受虐與重複受虐兒童危險因子探討

Risk Factors of Abuse and Recurrent Abuse among Children

林欣穎(Hsin Ying Lin)

指導教授 ： 陳品玲

臺北醫學大學/公共衛生學院/公共衛生學系暨研究所/碩士(2018年)

摘要

背景
2016 年世界衛生組織（World Health Organization, WHO） 的統計，四分之一的成人在兒童時期曾經遭身體虐待 ；根據 2014 年美國的統計，兒童虐待發生率每一千名兒童中有 17.24 位，同一年台灣衛生福利部的資料為每一千名兒童有 3.02 位，不只造成兒童將來生理、心理問題，更是一個嚴重的社會問題，研究發現五年內仍有三分之一受虐兒童再度遭受兒虐，重複受虐經驗對兒童健康會造成更嚴重的負面問題 。

目的
比較受虐兒童和非受虐兒童、單次受虐與多次受虐兒童人口學及醫療利用差異，以找出兒虐及兒虐復發的危險因子。作為醫護人員之參考，以準確即時的辨識高風險受虐兒。
方法
本篇研究為以次級資料分析兒虐個案的相關危險因子，取材自衛生福利部「事故傷害監測資料統計與加值應用計畫」，資料來源為衛生福利部衛生福利資料科學中心，使用 2000-2015 年門急診檔、承保檔及住院檔，串聯 2000-2015 年內政部戶籍檔及2006-2013 原住民戶籍檔，選取國際疾病分類第九版臨床修訂版（ICD-9-CM），單次受虐兒童（N-code 995.5x 與 E-code E967.x）、非受虐之非蓄意傷害兒童（E800-E999 排除他傷、醫療過失、藥物不良反應、傷害併發症或後期影響）及重複受虐兒童進行比較分析。

結果
共計有 11493 名受虐兒童，以性別和年齡和一比四的比例做配對，配對出 45972 位非受虐兒童，發現原住民發生兒虐(6.7%)機率明顯高於非原住民(3.6%) ( P <0.001)，居住於高度及低度都市化地區，發生兒虐的機率明顯高於居住於中度都市化地區( P <0.001)，受虐兒前一年因外傷至急診或住院的機率(70.0%)遠高於非受虐兒(9.6%) ( P <0.001)，受虐兒(9.3%)發育不良病史的機率顯著高於非受虐兒(2.8%) ( P <0.001)；原住民(AOR=1.92, 95%CI=1.80-2.06)、低都市化地區
(AOR=1.71, 95%CI=1.64-1.78)、前一年有傷害就醫紀錄(AOR=4.76, 95%CI=4.55- 4.97)及有發育不良診斷(AOR=3.76, 95%CI=3.50-4.04)皆明顯增加兒虐風險。發生單次兒虐者共有 11163 人，多次兒虐者共有 330 人，女童(3.8%)遭受多次兒虐的機率較高於男童(2.3%) ( P <0.001)。年紀小於三歲，產生多次兒虐的機會就越高( P =0.011)，就醫層級為醫學中心時產生多次兒虐的機率較高( P <0.001)，多次兒虐
者有較高的機率需至急診( P <0.001) 、平均住院天數較長(P=0.026)。多次受虐前一年有因傷害就醫機率較高( P <0.001)。有發育不良病史兒童產生多次兒虐的機率明顯較高( P <0.001)。在風險分析方面，女童、年齡未滿三歲、就醫院所層級為醫學中心皆會增加多次兒虐風險、前一年有傷害就醫紀錄(AOR=10.42, 95%CI=7.9613.65)及有發育不良病史(AOR=2.22, 95%CI=1.64-2.99)者皆明顯增加多次兒虐風險。有發育不良病史兒童再次兒虐就醫間隔大於一年的機率顯著較高( P <0.001)。
多次兒虐組前一年曾傷害多次就醫的機率顯著最高，單次兒虐者其次，無兒虐對照組機率最低( P <0.001)。

結論
根據本研究的結果的建議與呼籲增加急診對兒虐的診斷率，並建議兒少保護工作須長期追蹤照顧發育不良有特殊需要的兒童;以準確即時的辨識高風險之受虐兒及重複受虐兒，保障其安全，增進兒童健康與人權。

關鍵字

兒童虐待 ； 重複兒童虐待 ； 就醫行為 ； 危險因子

並列摘要

Background
According to the statistics of World Health Organization (WHO) in 2016, a quarter of adults were physically abused during childhood. Child abuse caused 115,000 deaths in
the world. The incidence of child abuse in the United States in 2014 was 17.24 per 1,000 children. In Taiwan it was 3.02 per 1000 children, according to Taiwan Ministry of
Health and Welfare. Child abuse not only affects the children's physical and psychological welfare, but also causes serious social problems. It was found that one
thirds of children would still be abused within five years. The repeated episodes of abuse cause more serious health problems for children.

Purpose
Comparing the differences in the demographics and medical uses of abused, repeated abused and non-abused children to identify the risk factors for the repeated abuse so the
health care workers can accurately and immediately identify those high-risk children

Method
This is a cohort study uses secondary database on abused children from "Statistical and Appraisal of Incidental Injury Monitoring Data Application Program" of the Ministry of Health and Welfare. The source is the “National Health Insurance Research Database” managed by the National Institute of Health and provided by the Health and Welfare Data Science Center. Using the inpatient expenditures by admissions (DD), registry for beneficiaries (ID) and ambulatory care expenditures by visits (CD) from 2000 to 2015 to select those cases of single abused children (N-code 995.5x and E-code E967.x), non-abused children (E800-E999 excluding injuries by others, medical negligence, adverse drug reactions, injury complications or late effects), and repeat abused children according to the international disease classifications, ninth clinical revision (ICD-9-CM), and linking to linked to the household registration files from the Ministry of the Interior
2000-2015, and the Aboriginal household registration files from 2006-2013 so to compare these three groups.

Results
A total of 11,493 abused children were matched by gender and age and a ratio of one to four to 45,972 non-abused children. It was found that the incidence of child abuse among aboriginal people (6.7%) was significantly higher than that of non-aboriginal people (3.6%). (P <0.001). High and low urbanization areas had higher incidence of child abuse than moderately urbanized areas (P <0.001). The abused children were more likely to visit the emergency room or even hospitalization due to injuries in the previous year as compared to non-abused children one year before (70.0% vs 9.6%, P <0.001). The incidence of underdevelopment was higher in abused children than in non-abused children (9.3% vs 2.8%, P<0.001). Aboriginal people (AOR=1.92, 95%CI=1.80-2.06), low-urbanized areas (AOR=1.71, 95%CI=1.64-1.78), a medical record of injury in the
previous year (AOR=4.76, 95%CI=4.55-4.97) and a diagnosis of underdevelopment (AOR=3.76, 95%CI=3.50-4.04) significantly increased the risk of child abuse. A total of 11,163 children had the diagnosis of single-time child abuse, and there were 330 children with the diagnosis of child abuse for multiple times. Girls (3.8%) were more likely to suffer multiple-time child abuse than boys (2.3%) (P <0.001). The risk of being abused multiple times was higher if the age was less than three years old (P =0.011). Those being abused multiple times were more likely to be treated at medical centers (P <0.001), visit the emergency department (P <0.001), have longer hospital stay (P=0.026). They were more likely to be treated for injuries in the previous year (P <0.001), as well as to have a history of underdevelopment (P<0.001). Girls, younger than three years old, treated at medical centers, records of seeking medical care due to injuries in the previous year (AOR=10.42, 95%CI=7.96-13.65), a history of underdevelopment (AOR = 2.22, 95%CI =1.64-2.99) significantly increased the risk of child abuse for multiple times. Undeveloped children were more likely to have the abuse interval of more than one year (P <0.001). Children abused for multiple times were most likely to seek medical care for injuries multiple times in the previous year, followed by children abused for a single time, then those without abused (P <0.001).

Conclusion
According to this research, the awareness of child abuse in the emergency room should be improved. Social workers need to follow up underdevelopment children in need for longer periods. It is hoped those with high-risk of being repeated abused could be identified and thus ensure their safety, welfare and human rights.

並列關鍵字

Child abuse ； Repeated child abuse ； Health care utilization ； Risk factor.

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