Child Sexual Abuse Prevention and Risk Reduction Literature Review for Parents & Guardians Several child sexual abuse (CSA) prevention efforts target parents and guardians, given that they are in a unique position to educate and protect their children from sexual victimization. This literature review examines research on prevention efforts targeting parents to support or reject three hypotheses: (1) Prevention efforts intended for parents increase their knowledge of CSA, (2) such prevention efforts motivate parents to educate and protect children from CSA, and (3) such efforts result in lower rates of child sexual victimization. This literature review analyzes research to determine (1) if child sexual abuse (CSA) prevention efforts intended for parents and guardians increase parents’ knowledge of CSA, (2) if such prevention efforts motivate parents to educate and protect their children from CSA, and (3) if such prevention efforts result in lower rates of child sexual victimization. This review looks at English- language research from 1987 to 2010 on educational programs, literature, community notification efforts, and therapy frameworks intended to educate parents about primary, secondary, and tertiary CSA prevention. The authors found that they could not conclusively indicate that CSA prevention efforts increase parents’ knowledge of CSA, given that current research on the topic is insufficient or contradictory. Some evidence indicates that CSA prevention efforts motivate many parents to discuss CSA with their children, but additional research is needed to replicate this finding. Finally, insufficient research is available to indicate whether CSA prevention efforts geared toward parents and caregivers result in lower rates of child sexual victimization. Future studies on all CSA prevention efforts targeting parents and caregivers is needed to address these gaps in the research literature. Several child sexual abuse (CSA) prevention efforts target parents and guardians, given that parents are in a unique position to educate and protect their children from sexual victimization. Understanding the efficacy of these efforts in raising parents’ awareness of CSA and preventing CSA occurrences is vitally important to the anti-sexual violence field. Understanding whether current and past CSA prevention efforts have benefited parents is key to developing effective educational efforts in the future. This literature review examines research on prevention efforts targeting parents to support or reject three hypotheses: (1) CSA prevention efforts intended for parents increase their knowledge of CSA, (2) such prevention efforts motivate parents to educate and protect their children from CSA, and (3) such prevention efforts result in lower rates of child sexual victimization. This literature review draws upon English- language research from 1987 to 2010 on educational programs, literature, and community notification efforts intended to educate parents about CSA. It examines findings on primary, secondary, and tertiary prevention efforts, strengths and weaknesses of target populations, and obstacles to prevention efforts. Strengths and weaknesses in parents’ knowledge Existing research on CSA can teach stakeholders about strengths and gaps in parents’ knowledge about CSA. To optimize educational efforts, stakeholders should utilize parents’ strengths and address knowledge gaps when designing CSA education programs for this population. One strength observed among the parents and guardians studied is knowledge of boys’ and girls’ risk for CSA victimization. One study of 5,241 respondents found that awareness and concern about child sexual abuse is relatively high among U.S. adults (Stop It Now!, 2010). For example, 95% of adults understood that most sexually abused children are victimized by someone they know, and 64% understood that many sexually abused children are victimized by other children or adolescents (Stop It Now!, 2010). In several studies analyzed by Baratsikos (2010), most parents correctly believed that girls were at a greater risk for CSA than boys, although it was widely acknowledged that boys could be CSA victims as well. Willingness to discuss CSA with one’s offspring is another potential strength indicated by research. In a study of 289 parents and guardians of young schoolchildren documented by Deblinger, Thakkar-Kolar, Berru, & Schroeder (2010), 78.9% had discussed CSA with their offspring. Despite strengths in many parents’ CSA knowledge, research has demonstrated gaps that can potentially be ameliorated by effective CSA training. The stereotype of the stranger sexual perpetrator still persists among some parents and guardians, indicative of a knowledge gap that CSA prevention efforts should address. Deblinger, Thakkar-Kolar, Berru, and Schroeder (2010) report that while most respondents (93%) warned their children about strangers as potential abusers, fewer warned children about adults known to the child (64.5%), other children (59.6%), someone the child met online (74.1%), and relatives (43%). Several studies reviewed by Babatsikos (2010) reported that less than 50% of respondents thought that CSA perpetrators were likely to be known to their victims. CSA prevention programs aimed at parents should dispel common stereotypes such as the assumption that most CSA perpetrators are strangers to the victim. The myth that sexual victimization usually leaves physical indicators is another potential knowledge gap that stakeholders should address. In a study of 246 residents in a rural Oregon town, Calvert (1999) found that 9% of respondents thought that physical signs of CSA would be present in some cases of CSA, and 61% thought they would be present in most or all cases. Additional research can determine whether or not this assumption is held by other populations of parents and guardians. Because most victims of CSA do not exhibit physical signs of abuse, CSA prevention programs should dispel the myth that sexual abuse often results in physical signs of abuse on a child’s body. Research provides conflicting information on whether or not parents protect their children from CSA by teaching them correct names of body parts. Deblinger, Thakkar-Kolar, Berru, and Schroeder (2010) found that 62.7% of respondents taught their children anatomically correct terms for genitals. On the other hand, a literature review by Wurtele and Kenny (2010) analyzed three studies on young children and found that the majority had not been taught proper names of genitals. CSA education efforts can convey to parents the benefits of teaching children correct names of genitals, and stakeholders may want to include this element in their outreach to parents. Risk reduction Sexual abuse risk reduction constitutes efforts to lessen one’s risk of sexual victimization. Risk reduction is distinct from primary prevention, which constitutes efforts to prevent the overall occurrence of sexually abusive acts. For example, an educational program that teaches children about their personal boundaries and saying “no” to unwanted touching would constitute CSA risk reduction. On the other hand, an educational program that teaches children to respect the physical boundaries of others and refrain from unwanted touching would constitute primary prevention. With regard to child sexual abuse, many risk reduction programs teach parents and caregivers how to reduce their children’s risk of sexual victimization. Along with formal education programs, literature for parents or caretakers on how to reduce children’s risk of sexual victimization has flooded the market, in the form of books (van Dam, 2001; Salter, 2003), magazine and newspaper articles, and brochures and websites. Also, public policy has brought forth community notification laws for sex offenders (i.e., Megan’s Law) that can provide parents and guardians with information on convicted perpetrators in their community. Educational programs Formal educational programs are one means by which parents educate themselves on child sexual abuse. Research suggests that parents generally support the concept of educating themselves and their children on child sexual abuse risk reduction (Elrod & Rubin, 1993). Several studies found that parents supported CSA prevention efforts spearheaded by doctors, teachers, and schools (Babatsikos, 2010). Though there is little research on parents’ involvement in these programs, several studies analyzed in Babatsikos (2010) found that a small to moderate percentage of surveyed parents (27% to 64%) had attended CSA risk reduction programs. For CSA educational programs to be successful, they must determine if attendees are conceptualizing CSA correctly, and if not, they must provide an accurate and comprehensive definition of CSA. Future research is needed to give stakeholders a clearer picture of how parents and guardians define CSA. Babatsikos conducted a literature review of 23 English-language studies published between 1980 and 2008 and found that only one study gauged parents’ definitions of CSA (Babatsikos, 2010). Deblinger, Thakkar-Kolar, Berru, and Schroeder (2010), however, indicated that parents and guardians realize that CSA can take many forms (i.e., inappropriate touching and photographs). Parents and guardians discussed topics with their offspring such as someone trying to lure the child into car (88.2%), someone trying to touch the child’s genitals (81.1%), someone trying to tempt the child with rewards (73.7%), teaching the child anatomically correct terms for genitals (62.7%), someone asking the child to touch their genitals (46.1%), someone showing the child their genitals (42.5%), and someone taking pictures of the child’s genitals (22.4%) (Deblinger, Thakkar-Kolar, Berru, & Schroeder, 2010). This suggests that parents have a broad understanding of what constitutes CSA, but additional research is needed to form a more complete picture. Some educational programs have been shown to increase parents’ awareness of their own children’s vulnerability to CSA and promote positive communication about CSA within families. Babatsikos (2010) found that parents who attended CSA prevention workshops had a higher appraisal of their children’s risk for CSA than parents who had not attended workshops. In a study of 41 parents who did not attend a CSA prevention program and 276 parents who attended an overview of a CSA prevention program, Kolko, Moser, Litz, and Hughes (1987) found that parents who attended the overview reported more positive communication at home about CSA. Future studies are needed to support this finding. Various factors appear to motivate parents to participate in CSA education programs. In a study of 101 parents, Elrod and Rubin (1993) found that most parents of preschool children cited interest in topic, qualifications of presenter, usefulness of information, distance, where they learned about program, time, and child care availability as important factors in their attendance of an education program on child sexual abuse. The study also found that most respondents would be more likely to attend a CSA education program if they received referrals from a spouse, doctor, or school. Less than 30% of respondents said that they would respond favorably to referrals from television, newspapers, mailed brochures or workplaces. However, risk reduction educational programs are not without limitations. Kolko, Moser, Litz, and Hughes (1987) found no significant differences between parents who attended an overview of a CSA risk reduction program and parents who did not in terms of how respondents rated the seriousness of CSA or their general knowledge of the topic. Low attendance has been a problem with some parental education programs. Referencing the “ESPACE” parental education program in Canada, Hebert, Lavoie and Parent (2002) noted that only 20% of invited parents actually participated in the program. Wurtele, Moreno, and Kenny (2008) observed that only 35% of eligible parents participated of the “Parenting Safe Children” workshop. Future research should explore reasons behind low participation rates as well as possible strategies for increasing program attendance. Mothers tend to participate in CSA educational programs more than fathers, according to studies on educational program attendance (Wurtele & Kenny, 2010). Research is needed on why women make up the preponderance of attendees in many programs, as well as on results of efforts to recruit fathers and male guardians into CSA education programs. Finally, community resistance and denial of CSA can thwart effective program implementation. In Plummer’s (2001) study of program leaders and advocates from 87 CSA prevention programs, 70% of respondents reported that they had encountered community resistance to prevention efforts or denial of CSA. Resistance and denial were strongest in communities that lacked financial resources for CSA programs, leading Plummer to speculate that community education might lead to increased program support (Plummer, 2001). An analysis of effective frameworks for CSA educational programs is critically needed. Educational programs can operate under a variety of theoretical frameworks, as Plummer observes (2001, p. 575): Programs aimed at preventing child sexual abuse have been driven by a variety of theoretical frameworks and employ distinct interventions. Some programs build upon feminist empowerment models that are adapted from rape crisis programs and others emphasize adult protection of vulnerable children (Cooper, 1991; Tobin & Farley, 1988). Public health models portraying sexual abuse as a “disease” work to alter the interaction between agent (perpetrator), host (victim), and environment (society). One theory driving prevention suggests that four necessary preconditions must exist for abuse to occur: an individual’s proclivity to abuse, lack of internal and external inhibitions impacting the offender, and offender access to the child. Removing any of the preconditions theoretically makes abuse impossible. This means that prevention could target any, or all, of the four preconditions (Finkelhor, 1984). Little research exists on which frameworks are most effective at educating parents, motivating parents to discuss the topic with their children, or reducing the occurrence of CSA. Future research should address this gap by exploring what, if any differences exist between program outcomes operating under different theoretical frameworks. For the field as a whole, there are few evaluations of the effectiveness of education programs for parents, and they provide mixed results. While a few evaluations found that programs increased parents’ awareness and attitudes, these were programs that focused on physical or emotional abuse and neglect, but not sexual abuse (Golub, Espinosa, Damon, & Card, 1987; Murphy, Hall, & Simpson, 2003), or about sexuality in general (Bundy & White, 1990), leaving their applicability to CSA educational programs in question. One evaluation of an education program specifically about child sexual abuse indicated that the program failed to yield any positive results, in that parents did not increase their knowledge of the prevalence or signs of child sexual abuse (Berrick, 1988). Literature Books and magazine articles generally focus on information about perpetrator characteristics, grooming tactics and strategies parents can use to protect their children. More condensed materials like brochures and websites are often created by advocacy or victim service organizations. While they are rarely evaluated, one such evaluation of the “7 Steps to Prevention” information on Darkness to Light’s website found that reading the information increased individuals’ knowledge about child sexual abuse prevalence and risk reduction concepts (Pleasant & Bennett, 2005). Educational literature is another means by which parents educate themselves about CSA prevention. Research indicates that educational literature designed to enhance parents’ self-efficacy (the belief that one is capable of taking effective action) can have a positive impact on parents’ intentions to discuss CSA with their children. In a study of 45 parents randomly assigned to either a CSA prevention workshop or a non-CSA prevention-related workshop, Burgess and Wurtele found a positive correlation between parents’ self-efficacy and intentions to talk to their children about CSA (Burgess & Wurtele, 1998). Additionally, Campis, Prentice-Dunn, and Lyman (1989) provided CSA educational materials to 165 mothers of elementary school-aged children. The study revealed that the strongest intentions to instruct children about CSA came from respondents who had read materials designed to reinforce self-efficacy (Campis, Prentice-Dunn, and Lyman, 1989). No research currently addresses whether or not educational literature on CSA primary prevention is effective in raising parents’ awareness of CSA. Minimal research exists on the effectiveness of more condensed literature such as brochures or websites (Pleasant & Bennett, 2005). Future studies should address this gap in the body of research. Community notification Community notification statues authorize or require authorities to notify residents if convicted sex offenders move into their communities. Evidence demonstrating the effectiveness of community notification policies in preventing CSA is mixed. While some research suggests that these policies do not prevent CSA victimization (Leib, 1996), other studies suggest that community notification may reduce the frequency of sexual victimization. Prescott and Rockoff (2008) found that while community notification laws are associated with a reduction in overall rates of sex offenses, but found no evidence that notification laws reduce recidivism among sex offenders (Prescott & Rockoff, 2008). In a study of uniform crime report data after implementation of Megan’s Law notification policies from 10 states, six states experiences no statistically significant change in the monthly incidence of rapes, three states saw a significant decrease in rape, and one state saw an increase in rapes (Vasquez, Maddan, & Walker, 2008). The applicability of this data to child sexual abuse rates is unclear, as the study did not distinguish between rapes of adult victims and rapes of child victims. More research is needed to determine why overall sex crime rates drop in some areas with community notification polices but not others, and if community notification policies impact CSA rates specifically. Research on how community notification policies are used by parents for educational or protective purposes is extremely limited. An exception is a study in Wisconsin funded by the National Institute of Justice (Zevitz & Farkas, 2000), which found that community notification meetings increased both attendees’ knowledge of the policy and anxiety about sex offenders. One study indicated that community notification polices, namely sex offender registries, may increase parents’ knowledge of convicted sex offenders in their community. In a study of sex offender registry use by 733 Michigan residents, Kernsmith, Craun, and Kernsmith (2009) found that parents with school-aged children were more likely to utilize the sex offender registry than parents of younger children (under four years of age) or nonparents. The impact of parents’ use of sex offender registries on CSA prevention is unclear. Evaluations of community notification policies have relied on assessment of crime rates or offenders’ recidivism, not on parents’ use of these policies to protect their children from specific sex offenders (Petrosino & Petrosino, 1999). While research indicates that community notification does not decrease the rates of sex crimes, it is unknown if community notification encourages parents and caregivers to adopt risk reduction tactics that result in reduced victimization. Though the current research indicates that these policies are ineffective in reducing rates of sexual abuse, the research literature is sparse, and additional research is needed on the effectiveness of community notification policies and the conditions necessary for optimal effectiveness. Specifically, research on parents’ access to and use of community notification information and its potential impact on their children’s avoidance of victimization would be beneficial to the field (Zevitz & Farkas, 2000). In addition, research on potential unintended consequences of community notification on parents’ protective strategies can edify stakeholders. Research on the effectiveness of community notification needs to be disseminated to primary prevention advocates to help determine advocacy priorities regarding primary prevention of child sexual abuse. Greater sharing of information and collaboration between policy researchers and prevention providers and experts is encouraged. Primary prevention Primary prevention of CSA involves preventing the occurrence of sexually abusive acts by taking action before a sexual assault has occurred (Centers for Disease Control and Prevention, 2004). For example, an educational program teaching children to respect the physical boundaries of others could constitute a primary prevention effort. Parents and caretakers are often the first educators of children, and thus are in a unique position to foster primary prevention of CSA. Unfortunately, most of the research discussing CSA prevention programs and publications actually analyze risk reduction programs and publications. Little to no research exists on the content and efficacy of parent and caregiver- oriented educational programs and written materials on CSA primary prevention. Educational programs A dearth of research exists on CSA educational programs for parents and caregivers geared toward primary prevention. Whether this is because few CSA primary prevention educational programs exist, or because the field has ignored existing programs is unclear. Most research articles that discuss CSA prevention programs are actually analyzing risk reduction programs, indicating disagreement among researchers on the definitions of primary prevention and risk reduction. Research on existing primary prevention programs is sorely needed, as well as greater clarity among researchers on the distinctions between CSA primary prevention and risk reduction. Literature While written materials for parents and caregivers on protecting children from abuse are plentiful, there is no information on their effectiveness in primary prevention of CSA. No research currently exists on CSA educational literature’s efficacy as a primary prevention tool. Research on books, magazines, websites and educational literature should be conducted to determine the value of this approach. To provide the most comprehensive picture of CSA prevention literature, research should consist of both evaluations and content analysis. Secondary prevention Secondary prevention of CSA involves immediate responses after abuse has occurred so as to respond to the short-term consequences of abuse and prevent additional harm (Centers for Disease Control and Prevention, 2004). For instance, literature advising parents how to sensitively and effectively respond to a child’s disclosure of CSA would be an example of secondary prevention. Parents are best positioned to engage in secondary prevention of child sexual abuse, provided they are equipped with the knowledge, skills, and motivation to respond effectively. In addition to supporting their child if they have been victimized, parents may also support their child who may be engaging in sexually reactive or abusive behaviors. Little research exists on secondary prevention efforts targeting parents, but results from one study indicate that such efforts are needed. A 2010 report by Stop It Now! found a disconnect between adults’ intentions to intervene and actual intervention in suspected CSA cases. While 91% of respondents said that they would intervene in a hypothetical CSA case, only 65% of respondents who suspected a real-life case of CSA intervened (Stop It Now!, 2010). Because some adults may lack the skills and knowledge needed to intervene in suspected CSA cases and prevent further abuse, educational efforts should provide parents with intervention strategies and resources. Education programs Findings are mixed regarding the effectiveness of education programs in motivating parents to engage in secondary prevention of CSA. Some programs demonstrated no impact on parents’ awareness of abuse indicators, nor did participants in those programs understand appropriate responses to abuse disclosures. In a study of a CSA educational program aimed at parents of preschoolers, Berrick (1988) found that of 116 participating parents, only 34% of parents attended the meetings. Berrick observed no statistically significant change between attendees’ perceptions of CSA prevalence before and after attending educational meetings. When surveyed before and after the educational meetings, attendees demonstrated no statistically significant change in their awareness of CSA indicators. Future evaluations of such programs may reveal why some programs succeed in educating parents while others fail. Evaluations of other education programs indicate that the programs did have a positive impact on parents’ comfort in discussing sexual abuse with their children (Bundy & White, 1990). At this time, little information is available about the effectiveness of secondary prevention-oriented education programs, a gap that needs to be filled with additional research. As parent involvement in secondary prevention is crucial, more education programs should be developed for parents. These programs should be based upon theory and research and should be rigorously evaluated, as little is currently known about the effectiveness of these efforts. Public communication campaigns Little research exists on public communication campaigns designed to educate parents about secondary prevention of CSA. One rare example is documentation of a Stop It Now! public communication campaign, which consisted of media and outreach efforts emphasizing adult responsibility in child sexual abuse prevention . During the course of the campaign, 39 children and adolescents with sexual behavior problems entered treatment for those problems as a result of a parent or caregiver’s inquiry (Chasan-Taber & Tabachnick, 1999). Aside from the efforts of Stop It Now!, few campaigns have been specifically designed to engage parents in secondary prevention efforts. Little is known about the potential effectiveness of future campaigns, essential components for success, and potential differential effects in different communities. Tertiary prevention Tertiary prevention of CSA involves long-term responses after abuse has occurred to address lasting consequences of sexual victimization (Centers for Disease Control and Prevention, 2004). Tertiary prevention efforts seek to engage parents in their victimized children’s healing and treatment processes. These efforts aim to ameliorate the negative consequences of abuse and to increase parents’ capacity to support their children’s recovery. The available research literature indicates that efforts targeting parents/caregivers can be effective in addressing the needs of both parents and child survivors (Stevenson, 1999), yet research literature on its effects (specifically on parents and caregivers) is relatively sparse (Elliot & Carnes, 2001). Educational programs Little research exists on the effectiveness of tertiary prevention educational programs geared toward parents. The available research provides some support for the effectiveness of education programs that focus on development of behavior management and problem solving skills, such as cognitive behavioral therapy (Jaramillo, 2006; Saywitz, Mannarino, Berliner, & Cohen, 2000; Saunders, Berliner, & Hanson, 2004). Literature There is a dearth of information regarding the effectiveness of books, brochures and audio-visual materials designed for parents of sexually abused children. One exception is an evaluation of a video presenting parents with information and suggested supportive responses to their children, with actors modeling specific responses (Jinicha & Litrownik, 1999). Mothers viewing this video were more knowledgeable about supportive responses, more likely to believe their child’s account of the abuse, and somewhat more likely to engage in supportive behaviors than those who viewed a vide that gave only general information about available services. This study suggests that audio-visual materials can be effective in at least impacting parents’ knowledge of behaviors deemed supportive of their child. Therapy Therapy (individual, family or support group therapy) is one method parents seek treatment for sexually abused children. A variety of specific family therapy models have been supported by theory and research (Hyde, Bentovim, & Monck, 1995; Saunders, Berliner, & Hanson, 2004). Other models, such as Attachment- Trauma Therapy, Family Resolution Therapy (FRT), and Intensive Family Preservation Services appear promising (Saunders, Berliner, & Hanson, 2004) but have not been heavily researched. Future research should investigate models other than cognitive-behavioral approaches to give the field a more comprehensive picture of which therapies work. Therapy may focus on the family as a whole and include parents, child survivors and siblings. The inclusion of family members in treatment methods has been demonstrated to increase the efficacy of the treatment provided directly to children (Dufour & Chamberland, 2002; Dufour & Chamberland, 2003; Elliot & Carnes, 2001; Grosz, Kempe, & Kelly, 2000; Saywitz, 2000). Available research also indicates that family therapy is an effective approach in treating non-offending parents as well as sexally abused children. Specifically, family therapy has been found to decrease parents’ distress and improve their parenting skills (Dufour & Chamberland, 2002; Dufour & Chamberland, 2003). Studies have yielded some evidence that the parents of sexually abused children can also benefit from individual cognitive behavioral treatment, particularly when the abused child also receives similar treatment (Deblinger, Steerb, & Lippmann, 1999; Elliot & Carnes, 2001; Ross & O’Carroll, 2004). As a whole, treatments are most effective when they are goal-directed. Thus, they should be designed to address specifically identified and measurable problems (Saunders, Berliner, &Hanson, 2004). To address their own secondary trauma, some parents of child survivors attend support groups. Some studies have found that parents participating in support groups with other parents improved their emotional health and their ability to support their victimized child (Grosz, Kempe, & Kelly, 2000; Hyde, Bentovim, & Monck, 1995). However, parent support groups were only one of the several treatments that parents and children received; as a result, changes cannot necessarily be attributed to the support groups alone. Regardless of parents’ actual participation in treatment, parental support can facilitate the recovery process of sexually abused children. Research strongly indicates that child survivors with parental support benefit more from treatment than children without such support (Cohen & Mannarino, 2000; Elliot & Carnes, 2001; DePanfilis & Zurayin, 2002; Feiring, Taska, & Lewis, 1998; Friedrich, Luecke, Beilke, & Place, 1992; Gries, Goh, Andrews, & Gilbert, 2000; Grosz, Kempe, & Kelly, 2000; Merrill, Thomsen, Sinclair, Gold, & Milner, 2001; Rosenthal, Feiring, & Taska, 2003; Saywitz, Mannarino, Berliner, & Cohen, 2000; Swanston, Pluketta, O’Toole, Shrimptona, Parkinson, & Oates, 2003). However, the field’s understanding of therapy as a form of tertiary prevention is incomplete. One knowledge gap involves responses by fathers and male caregivers versus those of mothers and female caregivers. The majority of the existing research on the impact of tertiary prevention efforts on non-offending parents has been on the mothers of abused children, but there is sparse research on the effect of these efforts on fathers or other male caregivers (Elliot & Carnes, 2001). Clinical observations and anecdotal evidence suggest that males may be less likely to participate in tertiary prevention efforts and that existing efforts may be less effective with males than with females (Grosz, Kempe, & Kelly, 2000). However, this has not received much attention and very little is known about tertiary prevention efforts targeting non-offending fathers or other male caregivers. Future research should examine the role of fathers and male caregivers in therapy intended as tertiary prevention. Another challenge in evaluating therapy is identifying which variables are responsible for certain outcomes. For example, Cohen, Mannarino, Berliner, and Deblinger (2000) observe that trauma-focused cognitive behavioral therapy is efficacious in decreasing trauma-related symptoms in children, but insufficient data exists to determine which therapy components are responsible for observed improvement. Because post-abuse therapy can feature multiple components, it is very difficult to determine which components are responsible for observed improvements. Finally, little research exists on responses by different types of parents and caregivers to tertiary prevention therapies. How these efforts affect different categories of parents of sexually abused children is unknown. For example, more empirically rigorous studies are needed to determine what role culture plays in treatment efficacy for sexually abused children and their caregivers (Cohen, Deblinger, Mannarino, & de Arellano, 2001). Future research should determine if differences exist along racial, ethnic, gender, socio-economic, age or geographic lines. Conclusion The research evaluated in this literature review did not conclusively support the first hypothesis that CSA prevention efforts increase parents’ knowledge of CSA. While studies indicate that some educational programs increased parents’ knowledge of CSA and their children’s risks for victimization, other programs demonstrated no such increase. While community notification programs were shown to make parents more knowledgeable about sex offender registry policies and the presence of convicted sex offenders in their communities, they did not demonstrably make parents better informed about CSA. A dearth of research on CSA educational efforts geared toward parents and caregivers makes it difficult to assess the efficacy of these efforts. Because of conflicting and insufficient information, additional research is needed to determine if CSA prevention efforts increase parents’ knowledge of CSA. A small amount of research supports the second hypothesis that CSA prevention efforts motivate parents to educate and protect their children from CSA. Several studies demonstrate that parents were more motivated to discuss CSA with their families and children after exposure to educational programs and literature. It is unknown if parent-child dialogue on CSA impacts child sexual victimization rates or if other efforts such as community notification motivate parents to discuss CSA with their children. It is also unknown whether prevention and risk reduction efforts motivate parents to undertake protective measures to guard their children from CSA. Because of the dearth of research literature on the subject, additional research is needed to indicate whether these results can be replicated with other educational initiatives. Finally, insufficient research exists to support the third hypothesis that CSA prevention efforts geared toward parents result in lower rates of child sexual victimization. While risk reduction, primary, secondary and tertiary prevention efforts can provide various benefits for parents and children, additional research is needed to determine if such prevention efforts have any impact on rates of child sexual victimization. Prevention efforts geared toward parents as a whole have not been evaluated in great depth and a dearth of research on educational literature, community notification and therapy is especially glaring. This gap in the literature needs to be filled with future studies on all types of prevention efforts intended for parents and caregivers. Reference list Babatsikos, G. (2010). Parents’ knowledge, attitudes, and practices about preventing child sexual abuse: A literature review. Child Abuse Review, 19, 107-129. doi:10.1002/car.1102 Berrick, J. D. (1988). 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Journal of Child and Adolescent Trauma, 1, 1–10. doi:10.1080/19361520802505768 Wurtele, S. K., & Kenny, M. C. (2010). Partnering with parents to prevent childhood sexual abuse. Child Abuse Review, 19, 130-152. doi:10.1002/car.1112 Zevitz, R. G., & Farkas, M. (2000). Sex offender community notification: Assessing the impact in Wisconsin (NCJ 179992). Retrieved from National Institute of Justice, U.S. Department of Justice: http://www.ncjrs.gov/pdffiles1/ nij/179992.pdf This project was supported by Cooperative Agreement #5VF1CE001751-02 from the Centers for Disease Control and Prevention. The content of this publication may be reprinted with the following acknowledgement: This material was reprinted, with permission, from the Pennsylvania Coalition Against Rape and National Sexual Violence Resource Center’s publication entitled Child Sexual Abuse Prevention and Risk Reduction: A literature review. This guide is available by visiting www.nsvrc.org © Pennsylvania Coalition Against Rape and National Sexual Violence Resource Center 2011. All rights reserved. NSVRC • 123 North Enola Drive, Enola, PA 17025 • 877-739-3895 • www.nsvrc.org • resources@nsvrc.org PCAR • 125 North Enola Drive, Enola, PA 17025 • 800-692-7445 • www.pcar.org • www.heroproject.org