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Child sexual abuse is using children for sexual purposes. It takes many forms, from the least intrusive, voyeurism, to the most intrusive, vaginal or anal intercourse. Child sexual abuse is a serious social problem that cuts across all income, racial, religious and ethnic groups, as well as rural, suburban and urban communities. Children with a physical or mental disability are especially vulnerable to sexual abuse (Health Canada, 1997). The research on child sexual abuse is extensive and fits the description of "gender-based" violence. Retrospective self-reports from large survey samples cite prevalence rates from 7% to 36% of girls and 3% to 29% of boys (Finkelhor, 1994). Victims may be very young, even infants, with estimates that as much as 33 to 50% of abuse occurs before the age of seven (Wurtele & Miller-Perrin, 1992). The Health Canada 1997 document noted that among adult Canadians, 53% of women and 31% of men reported being sexually abused as children. Offenders are most often known to the victim, male, and are adolescents in 25% of the cases. Sexual abuse in families is much more likely to happen repeatedly than to be a one-time event. It often progresses from less to more intrusive sexual behaviours. Researchers have also detailed the effects of sexual abuse on children. The recently completed Canadian Incidence Study of Reported Child Abuse and Neglect (Trocmé, MacLaurin, & colleagues, 2001) reports that the most common child problems after sexual abuse are depression or anxiety (29%), age-inappropriate sexual behaviour (17%), behaviour problems (14%), negative peer involvement (13%) and irregular school attendance (10%) at the time that the reports of child sexual abuse were substantiated. Despite the high rates of child sexual abuse for both males and females, including very young children, there are low identification rates of abuse by adults. Furthermore, few children reveal abuse. In Ontario, 1993 provincial statistics indicated that of 12,000 investigations for sexual abuse, 29% were substantiated and another 27% suspected (Health Canada, 1997). What We Know About School-based Sexual Abuse Prevention School-based sexual abuse prevention and intervention programs began in the 1970s when public awareness about the extent of child sexual abuse became heightened. The programs were primarily developed and funded by community organizations (Kohl, 1993). The 1980s was a decade of intense development of school-based sexual abuse prevention programs and research into their effectiveness, a direct response to disclosures of past and present abuse to social service agencies and parents’ concern for protecting their children from sexual abuse (Plummer, 1993). What we know about child sexual abuse prevention today is based on 30 years of experience and research. Due to this longevity, the completed research for this form of violence is more detailed than the other school-based violence prevention program areas. The programs reviewed here are only a fraction of the sexual abuse prevention programs that have been developed. Even with substantial research evidence of their effectiveness, some programs have not survived over time. We have included only evaluated programs that are currently available. Program Objectives: School-based sexual abuse prevention programs have become the mainstay of prevention efforts responding to the high rates of sexual abuse of children and the detrimental short- and long-term effects on children (Tutty, 1991). The goal of such programming is to reduce the incidence of child sexual abuse through arming children with the knowledge and skills to resist inappropriate touching or what to do if abuse has occurred. Recent revisions of some programs have expanded these objectives to include learning other personal safety knowledge and skills (e.g., stranger-danger). Finkelhor, Asdigan and Dziuba-Leatherman (1995) identified twelve elements considered necessary to be a comprehensive sexual abuse prevention program:
Across programs, the more comprehensive the material or the more programs attended, the higher the child scored on a short test of knowledge of prevention concepts. Program Content: Developmental and age-appropriate materials are essential. Many sexual abuse programs begin their efforts in the early school years (Preschool and/or Kindergarten to Grade 3). Tutty (1995) identified a common set of core concepts that is included in most of these programs: labeling of body parts; ‘good’, ‘bad’ and ‘confusing’ touches; body ownership; permission to say ‘No’; secrets about touching should not be kept; and to tell and keep telling until an adult believes them. Recommendations about core content that have emerged over time include stressing positive or negative feelings about a touch rather than that a touch is either good or bad, and using anatomically correct names for body parts such as a penis or breasts. Not all concepts are easily learned. Tutty (2000) noted that, across studies, before participating in a prevention program, elementary school students had difficulty with items about four issues: saying no to authority figures, understanding the possibility that trusted adults might act in ways that are unpleasant, rules about breaking promises and keeping secrets and that children are not to blame if they are touched in ways that feel uncomfortable (Wurtele, 1997). Several studies have noted that children have difficulty understanding the concept of "strangers". The fact that these items were particularly trying for the youngest children to learn and that a number at follow-up forgot some suggests that these may be more sensitive to developmental or to family beliefs. Age affects what knowledge and skills children learn (Tutty, 2000). For example, children in Grade 1 and higher are better able to grasp concepts about family members or known acquaintances touching inappropriately and about saying ‘no’ to being touched in ways that are uncomfortable — key prevention concepts. Though young children this age are vulnerable to abuse, they seem less able to grasp the varied and complex concepts and decision making involved with identifying potentially abusive situations. Daro (1994) concluded, after reviewing the outcomes of 38 studies, the strongest beneficial effects of prevention programming are for children aged 7 to 12. Some programs now include sexual abuse prevention information and training for children and youth from Kindergarten through to Grade 12. The content in the older grades is expanded to include learning about bullies, problem-solving skills, as well as a legal and rights based approach to sexual harassment and sexual assault. Some programs have high school students learn the concepts through preparing performances for presentation to the younger grades. A few programs have been adapted or created for use with special populations, such as children with disabilities and Aboriginal youth. However, these programs tend to be more recently developed and are most often not formally evaluated. Some programs have been translated into French and/or Spanish, but do not specify whether the content has been culturally adapted. Presentation Methods: These programs generally target children in the general population and use group-based instruction (Daro, 1994; Tutty 1996). In a review of 19 sexual abuse programs, MacMillan and colleagues (1994) identified various modes of presentation of prevention materials that contained one or more of the following elements: verbal instructions; film or videotape; behavioural training; skits, mimes or role-plays; use puppets or dolls, and a theatre production produced by adults or older students. Most of the programs reviewed for this resource manual approach prevention use multiple strategies over time. Those that provide a single presentation method (e.g., plays, assemblies, books, videotapes, games and comic books) usually suggest that their program needs to be combined with other longer programs to provide more opportunities for knowledge development and skill-building. It is generally agreed that prevention education should include an experiential component. While children may learn concepts by passive observation, listening and discussion, skills are best learned through active participation. Behavioural skills training approaches are more effective than passive learning procedures (Wurtele, Marrs & Miller-Perrin, 1992). In contrast to cognitive approaches such as films, books, and pure instruction, skill training involves instruction, modelling appropriate behaviours by the instructor and other students, rehearsal, social reinforcement, shaping and feedback. While children’s knowledge levels are similar whether instructors use active or passive teaching, their ability to apply personal safety skills to "what if" situations is significantly improved with behavioural skills training (Wurtele, Marrs & Miller-Perrin, 1992). Teacher Training: Most programs provide or encourage teacher training via video, manual, or in-service. Training usually includes background information about sexual abuse, teaching techniques used in the program and how to handle disclosures. Parent Involvement: Researchers have examined parental knowledge of sexual abuse and their interest in receiving more education on the topic (Elrod & Rubin, 1993). The main source of knowledge about sexual abuse for parents was the media, but this resource left parents with some significant deficits. The parents surveyed lacked knowledge about the incidence and prevalence of child sexual abuse, and at what age children typically disclose abuse. Overwhelmingly, parents looked to the school as the ideal place to educate parents to speak about these difficult issues with their children. Most prevention programs encourage parent involvement. They provide parents with background knowledge of sexual abuse and techniques to reinforce the knowledge and skills that the children learn at school. Videos, manuals, parent meetings, letters and homework assignments engage parents in the learning process with their children. However, prevention programs routinely have difficulty attracting more than about 10% of children’s parents to information and training sessions (Tutty, 2000). Tutty (1993) found that parents underestimated the knowledge of the older children, and overestimated what their youngest children (in Grades 1-3) knew of sexual abuse prevention concepts after having participated in a prevention program. However, higher levels of parental knowledge of sexual abuse issues were associated with increased accuracy in predicting the child’s level of knowledge. This supports the importance of encouraging parents to attend the parent training programs. Did They Work? Reviews suggest at least initial support for child sexual abuse prevention programs with children learning a statistically significant number of concepts after participation (Tutty, 1996; Wurtele & Miller-Perrin, 1992). The increases are typically very small, on average only one or two concepts. A recent meta-analysis conducted by Rispens, Aleman and Goudena (1997) found significant effect sizes both at posttest (d = .71) and at follow-up (d = .62) across 16 evaluations, suggesting that the few items that children learn on average appear to have a powerful effect. Educational programs may increase the conceptual awareness of school-age children about sexual abuse and teach children how to report actual or potential abuse (Daro, 1994). However, not all children learn from these programs nor is the learning all-inclusive (Daro, 1994). As noted by Tutty (2000), the few studies that compared children from different developmental stages consistently found statistically significant differences in knowledge, with younger children demonstrating lower levels of learning. In contrast, in a recent meta-analysis of 16 studies, Rispens et al. (1997) declared that "children younger than 5.5 years benefit more than older children from the programs, although the difference tends to disappear during the follow-up interval ... it suggests that there should be more opportunity for repeated learning" (p. 983). Tutty’s review (1996) noted that five studies evaluating the effects of gender in learning sexual abuse prevention concepts found no significant differences in the average knowledge of boys and girls after seeing programs. Another two studies reported that girls learned and maintained more concepts. Finkelhor et al. (1995) found that girls reported more client satisfaction with the programs. Another question is whether children remember the concepts over time. Tutty’s 1996 review described nine studies that collected follow-up information on periods longer than 2 months. Overall, the children retained their knowledge of abuse prevention concepts for up to a year. Whether the information is retained in the long-term, is generalizable, and whether informed children are truly capable of resisting abusive behaviour are difficult to demonstrate. Finkelhor and colleagues (1995) tackled these questions in a U.S. national telephone survey with 2000 children aged 10 to 16. Children who participated in comprehensive prevention programs performed significantly better on knowledge of child sexual abuse, were significantly more likely to use self-protection strategies when threatened or victimized and reported abuse when it occurred compared to children with no sexual abuse prevention programming or those with a less comprehensive program. Furthermore, the children and caretakers were consistently positive about the programs, with 40% of the youngsters saying that it had helped. The authors noted that, "This is the first study to suggest that, when children with prevention training do actually get victimized or threatened after their program exposure, they can behave to some extent in ways envisioned by prevention educators" (p.150). Researchers have assessed two types of unintended consequences of sexual abuse prevention programs: negative reactions and disclosures. One of the greatest concerns about child-directed prevention programs, especially on the part of parents, has been whether children would experience negative side effects such as fear or nightmares. Research has consistently found that only a small minority of children show negative reactions after participating in a child abuse prevention program (Tutty, 1997; Wurtele & Miller-Perrin, 1992). Daro, D.A. (1994). Prevention of child sexual abuse. The future of children: Sexual abuse of children, 42(2), 198-223. Elrod, J.M. & Rubin, R.H. (1993). Parental involvement in sexual abuse prevention education. Child Abuse & Neglect, 17, 527-538. Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse & Neglect, 18 (5), 409-417. Finkelhor, D., Asdigian, N., & Dziuba-Leatherman, J. (1995). The effectiveness of victimization prevention instruction: An evaluation of children’s responses to actual threats and assaults. Child Abuse & Neglect, 19(2), 141-153. Health Canada (1997). Child sexual abuse. Available online from the National Clearinghouse on Family Violence at http://www.hc-sc.gc.ca/hppb/familyviolence/childsa.htm Kohl, J. (1993). School-based child sexual abuse prevention programs. Journal of Family Violence, 8 (2), 137-150. MacMillan, H.L., MacMillan, J.H., Offord, D.R., & MacMillan, A. (1994). Primary prevention of child sexual abuse: A critical review. Part II. Journal of Child Psychiatry and Psychology, 35(5), 857-876. Oldfield, D., Hays, B., & Megel, M.E. (1996). Evaluation of the effectiveness of Project Trust: An elementary school-based victimization prevention strategy. Child Abuse & Neglect, 20(9), 821-832. Plummer, C.A. (1993). Prevention is appropriate, prevention is successful. In R. Gelles, & D. Loseke (Eds.), Current controversies on family violence (pp. 288-305). Newbury Park, CA: Sage. Trocmé, N., & MacLaurin, B. & colleagues (2001). Canadian incidence study of reported child abuse and neglect: Final report. Available on-line from the National Clearinghouse of Family Violence at http://www.hc-sc.gc.ca/hppb/familyviolence/ Tutty, L. (1991). Child sexual abuse: A range of prevention options. Journal of Child and Youth Care, Special Issue, 23-41. Tutty, L. (1992). The ability of elementary school aged children to learn child sexual abuse prevention concepts. Child Abuse & Neglect, 16(3), 369-384. Tutty, L. (1993). The relationship of parental knowledge and children’s learning of child sexual abuse prevention concepts. Journal of Child Sexual Abuse, 2(1), 83-103. Tutty, L. (1994). Developmental issues in young children's learning of sexual abuse prevention concepts. Child Abuse & Neglect, 18(2), 179-192. Tutty, L. (1995). The revised Children's Knowledge of Abuse Questionnaire: Development of a measure of children's understanding of sexual abuse prevention concepts. Social Work Research, 19(2), 112-120. Tutty, L. (1996). Prevention education: An integrative review of the research. In C. Bagley & W. Thurston with L. Tutty (Eds.), Understanding and prevention of child sexual abuse: Volume I. (pp. 369-389). Aldershot, England: Arena. Tutty, L. (1997). Child sexual abuse prevention programs: Evaluating "Who Do You Tell". Child Abuse & Neglect, 21(9), 869-881. Tutty, L. (2000). What children learn from sexual abuse prevention programs: Difficult concepts and developmental issues. Research on Social Work Practice, 10(3), 275-300. Wurtele, S. K. (1997). Child abuse prevention programs: Panacea or part of the solution? In Ammerman, R. T. & Herson, M. (Eds.), Handbook of prevention and treatment with children and adolescents: Intervention in the real world context (pp. 357-384). New York: Wiley. Wurtele, S. K., & Miller-Perrin, C. L. (1992). Preventing child sexual abuse: Sharing the responsibility. Lincoln, NE: University of Nebraska Press. Wurtele, S.K., Marrs, S.R. & Miller-Perrin, C.L. (1987). Practice makes perfect? The role of participant modelling in sexual abuse prevention programs. Journal of Consulting and Clinical Psychology, 55, 599-602. Prevention Programs Addressing Child Sexual Abuse
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