Child Abuse

Objectives • Define child abuse and neglect. • Describe and identify possible signs and symptoms associated with child abuse and neglect. • Identify the steps involved when confronted with a case of possible child abuse. • Understand and describe the dentist’s role, responsibility, and intent when reporting a suspected case of child abuse

Definition

• Child abuse is defined as any act that endangers or impairs a child's physical or emotional health or development. • Dental neglect is defined as parents’ failure to pursue the necessary dental treatment required to maintain the child’s oral health and to ensure their freedom from pain and infection.

Dental neglect

• It is defined as the parent’s persistent failure to obtain treatment for their child’s dental caries when such dental services are made available • Also defined as child maltreatment due to an absent or unjustifiable explanation for a child’s oral injury • Neglect occurs in 55% of child abuse cases

Dental neglect - 2

• Neglect occurs in 55% of child abuse cases. • Challenges vulnerable families face increases the risk of dental neglect of their children. • Vulnerability factors include poverty, single parenthood and large family sizes

Dental neglect - 3

• Dental caries in children have been treated as a neglected disease with little attention pair to the epidemic nature of the disease and its health and psychological consequences in children. • Children affected by neglected diseases are considered vulnerable to violations of their human rights.

Child Abuse

• Dental neglect is a from of child abuse • Other forms of child abuse include physical, emotional, sexual abuse. • Child abuse continues to be a serious cause of injury and death for many young children.

Child Abuse

• In 1997, just under one million children were victims of child abuse or neglect in the USA. • In 65% of physical abuse cases, there were head, neck, or facial injuries. • Physicians and dentists therefore play a key role in the detection, treatment, and reporting of child abuse.

Types and contributory factors

• Factors contributing to abuse include: stress, family crisis, lack of support network, substance/alcohol abuse, and learned behaviour.

The traumatised child

• Child abuse of only one form of the many trauma a child is exposed too. • It is difficult discussing about child abuse without discussing about the whole spectrum of trauma the child faces.

Sources of trauma

• • • • • •

Community violence - robbery, rape School violence – from students and teachers Domestic violence Complex trauma Medical trauma – serious illnesses Natural disaster – fire, hurricane, tornadoes

Sources of trauma - 2

• • • • •

Neglect – food, clothing, shelter Physical abuse – age inappropriate punishment Sexual abuse – older children, adults Kidnapping and terrorism Traumatic grief – early loss of someone you love

Sources of trauma - 3

• Children are faced with multiple forms of trauma in their everyday to day lives. The chances of a child facing a traumatic experiences appear to be increasing over the years.

Sources of trauma - 4

• More children are being exposed to the unfriendly home, school environment, neigbourhoods. Parents are unaware of the many traumatic experiences children face. Children do not know whom to turn too for succour.

Sources of trauma - 5

• By the time a child reaches the age of eighteen, the probability that any child will have been touched directly by interpersonal or community violence is approximately one in four.

Impact of trauma to the child

• Traumatic experiences alter the child’s physical, emotional, cognitive and social development. • A one off experience of psychological trauma do have short lived effects. • Where the trauma is sustained, then visible symptoms could be observed.

Impact of trauma to the child - 2

• Majority of children experiencing trauma will have some change in their behaviours and their emotional functioning. • Many children may exhibit no easily observable changes in their thinking, feeling or behaviour. • Rarely do caregivers connect the changes with trauma.

Traumatised children and dental care

• Occasionally, traumatised children may have associated dental injuries that brings them to the dental hospital.

Traumatised children and dental care - 2

• It is the responsibility of the dentist to be able to diagnose a traumatised child, handle the issue appropriately, and ensure the comprehensive management of the child beyond the immediate dental care needed.

What are the forms of trauma that may lead to oral health needs?

Forms of trauma with attendant oral health needs

• Sexual abuse with associated oral infections o Oral warts o Oral gonorrhea o Bruises on the palate

Forms of trauma with attendant oral health needs - 2

• Physical abuse o Soft tissue injury o Hard tissue injury • Emotional abuse o Fear and anxiety

Fear in traumatised children Although they appear outwardly calm, they may experience the rush of adrenaline and a hypervigilant, heart-racing, breathracing reaction of "fight, flight, freeze" in response to nonthreatening situations at almost any time.

Dental management of the traumatised child Is this a case of double jeopardy?

A traumatized child is less capable of concentrating. They are more anxious and they will pay more attention to 'non-verbal' cues such as tone of voice, body posture and facial expressions. This has important implications for how to manage dental injuries in the child.

Diagnosis

• A comprehensive history is important • Efforts must be taken to look for signs of trauma in a child. • Ask for a few of these possible signs as a routine when clerking a child patient. You just may be the one to address a chronic problem

Diagnosis - 2

• Retinal hemorrhage - diagnostic of shaken baby syndrome. • Fractured incisors - may be due to repeated trauma. • Burns on lips - due to forced feeding of hot food. • Bruises on lips - due to forced pacifier use.

Diagnosis - 3

• Frenum bruise - due to forced feeding of a nonambulatory child. • Oral or perioral syphilis or gonorrhea (pathognomonic of sexual abuse). • Veneral warts (condylomata acuminata) - highly indicative of sexual abuse.

Diagnosis - 4

• Palatal petechiae or erythema - probable sexual abuse. • Bite marks - 65% of them are visible while child is clothed. • Bruises in various stages of healing - indicative of multiple episodes of abuse.

Signs of trauma

• • • • •

Trouble sleeping or falling asleep Nightmares Problems concentrating or paying attention Difficulty getting along with family or friends Increase or decrease in appetite

Signs of trauma - 2

• Behaving more childlike such as bedwetting, clinging to caregivers, or thumb sucking • Avoidance of people, places and things • Nervousness or startling easily • Depression • Increased problems with school and grades

Signs of trauma - 3

• • • • •

Fear of touch. Overly anxious to please. Dramatic mood changes. History of suicide attempts. History of running away

Medical and social indicators

• • • •

From family with low income. Child has unexplained or inconsistent injuries. Evidence of delay in seeking care. Specific accusation by a child. Premature child (seven times more likely than a term-birth child to be abused).

Medical and social indicators - 2

• • • • •

Child living in an extremely isolated area. Child who is viewed as "different." Child with special needs. Child with very strict or overly critical parents. Abused children 8 times more likely to have untreated dental caries than other children.

Where the caregivers are abusers...

• They will only bring the child for medical care at late hours • They will hardly keep appointments • They avoid the use of the same clinic

Where the caregivers are abusers - 2

• They underplay the magnitude of the problem. • They explain the injury in a way that the source cannot match the magnitude. • They give lots of false information.

Where the caregivers are abusers - 3

• • • • • •

Caretaker is a substance/alcohol abuser. Hostile or aggressive attitude. Spouse is not biological parent of the child. Compulsive behaviour. Inflexible attitude. Has unreasonable expectations of the child.

Where the caregivers are abusers - 4

• • • •

Has unreasonable expectations of the child. Has previously abused a child. Blames a third party. Hostile or aggressive attitude.

Children who have had traumatic experiences may need some help coping with the trauma. Refer to a child psychologist for management.

Recording and preserving bite mark evidence

• Bite marks by an adult: intercuspal distance is greater than or equal to 3 cm. • Bite marks by a small adult/large child: intercuspal distance is 2.5 - 3 cm. • Photographs taken perpendicular to the bite marks. • Scale ruler in every photograph.

Recording and preserving bite mark evidence - 2 • Impression of bite marks are best done on a sedated child. Use a polyether impression material, with an outer plaster matrix for rigidity. • Buccal mucosa and tongue swabbed for evidence of semen. • Strict chain of custody must be maintained for all evidence samples submitted for forensic analysis.

Managing the child in the dental clinic

• Don't be afraid to talk about the traumatic event with the child even as the dentist. • Provide a consistent, predictable pattern for patient management. Inform the child of every action you will take during the cause of dental management.

Managing the child in the dental clinic - 2

• Discuss your expectations for behaviour during the dental management. • Talk with the child. Give age appropriate information. • Give the child "choices," and some sense of control.

Managing the child in the dental clinic - 3

• Protect the child. Do not hesitate to cut short or stop activities which are upsetting or traumatising. • Where you suspect that the child is being abused by the care giver, call in the social welfare department of the hospital to handle the case.

Leave a child with a remarkable experience at the end of the day in the dental clinic.

Management choices

• Use of age appropriate behavioural management strategies – time consuming but rewarding. • May need to use conscious sedation or nitrous oxide.

Management choices - 2

• Where there are multiple lesions or highly uncooperative, may need to use general anaesthesia. • Never do too many things at the same time – little incremental successful steps are important.

Physician’s responsibility

• The National Child Rights Act requires physicians, dentists, and healthcare workers help with the detection, documentation, treatment, and notification of authorities such as the police. • The role of the police is in determining whether abuse has occurred. • Where it occurs, the culprit is charged to court.

Handling a child is a priviledge, a trust; a divine opportunity to contribute to shaping a destiny. Taking appropriate simple actions and having an acute sense of your role as a child protector as a dentist may help you take steps that will positively change the course of life of a child. Be mindful of this responsibility.

Final words

Quiz 1

Some sources of trauma for the child: • Community violence - from students and teachers • School violence • Domestic violence • Medical trauma – serious illnesses • Natural disaster – robbery, rape

Quiz 2 Signs of trauma: • Trouble sleeping or falling asleep • Nightmares • Problems concentrating or paying attention • Difficulty getting along with family or friends • Good school grades

Quiz 3

Factors contributing to child abuse include: • Stress • Family crisis • Lack of support network • Substance/alcohol abuse • Learned behaviour

Acknowledgement • Slides were developed by Morenike Ukpong, Associate Professor in the Department of Paediatric Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria. • The slides was developed and updated from multiple materials over the years. We have lost track of the various references used for the development of the slides • We hereby acknowledge that many of the materials are not primary quotes of the group. • We also acknowledge all those that were involved with the review of the slides.