Randomized controlled trial of the Child Protection Unit: Grade and gender as moderators of CSA prevention concepts in elementary students

Abstract

Background

Despite the importance of child sexual abuse (CSA) prevention, there are few recent randomized controlled trials of school-based CSA prevention programs.

Objectives

(1) To evaluate the effects of the Second Step Child Protection Unit (CPU) on students’ CSA prevention concept knowledge, ability to recognize, report, and refuse unsafe touches, and perceptions of teacher-student relations and (2) investigate the moderating role of age and gender on program effectiveness.

Participants and setting

Eight elementary schools in a large suburban school district in the northeast United States were randomly assigned to the intervention or control condition, with analyses conducted on a total of 2172 students.

Methods

Students in intervention schools received the 6-week CPU and those in the control schools were exposed to business as usual. Students were administered assessments at baseline and then at post-test.

Results

Univariate Analyses of Covariance revealed that students in the intervention schools had significantly higher scores on all outcomes than students in the control schools at post-test, even after controlling for baseline scores. Children in younger grades made greater gains from the program, and girls scored higher than boys in CSA knowledge and ability to recognize, refuse, and report unsafe touches, but both boys and girls made significant gains.

Conclusions

Results support the importance of beginning early with school-based CSA prevention efforts. Although boys are still at a relative disadvantage in terms of their knowledge and ability in this area, they are able to make gains at the same rate as girls.

Introduction

Worldwide figures surrounding the prevalence of childhood sexual abuse (CSA) are startling, with an estimated 1 in 4 girls and 1 in 20 boys experiencing this type of abuse before late adolescence (Finkelhor, Shattuck, Turner, & Hamby, 2014). This figure represents the percentage of the population under the age of 18 that has experienced a single form or multiple forms of sexual abuse (Pereda, Guilera, Forns, & Gómez-Benito, 2009). Short and long-term consequences of experiencing sexual abuse before the age of 18 include a variety of behavioral and emotional problems, an increase in risky sexual behaviors and revictimization, and a multitude of other psychosocial impacts (Daigneault, Vezina-Gagnon, Bourgeois, Esposito, & Hebert, 2017; Tang, Qu, Li, & Tan, 2018). Victims of CSA are significantly more likely than their peers to experience anxiety disorders, personality disorders, and conduct disorders (Srivastava, Chaudhury, Bhat, & Patkar, 2017). These statistics support the need for prevention of and response to the issue of CSA (Collin-Vezina & Garrido, 2016).

A review of the research literature on CSA prevention programs indicates outdated studies that examine only a limited number of variables, such as age or gender, that might affect program outcomes (Babatsikos, 2010; Davis & Gidycz, 2000). The current study advances CSA prevention literature by evaluating the effectiveness of a comprehensive school-based abuse prevention program on a sample of suburban elementary school-children as compared to a waitlist control condition, with age, and gender as moderators.

Given the prevalence and adverse impact of CSA, a need to educate parents, professionals, and the public about CSA is imperative (Kenny & Wurtele, 2012). Preventive efforts can be addressed within a multi-tiered system of prevention, including the primary level which aims at preventing CSA, secondary approaches which address immediate responses to CSA, and tertiary level efforts that focus on long-term responses and care following CSA. Prevention strategies that have shown some success include parent and caregiver education and support and skills training to assist children in developing knowledge and prevention strategies for self-protection. Involving parents in educating children about CSA is effective in encouraging children to use self-protection skills (Babatsikos, 2010; Nickerson, Livingston, & Kamper-DeMarco, 2018). Nickerson et al. (2018) also found that family education videos increased parent knowledge, motivation, and discussions with children about CSA. Further support can be offered in schools through CSA prevention programming, due to their wide reach and impact on children’s lives (Brassard & Fiorvanti, 2014; Nickerson, Heath, & Graves, 2010).

Most abuse prevention programs targeted for children are school-based, typically taking place in late elementary school (Davis & Gidycz, 2000; Finkelhor, 2009). School-based CSA prevention programs are varied in their format, length, and age of targeted audience, but all encompass similar goals of reducing a child’s vulnerability, developing appropriate knowledge surrounding sexual abuse, teaching how to respond in at-risk situations, and encouraging adherence to safety rules (Daigneault, Hébert, McDuff, & Frappier, 2012). Topics covered by most programs include understanding body ownership, various types of touches, recognizing and refusing abusive situations, and disclosing abuse to a trusted adult (Davis & Gidycz, 2000; Saslawsky & Wurtele, 1986; Tutty, 1992). These programs can be integrated into the school curriculum, with flexibility to modify in a developmentally appropriate manner (Brassard & Fiorvanti, 2014; Daro, 1994). Due to their daily interactions with students, teachers and other school staff members are well-positioned to enhance learning experiences surrounding sexual abuse prevention and to recognize behavioral indicators of abuse in a child (Nickerson et al., 2010; Renk, Liljequist, Steinberg, Bosco, & Phares, 2002; Scholes, Jones, & Nagel, 2014).

Despite the prevalence of school-based abuse prevention programs, research evaluating the effectiveness of these programs is somewhat limited. Early research contributed to increased attention on the subject, but faced limitations leading to inconclusive results on the impact of the prevention programs (Hazzard, Webb, Kleemeier, Angert, & Pohl, 1991). Subsequent efforts to evaluate school-based programs showed an increase in children’s knowledge surrounding abuse prevention concepts and self-protection skills (Davis & Gidycz, 2000; Finkelhor & Dziuba-Leatherman, 1995; Rispens, Aleman, & Goudena, 1997; Tutty, 1997, 2000), however, generalizability of some results is difficult due to small sample sizes. Programs that utilized more active participation, rehearsal, and reinforcement of self-protection skills have produced significantly higher knowledge and skill gains as opposed to having the skills modeled by an instructor or teacher (Brassard & Fiorvanti, 2014; Davis & Gidycz, 2000; Hazzard et al., 1991). Programs longer than four sessions that involve repetition and multiple delivery and practice methods, such as engaging activities, didactic instruction, videos, and puppets have also had positive impacts on knowledge growth (Brassard & Fiorvanti, 2014; Davis & Gidycz, 2000).

The Committee for Children’s (2014) Second Step Child Protection Unit (CPU) curriculum was developed to provide students with tools to dispel false assumptions surrounding CSA. Ideally, the CPU is taught in conjunction with broader Second Step Social Emotional Learning curriculum, which teaches children skills for learning, empathy, emotion management and problem solving. The CPU focuses more specifically on giving teachers tools to recognize and respond to abuse and teaches students about safety, not keeping secrets, and touching. School personnel training is implemented in online modules using realistic scenarios which teach staff how to recognize indicators of abuse and neglect, respond appropriately to these situations, and report abuse. Teachers and counselors then learn how to teach the lessons and use the supporting resources (Committee for Children, 2014). Research has suggested that increasing school personnel’s knowledge of potential correlates of CSA and a child’s functioning in the school context could prove beneficial (Daigneault & Hebert, 2009). After staff training is complete, teachers and/or counselors provide six weeks of comprehensive lessons to students in the classroom, providing a multi-layered approach to child safety. This child protection strategy can prepare students and adults to recognize, respond to, and report abusive situations (Committee for Children, 2014). The first version of this program, “Talking About Touching,” was evaluated and demonstrated increased awareness of personal safety issues in all age groups (K-6), although limitations are noted in the small sample sizes and the number of items included in the test procedure (Madak & Berg, 1992). The present study used a large sample size and measures with established reliability to examine the effectiveness of the CPU.

Outcomes assessed in CSA prevention programs include knowledge about abuse prevention concepts, self-protection skills in hypothetical scenarios (Rispens et al., 1997; Walsh, Zwi, Woolfenden, & Shlonsky, 2015), and potential unintended negative consequences (Wurtele & Miller-Perrin, 1987). Student perceptions of school climate, and in particular, teacher-student relations, are rarely if ever assessed. We contend that teacher-student relations are of particular interest when considering school-based programs that include staff training in social-emotional learning, safety, or mental health (e.g., CSA prevention programs). All school staff play a crucial role in educating children about CSA and self-protection, though many teachers have shown a lack of knowledge about identification and reporting of CSA (Kenny, 2004; Kleemeier, Webb, Hazzard, & Pohl, 1988). When CSA prevention programs are implemented with a staff-training component, teachers have been shown to increase knowledge and awareness of CSA (Kleemeier et al., 1988). This training can lead to establishing positive and trusting teacher-student relationships, ultimately serving as a protective factor for maltreated children (Hamre & Pianta, 2001). Barriers identified in disclosure of abuse include lack of a trusted adult, inadequate adult response to a previous disclosure, or fear of being disbelieved (Jernbro, Otterman, Lucas, Tindberg, & Janson, 2017). The staff training provided by the CPU curriculum includes online training and resources, including online modules on policies and procedures, recognizing, responding, and reporting abuse, and teaching the student lessons. The current study examined teacher-student relations from the students’ perspectives to see if the CPU improved teacher-student relations compared to the condition.

Research on the moderating role of age and gender in school-based CSA is limited and conflicting. Mixed results have been reported when considering a child’s age in his or her knowledge growth and retention of material in CSA prevention programs. A meta-analysis conducted by Davis and Gidycz (2000) showed that older children are better able to retain prevention concepts at follow-up evaluation than their younger counterparts. Older students also are better able to predict the likelihood of abuse in vignettes (Jacobs, Hashima, & Kenning, 1995). Because young children’s cognitive, moral, and physical skills are less developed, it has been asserted that they may have difficulty understanding the concepts and retaining the skills taught (Daro, 1994; Renk et al., 2002; Tutty, 2000). However, preschool children have been able to learn to recognize unsafe situations and can acquire the skills that could prevent sexual victimization (Wurtele & Owens, 1997). Other research supports that children in preschool and early elementary school experienced more gains than children in late elementary school from most prevention programs, with larger increases seen potentially due to lower baseline knowledge of abuse prevention concepts compared to older students (Davis & Gidycz, 2000).

Although some studies have reported no significant overall effects of gender on knowledge of CSA (Tutty, 1997), others have found that females may be more knowledgeable than males regarding CSA and its prevention (Finkelhor, Asdigian, & Dziuba-Leatherman, 1995; Hazzard et al., 1991). Girls tend to demonstrate better problem-solving skills than boys, leading to a difference in decision-making during practice scenarios (Scholes et al., 2014). It is possible that CSA prevention may disadvantage boys, due to a traditional focus on females, leading to inaccurate assumptions that boys are unlikely to become victims of CSA (Finkelhor & Dziuba-Leatherman, 1995). Furthermore, traditional stereotypes that position men as the aggressors may create barriers to successful engagement in CSA prevention programs for boys, which in turn may impact boys’ growth in learning these concepts (Finkelhor, 1994; Scholes et al., 2014). The CPU includes both boys and girls as victims and perpetrators, and the current study investigated both age and gender as moderators of intervention effectiveness.

The current study aimed to (1) evaluate the effects of the CPU lessons on students’ CSA prevention concept knowledge, ability to recognize, report, and refuse unsafe touches, and perceptions of teacher-student relations and (2) investigate the moderating role of age and gender on program effectiveness. The Second Step CPU logic model (see Fig. 1) suggests that the student lesson and reinforcement activity components of the intervention will increase student knowledge of personal safety rules and the ability to recognize, report and refuse unsafe situations and touches. Therefore, we hypothesized that students who participated in the CPU lessons would show significant increases in abuse prevention knowledge at post-test, as measured by the Children’s Knowledge of Abuse Questionnaire - Revised (CKAQ; Tutty, 1997) and the Personal Safety Questionnaire (PSQ; Saslawsky & Wurtele, 1986), as well as increased ability to recognize, report, and refuse unsafe and sexually abusive situations from pre-test to post-test as measured by the “What If” Situation Test-III-R (WIST-R; Wurtele, Kast, & Kondrick, 1988; Wurtele, Hughes, & Owens, 1998). Additionally, the logic model emphasizes that intervention components that foster positive relationships with students through safe and supportive environment strategies; thus, we hypothesized that teacher-student relations would improve significantly in the intervention condition as assessed by the Teacher-Student Relations Subscale of the Delaware School Climate Survey (TSR-DSCS; Bear, Gaskins, Blank, & Chen, 2011; Bear, Yang, Pell, & Gaskins, 2014). Based on previous research, we further hypothesized that age and gender would moderate the effects of the intervention, with larger increases found in female students (Chen & Chen, 2005) and younger students experiencing greater gains than older children (Davis & Gidycz, 2000).