Child Sexual Abuse Module in the Child Abuse Pediatrics Curriculum for Physicians (CAP-CuP)

Abstract

Introduction

Child sexual abuse afflicts over 50,000 children in the United States per year but is undertaught in medical training.

Methods

We designed an interactive module on child sexual abuse as part of a core curriculum in child abuse pediatrics. The module was targeted toward physicians who treat children, at any stage of training (i.e., from medical students to practicing physicians). We evaluated the module in three ways: presentation to an audience of pediatric practitioners at a continuing medical education (CME) conference to solicit qualitative feedback; presentation to an audience of family medicine residents with a short pre- and postmodule assessment measuring confidence and knowledge; and presentation to a small group of medical students, with the same pre- and postmodule assessment. After completion of the module, participants were provided with the 2024 revised Sexual Abuse and Assault Pocket Tool as an adjunct for clinical use, reflecting the latest US Centers for Disease Control and Prevention guidelines.

Results

Participants in the three presentations included 39 pediatric practitioners at the CME conference, 19 family medicine residents at their required educational conference, and five medical students participating in a child abuse elective. Qualitative feedback from the CME audience was favorable, and participants’ knowledge scores in the resident and medical student audiences increased from before to after the module.

Discussion

This interactive module about child sexual abuse has received favorable qualitative and quantitative feedback from a variety of pediatric practitioners, ranging from medical students to physicians.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Recognize the importance of disclosure and know how to triage a concern for child sexual abuse.
• 2.Identify genital exam findings that are specific versus nonspecific for trauma.
• 3.Describe important components of trauma-informed care.

Introduction

Child sexual abuse afflicts over 50,000 children in the United States per year but is undertaught in medical training.^1–4 Notably, residents have significantly less comfort performing and interpreting exams for child sexual abuse in comparison to physical abuse⁴ and demonstrate need for training in this area.^2–4 Front-line providers in primary care and emergency departments must be equipped to appropriately triage concerns from caregivers, perform limited external genital exams, and know when to consult an expert. Minimal training for front-line providers in combination with limited availability of experts⁵ pose concerns for missteps in management and imprecision in reporting (e.g., unnecessary reports made to child protection for nonspecific concerns and physical findings^6–8).

Unfortunately, there is no standard curriculum available for teaching physicians about child sexual abuse. In 2020, Sagalowksy and colleagues conducted a qualitative needs assessment for pediatric residents on this topic and made four recommendations for an ideal curriculum: (1) prelearning; (2) live workshop; (3) real-time tools; and (4) clinical experience.⁹ First, they noted, in particular, the importance of prelearning that is asynchronous, is interactive, and incorporates videos, cases, and decision branch-points. Second, they recommended that prelearning be followed by a live workshop that is interactive and case-based, involving simulated patients or manikins. Third, they recommended that participants be given real-time tools for clinical use. Fourth, they recommended that participants be given the opportunity to put their knowledge into practice in clinical settings. Due to the sensitive and medicolegal nature of these cases, clinical exposure can be a limiting factor in education. In contrast to other areas of medicine where graduated autonomy of medical trainees can be supported in clinical settings with real patients from the very beginning, we propose that a baseline level of training about how cases of child sexual abuse are handled is imperative before entry into the clinical setting.

Available teaching resources on the topic of sexual abuse and assault are limited to cases of adult sexual assault^10,11 or human-trafficking,^11,12 and have been targeted primarily to medical students. There are two role-play teaching modules published in MedEdPORTAL that focus on child sexual abuse and assault. One module is a simulated scenario with a mother who has concern about her young daughter.¹³ The other module is a manikin-based skills session for forensic evidence collection in an adolescent reporting sexual assault.¹⁴ Both of these sessions would be fitting for the live workshop element of the Sagalowksy curriculum.⁹ As for the prelearning and clinical tool elements, we propose the following five priorities. (1) The focus should be on child and adolescent patients. (2) The target audience should be physicians who treat children. (3) The material should incorporate tips for teaching children body safety, since even trusted adults in positions of authority can pose a risk.^15–17 (4) The material should incorporate trauma-informed care, which means collaborating to build systems that ensure physical and psychological safety for victim-survivors of trauma.¹⁸ (5) The material should be updated routinely to reflect updates in practice guidelines.^19,20 For example, a sexual abuse pocket tool previously published in MedEdPORTAL in 2012 is due for updating in accordance with the latest US Centers for Disease Control and Prevention guidelines,¹⁹ and guidelines for interpretation of sexually transmitted infection testing and genital examination findings were recently updated²⁰ (as occurs every 5 to 10 years^20–22).

We created an interactive module that fulfills these five priorities. We highlight in this work the nuances of disclosure in young children (i.e., the process by which young children tell about sexual abuse happening to them), the risk of leading or repeated questioning,²³ the interpretation of prepubertal female genital exams,²² and the experience of male victims.²⁴ In addition, we collaborated with the authors of the original 2012 Sexual Abuse Pocket Tool²⁵ to revise and expand the tool in accordance with updated CDC guidelines.¹⁹ The final product (the 2024 Sexual Abuse and Assault Pocket Tool) is an updated, accessible clinical resource that can be provided to participants as an adjunct after an interactive module on fundamental child sexual abuse education. The module is versatile for adapting to various formats such as individual self-paced completion, small-group presentation, and large-group presentation.

Methods

We created a child sexual abuse module (Appendix A) in 2022 as part of a core curriculum in child abuse pediatrics targeted toward physicians who treat children, at any stage of training (i.e., from medical students to practicing physicians). The curriculum is known as CAP-CuP (for Child Abuse Pediatrics Curriculum for Physicians). The module author (Katie Johnson) is a child abuse pediatrician who has completed both adult and pediatric Sexual Assault Nurse Examiner training and routinely cares for victim-survivors of child sexual abuse and assault. The module was reviewed and edited by two board-certified child abuse pediatricians with similar experience (Emily Brown and Caitlin Crumm). The adjunct pocket tool was originally described in 2012, including one of the co-authors of this project (Lynn Sheets).²⁵ It was recently updated by two additional co-authors (Hillary Petska and Lauren Frank).

We built the child sexual abuse module in PowerPoint, though it is optimally implemented with the use of a quiz-based polling software such as Kahoot! or PollEverywhere. Polling software is recommended, but not required, for implementation. Hyperlinks to the optional Kahoot! audience-response version of the presentation as well as a presenter script are included in the PowerPoint slide notes (Appendix A) as well as the technical guide (Appendix B) to facilitate accessibility, accuracy, and reliability in the presentation of this material. When polling software is not used, participants may use a pen and paper or a personal cell phone or computer to record their answers. The audience-response questions were incorporated with the purpose of making the material more challenging and switching the audience from passive to interactive learning, thus solidifying the learning points.²⁶ In addition, the format of the presentation alternates between a presenter script and the use of audiovisual media to engage the audience through storytelling.^23,24 Lastly, a wide range of Creative Commons licensed visual aids were sought out for this presentation to ensure variety in visual diagnosis, interpretation, and diversity in patient skin tone.^22,27

We conducted pilot-testing of this module, including presentation to large audiences, small groups, and individual, self-paced completion by pediatric and family medicine residents. Informal feedback from the residents reaffirmed that the material was thought-provoking, the slides were easy to understand with or without a presenter, and the optional game-based format was engaging. The use of Kahoot! encourages engagement of the audience through friendly competition and reinforces psychological safety in the teaching of sensitive material by incorporating light-hearted visuals, music, and anonymous player nicknames.²⁸ To further foster psychological safety in the presentation of this material, the opening disclosure slide acknowledges that this content can spur emotional responses and encourages debriefing with trusted mentors and colleagues.

This project was approved by the Mayo Clinic Education Research Committee and was deemed exempt by the Mayo Clinic Institutional Review Board. We evaluated the module in three different formats. First, the module author presented the child sexual abuse module in-person to an audience of pediatric practitioners at Mayo Clinic Pediatrics Review, a continuing medical education (CME) conference. This conference utilized Vevox (as opposed to Kahoot!) for audience-response polling, in accordance with the conference protocol. The module was easily adapted for use with this audience-response system. The conference hosts collected feedback from the audience, which was used by the authors to assess acceptability and effectiveness of the teaching material. Participants were asked to rate the content and the presentation skills for this module on a 5-point scale (1 = poor, 5 = excellent). They were also given the opportunity to provide qualitative feedback, including strengths and areas for improvement.

Second, the module author presented the child sexual abuse module in-person to an audience of family medicine residents during a 45-minute routine educational conference. A pre- and postmodule assessment consisting of five questions was used to evaluate the participants’ confidence and knowledge relating to child sexual abuse. The first question evaluated self-rated confidence in responding to a concern for child sexual abuse, scored on a scale of 1 to 10 (1 = not at all confident, 10 = completely confident). The next four questions evaluated knowledge about managing cases of suspected child sexual abuse (Appendix C). The knowledge questions were written by the module author (Katie Johnson), who specializes in medical education and serves on an editorial board for creation of child abuse pediatrics study content. Question stems and answer choices were subject to character limitations to accommodate the optional use of Kahoot! for collecting audience responses. The assessment questions were reviewed and edited by two board-certified child abuse pediatricians with experience creating and validating child abuse pediatrics study content (Emily Brown and Caitlin Crumm). The family medicine audience consisted of first-, second-, and third-year residents attending their monthly all-resident educational seminar. Of the 27 family medicine residents in the program, 8 had completed a child abuse rotation before this presentation and thus had completed the child sexual abuse module previously. Audience responses for each participant were calculated using descriptive statistics, including median scores with interquartile range (IQR) for responses to the confidence-level question (question 1) and the proportion of correct responses for the multiple-choice and true/false knowledge questions (questions 2–5). We conducted a subgroup analysis to compare results from residents who had completed the module previously versus those who had not.

Third, in order to evaluate whether presentation of the material was feasible (i.e., capable of being presented effectively and with ease) by someone other than the module author, the module was presented in-person by a pediatric resident (Maheen Bangash) to a small group of medical students completing a child abuse elective. The technical guide (Appendix B) was used to facilitate presentation of this material by a physician who had not completed specific training in child abuse pediatrics. Feasibility was measured in two ways, by (1) seeking qualitative feedback on the experience from the resident presenter, and (2) reviewing pre-and postmodule assessment results from the medical students.

The duration of all presentations was approximately 45 minutes. For the presentation, the following materials were needed:

• •Presenter: A computer with internet connection, a projector screen, and the ability to share visual and audio content. The hyperlinks to the optional Kahoot! audience-response materials for large groups (Appendix A, Appendix B) was used for all presentations.
• •Participants: A cell phone or personal computer with internet connection.

After the presentation, we provided attendees with a recently revised version of the 2024 Sexual Abuse and Assault Pocket Tool²⁵ for clinical use (Appendix D).

Results

In the CME conference presentation, there were 39 attendees from a multidisciplinary audience that was primarily composed of pediatric physicians (33%, n = 13), nurse practitioners (41%, n = 16), and physician assistants (15%, n = 6). The remaining audience members were nurses (5%, n = 2), “other healthcare professionals” (3%, n = 1), and students (3%, n = 1). Of the 39 attendees, 37 filled out the presentation evaluation for this module (response rate = 95%). One hundred percent of respondents rated the content and the presentation skills as excellent or very good. Qualitative feedback regarding the strengths and areas for improvement was solicited. Illustrative examples of the qualitative feedback commentary are shown in Table 1. We organized the comments into three distinct themes: tone, presentation style, and clinical application. No specific areas of improvement were noted, and thus no changes were made to the content based on the CME conference feedback.

Table 1. Qualitative Feedback About the Child Sexual Abuse Module From Attendees at the CME Conference.

In the family medicine audience who performed the pre- and postmodule confidence and knowledge assessments, there were 19 family medicine resident attendees. Residents’ self-rated confidence increased only minimally, from a premodule median score of 5 (interquartile range [IQR] 4–6) to postmodule median score of 6 (IQR 5–7) (Figure 1). However, residents’ knowledge scores increased notably, from a premodule median score of 50% (IQR 50%–75%) to postmodule median score of 100% (IQR 100%–100%; Figure 2). The subgroup analysis comparing baseline self-rated confidence and knowledge scores of residents who had completed the module previously versus those who had not is shown in Table 2. The top three Kahoot! winners—those having earned points in the pre- and postmodule assessments as well as in the audience-response questions dispersed throughout the presentation—were all first-year residents who had completed the module months prior to the presentation. Of note, self-identification as a winner at the conclusion of the session was voluntary in order to prioritize participant confidentiality and psychological safety.

Figure 1. Participants’ self-rated confidence level in responding to a concern for child sexual abuse in pre- versus postmodule assessments. Box plots show the median scores with interquartile range (scale 1–10; 1 = not at all confident, 10 = completely confident). The median confidence level increased from 3 (IQR: 3.00–4.00) to 4.5 (IQR: 3.75–5.35) for the medical students and to 5 (IQR: 4.00–6.00) to to 6 (IQR: 5.00–7.00) for the residents. The whiskers extend to a maximum of 1.5 × IQR above and below the 3^rd and 1^st quartiles, respectively. Outliers beyond these ranges are indicated by dots.

Figure 2. Percentage of participants’ correct responses to four knowledge-based questions about managing cases of suspected child sexual abuse in pre- versus postmodule assessments. The median knowledge score increased from 75% (IQR: 75%-75%) to 100% (IQR: 100%-100%) for the medical students and 50% (IQR: 50%-75%) to 100% (IQR: 100%-100%) for the residents. The whiskers extend to a maximum of 1.5 × IQR above and below the 3^rd and 1^st quartiles, respectively.

Table 2. Comparison of Baseline Confidence and Knowledge Scores Among Family Medicine Residents Who Had Completed the Child Sexual Abuse Module Previously Versus Those Who Had Not.

In the presentation by a pediatric resident to medical students, there were five medical student attendees. We again observed a minimal increase in the medical students’ self-rated confidence, from a premodule median score of 3 (IQR 3–4) to postmodule median score of 4.5 (IQR 3.75–5.25) (Figure 1), and we observed a more pronounced increase in scores on the knowledge questions (Figure 2). The median score on the knowledge questions before the module was 75% (75%–75%) and the median score after the module was 100% (100%–100%).

Discussion

This interactive module about child sexual abuse received favorable qualitative and quantitative feedback from a variety of pediatric practitioners ranging from medical students to physicians. The qualitative feedback focused on appreciation for the tone, presentation style, and clinical applicability. The quantitative data demonstrated increased scores on knowledge questions among participants. While the minimal increases in self-rated confidence levels did not reflect the concomitant increase in short-term knowledge scores, a tangible tool (Appendix D) was provided to participants after the presentations, which we hope will bolster confidence in the clinical setting. A past version of this tool was reported to “markedly [improve] comfort with conducting sexual assault evaluations” among healthcare professionals.²⁵

In addition to a large audience of pediatric practitioners, the child sexual abuse module has undergone pilot-testing with (and continues to be used by) residents in family medicine, pediatrics, and emergency medicine on the child abuse pediatrics elective rotation at Mayo Clinic. It is worth noting that the family medicine residents who had completed the interactive child sexual abuse module months prior to the presentation had slightly higher confidence levels and knowledge scores in the premodule assessment, despite being some of the most junior members of the audience (i.e., four of five were interns). The three highest-scoring participants in the Kahoot! module were among these first-year residents having completed the module months prior. It was also notable that the medical students had a higher median knowledge score at baseline than the family medicine residents, which may have been attributable to small sample sizes or the fact that the medical students were a group who self-selected into a child abuse elective, whereas the family medicine presentation was required for all residents.

Our module provides new contributions to child sexual abuse education by including up-to-date clinical recommendations and filling known gaps in medical education.^2–4 We also created a pocket tool (Appendix D) that may be provided as an adjunct for use in the clinical setting. This module can be presented by physicians in a variety of settings and supports learner engagement through its interactive format. Multidisciplinary audiences can benefit from the content, as was demonstrated by the qualitative feedback from the CME conference.

One lesson learned from this project was how to create material on a sensitive topic that is feasible for presentation by someone (other than the module author) who may not have specific training in child abuse pediatrics. The technical guide and script (Appendix B) proved effective for this purpose, as evidenced by the feedback from the resident presenter. The feasibility of having this material presented by non–child abuse pediatricians is important, given workforce threats to the field of child abuse pediatrics⁵ resulting in fewer child abuse pediatricians available to teach this material. Another lesson learned was how to seamlessly pair the technical guide and script (Appendix B) with the optional use of Kahoot! polling software to present the material. Unlike PowerPoint, Kahoot! does not offer presenters the option to display slides with an accompanying script on a separate monitor. This can be mitigated by casting only the internet browser with Kahoot!–as opposed to the entire screen–to the audience, so that the script document can be opened and viewable only to the presenter. Another option is to use a printed copy of the script.

Limitations of this project include its primarily didactic form, although this is optimized through use of an optional game-based platform that has been shown to be effective in prior literature.²⁸ There was a missed opportunity to use a conceptual framework such as Kolb's Theory of Experiential Learning or Kern's Model of Curriculum Development, but several elements of these frameworks were utilized nonetheless. Framework elements that were utilized included identification of a problem or educational gap,^2,3 development of objectives, use of creative educational strategies,^26,28 implementation of the teaching material, evaluation of the material, solicitation of feedback, and identification of experiential learning opportunities^13,14 to pair with our module and pocket tool. Due to the relatively small sample sizes, we were limited to descriptive statistics rather than inferential statistics. We have drawn our data from participants’ short-term recall and self-rated confidence, which are both relatively low on Bloom's Taxonomy of Educational Objectives.²⁹ Furthermore, the knowledge questions were not pilot-tested, and the clinical use of the pocket tool was not studied. The minimal increase in confidence despite noticeable improvements in knowledge may indicate a need to further bolster the confidence of participants.

Additional opportunities for further research may include expanding the presentation to other audiences, such as child protective services case workers (removing the genital exam section) and public health nurses. Trialing the presentation on nonphysician audiences (with appropriate additions or omissions based on audience objectives) is also reasonable, considering the multidisciplinary nature of child abuse pediatrics. This module could be paired with a simulated case, such as those previously published in MedEdPORTAL,^13,14 along with a targeted evaluation form³⁰ and debrief regarding emotional responses and lessons learned. Role play scenarios could involve opportunities to practice trauma-informed care, consider the nuances of a sexual abuse disclosure in a young child, and appropriately triage a new disclosure. In addition, a study evaluating whether use of the pocket tool increases adherence to clinical guidelines after the module presentation would be beneficial. Any of these modalities could serve to reinforce this needed content for medical trainees and multidisciplinary partners who serve one of our most vulnerable patient populations.

Funding Statement

None to report.