Pediatric Dentistry - a Clinical Approach, 3ed.

CHAPTER 26. Child Abuse and Neglect: The Dental Professionals’ Role in Safeguarding Children

Göran Dahllöf, Therese Kvist, Anne Rønneberg, and Birgitte Uldum

Children are abused and neglected all over the world, every day. It is essential to recognize children who live under harmful conditions in order to protect and support them from negative health development. All professionals in dental care in the Nordic countries are legally mandated to unconditionally and immediately report any suspicion of child abuse and neglect to the social services. The dental team is in a unique and good position to recognize children at risk as they often meet children and their families on a regular basis throughout the childhood, and as signs of child abuse and neglect and domestic violence can manifest in and around the head and neck area or in certain behaviors. Having up‐to‐date knowledge of how to recognize and manage child abuse and neglect is an important part of dentistry.

Definition of child abuse and neglect

Child maltreatment is often used as a universal term for all types of abuse and neglect. There are four types of abuse included in the term “child maltreatment”: physical abuse, emotional abuse (intimate partner violence included), sexual abuse, and neglect [1]. In Table 26.1 the definitions for each type of abuse are explained. Dental professionals are obliged to report all types of abuse and for that reason this chapter uses the term child maltreatment with type of abuse further specified when needed.

Table 26.1 Definitions of child maltreatment and its components.

Type of abuse

Definition

Child maltreatment

Any act of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. Harm does not need to be intended

Child physical abuse

Intentional use of physical force or implements against a child that results in, or has the potential to result in, physical injury

Child sexual abuse

Any completed or attempted sexual act, sexual contact, or non‐contact sexual interaction with a child by a caregiver

Child psychological abuse

Intentional behavior that conveys to a child that he/she is worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another’s needs

Child neglect

Failure to meet a child’s basic physical, emotional, medical/dental, or educational needs; failure to provide adequate nutrition, hygiene, or shelter; or failure to ensure a child’s safety

Intimate partner violence

Any incident of threatening behavior, violence, or abuse (psychological, physical, sexual, financial, or emotional) between adults who are, or have been, intimate partners or family members, irrespective of sex or sexuality

Source: Gilbert et al. 2009 [1]. Reproduced with permission of Elsevier.

Prevalence of child maltreatment

Estimating the prevalence of child maltreatment is difficult as it depends on the research method and the definitions used. Some countries use child protection registers whereas in others there are official statistics from police reports, and self‐reports from abusing parents and from abused children. Irrespective of research method, self‐reports result in a higher prevalence figure than official reports, indicating that many cases remain unrevealed [1]. Underreporting from dental professionals to the social services is also common [2].

In industrialized countries the prevalence of corporal punishment varies from 5 to 35%. Sexual abuse of girls ranges between 15 and 30% and of boys it is 5 to 15%. Intimate partner violence varies between 8 and 25% [1]. According to a 2014 report by the World Health Organization, 23% of adults report to have been physically abused as children, 36% report previous experience of emotional abuse, and 16% report child neglect [3]. Two Swedish national population‐based studies found that 13–15% of adolescents reported self‐experienced physical abuse and of these 3–6% reported they had been abused on repeated occasions. Further, 7–10% reported intimate partner violence in their homes [4,5]. Globally, 30% of women report exposure to intimate partner violence [6]. Being exposed to several types of abuse, so called poly‐victimization, is common [4,7].

Risk factors for exposure to maltreatment

Identifying children at risk of maltreatment is difficult. Several factors in combination such as family, child, and the social context often interact and may compound the risk [1,8]. One major risk factor is intimate partner violence. Children who live in families where there is violence between adults are often exposed to physical abuse themselves. In addition, they witness the abuse of another family member, which is psychological abuse in itself [1,4,5,9,10]. Therefore it is important for the general dental professional to recognize adults exposed to intimate partner violence when dealing with child maltreatment and not focus solely on abuse directed towards the child.

Young children and children with functional disabilities or chronic health conditions are vulnerable groups with an increased risk of being physically abused as these groups cannot protect themselves, they may have difficulties expressing what they are exposed to, and furthermore their behavior may confer extreme stress on the parents. Other factors that can increase the risk for maltreatment are low socioeconomic conditions, parents’ own history of being abused as child, parents with substance abuse, and families with parental psychiatric and mental disorders [1,4,9,11,12].

Social services: child protection and support

Child protection and providing support to maltreated children is managed by the social services, the authority that investigates and manages vulnerable social relations for both children and adults. The legal obligation to report suspicions of child maltreatment is regulated and formulated in the social services act in each of the Nordic countries. Reporting a suspicion of child maltreatment to the social services is always with the child’s best interest in focus.

After the report is received at the social services, the report is evaluated for possible investigation. An investigation includes gathering of information on the child’s situation: family, health, and social relations. This process aims to determine whether maltreatment is present and whether the child and family require any supportive or protective intervention. The reporter can be contacted for more information and the reporter can ask for feedback regarding the report and its progress. In a Scandinavian context, the aim of the social services is family oriented and favors collaboration but in other parts of the world such as USA and the United Kingdom, the focus is to protect‐child protection.

Overall, the social services organize interagency cooperation between police, schools and health organizations, and they decide or suggest appropriate interventions according to the social services act. The social services also work with “children’s houses,” which are places for interagency cooperation. Children’s houses offer a setting that make it easier for children exposed to physical and sexual abuse to be met by social services, police, prosecutor, child psychiatry, and pediatric medicine in the same place. Thereby, the child does not have to travel between settings for a medical examination or a hearing. All Nordic countries have children’s houses, but organization and content may vary from country to country. At some children’s houses a dental professional is available upon request.

Recognition of child maltreatment

Child maltreatment can be recognized or suspected when finding physical signs or symptoms, by observing behaviors, either of the child or in the interaction between the child and the adult, or by direct disclosure from a child, a parent or a third party. Child abuse can also be suspected when treating an adult (without having met the child) where a suspicion is raised regarding intimate partner violence. As always, a thorough social, medical and dental history should be taken in the clinical encounter with adults and children.

Physical abuse

Inflicted injuries can be found on the whole body although not always recognizable to the dental professional due its location. Different objects such as hands, belts, and many other things can afflict physical injury. As the facial region is often injured during physical violence, dental professionals have a particularly good opportunity to observe and uncover signs of abuse when the orofacial region is well illuminated during the clinical examination.

Bruising is common after abusive injuries and patterns of the bruises can help to identify a previous abuse [13]. Several colors in the bruise, several bruises and in different stages of healing may indicate injuries inflicted over time. However, estimating the age of bruises is difficult and not recommended as the scientific evidence is weak [13,14].

Inflicted burns can be found in the mouth due to bottle‐feeding infants with overheated drinks or with a hot spoon during feeding or by immersing the child into scalding water. Cigarettes can cause lesions that are small and circular on the skin.

Bite marks on skin can appear as bruises, abrasions or lacerations. They can be caused by animals or humans, perpetrators or victims, children or adults, inflicted as punishment, part of physical or sexual abuse, or self‐inflicted. Cases of children biting their own arm during abuse in order to keep quiet or not cry have been described. Almost 25% of 112 bite marks were found on face and head [15]. As bite marks persist for a varied period of time (from less than 24 hours to 2 or 3 days or longer) it is essential to document a bite mark when it is first noticed. Two half circles opposing each other, occasionally with a central area of ecchymosis between the arches, may be found. A distance of 3 cm or more between the canines may indicate that an adult was involved in the injury [16].

Separating accidental injuries from non‐accidental injuries

When a child presents with an injury in the dental setting, the dentist must evaluate whether the injury is accidental or non‐accidental. Non‐accidental bruises can be separated from accidental bruises on the basis of the age of the child and the pattern of the bruises [17–19]. Small children, unable to walk or crawl, are not likely to have inflicted bruises on themselves by accident and the same applies to children with severe mobility impairment. Bruising on and behind the ears, or on the neck and cheeks in these children should raise awareness of an inflicted injury (Figures 26.1 and 26.2). This “triangle of safety” (ears, side of face, and neck, top of shoulders) is rarely subjected to accidental injury whereas accidental trauma more often occurs in other parts of the body and face (bony prominences) (Figure 26.3a,b). A number of pointers that should raise a suspicion of physical abuse are listed in Box 26.1 [20].

Illustration of a child’s head as observed from the left. It features slap marks on the cheek and petechial bruising at a finger width spacing (inset).

Figure 26.1 Gripping a child’s cheeks during forced feeding will leave an impression of the thumb on one cheek and impressions of the four other fingers on the other cheek.

Image source: Harris et al. 2006 [19]. Reproduced with permission of Committee of Postgraduate Dental Deans and Directors (COPDEND) UK.

Illustration of a child’s head as observed from the front. It features finger marks on each cheek where it was gripped during forced feeding.

Figure 26.2 Slap marks on the cheek. The fingers of the hand will leave impressions. Petechial bruising at a finger width spacing. Marks form between the fingers on the slapped area.

Image source: Harris et al. 2006 [19]. Reproduced with permission of Committee of Postgraduate Dental Deans and Directors (COPDEND) UK.

Two illustrations of a child with labeled areas of the body that can be subject to accidental injuries (left) and non-accidental injuries (right).

Figure 26.3 Helpful illustrations to distinguish (a) accidental injuries from (b) non‐accidental injuries.

Source: Harris et al. 2006 [19]. Reproduced with permission of Committee of Postgraduate Dental Deans and Directors (COPDEND) UK.

Box 26.1 Pointers to recognizing nonaccidental injuries which are suggestive of inflicted trauma. Adapted from Speight 2006 [20]. Reproduced with permission of Elsevier.

·     There is a delay or omission in seeking medical help.

·     The story of the injury is vague and lacking in detail.

·     Mismatch between anamnesis of injury and appearance of injury (bilateral injury).

·     The parents’ affect is abnormal and they may be preoccupied with their own problems.

·     The parents’ behavior is abnormal; they may be unwilling to share information, hostile, aggressive or indifferent.

·     The interaction between parent and child may be abnormal. The child may be sad, quiet or withdrawn. In rare cases the child may exhibit ‘frozen watchfulness’.

·     The child may say something. Maybe the child’s story differs from the parent’s story.

Additional pointers

·     An alleged small trauma has resulted in a comprehensive injury.

·     The parent blame third party i.e. a sibling for the injury.

·     Seeking help for another compliant than the injury.

·     Inadequate or no response to information of the severity of the injury.

·     The story of the injury varies from time to time.

Psychological abuse

Signs of psychological abuse are most likely found when observing the child’s behavior and interactions with those around them. Possible signs in the child’s behavior are emotional frustration, submission, aggressiveness, and lack of concentration and social skills [19]. Older children and adolescents may react to emotional abuse (and other types of abuse) by experimenting with drugs or alcohol, by criminal behavior, by running away from home, or by inflicting injuries on themselves [21]. It can be difficult to distinguish poor parenting from emotional abuse, but behaviors that cause severe problems to children’s development are generally considered as emotional maltreatment. This includes, for example, severe nonresponsiveness, insults or threats towards the child. Emotional abuse also includes intimate partner violence [22].

Neglect

Child neglect can be recognized when parents or caregivers fails to provide basic needs such as food, clothing, medical and dental care, education, and protection from danger [1,19]. Persistent general neglect can result in failure to thrive which manifests as poor weight gain, growth retardation, delayed development, and abnormal behavior [23].

Oral and dental aspects of child maltreatment

Physical abuse

Although studies have shown that the prevalence of intraoral injuries is low, traumatic injuries such as fractures to the teeth, roots and alveolar bone, intrusion, luxation, and avulsion are found [24,25]. Other dental factors shown to be associated with physical abuse and intimate partner violence include unexplained dental traumas both acute and healed, untreated caries, dental behavioral management problems (DBMP), and poor self‐perceived oral health [26–31].

Sexual abuse

Recognition of childhood sexual abuse is difficult as it has various and broad manifestations. Signs recognized by the dental team may be associated with physical, emotional, and dental symptoms. Unexplained injury of teeth or the palate, particularly petechiae at the junction of the hard and soft palate, may be signs of forced oral sex [32]. The child or the adolescent may also react with dental fear as shown in several studies among adult women with previous experience of sexual abuse [33–35]. Poor self‐perceived oral health is also associated with forced sex [31].

Dental neglect

Dental neglect is defined by the American Academy of Pediatric Dentistry as “a willful failure of parent or guardian to seek and obtain comprehensive dental treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection” [36].

As caries has a multifactorial etiology, extensive dental caries is not by default synonymous with dental neglect. Certain features of dental neglect can, however, be identified: failure or delay in seeking treatment for dental caries or trauma, failure to complete a recommended treatment, and allowing the child’s oral health to deteriorate [37]. Signs and symptoms suggestive of dental neglect are presented in Box 26.2. It is important to stress that no signs or symptoms are pathognomonic of child abuse and neglect. Possible differential diagnoses should always be considered (Box 26.3).

Box 26.2 Signs and symptoms suggestive of dental neglect

·     Repeated tooth ache and emergency visits

·     Disturbed sleep

·     Not taking part in daily life activities (playing with friends, kindergarten, school)

·     Repeated prescription of analgesics and antibiotics

·     Repeated referral to treatment under general anesthesia

Box 26.3 Possible differential diagnosis when suspecting child maltreatment

Diagnosis

Can be mistaken for

Impetigo

Cigarette burn

Conjunctivitis

Trauma to the eye

Hemophilia and von Willebrand

Bruises

Osteogenesis imperfecta

Fracture of bone

Amelogenesis imperfecta, dentinogenesis imperfecta

Early childhood caries, caries

Hypomineralization

Caries

Self‐inflicted injuries

Cuts, burns, bruises

Birth marks, Mongolian blue spots

Bruises

Box 26.4 Good clinical practice for local guidelines

·     A list of signs and symptoms indicative of child abuse and neglect

·     Appropriate questions and information to ask and share with the child and the family

·     A prefabricated form to report a suspicion

·     A contact list for appropriate contacts (with address and telephone numbers) with the social services and police on a local level

Managing a suspicion of child maltreatment

Any suspicion of child maltreatment should be reported to the social services. All dental professionals must trust their own judgment. It is good clinical practice and helpful to have local and national guidelines on how to manage a suspicion [38]. The guidelines should be easily available for all employees, preferably on the local intranet and in paper form, and should include crucial information of how to write a report, and contact information for the local social services (Box 26.4).

In the Nordic countries, child dental care is free of charge (financed by taxes). Therefore, economy is an issue that should not prevent parents from seeking dental care for their children. However, taking days off from work can be a barrier for parents as this can have economic consequences. Therefore, in order to prevent negative dental health development and dental neglect it is important to set up a treatment plan and time plan that suits the individual family.

Documentation of suspected child maltreatment is important for child protection and standard procedures include personal and medical information and dental history. In addition it is good clinical practice in pediatric dentistry to take notes on accompanying persons (e.g., their relationship with the child) and to describe how the child cooperates, how it interacts with its parents, and if there are behaviors that affect the treatment or that deviate from what is expected [19]. All injuries (minor and major), attendance or non‐attendance and cancelled appointments (including the explanation for cancellations or missed appointments) should be recorded. This makes it possible to see patterns in behaviors and injuries over a period of time. Pre‐drawn sketches of the head and neck area can be useful for describing injuries and, in addition, clinical photos and radiographs are often essential. You can also draw the lesion to describe an injury. It is important to describe all clinical findings thoroughly; location on body, size and shape, preferably using some ruler or other device to estimate size [19]. Regarding bruises and bite marks, interpretation and documentation of legal aspects is to be managed within forensic odontology.

All reports to the social services and or the police must be recorded in the dental record with an explanation of why the report is filed. The ethical principle of confidentiality towards the patient is fundamental but in the case of a request from the social services, police or prosecutor the ethical principle of confidentiality is not applicable. As the child and the caregiver are entitled to the dental record by request, notes in the dental record must be based on objective facts and written without expressing personal opinions and values (Box 26.5).

Box 26.5 Practical guide to writing a report to the social services

·     Aim to render statements and information as literally as possible and note who provides the information (the child? parents? witness?)

·     Describe any findings in an objective manner

·     Describe the child`s behavior during examination, e.g., anxious, indiscriminate behavior, withdrawn, restless, upset, troubled, crying etc.

·     Describe how the child and parents interact, e.g., the parents adapt to the child, see their child’s needs, how they talk with the child, do they talk in a personalized way, are they supportive, act as controlling, or seem to be uninvolved in the child

·     Describe parental behavior without interpretations

·     Describe the results of any supplementary examinations

·     The forensic part of the medical examination (disengagement preventive, photographic documentation), should be kept in a separate archive. It is important to disclose all this information in an open journal

·     Always try to attain fair and objective description without interpretations

·     Assessments and conclusions in the direction of child abuse/neglect must be sustained objectively and precisely

·     Information must be provided regarding any inquiries for other instances and further plan of action

Management of dental neglect

When managing dental neglect there are some factors that should be considered. These are evaluation of dental disease, parental awareness of disease, access to dental care, autonomy of the child, and vulnerability of the child. Following recommendations according to the British Society of Paediatric Dentistry, a three‐step intervention could be carried out when dental neglect is suspected: (1) preventive dental management; (2) preventive multi‐agency management; and (3) report to the social services [39]. Preventive management includes sharing one’s concerns with parents providing information on what changes are required (e.g., toothbrushing, dietary habits), then offer support, liaise with parents, review progress, and keep good dental records. The second level includes appropriate consultations with other health professionals, school nurses, and social workers. Third, if there is no progress, a report to the social services is indicated. However, if at any time during this procedure family show reluctance or incapability to manage, the social services must be contacted in order to ensure that the child and the family receive support. An example of management of a case of dental neglect is presented in Box 26.6. How to manage a suspicion of child maltreatment is summarized in Figure 26.4.

Flowchart of how to manage a suspicion of child maltreatment, from discussing it with an experienced colleague or immediate supervisor up to providing assistance measure to the child or taking the child into care.

Figure 26.4 Flowchart of how to manage a suspicion of child maltreatment

Adapted from Strand 2013 [45]. https//www.duo.uio.no/handle/10852/38879 (E‐pub).

Box 26.6 Case report: example of how to manage dental neglect

A boy was first seen by the dentist at 1 year and 8 months of age. He had caries lesions in the upper front and was being breastfed. The single mother is familiar with recommendations of toothbrushing, use of toothpaste, and etiology of caries. The boy cries when she attempts to brush his teeth, and therefore she does not brush, she believes that is an abuse to brush when he is crying. Over the next 6 months and more than 15 consultations with the dentist the boy’s oral heath does not improve, he is still being breastfed, no toothbrushing, and he has new caries lesions. The mother suspects that her son has toothache because he has fallen down and hit his teeth. The mother also believes that something in the drinking water is damaging her son’s teeth. Because of severe early childhood caries and possible pain, the dentist refers the boy for treatment under general anesthesia and reports the dental neglect suspicion to social services. The mother seeks a second and a third opinion. The second dentist also reports her concern to social services, and 2 months later with the intervention of social services and when the boy is 2 years and 4 months old he has six extractions and four fillings done under general anesthesia. Social services keep in contact with the family and provide additional support for the boy as well as the mother.

Interview with children and families regarding suspicions of maltreatment

Children exposed to maltreatment must never be blamed. The child has a right to be listened to from a child’s perspective. Children who have been abused and neglected may never tell and may hesitate to share information about their situation. They may fear not being believed, feel shame and guilt, and they may fear punishment. They may even think that the abuse and neglect is a normal part of life. Children find it easier to tell if they are given the opportunity to talk and if they feel it has a purpose [40]. If a child offers an invitation to conversation it is important that the adult responds without fear or sadness. When asking regarding an experience of violence it is important to be alone with the child, use open questions, and allow time for a response. Respond truthfully and inform the child of the obligation to report, and never promise to keep a secret. Useful phrases and recommendations for handling the disclosure conversation are listed in Box 26.7.

Box 26.7 Recommendations for appropriate response to a child’s disclosure.

Source: Adapted from WHO, 2006 [46]. Reproduced with permission of World Health Organization.

Reacting to a disclosure

·     Treat the child with dignity and respect.

·     Remain calm; do not express reactions such as shock or moral indignation.

·     Avoid expressing disapproval or being emotional.

·     Listen attentively to a child, allow silence, do not correct or challenge.

·     Never force the child to show their physical injuries.

·     Avoid words that may disturb or frighten the child—such as “rape”, “incest” or “assault”.

·     Offer the child reassurance and support.

·     Answer a child’s questions as simply and honestly as possible.

·     Only make promises that can be kept. Tell the child the information will be shared only with people who are trying to give help and protection.

·     Never promise to keep a secret.

Useful sentences during a disclosure

·     You were very brave to talk about this.

·     I am glad you are telling me about this.

·     I am sorry that this has happened to you.

·     I will do everything I can to help.

In general, it is good practice to share your concerns and intention to report with the family [19]. However, information on a suspicion of abuse or neglect should not be shared with the family when there is a concern for criminal actions such as sexual or physical abuse. In these situations (or when feeling uncertain), contact the social services (or the police) while the child still is at the clinic, without telling the family.

The focus of the report is in the child’s best interest and must outweigh eventual fear of a conflict with the parents or uncertainty of suspicion. In case of uncertainty of how to manage a suspicion the dentist can consult with colleagues, other professionals or the social services. However, in the end it is the responsibility of the individual dental professionals to report or not. Summarized in Box 26.8 is a practical guide with questions the dental professionals should ask themselves in case of a suspicion.

Box 26.8 Useful questions when suspecting child maltreatment

Questions

Yes

No

Have there been several incidents with “not show up” for dental treatment without reasonable explanation?

   

Previous concerns about the child or siblings?

   

The general appearance of the child, their state of hygiene, whether they appear to be growing well or are ‘failing to thrive’

   

When you examine the child, do they have injuries that cannot be explained?

   

Any dental, oral or facial injuries, their site, extent and any specific patterns?

   

Delay in presentation of an injury?

   

Discrepancies between the history and examination findings? Do the child and the guardians/caregivers tell the same story?

   

Do you have any concern about the child`s behavior and interaction between the child and the caregivers?

   

Forensic oral examination

Both the police and the prosecutor can request a forensic report from a dentist regarding the child’s oral health status or request the dentist to give an expert opinion on a traumatic injury. However, it is important that the dentist only offer opinions based on their professional knowledge and within their area of expertise. Dentists are obliged to provide information and opinion on the clinical findings, the management of these findings, and their possible origin (i.e., accidental or non‐accidental). Contact the local department of forensic odontology if uncertain regarding a forensic report or regarding all evaluations of bruises and bite marks. Each country has specific guidelines and recommendations. Listed in Box 26.9 are important notes to consider in a forensic report.

Box 26.9 Practical guide to consider when requested to write a forensic report. Always use specific recommendations and guidelines pertinent to each country.

·     Request specific and clear information regarding question formulation

·     Thorough history. Give brief account of past illnesses, background information relating to the present incidence

·     Previous traumatic injury

·     Explanation of how the injury was originated

·     Take photographs and radiographs if possible with the use of a ruler to show sizes

·     Only offer opinions based on your knowledge and within your level of expertise

·     Use phrases and words that can be understood by laymen

·     Be descriptive, not interpretive.

·     Remember that your report will be a part of the judicial investigation

·     A copy of the dental journal is not a forensic report

Health implications of child maltreatment

Child abuse and neglect is a problem all over the world that continuously impairs the health and well‐being of children. All forms of abuse can cause negative long‐lasting consequences for health, education, and future parenting abilities. Other serious consequences include serious physical injuries or death during childhood [1]. Studies show relationships between child maltreatment and other adverse childhood experiences with a variety of conditions such as heart disease, obesity, alcoholism, drug abuse, and depression. It has been demonstrated that persons exposed to different negative childhood experiences, have increased risk of participating in harmful activities, having difficulties in establishing relationships, and development of a negative attitude. The stress of being exposed to abuse is associated with behavior problems, post‐traumatic stress disorders, and somatic symptoms such as stomachache, headache and disturbed sleeping patterns in childhood [1,41–43]. Adverse experiences have also been shown to increase the likelihood of having poor dental health. Additionally, multiple adverse experiences in childhood have a cumulative negative effect on the condition of the teeth and increase the risk of dental caries [44]. It has been shown that a poor self‐perceived oral health is associated with previous exposure to child physical abuse, intimate partner violence, bullying, and forced sex [31]. Child abuse should be considered as a possible cause when meeting children and adolescents with a poor subjective oral health and psychosomatic symptoms or patterns of symptoms not explained by other causes [31,43].

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