evidence to support that CSA screening is occurring in schools is not strong. At the same time, SNs recognize their role in CSA identification, screening, and referral. The next steps should include determining the best approaches for screening, educational interventions with SNs specific to screening and dialoguing, and modification or development of a tool that can be tailored for use specifically by SNs for screening when CSA is suspected.
Footnotes
Acknowledgments
We want to acknowledge Dr. L. Kathleen Sekula PhD, PMHCNS, FAAN, Dr. Joan Such Lockhart, PhD, RN, CNE, ANEF, FAAN, and David A. Nolfi, MLS, AHIP for their contribution toward this work.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
