虐待儿童问题基础课程 为从事健康卫生事业的专职人士而准备

国际阻止虐待忽视儿童协会 （ISPCAN）医学课程开发专责小组制定 成员：史蒂夫·布施博士 (主席)，伊芙琳·艾森斯坦博士（共同主席），莫深哈·斯木博士，兰达·优素福博士，帕特丽夏·赖佘博士，图费勒·穆罕默德博士，玛格丽特·林奇博士和兰德尔·亚历山大博士   霍华德·杜堡威特兹博士，主持人及编辑 ISPCAN 的支持工作人员

案例1 男性婴儿：美国 经济上有压力的家庭 易哭闹的婴儿 臀部伤痕 中耳炎 硬膜下血肿 广泛的视网膜出血

易哭闹的婴儿 来源：美国儿科学会 Ask the audience if they have any suggestions as what may have happened. Infant crying can be very stressful for parents, and can increase the risk for maltreatment. Excessive crying may lead to caregiver fatigue, and feelings of frustration, anger, and/or inadequacy when efforts to soothe the baby are unsuccessful. The caregiver may direct this anger and frustration toward the baby, leading to abusive acts such as shaking, and/or slamming the baby down. The child has a subdural hematoma (bleeding in the space between the brain and skull – photo top right), fractured ribs (photo – bottom right) and extensive retinal hemorrhages (bleeding in the back of the eye – photo bottom left): classic findings of abusive head trauma or Shaken Baby Syndrome. This collection of findings is due to shaking the child forcefully while tightly squeezing the ribcage. The result is injury to the brain, eyes and rib fractures. Injuries to the ends of the arm and leg bones (metaphyseal fractures) can also occur from flailing of the extremities during shaking. The severity of symptoms is directly related to the force used. Often there may be a number of minor episodes of shaking with less severe symptoms initially such as irritablity, poor feeding, lethargy and to cry even more. This can lead to further episodes of shaking. 20 to 30% of babies who are injured this way die and many who survive have life long disabilities. 4

讨论 什么是虐待儿童？ 虐待儿童、身体上虐待儿童、虐待性颅脑外伤有多常见？ 博比的受伤是由于虐待引起的吗？ 博比的诊断是什么？ 在博比的两个星期定期的健康检查中，为什么医生不怀疑是虐待？ Here are some of the questions about Bobby that we will be discussing.

什么是虐待儿童？

虐待儿童 利用职责、信赖或权力的关系，在肉体上和/或精神上进行各种形式的虐待、性虐待、疏忽或疏忽治疗或商业性或其他性质的剥削，对儿童健康、生存、发展或尊严造成实际或潜在危害。 (世界卫生组织 1999) This slide gives the formal definition of Child Abuse as developed by WHO in 1999. The key point is that acts of omission or commission that interfere with a child reaching his or her full potential are considered maltreatment. Acts of commission include physical and sexual assault as well as commercial and sexual exploitation, while acts of omission include various forms of neglect, such as nutritional neglect (lack of adequate food), educational neglect (lack of adequate education), and medical neglect (lack of adequate medical care, including mental health care). This is a good time to ask “What do you consider Child Maltreatment?” This is also the correct time to discuss terminology. The term child maltreatment will be used to include both abuse and neglect throughout this seminar. 7

虐待儿童的发生率 每1000的发生率 Determining the frequency of child maltreatment is challenging. There are many sources of data on maltreatment, and some capture more cases than others. Here is an example of multiple data sources from the United States (1) NCANDS is the National Child Abuse and Neglect Data System. It includes only cases of maltreatment that are reported to state Child Protective Service (CPS) agencies. (2) NIS-4 is the 4th National Incidence Study on Child Abuse and Neglect. It contains cases of child maltreatment reported to CPS, but also contains cases of maltreatment that are known to professionals but not reported. (3) The self-report data comes from an anonymous telephone survey conducted in North and South Carolina, United States. As you can see, many incidents of maltreatment never come to the attention of CPS or other professionals 8

虐待儿童的发生率 每1000的发生率 Data sources: World Health Organization. World report on violence and health, Chapter 3, Child abuse and neglect by parents and other caregivers. While official rates of child maltreatment in Canada are similar to those of the United States, worldwide estimates of physical and sexual abuse are much higher. 9

知的个案只是冰山的一角 Remind the audience that none of the data sources mentioned previously can identify all episodes of child maltreatment. 10

残酷体罚率 来源：世界卫生组织世界安全研究 朗岩•DK， 《儿科医学》，2010；126：e701-11 Rates and types of harsh physical punishment show much variation from one country to another. Actions considered acceptable by most people in one community, state, or country may be considered abuse elsewhere. 来源：世界卫生组织世界安全研究 朗岩•DK， 《儿科医学》，2010；126：e701-11 11

心理惩罚率 来源：世界卫生组织世界安全研究 Some forms of psychological maltreatment are extremely common around the world. Again, the rates of different types of psychological maltreatment vary from country to country. 来源：世界卫生组织世界安全研究 12

虐待性头部创伤 摇晃小于两岁的儿童 基南: 特别护理病房入院和死亡 西奥多: 家长报告 Ask the readers why they think the rates are so different. Possible explanations: Keenan study: Misses non-ICU hospital admissions, emergency department, and outpatient visits, children who don’t get any medical attention Theodore study: shaking incidents may include many children who are not injured from more minor shaking 基南等，《美国医学协会期刊》，2003;290:621-6 西奥多等，《儿科医学》，2005;115:e331-7 13

虐待儿童的比率高于大多数"官方"统计数据 不过虐待儿童比其它儿童童年问题更常见吗? 14

与其它童年问题比较 *表示流行。所有其它都是发生率 These comparisons are taken from U.S. data, but make the point that child maltreatment is more common than many other childhood medical conditions. *表示流行。所有其它都是发生率 15

博比的受伤是虐待造成的吗?

鉴别诊断 #1 -创伤 #2 -创伤 #3 -创伤 While there may be conditions that cause each of these findings in isolation, the combination of subdural hemorrhage, extensive retinal hemorrhage, brain injury, and fractures is diagnostic for trauma, most likely from child abuse.

鉴别诊断 硬膜下血肿 非加害造成的创伤 不正常流血现象 破裂性动脉瘤 过度弹性皮肤综合征 戊二酸血症第一型 鉴别诊断 硬膜下血肿 非加害造成的创伤 不正常流血现象 破裂性动脉瘤 过度弹性皮肤综合征 戊二酸血症第一型 Because each of Bobby’s findings can occur in isolation, it is important to consider the differential diagnosis for each individual finding. Ehlers-Danlos is a connective tissue disorder. Children with this condition have fragile and hyperelastic skin, easy bruising, and hypermobile joints. Glutaric aciduria type I is a metabolic disorder in which children develop seizures, abnormal movements, and loss of developmental milestones.

鉴别诊断 视网膜出血 正常出生 不正常流血现象 高血压 代谢紊乱 动脉瘤 心肺复苏 感染 上面症状很少引起广泛性出血！ Retinal hemorrhages can be seen in a number of medical conditions. However, they are generally few in number and confined to the posterior pole. Extensive retinal hemorrhages that extend to the periphery of the retina, and occur in multiple layers of the retina are very specific for child abuse. Extensive retinal hemorrhages are occasionally seen in crush injuries to the head. However, this diagnosis should be obvious from the history and clinical findings.

肋骨骨折的鉴别诊断 非加害造成的创伤：应该是严重创伤史（如，机动车撞击，直接一击) 分娩受伤：难产史 代谢性骨病：成骨不全症，佝偻病等。 过早分娩的早产儿 Ask the audience why rib fractures are uncommon in infants. Remind them that in young children, ribs are still predominantly composed of cartilage, and are therefore very flexible and are more likely to bend than break. There are still some conditions and injuries that can lead to rib fractures, and it is important to consider and rule out these possibilities when diagnosing abuse.

肋骨骨折 高特征的虐待 特别是在后部或外侧 通常是看不见的。 急性肋骨骨折常常难发现，特别是在前部或外侧 1-2周后愈合时很容易在X光片上看到 This x-ray shows healing rib fractures, indicated by the arrows. Remind the audience that when rib fractures heal, callus forms, leading to a rounded appearance on x-ray. This callus is often easier to identify than acute rib fractures, where it may be difficult to distinguish fracture lines from lung markings.

肋骨骨折-损伤的机制 压迫胸部导致后肋骨以脊柱作杠杆。 压迫使得头部和颈部的内侧骨骼拉紧，造成骨折。 科磊曼•PK，受虐儿童的诊断影像，第二版，圣路易斯，密苏里州：莫斯比出版社，1998，p116.

博比的诊断结果是什么？

虐待性颅脑外伤是 任何对孩子头部造成的伤害

虐待性颅脑外伤 摇晃婴儿综合症 摇晃影响综合症 加害造成的创伤性脑损伤 Many terms are used by professionals and lay persons to indicate abusive head trauma. The American Academy of Pediatrics recommends that professionals NOT use the term shaken baby syndrome, as it indicates a mechanism, rather than a diagnosis. However, shaken baby syndrome is a term that is often more familiar to lay audiences. 加害造成的创伤性脑损伤

定义 虐待性颅脑外伤-任何对孩子头部加害造成的伤痕 包括“摇晃婴儿综合症”和“摇晃影响综合征” 接触和/或非接触损伤 Inflicted injuries can include contact injuries (e.g. head hitting an object, object hitting the head, or object and head hitting each other) and non-contact injuries (i.e. shaking).

流行病学 最常见于婴幼儿 被报导摇晃损伤儿童最大至5岁 至少 2/3 头部严重受伤发生在婴儿身上 The highest rates of AHT are seen in infants, with epidemiologic studies providing rates of about 30 cases/100,000 children. Rates in children age 1-2 are about 17 per 100,000.

诊断结论 硬膜下出血 视网膜出血 脑损伤 骨折 —尤其是肋骨和骨干骺端 The diagnostic constellation of findings includes subdural and retinal hemorrhages, brain injury, and fractures.

可能的触发因素 哭叫 上厕所训练 可察觉的不良行为 没有任何因素 Crying is a common trigger for shaking or otherwise abusing an infant. The peak age for colic (~ 3 months) is also the peak ages for abusive head trauma. Abuse may result from the combination of a colicky baby who won’t stop crying, and a caregiver who is lacking sleep, frustrated because of his/her inability to calm the baby, and momentary loss of impulse control.

迹象和症状 不那么严重 更严重 癫痫 呆滞 易触怒 失去知觉 呼吸困难 胃口不好 死亡 呕吐 The signs and symptoms of abusive head trauma can be quite variable, depending on the severity of injury. Children with more severe injuries also have more obvious symptoms, including breathing difficulties, seizures, loss of consciousness, and possibly death. The diagnosis of abusive head trauma in children with less severe injuries may be missed, because symptoms such as lethargy, irritability, poor appetite, and vomiting are non-specific. These children may be diagnosed with reflux, colic, or gastroenteritis. Often the possibility of abuse is not considered.

在婴儿2 周的例行检查时，为什么医生不怀疑虐待？ Ask the audience to come up with reasons why the doctor might not have diagnosed abuse, and why he/she might not have even considered abuse.

虐待儿童因素示意图 儿童 社会 社区 家庭 父母 专业人员 贝尔斯基，《心理学期刊》，1993;114:413 Developmental-Ecological theory posits that there are multiple and interacting factors that contribute to child maltreatment. These begin with the child, and extend outward to the society at large. Each level may interact with all other levels. Use this theory to begin a discussion about specific risk factors that might be included in each level 专业人员 贝尔斯基，《心理学期刊》，1993;114:413 32

儿童风险因素 特殊特征– 双胞胎、有残障儿童、早产、不想要的意外怀孕 年龄-幼小孩子 性别 女孩：有更高风险遭遇杀婴、性虐待、教育和营养疏忽 男孩： 身体虐待的风险更高 特殊特征– 双胞胎、有残障儿童、早产、不想要的意外怀孕 Factors that increase a child’s risk for maltreatment include anything that might make a child more difficult to care for. These may include young age, handicap, or excessive crying. Gender is also a risk in specific ways. Provide the audience with the following example: A couple have a 6 week old baby who has become increasingly colicky. He cries incessantly throughout the evening. The parents cannot console the child for long, despite feeding, rocking and walking with him. He wakes several times at night, leaving both parents exhausted. The baby gets more irritable as the day goes on, and is at his worst when the father gets home from work in the evening. Ask the audience “what do you think might happen?” 33

父母/儿童照顾者的风险因素 年轻 单身家长 不想要的意外怀孕 育儿技能差 吸毒 身体或精神疾病 Any parent or caregiver characteristics that may increase stress in their lives may increase the risk of maltreatment. Some of these are lack of knowledge and experience in dealing with children and others are from outside pressures. Younger, single parents with little or no supports are one group that appears to have a high level of stress in their lives. Parents with substance abuse problems, mental health issues, relationship difficulties or have work related stresses are also at higher risk to lose control. To continue the example of the colicky infant, imagine the effect of her constant crying and the general difficulty in consoling her, on a caregiver who is drunk or angry with a spouse. Later on we will discuss prevention, but take a minute and ask the audience to “consider what we could do to help the parents and lessen the possibility of the child being maltreated.” 34

家庭风险因素 过分拥挤的生活环境 贫穷 较大的压力 家庭暴力 Family factors that increase stress can also contribute to maltreatment. Remind the audience about the parents with the colicky infant. The family lives in a low income apartment building where every sound is heard in the next apartment. The child cries for hours. Neighbours complain to the building superintendent, who tells the family if this continues they will have to move. The parents fight over how to stop the crying. This wakes the child, who begins to cry again. The neighbour bangs on the wall and shouts that if they can’t control the child he will come over and do something about it. Ask the audience “What happens now?” 35

社区/社会因素 无有儿童保护法/执法不力 儿童的价值有限 社会接受的暴力 （家庭、 社区或社会 — 包括战争） 文化规范 社会不公正-贫穷 Note that limited value of children can indicate all children, or specific groups of children (e.g. disabled, minority, Many societies look at physical discipline as every parent’s right and often their obligation. “Spare the rod, spoil the child” is a common saying. In some places children are not valued until they are old enough to contribute to the family. Still other cultures will restrict educational opportunities due to poverty and a lack of understanding of the need and value of education. On the other hand there are cultures where success is measured by the level of education of children and they justify harsh discipline as a tool to enforce school achievement. It is the weak groups in society; the elderly, women, the infirm and children who suffer the most from war, crime and violence in general. To continue the example of the crying infant; ask the audience “What if the father did beat or shake the child and no one cared? 36

职业上的因素 不能够： 承认存在虐待儿童现象 识别和处理虐待儿童问题 对儿童和家庭提供必要的服务 帮助制止虐待 促进健康、发展和安全 处理主要危险因素

讨论 当博比带症状回来时医生为什么不怀疑孩子被虐待？ 假设是虐待，你认为博比被虐待的后果是什么？ 你觉得虐待为什么可能会发生在这个家庭里呢？ 38

当博比带症状回来时医生为什么不怀疑他被虐待？

教学要点 医生看病历找答案；不顾病历很难。 想到虐待，便让人产生不舒服的感觉，特别是在 那些“好”的，有同情心的家庭 加害造成的创伤往往是不公开的 As child health care providers, we depend a great deal on the information provided to us by parents. However, with child abuse, this history is often absent or misleading. Keep in mind that an absent history doesn’t mean that a caregiver is hiding something. It may be that the child was injured in someone else’s care, and this caregiver is unaware. 40

无或具误导性的病历 _______________________ 临床表现 非特定的调查结果 + 无或具误导性的病历 _______________________ 漏诊 The combination of non-specific findings and an absent or misleading history may lead to the diagnosis of abuse being missed.

漏诊 在这些家庭中更常见： 白人 已结婚的父母 高收入S A paper published by Carole Jenny and colleagues in JAMA in 1999 showed that physicians were more likely to miss the diagnosis of abusive head trauma when the parents were white, married, and of higher income.

对受害者的结果 精神发育迟滞 严重颅脑损伤 学习障碍 癫痫 听觉和语言障碍 视觉障碍 行为障碍 死亡 Outcomes for victims can be quite variable, depending on the severity of the injury. Some children with more minor injuries may recover with only mild sequelae, e.g. learning or behavioral problems. Children with more severe injuries may have more serious sequelae, including death.

你为什么觉得虐待可能 在这个家庭里发生呢？ Have the participants think about the risk factors present in this family, and how they may have resulted in abuse of this child.

案例二 玛丽亚-少年母亲，巴西 发现昏迷，可能自杀未遂 3个月和4岁大的孩子 — 脏，饥饿，发育上有问题 3个月和4岁大的孩子 — 脏，饥饿，发育上有问题 艾琳娜-4 岁女孩经常手淫 — 身体体检正常 玛丽亚幼年时被性虐待

讨论 艾琳娜被性侵犯吗？ 艾琳娜的身体检查是如何影响你的想法的？ 玛丽亚儿童时期被虐待的后果是什么？ Here are some of the questions that we will be discussing as we review what happened with Elena and Maria. 46

讨论 艾琳娜和她的兄弟是否被忽视？ 玛丽亚的经历和她孩子们的被忽视和性虐待之间的关系是什么？ Here are some of the questions that we will be discussing as we review what happened with Elena and Maria. 47

艾琳娜被性侵犯了吗？?

儿童性侵犯 使孩子参与性活动中，但他/她： 不完全懂 不能给予知情应允 发育上未准备好 违反法律和社会的禁忌 儿童会受成人或其他孩子的性利用，这些人由于年龄或发育上的原因处于职责、 权力或信赖的地位中。 (来自ISPCAN和WHO的"防止虐待儿童"，2006) This definition of Sexual Maltreatment of children is also from “Preventing Child Maltreatment” (WHO & ISPCAN 2006). Simply stated it says that the involvement of children in sexual activity of any sort, by an adult or older child in a position of trust or power, is maltreatment. This form of maltreatment is often a very difficult type to identify and difficult to prove. You should ask the audience if sexual maltreatment is an issue in their community. In some communities sexual maltreatment, whether involving children or adults, is such a taboo that it is not accepted as something that happens there. 49

儿童性侵犯 常常是“隐藏”的威胁 所有形式的性活动都包括在内，不只是性交和其他肉体形式的 包括儿童卖淫和色情暴露 Sexual maltreatment not only includes the usual physical acts. It includes exposure to pornography and child prostitution. One point to make is that children are frequently reluctant to disclose sexual maltreatment and often not believed when they do. Studies indicate a child often has to tell several adults before someone listens to them. Even when they are believed most often there are no physical findings to prove a sexual contact took place. It is their word against that of the adult. The child may feel they have done something bad and be reluctant to disclose for this reason. 50

罪犯人的特征 没有典型的形象 很多人表现正常，很成功和没有犯罪记录 多数是男性 大多数是孩子熟悉的人，许多处在信任、 权威的地位 大多数是孩子熟悉的人，许多处在信任、 权威的地位 20-40%青少年 多数 （不是全部）自己受到过虐待 While sexual assault perpetrated by strangers often garners the most media attention, most abusers are people whom the victims know and often trust.

儿童特征 大约85%是女性（系统记录的已知案件中） 峰值年龄： 女孩和男孩 — 早期学龄 5-7岁 女孩子 — 14-15岁 脆弱，贫穷的人 女孩和男孩 — 早期学龄 5-7岁 女孩子 — 14-15岁 脆弱，贫穷的人 Ask the audience why this statistic about the percentage of girls vs. boys may be inaccurate. (Answer – boys may be more reluctant to disclose, may feel greater sense of shame, may fear being labeled as homosexual). Interviews with imprisoned perpetrators of sexual abuse indicate that they often look for children (and their caregivers) who are vulnerable and needy, as they are easier targets.

辨认儿童的方法 身体痕迹：受伤或感染 儿童泄露 — 对另一个孩子、父母、治疗学家或信任的成人 儿童性侵犯另一个孩子 儿童使用色情语言，有超出正常年龄或发育的行为 There are a number of ways that children who have been sexually abused may come to the attention of professionals. Physical injury and infection are the least common ways that children are identified – fewer than 5% of children who have been sexually abused have physical evidence of abuse. More often, a child’s statements or behavior lead someone to suspect abuse.

艾琳娜的常规检查排除性虐待的可能性吗？ Based on the information from the previous slide, the audience should be aware that most children who have been sexually abused have normal exams. Ask them to think about why this may be the case.

医学检查-结果 “检查结果正常是正常的” 95%以上涉及的儿童体检体检结果正常 为什么？？？ 性侵犯行为可能没有留下损伤（如爱抚) 造成伤害增加被披露的风险 在揭露和医学鉴定之前伤痕愈合往往无疤痕

医学评价 — 什么是不正常 生殖器损伤 — 急性 - 眼泪，擦伤，咬痕 亚急性、慢性 — 愈合的处女膜裂缝，伤痕 性传播感染 怀孕 亚急性、慢性 — 愈合的处女膜裂缝，伤痕 性传播感染 怀孕 法医证据 — 精子、 精液等。 As noted in the prior slide, it is unusual for children to have abnormal exams. Genital injury, either acute or chronic, indicates that some trauma has occurred. If there is a history of sexual abuse, or an absence of any history of accidental injury, sexual abuse is very likely. Sexually transmitted infections may be transmitted perinatally, or may be from consensual sex in a teenager. However, outside of these periods, sexually transmitted infections such as gonorrhea, chlamydia, and syphilis are highly likely to be from sexual abuse. Herpes is also likely to be from sexual abuse. However, transmission through non-sexual means (e.g. a child with an oral herpes lesion touching her mouth and then her genital area) is possible. HIV may also be transmitted through sexual abuse, however, infection via perinatal transmission, IV drug use, or blood transfusion must also be considered.

儿童性欲化行为 可能的原因：: 性虐待 不了解社会规范 性好奇/探索 暴露在明显的性活动面前 例如儿童身心发展残疾 在家里看电视、电影时见到现场动作 看色情 可能出于无心，疏忽，或虐待 Sexualized behavior in a child may lead to caregiver suspicions about the possibility of sexual abuse. While sexually explicit behavior can be a manifestation of abuse, other causes should also be considered. Some sexualized behavior may be imitation of behavior to which a child is exposed. For example, a child may witness sexual activity in the home. When space is limited, all family members may share the same sleeping quarters, making this exposure difficult to avoid completely. Children living in nations at war may be inadvertently (or purposefully) exposed to sexual assault of women by enemy forces. In homes with televisions and computers with internet access, sexually explicit material is pervasive, and easy to find. At times, exposure to sexually explicit activities or material may be completely inadvertent (e.g. a child unexpectedly entering a room where adults are having sex or viewing sexually explicit media). It is also possible that an adult is viewing explicit material or engaging in explicit activity without regard to the child’s presence. This behavior should be considered neglectful. Finally, an adult may expose a child to sexually explicit material as part of a victim grooming process. Young children, particularly in the preschool years, are curious about their own bodies, as well as those of the opposite sex. Looking, touching, and asking about genitalia may reflect this curiosity. Children may touch their genitals because it feels good, even though they have little or no understanding of sexuality. Children with developmental disabilities may have difficulty understanding societal norms, and may engage in sexual behavior such as masturbation because it feels good. These children may not understand that such behavior is not appropriate in public.

常见的行为-2-9岁（不太可能与虐待有关） 弗里德里希• WN，儿童规范性性行为，《儿科医学》，1998；101:e9 男孩 在家里触摸性部位 摸乳房 站得太近 想看其他人赤裸裸的样子 在公众场合触摸性部位 手淫 女孩 The data on the next several slides are based on research conducted by William Friedrich and colleagues. Parents of children who had not (to the best of the parents’ knowledge) been sexually abused reported on the behavior of their children. This slide shows the most common behaviors of boys and girls age 2-9 years. Note that the common behaviors in boys and girls in this age group are very similar.

常见的行为-10-12岁（不太可能与虐待有关） 弗里德里希• WN，儿童规范性性行为，《儿科医学》，1998；101:e9 男孩 对异性很感兴趣 想看电视上裸体画面 想看裸照 知道更多关于性的事情 谈性行为 在家里触摸性部位 女孩 站得太近 This slide shows Friedrich’s study results for children in the preteen years. Again, the behaviors of boys and girls are similar, but there is more variation in the frequency of behavior among boys and girls in this age group, compared to the younger children.

不常见的行为@2-12岁 (更有可能与虐待有关） 1。放性部位入嘴里 2。要求从事性行为 3。用物件行手淫 4。将物件插入阴道/肛门 5。模仿性交 6。制造性声音 7。尝试舌吻 8。脱其他人的衣服 9。要求看不健康的电视 10。与布娃娃模仿性行为 This slide also shows data from Friedrich’s research. However, these are the behaviors that were least commonly reported by parents. It is important to note that these behaviors, while uncommon, do not automatically indicate abuse. However, they are red (or pink) flags that should trigger additional assessment of the child’s safety and potential inappropriate exposures.

引发关注的行为 过度注重性行为、超出正常发育阶段的知识 尽管重新指引，还有不当行为 与年长/年幼的孩子进行性行为/探索/利诱 伤害自己或其他人的生殖器官 令人不安的如厕行为 画的画上殖器官占主导 与动物性接触 These behaviors are worrisome, and should prompt additional assessment.

玛丽亚性虐待的后果是什么？

性虐待的影响－身体健康 短期内 长期： 急性损伤 性病 肠道问题(过敏性肠道） 慢性疼痛 (头痛、 腹部、 背部、 或骨盆疼痛) 肥胖，未能茁壮成长 躯体症状 Long term cohort studies and retrospective studies have shown a variety of impacts of CSA on adult health, both physical….

性虐待的影响- 心理健康 行为问题 — 躲闪，发泄，不法行为 抑郁症 创伤后精神紧张性障碍和其他精神不安障碍 滥用药物 行为问题 — 躲闪，发泄，不法行为 抑郁症 创伤后精神紧张性障碍和其他精神不安障碍 滥用药物 饮食失调 — 厌食，贪食症 失学 低自尊、 人际交往困难 And mental..

艾琳娜和她的兄弟是否被忽视了吗？ Ask the audience whether Elena and her brother have been neglected. Remember that when found, Elena and her brother were dirty and hungry. They both appeared to have developmental delays.

以儿童为中心的对疏忽的定义 基本需要包括足够的： 食品 监督 卫生保健 爱和养育 服装 保护 教育 家 Rather than blaming a caregiver for what they fail to do, many experts advocate for using a child-centered definition, described above. Review the definition, then have the group come up with a list of basic needs. Sometimes the entire responsibility can be ascribed to a single individual (or set of parents). Often, however, the situation is more complicated, and the responsibility for ensuring children’s basic needs lies in many hands, including health care providers, schools, and government. It appears clear that Elena and her brother were not receiving adequate food. Their developmental delays may indicate inadequate maternal bonding and nurturance. Maria may have attempted suicide and was found unconscious. Therefore Elena and her brother were not receiving adequate supervision. 66

玛丽亚自己的经历和她孩子们被疏忽和性虐待之间的关系是什么？ Ask the audience to think about which long-term effects Maria may have suffered, and how they may relate to the sexual abuse and neglect of Elena. For example, as a result of her own sexual abuse, Maria may be dealing with depression and PTSD. These conditions may make it difficult for her to meet the basic needs of her children. They may also make it difficult for Maria to take steps to keep her children safe from abuse and exploitation. In addition, Maria may suffer from low self esteem and difficulty forming healthy relationships. She may therefore choose partners who take advantage of her and her children. Finally, her partner may have targeted Maria and her children because of the children’s neediness, and Maria’s inability to protect them.

教学要点 所有形式的虐待都随社会风险因素尤其是贫穷的增加而增加 性虐待是最不相关的 疏忽是最相关的 每个种族、社会和经济都会发生各种形式的虐待

补充教学要点 虚假指控是罕见的 虚假否认则很常见 被性侵犯的儿童长大后往往成为麻木不仁的证人s 离家出走 流浪儿童 违法者

教学要点 忽视：未能满足儿童的基本需要 (权益) 情绪 营养 房屋 安全 健康 教育

教学要点 疏忽可能看上去是无恶意的 它不是 它具有严重的潜在影响: 身体：比如发育成长缓慢、营养摄取不良、死亡 认知： 比如发育迟缓、学习问题 心理健康： 比如情绪和行为问题 社会：未成年人不法行为和犯罪行为

案例三 中年男子： 中国 有身理和心身疾病 滥用烟酒 小时候挨打 目击家庭暴力 断绝了与"导师"的关系 与社会隔离

讨论 你能识别或怀疑是哪些“不良的童年经验”？ 你认为老张和他的导师之间发生了什么？ 可能是性虐待吗？ Ask the audience, “Which of Lao Zhang’s experiences growing up might be considered adverse childhood experiences?” and “What other childhood events might be considered adverse childhood experiences?” Abuse and neglect should definitely be considered adverse childhood experiences (sometimes called ACEs). Witnessing domestic violence could also be considered an ACE (and many experts would also consider this to be child maltreatment). Other ACEs include death of a parent, natural disasters such as earthquakes or floods, war, or famine.

讨论 哪些可能的行为后果与老张的童年经历有关？ 哪些医疗后果已经发生或可能出现在像老张这样的病人中？ Ask the audience to think about possible behavioral, medical, and mental health consequences of ACEs. 74

虐待儿童的影响 每个孩子都受到影响 — 程度不同 几个决定影响的因素： 后果包括： 虐待的性质 儿童的个性 保护因素 生理 心理 行为 社会 In this section we will look at the impact of child maltreatment on children. This slide notes the important point that every child is affected by maltreatment. However, it recognizes the degree of the impact is variable dependant on the type and intensity of the abuse and the presence of protective factors. Ask the audience, “What are some examples of these consequences?” 75

生理后果 受伤 例如骨折、 烧伤、 内脏器官受伤、 割伤、 颅脑损伤 脑发育受损 短期和长期残疾 死亡 Some of the consequences, such as those associated with Physical Maltreatment are more obvious. Broken bones, lacerations and other physical injuries are easily identified. Longer term effects such as impaired brain development secondary to head injury may not be obvious initially but cause life long difficulty for the child who was injured. 76

缺血性心脏病机率 与不良童年经历次数间的关系 This slide looks specifically at how increasing ACE scores influence the odds of ischemic heart disease in adults. The authors controlled for medical and psychosocial risk factors, as these can also contribute to ischemic heart disease. 77

心理后果 共同点包括： 直接的问题是孤独、恐惧和不信任 终身抑郁、 自卑、 关系障碍问题 认知发展受损 Children may develop both short-term and long-term psychological consequences from maltreatment. Some examples are listed in this slide. More details follow in subsequent slides. 78

自杀风险与不良童年经历评分间的关系 Child maltreatment can lead to long-term mental health consequences. This data is also from the ACE study. In this study, adults with 4 or more adverse childhood experiences had 12 x the odds of suicide compared to adults with no adverse childhood experiences. 79

教学点 很多年长的人遭受虐待但他们可能认为不是被虐待，或不想讨论 特别是男孩的性侵犯 目睹家庭暴力严重影响儿童的成长

教学点 “不良童年经历”可能会影响长期的健康 健康问题（例如心脏病) 心理健康问题 （如抑郁、自杀） 由于压力，社会隔离而容易受伤

案例四 六岁女童 在七个月的时候： 有股骨骨折的症状 旧的和新的肋骨骨折 “经典干骺端病变” 保护 家庭治疗 重新愈合

讨论的问题 你认为造成琶瓦沙多处骨折的原因是什么？ 当琶瓦沙被带走时她身上可能发生了什么事情？ 哪些服务可能会有对琶瓦沙和她的家人有所帮助 ？

造成琶瓦沙多处骨折的可能原因是什么？ Seems impossible to answer most of these. 84

长骨骨折的鉴别诊断 儿童虐待 非加害的 (意外伤害) 增加骨折风险的内科疾病 成骨不全 佝偻病 While abuse is the most common cause of fractures in children this young, other causes need to be considered. Severe accidental injury can cause one or more fractures, however, this should be clear from the history. Some medical disorders can also cause easy fractures in young children, and should also be considered. Osteogenesis imperfecta is a disorder of collagen synthesis that can lead to easy fractures. There are several different forms of this disorder. The more severe forms should be obvious because of bone abnormalities present at birth. The less severe forms may not be obvious. Some additional traits that may be seen in osteogenesis imperfecta are blue sclerae, hearing loss (or family history of hearing loss), dentinogenesis imperfecta (teeth that easily break and decay), and family history of easy and frequent fractures. Rickets is a bone disease that results from inadequate vitamin D stores. Risk factors for rickets include dark skin, limited sun exposure, and inadequate vitamin D intake from breast milk or formula. The bones of children with rickets may show tenderness, rachitic rosary (bumps along the ribs), frontal bossing (prominence of the forehead), and thickening of the wrists and ankles. This condition can be identified and distinguished from abuse through laboratory testing. 85

长骨骨折 低特异性的虐待 除婴儿外 (会走路前的儿童) 螺旋或斜向裂缝：非特定的 表明扭转(扭伤)的力 Long bone fractures are very common, and are more often the result of accidental injury than the are from abuse. The exception to this rule is in infants. Their lack of mobility makes it unlikely that they will injure themselves. There is a common misconception that spiral fractures are very specific for abuse. However, recent clinical and biomechanical studies have shown that accidental spiral fractures can occur. The spiral appearance indicates only that a torsional or twisting force caused the fracture. The spiral appearance does not indicate whether the injury is abusive or not.

长骨骨折— 股骨 常见的非加害模式： 婴儿还不会走时发生股骨骨折是非常可疑有虐待的可能的 奔跑和跌落，尤其是在旋转运动 以假脚转身而跌伤 In ambulatory (walking) children, femur fractures occur commonly in the two instances noted above.

肱骨— 长骨骨折 骨干骨折 髁上骨折 考虑儿童的年龄和损伤历史 跌落时肘部受伤 大多数不是蓄意加害造成的 虐待更有可能发生在婴儿身 As with the femur, fractures of the humerus are more often accidental than inflicted. However, in non-mobile children, abuse is much more likely. A common accidental humeral fracture is the supracondylar fracture. This is a fracture of the distal humerus that is often the result of a fall onto the elbow.

长骨骨折— 胫骨 初学走路孩子的骨折 非蓄意加害的 倾斜的无移位的胫骨远端骨折 轻伤或无外伤史 刚刚开始爬或走路的婴儿和初学走路的孩子 A common accidental tibia fracture is the toddler’s fracture, described above.

长干骨骨折—典型干骺端损伤(CML) 取决于视图，边缘或屁股柄骨折 机制：过度扭曲或拉动肢体，或在摇晃时加速/减速 非常明确是虐待 The classic metaphyseal lesion is seen in infants, at the metaphysis. Depending of the angle of the x-ray, it can have the appearance of a corner fracture (left-sided images) or a bucket handle fracture (right sided images). These fractures are highly specific for abuse in infants. They typically occur from twisting or pulling of an extremity, or from acceleration/deceleration forces that can occur during shaking.

总结 - 诊断 骨折的特征 高 中 低 典型干骺端损伤 骨膜新骨 肋骨 锁骨 肩胛骨 長骨干骨折 脊柱棘突 线形颅骨 胸骨骨折 多处骨折，特别是两侧 骨膜新骨 肋骨 不同年龄段发生的骨折 锁骨 肩胛骨 骨骺分离 長骨干骨折 脊柱棘突 椎骨体 线形颅骨 胸骨骨折 手指/脚趾 复杂颅骨骨折 克莱因曼·PK，《虐待儿童诊断影像》，第二版，密苏里州圣路易斯市：莫斯比有限公司，1998. P9 This slide shows a summary of the specificity of various fractures for physical abuse. Among the fractures with a high specificity of abuse, we have already discussed rib fractures and classic metaphyseal fractures. Fractures of the scapula, spinous process and sternum are uncommon under any circumstances, and require a significant amount of force. In the absence of a history of severe injury, such as a motor vehicle crash, these fractures are diagnostic for abuse.

当琶瓦沙被带走时她身上可能发生了什么事情？ The answer to this question depends on the systems and resources available in Palwasha’s community. She may have been placed in foster care. If extended family was available to serve as a resource, she may have been placed in kinship care. Ideally, Palwasha’s parents (or the person responsible for her injuries) would receive services such as parenting education and anger management. An ideal system would also assess Palwasha’s family for maltreatment risk factors such as parental depression, intimate partner violence, substance abuse, etc. If Palwasha had siblings, they would also be assessed for possible maltreatment. Finally, Palwasha would be provided with trauma-focused counseling to prevent long-term mental health sequelae. 92

讨论 你们社区有什么制度保护受虐待的儿童？ 你们是怎样起动该制度的？ 你们社区有哪些服务去治疗受虐待的儿童、他们无虐待性的家庭成员和那些虐待儿童的人？ These questions are intended to generate discussion among participants. Every country, state, and/or region has a different system for addressing child abuse and neglect. And all have different resources available to help families in which maltreatment has occurred. Participants can explain the processes in their own region, and discuss what components work well, and what could be improved.

教学重点：帮助受虐待儿童的步骤 识别虐待 阻止虐待，防止进一步虐待 处理生理疾病和情绪上的影响 支持家庭— 帮助让它变得安全 或 提供一个安全的另外的家

教学重点： 很多受虐待的儿童蒙受一生的问题 不过… 很多受虐待的儿童成为成功人士 Children are incredibly resilient. Many children have protective factors such as strong social support or self-efficacy that help protect them from long term negative outcomes 很多受虐待的儿童成为成功人士

如需要一份电子副本… 请发送电子邮件至： training@ispcan.org

教学重点 你们社会/法律制度是如何提供保护的？ 你能如何改进它？ 为受虐待儿童和他们的家庭提供哪些治疗方法？ 如何改善让更多的人更容易接受到你们的保护和治疗方法？

教学重点 高达1/3由蓄意加害造成的头部外伤病例在第一次报告中遗漏了 27 %再次受虐待 40%有并发症 7%死亡 98

教学重点 性虐待体现在许多方面： 受伤 性传播感染 揭露 情感和行为的变化 创伤后精神压力症（PTSD） 99

教学重点 大于90%身体检查都正常 爱抚 口腔及肛门性交 伤口愈合 解剖变化 100

教学重点 许多虐待的后期后果： 创伤后精神压力症、抑郁、自杀 品行障碍，干扰学校，吸毒 早期性生活、怀孕、性传播感染、艾滋病 101

讨论 玛丽亚的孩子被忽视的后果是什么？ 什么社会、环境及家庭因素造成这种情况？ 102

讨论 玛丽亚想和她的孩子们在一起的法律权利是什么？ 保罗有哪些权利和责任去帮助，扶养和探望他的孩子？

教学重点 家庭的权利和责任？ 玛丽亚 保罗 大家庭 社会制度的能力去代替或援助家庭？ 104

谢谢 105