Impact of a Child Sexual Abuse Prevention Package (CSAPP) on Knowledge of Appropriate and Inappropriate Touch Among Children With Intellectual Disabilities

TL;DR

This study shows that a prevention package improves children with intellectual disabilities' understanding of appropriate and inappropriate touch.

Contribution

The study demonstrates the effectiveness of the CSAPP in increasing awareness about sexual abuse prevention in children with intellectual disabilities.

Findings

The CSAPP significantly improved children's awareness of good and bad touch.

There was a statistically significant difference in awareness scores before and after the intervention.

The study highlights the urgent need to teach sexual abuse prevention to children with intellectual disabilities.

Abstract

Introduction: Child sexual abuse covers a vast spectrum, which includes asking or pressuring a child to engage in sexual activities, indecent exposure of their own genitalia, or forcing the child into exposure, displaying pornography to a child, actual sexual contact against the will of the child, viewing or engaging in physical contact with the child's genitals for sexual purposes or using a child to produce child pornography. The current study aimed to determine the impact of the Child Sexual Abuse Prevention Package (CSAPP) among selected categories of intellectually disabled children.

Methods: A quantitative quasi-experimental design was used with an enumeration sampling technique to collect data from 20 mentally challenged children in three phases: pre-interventional phase to assess the awareness regarding good touch and bad touch among the selected mentally retarded children, interventional phase to impart awareness on good touch and bad touch through CSAPP, and post-interventional assessment.

Results: There was a statistically significant difference (p < 0.0001) between the awareness scores in all five domains of the CSAPP regarding the distinction between good touch and bad touch. There was a statistically significant difference (p < 0.0001) between the awareness scores before and after the intervention, as assessed by the pre-test and post-test.

Conclusion: The present study has brought out the urgent need to teach mentally retarded children about good touch and bad touch in the context of the prevention of sexual abuse to increase awareness and also spread it among more children. The CSAPP has proved to be effective in increasing awareness among the selected categories of mentally retarded children. The Department of Education, different special schools, and also the hospitals can help in spreading knowledge and awareness regarding the prevention of sexual abuse and good touch and bad touch among mentally retarded children, and contribute to protecting our children.

Tables

Table 1. Comparison of children’s overall awareness score before and after intervention of each domain under the interventionStatistical analysis was performed using the Wilcoxon signed-rank test. * Significance level set at p < 0.0001.

Domains	Pre-test (mean ± SD)	Min-Max	Post-test (mean ± SD)	Min-Max	Z value	P-value
Awareness of private parts of their own body	2.40 ± 0.8	0-3	4.5 ± 0.6	3-5	210.000	<0.0001*
Awareness of swimsuit rule in relation to good touch and bad touch	0.1 ± 0.4	0-1	2.55 ± 0.6	2-3	210.000	<0.0001*
Awareness of an unsafe touch	0.45 ± 0.9	0-2	2.35 ± 0.4	2-3	171.000	<0.0001*
Awareness regarding expected response towards unsafe situations	1.45 ± 0.9	0-2	3.55 ± 0.5	3-4	171.000	<0.0001*
Awareness about what are the unsafe situations	1.55 ± 1.05	0-3	3.95 ± 0.8	3-5	210.000	<0.0001*

Table 2. Comparison of children’s awareness score on good touch and bad touch before and after the intervention* Significance level set at p < 0.0001.

Awareness score	Mean	Standard deviation	Standard error	t value	P-value
Pre-test	5.95	2.74	0.469	-23.211	<0.0001*
Post-test	16.85	1.42

Full text

Introduction

Child abuse can be defined as abuse in children as any kind of harm or neglect by an individual who might be a parent or any other caregiver. Child sexual abuse is defined as a form of abuse in children that is committed by sexually abusing or assaulting a child by an adult or an older adolescent. It covers a vast spectrum, which includes pressuring a child to engage in different kinds of sexual activities, like pressuring the child into indecent exposure of their genitalia or forcing the child to similar exposure, displaying adult videos to a child, or performing actual sexual contact with the child against their will. It also includes viewing or engaging in physical or sexual contact with the child [1]. Data suggested that around the world, approximately one billion children aged 2-17 years have experienced either type of the four forms of abuse in the last year [2]. The World Health Organization (WHO) in 2020 indicated that worldwide, 1 in 13 men and one in five women had reported having experienced either form of sexual abuse by the age of 17 years [3]. Studies published from 2000 to 2020 have shown that there was an increase in the prevalence of sexual abuse against people with intellectual disabilities as compared to that among the general population. A report by the WHO found that worldwide, mentally challenged children experienced a 4.6 times higher risk of sexual abuse than children without intellectual disability [4].

Children affected with any form of disability are much more prone to neglect, abuse, or maltreatment, as reported by many studies, which has subsequently increased in rate during recent years. In India, the sexual abuse rate is about 1.67 to 3.80 times higher for children with disabilities than for their non-disabled peers. The most reported risk factors were the child’s gender, dysfunctional family, isolation, or experiencing any other types of abuse [5]. The safety and protection services for children, which are delivered by government child protection agencies for disabled children, have always faced significant barriers.

A report states that only 6.7% of victims received such services in cases of need. Special schools for children with disabilities also tend not to provide proper information or spread awareness regarding child protection services for disabled children for fear of competition or unprofessionalism. Most of these schools were funded by charities and created sympathy among society, rather than posing it as a social responsibility to contribute to actual help and services for children with special needs. In India, where child sexual crimes are much more prevalent, priority can be given to child sexual abuse and child trafficking for commercial purposes or sexual exploitation. A focused and systemic approach to only a particular major issue can give the whole country a realistic chance of success [6]. Previous studies have reported that children with disabilities, particularly intellectual disabilities, face more inconvenience in recognizing and reporting sexual abuse than other children without disabilities [7]. Hence, the current study intends to determine the impact of the Child Sexual Abuse Prevention Package (CSAPP) in imparting awareness regarding good touch and bad touch among selected categories of mentally challenged children.

Materials and methods

A quantitative quasi-experimental research approach was employed, utilizing a “one-group pre-test post-test design” as the appropriate design. The study was conducted at the Chetana Institute for the Mentally Disabled in Bhubaneswar, Odisha, India. The present study employed a total enumeration sampling technique; all children who fulfilled the inclusion and exclusion criteria under the educable and trainable categories were included in the study. The total number of children included in the study was 20. The study considered inclusion criteria as the children in mental retardation categories of educable and trainable, and aged 5-18 years. The study excluded children who had unattainable communication difficulties or disorders.

Description of intervention

The study intervention involves teaching selected children with mental challenges using a validated audio-visual aid (a flip chart, audio drama, and demonstrations with the help of two dolls - one male and one female) to understand the basic concepts of good touch and bad touch. The intervention addressed five key subtopics related to the concepts of good touch and bad touch, with the aim of enhancing children’s understanding of personal safety in an age-appropriate and sensitive manner.

First, the intervention focused on building awareness of private parts of the child’s own body, including the mouth, chest, areas between the legs, and the bottom. Children were also guided to understand basic differences between male and female bodies in a simple and respectful way. The second component of the intervention introduced the swimsuit rule to help children distinguish between good touch and bad touch. Children were taught to identify the parts of the body that are covered by a swimsuit and to recognize that these areas are considered private parts. Emphasis was placed on the understanding that no one is allowed to touch these private parts, except parents or doctors, and even then, only in the presence of a parent or trusted caregiver, to ensure safety and transparency. The third aspect of the intervention focused on developing awareness of unsafe touch. Children were helped to recognize that any touch that makes them feel uncomfortable, bad, or confused is not acceptable. They were encouraged to understand that being touched in places where they do not want to be touched, or in ways that feel wrong to them, is considered unsafe and should not be ignored. The fourth subtopic addressed awareness of unsafe situations that children may encounter. This included situations where someone attempts to touch a child’s private body parts, asks the child to touch another person’s private parts, requests the child to remove their clothes without a valid reason, or attempts to take photographs or videos of the child without clothes. Children were also sensitized to situations in which someone shows them pictures or videos of people without clothes, helping them recognize these scenarios as inappropriate and unsafe. The final component of the intervention focused on helping children understand the expected responses to unsafe situations. Children were taught that they have the right to refuse and to say no firmly when they feel unsafe. They were guided on the importance of getting away from the unsafe place as quickly as possible and calling out or screaming for help when necessary. Emphasis was also placed on the importance of reporting any such incidents to a parent, guardian, or another trusted elder to ensure protection and support.

Content validity of the intervention

Content validity was established to ensure that the intervention comprehensively covered essential domains related to personal safety, good touch, and bad touch. The intervention content was mapped against established child safety guidelines and literature on child sexual abuse prevention and personal safety education. An expert panel consisting of pediatric nursing faculty, mental health professionals, child development specialists, and special education experts independently evaluated each component of the intervention for relevance, adequacy, representativeness, and appropriateness for children with mental challenges. Experts rated the relevance of each subtopic and activity, and suggestions were obtained for improvement. Necessary revisions were incorporated to strengthen conceptual clarity, logical flow, and comprehensiveness. The finalized intervention demonstrated satisfactory content validity with a content validity index (CVI) of 0.9 and was considered suitable for implementation in the study.

The validated intervention was implemented through individualized, one-to-one sessions, each lasting approximately 30 minutes per day, tailored to the specific needs of each child. During each session, three topics were covered to facilitate focused learning and understanding. Children were encouraged to repeat the content during the sessions to reinforce understanding and retention. Following a seven-day gap after the intervention was completed, an evaluation was conducted using a structured assessment tool to determine the effectiveness of the intervention in improving children’s knowledge and understanding of good touch and bad touch.

Research instruments

Two tools were used for data collection in the study. Tool 1 consisted of a proforma designed to collect socio-demographic information of mentally challenged children, including variables relevant to understanding their background characteristics. Tool 2 was an image-guided structured interview questionnaire, developed separately for male and female children to ensure appropriateness and sensitivity.

This questionnaire comprised a total of 20 items distributed across five domains, namely awareness of private parts of one’s own body with five items, understanding of the swimsuit rule in relation to good touch and bad touch with three items, awareness of unsafe touch with three items, awareness regarding expected responses to unsafe situations with four items, and awareness of unsafe situations with five items. The description of the interview questionnaire is attached in the Appendices. For interpretation, each correct response was awarded one mark, while incorrect responses received no marks, resulting in a maximum possible score of 20, with higher scores indicating better awareness and understanding of good touch and bad touch.

Ethical clearance was obtained from the Institutional Ethics Committee of AIIMS Bhubaneswar (IEC/AIIMS BBSR/NURSING/2023-24/11, dated July 15, 2023), and administrative permission was obtained from the Chetana Institute for the Mentally Disabled, Bhubaneswar, Odisha. The entire research process was explained clearly to the participants using the Participant Information Sheet (PIS), and informed written consent was obtained from the relevant class teachers.

Pre-test was performed using a structured interview questionnaire (image-guided) in the teacher’s presence. After the pre-test, the CSAPP was implemented for each child on a one-to-one basis with help from the teachers. Post-tests were conducted one week after the intervention, using the same structured interview questionnaire (Image-guided) in the presence of the teacher. Data were collected accordingly, along with the conduction of pre-tests and post-tests. Collected data were entered, coded, and analyzed using IBM SPSS Statistics for Windows, Version 26 (Released 2018; IBM Corp., Armonk, New York, United States). Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to summarize socio-demographic variables and awareness scores. Inferential statistics were applied to evaluate the effectiveness of the intervention.

Results

The socio-demographic profile of the participants revealed that nearly 60% of the children were male, while 40% were female. The majority of participants, 95%, were adolescents, while the remaining 5% belonged to the school-age group. Regarding educational status, 75% of the children were studying at the primary level, while 25% were in middle school. All 20 children had Odia as their mother tongue and were instructed exclusively in the Odia language. In terms of birth order, all participating children were firstborn. For quantitative analysis, responses obtained through the image-guided structured interview questionnaire were converted into numerical values using a predefined scoring system. In regard to intervention effectiveness, since domain-wise awareness scores did not follow a normal distribution, the Wilcoxon signed rank test was used to compare the pre-test and post-test scores across the five domains of the CSAPP. The results demonstrated a statistically significant improvement in awareness scores across all five domains following the intervention, with p-values less than 0.05, as shown in Table 1. For comparison of the overall awareness scores before and after the intervention, a paired t-test was employed, as the total scores approximated normal distribution. The analysis revealed a statistically significant difference between pre-test and post-test mean scores, indicating a substantial improvement in children’s awareness regarding good touch and bad touch after the intervention, with the level of significance set at p < 0.05 (Table 2).

Table 1: Comparison of children’s overall awareness score before and after intervention of each domain under the interventionStatistical analysis was performed using the Wilcoxon signed-rank test. * Significance level set at p < 0.0001.

Table 2: Comparison of children’s awareness score on good touch and bad touch before and after the intervention Significance level set at p < 0.0001.*

Discussion

Sexual abuse has been one of the most prevalent forms of violence inflicted on mentally challenged children. Being deficient in social, interactive, and behavioral skills, mentally challenged children are more prone to encounter sexual abuse and assault in our society or even inside their homes. Therefore, it has now become a necessary skill to be taught to mentally challenged children and increase their awareness regarding sexual abuse and its prevention. The present study showed that the children's awareness regarding private parts of their bodies increased statistically after the package intervention. This result is consistent with the results of a study conducted by Alamdarloo et al. on the effect of a sex education intervention on the sexual knowledge of female adolescents with intellectual disabilities. Their study showed that their teaching intervention had increased the children’s general sexual knowledge and different subparts under the overall content, like differentiating between public and private parts and places, puberty and its changes, intimate and social relationships, social sexual boundaries, and considering safe sex practices and their legal aspects [8]. In the present study, it was observed that the children's awareness of unsafe touch, their understanding of expected responses to unsafe situations, and their recognition of unsafe situations increased statistically after the package intervention. This result is consistent with the results of a study conducted by Kucuk et.al., which reported that after providing complete intervention, there was an increase in knowledge and skills among the children regarding protecting themselves from possible sexual abuse and similar situations [9]. In this study, it was observed that the children's awareness of unsafe touch, expected responses to unsafe situations, and knowledge about unsafe situations increased statistically after the intervention. This result is consistent with the results of an experimental study conducted by Reis et al. that resulted in a considerable increase in knowledge regarding the prevention of sexual offences, especially improving their ability to recognize situations of abuse and increase their chances to prevent such behaviour towards them and take action in similar situations [10]. The result is consistent with the results of a randomized controlled trial conducted by Lee and Tang in China, which showed that conducting behavior skill training sessions with reinforcement and repeated sessions is effective in enhancing awareness regarding child sexual abuse and their skills of self-protection [11].

In the present study, it was observed that the children's awareness of unsafe touch, their understanding of expected responses to unsafe situations, and their recognition of unsafe situations increased statistically after the package intervention. This result is consistent with the results of the study conducted by Warraitch et al. in Pakistan, that teaching interventions on some basic concepts of sex education have proved to be of much influence in improving knowledge and skills regarding the prevention of sexual abuse [12]. In the current study, it was discovered that the children had a very low level of awareness regarding good touch and bad touch before the intervention was provided. Intervention programs to increase the knowledge and understanding among mentally challenged children can be conducted on a large scale by the government. Different non-government organizations have also contributed to the welfare of mentally challenged children, but the aspect of their safety against child sexual abuse has most often been ignored or not given much importance. Through this study, it was concluded that the mentally challenged children of these selected categories can be provided with awareness with proper intervention. So, our government can take initiatives to work towards spreading awareness and improving the safety of mentally challenged children at school. It was also discovered that knowledge and skills regarding good touch and bad touch were not included in the regular school curriculum for mentally challenged children. Including the contents regarding different concepts of good touch and bad touch will improve their awareness of self-protection and also enhance vigilance among mentally challenged children. While interacting with the teachers and the caregivers present in the school, it was also found that there was no specialized course for the teachers regarding the prevention of sexual abuse among differently-abled children. Although sex education has been introduced to children during puberty in schools for other children, special schools have yet to do so for mentally challenged children. Introducing sex education and teaching about good touch and bad touch to these children will eventually lead to the further spread and prevention of sexual abuse. Children will become more self-sufficient, and their dependability will decrease, potentially leading to an increase in self-confidence and personality improvement.

The study has implications for school health services, as a school health nurse can teach all the children about good touch and bad touch in the context of child sexual abuse prevention, which will ultimately help them prevent and protect from sexual abuse and spread awareness regarding child sexual abuse and its prevention. The content about good touch and bad touch in the context of child sexual abuse prevention should be included in school curricula, and school health nurses can help disseminate this knowledge effectively. Education on good touch and bad touch in the context of child sexual abuse prevention can be included in the curriculum of nursing students under preventive pediatrics within the pediatric nursing curriculum, as in nursing education. Education on good touch and bad touch in the context of child sexual abuse prevention can be taught to nursing students under the management of mentally challenged children for further awareness. It also has applications in the Board of School Education, as newer policies and regulations regarding good touch and bad touch in the context of child sexual abuse prevention, especially for mentally challenged children, can be introduced in schools. Committees for child sexual abuse prevention should be formed in schools for the prevention and early recognition of child sexual abuse. The study demonstrates that children with mental disabilities can acquire knowledge and awareness about good and bad touch, and the knowledge intervention in the study is strong enough to bring a change in the knowledge and behavior of mentally challenged children of the educable and trainable category. It can be used in special schools to raise awareness or be incorporated into their curriculum to be implemented more effectively. The study's limitations are that it only used one setting, a small sample size, and followed a one-group pre-test and post-test design.

Conclusions

The present study concluded that there was an increase in awareness regarding good touch and bad touch among the children. There was a statistically significant improvement in awareness scores in the domains of awareness of private parts of their own body, awareness of the swimsuit rule in relation to good touch and bad touch, awareness of an unsafe touch, awareness of what are unsafe situations, and awareness regarding expected response towards unsafe situations. It can be concluded that conducting training sessions on the prevention of sexual abuse for mentally challenged children will increase their knowledge and awareness and improve their self-protection skills.