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 Review Article
Child Sexual Abuse Prevention: Are Safe Environment Training Programs Effective? A Topical Review of the Literature

Angelo P. Giardino MD, PhD,1.2 Kavita Desai Esq,3 Dawn Lew Esq.3, Mary Jane Doerr, BA, MA4, Bernie Nojadera, BA, MSW4

1Baylor College of Medicine, Houston, Texas, USA
2Texas Children’s Hospital, Houston, Texas, USA
3Children at Risk, Houston, Texas, USA
4United States Conference of Catholic Bishops, Washington, D.C, USA

*Corresponding author: Angelo P. Giardino, MD, PhD, Professor & Section Chief, Baylor College of Medicine, Senior Vice President/ Chief Quality Officer, Texas Children’s Hospital, 6621 Fannin, Suite A135, Houston, Texas 77030, USA,  Tel: 832 824 1128; Email: apgiardi@texaschildrens.org

Submitted: 07-20-2015 Accepted: 07-27-2015 Published: 07-24-2015  

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Article


Abstract

Child victims of sexual abuse face a number of short and long-term difficulties as a result of their victimization. Prevention of child sexual abuse is ideal since the victimization would be stopped prior to a child being harmed and suffering the consequences of such betrayal of trust and abuse. The literature surrounding child sexual abuse prevention programs, typically called “safe environment training” is examined to determine the evidence for their effectiveness. This topical review explores the evidence to support core elements in the curricular structure that may indicate effectiveness. The ultimate goal of actually preventing child sexual abuse is difficult to reach from a methodology perspective. At this point, the literature contains measures related primarily to the structure and process of the safe environment program and the outcomes assess typically include an increase the child’s knowledge about the risk of child sexual abuse, a strengthening of their own self-awareness about body safety and information about what to do if approached by a perpetrator. Ideal programs are those that are of sufficient length to allow for adequate content to be shared, developmentally sensitive to different age groups and one’s that have parental involvement. More research is needed to build upon the current educational structure and process evidence base but at the present time well-constructed safe environment programs that are delivered in a educationally sound manner are likely to be of some value in an overall all effort to reduce the risk of child sexual abuse.

Keywords: Child Sexual Abuse; Safe Environment; Prevention; Effectiveness Review

Introduction

In 2013, according to the US Department of Health and Human Services, at least 60,956 children were known to have been sexually abused in the US. Sexual abuse is a crime that leaves a significant scar in the lives of victims, and the consequences can be especially severe when the victim is a child. Abused children may face serious long-term difficulties with psychological and mental health [1]. Victims of sexual abuse are often at a higher risk for depression, anger, substance abuse, sexual difficulties, self-destructive behavior, and sexual revictimization [2]. While the exact number of incidents is difficult to measure, it has been well documented that child sexual abuse occurs across a broad spectrum of socioeconomic and ethnic groups [3]. The prevention of child sexual abuse before the victimization actually happens and harms the child remains a major objective owing to the significant negative consequences that victims experience as a result of this victimization. This paper seeks to explore the question surrounding the effectiveness of child sexual abuse prevention programs, typically called “safe environment training” where the child is provided training on how to recognize the risk of such abuse and how to respond should a perpetrator attempt to sexually abuse the child. The paper also seeks to identify the core components and best practices associated with successful safe environment programs. (See Table 1 and Table 2) Articles from academic journals which discuss the impact, effectiveness, and implementation of such safe environment child sexual abuse prevention programs are reviewed.

Table 1. Best Practices in Implementation.

pedia table 7.1

Table 2. Best Practices in Curriculum.

pedia  table 7.2

Studies of effectiveness of prevention programs

Scholars have undertaken individual reviews of a number of primarily school-based child sexual abuse prevention programs, as well as meta-analyses of multiple studies. Without exception, scholars remark on the methodological failings of the studies, which often fail to live up to rigorous scientific standards. For instance, many do not use control groups [1,3,4,5]. Many have sampling problems and lack reliable and valid measures, and do not adequately report demographic information [3,4]. Aggregating the studies to conduct meta-analyses is challenging due to the variation present in the studies. There are a variety of definitions of child sexual abuse, encompassing everything from “unwanted sexual contact,” to “contact abuse,” “non-contact abuse,” “penetrative abuse,” and “nonpenetrative abuse” [2]. Some studies use criminal definitions of child sexual abuse, while others use child protection or clinical definitions [3]. Studies also use different cut-off ages when measuring abuse, ranging anywhere from 15 to 18 years old [2].

Researchers also note inherent methodological difficulties involved in attempting to quantify the effectiveness of child sexual abuse prevention programs in terms of whether the programs reduce child sexual abuse levels. Prevalence rates are notoriously inaccurate because so many instances of child sexual abuse go unreported [2]. Many researchers do not even attempt to assess whether the programs studied reduce the incidence of child sexual abuse because of the fundamental difficulty of that determination, in part because prevention programs often increase the disclosure rates of abuse [3, 5-7]. Furthermore, extrapolating a potential change in children’s behavior from their responses to a knowledge test is bound to be imprecise, but there are ethical limitations to testing changes in children’s behavior using simulated scenarios [4, 5, 6, 8].

Notwithstanding the methodological challenges, scholars have conducted thorough reviews of the research on the effectiveness of child sexual abuse prevention programs. More than two decades of research have concluded that child-focused sexual abuse prevention programs increase children’s knowledge about sexual abuse, increase reporting of past and current abuse, and teach children self-protection skills [1-4,6,8-10]. As early as 1989, scholars were compiling the available research on child sexual abuse prevention programs to assess the overall effectiveness of such programs. Reppucci and Haugaard [4] acknowledge that children do gain knowledge as a result of the programs, and that reports show that the programs increase disclosure of abuse. However, they argue that “self-protection against sexual abuse is a very complex process for any child and that few, if any, prevention programs are comprehensive enough to have a meaningful impact on this process” [4]. In order to prevent abuse, children must first understand that they are in an abusive situation, must believe that they can and should do something to stop it, and finally must have and use self-protection skills [4]. These steps involve complex emotional and cognitive processes, and children will require clear, definitive instructions in order to grasp them [4]. Children benefit from active role-play rather than passive learning during prevention training, and one or two lessons are not sufficient to teach children to repel an abuser or to report abuse [4]. Finally, Reppucci and Haugaard [4] report that follow-up instruction is essential for knowledge retention, and recommend some form of review work succeedingthe initial training to increase retention of the material.

Eight years later, Rispens, Aleman and Goudena [8] found “no doubt about immediate program effectiveness” in their meta-analysis of school-based sexual abuse prevention programs (p. 981). They conclude that children, even young children, learned the concepts and self-protection skills presented, and that knowledge retention, while it did decrease over time, was satisfactory [8]. In keeping with the view of Reppucci and Haugaard [4] regarding clarity of instruction, the authors discern that programs that explicitly taught self-protection skills  were more effective than those that merely focused on sexual abuse concepts [8]. Additionally, like Reppucci and Haugaard [4], Rispens, Aleman and Goudena [8] recommend extended instruction time and regular follow-up training. They found that children, especially younger children, tend to forget what they had learned after a period of time, and thus recommended repeating the program at regular intervals [8].

In a 2001 study, Plummer found child sexual abuse prevention programs had moved from “Stage One,” where the concern was primarily development and implementation, to “Stage Two,” where programs face the challenges of continuance, ongoing quality control, the incorporation of emerging research, and fine-tuning. Plummer[9] echoes the findings of arlier researchers in concluding that children learn basic facts about sexual abuse, and that even young children can learn self-protection skills through prevention programs. She reports that there is widespread parental support for prevention training [9]. However, despite clear evidence that multiple sessions of instruction are necessary for effectiveness, Plummer [9] reveals that two-thirds of the programs she reviewed offered only one lesson. Over 70% of the programs surveyed expressed concern about resources, which may explain the lack of adequate instruction time [9]. She stresses the need for collaborative community efforts to support prevention programs, and a need, now that many programs have moved from Stage One to Stage Two, for examination and adoption of the best practices in field [9].

Bolen [6] reaffirms the previous research in concluding that child sexual abuse prevention training is effective in teaching children sexual abuse concepts and self-protection skills. However, she argues that “even the best prevention programs targeted at school-age children (that is, potential victims) cannot be effective” in preventing the occurrence of sexual abuse, because it is simply not possible to teach children the necessary skills to address all the varied, diverse ways in which they may be approached by abusers [6]. As 95% of abusers are male, Bolen [6] advocates for programs directed at young men and boys that promote healthy relationships and a healthy expression of masculinity that allows men and boys to develop a nonaggressive sexuality. She does not suggest, however, that child-directed prevention efforts be terminated [6]. Rather, recognizing the utility of the programs in teaching children sexual abuse concepts and self-protection skills, as well as increasing disclosure of abuse, she recommends that healthy relationship programs be instituted in addition to child sexual abuse prevention programs [6].

A comprehensive review of the evidence concerning the effectiveness of school-based sexual abuse prevention training from 1990 forward was conducted by Topping and Barron [3]. They conclude that school-based programs have a positive impact on children’s knowledge of sexual abuse and their self-protection skills [3]. However, while nearly all the studies reviewed reported an increase in children’s knowledge, often these gains were small, and older children made greater gains than younger children [3]. Self-protection skills are difficult to measure, as few studies utilize direct observation due to ethical restraints [3]. However, self-reporting indicates that children are more likely to use self-protection skills after participating in training, view themselves as more effective in stopping abuse, and are more likely to report abuse [3]. Studies found positive emotional results in that children felt more self-confident and assertive, and less anxious due to increased knowledge of how to deal with unsafe situations [3]. Importantly, prevention programs encouraged dialogue between parents and children, which is crucial because most abuse occurs within the family, and also because parental support plays such a vital role in recovery after abuse [3]. Disclosure of abuse increased following training, and false allegations were found to decrease [3]. However, Topping and Barron [3] caution that 74% of disclosures by children are accidental, and that many factors beyond prevention training can influence whether a disclosure is made. Finally, Topping and Barron [3] found that gains in knowledge were maintained in the months following training, but that repeated exposure to the material and follow-up sessions had a significant impact on the level of knowledge retention. Children who participated in multiple training sessions learned and retained significantly more than others, even when the training had been completed years earlier [3]. Thus, reviewing the data, Topping and Barron conclude  that to be adequately effective, prevention programs need to be at least four to five sessions long [3].

Mikton and Butchart [1] again reiterate that the “reviews are all but unanimous” that school-based sexual abuse prevention programs are effective at increasing children’s knowledge about sexual abuse and improving their selfprotective behaviors (p. 4). They note that unfortunately, the studies are equally in agreement that evidence is lacking as to whether the programs actually reduce sexual abuse [1]. Finkelhor [10] agrees. He stresses that children can and do acquire the concepts taught by sexual abuse prevention programs, and that the programs also promote disclosure and discourage self-blame [10]. These are significant effects, as disclosure may cut short the abuse, and discouragement of self-blame may mitigate the negative psychological effects of abuse [10]. Furthermore, abused children who had participated in prevention training often express the belief that they stopped the situation from getting worse and protected themselves from injury [10]. These positive self-assessments are associated with better mental health outcomes. Finkelhor [10] also emphasizes that the increase in communication between parents and children following training is meaningful. Finkelhor [10] argues that prevention programs aimed at children are a critical component of a comprehensive strategy to prevent and address child sexual abuse, which should also include law enforcement initiatives aimed at offenders and therapy of both victims and abusers.

Lalor and McElvaney[2], like Finkelhor [10]and Bolen [6] before them, stress the need for a holistic approach to preventing child sexual abuse, of which school-based prevention programs are an important component. They reaffirm the conclusions of the previous research, finding  that prevention programs improve children’s safety skills and their knowledge about sexual abuse, but that these gains may not lead to the reduction of child sexual abuse [2]. To maximize the effectiveness of prevention programs, Lalor and McElvaney [2] find that teacher’s attitudes and centralized responsibility for program coordination are important. They advocate for a global public health response to child sexual abuse, with media campaigns and therapeutic intervention accompanying school-based prevention programs [2].

Analysis

Ideal prevention programs

As detailed above, conclusive evidence now demonstrates that child-focused sexual abuse prevention programs are effective at teaching children about sexual abuse, arming them with self-protection skills, and increasing disclosure rates. However, not all prevention programs are created equal. Clearly, some models are more effective than others, and researchers have been able to identify qualities that mark a successful program.

Through review of the evidence, scholars and researchers have been able to identify core goals and components of effective child sexual abuse prevention programs that should guide the implementation of programs going forward. First, children must be given a clear understanding of what child sexual abuse is and how to recognize it [1, 3, 11]. Children should also be taught how common abuse is [12], the dangers posed by the internet, how to identify  potential abusers, and that abusers are often family members or family friends or acquaintances [11]. Second, children need instruction on body ownership; for instance, the difference between appropriate and inappropriate touches [1,3]. Third, children must be trained in specific self-protection skills, such as how to say no and strategies to avoid abuse [1,3]. Fourth, it is critical to victim’s mental health outcomes that they learn that it is not their fault if they are abused [1,3,11]. Finally, an essential component of child-focused prevention programming is detailed training on the importance of reporting past or ongoing abuse [1,3,11,12], including recognition of some of the common barriers to disclosure [12]. Training on the reporting of abuse should not only consist of instruction to victims on telling a trusted adult [1,3,11], but should also contain training for friends of victims in disclosure and disclosure promotion [12].

The implementation of prevention programs is just as vital to their success as their content. Programs should begin early in a child’s life, use developmentally appropriate materials, and use active, systematic and specific skills training [13]. Successful programs should incorporate the following methods of instruction in order to engage children:

Modeling (seeing best practices of how to respond in abuse situations)

Group discussion (talking about the best practices that were modeled) Role-playing (rehearsing the skills learned) [13,3]. Prevention programs should be a comprehensive part of a child’s education—repeated multiple times a year and repeated for several years [13] The evidence suggests that programs need to be at least 4 sessions long to effectively deliver information to children[3]. Additionally, programs should be designed so that they can be taught by a range of presenters [3]. It is crucial that programs involve active parental input [3,13]. Finally, programs should contain an evaluation component, so that
assessments can be easily conducted [3].

Criticisms of programs

Notwithstanding the noble goals of child sexual abuse prevention programs and a shared interest in preventing the sexual abuse of children, opponents and researchers have critiqued child-focused prevention programs for issues ranging from their content, effectiveness, to their theoretical underpinnings. The potential concerns of parents whose children may participate in the safe environment training should also be considered. However, although parental resistance is often a concern to those orchestrating the implementation of child-focused sexual abuse prevention programs, research shows that parents overwhelmingly support such programs [5]. Still, there are instances of parents expressing concern that schools are not the appropriate places for instruction regarding sexual abuse, and that such training should be left to parents [5]. Other parents object to the time prevention programs take away from traditional subjects[5]. Child sexual abuse prevention programs, have typically dealt with these concerns by allowing parents to opt-out of training on behalf of their children, should they see fit.

Scholarly research has found limited evidence of any negative effects caused by child-focused sexual abuse prevention programming. (See Table 3) While some studies found an increase in worry in children following training, this may actually be an appropriate reaction, in that it demonstrates that children are taking the threat of sexual abuse seriously [4,8]. Only a small number of children reported any other negative reaction, such as loss of sleep or appetite, nightmares, bedwetting, or behavioral issues [4]. Most of the negative effects reported by children are small, mild, and brief in duration [3]. However, one study found that teaching children to say no to abusers was effective only if the child was not alone when approached, and that once an abuser was alone with a child, resistance was likely to lead to injury [6]. However, Finkelhor [10] disputes the relevance of this finding, stating that there is no statistically significant evidence of increased injury caused by resistance. This issue clearly warrants further investigation in order to settle the facts and develop an appropriate response.

Table 3. Summary of Scholarly Research.

pedia  table 7.3

As detailed above, the literature on child sexual abuse prevention programs establishes that the training is generally effective at teaching children about sexual abuse, equipping them with self-protection skills, and increasing disclosure rates. Notwithstanding criticism from various corners, there appears to be widespread parental support for programs that educate children about sexual abuse [9], and the programs seem to increase dialogue between parents and children on the subject [3]. Studies have also found positive emotional results to prevention training, including increased confidence [3], less self-blame, and a belief they protected themselves and stopped the situation from getting worse in the event of abuse [10]. Negative side-effects of the training are minor and brief, if any, or disputed, in the case of whether resistance can lead to greater injury. Overall, then, the balance of the research strongly supports the continuation of child sexual abuse prevention programs.

Other prevention models

Sexual abuse prevention programs directed at children clearly have an important role to play as part of a larger strategy to eliminate the sexual abuse of children; however, they are not the only tool that can, or should, be used for this goal. To make a substantial impact in reducing child sexual abuse, a holistic and multi-pronged approach is necessary. Researchers have suggested other prevention programs which are useful to consider. Media campaigns can be effective in increasing awareness of the widespread prevalence of child sexual abuse, encouraging reporting and improving attitudes towards victims, and correcting misconceptions about child sexual abuse [2]. Bolen [6] argues that to have maximum impact at preventing child sexual abuse, the best approach is to attack the offending behavior itself. As most offenders are male, she advocates programming directed at young men and boys that encourages healthy relationships and the development of a healthy, nonaggressive expression of masculinity and sexuality [6]. Law enforcement strategies that increase the likelihood that offenders are arrested and prosecuted will prevent those offenders from victimizing more children, and may also serve as a deterrent for potential abusers [10]. Additionally, although not strictly prevention methods, therapy for abusers can prevent recidivism, whereas therapy for victims can lessen the long term negative psychological effects of abuse [2]. Finally, it is necessary to understand child sexual abuse as a global public health crisis and incorporate its prevention into broad-based programs aimed at reducing child maltreatment generally [1,2].

Limitations of research

As a guide for future research, it may be helpful to discuss the limitations of the current evidence on the effectiveness of child sexual abuse prevention programs. Aside from the methodological flaws, many areas of inquiry have been neglected and would benefit from the attention of researchers and scholars. Currently, research investigates the knowledge gain, self-protection skills, emotional impact, risk perception, disclosure rates, maintenance of gains, negative effects, and parental involvement produced by prevention programs [3]. However, further analysis is needed on the effect of gender, socioeconomic status, and ethnicity on children’s gains, the effect of the identity of the presenter, and the differences between programs based on locations in rural, suburban, or urban settings [3]. The varying effectiveness of different pedagogical approaches to teaching also needs to be explored, as does the relative effectiveness of the different core themes programs seek to impart to children [3]. Program fidelity was identified as an area of major concern that warrants further inquiry, as presenters often modify curriculum based on their comfort levels and specific circumstances [3,7]. Although many studies attempted to assess self-protection skills in children, the ability of children to transfer their training to real life is a critical issue and one that needs more study [2,8]. Cost-effectiveness is another area ripe for review [3]. Finally, due to the significance of issue of possible negative effects, this area, although it has received some attention, deserves more follow-up [3,8].

The central question surrounding child sexual abuse prevention programs, and the central focus of this paper, is whether safe environment training is effective. However, attempting to evaluate whether prevention programs reduce child sexual abuse may actually be the wrong question to ask. To date, no study has been able to reliably measure whether prevention programs have an effect on the incidence of abuse, [3], and that fact may be that no study ever could. The majority of child sexual abuse is never reported, thus making it impossible to know the rates of abuse within a targeted population [7]. To further complicate the problem, effective prevention programs are likely to increase reports of abuse, which may create the false impression that abuse rates are increasing when they are not [7]. Furthermore, it may take years for the benefits of child sexual abuse prevention training to appear, and research practices are complicated by privacy concerns [7]. Therefore, the appropriate measures of effectiveness should be whether the programs increase children’s knowledge about sexual abuse, heighten their self-protection skills and behaviors, and improve their attitudes regarding abuse [7,11].

Conclusion

It is clear from the evidence that child sexual abuse prevention programs can be effective in a number of important respects; namely, increasing children’s knowledge of sexual abuse, improving their self-protective behaviors, and raising disclosure rates. Although their effectiveness in reducing child sexual abuse is unproven, and is likely to remain so, it would be foolish to discard programs that have such significant and well-proven benefits.

Specifically, the programs used in safe environment training should be evidence-based, should begin early in a child’s life and be repeated at least 4 times a year for multiple years. Programs should be designed so that they can be taught by a range of presenters, who should be trained to feel comfortable with the material and particularly in how to respond to disclosures of abuse. Training should include active parental involvement, and should have built-in evaluation components. Curriculum should not exist primarily of audio or video materials, but should engage children with modeling, group discussion, and role-playing. However, standards to ensure program fidelity should be enforced. Clear and specific instruction should be given in skills training and the importance of reporting past, present and future abuse.

References

 References

1.Mikton C. Butchart A. Child maltreatment prevention: a systematic review of reviews. In Bulletin of the World Health Organization. 2009, 87(5): 353-361.

2.Lalor, K & McElvaney, R. Child sexual abuse, links to later sexual exploitation/high- risk sexual behavior, and prevention/ treatment programs. In Trauma, Violence and Abuse, 2010, 11(4):159-177.

3.Topping, KJ & Barron, I. G. School-based child abuse prevention programs: a review of effectiveness. Review of Educational Research. 2009, 79(1), 431-463.

4.Reppucci ND, Haugaard J J. Prevention of child sexual abuse: Myth or reality. In American Psychologist. 1989, 44(10):1266-1275.

5.Madak PR. ,Berg DH. The prevention of sexual abuse: an evaluation of “talking about touching.” In Canadian Journal of Counseling. 1992, 26(1):29-40.

6.Bolen RM. Child sexual abuse: Prevention or promotion? In Social Work . 2003, 48(2): 174-185.

7.Logan J. The effectiveness of safe environment training programs for children and adults. Available upon request from the United States Conference of Catholic Bishops at 3211 Fourth Street NE, Washington DC 2001, 202-541-5413. 2012.

8.Rispens J, Aleman A, Goudena PP. Prevention of child sexual abuse victimization: A meta-analysis of school programs. In Child Abuse & Neglect. 1997, 21(10): 975-987.

9.Plummer CA. Prevention of child sexual abuse: A survey of 87 programs. In Violence and Victims. 2001, 16(5): 575- 588.

10.Finkelhor D. The prevention of childhood sexual abuse. In The Future of Children. 2009, 19(2): 169-194.

11.Hudson PE. Program response to RFI. Available upon request from the United States Conference of Catholic Bishops at 3211 Fourth Street NE, Washington DC 20017, 202-541- 5413. 2012.

12.Kellogg N. Email to Deacon Bernie Nojadera in response to RFI. Available upon request from the United States Conference of Catholic Bishops at 3211 Fourth Street NE, Washington DC 20017, 202-541-5413. 2012.

13.Rizutto, A. Implementation of the USCCB Charter for the protection of children and young people for Catholic dioceses. Available upon request from the United States Conference of Catholic Bishops at 3211 Fourth Street NE, Washington DC 20017, 202-541- 5413. 2011.

 



Cite this article: Giardino, A.P. et al. Child Sexual Abuse Prevention: Are Safe Environment Training Programs Effective? A Topical Review of the Literatures. J J Pedia. 2015, 1(1): 006.

 

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