Citation:

Tutty, L. M. (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.

Prevention Education: An Integrative Review of the Research

By Leslie M. Tutty, D.S.W.

Introduction

In response to the unfolding evidence that child sexual abuse is not rare, but an occurrence

that approximately one in four girls and one in ten boys may experience in some form before they

become adults (Finkelhor, 1993), prevention has become the vanguard of a generation of nervous

parents and professionals. It is hoped that with participation in a sexual abuse prevention program,

children can be safeguarded from the often long-term and severe consequences of such abuse

(Bagley & Young, 1990). The trauma is thought to be reflected not only in sexual distress as an adult,

but in difficulties with trust, feelings of stigmatization, and powerlessness (Finkelhor & Browne,

1985).

A further rationale for prevention is provided by incidence and prevalence studies that have

identified common misconceptions about the nature of child sexual abuse. The new facts show that

sexual abuse is perpetrated more often by familiar figures (80%) than by strangers (20%); that

incestuous abuse by fathers, step-fathers, siblings and grandparents is relatively common, accounting

for about one quarter of abusive incidents (Wurtele & Miller-Perrin, 1992); and that 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). Primary prevention programs are intended to educate the

public about who is at risk of abuse and what strategies may be used to evade potential victimization.

Since children rarely intentionally disclose sexual abuse (Sorensen & Snow, 1991), it is hoped that

they might be encouraged to do so in order to interrupt abuse that, not uncommonly, continues for

years.

Many diverse prevention strategies have been developed for various target audiences

including offenders, potential victims, parents and the professionals who must deal with disclosures

and treatment. This paper will primarily focus on the most widely-produced and researched

prevention programs, those directed at the general population of children, reviewing research on

their efficacy and identifying gaps that remain in our understanding of how such programs might

become more effective. Finally, the paper will address the more general question of whether child-

directed abuse prevention programs can meet society's need to protect children from sexual abuse,

or, if not, what other prevention audiences should be targeted.

An Overview of Child Sexual Abuse Prevention Programs

A useful conceptual framework with which to categorize the wide array of prevention

strategies is Finkelhor's (1984) four preconditions to sexual abuse. The first two preconditions are

that the offender must first have the motivation to sexually abuse children, and then must overcome

internal inhibitions that may act to prevent such behaviour. Thirdly, the offender must overcome

external impediments to gain access to a child. Fourthly, a child's possible resistance must be

undermined by the perpetrator. The first and second preconditions suggests the development of

prevention programs aimed at potential offenders, typically by attempting to convince them that

sexual abuse is not sanctioned by society and that they will be prosecuted. The third precondition,

while phrased in terms of the offender, suggests elements over which parents have control if they

are sensitized to the risks involved. So, for example, knowing that children are at more risk of abuse

from familiar adults in their own home, can shift the emphasis from concern about strangers, which

is the way in which parents typically conceptualize sexual abuse, to more caution about baby-sitters

and other caregivers. Finally, the fourth precondition suggests that children can be taught to

recognize situations where they might be at risk for abuse and ways in which they might be able to

escape. While the preconditions suggest a wide range of options for prevention programs (Tutty,

1991), it is the fourth precondition that has become the major focus.

Child-directed programs typically introduce prevention concepts using a format that will

capture the attention of young children - a play, puppet show, storybook or colouring book. The core

concepts that are utilized across the majority of programs include the fact that there are different

kinds of touches (Anderson, 1986), that you can trust your feelings in response to touches, that

sometimes it is permissible to say no to an adult, that if you're uncomfortable in a situation you can

attempt to leave, and that telling a trusted adult is important, even if you've been told to keep touches

a secret (Tutty, 1995). Also important is the idea that familiar adults or relatives might touch children

in ways that feel uncomfortable, and that boys are at risk of abuse. Many include not only a

presentation of the core concepts, but the opportunity to discuss the ideas and to role-play how a

child might disclose if she found herself in an abusive situation. Programs have been developed for

children as young as three years of age. Prevention programs designed for high risk groups such as

disabled children or children with emotional difficulties are available (Haseltine & Miltenberger,

1990). Some vulnerable groups, such as step-children who are at five times the risk of children in

biological families (Finkelhor, 1993), have not been targeted as successfully.

Child-directed programs are common across North America (Kohl, 1993). In a recent U.S.

nationally representative phone survey with 2000 children aged 10-16, 67% had participated in a

victimization prevention program at some time (Finkelhor & Dziuba-Leatherman, 1995).

Nevertheless, child-directed programs, especially those aimed at preschoolers, are controversial,

with critics such as Reppucci and Haugaard (1993), and Webster (1991) questioning their efficacy,

countered by advocates such as Plummer (1993). This paper neither supports nor denounces child

abuse prevention programs, but identifies issues supported by the research and questions that require

further study.

The Efficacy of Child-Directed Sexual Abuse Prevention Programs

In the past decade over 40 research articles on child-directed prevention programs have been

published (for reviews see Daro, 1994; Dubé, Heger, Johnson, & Hébert, 1988; Reppucci &

Haugaard, 1993; Tutty, 1990a; Wurtele, 1987; Wurtele & Miller-Perrin, 1992). The two most

commonly utilized outcome variables for testing the efficacy of child abuse prevention programs are

knowledge of abuse prevention concepts and behavioural change. While information about both

behaviour and knowledge would ideally be collected to demonstrate that prevention programs are

working as planned, there are problems with using behavioural change as an outcome variable. Such

an outcome is usually measured by simulating a potentially abusive situation, with a stranger

approaching a child and requesting that he accompany the adult under the guise of helping in some

manner (Fryer, Kraiser & Miyoshi, 1987a; 1987b; Poche, Brouwer, Swearingen, 1981). Although

one of the major concerns about using this method of validating programs has been the ethics of such

a simulation (Conte, 1987), another problem is that it can only be used to assess responses to

strangers. Since the majority of perpetrators of sexual abuse are known to the victim, this method

has limited utility. Thus, although knowledge gain is limited to the extent that one cannot be certain

that it will translate into changed behaviour, it remains the initial criteria to evaluate whether a

program is effective.

A further obstacle for those who wish to evaluate their prevention programs is that, to date,

there are few psychometrically sound measures available to assess children's knowledge levels.

Exceptions include the Personal Safety Questionnaire often used in conjunction with the "What if

Situations Test" (Saslawsky & Wurtele, 1986), both of which are commonly used to test programs

for preschool and young elementary school students, the "What I Know About Touching Scale"

(Hazzard, Webb, Kleemeier, Angert & Pohl, 1991) and the "Children's Knowledge of Abuse

Questionnaire" (Tutty, 1992; 1995), both of which were developed for elementary school-aged

children.

Preschool Programs. Since much of the controversy about child-directed sexual abuse

prevention programs centres around what age it is appropriate to introduce such ideas, whether

preschool-aged children can grasp the concepts, and whether they can do so with no negative side-

effects (Berrick, 1989; Daro, 1989; Reppucci & Haugaard, 1993), research on preschool programs

will be regarded separately from that targeted to elementary school children. Of sixteen studies

evaluating prevention programs for preschoolers, arguments remain regarding the ability of these

very young children to learn the material, despite the fact that the research generally supports the

programs. The results of eight pre/post studies that did not utilize a control group design suggest that

preschoolers can learn prevention concepts or behavioural skills (Borkin & Frank, 1986; Christian,

Dwyer, Schumm, & Coulson, 1988; Gilbert, Berrick, LeProhn & Nyman, 1989; Kraiser, Witte, &

Fryer, 1989; Miltenberger & Thiesse-Duffy, 1988; Nemerofsky, Carran & Rosenberg, 1994; Poche

et al., 1981; Stillwell, Lutzker & Greene, 1988).

Eight additional, better-designed studies that included control groups (Conte, Rosen,

Saperstein & Shermack, 1985; Hill & Jason, 1987; Peraino, 1990; Ratto & Bogat, 1990; Wurtele,

1990; Wurtele, Kast & Melzer, 1992; Wurtele, Gillespie, Currier, & Franklin, 1992; Wurtele, Kast,

Miller-Perrin, & Kondrick, 1989) demonstrated significant increases in knowledge and skill levels

in the preschool children who participated in the prevention programs as compared to children who

did not. Despite the fact that their own research recorded gains on every dimension tested, Gilbert et

al. (1989) have raised questions about the limited extent of the gains in knowledge and the retention

of these concepts over time for preschool-aged children. As an example of such difficulties, Liang,

Bogat and McGrath (1993) found that 3 year-olds were consistently less competent in learning the

skills as compared to 4 and 5 year-olds. Further, Borkin and Frank (1986) found that only half of the

four and five year old children were able to recall the safety rules taught in a puppet presentation.

One of the key concerns about programs developed for preschoolers is that the responsibility

for safety issues should lie more appropriately with parents and caregivers than with such young

children (Cohn, 1986; Daro, 1989; Loiselle & Gaulin, 1995). This is a point with which most

proponents of preschool programs would not disagree, however they would, in response, not replace

or eliminate programs for children but expand them by incorporating parent programs.

As is particularly appropriate when dealing with very young children, several studies have

investigated the possibility of using parents to teach prevention skills. An early study did not produce

encouraging results. Miltenberger and Thiesse-Duffy (1988), using a small sample of 11 six to seven

year old children and 13 four to five year old preschoolers, found that when the program was taught

by parents, it did not produce changes in knowledge or skills in the area of personal safety in either

age-group of children. When individual behavioral skill training was subsequently offered by the

authors to children who did not achieve criterion performance, the children made significant gains.

Follow-up at two months, however, showed that only the older children retained their skills. The

results are difficult to interpret in light of the complex design, the small sample size and the fact that

parental involvement was not the sole intervention.

Another series of recent articles examined the effectiveness of parents as compared to

teachers as educators of abuse prevention concepts to preschool-aged children. For example, Hill

and Jason (1987) found greater gains for preschool children when, in addition to a parent workshop,

the children also received the prevention training from their teacher. In more rigorous research,

Wurtele, Gillespie, Currier, and Franklin (1992), and Wurtele, Kast and Melzer (1992) found that

preschool children whose parents were taught a behavioral program (instruction, modelling,

rehearsal & social reinforcement) did as well as children who had been trained by teachers, and both

the experimental groups did better than children randomly assigned to a control group. Children who

had received training both at home and at school showed better skills than children taught only at

school (Wurtele, Kast & Melzer, 1992). Repetition of the material and the inclusion of parents in the

training, thus, both proved to be useful additions to the preschool prevention programs.

In summary, although the research on preschool programs suggests that 4 and 5 year-old

children do learn some of the prevention concepts, in general, children younger than that have

difficulty understanding and maintaining these ideas. Many concerned parents attempt in good faith

to teach even 1 and 2 year old children about sexual abuse. They are often frustrated in their efforts,

and repeat the exercise with limited success. What messages they are conveying to their young

children about trust and safety has not been evaluated but should be of concern. A clear statement

from prevention educators about at what age materials are of benefit would be helpful. Further, a

shift in emphasis to more general prevention ideas such as self-esteem and fostering open parent-

child relationships so that preschoolers confide whenever they are uncomfortable is preferable to

continuing to utilize programs that may well be effective with older children.

Elementary School Programs. The results of the research on prevention programs for older

children have also yielded consistent findings, although, as befits a new area of research, some of

the early studies on the efficacy of such programs were exploratory in nature and did not utilize

research designs that included large samples, control groups or the statistical analysis of total test

scores. Nevertheless, most suggested improvements in children's knowledge after they participated

in a prevention program (Briggs & Hawkins, 1994; Garbarino, 1987; Plummer, 1984; Sigurdson,

Strang & Doig, 1987; Swan, Press & Briggs, 1988). An additional eleven well-designed studies that

included control groups (Blumberg, Chadwick, Fogarty, Speth, & Chadwick, 1991; Conte et al.,

1985; Dhooper & Schneider, 1995; Downer, 1984; Fryer et al., 1987b; Harvey, Forehand, Brown,

& Holmes, 1988; Hazzard et al., 1991; Saslawsky & Wurtele, 1986, Tutty, 1992; Volpe, 1984; Wolfe

et al., 1986) all found statistically significant gains in knowledge and/or skills, although these

improvements were typically an increase in only one or two prevention concepts, a point that will be

discussed in more detail later.

Another question about child sexual prevention programs has been whether children would

remember the concepts over time. Nine studies collected follow-up information on periods longer

than 2 months, finding that children retained their knowledge of abuse prevention concepts over 3

months (Saslawsky & Wurtele, 1986; Wurtele, Saslawsky, Miller, Marrs, & Britcher, 1986), 5

months (Tutty, 1992; Wurtele, Kast & Melzer, 1992), 6 months (Fryer et al., 1987b; Kolko, Moser,

Litz, & Hughes, 1987; Ray & Deitzel, 1985) and 1 year (Briggs & Hawkins, 1994; Hazzard et al.,

1991; Hazzard, 1993).

Finally, 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 (Nibert, Cooper & Ford, 1989;

Tutty, 1990b; Wurtele & Miller-Perrin, 1987).

Finkelhor and Dziuba-Leatherman (1995) add an important dimension to this question.

While 16% of the 10 to 15 year olds in their U.S. national phone survey reported worrying more

about abuse after participating in a victimization prevention program, a fact that was corroborated

by their caretakers, these same individuals gave the most positive feedback about the utility of the

program. Finally, the group of youngsters who worried were those most likely to have used the skills

that had been taught.

Comparisons of Programs and Formats: Having evidence that, in general, the programs

are effective, several researchers have taken the appropriate next step in the overall assessment of

prevention programs, that of comparing different approaches. Wurtele, Saslawsky, Miller, Marrs,

and Britcher (1986) compared four groups: 1) a film presentation, 2) a behavioural skills training

program, 3) both the film and the behavioural skills program and 4) a control group. The film alone

did not result in significant learning, however, in both conditions that included the behavioural

component children learned significantly more prevention concepts and skills as compared to

children in the control condition. Wurtele, Marrs, and Miller-Perrin (1987) compared a program for

kindergarten children that included practising skills, compared to a group where the children simply

watched the presenter model the skills. They found that children who practised the skills scored

significantly higher in knowledge levels and appropriate responses to vignettes. A later study that

compared a behavior-skills training program for preschoolers with a feelings-based program

(Wurtele, Kast, Miller-Perrin, & Kondrick, 1989) found, in this instance, that both programs resulted

in increases in knowledge as compared to the control group condition. Blumberg et al. (1991) found

significant differences on knowledge of touch discrimination for kindergarten to Grade 3 children

who participated in a role-playing group as compared to a control group that received a fire-

prevention program. However, the group of children that received only a play or a puppet show did

not improve to a greater degree than the control group. These studies provide strong support for

including a practice component in prevention programs.

Other research (Tutty, 1990b) has also suggested that repetition of the concepts is critical. In

a comparison of Grade 3 students, some of whom had received supplementary sessions in addition

to seeing a prevention play and some who did not, children who had both answered the pretest of the

knowledge questionnaire and had attended supplementary sessions scored significantly higher on a

knowledge questionnaire at posttest. Providing a number of opportunities to expose children to

prevention concepts, thus, appears to help consolidate learning.

In respect to questions about who should deliver the programs, the previously-mentioned

studies by Wurtele and colleagues that compared the efficacy of parents versus teachers as educators

of preschool-aged children (Wurtele, Kast et al., 1992; Wurtele, Gillespie et al., 1992) demonstrated

that both can provide effective training. Children who received a combination of both school-based

and home-based programs were better able to identify appropriate-touch requests and to show higher

levels of personal safety skills than children taught solely at school (Wurtele, Kast & Melzer, 1992).

Hazzard, Kleemeier and Webb (1990) found that teachers were as effective as expert consultants in

presenting a prevention program to students in grades 3 and 4. Further research comparing programs

and various formats is highly recommended.

Disclosures. While we do not know whether the information that children learn is sufficient

to prevent sexual abuse, it hopefully provides permission to disclose abuse once it has occurred.

Disclosures are a common occurrence after the presentation of school-based programs, although

many of these have previously been reported (Hazzard et al., 1990). However, recent research has

questioned the extent to which children act upon the exhortation to disclose abuse. In their U.S.

national incidence phone survey, Finkelhor and Dziuba-Leatherman, (1995) reported that abused

children who were in programs where they were advised to disclose abuse were no more likely to

do so than children without programs. Furthermore, in interviews with 22 children, all of whom had

been sexually abused by the same school caretaker, half had seen a prevention video, “Too Smart

For Strangers” (Pelcovitz, Adler, Kaplan, Packman, & Krieger, 1992). Notably, the abuse was

discovered accidently, and in subsequent interviews none of the children reported having learned

any useful information from the video that might have ended their abuse sooner. Nevertheless,

several factors about this particular program raise questions about its validity, including the fact that

no discussion followed the film and its major focus was on abuse by strangers, rather than familiar

adults.

On a somewhat more optimistic note, Sorensen and Snow (1991) looked retrospectively at

630 children who had disclosed sexual abuse. Most (74%) disclosed accidently rather than

purposefully, with adolescents being much more likely to disclose purposefully than younger

children. The authors found that, "Among primary-school-age children who purposefully told, the

influence of educational awareness programs was dramatic. The programs were not exclusively on

sexual abuse prevention, but all identified inappropriate behaviours and stressed assertiveness and

personal rights" (1991, p.14). Further, Kolko et al. (1987) looked at disclosure rates six months after

children had participated in a prevention program. Twenty of 349 students who were in the

experimental conditions had reported incidents of inappropriate touch by an adult. No child in the

control condition reported such an occurrence although there is reason to expect that they may have

experienced similar rates of inappropriate touching. Further research should focus on disclosure rates

as a way of evaluating sexual abuse prevention programs.

Developmental Issues. Although the results of the best designed studies show increases in

knowledge of prevention concepts that are statistically significant, in practical terms the gains are

rather small. Why this should be so remains a puzzle. In the few studies that reported a statistical

comparison of the responses of children from different age groups, older children consistently

learned more of the concepts than younger children, even among elementary school-aged children

(Borkin & Frank, 1986 [3,4, & 5 years]; Conte et al., 1985 [4-5 & 6-10 years]; Hazzard et al., 1991

[Gr. 3 to Gr. 4]; Nemerofsky et al., 1994 [age 3 versus 4,5,6]; Saslawsky & Wurtele, 1986 [Kind/Gr.1

& Gr. 5-6]; Tutty, 1992 [Gr. 1, Gr.3, Gr.6]). With such clear age-differences in response to programs,

developmental issues ought to be considered in both the planning and the evaluation of programs, as

has been suggested by Adams (1986), Berrick (1991), de Young (1988), Daro (1991), and Pelcovitz

et al., (1992). While the creation of age-appropriate materials is typical when materials are prepared

by educators, many programs for sexual abuse prevention have been produced by other professionals

(i.e. child welfare workers, advocates from assault centres), who do not have a background in child

development. As such, the same materials may be utilized and seen as appropriate for the entire

spectrum of children aged three to twelve. When one analyzes the content of the prevention

concepts that comprise child abuse programs it becomes clear that these are not merely facts, but

beliefs that contradict various current cultural and family norms about how children should behave.

For example, giving permission for children to say no to a grown-up is contrary to what many young

children have been taught. However, little work has thus far conceptualized the way in which

developmental differences might affect children's responses to child abuse prevention programs.

Two research studies (Wurtele & Miller, 1987; Miller-Perrin & Wurtele, 1989) found that children

from three distinct age-groups in a range of from 4 to 12 years, showed distinctive responses in

reaction to a vignettes about personal body safety in relation to their expectations about the

characteristics of the perpetrator, how the victim should respond and whether they would want to

have the victim for a friend, again suggesting the importance of development.

A recent analysis of the items endorsed by children in grades 1, 3 and 6 (N = 111) (Tutty,

1994), looked at differences on the basis of developmental theories of the relationship with authority

figures (Damon, 1980) and moral development (Piaget, 1963, cited in de Young, 1988). Age, as

previously reported, was the most consistently significant variable throughout this study, with clear

differences found between the children in different grades, such that the older the child, the higher

score they achieved on the knowledge measure. Although there were overall significant pre/post

increases in only 8 items of 35, developmental differences appear to be involved in many of the other

items, masking significant changes for selected age groups. On many items, one age group would

improve while the others changed minimally. There were only five items that improved significantly

for all children of all age groups.

Items that which were likely to present difficulty at pretest and at posttest for the younger

children seemed to be in regard to three major issues: saying no to authority figures, understanding

the possibility that trusted adults might act in ways that are unpleasant, and rules about breaking

promises and keeping secrets. The fact that these items were particularly difficult for the youngest

children to learn suggests that these may be more sensitive to developmental or to family beliefs. For

example, while Grade 3 students improved substantially in their response to the item “if a grown-up

tells you to do something you always have to do it,” the Grade 1 children evidenced little change. In

the development of basic trust, children need to believe that adults can be relied upon, and it is not

until they are older that they are able to understand that there are exceptions to such principles.

Participating only in the prevention program was insufficient to change the opinion of most of the

Grade 1 children about whether they could sometimes defy an adult's request. The item analysis

identified a similar reluctance on the part of younger children to believe that someone in one's family

might touch your private parts in a way that is confusing. More students answered these items

correctly after they participated in the prevention program, but younger children remained the least

likely to endorse this idea.

In several cases, the children of one age-group actually lost ground on some concepts after

being in the prevention program. For children in Grade 1, for example, there was a significant loss

of knowledge in the case of 4 items, two in regard to strangers (you can always tell who’s a stranger

- they look mean; only strangers would try to touch children's private parts in a way that feels bad),

one in regard to secrets, and one in regard to who is to blame if one's private parts are touched (If

someone asks to touch you private parts and says it’s a secret then you can't tell; It’s your fault if

someone touches your private parts in a way that you don't like). Students in Grade 3 scored

significantly worse on 3 items: You can always tell who's a stranger - they look mean; Sometimes

it’s OK to say no to a grown-up; It’s OK for someone you like to hug you). While these

misconceptions may be due to the abstract nature in the way these concepts were conveyed, or may

represent areas not addressed by the particular program evaluated, it is important to know whether

children are changing their ideas in response to the information that is being presented. The results

of this exploratory study have implications for developmental principles that might be emphasized

and repeated in programs for younger age-groups. The study highlights the complexity in teaching

children prevention concepts and suggests that we must attend to developmental issues to a greater

degree than has been accomplished to date.

Other Child Characteristics and Learning Prevention Concepts. Besides looking at the

effects of age, relatively little research has investigated other characteristics such as gender,

socioeconomic status, culture, race, or religious background that might differentiate who integrates

sexual abuse concepts. Most of the research that evaluated the effects of gender found no significant

differences in the average scores of boys and girls after seeing programs (i.e. Briggs & Hawkins,

1994; Dhooper & Schneider, 1995; Peraino, 1990; Tutty, 1992), although two studies by Hazzard

and colleagues (1990; 1991) and reported that girls learned and maintained more of the material.

Finkelhor and Dziuba-Leatherman (1995) found that girls reported more client satisfaction with the

programs.

Similarly, several studies analyzed the effect of race (Briggs & Hawkins, 1994; Peraino,

1990), concluding that this factor did not make a significant difference in knowledge. Interestingly

though, although Finkelhor and Dziuba-Leatherman reported that satisfaction levels with the

prevention programs were high across all participants, children who are black and from lower socio-

economic status families reported both the highest positive reactions and skill-utilization. Further

research that evaluates the effects of such intervening variable is clearly indicated.

Summary of Research on Child-directed Prevention Programs

The well-designed research on child-directed sexual abuse prevention programs for both

preschool and elementary school-aged children consistently shows significant increases in

knowledge and/or skill levels. The inclusion of practice elements such as role-playing increases the

likelihood that children will learn the material. Supplementary sessions similarly help the

consolidation of learning. Nevertheless, younger children learn less than older children and a

consideration of developmental stages suggests that each program evolve a different emphasis for

children of various ages.

A recent meta-analysis of the research on prevention programs reported large effect sizes for

both preschool programs (d = 0.86) and elementary school programs (d= 0.98), providing strong

support for the programs (Berrick & Barth, 1992). Interestingly though, the authors were reluctant

to endorse the programs stating that:

The meta-analysis demonstrates that children of all ages can improve their scores on child

abuse knowledge measures but does not inform whether the type or amount of knowledge

they learn sufficiently protects them from abuse. (1992, p. 14)

This point, though well-taken, is one of the issues that has not been the focus of research to

date. Proving that programs are, in fact preventative, will only be possible in retrospective studies

and will present dilemmas regarding reporting any disclosures of abuse to the appropriate authorities.

A more useful question at this point is how to enhance the learning of children given the consistent

difficulties that young children experience in acquiring more than one or two prevention concepts

after each exposure to the prevention materials. Another response to these findings is that it may

make sense to re-label child-directed abuse prevention programs as early intervention rather than as

prevention, since it is a mistake to assume that children have the strength or the psychological

sophistication to escape an abusive situation even if they can identify the situation as abusive. Conte

and Fogarty (1990) similarly suggest focusing on encouraging disclosure rather than attempting to

prevent abuse. Rather, the benefits from prevention programs may lie in interrupting the duration of

the abuse as well as the intrusiveness of the behaviour since sexual touch is likely to proceed to more

invasive sexual behaviour if the relationship continues.

To conclude, in their U.S. national incidence phone survey of 2000 10-16 year-olds

Finkelhor, Asdigian and Dziuba-Leatherman (1995), reported that 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. Furthermore, the children and caretakers were consistently

positive about the programs, with 40% of the youngsters saying that it had helped. When asked to

remember incidents when they had used what they had learned children mentioned getting out of

fights, avoiding suspicious strangers, saying no to adults and helping a friend. The authors note 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).

Sexual Abuse Prevention: A Broader Perspective

The efficacy of child-directed prevention programs must be put into perspective by clarifying

that, as is suggested in the first section of this paper, it is only one of a number of prevention

strategies. Given the relative availability of school-based programs and informal materials to teach

prevention concepts, such as books and videos, it is easy to forget that no matter how well the

programs work, prevention must be aimed at audiences beyond the potential victims. Programs for

children have been criticized for conveying the expectation to both parents and the child, that

children will be able to prevent abuse. Since perpetrators are by definition older and often larger,

sometimes utilizing threats and violence, at other times using enticement or entrapment (Sgroi &

Bunk, 1988), it is unrealistic to solely target the victims. Rather, prevention should take a wider

community-based perspective.

Parental Programs. Whenever one intervenes with children, one must be concerned about

how the subsequent interaction with their parents might affect their learning. A decade ago,

Finkelhor (1982) found that 500 Boston parents were more reluctant to discuss sexual abuse with

their child than other similarly uncomfortable topics such as suicide and normal sexuality. While this

discomfort is understandable, it does not make sense to provide children with information about

sexual abuse, without simultaneously involving their parents.

Developers of prevention programs have long been aware of parents as another important

prevention audience (Adams & Fay, 1986; Miller-Perrin & Wurtele, 1988), however, attempts to

engage them have met with varied success. A common experience is that it is difficult to entice

parents to attend programs when they are offered. For example, Berrick (1988), in evaluating a

program developed for parents of preschoolers, found that only one-third took the opportunity to

participate. Those who did attend learned little about the prevalence of sexual abuse, indicators of

abuse or appropriate responses to a disclosure of abuse; the essential concepts such a program is

designed to convey. Similarly, Spungen, Jensen, Finkelstein and Satinsky (1989) found that, despite

intensive efforts to encourage parents to attend workshops, only about one-quarter of the parents of

1000 children came. A comparable percentage of parental attendance was reported in Tutty (1990b).

A logical question is whether, with the recent media attention to sexual abuse, parents are

already educating their children about sexual abuse and so do not need to attend educative programs.

A recent study (Wurtele, Kvaternick, & Franklin, 1992) looked in some detail at the content of the

information that parents conveyed to their children. Over half of a sample of 375 parents of preschool

children reported that they had discussed sexual abuse with their child. While many warned their

children that someone might try to touch their genitals, there remained an emphasis on "stranger-

danger". This reluctance to discuss the possibility that familiar adults and even family members

might be possible perpetrators, results in the continuation of the comfortable myth that abduction

and touching by strangers are the most significant dangers for children. Such research provides

support for the idea that many parents need to be educated about the incidence and seriousness of

sexual abuse.

Many of the best school-based prevention programs invite parents to attend a preview and

joint child/parent programs have been recommended (Kolko et al., 1987). Binder and McNeil (1987)

evaluated a program where parents and children attended separate 2 hour workshops. Afterwards,

the parents seemed generally more confident in their child's ability to respond appropriately in

potentially abusive situations. The authors concluded that, "school-based programs are likely to

complement and improve parents' ability to educate their children about preventing sexual abuse"

(p. 504). The program seemed to have stimulated communication between parents and children, an

important outcome. Little research is available on the success of similar joint parent/child programs,

and the lower priority given these represents a significant gap in the provision of comprehensive

prevention programming (Tutty, 1990c).

A particularly well-designed study (McGee & Painter, 1991), suggests that if parents attend

a parent program, the experience does have an impact. The authors compared the effectiveness of

two different, video-taped programs (Feeling Yes, Feeling No; Strong Kids, Safe Kids) on the

knowledge, attitudes and potential response to a disclosure of abuse of 300 parents who had been

randomly assigned to the different research conditions. Parents who attended Feeling Yes, Feeling

No, by the Green Thumb Theatre of Vancouver, reported feeling ultimately more comfortable

discussing sexual abuse with their children. All of the parents involved in the research had

volunteered to participate in a parent prevention program, distinguishing this group from other

research by the high motivation of the parents. McGee and Painter's research does not, therefore,

address the problem of how to encourage less-interested parents to take advantage of programs which

are offered.

A recent research study (Tutty, 1993) is one of the first empirical documentations of a

relationship between parental knowledge and child knowledge. First, the grade level (age) of the

child was found to be a key variable in both children's knowledge of prevention concepts and in their

parent's ability to predict their responses. Parents (N = 201) were least able to predict how younger

(kindergarten and Grade 1) children would respond to abuse prevention questions and they seriously

overestimated their young child's understanding of prevention concepts as compared to older

children in Grade 3 or Grade 6 whose understanding of prevention concepts is greater. This finding

is similar to a recent study on safety skills (Yarmey & Rosenstein, 1988) in which parents

overestimated their five year old child's ability to remember his name, address, and phone number

in case he was lost. The consequence of the misperception that their child understands sexual abuse

prevention concepts is that parents may become complacent about the need for providing or

reinforcing prevention information. It is essential to stress to parents that their young children will

need repetition and support in order to learn the concepts and that parents must maintain considerable

responsibility for this process.

Secondly, a parent’s own knowledge about the seriousness of child sexual abuse was found

to be related to their ability to predict their child’s responses to prevention items. Parents who

understood the extent and the serious consequences of child sexual abuse were better able to

accurately assess how their child would answer items about such abuse. While it is not known

whether this finding might be as a result of parents being more willing to talk to their children if they

are more aware of the seriousness of abuse, such would be a potential goal for parent programs.

With the wide-spread availability of child-directed school-based programs, a risk is that

parents will feel that they need not take a role in their child's education about abuse. Parents need to

be cautioned that, although prevention programs do have an impact on children's learning, the

material seems to be learned slowly and progressively as children mature. Parents must be convinced

that their input remains critical in helping their child to learn concepts that may be at odds with their

developmental level. Placing a priority on parental involvement would allow for reinforcement of

the concepts at home, and providing the opportunity for potentially important dialogue. We must

find ways to encourage parents to attend the abuse prevention programs being offered to their

children. Further experimentation is needed with ways to overcome parental resistance to such

invitations, especially on the part of fathers.

Community-Focused Prevention. Prevention programs to address child sexual abuse are

best seen as a multi-modal collection of programs, some directed to children, some to parents, and

others to training professionals such as teachers, medical personnel, and members of the helping

professionals about the signs of abuse and how to respond to disclosures (i.e. Kleemeier, Webb,

Hazzard, & Pohl, 1988). Such programs aid workers in recognizing potential danger signals and

provide clear instructions to handle children's reports of abuse in ways are as non-intrusive as

possible while still gathering information that might be useful in court proceedings. In addition,

sufficient community resources need to be in place to handle disclosures and to provide treatment to

victims of abuse.

This does not discount the utility of child-directed programs. The best examples of abuse

prevention programs include parent and professional training components in addition to well-

developed programs for children complete with supplementary materials. The ideal would be to

include the child-directed programs in a comprehensive school program that first teaches “normal”

sexuality (Loiselle & Gaulin, 1995). As an example of the need for such education, Wurtele, Melzer

and Kast (1992) found that few of 271 preschoolers knew the anatomically correct terms for genitals

although almost all could correctly label other body parts. If child abuse prevention represents a

child's first introduction to issues of sexuality there is a risk that sex becomes a negatively-framed

issue. A more broadly-based program might also address issues that enhance the possibility that

children will utilize the skills and knowledge learned in abuse prevention, such as self-esteem and

assertiveness. Fryer et al. (1987a) reported that children with high self-esteem were able to put into

action the prevention concepts that they had been taught to a significantly greater degree than

children with low self-esteem.

Treatment for victims is another essential strategy, considered as secondary prevention.

Although it must be clarified that not all victims become perpetrators, given statistics that

demonstrate that most perpetrators of sexual abuse were themselves victims (Groth & Burgess,

1979), treatment for victims must surely become one of the most important prevention interventions.

Yet, in times of economic restraint, services for abuse victims are often among the first to be reduced

or eliminated. Both encouraging children to disclose abuse and offering treatment have the potential

to prevent victims from acting out their sexual trauma by victimizing other children, especially when

treatment for perpetrators is fraught with disappointments and controversy.

Conclusion

The impact of having been sexually abused as a child continues to be highlighted as more

adult survivors come forth, as child abuse agencies continue to be flooded with reports, and as it

becomes increasingly apparent that many individuals who seek treatment for issues such as

addiction, wife assault, and mental health concerns were sexually abused as children. Hearing the

stories of these victims leads to only one conclusion: the emphasis must be on prevention.

This paper suggests that, while the initial findings about child-directed programs are

encouraging, teaching prevention concepts is not as simple as was first believed and further

experimentation with parental involvement, and targeting information to children's developmental

levels should be the focus of the next generation of programs and research. Of primary concern is

the belief by some parents that having their child participate in a sexual abuse prevention program

constitutes sufficient protection. It is argued that we are only in the beginning stages of understanding

how to help children integrate the core concepts that might help them to avoid or to escape some

potentially abusive situations. However, in many cases early disclosures from victimized children is

the most that can be hoped for, highlighting the fact that prevention must be a multi-modal effort,

aimed at diverse audiences.

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