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OBJECTIVE: To determine the intra-rater and inter-rater reliability of the Sexual Knowledge Picture Instrument (SKPI), a potential diagnostic instrument for young suspected victims of sexual abuse containing three scoring forms, that is, verbal responses, non-verbal reactions and red flags. DESIGN: Video-recorded SKPI interviews with children with and without suspicion of child sexual abuse were observed and scored by two trained, independent raters. The second rater repeated the assessment 6 weeks after initial rating to evaluate for intra-rater reliability. SUBJECTS: 78 children aged 3-9 years old were included in the study. 39 of those included had known suspicion of sexual abuse and the other 39 had no suspicion. MAIN OUTCOME MEASURES: Intra-rater and inter-rater reliability of the scores per study group and in the total sample were assessed by Cohen's kappa and percentage of agreement (POA). RESULTS: The median intra-rater Cohen's kappa exceeded 0.90 and the POA exceeded 95 for all three forms in both study groups, except for the red flag form (median Cohen's kappa 0.54 and POA 87 in the suspected group, and 0.84 and 92, respectively, in the total sample). For the verbal scoring form the median inter-rater Cohen's kappa and POA were 1.00 and 100, respectively, in both groups. For the non-verbal form the median inter-rater kappa and POA were 0.37 and 97, respectively, in the suspected group, and 0.47 and 100, respectively, in the control group. For the red flag form, they were 0.37 and 76, respectively, in the suspected group and 0.42 and 77, respectively, in the control group. CONCLUSION: The reliability of the SKPI verbal form was sufficient, but there is room for improvement in the non-verbal and red flag scoring forms. These forms may be improved by adjusting the manual and improving rater training.

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Background: The Sexual Knowledge Picture Instrument (SKPI) is a child-friendly picture book that was developed as a diagnostic tool for sexual abuse in young children and is currently being validated. The aim of the current study was to explore the verbal and non-verbal reactions of non-abused Dutch children, aged 3-9 years, to the SKPI and to assess differences in reactions between genders and age groups. Methods and analysis: Subject recruitment took place at preschools and primary schools. All children underwent a recorded video semi-structured interview with the SKPI. Interview recordings were scored by an independent rater who used scoring lists for verbal and non-verbal reactions. Non-parametric tests were used in statistical analyses. Results: Of the 90 children (median age 5 years) participating in the study, most correctly named the genitals and their non-sexual functions. Only 34 showed an understanding of the picture depicting adult sexuality, with just one child describing a sexual function. Girls (n=45) gave more correct answers (median 87%) than boys (n=45, median 78%; p=0.006). Giggling was the most frequently observed non-verbal reaction, with a total of 186 instances in 54 children. Conclusion: Non-abused children up to 9 years of age showed only limited knowledge of the sexual function of the genitals and hardly any insight into adult sexuality.

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BACKGROUND: The consequences of child sexual abuse (CSA) can be significant and can affect short-term and long-term mental, sexual and physical health. In order to offer timely and appropriate care for the child, early recognition of CSA is necessary. The lack of specific physical and psychological signs and barriers to abuse disclosure that these young victims face makes it difficult for medical and psychological professionals to recognise and confirm CSA signs. We aimed to validate the Sexual Knowledge Picture Instrument (SKPI) as a diagnostic instrument for CSA. METHODS AND ANALYSIS: An observational study to quantify the intraobserver and interobserver reliability and diagnostic accuracy of the SKPI will be performed. A total of 250 subjects from three groups will be included in the study: (1) a group of suspected CSA victims, recruited from three academic paediatric hospitals; (2) a case group of (proven) victims of CSA, recruited in cooperation with the Dutch Police Vice Squad; and (3) a control group of children, recruited from preschools and primary schools. All children will be interviewed using the SKPI, and to investigate reliability, video recordings will be assessed and reassessed by the same and a different blinded rater, respectively. Within 1 year, the results of the SKPI will be compared with the conclusions from the independent child protective services or police reports. If necessary, the SKPI will be modified to improve its reliability and accuracy. ETHICS AND DISSEMINATION: This validation study of the SKPI is necessary for obtaining a reliable diagnostic tool, which will enable medical and psychological professionals to detect CSA in young victims at an early age and start intervention/treatment. TRIAL REGISTRATION NUMBER: NL 50903.018.15.