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Child Sexual Abuse is a Public Health Problem in Pennsylvania
Child sexual abuse (CSA) affects an average of 2,300 children in Pennsylvania each year. Children who experience CSA are at risk for a lifetime of adverse outcomes including poor physical and mental health, poor interpersonal relationships, and increase the potential for future victimization. The prevention of CSA is complex and, we believe, requires the effort of multiple sectors within a community. CSA is an important public health priority, and the Commonwealth of Pennsylvania is in a unique position to serve as a leader in CSA prevention.
A Partnership is Formed
In 2015, an agreement was reached to direct $60 million in monetary penalties levied on the Pennsylvania State University (PSU) by the National Collegiate Athletic Association (NCAA) to the Pennsylvania Commission on Crime and Delinquency (PCCD) and PSU. Of that funding, $12 million was redirected to Child Maltreatment Solutions Network (CMSN) at PSU, which was created in 2012 to “advance the University’s academic mission of research, education and service regarding child maltreatment,” and $48 million was directed to PCCD to be distributed pursuant to Act 1 of 2013, known as the “Endowment Act.” PCCD directed the Children’s Advocacy Center Advisory Committee (CACAC), as supported by the staff of the Office of Research and Child Advocacy (ORCA), to provide advice and counsel on the direction of these funds. The CACAC then voted to create a Prevention Subcommittee to develop a funding announcement for programs or projects preventing CSA.
The Safe and Healthy Communities Initiative
The Safe and Healthy Communities Initiative (SHCI) is the resultant cooperative project between the CMSN and PCCD. The SHCI PSU team, is led by Dr. Jennie Noll (Project Co-Investigator; Director, CMSN) and Dr. Kate Guastaferro (Project Co-Investigator), consists of Kathleen Zadzora, M.S. (Implementation Coordinator), Jonathan Reader, M.S. (Graduate Assistant), and a number of undergraduate students. The PCCD team consists of Kirsten Kenyon (Director, Office of Research Evaluation and Strategic Policy Development), Christina Cosgrove (Grant Administrator), and Lindsay Vaughn (Executive Policy Manager).
Pennsylvania counties selected to participate in SHCI through a competitive application process include Bucks, Chester, Somerset-Cambria (two counties forming a single applicant), and York. This collaborative prevention effort, years in the making, seeks to prevent CSA across the Commonwealth using the best evidence-based programs and methodologies available.
Although the Initiative is only active in a handful of counties presently, the long-term goal is to scale up the effort across the Commonwealth.
SHCI consists of three evidence-based components that will be rolled out in the awarded counties over the course of three years via a staggered implementation approach (see Research tab). The three components are a community-based intervention, a school-based intervention, and a parent-focused intervention. We believe by targeting different segments of the population (i.e., adults in the community, children, and at-risk parents), the prevention of child sexual abuse (CSA) is attainable. Each component is described in detail below including our implementation goals.
Community-based Component: Stewards of Children (Stewards) ®
Stewards of Children targets adults in the community at-large and seeks to improve knowledge of CSA, decrease myths surrounding CSA, and increase preventive behaviors such as calling in possible allegation of CSA. Stewards teaches adults in the community:
- The facts about CSA;
- How to minimize opportunity for children to be sexually abused;
- How to talk about CSA;
- How to recognize the signs of CSA; and
- How to react responsibly.
Training is offered in-person at a group session as well as available online. Both the in-person and online workshops last approximately 1.5 hours. Our goal is to have Stewards reach 5% of the adult population in each of the awarded counties through a combination of in-person and online trainings. Darkness to Light, the purveyor of the Stewards program, believes it is at this threshold where communities reach the ‘tipping point in prevention’.
The evidence-base for Stewards indicates the program improves adults’ knowledge, attitudes, and preventive behaviors regarding CSA. Rheingold and colleagues (2015) report that, compared to adults who did not receive training, adults randomized to Stewards training: (1) demonstrated greater knowledge about CSA, (2) believed fewer myths related to CSA, and (3) enacted a greater number of CSA prevention behaviors. Both the in-person and the online trainings were found to be equally effective for improving adults’ knowledge, attitudes, and preventive behaviors regarding CSA (Rheingold et al., 2015).
Selected Reference(s) (requires Journal Access):
Letourneau, E.J., Nietert, P.J., & Rheingold, A.A. (2016). Initial assessment of Stewards of Children program effects on child sexual abuse reporting rates in selected South Carolina counties. Child Maltreatment, 21(1), 74-79.
Rheingold, A.A., Zajac, K., Chapman, J.E., Patton, M., de Arellano, M., Saunders, B., & Kilpatrick, D. (2015). Child sexual abuse prevention training for childcare professionals: An independent multi-site randomized controlled trial of Stewards of Children. Prevention Science, 16(3), 374-385.
School-based Component: Safe Touches
Safe Touches teaches elementary-aged children to trust their feelings about “icky” (i.e., inappropriate) touches, say no to someone trying to give them a not-safe touch, walk away or remove themselves from the situation, and report inappropriate or potentially inappropriate touching to a trusted adult. Children are taught these CSA prevention concepts via an interactive puppet show featuring racially ambiguous puppets.
Safe Touches is delivered in a single 50-minute session led by two Master’s level co-facilitators. Our goal is to deliver Safe Touches to all 2nd grade students in the awarded counties.
Pulido and colleagues (2015) examined the effectiveness of Safe Touches by randomly assigning 2nd and 3rd grade children to receive Safe Touches or participate in regular school activities. Students who received Safe Touches showed significant improvements in their knowledge of inappropriate touches (e.g., “even hugs and tickles can turn into bad touches if they go on too long”) compared to students who did not receive Safe Touches. Students in 2nd grade showed greater improvement in knowledge about inappropriate touches than 3rd grade students.
Selected Reference(s) (requires journal access):
Pulido, M.L., Dauber, S., Tully, B.A., Hamilton, P., Smith, M.J., & Freeman, K. (2015). Knowledge gains following a child sexual abuse prevention program among urban students: A cluster-randomized evaluation. American Journal of Public Health, 105(7), 1344-1350.
Parent-focused Component: Smart Parents – Safe and Healthy Kids (SPSHK)
Parents have a responsibility to create a happy, healthy, and safe environments for their children. Many parent-education programs exist giving parents the skills to do this, but no parent-education program exists for the prevention of CSA specifically. Capitalizing on skills taught in existing parent-education programs, we seek to efficiently and economically help parents prevent their child from experiencing sexual victimization by teaching them about children’s healthy sexual development, facilitating parent-child communication regarding sex and sexual abuse, and enacting measures to ensure their children’s safety (i.e., monitoring and vetting of babysitters). SPSHK is a module developed by the PSU Research team and led by Dr. Kate Guastaferro. Designed as a single additional session added toward the end of an evidence-based parent education program, SPSHK aims to improve parents’ knowledge about sexual development (i.e., demonstration of age-appropriate and inappropriate behaviors), facilitate parent-child communication about sex and CSA, and empower parents to take charge of their children’s safety (i.e., vetting potential babysitters, monitoring exposure to media).
For the purpose of the Safe and Healthy Communities Initiative, we limited the programs to which SPSHK could be added. These programs are Incredible Years, Parents as Teachers, and SafeCare. These programs were selected based on the level of empirical support for the model (i.e., evidence-based programs), the willingness of model developers to add the SPSHK module, and which programs were most widely implemented in the Commonwealth currently. Our intent is that all parents in the awarded counties referred to General Protective Services and who are receiving these specific parent-education programs receive SPSHK.
In the paragraphs that follow, we describe the programs to which SPSHK will be added in the Safe and Healthy Communities Initiative. At the end of this section we describe the progress toward establishing the evidence-base for the module itself prior to its roll out in the stepped-up intervention design.
The Incredible Years®
The Incredible Years is a parent-education program for parents of children 0–13 years old. Delivered in a group format over the course of 8 – 20 sessions by co-facilitators, IY aims to increase positive parenting and parent-child bonding, decrease harsh discipline, increase monitoring, and improve parent-child communication. Skills are taught through didactic presentations in which facilitators review parenting strategies with parents (e.g., appropriate use of time out), use DVDs to show vignettes of good and poor parenting practices (e.g., use of praise), and discuss what makes for good or poor parenting as a group (e.g., how to engage in child-led play sessions). Parents then role-play good parenting practices with one another under the guidance and supervision of the two co-facilitators.
Improvements in parental attitudes and parent-child interactions have been demonstrated as well as reductions in harsh discipline in a series of randomized controlled trials (e.g., Reid, Webster-Stratton, & Hammond, 2007; Webster-Stratton, Reid, & Hammond, 2004). IY is implemented internationally and has been delivered to parents from a variety of populations, including parents involved with child welfare (Webster-Stratton & Reid, 2010).
Parents as Teachers®
Parents as Teachers is a home-based parent-education program that incorporates personal visits, group connections, resource referrals, and child developmental screening to achieve four program goals:
- Increase parent knowledge of child development and parenting practices;
- Identify early detection of developmental delays and health issues (i.e., vision and hearing screening);
- Prevent child maltreatment; and
- Increase children’s school readiness (Albritton, Klotz, & Roberson, 2003).
Parent educators provide services to families with children from the prenatal period through kindergarten; it is possible that a parent educator will work with multiple children in the home. Families are visited at least once a month, but may be more frequent based on the level of risk of the family. Services typically last for two years, but may go longer if the family has other children not yet in kindergarten.
Findings from PAT trials include improvement in parenting knowledge, attitudes, and behaviors (Pfannenstiel & Seltzer, 1989; Wagner & Clayton, 1999). Other research indicates the effectiveness of PAT in decreasing the achievement gap between low-income and more advantaged children at Kindergarten entry (Pfannenstiel, Seitz, & Zigler, 2003), and improves parents engagement with their child’s schooling (Zigler, Pfannenstiel, & Seitz, 2008). PAT has also been found to improve children’s language ability, social development and other cognitive abilities (Drotar, Robinson, Jeavons, & Kirchner, 2009; Wagner, Spiker, & Linn, 2002).
SafeCare is an in-home parent-training program designed for parents of children birth to five and is the only program to target the prevention of the most pervasive form of maltreatment, neglect. SafeCare teaches skills in three areas: child health, home safety, and parent-child/parent-infant interaction (Guastaferro, Lutzker, Graham, Shanley, & Whitaker, 2012). Parents of children under 18-months old (or who are not yet ambulatory) receive the parent-infant interaction module whereas parents of children over 18-months (or who are ambulatory) receive the parent-child interaction module. Each module has 6 sessions– the entire model is typically delivered in 18–20 weeks, depending on a parent’s mastery of the material. The goal of each module is:
Child Health Module: Identify symptoms and illnesses, decide when symptoms need emergency services, doctor’s attention, or can be cared for at home, and use health reference materials including a health recording chart.
Home Safety: Identify hazards in the home and remove hazards in the home.
Parent-Infant Interaction (when applicable, depending on child’s age): Increase positive interactions to support development, enhance responsiveness to infant needs and signals, and plan age-appropriate activities that stimulate development.
Parent-Child Interaction: Learn and improve positive interaction skills, use organized process for play and routine activities, and engage children in age-appropriate activities to stimulate development.
In general, research indicates SafeCare is effective in improving parenting skills and reducing risk for child maltreatment, specifically neglect (Gershater-Molko et al., 2003, 2002). In a recent statewide implementation trial, parents who received SafeCare were significantly less likely to have a repeat referral to CPS in the year following SafeCare delivery compared to parents who received services as usual; remarkably, these findings were maintained 6 years post-intervention (Chaffin, Hecht, Bard, Silovsky, & Beasley, 2012).
Smart Parents – Safe and Healthy Kids: Establishing the Evidence-base
A randomized-controlled trial (RCT) evaluating the effect of SPSHK added onto existing parent-education programs is planned for 2018.
To date, we have completed an acceptability and feasibility pilot. This kind of work establishes the ‘face value’ of a new curriculum; it is important to ensure the curriculum evaluated in a resource intensive RCT is well accepted and feasibly delivered. A manuscript describing this process is currently in preparation by Dr. Guastaferro and colleagues.
With regard to acceptability, we asked the following research questions: (1) will our module content be received by parents, and (2) will our module content be received by facilitators of Incredible Years and Parents as Teachers? Results suggest that SPSHK is acceptable to both parents and facilitators:
“Excellent information to help parents protect their kids from abuse.” – A facilitator
“I didn’t have a least favorite part, it was overall very informational” – A parent
Feasibility testing examined whether SPSHK could realistically be delivered in a single extra session. We delivered the SPSHK module to approximately 20 parents (individual and group sessions) and determined that it was feasible to deliver the module in one additional session.
Selected Reference(s) (requires journal access):
Chaffin, M., Hecht, D., Bard, D., Silvosky, J.F., & Beasley, W.H. (2012). A statewide trial of the SafeCare® home-based services model with parents in Child Protective Services. Pediatrics, 129(3), 509-515.
Drotar, D., Robinson, J., Jeavons, L., & Lester Kirchner, H. (2009). A randomized, controlled evaluation of early intervention: The Born to Learn curriculum. Child: Care, Health and Development, 35(5), 643-649.
Gershater-Molko, R. M., Lutzker, J. R., & Wesch, D. (2002). Using recidivism data to evaluate project SafeCare®: Teaching bonding, safety, and health care skills to parents. Child Maltreatment, 7(3), 277-285.
Gershater-Molko, R. M., Lutzker, J. R., & Wesch, D. (2003). Project SafeCare®: Improving health, safety, and parenting skills in families reported for, and at-risk for child maltreatment. Journal of Family Violence, 18(6), 377-386.
Guastaferro, K.M., Lutzker, J.R., Graham, M.L., Shanley, J.R., & Whitaker, D.J. (2012). SafeCare®: Historical perspective and dynamic development of an evidence-based scaled-up model for the prevention of child maltreatment. Psychosocial Intervention, 21(2), 171-180.
Pfannenstiel, J. C., Seitz, V., & Zigler, E. (2003). Promoting school readiness: The role of the Parents as Teachers program. NHSA Dialog: A Research-to-Practice Journal for the early Intervention Field, 6(1), 71-86.
Reid, M.J., Webster-Stratton, C., & Hammond, M. (2007). Enhancing a classroom social competence and problem-solving curriculum by offering parent training to families of moderate- to high-risk elementary school children. Journal of Clinical Child & Adolescent Psychology, 36(4), 605-620.
Webster-Stratton, C., & Reid, M. (2010). Adapting The Incredible Years, an evidence-based parenting programme, for families involve in the child welfare system. Journal of Children’s Services, 5(1), 25-42.
Webster-Stratton, C., & Reid, M. J. (2017). The Incredible Years parents, teachers and children training series: A multifaceted treatment approach for young children with conduct problems. In J. Weisz & A. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents, 3rd edition. New York: Guilford Publications.
Webster-Stratton, C., Reid, M.J., & Hammond, M. (2004). Treating children with early-onset conduct problems: Intervention outcomes for parent, child, and teacher training. Journal of Clinical Child & Adolescent Psychology, 33(1), 105-124.
Our objectives are three-fold: (1) reduce rates of CSA in intervention counties, (2) change participating adults’ knowledge, attitudes, and behaviors related to preventing CSA, and (3) Change participating children’s ability to recognize and avoid unsafe touches and talk to a trusted adult.
- How does each intervention component affect knowledge, attitudes, and behaviors related to CSA prevention?
- Are these effects maintained over time?
- What is the effect of these components together?
- How do these components affect the general knowledge and awareness of CSA on a county level?
- What effect does a comprehensive prevention strategy have on referral and substantiation rates of CSA?
We are using a staggered implementation design in the SHCI. This approach affords several advantages: (1) adequate time for set-up and training of each component is allowed, and (2) we’re able to assess the impact of each initiative component of the project independent from each other. Since this is the first time all of these components have been implemented together and at this scale, it is important for us to measure the effect of each component individually and collectively to make informed decisions about the efficacy and economy of this approach.