Preventing Child Sexual Abuse: Research Inconclusive About Effectiveness
of Child Education Programs (Letter Report, 07/26/96, GAO/GGD-96-156).

Pursuant to a congressional request, GAO reviewed research results on
programs designed to educate children on how to avoid becoming victims
of sexual abuse.

GAO found that: (1) of the numerous studies that are being done on the
effectiveness of child sexual abuse education programs, there is no
direct evidence that any of these programs are effective in reducing the
incidence of child sexual abuse; (2) although the research focused on
whether children could acquire knowledge about sexual abuse and learn
skills to avoid abusive situations, it was not clear whether children
actually retained or used the knowledge they acquired in these programs;
(3) research reviews agreed that these programs were most effective in
teaching concepts to older children and when using active rather than
passive methods; (4) definitive conclusions regarding program
effectiveness could not be drawn because of numerous methodological
limitations; (5) the outcome measures used in the evaluation studies
were not valid indicators of prevention because many of the results were
self-reported and outcome measures were not standardized; (6) many of
the research studies lacked comparison groups, did not pretest
children's knowledge, skills, and anxiety prior to their entrance into
programs, and had inadequate follow-up periods; and (7) better research
is needed to demonstrate the effectiveness of sexual abuse education
programs.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  GGD-96-156
     TITLE:  Preventing Child Sexual Abuse: Research Inconclusive About 
             Effectiveness of Child Education Programs
      DATE:  07/26/96
   SUBJECT:  Children
             Sex crimes
             Sexual abuse
             Research reports
             Statistical methods
             Behavioral sciences research
             Educational programs
             Crimes or offenses
             Evaluation methods

             
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Cover
================================================================ COVER


Report to the Chairman, Subcommittee on Crime, Committee on the
Judiciary, House of Representatives

July 1996

PREVENTING CHILD SEXUAL ABUSE -
RESEARCH INCONCLUSIVE ABOUT
EFFECTIVENESS OF CHILD EDUCATION
PROGRAMS

GAO/GGD-96-156

Preventing Child Sexual Abuse

(183606)


Abbreviations
=============================================================== ABBREV


Letter
=============================================================== LETTER


B-272553

July 26, 1996

The Honorable Bill McCollum
Chairman, Subcommittee on Crime
Committee on the Judiciary
House of Representatives

Dear Mr.  Chairman: 

This report responds to your request that we review and synthesize
the current state of research knowledge on ways to prevent sex crimes
against children.  Our first report, issued in June 1996, described
and synthesized reviews of the research literature on the
effectiveness of treatment programs for sex offenders.\1 In this
report, we describe and synthesize reviews of the research literature
on education programs designed to help children avoid becoming
victims of sexual abuse.  We describe these reviews, report their
findings on the effectiveness of education programs in preventing
sexual abuse, and report their assessments of the supportability of
conclusions drawn from existing research studies. 

The third report, which we plan to issue later this year, will review
the research literature on the likelihood of child victims of sexual
abuse becoming adult sexual abusers of children and what may be done
to prevent this from happening. 


--------------------
\1 Sex Offender Treatment:  Research Results Inconclusive About What
Works to Reduce Recidivism (GAO/GGD-96-137, June 26, 1996). 


   BACKGROUND
------------------------------------------------------------ Letter :1

The problem of child sexual abuse has received increasing attention
in recent years.  Deriving accurate estimates of the magnitude of the
problem is difficult, however, because research has indicated that
abuse tends to be underreported, definitions of what constitutes
sexual abuse and the ceiling age used (e.g., whether abuse occurred
prior to age 16 or 18) may vary across studies, and there are
numerous other methodological difficulties in collecting data on this
subject.  These caveats provide a context for the abuse figures that
follow:  The U.S.  Department of Health and Human Services reported
that about 140,000 new cases of child sexual abuse were reported to
and determined to be indicated or substantiated by state child
protection agencies in 1994.\2 It has also been reported that between
25 and 35 percent of all sexually abused children are under the age
of 7 and that 75 percent of the victims are abused by someone they
know.\3

Since the early 1980s, there has been a tremendous growth in sexual
abuse prevention programs targeted at children of preschool and
elementary school age.  In 1989, 18 states mandated school-based
child sexual abuse prevention programs.\4 Surveys of school
administrators have found that 48 to 85 percent of school districts
offer these programs.\5 The programs, typically delivered in
classroom settings, are based on the assumption that children will be
able to protect themselves from sexual abuse if they are taught to
recognize instances of abuse and are trained in personal safety
skills.  Programs may also focus on helping children who are victims
of past or ongoing sexual abuse, by encouraging them to disclose
these incidents to parents or other responsible adults. 

The growth in prevention programs has proceeded faster than the
evaluation of their effectiveness.  Questions exist about whether
children learn and retain material taught in the programs, and
whether informed children are truly capable of resisting abusive
behavior directed at them by older and stronger offenders. 
Demonstrating empirically that prevention programs work is a
difficult and challenging task.  Methodological obstacles include
selecting the criteria for judging success of the program, ruling out
alternative explanations for results obtained by using a comparison
group of children who were similar to those exposed to the education
program except that they did not receive instruction, and studying
children for a long enough period to ensure that the program has
lasting effects.  There are also ethical obstacles to determining
program effectiveness.  These include the issue of denying a
comparison group of children a potentially beneficial education
program.  Ethical considerations also arise in trying to measure
accurately whether young children can use what they have learned to
resist offenders.  Some argue that exposing young children to a
simulated abusive episode, while potentially a good measure of
children's capability to respond to an actual assault, may be unduly
traumatic, or may desensitize children to dangerous situations. 


--------------------
\2 U.S.  Department of Health and Human Services, National Center on
Child Abuse and Neglect, Child Maltreatment 1994:  Reports from the
States to the National Center on Child Abuse and Neglect (Washington,
D.C.:  U.S.  Government Printing Office, 1996).  The figure of
140,000 sexual abuse cases was based on responses from 47 states and
the District of Columbia.  Connecticut, Maryland, and West Virginia
did not provide figures on the number of substantiated or indicated
sexual abuse cases.  A substantiated or indicated case represents a
type of investigation disposition in which sufficient evidence is
established under state law to conclude that maltreatment occurred,
that the child is at risk of maltreatment, or that there is reason to
suspect maltreatment.  State agencies differ in how they report
incidence data, with some counting each incident of abuse once
regardless of the number of children involved, and others counting
each child involved separately.  Some children may be counted more
than once if multiple incidents of abuse are reported during the
year. 

\3 S.  Wurtele, "Sexual Abuse." In Handbook of Prevention and
Treatment with Children and Adolescents:  Intervention in the Real
World Context, eds.  R.T.  Ammerman and M.  Hersen (New York:  Wiley,
in press). 

\4 J.  Kohl, "School-based Child Sexual Abuse Prevention Programs,"
Journal of Family Violence, Vol.  VIII (1993), pp.  137-150. 

\5 Deborah A.  Daro, "Prevention of Child Sexual Abuse," The Future
of Children, Vol.  IV, No.  2 (Summer/Fall 1994), pp.  198-223; D. 
Helge, Child Sexual Abuse in America -- A Call for School and
Community Action (Bellingham, Washington:  National Rural Development
Institute, 1992). 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

We identified 16 reviews that provided qualitative or quantitative
summaries of research on education programs designed to prevent
sexual abuse.  The reviews discussed the studies in terms of program
effectiveness and methodological adequacy. 

There was general consensus among the reviews that there was not as
yet any direct evidence that these programs were effective in
preventing the occurrence of child sexual abuse.  The reviews focused
on whether children could acquire knowledge about sexual abuse and
learn skills that might prove useful in an abusive situation, as well
as whether programs prompted victimized children to disclose ongoing
or past abuse.  There was general consensus that children could learn
concepts about abuse, although it was clear that some concepts were
more difficult to grasp than others.  For example, children had a
difficult time grasping the concept that abuse could be perpetrated
by a family member.  There was less consensus about whether knowledge
was retained over the long term, whether children could learn skills
for resisting abuse, and whether children would disclose new
instances of abuse after participating in the program.  Finally, the
reviews generally agreed that programs were more effective in
teaching concepts to older children, and that concepts and skills
could be grasped better when taught with active participation (e.g.,
modeling or role-playing techniques) than with more passive methods
(e.g., films or lectures). 

Most reviews reported that methodological limitations in the research
precluded conclusions about the effectiveness of education programs
in preventing sexual abuse.  The problems identified may be grouped
into two broad categories:  (1) limitations in the outcome measures
used, and (2) limitations in the design of studies. 

A majority of the research reviews noted that the outcome measures
used in evaluation studies were not valid indicators of prevention. 
These reviews emphasized the need to develop measures that would
directly indicate whether sexual abuse was avoided following
education programs.  The reviews also criticized the reliance on
verbal self-report measures because studies have found little
correspondence between what children say they will do and their
actual behavior.  More generally, the reviews noted the lack of
standardization of outcome measures in this field, including the
tendency of evaluators to develop new and unique outcome measures for
each study, and their failure to measure or report information on the
statistical properties of the testing instruments (such as test
reliability) that would enable other researchers to refine the
instruments and replicate earlier results.  The reviews pointed to
the need for systematic data collection about disclosures of sexual
abuse and about potential negative side effects produced by the
programs. 

All the research reviews identified design weaknesses in the studies. 
Chief among these was the absence of comparison groups (against which
to compare groups exposed to an education program) and,
alternatively, the use of comparison groups of children who differed
in systematic ways from the children receiving the education program. 
The latter situation made it difficult to judge whether differences
in outcomes were a result of the program or were an effect of
selecting only certain kinds of children for the program.  Half of
the reviews noted that some studies failed to pretest children on
measures of knowledge, skills, and anxiety prior to their
introduction to the program.  This made it difficult to establish a
baseline against which to compare changes that occurred as a result
of participation in the program.  A number of reviews identified
inadequate follow-up periods.  Only a few studies collected follow-up
information on children's knowledge for periods longer than 3 months. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :3

To examine the effectiveness of education programs to prevent child
sexual abuse, we collected, reviewed, and analyzed information from
16 research reviews issued between 1986 and 1996.  These reviews were
identified through a multistep process that included contacting known
experts in the sex offense research field, conducting computerized
searches of several online databases, and screening over 100 studies
on sexual abuse prevention programs.  We sent the list of reviews to
two experts, who have done extensive research in the field, to
confirm the comprehensiveness of our list of research reviews.\6

We used a data collection instrument to systematically collect
information on the research reviews of education programs.  We
collected information on program targets, settings and objectives;
methods of presentation and characteristics of presenters; outcome
measures; methodology issues; follow-up periods; and conclusions
reached from these reviews.  (See app.  I for a more detailed
description of our methodology.)

We sent a draft of this report to the two experts previously
consulted, and one additional expert, to ensure that we had presented
the information about the reviews and research articles accurately.\7
Their comments were incorporated where appropriate.  We did not send
a draft to any other agency or organization because we did not obtain
information (other than study citations) from such organizations for
use in this study.  We did our work between October 1995 and June
1996 in accordance with generally accepted government auditing
standards. 


--------------------
\6 Appendix II lists the experts we used for identifying research in
this area. 

\7 Appendix II lists the experts who reviewed this report. 


   DESCRIPTION OF THE RESEARCH
   REVIEWS
------------------------------------------------------------ Letter :4

The 16 research reviews covered about 135 studies on education
programs designed to help children prevent sexual abuse.  Of these
studies, 65 were cited in 2 or more reviews, and 34 were cited in 5
or more reviews.  Given the widely varying levels of detail provided
in the research reviews, we could not always determine whether
reference was being made to an evaluation of an education program or
to other types of studies on education programs (e.g., descriptions
of programs, or specific materials available for use by schools or
parents).  We therefore could not precisely determine the total
number of studies on education programs covered in these research
reviews.  We also did not determine how many studies covered in the
16 research reviews were duplicative in terms of researchers
publishing multiple articles based on the same set of data.  The
earliest study included in a research review was published in 1979;
the most recent was published in 1995. 

Almost all of the research reviews provided narrative assessment of
original research studies, with approximately one-half providing a
tabular summary of at least some of the studies covered.  Two reviews
performed a meta-analysis, a statistical aggregation of the results
from multiple studies, to derive an overall quantitative estimate of
the effectiveness of education programs. 

Most research reviews did not restrict their coverage to a single
type of setting (classroom, home, or other community setting),
specific target group (children, teachers, or parents), or specific
outcome measure (knowledge, skills, or disclosures of abuse).  The
two reviews that employed meta-analysis focused specifically on
knowledge and skills acquired by children.  Two other research
reviews limited their coverage to published studies. 


   RESEARCH REVIEWS FOUND NO
   DIRECT EVIDENCE THAT EDUCATION
   PROGRAMS PREVENT THE OCCURRENCE
   OF CHILD SEXUAL ABUSE
------------------------------------------------------------ Letter :5

Fifteen of the 16 research reviews concluded that there was no
evidence from the empirical studies they reviewed that demonstrated
the effectiveness of education programs in actually preventing the
occurrence of child abuse.  This did not mean that the programs were
ineffective, but rather that none of the studies had been designed so
that the link between what was taught in education programs and
actual prevention of sexual abuse could be adequately tested.  The
one review that did not offer a conclusion about prevention was
limited in scope in that it only reviewed program effects on
knowledge and skills. 

Most education programs aim for more short-term objectives than
prevention of sexual abuse, and nearly all of the research reviews
included some discussion of these short-term objectives.  Fourteen of
the 16 reviews discussed the goal of teaching children concepts about
sexual abuse (defining "appropriate" and "inappropriate" forms of
touching, defining what are "private parts," and informing children
that abuse could be committed by people known to them).  Fifteen of
the reviews discussed the goal of teaching children skills for
resisting or avoiding abusive situations (saying "no," physical
defense, or leaving the scene).  Fourteen of the 16 reviews discussed
the programs' goal of encouraging children to disclose past or
ongoing incidents of abuse to parents or other responsible adults. 

Thirteen of the 16 reviews concluded that education programs were
generally effective in teaching children new concepts about sexual
abuse.  Eight of the reviews concluded that these programs were
effective in teaching children skills, such as saying no or leaving
the scene.  Many reviews noted that some concepts were more difficult
to learn than others--for example, the concept that abuse could come
from someone in the child's family was particularly difficult for
children to grasp.  Most of the reviews discussed whether knowledge
and skills gained in programs were retained by children over the long
term.  Nine of the reviews concluded that studies showed that
knowledge or skills could be retained for periods ranging from 3
months to 1 year.  Four other reviews concluded that results for
long-term retention were mixed or that the research was inconclusive. 
Reviewers who concluded that children made knowledge or skills gains
after participating in education programs nevertheless cautioned that
little was known about whether these gains made children any more
capable of resisting actual attempts at sexual abuse.  Of the 14
reviews that looked at disclosures, 4 noted that there was at least
tentative support for the conclusion that programs were effective in
encouraging children to disclose past or ongoing incidents of sexual
abuse.  The remainder either offered no conclusions or noted that the
findings were inconclusive.  Many of the reviews, including those
with positive conclusions regarding disclosure, also noted that more
systematic research was needed in this area. 

Half of the reviews discussed side effects of education programs,
both negative and positive.  Some critics of education programs have
raised concerns that children who participate in these programs may
have increased anxiety or fear that abuse might "happen to them," may
become oversensitive to appropriate situations involving touch, or
may develop negative attitudes towards sexuality.  Proponents of
education programs have argued that programs may make children feel
safer and more able to protect themselves or more willing to discuss
sexual abuse concepts with their parents.  Five of the eight reviews
that discussed side effects concluded that there was little evidence
of negative side effects, and three concluded that the research
findings on this topic were mixed.  Five reviews mentioned possible
positive side effects, including increased discussion of child sexual
abuse between children and parents. 

Most of the reviews included some discussion of the techniques used
to present concepts or skills to children.  These techniques vary
considerably, ranging from classroom lectures; to films, puppet
shows, or theatrical performances; to programs that involve more
active participation by children, such as role-playing abusive
scenarios or rehearsing behaviors that might be used to avoid or
resist abuse.  Twelve of the 16 reviews concluded that children who
participated in programs that used more active techniques (e.g.,
modeling, role-playing, or behavior rehearsal) made greater knowledge
or skill gains than children participating in programs that used more
passive techniques (e.g., lectures or films). 

A majority of the reviews did not specifically mention, for at least
some of the studies they reviewed, the total length of the education
program or the total number of sessions involved.  Those reviews that
discussed program duration and frequency of sessions noted that
programs varied considerably, from single sessions lasting less than
an hour, to ones presented over several days.  Nevertheless,
education programs typically are short in duration and limited in
intensity.  One review noted that a school-based education program is
"most likely offered during one session of less than 2 hours
duration."\8 None of the reviews had specific conclusions regarding
the optimum duration or intensity of programs, although several noted
that programs that involved multiple sessions, periodic "booster"
sessions to review material covered in earlier sessions, and/or
active participation were most likely to have positive results. 

All of the reviews discussed programs targeted towards elementary
school children, and 15 of 16 reviews discussed programs targeted
towards preschool children.  Eleven of 16 reviews concluded that
education programs were more likely to be effective with older
children than with younger ones.  Nevertheless, some reviews
concluded that preschool-age children could gain knowledge about
sexual abuse if they participated in programs that included
repetition, active learning techniques, and parent education. 

Discussion of programs targeted at adolescents, parents, and teachers
and other professionals was much more limited in the research
reviews.  Only two of the reviews discussed programs targeted towards
high school or junior high school students, eight reviews discussed
programs that involved some components of parent education, five
reviews discussed programs targeted at teachers, and two reviews
discussed programs targeted towards school counselors, nurses, or
childcare workers in residential institutions.  Noting that most
education programs were focused on children, and that most were
delivered in school settings, several reviews suggested that programs
might be more effective if they were linked with comprehensive
community efforts to prevent child sexual abuse. 

Only two reviews attempted to quantify the overall effectiveness of
education programs, and they did so using a statistical aggregation
technique called meta-analysis.  Each meta-analysis found that
participants in both preschool and elementary-school programs made
knowledge gains that were either moderately or substantially greater
than those of comparison groups.\9 One of the meta-analyses further
reported that programs that used more active formats (modeling and
role-playing) were more effective than those that used passive
formats (lecture, films, and stories).\10

Most reviewers, even those who were quite positive about the
effectiveness of programs in teaching concepts and skills, agreed
that more work was needed before firm conclusions could be reached. 
They cited the methodological limitations of studies as a major
obstacle to drawing firm conclusions about program effectiveness. 


--------------------
\8 S.  Wurtele, in press, p.  11. 

\9 J.  D.  Berrick and R.  P.  Barth, 1992; T.  Heidotting and S.  W. 
Soled, in preparation. 

\10 T.  Heidotting and S.  W.  Soled, in preparation. 


   RESEARCH REVIEWS IDENTIFIED
   METHODOLOGICAL LIMITATIONS IN
   EVALUATING THE EFFECTIVENESS OF
   EDUCATION PROGRAMS
------------------------------------------------------------ Letter :6

The research reviews found that conclusions about the effectiveness
of education programs were impeded by methodological weaknesses in
the studies.  The problems identified may be grouped into two broad
categories:  (1) limitations in the outcome measures used and (2)
limitations in the design of studies. 


      LIMITATIONS IN OUTCOME
      MEASURES
---------------------------------------------------------- Letter :6.1

A majority of the research reviews noted that the outcome measures
used in evaluation studies were not valid indicators of prevention. 
These reviews emphasized that most research studies measured whether
children learned concepts about sexual abuse and personal safety
skills, but that no study had developed reliable and valid measures
to examine whether education programs resulted in long-term
reductions in the incidence of sexual abuse.\11

The reviews noted other limitations in measures of more proximal
outcomes--i.e., gains in knowledge and skills.  Five reviews
criticized the primary research studies for their overreliance on
verbal self-report measures.  Such measures are widely used, both to
test for gains in knowledge about sexual abuse and to test whether
children say they will use the self-protection strategies that they
have learned in education programs.  But self-reports may be
unreliable measures of what children have learned and what they are
capable of doing.  Some studies have found little correspondence
between what children say they will do and their actual behavior. 
The reviews recommended supplementing verbal self-report measures
with behavioral measures that could more reliably indicate how
children would behave in actual encounters with an abuser. 

Twelve of the reviews discussed studies that had attempted to test
children's behavior using "real life simulations." In these, children
were lured by potential abductors who were associates of the
researcher.  Reviewers cautioned that these kinds of measures have
several limitations.  Since they measure children's responses to
strangers, and since research shows that most sexual abuse is
perpetrated by persons known to the victim, they may not be valid
measures of children's ability to resist most abusers.  And there are
potential ethical problems.  For example, such simulations may unduly
frighten children, on the one hand, or may desensitize them to truly
dangerous situations, on the other.\12

One review mentioned a recent set of studies that used a different
method for collecting data on children's resistance skills in
real-life situations.\13 The investigators conducted a national
telephone survey of children ages 10 to 16 in which they queried them
about their experiences with sexual abuse and with prevention
programs.  The survey found that 67 percent of respondents had been
exposed to a prevention education program in the course of their
schooling.  Approximately 40 percent of the children who were exposed
to a prevention program reported specific instances where they used
the information or skills taught in the programs to protect
themselves.  Children who reported being victimized were more likely
to use self-protection strategies if they had received comprehensive
prevention instruction, which included opportunities to practice the
skills in class, multiday presentations, and materials to take home
to discuss with parents.  While the findings are suggestive, the
reviewer stated that the study relies on self-report information with
no independent confirmation of such reports, and the findings apply
only to older children (those aged 10 to 16). 

Several reviews pointed to the need for systematic data collection on
whether children were more likely to disclose past or ongoing
instances of abuse after exposure to an education program.  A 1996
review noted that too few researchers provide information about
disclosures during or subsequent to education programs, and that
those who do report disclosures report only the actual number or
percentage and fail to provide additional information (e.g., type of
abuse, past versus ongoing, consequences of disclosure, disposition
of case).\14

More generally, several reviews noted the lack of standardization of
outcome measures in this field.  Investigators have tended to develop
new and unique outcome measures for each new study, making it
difficult to compare findings and make overall generalizations about
program effectiveness\15 .  This problem has been compounded because
many studies have failed to measure or report information on the
statistical properties of the testing instruments (for example, test
reliability).  Such information would enable other researchers to
refine the instruments and replicate earlier results. 


--------------------
\11 A survey conducted by the National Center on Child Abuse
Prevention Research asked federally appointed liaisons for child
abuse and neglect in each state and the District of Columbia to
provide data on the number of children reported for sexual abuse (C. 
Lung and D.  Daro, Current Trends in Child Abuse Reporting and
Fatalities:  The Results of the 1995 Annual Fifty State Survey,
National Committee to Prevent Child Abuse, 1996).  The results showed
that the number reported as sexually abused grew in the 1970s and
1980s, reaching a high point of over 400,000 cases in 1991, and then
declined in recent years to around 300,000 cases in 1995.  In
addition, of all reported cases of abuse and neglect, the proportion
involving sexual abuse has dropped from 16 percent in 1986 to 10
percent in 1995.  One expert reviewer of our draft report commented
that a possible explanation for these declines might be the efficacy
of sexual abuse prevention programs.  However, there are as yet no
research data demonstrating a causal link between outcomes of
prevention programs and changes in incidence rates.  Without such
data, it is difficult to tell whether decreases in the number of
reported sexual abuse cases are due to the effectiveness of
prevention programs, changes in how data are recorded, changes in the
appeal process, changes in definitions of information and referral
calls, or other possible explanatory factors. 

\12 Two expert reviewers of our draft report commented that
researchers who intend to use behavioral measures face a host of
logistical and ethical challenges.  For example, they both noted that
it is very difficult to devise behavioral measures of resisting abuse
and that simulating the perpetration of child sexual abuse for
research purposes may be unethical.  One of the reviewers also noted
that obtaining approval from human subject protection committees and
obtaining parental consent to use such behavioral measures may be
difficult.  Even if parents consent, researchers still have a
responsibility to debrief the study participants when the study is
concluded.  Researchers are reportedly struggling with determining
the best ways to debrief children, many of whom may not be able to
fully understand the explanation given. 

\13 David Finkelhor, Nancy Asdigian, and Jennifer Dziuba-Leatherman,
"The Effectiveness of Victimization Prevention Instruction:  An
Evaluation of Children's Responses to Actual Threats and Assaults,"
Child Abuse and Neglect, Vol.  XIX, No.  2 (1995), pp.  141-153;
David Finkelhor and Jennifer Dziuba-Leatherman, "Victimization
Prevention Programs:  A National Survey of Children's Exposure and
Reactions," Child Abuse and Neglect, Vol.  XIX, No.  2 (1995), pp. 
129-139. 

\14 S.  K.  Wurtele, in press. 

\15 Outcomes have been assessed in different ways, depending on the
types of program effects the researcher is investigating. 
Researchers have developed questionnaires to assess changes in
knowledge of sexual abuse concepts, which may include items covering
definitions of sexual abuse, descriptions of victims and
perpetrators, and other concepts (e.g., "The victim is never at
fault.").  Measures used to assess knowledge of prevention skills may
include descriptions of hypothetical encounters with adults, followed
by questions about whether these situations are safe or unsafe and
what would be an appropriate response on the part of the child.  Some
researchers have enacted a role-play of an unsafe encounter and
required children to say "no," leave the situation, and immediately
tell a parent about the incident.  Children's scores are based on the
degree to which they perform the response correctly.  As described
above, actual resistance behavior has been measured by the use of
simulated stranger abductions, where children's responses are
observed and coded for correctness. 


      LIMITATIONS IN STUDY DESIGN
---------------------------------------------------------- Letter :6.2

All of the research reviews identified design weaknesses in the
studies.  Over half the reviews noted, for at least some of the
studies they reviewed, the absence of comparison groups (against
which to compare groups exposed to an education program) or the use
of comparison groups of children who differed systematically from
children who were exposed to the program.  This made it difficult to
judge whether differences in outcomes were a result of the program or
were an effect of selecting only certain kinds of children for the
program.  Some more recent reviews noted that absent or inadequate
comparison groups was more a problem in earlier studies, and that a
number of well-designed studies now existed. 

Eight of the reviews noted that some studies failed to pretest
children on measures of knowledge and skills, or on measures of fear
and anxiety, before exposing them to the education program.  Without
a baseline measure, it is difficult to determine whether post-program
knowledge, skill, or fear levels changed as a function of program
participation. 

A number of reviews identified inadequate follow-up periods.  They
reported that only a few studies collected follow-up information on
children's knowledge for periods longer than 3 months, with the
longest follow-up period being 18 months.  There was also a large
variation in the follow-up period used across studies.  Reviews noted
that it is important to establish whether programs have lasting
effects, as well as to determine what kinds of ongoing education are
required to maintain or enhance initial program effects.  In
addition, some reviews pointed out that follow-up studies need to pay
more attention to side effects or unforeseen consequences of
participation.  Although the reviews that discussed side effects
found little evidence of initial negative consequences, many reviews
noted that there was as yet little information on the long-term
consequences of participation. 


   CONCLUSIONS
------------------------------------------------------------ Letter :7

A growing number of studies are being done on the effectiveness of
child sexual abuse education programs, many of which were assessed in
the research reviews described and synthesized in this report.  The
most optimistic reviews have concluded that education programs showed
some promise for imparting knowledge to children about sexual abuse,
as well as teaching them personal safety skills for preventing sexual
abuse.  However, nearly all these reviews reported that definitive
conclusions could not be drawn because no study yet had developed
measures of whether these programs were effective in reducing the
incidence of child sexual abuse.  There was consensus that to
demonstrate the effectiveness of sexual abuse education programs more
and better research would be required. 

We are sending copies of this report to the Ranking Minority Member
of the House Subcommittee on Crime.  Copies will also be made
available to others upon request.  The major contributors to this
report are listed in appendix III.  Please call me at (202) 512-8777
if you have any questions about this report. 

Sincerely yours,

Laurie E.  Ekstrand
Associate Director, Administration
 of Justice Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

We collected, reviewed, and analyzed information from available
published and unpublished reviews of research on education programs
to prevent child sexual abuse.  Identifying the relevant literature
involved a multistep process.  Initially, we identified experts in
the sex offense research field by contacting the Department of
Justice's Office of Juvenile Justice and Delinquency Prevention and
Office of Victim Assistance, the National Institute of Mental
Health's Violence and Traumatic Stress Branch, the American
Psychological Association, and selected academicians.  These contacts
helped identify experts in the field, who in turn helped identify
other experts.  We also conducted computerized searches of several
online databases, including ERIC (the Education Resources Information
Center), NCJRS (the National Criminal Justice Reference Service),
PsycINFO, Dissertation Abstracts, and the National Clearinghouse on
Child Abuse. 

We screened over 100 studies on sexual abuse prevention programs to
determine their relevance to our work.  This process revealed that a
number of reviews of the research literature had been written.  And,
because of the level of effort involved in identifying and analyzing
the large number of original research studies on sexual abuse
education programs and our identification of a sufficient number of
reviews of the research literature, we decided to base our synthesis
on the research reviews. 

A limitation of basing our work on the reviews was that we did not
assess the original studies, but rather relied on the descriptions
and assessments provided by the authors of the reviews.  The reviews
did not always cite the specific information, such as the outcome
measures used, or whether comparison groups were used, on all studies
they covered.  This sometimes was because full descriptions of the
research were not provided in the original studies themselves.  This
made it difficult to assess, in some cases, the extent to which
limitations noted by a review characterized most of the studies that
were reviewed or a small subset of the studies. 

We sent the list of reviews to two experts, who have done extensive
research in the field, to confirm the comprehensiveness of our list
of research reviews.\16 Also, as a final check, we conducted a second
search of computerized online databases in March 1996 to ensure that
no new reviews had been published since our original search in
October 1995. 

We identified 20 research reviews on sexual abuse education programs
issued between 1986 and 1996.  We included 16 of these 20 reviews in
our analysis.  We were unable to obtain three reviews in time to
include in our analysis.  One other review was not included because
the authors had written a more recent review that was more
comprehensive.  Of the 16 reviews, 9 had been published since 1990, 1
had been submitted for publication but had not yet been published,
and 1 had been presented at a professional conference and was being
revised for initial submission to a journal for publication. 

We developed a data collection instrument to systematically capture
information on program targets, settings, and objectives; methods of
presentation and characteristics of presenters; outcome measures;
methodology issues; follow-up periods; and conclusions reached.  Each
research review was read and coded by a social scientist with
specialized doctoral training in evaluation research methodology.  A
second senior social scientist then read the research reviews and
verified the accuracy of the coding of every item on every completed
instrument. 

We sent a draft copy of our report to the two experts who reviewed
the comprehensiveness of our list of research reviews, as well as one
additional expert.  Appendix II lists these experts.  They generally
agreed that we presented information on the research reviews fairly
and accurately, and made technical suggestions that we incorporated
into the report as appropriate.  We did not send a draft to any other
agency or organization because we did not obtain information other
than study citations from such organizations for use in this study. 


--------------------
\16 Appendix II contains the list of experts we used in this effort. 


EXPERTS CONSULTED
========================================================== Appendix II

The following experts commented on the draft report.  The objective
of the review was to ensure that we were presenting information
fairly and accurately.  Those with asterisks next to their names also
reviewed our listing of research reviews to help ensure that our
coverage of the literature was comprehensive. 

Dr.  David Finkelhor*
Family Research Laboratory
University of New Hampshire
Durham, New Hampshire

Dr.  Jeffrey J.  Haugaard
Department of Human Development and Family Studies
Cornell University
Ithaca, New York

Dr.  Sandy K.  Wurtele*
Department of Psychology
University of Colorado
Colorado Springs, Colorado


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix III

GENERAL GOVERNMENT DIVISION,
WASHINGTON, D.C. 

Evi L.  Rezmovic, Assistant Director, Administration of Justice
Issues
David Alexander, Senior Social Science Analyst
Douglas Sloane, Supervisory Social Science Analyst
Barry Seltser, Supervisory Social Science Analyst

LOS ANGELES FIELD OFFICE

Tom Jessor, Evaluator-in-Charge


RESEARCH REVIEWS USED IN THE
SYNTHESIS
============================================================ Chapter 0

Berrick, Jill D., and Richard P.  Barth.  "Child Sexual Abuse
Prevention:  Research Review and Recommendations." Social Work
Research and Abstracts, Vol.  XXVIII, No.  4 (December 1992), pp. 
6-15. 

Carroll, Leslie A., Raymond G.  Miltenberger, and H.  Katherine
O'Neill.  "A Review and Critique of Research Evaluating Child Sexual
Abuse Prevention Programs." Education and Treatment of Children, Vol. 
XV, No.  4 (November 1992), pp.  335-354. 

Conte, Jon R., and Linda A.  Fogarty.  "Sexual Abuse Prevention
Programs for Children." Education and Urban Society, Vol.  XXII, No. 
3 (May 1990), pp.  270-284. 

Conte, Jon R., Carole Rosen, and Leslee Saperstein.  "An Analysis of
Programs to Prevent the Sexual Victimization of Children." Journal of
Primary Prevention, Vol.  VI, No.  3 (Spring 1986), pp.  141-155. 

Daro, Deborah A.  "Prevention of Child Sexual Abuse." The Future of
Children, Vol.  IV, No.  2 (Summer/Fall 1994), pp.  198-223. 

Finkelhor, David, and Nancy Strapko.  "Sexual Abuse Prevention
Education:  A Review of Evaluation Studies." In Prevention of Child
Maltreatment:  Developmental and Ecological Perspectives, eds.  D.J. 
Willis, E.W.  Holden, and M.  Rosenberg (New York:  John Wiley and
Sons, 1992), pp.  150-167. 

Heidotting, Terri, and Suzanne W.  Soled.  "School-based Sexual Abuse
and Personal Safety Prevention Programs for Children:  A
Meta-analysis" (unpublished). 

Kolko, David J.  "Educational Programs to Promote Awareness and
Prevention of Child Sexual Victimization:  A Review and
Methodological Critique." Clinical Psychology Review, Vol.  VIII
(1988), pp.  195-209. 

MacMillan, Harriet L., et al.  "Primary Prevention of Child Sexual
Abuse:  A Critical Review.  Part II." Journal of Child Psychology and
Psychiatry, Vol.  XXXV, No.  5 (1994), pp.  857-876. 

O'Donohue, William, James H.  Geer, and Ann Elliott.  "The Primary
Prevention of Child Sexual Abuse." In The Sexual Abuse of Children. 
Volume II:  Clinical Issues, eds.  William O'Donohue and James H. 
Geer (Hillsdale, New Jersey:  Lawrence Erlbaum Associates, Inc.,
1992), pp.  477-517. 

Reppucci, N.  Dickon, and Jeffrey J.  Haugaard.  "Prevention of Child
Sexual Abuse:  Myth or Reality." American Psychologist, Vol.  XLIV,
No.  10 (October 1989), pp.  1266-1275. 

Tharinger, Deborah J., et al.  "Prevention of Child Sexual Abuse:  An
Analysis of Issues, Educational Programs, and Research Findings."
School Psychology Review, Vol.  XVII, No.  4 (1988), pp.  614-634. 

Tutty, Leslie M.  "Are Child Sexual Abuse Prevention Programs
Effective?  A Review of the Research." Revue Sexologique, Vol.  I,
No.  2 (1993), pp.  93-114. 

Wurtele, Sandy K.  "Sexual Abuse." In Handbook of Prevention and
Treatment With Children and Adolescents:  Intervention in the Real
World Context, eds.  R.T.  Ammerman and M.  Hersen (New York:  Wiley,
in press). 

Wurtele, Sandy K.  "School-based Sexual Abuse Prevention Programs:  A
Review." Child Abuse and Neglect, Vol.  XI (1987), pp.  483-495. 

Wurtele, Sandy K., and Cindy L.  Miller-Perrin.  Preventing Child
Sexual Abuse:  Sharing the Responsibility (Lincoln, Nebraska: 
University of Nebraska Press, 1992). 


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