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. 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. 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. Surveys of school administrators have found that 48 to 85 percent of school districts offer these programs. 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. 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. 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. 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. 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. 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." 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. 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). 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. 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. 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. 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. 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.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). 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. 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. 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. 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.

Summary:
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.