儿童心理行为及其发育障碍 第24讲 儿童性虐待

1　概述儿童性虐待 (childsexualabuse)是指成年人利用 16岁以下儿童获得性的满足 ,造成儿童明显的心理或精神创伤的现象。目前西方学者对性虐待的认识意见不一。Mrazek1980年把性虐待行为分为以下 4类 :(1)观看儿童性器官或对儿童进行性暴露 ;(2 )猥亵行为 ;(3)性交 ;(4)强奸。而另外一些学者则只把与儿童年龄相差较大的人同儿童发生长期性关系称做儿童性虐待。从临床角度出发 ,判断性虐待行为需考虑以下几方面因素 :(1)性行为发生的频率与性质 ;(2 )受害儿童的年龄、智龄以及情感发展状态 ;(3)儿童是否受到情感伤害 ;(4)施虐者与受害者双…     

Child protective services and domestic violence

Studies estimate that domestic violence is present in at least one-third of the families involved in child protective services (CPS). Yet, until recently, CPS has not directly addressed domestic violence in its handling of child abuse and neglect cases. By the same token, domestic violence programs have historically emphasized services for battered women, with limited understanding of the child safety goals of CPS. Despite these historical differences, collaborative efforts between CPS and domestic violence service programs are emerging based on a common goal of safety from violence for all family members. Innovative strategies include the use of domestic violence specialists in a variety of child protection settings for case consultation and for support to the battered women, direct referrals of battered women from domestic violence programs to family preservation services, and cross-training of CPS workers and domestic violence service providers. A survey of state CPS administrators and domestic violence coalition directors conducted for this article revealed that although there is mutual interest in greater collaboration, such efforts remain limited. New forums, such as CPS citizen review panels and community-based CPS partnerships, hold promise for further collaboration. Critical to successful strategies are supportive agency leadership, greater trust and understanding across systems, a recognition of common goals, and a willingness to change policies and practice.     

Child sexual abuse. Physical examination

Twenty-nine children were subjected to physical examination as part of a population-based study comprising 41 children, aged 0-17 years, all assumed to be victims of sexual abuse. The hymenal opening was measured with transparent test tubes of known diameters using a new, simple and reproducible method. The examination was in no case performed under anaesthesia. A dilated hymenal opening and/or other physical evidence of trauma or disease were found in 19/29 children. Examination results evaluated in the light of anamnestic information indicated that sexual abuse had occurred in 10 cases but in only 3 of these cases the suspect was convicted. Additional studies are required to shed light on age-related normal variations in genital anatomy.     

Child victims of sexual abuse in Cameroon]

Reports of sexual abuse in children are infrequent in the French-speaking nations of black Africa. This study was undertaken to determine the incidence of sexual abuse in children in Yaounde, describe the profile of victims, and identify factors associated with sexual abuse. Seventeen female rape or attempted rape victims were enrolled over an 8-month period. Most (57.05%) were 7 to 15 years of age and lived in underprivileged neighborhoods. Genital bleeding (12 cases), hymenal tears (14 cases) and/or perineal tears were the main lesions found. Most of the rapists were young adults (19-45 years old in 70.5% of cases) who were neighbors, relatives or friends of the family, and single (58.82%). The motivations of the rapists were unclear. This medicosocial reality which is new in Cameroon needs attention.     

Assessment and follow-up of suspected child abuse in preschool children with fractures seen in a general hospital emergency department

OBJECTIVE: To evaluate the emergency department assessment and follow-up of possible child abuse in children with fractures. METHODS: A retrospective audit was conducted of children up to 3 years of age who presented with a fracture to a general hospital emergency department over a 2-year period. RESULTS: In the 98 cases included, there was no documentation of complete physical examination in 57% of cases, whether the injury was witnessed in 54%, or time of injury in 18%. In 27% of cases the history documented was too brief to assess consistency of the injury with the history. Seventy-five per cent of children with known prior injuries did not have their past history documented. In 80% of all cases there was no indication that the emergency department doctor had considered the possibility of child abuse. Emergency doctors did not recognize four out of 16 cases (25%) with inconsistent histories. There was poor follow-up of patients in whom abuse was suspected: 46% of children less than 2 years had neither a skeletal survey nor bone scan. Patients referred to a paediatrician by the emergency department were significantly more likely to have a skeletal survey performed and to have the diagnosis of child abuse confirmed. CONCLUSIONS: Emergency department staff in a general hospital do not document or assess for all of the indicators of child abuse in a high-risk population and they do not document consideration of the diagnosis in the majority of cases. Emergency department staff need more training and more resources to allow for full assessment of child abuse. Suspected child abuse cases should be referred to a paediatrician to improve investigation and follow-up.     

Testing for genital gonorrhea infections in prepubertal girls with suspected sexual abuse

BACKGROUND: The medical diagnosis of child sexual abuse is based on a combination of factors, including disclosures by the child, specific physical examination findings and sexually transmitted infections. Genital infections with Neisseria gonorrhoeae (GC) are regarded as definitive evidence of sexual contact in children, but current microbiologic culture methods have low sensitivity for detecting vulvovaginal GC infections in prepubertal girls. METHODS: To compare the three strategies of culture alone, nonculture alone (Gen-Probe PACE 2) and sequential testing for genital GC (nonculture followed by culture of nonculture positives), we conducted a decision analysis to identify optimal testing strategies using published test sensitivities, specificities and pretest probabilities of genital GC. We surveyed community child welfare professionals to determine values for each potential health outcome. RESULTS: Sequential testing yielded a higher overall health outcome value (0.855) than culture (0.834) or nonculture methods (0.838). These results were insensitive to changes in GC prevalence, test characteristics and individual health outcome values over clinically important ranges. With a baseline prevalence of 10%, more children (4 per 100) with GC infection were missed by culture than were inaccurately labeled as having GC infection (0.5 per 100) by nonculture methods. Sequential testing yielded fewer false negative results (0.8 per 100) than culture and had no false positives. CONCLUSIONS: With the use of clinical decision analysis, sequential testing using nonculture methods followed by culture was preferred to culture or nonculture methods alone in the evaluation of GC in prepubertal girls with genital discharge. Current recommendations for GC testing should be reassessed with clinical decision analysis as new test methods or strategies become available.     

Child sexual abuse: psychosocial risk factors.

Child sexual abuse is a problem of epidemic proportions in the United States. Child sexual abuse has been recognized as a predictor of many physical and psychological problems. It is important that clinicians have the ability to recognize the psychosocial dynamics present in families in which child sexual abuse takes place. Studies have shown that early detection and treatment of child sexual abuse leads to better outcomes for the victims. The literature discusses psychosocial risk factors present in families of child sexual abuse victims. An understanding of these characteristics may enable professionals to identify children at risk for child sexual abuse and may lead to earlier detection, protection, and treatment for victims. A case study illustrates psychosocial characteristics present in the family of a sexual abuse victim. Implications for practice are discussed, and a plan to assess families for psychosocial risk factors and intervene appropriately is outlined.     

Genital examination under ketamine sedation in cases of suspected sexual abuse

Sedation for genital examination in suspected sexual abuse is seldom discussed. The cases are presented of three children in whom genital examination was facilitated by ketamine sedation; these children could not be examined under any other circumstances. Ketamine provides safe, effective sedation, analgesia, and amnesia in an ambulatory setting. Its use should be considered in selected patients.     

The evaluation of sexual abuse in children

This clinical report serves to update the statement titled "Guidelines for the Evaluation of Sexual Abuse of Children," which was first published in 1991 and revised in 1999. The medical assessment of suspected sexual abuse is outlined with respect to obtaining a history, physical examination, and appropriate laboratory data. The role of the physician may include determining the need to report sexual abuse; assessment of the physical, emotional, and behavioral consequences of sexual abuse; and coordination with other professionals to provide comprehensive treatment and follow-up of victims.