Hugs and Kisses — A Model for Child Sexual Abuse Prevention

By Jimmy A. Young, PhD, MSW, MPA; Hannah Miller, EdM; and Angie Mann-Williams, PhD, LCSW

The most recent data from the Child Maltreatment 2018 report show that the number of victims of child abuse and neglect rose to 678,000 in 2018 from 675,000 in 2014 (U.S. Department of Health & Human Services, 2020). The report further illustrates that 7% of those victims were sexually abused only. Previous studies have shown child sexual abuse (CSA) to be a silent epidemic affecting 1 in 4 girls and 1 in 20 boys in the United States (Finkelhor, Shattuck, Turner, & Hamby, 2014).

The definition of CSA has evolved over the years and is broadly understood now as “any sexual activity perpetrated against a minor by threat, force, intimidation, or manipulation” (Collin-Vézina, Daigneault, & Hébert, 2013). It is well established in the research literature that the traumatic experiences of CSA can result in psychological, behavioral, and physiological effects that last well into adulthood (Felitti et al., 1998; Hamby, Finkelhor, & Turner, 2012; Paolucci, Genuis, & Violato, 2001; Whitaker et al., 2008). It is critical that effective prevention and awareness efforts be utilized to help reduce the incidence and prevalence of CSA.

Hugs and Kisses — A CSA Prevention Program
Virginia Repertory Theatre in Richmond, VA, has been addressing the issue of CSA since 1983 through a program called Hugs & Kisses (Hugs). Hugs is a musical play produced by Virginia Rep in partnership with Families Forward Virginia (the state chapter of Prevent Child Abuse America) and the Virginia Department of Social Services. The Baxter Perkinson Center for the Arts and Education was added as an additional partner in July 2019. The program serves as the state’s principal CSA prevention and early intervention program.

In 1981, Ann Childress of the Virginia department of social services approached Bruce Miller, artistic director of then Theatre IV, and asked if they would develop the world’s first play that talks candidly to children K-5 about the issue of CSA. After 18 months of research, the theatre developed Hugs & Kisses. Initially, not a single school in Virginia would accept a free performance. In response, the coproducing agencies staged seven open statewide workshops. In the middle of this introductory tour, the infamous McMartin case broke in California. For the first time, the issue of CSA appeared on the covers of Time and Newsweek, and the phones at Theatre IV began to ring.

Today, the play has been seen in every school district in Virginia by approximately 1.9 million children. For 99% of these children, it serves as a prevention program, delivering safety messages that help them keep sexual abuse out of their futures. Anecdotal reports indicate that for approximately 1% of its audience, Hugs serves as an early intervention program. An estimated 19,000 children have come forward for the first time immediately following a performance to address a concern about their personal victimization. Because of the safety net established in cooperation with the three producing partners, each of these children has received the help they needed to address effectively their individual situation.

Hugs tells the story of a little girl who has been sexually abused. During the course of the play, the little girl and her friends learn life lessons about good touch, bad touch, and secret touch, which empower her to talk to a trusted adult who can bring help. The primary safety lessons taught in the play are: 1) the concept of secret touching; 2) if you experience secret touching you should tell a trusted adult; 3) private parts of your body are those that are covered by a swimsuit; 4) children have the right to say “no” to secret touching; and 5) secret touching is never the child’s fault. These safety lessons relate to the two broader themes of the play: touch knowledge and action knowledge.

In addition to its effectiveness, Hugs is recognized nationally for its pioneering role in developing best practices for talking with children about CSA. Appropriate messaging was developed through comprehensive national research. After serving as the keynote address at the 1984 national conference of the National Committee for Prevention of Child Abuse, and performing before the 1985 U.S. Senate Subcommittee on the Sexual Victimization of Children, the talking points created for the play have been used worldwide. It has been adopted as a model project in the nation of Israel and by the Attorney General’s office in the state of New York. In appreciation for his work on Hugs, playwright/director Bruce Miller received the Commissioner’s Award from the U.S. Department of Health and Human Services. With a rich 37-year history, Hugs continues to be an innovative prevention program with a rigorous evaluation model.

Hugs and Kisses Evaluation Model
The play has been evaluated every year since 1997 and each year the results indicate that children from kindergarten through fifth grade regularly learn the program’s prevention lessons. The play has also been an effective resource for teachers to enhance their knowledge and confidence in discussing CSA with their classes. Part of the Hugs model is encouraging teachers to hold a postplay discussion, and these discussions have been shown to help enhance students’ knowledge of the play’s primary lessons. The innovative two-part mixed methods evaluation gathers information from children using a valid and reliable questionnaire to assess their knowledge regarding the two broad themes, and information from teachers regarding the postplay discussions. The teacher evaluation questionnaire is meant to help evaluate their understanding of the content of the play and their readiness to discuss the main themes during the postplay discussion. In addition, selected teacher data are also matched to data from the students in their classrooms to better understand the relationship between the resources used by teachers and the knowledge gained by their students. The greatest strength of the evaluation is that it consistently demonstrates that children who view the Hugs & Kisses play increase their knowledge of good touch, bad touch, and secret touch, and know they can take action to stop secret touching. Additionally, teachers who hold a postplay discussion across all grades are able to further reinforce those lessons and increase student comprehension of the play’s concepts.

For example, results from the 2016 evaluation year involved 50 randomly selected schools with 31 schools participating in the evaluation, a 62% response rate. This participation netted 2,700 children’s questionnaires and 154 teacher’s questionnaires. Children’s level of knowledge regarding the play’s concepts was assessed using a seven-item questionnaire after viewing the play. The 2016 evaluation year factor analysis revealed two factors representing 42.9% of the variance. The two factors represent the broad themes of the play, action and touch knowledge. All grades combined scored 84.5%, surpassing the benchmark of 80%. Postplay discussions averaged just over seven minutes and those children whose teacher held a discussion scored better overall (85.74%) compared with those children whose teacher did not hold a discussion (83.37%). Viewing the play is critical to raising children’s touch knowledge and action knowledge and having a postplay discussion further reinforces that comprehension (Mann-Williams & Young, 2019).

Role of School-Based Prevention Programs
School-based prevention programs have been utilized for decades and represent a popular strategy to raise awareness of CSA because of the relative ease of implementation, low costs, and ability to reach large numbers of children (Finkelhor, 2009; Holloway & Pulido, 2018). Despite the popularity of these programs, there have been challenges related to identifying how best to replicate them, increase fidelity, and report on processes related to these programs (Topping & Barron, 2009). Most school-based prevention programs take place in the classroom and rely on teachers to implement workshops or specific curricula to teach children preventive strategies and provide them with increased knowledge about CSA (Brown, 2016; Collin-Vézina, Daigneault, & Hébert, 2013; Holloway & Pulido, 2018; Nickerson, Livingston, & Kamper-DeMarco, 2017). The Hugs & Kisses prevention program not only increases knowledge among children but also helps teachers be prepared to reinforce that learning. Over the years of this evaluation, Hugs has always been identified as the top resource for helping teachers feel more prepared to identify and discuss CSA.

For the first time, Hugs is now being made available for licensing nationwide. This time-tested prevention and early intervention program fulfills many gaps identified within the literature by blending the engaging power of live theatre with the opportunity for postperformance one-on-one conversation with children. The continued evaluation of the play will serve as a foundation for measuring the effectiveness of this unique mode of prevention. All parties associated with the implementation and evaluation of the program particularly look forward to assessing its impact in the broader national population.

— Jimmy A. Young, PhD, MSW, MPA, is an associate professor in the department of social work at California State University San Marcos.

— Hannah Miller, EdM, is the associate director of community health + wellness for Virginia Repertory Theatre in Richmond, VA.

— Angie Mann-Williams, PhD, LCSW, is an assistant professor in the School of Social Work at Eastern Michigan University.

References
Brown, D. M. (2016). Evaluation of safer, smarter kids: Child sexual abuse prevention curriculum for kindergartners. Child and Adolescent Social Work Journal, 34(3), 213-222.

Collin-Vézina, D., Daigneault, I., & Hébert, M. (2013). Lessons learned from child sexual abuse research: Prevalence, outcomes, and preventive strategies. Child and Adolescent Psychiatry and Mental Health, 7(22), 1-9.

Felitti, V. J. et al. (1998). Relationship of child abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245-258.

Finkelhor, D. (2009). The prevention of child sexual abuse. The Future of Children, 19(2), 169-194.

Finkelhor, D., Shattuck, A., Turner, H. A., & Hamby, S. L. (2014). The lifetime prevalence of child sexual abuse and sexual assault assessed in late adolescence. Journal of Adolescent Health, 3, 329-333.

Hamby, S., Finkelhor, D., & Turner, H. (2012). Teen dating violence: Co-occurrence with other victimizations in the National Survey of Children’s Exposure to Violence (NatSCEV). Psychology of Violence, 2(2), 111-124.

Holloway, J. L., & Pulido, M. L. (2018). Sexual abuse prevention concept knowledge: Low income children are learning but still lagging. Journal of Child Sex Abuse, 27(6), 642-662.

Mann-Williams, A., & Young, J. A. (2019, October). Hugs & Kisses: An innovative prevention program and evaluation model. E-Poster presented at the Council on Social Work Education, Annual Program Meeting, Denver, CO.

Nickerson, A. B., Livingston, J. A., & Kamper-DeMarco, K. (2017). Evaluation of second step child protection videos: A randomized controlled trial. Child Abuse & Neglect, 76, 10-22.

Paolucci, E. O., Genuis, M. L., & Violato, C. (2001). A meta-analysis of the published research on the effects of child sexual abuse. The Journal of Psychology, 135(1), 17-36.

Topping, K. J., & Barron, I. G. (2009). School-based child sexual abuse prevention programs: A review of effectiveness. Review of Educational Research, 79(1), 431-463.

U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2020). Child Maltreatment 2018. Retrieved from https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment

Whitaker, D. J., Le, B., Hanson, R. K., Baker, C. K., McMahon, P. M., Ryan, G., Klein, A., Rice, D. D. (2008). Risk factors for the perpetration of child sexual abuse: A review and meta-analysis. Child Abuse & Neglect, 32(52), 199-215.