研究背景：兒童在醫院被醫師下「兒虐」診斷，而且被填寫到健保申報資料上，表示這次兒虐傷害是非常嚴重且明顯。過去研究已經指出：兒虐事件不是突發獨立事件，大多數兒虐小孩是長期居住在不良脈絡，先是照護不良(譬如比較常生病或沒有按時接種預防針)，再來是忽略(譬如較常發生事故傷害)，然後是一些不容易與事故傷害區分的嚴重身體傷害(又稱為前哨傷害)，最後才發生明顯兒虐浮上海面成為看得見的冰山一角。過去雖然有不少回溯兒虐個案就醫特徵差異的研究，但是大多只能用使用較簡單的特徵變項進行風險比值計算。
研究目的：本研究試圖利用行政資料以縱貫面的角度逐一探討兒虐個案的就醫成長歷程，嘗試勾勒兒虐歷程冰山輪廓。
研究方法：本研究為回溯性世代追蹤個案研究，資料來源為國家衛生研究院釋出的全民健康保險研究資料庫百萬歸人檔。百萬歸人檔為2000，2005及2010年的抽樣，包含1996-2012年的資料。兒虐個案採「國際疾病分類臨床修正第九版」來定義，凡2歲以下且住院、門急診主次診斷碼出現995.5X及傷害外因碼E960~E969即定義兒虐個案。將每個個案依月齡將所有門急診、住院次數及診斷（分為一般非傷害疾病、非前哨傷害外傷、前哨傷害等）進行描述性統計分析、個案分析及繪圖。
結果： 2歲以下兒虐個案共83人，以男生、小於1歲較多，75%為身體虐待，最常診斷兒虐是在區域醫院、急診，24%兒虐個案在診斷前1~3個月門診次數有比對照組增加的情況，6%在診斷前有前哨傷害，6%在診斷前曾發生非前哨傷害之外傷，72%在診斷當次合併有傷害發生，其中60%為前哨傷害，而7%有重複兒虐的情況。繪出個案之冰山輪廓，約17%個案露出海平面的部分較寬，表示在發生兒虐或重複兒虐前已有顯示徵兆。
結論： 以健保就醫資料來看，2歲以下兒虐個案約九成屬於突發型，就醫紀錄中沒有明顯徵兆，約10%在診斷前曾發生過外傷，其中一半為與兒虐較相關之前哨傷害，72%個案在診斷兒虐時有合併外傷，其中近六成是前哨傷害，7%會發生兩次以上兒虐，若能多留意有傷害發生的兒童，或許能夠提早診斷及介入，避免一半以上的個案在未來發生或再次發生兒虐事件。

Child abuse might be a chronic course. The aim of this study was to show the whole life course of medical services use of the children who were abused before two years old by administrative claim data and try to draw the outline of trajectory iceberg of the abused children. The data were obtained from Longitudinal Health Insurance Database 2000, 2005 and 2010, National Health Insurance Research Database. Cases were defined when the child had medical record with ICD-9-CM codes 995.5X or E960-E969 before 2 years old. We analyzed all the medical claim data for each case before and after their first child abuse diagnosed. Eighty-three cases were found from the three databases. Most cases were boys and less than 1 year-old and about 75% were classified as physical abuse. About 10% of cases had injury histories before abuse and half were sentinel injuries. Six cases had repeated abuse before their last follow-up and 2 cases were died. The outline of trajectory iceberg was drawn for these cases and showed the visible part of iceberg above sea level were larger which meant some clues might be showed up before abuse diagnosed. Seventy-two percent of cases had injuries at the time of child abuse diagnosed. If we can pay more attention to the children, who have injuries before 2 years old, more abused cases might be noted earlier and more severe injuries could be avoided.

Barlow, K.M., Milne, S., Aitken, K., &Minns, R. A. (1998). A retrospective epidemiological analysis of non-accidental head injury in children in Scotland over a 15 year period. Scottish Medical Journal, 43(4), 112–114.
Ben-David, V., Jonson-Reid, M., Drake, B., & Kohl, P. L. (2015). The association between childhood maltreatment experiences and the onset of maltreatment perpetration in young adulthood controlling for proximal and distal risk factors. Child Abuse & Neglect, 46, 132-141.
Brownell, M. D., & Jutte, D. P. (2013). Administrative data linkage as a tool for child maltreatment research. Child Abuse & Neglect, 37(2-3), 120-124.
Case, M. E. (2007). Abusive head injuries in infants and young children. Legal Medicine, 9(2), 83-87.
Chaffin, M., Kelleher, K., & Hollenberg, J. (1996). Onset of physical abuse and neglect: Psychiatric, substance abuse, and social risk factors from prospective community data. Child Abuse & Neglect, 20(3), 191-203.
Chiang, W. L., Huang, Y. T., Feng, J. Y., & Lu, T. H. (2012). Incidence of hospitalization due to child maltreatment in Taiwan, 1996–2007: A nationwide population-based study. Child Abuse & Neglect, 36(2), 135-141.
Connell, C. M., Bergeron, N., Katz, K. H., Saunders, L., & Tebes, J. K. (2007). Re-referral to child protective services: The influence of child, family, and case characteristics on risk status. Child Abuse & Neglect, 31(5), 573-588.
Coohey, C. (2006). Physically abusive fathers and risk assessment. Child Abuse & Neglect, 30(5), 467-480.
Covington, T. M. (2011). The US National Child Death review case reporting system. Injury prevention, 17(Suppl I), i34-i37.
Cross, D., Crow, T., Powers, A., & Bradley, B. (2015). Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, African-American men and women. Child Abuse & Neglect, 44, 26-35.
Crume, T. L., DiGuiseppi, C., Byers, T., Sirotnak, A. P., & Garrett, C. J. (2002). Underascertainment of child maltreatment fatalities by death certificates, 1990–1998. Pediatrics, 110(2), e18-e18.
Deans, K. J., Thackeray, J., Groner, J. I., Cooper, J. N., & Minneci, P. C. (2014). Risk factors for recurrent injuries in victims of suspected non-accidental trauma: a retrospective cohort study. BMC pediatrics, 14(1), 217.
Diderich, H. M., Dechesne, M., Fekkes, M., Verkerk, P. H., Buitendijk, S. E., & Oudesluys-Murphy, A. M. (2014). What parental characteristics can predict child maltreatment at the emergency department? Considering expansion of the hague protocol. European Journal of Emergency Medicine, 22(4), 279-281.
Duncan, A. E., Sartor, C. E., Jonson-Reid, M., Munn-Chernoff, M. A., Eschenbacher, M. A., Diemer, E. W., ... & Heath, A. C. (2015). Associations between body mass index, post-traumatic stress disorder, and child maltreatment in young women. Child Abuse & Neglect, 45, 154-162.
Eckenrode, J., Smith, E. G., McCarthy, M. E., & Dineen, M. (2014). Income inequality and child maltreatment in the United States. Pediatrics, 133(3), 454-461.
Ewigman, B., Kivlahan, C., & Land, G. (1993). The Missouri child fatality study: Underreporting of maltreatment fatalities among children younger than five years of age, 1983 through 1986. Pediatrics, 91(2), 330–337.
Fallon, B., Trocmé, N., Fluke, J., MacLaurin, B., Tonmyr, L., & Yuan, Y. Y. (2010). Methodological challenges in measuring child maltreatment. Child Abuse & Neglect, 34(1), 70-79.
Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2009). Lifetime assessment of poly-victimization in a national sample of children and youth. Child Abuse & Neglect, 33(7), 403-411.
Finkelhor, D., Vanderminden, J., Turner, H., Hamby, S., & Shattuck, A. (2014). Child maltreatment rates assessed in a national household survey of caregivers and youth. Child Abuse & Neglect, 38(9), 1421-1435.
Fisher, M. H. (2009). Letter to the editor: Literature analysis to determine the inclusion of children with disabilities in abuse interventions. Child Abuse & Neglect, 33(6), 326.
Fluke, J. D. (2008). Child protective services rereporting and recurrence—Context and considerations regarding research. Child Abuse & Neglect, 32(8), 749-751.
Freisthler, B., Holmes, M. R., & Wolf, J. P. (2014). The dark side of social support: understanding the role of social support, drinking behaviors and alcohol outlets for child physical abuse. Child Abuse & Neglect, 38(6), 1106-1119.
Friedlaender, E. Y., Rubin, D. M., Alpern, E. R., Mandell, D. S., Christian, C. W., & Alessandrini, E. A. (2005). Patterns of health care use that may identify young children who are at risk for maltreatment. Pediatrics, 116(6), 1303-1308.
Frioux, S., Wood, J. N., Fakeye, O., Luan, X., Localio, R., & Rubin, D. M. (2014). Longitudinal association of county-level economic indicators and child maltreatment incidents. Maternal and child health journal, 18(9), 2202-2208.
Fuchs, A., Möhler, E., Resch, F., & Kaess, M. (2015). Impact of a maternal history of childhood abuse on the development of mother–infant interaction during the first year of life. Child Abuse & Neglect, 48, 179-189.
Gera, S. K., Raveendran, R., & Mahadev, A. (2014). Pattern of fractures in non-accidental injuries in the pediatric population in Singapore. Clinics in orthopedic surgery, 6(4), 432-438.
Gibbons, C. L., Mangen, M. J. J., Plass, D., Havelaar, A. H., Brooke, R. J., Kramarz, P., ... & Kretzschmar, M. E. (2014). Measuring underreporting and under-ascertainment in infectious disease datasets: a comparison of methods. BMC public health, 14(1), 147.
Greger, H. K., Myhre, A. K., Lydersen, S., & Jozefiak, T. (2015). Previous maltreatment and present mental health in a high-risk adolescent population. Child Abuse & Neglect, 45, 122-134.
Guenther, E., Knight, S., Olson, L. M., Dean, J. M., & Keenan, H. T. (2009). Prediction of child abuse risk from emergency department use. The Journal of pediatrics, 154(2), 272-277.
Holt, S., Buckley, H., & Whelan, S. (2008). The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse & Neglect, 32(8), 797-810.
Harford, T. C., Yi, H. Y., & Grant, B. F. (2014). Associations between childhood abuse and interpersonal aggression and suicide attempt among US adults in a national study. Child Abuse & Neglect, 38(8), 1389-1398.
Harper, N. S., Feldman, K. W., Sugar, N. F., Anderst, J. D., Lindberg, D. M., & Examining Siblings To Recognize Abuse Investigators. (2014). Additional injuries in young infants with concern for abuse and apparently isolated bruises. The Journal of pediatrics, 165(2), 383-388.
Herman-Giddens, M. E., Brown, G., Verbiest, S., Carlson, P. J., Hooten, E. G., Howell, E., & Butts, J. D. (1999). Underascertainment of child abuse mortality in the United States. JAMA, 282(5), 463-467.
Hinds, T., Shalaby-Rana, E., Jackson, A. M., & Khademian, Z. (2015). Aspects of abuse: abusive head trauma. Current problems in pediatric and adolescent health care, 45(3), 71-79.
Hooft, A., Ronda, J., Schaeffer, P., Asnes, A. G., & Leventhal, J. M. (2013). Identification of physical abuse cases in hospitalized children: accuracy of international classification of diseases codes. The Journal of pediatrics, 162(1), 80-85.
Hooft, A. M., Asnes, A. G., Livingston, N., Deutsch, S., Cahill, L., Wood, J. N., & Leventhal, J. M. (2015). The accuracy of ICD codes: identifying physical abuse in 4 children's hospitals. Academic pediatrics, 15(4), 444-450.
Hymel, K. P., Armijo-Garcia, V., Foster, R., Frazier, T. N., Stoiko, M., Christie, L. M., ... & Wang, M. (2014). Validation of a clinical prediction rule for pediatric abusive head trauma. Pediatrics, 134(6), e1537-e1544.
Kelly, P., MacCormick, J., & Strange, R. (2009). Non-accidental head injury in New Zealand: the outcome of referral to statutory authorities. Child Abuse & Neglect, 33(6), 393-401.
Kemp, A. M., Dunstan, F., Harrison, S., Morris, S., Mann, M., Rolfe, K., ... & Maguire, S. (2008). Patterns of skeletal fractures in child abuse: systematic review. British Medical Journal, 337-344.
Kemp, A. M., Maguire, S. A., Nuttall, D., Collins, P., & Dunstan, F. (2014). Bruising in children who are assessed for suspected physical abuse. Archives of disease in childhood, 99(2), 108-113.
Kretzschmar, M. E. (2014). Measuring underreporting and under-ascertainment in infectious disease datasets: a comparison of methods. BMC public health, 14(1), 147-163.
Last, J. M. (1963). The iceberg: completing the clinical picture in general practice. Lancet, 282(7297), 28-31.
Leaman, A. M., Holt, A., & Ramakrishnan, R. P. (2010). Emergency department attendance by children at risk of abuse. Emergency medicine journal, 27(1), 26-28.
Lee, L. K., Fleegler, E. W., Forbes, P. W., Olson, K. L., & Mooney, D. P. (2010). The modern paediatric injury pyramid: injuries in Massachusetts children and adolescents. Injury Prevention, 16(2), 123-126.
Lee, S. J., Guterman, N. B., & Lee, Y. (2008). Risk factors for paternal physical child abuse. Child Abuse & Neglect, 32(9), 846-858.
Leeb, R. T., Paulozzi, L. J., Melanson C., Somin, T. R., & Arias, I. (2008). Child Maltreatment Surveillance Uniform Definitions for Public Health and Recommended Data Elements. Centers for Disease Control and Prevention, USA.
Lindberg, D. M., Beaty, B., Juarez-Colunga, E., Wood, J. N., & Runyan, D. K. (2015). Testing for abuse in children with sentinel injuries. Pediatrics, 136(5), 831-838.
Lindo, J., Schaller, J., & Hansen, B. (2013). Economic conditions and child abuse. National Bureau of Economic Research Working Paper # 18994.
Maguire-Jack, K., Lanier, P., Johnson-Motoyama, M., Welch, H., & Dineen, M. (2015). Geographic variation in racial disparities in child maltreatment: The influence of county poverty and population density. Child Abuse & Neglect, 47, 1-13.
Manders, J. E., & Stoneman, Z. (2009). Children with disabilities in the child protective services system: An analog study of investigation and case management. Child Abuse & Neglect, 33(4), 229-237.
Mash, C., Frazier, T., Nowacki, A., Worley, S., & Goldfarb, J. (2011). Development of a risk-stratification tool for medical child abuse in failure to thrive. Pediatrics, 128(6), e1467-e1473.
McCarthy-Jones, S., & McCarthy-Jones, R. (2014). Body mass index and anxiety/depression as mediators of the effects of child sexual and physical abuse on physical health disorders in women. Child Abuse & Neglect, 38(12), 2007-2020.
McPhie, M. L., Weiss, J. A., & Wekerle, C. (2014). Psychological distress as a mediator of the relationship between childhood maltreatment and sleep quality in adolescence: Results from the Maltreatment and Adolescent Pathways (MAP) Longitudinal Study. Child Abuse & Neglect, 38(12), 2044-2052.
Mills, P., Newman, E. F., Cossar, J., & Murray, G. (2015). Emotional maltreatment and disordered eating in adolescents: Testing the mediating role of emotion regulation. Child Abuse & Neglect, 39, 156-166.
Morad, Y., Wygnansky‐Jaffe, T., & Levin, A. V. (2010). Retinal haemorrhage in abusive head trauma. Clinical & experimental ophthalmology, 38(5), 514-520.
Moulton, S. J., Newman, E., Power, K., Swanson, V., & Day, K. (2015). Childhood trauma and eating psychopathology: A mediating role for dissociation and emotion dysregulation?. Child Abuse & Neglect, 39, 167-174.
Newton, A. W., & Vandeven, A. M. (2005). Update on child maltreatment with a special focus on shaken baby syndrome. Current opinion in pediatrics, 17(2), 246-251.
Ney, P. G., Fung, T., & Wickett, A. R. (1994). The worst combinations of child abuse and neglect. Child Abuse & Neglect, 18(9), 705-714.
Niederkrotenthaler, T., Xu, L., Parks, S. E., & Sugerman, D. E. (2013). Descriptive factors of abusive head trauma in young children—United States, 2000–2009. Child Abuse & Neglect, 37(7), 446-455.
O'Donnell, M., Nassar, N., Leonard, H., Jacoby, P., Mathews, R., Patterson, Y., & Stanley, F. (2010). Rates and types of hospitalisations for children who have subsequent contact with the child protection system: a population based case-control study. Journal of epidemiology and community health, 64(9), 784-788.
Petska, H. W., & Sheets, L. K. (2014). Sentinel injuries: subtle findings of physical abuse. Pediatric clinics of North America, 61(5), 923-935.
Pierce, M. C., Kaczor, K., Aldridge, S., O'Flynn, J., & Lorenz, D. J. (2010). Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 125(1), 67-74.
Raissian, K. M. (2015). Does unemployment affect child abuse rates? Evidence from New York State. Child Abuse & Neglect, 48, 1-12.
Reijneveld, S. A. (2007). Re: Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: Convergent evidence for crying as a trigger to shaking (Barr, Trent, & Cross, 2006). Child Abuse & Neglect, 31(6), 601-602.
Rieder, R., & Bepperling, S. L. (2011). Heinrich Triangle for Ground Operation. Journal of System Safety, 47(5), 23-28.
Sahai, V. S., Ward, M. S., Zmijowskyj, T., & Rowe, B. H. (2005). Quantifying the iceberg effect for injury: using comprehensive community health data. Canadian Journal of Public Health/Revue Canadienne de Sante'e Publique, 328-332.
Schnitzer, P. G., Slusher, P., & Van Tuinen, M. (2004). Child maltreatment in Missouri: combining data for public health surveillance. Amarican Journal of Preventive Medicine, 27(5), 379-384.
Schnitzer, P. G., Covington, T. M., Wirtz, S. J., Verhoek-Oftedahl, W., & Palusci, V. J. (2008). Public health surveillance of fatal child maltreatment: analysis of 3 state programs. American Journal of Public Health, 98(2), 296-303.
Schnitzer, P. G., Slusher, P. L., Kruse, R. L., & Tarleton, M. M. (2011). Identification of ICD codes suggestive of child maltreatment. Child Abuse & Neglect, 35(1), 3-17.
Schnitzer, P. G., Gulino, S. P., & Yuan, Y. Y. T. (2013). Advancing public health surveillance to estimate child maltreatment fatalities: Review and recommendations. Child welfare, 92(2), 77-98.
Scott, D., Tonmyr, L., Fraser, J., Walker, S., & McKenzie, K. (2009). The utility and challenges of using ICD codes in child maltreatment research: A review of existing literature. Child Abuse & Neglect, 33(11), 791-808.
Scott, D., Walker, S., Fraser, J. A., & Valmuur, K. (2014). A needle in a haystack: The use of routinely collected emergency department injury surveillance data to help identify physical child abuse. International journal of injury control and safety promotion, 21(3), 227-235.
Sheets, L. K., Leach, M. E., Koszewski, I. J., Lessmeier, A. M., Nugent, M., & Simpson, P. (2013). Sentinel injuries in infants evaluated for child physical abuse. Pediatrics, 131(4), 701-707.
Sheybani, E. F., Gonzalez-Araiza, G., Kousari, Y. M., Hulett, R. L., & Menias, C. O. (2014). Pediatric Nonaccidental Abdominal Trauma: What the Radiologist Should Know. RadioGraphics, 34(1), 139-153.
Simkiss, D. E., Stallard, N., & Thorogood, M. (2013). A systematic literature review of the risk factors associated with children entering public care. Child: care, health and development, 39(5), 628-642.
Spivey, M. I., Schnitzer, P. G., Kruse, R. L., Slusher, P., & Jaffe, D. M. (2009). Association of injury visits in children and child maltreatment reports. Journal of Emergency Medicie, 36(2), 207-214
Stevens, K. I., Schneiderman, J. U., Negriff, S., Brinkmann, A., & Trickett, P. K. (2015). The whole picture: child maltreatment experiences of youths who were physically abused. Child Abuse & Neglect, 43, 30-41.
U.S. Department of Health and Human Services. Retrieved from http://www.acf.hhs.gov/programs/cb/research-data-technology/reporting-systems/ncands
U.S. Department of Health and Human Services (2015). Retrieved from http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment
United Nation Human Right. Committee on the rights of the child. Retrieved from http://www.ohchr.org/EN/HRBodies/CRC/Pages/CRCIndex.aspx
van der Kooij, I. W., Nieuwendam, J., Bipat, S., Boer, F., Lindauer, R. J., & Graafsma, T. L. (2015). A national study on the prevalence of child abuse and neglect in Suriname. Child Abuse & Neglect, 47, 153-161.
Vincent, S. (2014). Child Death Review Processes: A Six‐Country Comparison. Child abuse review, 23(2), 116-129.
Wadman, M. C., Muelleman, R. L., Coto, J. A., & Kellermann, A. L. (2003). The pyramid of injury. Annals of Emergency Medicine, 42(4), 468-478.
Wibbenmeyer, L., Liao, J., Heard, J., Kealey, L., Kealey, G., & Oral, R. (2014). Factors related to child maltreatment in children presenting with burn injuries. Journal of Burn Care & Research, 35(5), 374-381.
Widom, C. S., DuMont, K., & Czaja, S. J. (2007). A prospective investigation of major depressive disorder and comorbidity in abused and neglected children grown up. Archives of general psychiatry, 64(1), 49-56.
Widom, C. S., Czaja, S. J., & Dutton, M. A. (2008). Childhood victimization and lifetime revictimization. Child abuse & neglect, 32(8), 785-796.
Wildeman, C., Emanuel, N., Leventhal, J. M., Putnam-Hornstein, E., Waldfogel, J., & Lee, H. (2014). The prevalence of confirmed maltreatment among US children, 2004 to 2011. JAMA pediatrics, 168(8), 706-713.
Winn, D. G., Agran, P. F., & Anderson, C. L. (1995). Sensitivity of hospitals’ E-coded data in identifying causes of children’s violence-related injuries. Public Health Report, 110(3), 277–281.
Wood, J. N., Fakeye, O., Mondestin, V., Rubin, D. M., Localio, R., & Feudtner, C. (2015). Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Bruises. Pediatrics, 135(2), e312-e320.
World Health Organization. Retrieved from http://www.who.int/topics/child_abuse/en/

中文部分
邱孟君（民104）。母親慢性疾病與新生母親慢性疾病與新生兒先天性心臟病的相關性（未出版之碩士論文）。國立成功大學，臺南市。
兒童福利法（民82年2月5日）
兒童及少年福利與權利保障法（民104年2月4日）。
國家衛生研究院全民健康保險研究資料庫（2015）取自http://nhird.nhri.org.tw/talk_07.php
彭淑華（2011）。台灣兒童及少年福利政策與法令制度之發展。社會福利模式-從傳承到創新研討會
葉肅科（民101）。台灣兒童及少年福利與權益保障法： 回顧與展望。社會發展季刊，139，31-41。
衛生福利部保護服務司。取自 http://www.mohw.gov.tw/CHT/DOPS/
衛生福利部中央健康保險署（2013）。2013-2014全民健康保險年報。
衛生福利部（2014）。兒少虐待及疏忽醫事人員工作手冊。
衛生福利部統計處（2015）。民國103年死因統計年報。 取自http://www.mohw.gov.tw/CHT/DOS/Statistic.aspx?f_list_no=312&fod_list_no=5488
衛生福利部統計處（2015）。104年婦幼主題式資料庫說明會資料。 取自http://www.mohw.gov.tw/cht/DOS/DM1.aspx?f_list_no=313&fod_list_no=5368