Introduction
The estimated worldwide prevalence of child sexual abuse (CSA) ranges between 0.4% and 31%.1–3 The consequences of CSA can be major, affecting both short-term and long-term health and having both physical (from acute injuries to life-long chronic diseases) and psychosocial (eg, depression, anxiety disorders, post-traumatic stress disorder (PTSD), substance abuse and difficulties in forming intimate and trusting relationships) manifestations.4–7 In order to offer timely and appropriate care for victims, it is necessary for medical and psychological care professionals to recognise CSA early. Related physical injuries might heal quickly, and young children in particular experience many barriers to disclosing abuse.8–10 Symptoms of PTSD and age-inappropriate sexual behaviour and knowledge are considered the most commonly identified signs of CSA.11
Meanwhile, research on adult survivors of CSA shows that some of the cues the survivors gave as young children, such as telling about the abuse ‘in their own words’ or showing non-verbal and behavioural signs, remained unidentified by professional caregivers over time.9 12–14
The Sexual Knowledge Picture Instrument (SKPI) is a child-friendly picture book that was developed for professionals to assess a child’s knowledge of intimate body parts, intimacy, and adult sexuality, and to observe their non-verbal reactions at the same time.11 The pictures show daily routines in the lives of most children, gender differences, body parts and their functions, and normal intimate behaviour between children and/or adults. A manual for professionals was also developed. The manual contains instructions, a semi-structured interviewing protocol, and a scoring list for the evaluation of verbal and non-verbal reactions of the child. The SKPI is currently being validated in a study to determine its value as a diagnostic tool for CSA in young children.15 The main hypothesis in this study is that abused children can be distinguished from non-abused children by their verbal and non-verbal reactions to the instrument, and that looking at the pictures may lower the burden for abused children to disclose.15
As a first step in the validation of the SKPI, the current study investigated the verbal and non-verbal reactions to the SKPI in a group of non-abused Dutch children between the ages of 3 and 9. The aim of this study was to establish ‘normal’ values of verbal and non-verbal responses to the SKPI. We expected to see no non-verbal responses related to stress or discomfort during the interviews. An additional aim of the current project was to compare the sexual knowledge of boys and girls. The hypothesis was that we would find no differences in the sexual knowledge of young, non-abused boys and girls.
In our validation study currently being conducted, the reactions of the non-abused children will be compared with the verbal and non-verbal reactions of a group of (alleged) victims of CSA and the and inter-rater and intrarater reliability of the SKPI are investigated.