Screening youth athletes – new SEMS sports pediatric pre-participation questionnaire

Schaub Florian¹, Wenger Nathalie², Marx-Berger Daniela^3
1 Universitäts-Kinderspital Zürich and Universitätsklinik Balgrist, Sportmedizin und Notfallstation
² Centre SportAdo, Swiss Olympic Medical Center, CHUV, Lausanne
³ Sportmedizin Ostschweizer Kinderspital, St. Gallen

Abstract

In order to possibly better match the needs of youth athletes, the SEMS pre-participation questionnaire has undergone some significant adaptations for this group of patients. One of the changes is the usage of the more personal first-name address in either of the Swiss national languages (German, French, Italian). Some smaller modifications include for example inquiring about the parent’s height or adapting the assessment of a voluntary weight change (apart from normal growth-related changes). The most relevant addition is that of new safeguarding questions. These aim to give athletes an opportunity to make their voices heard when they experience misconduct or abuse. It is of high importance that affirmative responses are taken seriously. Of equally important note is the possibility of the athlete’s request for discretion. To what extent the questions are accepted by both the examiner and the athletes remains to be seen. De-tabooing the topic might however be one of many ways to help to create safer training environments for our young athletes, and to avoid serious short- and long-term consequences.

Résumé

Afin de mieux répondre aux besoins des jeunes sportifs, le questionnaire SEMS de pré-participation a subi quelques adaptations significatives pour ce groupe de patients. L’un des changements est l’utilisation du langage plus adapté par le tutoiement dans l’une ou l’autre des langues nationales suisses (allemand, français, italien). D’autres modifications mineures consistent par exemple à demander la taille des parents ou à adapter l’évaluation d’un changement de poids volontaire (hormis les modifications normales liées à la croissance). L’ajout le plus pertinent est celui de nouvelles questions concernant les abus et la protection des athlètes. Celles-ci visent à donner aux athlètes la possibilité de faire entendre leur voix lorsqu’ils sont victimes de mauvais traitement ou d’abus. Il est primordial que les réponses affirmatives soient prises très au sérieux. Il est tout aussi important que l’athlète puisse demander à bénéficier d’une stricte confidentialité. Il reste à voir dans quelle mesure les questions sont acceptées à la fois par l’examinateur et par les athlètes. La suppression du tabou sur ce sujet difficile pourrait toutefois être l’un des nombreux moyens de créer des environnements d’entraînement plus sûrs pour nos jeunes athlètes et d’éviter de graves conséquences à court et à long terme.

Mots clés: visite médicosportive, examen de non contre-indication, abus, protection, prévention, questionnaire.

Introduction

In Switzerland, sports medical check-up examination (pre-particiaption, PPE) is recommended for competitive and elite athletes. These recommendations include young athletes who train at high competitive level too. Depending on their sport and performance level, high training volumes are frequent at a very young age, making prevention even more important.
A PPE or the annual check-up are a great opportunity not only for a routine preventative physical examination but also to discuss various subjects with young athletes such as training and regeneration, nutrition, sleep, coping with school demands, overload, antidoping and much more. The overall preventive aspect of this examination cannot be over-emphasized as it could have an impact not only on their careers, but also on a large part of their lives.
For screening athletes in Switzerland, Sport & Exercise Medicine Switzerland (SEMS) has provided very helpful questionnaires which also help to identify important subjects that might need specific attention. But the questionnaires are designed for athletes in general. However, children and adolescents may not feel properly addressed on a personal level by the wording. Adapting the formal language and changing some questions in order to accommodate this demand has therefore been a request for some time.
More recently, it has also become increasingly clear, that there is an urgency for action on the area of safeguarding athletes – the younger ones in particular [1]. This is why the idea has arisen to adapt the existing questionnaire in a way that is more suitable for young athletes and extend it by ­adding questions addressing harassment and abuse.
The prevalence of abuse in sports is assumingly high and nonetheless most likely underestimated [2]. Media reports like the ’Magglingen-Protokolle’ (Das Magazin, 10/2020, TA Media) have brought the issue to our attention in an unfiltered manner and made us realize that abuse occurs in our surroundings, in places that we thought were safe for our young athletes. Awareness has also been increased in regards of different types of abuse (neglect, physical, verbal, psychological/emotional or sexual abuse) [3]. This misconduct towards athletes of all levels can have serious consequences, starting from dropping out of sports in general, failure in school, up to mental health problems leading to depression or even suicide [4]. Thus, it is crucial to detect such malpractice or toxic environments as early as possible and ideally prevent it from happening.
Addressing issues like harassment and abuse is nothing that comes easily neither for athletes nor for the person assessing them. Having these questions readily formulated in written can ease the process by opening a door for discussion. It also indicates that it is okay to talk about an abusive situation. An additional emphasis on confidentiality may help to create a climate of trust where voicing maltreatment is safe.

Method

The existing SEMS questionnaire for all athletes has been used as the basis. In a first step, the sentences using the formal wording were adapted into a more personal ’first-name term phrasing’ (“Du” in German and “Tu” in French).
In a second step, a re-assessment of the existing questions was performed. Questions that where not sensible for a pediatric population were modified to better suit the need. In particular, the question regarding whether or not there has been a weight change in the last two years falls into this category. On the one hand, it can be assumed that a young person will experience growth-related weight changes. On the other hand, in our opinion the way the question was asked could potentially trigger negative association with eating disorder, particularly in athletes in aestetic sports or sports with weight relevance. The new version implies that weight changes are normal during growth.
Finally, questions with pediatric relevance where added. These include the questions about the athlete’s parents height in order to be able to estimate the genetic target height. Another question that seemed important, as this particularly affects children and adolescents, is whether school, sport and leisure are still in a satisfactory balance. Furthermore, a copy of the vaccination certificate is also requested so that missing or recommended vaccinations can be discussed.
In order to address the difficult topic of abuse in sports, a working group of experts was formed. Members of this group were Prof. Dr. phil. Markus Landolt, head of psychiatry of the Children’s Hospital Zürich and trauma expert, Dr. phil. Katharina Albertin, sports psychologist and meanwhile former head of Swiss Association of Sports Psychology (SASP) and Dr. med. Florian Schaub, sports pediatrician and initiator for the group. The task consisted of developing questions to evaluate whether various forms of abuse (neglect, physical, verbal, psychological/emotional or sexual abuse) had been experienced. This working group developed five questions and an introductory section, explaining to the young athlete why these questions are being asked. The five questions were then discussed by the new SEMS ’pediatric’ clinical commission, and finally approved by the SEMS committee.
Additionally, acknowledging the crucial sensitivity of these safeguarding questions and the importance of this point for young athletes, information on confidentiality has been reinforced in the introduction (Fig. 1) and repeated in this new ’Safeguarding’ section (Fig. 2).
The presentation of this new youth athlete questionnaire at the annual SEMS meeting in October 2023 led to one additional question assessing unsafe or unhealthy training methods (Thanks to Dr. C. Bagutti, SEMS member) given that this subject has not been sufficiently covered by the other questions. The Safeguarding section now includes six questions (Fig. 3 and 4).

Discussion

The goal of the new questionnaire is to address children and adolescents in an age-group appropriate and engaging language. This can hopefully be achieved by formulating the sentences in the same way that people in this age group are usually approached and avoiding unnecessary questions.
Furthermore, the aim is to remove taboos and give children and adolescents the opportunity to express circumstances of abuse or neglect that might lead into emergence of psychological trauma later on. Also discussing the topic might have preventative effect. All this should ideally be happening in a climate of trust, with confidentiality reinforced and guaranteed.
PPE questionnaires are commonly used internationally. A few questionnaires have also been developed aiming at the pediatric population. However, according to our knowledge, there are no PPE questionnaires that assess the child’s or adolescent’s wellbeing from a safeguarding point of view.
It remains to be seen whether this new questionnaire will be accepted, both on the side of athletes and examiners. Feedback from our colleagues is thus very desirable and can be given via info@sems.ch.
It would be of interest to find out the prevalence of abuse detected through the use of the youth athlete questionnaire. Quantifying the number of completed questionnaires might however pose difficulties given the numerous healthcare practices and sports medicine centers where sports medicine check-up examinations are being performed. In addition, ­cases of abuse that have already been reported would possibly double-up through this detection method. On the other hand, the cases where strict confidentiality was requested by the victim could incorrectly reduce the prevalence. We could start an assessment by gathering prospectively the PPE survey of youth athletes from medical institutions in different regions of Switzerland that see high numbers of youth ­athletes.
Another point of discussion is which patients should complete the youth athlete questionnaire. The view of the pediatric clinical commission of SEMS is that athletes up to the age of 16 should certainly be included regardless the sport practiced. Depending on the culture and usual interaction with the athlete (“Du” or “Sie” / ”Tu” or “Vous”) the questionnaire might also be used up to the age of 18-20 years.
Last but not least this new questionnaire has so far only been developed in German, French and English – the Italian version will follow soon. (SPU Dokumente | Sport & Exercise Medicine Switzerland SEMS) [5].

Conclusion

Questionnaires are an effective way to assess areas that might need further evaluation or prevention [6]. It seems likely that the more the person completing the questionnaire feels personally addressed, the greater the benefit of the questionnaire will be.
In the new SEMS youth athlete PPE questionnaire, slight changes regarding language and content were made, but the most relevant additions are the safeguarding questions. There is a strong consensus that there is no space for abuse in sports, whether it is neglect, physical, psychological/emotional, verbal or sexual. It is obvious that a questionnaire can never solve the problem. However, it might help the examiner to address safeguarding issues and will certainly reduce the silent acceptance of abusive situations and give a voice to young athletes who find themselves in toxic environments.

Corresponding author

Florian Schaub
Universitäts-Kinderspital Zürich
Sportmedizin, Notfallstation
Steinwiesstrasse 75, 8032 Zürich
Tel. +41 44 266 75 35
E-mail: florian.schaub@kispi.uzh.ch

References

1. Bode L, Vertommen T, Nührenbörger C. (2023). Safeguarding the young athlete in sport. Sports Orthopaedics and Traumatology. 39:145-154.
2. Hartill M, Rulofs B, Lang M, Vertommen T, Allroggen M, Cirera E., et al. (2021). CASES: Child abuse in sport: European Statistics – Project Report, Edge Hill University, Ormskirk, UK, 2021.
3. Mountjoy M, Brackenridge C, Arrington M et al. (2016). The IOC Consensus Statement: harassment and abuse (non-accidental violence) in sport. Br J Sports Med 2016;0:1-11.
4. Kaiser D. (2022). Schutz von Kindern und Jugendlichen im Sport. ­Paediatrica 33:4-6.
5. https://sems.ch/publikationen/spu-dokumente
6. Fox C. Questionnaire development. J Health Soc Policy. 1996;8(1):39-48.