Ethical approval and consent
The research was carried out and allowed to publish with permission from the Ethics Committee of Yixing center for disease control and prevention (CDC) (Ref number 2016002) and Ethics Committee of Jiangsu Provincial CDC (Ref number JSJK2018-B025-02). The surveys got informed consents from children’s parents or other legal guardians. Children participated could quit at any phase of survey if he or she wanted.
School and Children
25 of 44 middle schools in Yixing were chosen to paticapate the research by random sampling methods from April 2018 to April 2019. All children in 25 middle schools were field questionnair investigated, while students in third grade senior middle school were excluded. The definition of the Children in the research means human beings below the age of 18 years.
Investigators and psychological consultants
Questions involved in field investigation may cause serious emotional fluctuation like anxious and nervous in some children, even excessive behaviors like self-mutilation, has the risk of re-traumatization if ever used to experience impressive violence or existed potential internal psychological trauma. Protecting children from potential dangers due to their participation was the key consideration of research. Professional psychological intervention from Yixing Psychological Association would necessary to protect children in field and continued follow-up investigation. Mental health department of Yixing Renmin Hospital, a Top Grade A hospital accoding to the measures for the administration of the hospital, was designated professional medical institution. Technical supports were got from School of Public Health, Southeast university and Center for Mental Health Education and Research, Nanjing medical university.
Recruit investigator and psychological consultants
86 investigators were public health professionals from Yixing CDC, JiangSu provincial CDC, local governmental hospitals and community health care centers. They had medical background and abundant practical experience of field investigation.
44 psychological consultants from Yixing Psychological Association were recruited in the research. They had qualified license as psychological counselor and more than 5 years counseling experience.
The teachers of the Institute of Psychology of the Chinese Academy of Science were invited to carry out two stages of professional training and examinations lasting five days directed on VAC to investigators and psychological consultants. Investigator and psychological consultants had qualification of participation following work after passed examinations.
Seven Principles were strictly executed in the VAC surveys, including relationship principle, control principle, acceptance principle, protection principle, voluntary principle, confidentiality principle and positive principle.
Principle 1: No matter what kinds of symptoms to deal with, top priority was establishing good relationship with children.
Principle 2: Get consent of child at first, let they have senses of control.
Principle 3: Any performance of a child may be normal response in state of stress or psychological trauma, should not to be evaluated and blamed.
Principle 4: Any action has possibility of causing children injuries again should be stopped.
Principle 5: Children have rights to refuse to participate in field investigation and intervention.
Principle 6: All information must be strictly confidential.
Principle 7: All investigation and intervention must end up with positive meaning and guidance.
Burden for the collection of information is estimated to average 60 minutes per child, including time for reviewing instruction and answering questionnaire, gathering and maintaining the data.
The questionnaire was made by Center for Chronic Noncommunicable Diseases, Chinese CDC and divided into two parts.
Part 1: Background, information about family demographics, basic economic situation, unattended children and so on.
Part 2: Attitude towards parents or other legal guardians physical punishment, questions about safety issues, sexual violence and multi-angle peer violence, if need psychological help or not and so on.
Identification of crisis case
The following criterias for identification crisis cases were formulated according to Diagnostic and Statistical Manual of Mental Disorders (version 5) (DSM-5) and International Classification of Diseases (version 10) (ICD-10) to recognize the child in need of psychological intervention timely and directly. The child manifested any criteria were defined as a crisis case.
Criteria 1: The child show Intrusions reactions during the investigation: body shaking, shortness of breath or difficulty, could not touch things related to events (touch the scene), not self-forgiving, self-cursing, self-blaming.
Criteria 2: The child show avoidance reactions during the investigation: crying, refusing to answer questions related to violence, physical pain and discomfort, depression, depression, laziness, not communicating with people, request to leave the scene of the investigation.
Criteria 3: The child show high alert reactions during the investigation: fear of strangers and strange environment, cry, break things, beat people, anger, blame, blame.
Criteria 4: The child sought psychological crisis intervention or psychological assistance initiatively or actively in field investigation or his/her questionnaire.
Trial surveys in 30 classes in three schools were conducted by experienced psychological consultants and investigators in first one month. The details of questionnaire, difficulties in field investigation, experiences and considerations in trial survey were further summarized and analyzed to improve survey procedures according to cooperation of 18 departments including Yixing CDC and Jiangsu provincial CDC, Yixing Health Commission, Yixing Psychological Association, Yixing Women's Federation, Yixing Education Bureau, Yixing People's Procuratorate, Yixing Civil Affairs Bureau, Southeast University, Nanjing medical university, Yixing Renmin Hospital, etc.
At least one investigator and one psychological consultant together took charge of one class in field investigation. Another one investigator or psychological consultant was in charge of one teaching building floor. A general leader who was the most experienced investigator and also psychological consultant been trained, called child health development consultant, charged of the investgation and following intervention including contacting with questionnaire crisis cases and overall assessment.
In the beginning of field investigaton, child involved in the research got informed consent and the Health Service Information Card including telephone number of relevant organizations of violence control and prevention, such as Yixing Women's Federation, Yixing Women and Chindren’s Rights Protection reception center, Youth rights protection and psychological counseling hotline, Women's federation rights protection public welfare hotline, child health development consultant, et, al.
When the children appeared emotional or behavioral reactions defined as cirsis cases with four criterias during the field investigation, investigators must ensure no body could see their questionnaire during the break to maintain confidentiality, psychological consultants must timely carry out scene psychological intervention following above seven principles to relax their emotions and ask if they would like to make appointment for psychological intervention next time. If the children were still emotionally unstable or unable to continue to answer questions, psychological consultant must ask if they would like to make appointment for answering the questionnaire again or psychological intervention. After consultation intervention, psychological consultants assessed to end case or continue following up. If following up, the survey team decide if referral the case to relevant governmental organizations: Yixing Women's Federation, Yixing Education Bureau, Yixing people's Procuratorate, Yixing Civil Affairs Bureau. Fill out the Referrals Card once make referral and write case report.
When the children defined as crisis cases in their questionnaire, child health development consultant send phone text messgae to them, assess cirsis, assign psychological consultant to psychological consultaion, and decide if make referral.