Child abuse—Are we powerless to help?

Child abuse is a major social problem and occurs in all income, racial, religious and ethnic groups. It is happening worldwide and crosses all socioeconomic and educational classes, urban and rural communities. It has major health, treatment and cost implications for each country. However, it is difficult to establish the true incidence and prevalence of abuse in any given country as so many cases are not reported and investigated, or are simply not recognised, or it may be that information systems are incomplete or limited and children slip under the radar. Another difficulty is that there are different attitudes to child care in different cultural and religious groups, and the crossover from legitimate punishment to abuse also varies between cultures and countries.

There are different definitions of abuse, so for practical purposes it may be easier to use a general approach: a child is considered to be abused if he/she is treated in a way that is unacceptable in a given culture at a given time. A child is considered to be a person under 18 years of age (Child Care Act 1983). It may involve a single or repeated incident(s).

Abuse is often divided into several sub-categories, but they often occur in combination, eg, a physically abused child may also suffer from neglect and emotional abuse. These categories do not include child trafficking and abduction.

Physical abuse
This can be regarded as any non-accidental injury or trauma to a child and may involve punching, hitting, shaking, burning, scalding, biting, drowning, suffocating, poisoning or anything else that can cause physical harm to a child.

Sexual abuse
This involves enticing or forcing a child to take part in sexual activities (and prostitution) whether or not the child is aware of what is happening. It may include physical contact, such as touching, fondling and penetration, and non-contact activities, such as involvement with pornography or encouraging a child to act in a sexually inappropriate way.

Emotional abuse
Emotional abuse is the persistent emotional maltreatment of a child to cause severe and persistent adverse effects on the child’s emotional development and well-being. It may involve making the child feel worthless, ignoring, isolating, humiliating, frightening or shouting at the child.

Neglect
This is described as the persistent failure to meet a child’s basic physical and/or emotional needs that may result in the serious impairment of the child’s health and development. This might include depriving the child of food, shelter, clothing, and failing to protect the child from harm or danger. Interestingly, it may also apply to the failure to seek and access appropriate medical and dental care/treatment. Neglect is the main reason for the placement of children on the child protection register in England and the United States, followed by physical injury.

Fabricated or induced illness Sometimes referred to as Munchausen’s Syndrome by Proxy, it is considered to be a psychological disorder of the perpetrator. Illness (or another health problem) is fabricated, induced or exaggerated, often in a child, deliberately by another person (usually the mother) and often attributed to the need to gain attention for herself. As a result, the child may be subjected to essentially unnecessary examinations, investigations and surgery.

The unborn child may also be at risk from actions of the mother (substance abuse, trauma etc), or from acts of violence inflicted on the pregnant woman. A significant number of assaults on women by their male partners begin during the first pregnancy.

Consider that in England and Wales there are on average 1–2 children that die every week as a result of abuse/maltreatment. In the United States it is estimated that over 1,000 children die from physical injuries associated with abuse every year. The World Health Organisation estimates that there were 57,000 deaths, of children under fifteen years of age, attributed to homicide in 2000. Shocking and unacceptable!

The reasons for abuse are complex: there may be a number of contributory factors involved that increase the likelihood for abuse to occur, and these may be compounded by stressful life events, for example: divorce, a family death and unemployment. There is a strong link between domestic violence and child abuse. Understanding the reasons for abuse may assist with prevention, intervention, treatment and policy-making.

Some risk and contributory factors for abuse are:

- disabled children
- premature babies
- low birth weight babies (A study looking at abuse in pregnant women and adolescents, found that the
  incidence of low birth weight was higher in those who had been abused. Curry et al 1998)
- social isolation of families
- breakdown of family unit
- parental history of domestic abuse
- socioeconomic disadvantage
- poor parenting skills
- substance abuse
- young, single parent
- mental health condition of parent/caregiver

Studies have shown that most children are abused in the home by adults that they know. The most likely person to abuse them is the primary caregiver (often the mother) or the mother’s partner. Reviewing my own cases, most abuse was inflicted by the parents (one or both) or the mother’s boyfriend, who was not the biological father of the child. However, other family members or friends may be involved. Large numbers of cases of child abuse also occur within institutions or organisations that involve children, such as schools, care homes, churches etc. Almost half of all physical abuse victims are aged seven years or younger. In England, the largest group of children on the child protection register are 0–4 year olds, with males and females of this age being almost equally at risk.

Role of the dental team

Studies have shown that approximately 60 per cent of abused children have injuries to the head, face and mouth (Cairns et al. 2005, Jessee 1995). As dental team members we have regular contact with children and their families, but ask yourselves the following questions:

- Would you or your team members recognise the signs and symptoms of abuse?
- Would you know how best to record any suspicions?
- Would you know what action to take in a case of suspected abuse?
- How safe is your practice for children?

When discussing child abuse with dental colleagues it is clear that there are barriers to becoming involved, such as concerns with confidentiality and disclosure, uncertainty about what to do, non-recognition of injuries and the fear of getting it wrong and retribution from the families concerned. Also, fear of getting involved in the social or legal issues. Are we looking for indicators of abuse during a busy surgery and are we reluctant to consider that abuse may be the explanation? At a presentation on this subject that I gave to dentists, albeit some years ago, I was informed by one colleague: “Oh, but mine is a private orthodontic practice—my patients don’t do that sort of thing.” Time to reconsider!

In the United Kingdom (and in many other countries) the reporting of suspicions of child abuse is not mandatory (it is in the United States). However, we have a professional responsibility to act in the best interests of the patient in our care. In the UK the General Dentil Council’s updated Standards Guidance booklet states that “the dental team has an ethical responsibility to find out about and follow local procedures for child protection and to co-operate with other members of the dental team and other healthcare colleagues in the interests of patients.”

Dental professionals are not responsible for making the diagnosis of child abuse or neglect (as this is much more involved than simply the recognition of injuries) but should be observant and share any concerns appropriately. The relevant agencies and medical professionals will then assess the child in the context of medical, family and social history, developmental stage, explanation given, clinical examination and relevant investigations. It may be justified (in certain circumstances, but always get advice from your Protection Agency) to disclose confidential patient information without consent if it is in the public interest or the patient’s interest.

Possible indicators of child abuse (general):

- injury not consistent with the history/explanation given
- injury not consistent with the child’s age and stage of development
- multiple injuries at various stages of healing
- trauma to non-exposed and non-prominent sites of the body
- evidence of previous bone fractures
- bilateral bruising (and bruise clusters) not consistent with the history (Maguire et al. 2005)
- significant delay in the presentation for care
- do caregivers interact with the child in an appropriate manner and vice-versa?
- disclosure by the child (or someone else)

Most injuries to the mouth and dental structures of children are not caused by abusive actions, but occur in falls, fights, sports and car/bike/skateboard accidents. BUT, it is important that as dental professionals we can identify suspicious injuries from those caused by accident (Symons et al. 1987, Welbury et al. 1998).

Oral findings that have been noted in child abuse cases (hard and soft tissue):

- bruising and laceration of lips
- mucosal bruising/laceration
- tooth trauma (fractures, intrusion, avulsion of teeth)
- missing teeth not explainable by decay or periodontal status
- single or multiple apical lesions, or fractured teeth in the absence of decay or unclear history
- tongue injuries
- frenal laceration
- bone fractures to the maxillofacial complex
- oropharyngeal bruising/laceration (associated with sexual abuse, or forced feeding or forced insertion
  of pacifier)
- oral signs of sexually transmitted disease (for example: Gonorrhea, Condyloma Acuminata)
- oral/intra-oral burns—due to hot or caustic foods/fluids
- ignoring needs for medical/dental care following injury

There are well protected areas of the body that are rarely traumatised accidentally—ears, neck, abdomen, inner thighs. Beware conditions that can present in a similar way to abuse: birthmarks may look like bruising, unexplained and frequent bone fractures may (occasionally) be due to osteogenesis imperfecta (Wright et al. 1983). Consider the possibilities: always check the medical history for underlying medical conditions and bleeding disorders and refer to medical colleagues, if uncertain, for further investigation.

Over the years, I (and my forensic colleagues in the UK) have seen many children with biting injuries on their faces and elsewhere on the body, caused by adult dentitions. Such injuries are recognised as nonaccidental injuries and require further investigation (Dorion 1982). The injury should ideally be examined by an appropriately trained and experienced forensic dentist (working as part of the investigatory team) who will document and photograph the injury and ensure that relevant swabs are taken for DNA analysis. Dental impressions will be needed from any potential suspect(s) with consent. If the dental evidence is of sufficiently good quality to permit bite mark analysis, it may be possible to identify the biter.

The dental record

Making and keeping accurate and comprehensive dental records is a medico-legal obligation and reflects good practice and patient care. When abuse is suspected, also record the following if possible:

- any disclosures of abuse? (use child’s own words)
- who accompanies the child to the surgery?
- history and explanation, observations on behaviour of child and carer
- location and type of injury (for example: bruise/laceration, size, shape, colour, unusual features, tooth
  fracture etc)
- photograph with written consent
- reason for your concerns and decisions made (also referral contacts)
- consent for disclosure
- any treatment needed or referral for specialist opinion/treatment

If referral to Social Services (or other appropriate protection agency) is necessary and consent is an issue, the child’s safety must be considered. Seek advice from a senior or experienced colleague and remember your dental defence/protection agency will be able to guide you. For more detailed guidance please refer to the reading list at the end of this article.

The American Academy of Paediatric Dentistry defines dental neglect as the wilful failure of a parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection. Children are dependent on their carers to take them for treatment and respond to their dental needs. However, before we jump in shouting ‘neglect,’ consider whether it is lack of knowledge (of the carer), difficulty complying with oral hygiene measures/instructions or dietary needs that is causing the problems and not wilful neglect. The child presenting with rampant caries may have a parent/caregiver who does not realise the problems associated with poor oral hygiene, sweet drinks or sweetened pacifiers. It is the role of the dental team to educate and encourage parents/carers (along with the provision of appropriate treatment) and give follow-up appointments and perhaps a reminder when a child fails to attend for examination or treatment.

Dental neglect or deliberate neglect?

Missed appointments, irregular attendance, failure to complete treatment, returning with pain at repeated intervals, and needing repeated general anaesthesia for dental extractions are possible reasons for concern. All members of society have a shared responsibility to protect children and as professionals we must work as part of the multidisciplinary teams to ensure child safety and protection. It is easy for dental professionals to work in isolation and not feel part of teams leading to lack of communication.

We need to ensure that our practices/surgeries are safe and provide a caring approach to our small patients. This should include making sure that our staff is safe to be around children, including criminal checks when recruiting new members of the team. In the UK in 2002, two ten year old female friends disappeared from near their homes. Their bodies were found eleven days later. The man convicted of their murder worked at the school that they attended and was someone they knew. It was discovered that he had a history of alleged offences against children, but was still working in an environment that gave him child access.

Ensure that your dental practice/hospital/community setting has up to date policies and training on the prevention of child abuse, training in the recognition of signs of abuse, a step by step plan of actions and contacts, should child abuse be suspected, and contact details for resources offering help to struggling parents/carers.

It would seem that the number of police callouts to domestic disputes where child abuse may also be an issue is increasing. We recognise that there is a distinct relationship between parenting and how that child may develop and what will happen in the future. Early involvement of support agencies and recognition, intervention and education for struggling parents/families may make a difference, but requires funding from both government and local levels. Families and individuals need to understand that violence towards children is not acceptable and is not part of ‘normal behaviour’. Worldwide change is needed.

This article was written from experience gained from my role as a forensic dentist (and dental practitioner) working as part of the multi-agency teams to assess and investigate child abuse. The emphasis is on the recognition of physical injuries. My aim is to give a basic overview (not all aspects, questions and answers can be given in one article!) and inspire you to take a closer look at your dental surgery policies and to be proactive in protecting vulnerable children. If the dental team can help to prevent suffering of just one child in our careers, then it has been worthwhile—one step towards making the world a safer place.

Recommended reading
1) Sinha S, Acharya P, Jafar H, Bower E, Harrison V, Newton J T: The Management of Abuse—A Resource Manual for the Dental Team. London. 2004. Available from www.shancocksltd.com.
2) Hobbs CJ, Hanks HGI, Wynne JM: Child Abuse and Neglect. A Clinician’s Handbook. Second Edition. London: Churchill Livingstone 1999.
3) Herschaft EE, Alder ME, Ord D, Rawson RD, Smith ES (editors): Human Abuse and Neglect. In: Manual of Forensic Odontology. American Society of Forensic Odontology, Fourth Edition, 2006: 210–243.

Editorial note: A complete list of references is available from the publisher. This article was originally published in Dental Tribune Asia Pacific Vol. 6, No. 7+8, 2008.

Contact info

You may contact the author at judy.hinchliffe@gmail.com.