By Priyanka Pant

CHILD ABUSE

AND NEGLECT

Child abuse is a major public health problem all over the world. There are four major types of abuse: physical abuse, sexual abuse, emotional abuse and neglect. Although the injuries of child abuse are many and varied, several types of injuries are common to abuse. Many of these injuries are within the scope of dentistry or easily observed by the dental professional in the course of routine dental treatment.

INTRODUCTION

According to Selwyn et al. child abuse is defined as “the non-accidental physical injury, minimal or fatal, inflicted upon children by persons caring for them.”

According to Journal of Child Abuse and Neglect, child abuse is "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, an act or failure to act which presents an imminent risk of serious harm."

Physical abuse 31.8%

Educational abuse 26.3%

Emotional abuse 23.3%

Sexual abuse 6.8%

Failure to thrive 4.0%

International drugging or poisoning

Not specified

Munchausen syndrome by proxy

Not specified

TYPES OF CHILD ABUSE

Emotional neglect 27.8%

Health care neglect including dental neglect

8.7%

Physical neglect 7.8%

TYPES OF CHILD NEGLECT

Stresses Ego Weaknesses Vectors

Youthful parenthood Character disorders Stresses created

Unplanned parenthood Impulsive-aggressive Psychodynamics

Low SES Rigid-exacting Collusion by partner

Social isolation Immaturity Cultural discipline

Long parenthood Passive dependency Absence of other needs

Partner discord Psychic disorders Facilitation by partner

Altered physical status Low self esteem

Frustration Inability to empathize

Child (infantile colic) Inability to trust

PROBABLE FACTORS RESPONSIBLE IN CHILD ABUSE

INJURIES FREQUENTLY ENCOUNTERED IN ABUSED CHILDREN

The indicators that may be noticeable to the dental professional include trauma to the teeth and injuries to the mouth, lips, tongue or cheeks that are not consistent with an accident. Other common signs of child abuse include fractures of the maxilla and mandible and oral burns. Injuries to the upper lip and maxillary labial frenulum may be a characteristic in severely abused young children.

The dentist and his staff should be educated to get a visual impression of the child as he enters the reception room.

EXAMINING CHILD ABUSE/NEGLECT

Many abused or neglected children due to fear may appear overly vigilant or display a frozen watchfulness staring constantly. There are no spontaneous smiles and almost no eye contact

The dentist should observe the child for lack of cleanliness, for small stature with respect to age and for evidence of malnutrition. Typical signs of malnutrition include a posture of fatigue with rounded shoulders.

COMMON SITES TO BE OBSERVED AND EXAMINED(General Physical Findings)

Overdressed children should also be noted, long sleeves or high necked shirts during summer may be worn to cover signs of physical abuse.

Face, neck should be examined for peri-orbital ecchymosis, sclera hemorrhage, ptosis, deviated nasal septum, cigarette burn marks and hand slap marks

Corners of the mouth are reported with binding marks from a gag tied in place for hours to force the feed.

Sometimes, a spoon or fork applied with enough force or determination, which may result in fracture anterior teeth or torn frenulum.

While moving child up in the dental chair in a supine position if child complains of pain, trauma is suspected. Belt marks, electric cord marks, bite marks, bruises or fracture of ribs or clavicles should be suspected and dentist should confirm by checking them which can be performed in short time.

Examination of dental injuries includes thorough visual observation, radiographic studies, manipulation of the jaws, pulp vitality tests, and percussion. Trans-illumination may also be helpful.

FINDINGS ON A DENTAL EXAMINATION

These injuries may result from blunt force trauma. For example, the labial frenulum may be torn when a hand or other blunt object is forcibly applied to the upper lip to silence the child . Injuries of this type may also occur in forced feeding, as a result of the bottle being forced into the mouth.

TEARING OF THE LABIAL AND LINGUAL FRENULUM

Severe trauma to the lower face may loosen teeth, completely displace them from their alveolar sockets, and/or cause dental

fractures. It is not uncommon for root fractures to occur, but this finding may be missed unless the radiographs are examined carefully. These injuries, as well as most other traumatic injuries, may be accidental rather than abusive.

Therefore, one must always determine whether the injury is compatible with the explanation given. If the dental injuries resulted from a fall, for example, one would expect to also find bruised or abraded knees, hands, or elbows. When these additional injuries are not present, further inquiry is required.

Loosened, fractured, or avulsed teeth

In examining a child who has experienced recent trauma, it may be noted that one or more teeth has been lost prior to the present incident. The etiology of this earlier tooth loss should be investigated. If it was due to ―an accident , a ‖pattern of repeated trauma has been established. This pattern needs to be evaluated, and child abuse is one of the possibilities to be considered.

PREVIOUSLY MISSING TEETH

It is not uncommon to find contusions, lacerations, burns, or scars on the lips of abused children. Bruises to the lip may result from forced feeding. Burns on the lip, as well as burns on the face or tongue, may be signs of physical punishment. Bruises at the angles of the mouth may result from efforts to gag or silence a child.

TRAUMA TO THE LIP

The tongue of an abused child may exhibit abnormal anatomy or function due to scarring. This may result from a burn or other trauma.

TRAUMA TO THE TONGUE

Trauma to the mouth may also cause ulceration of the palate or uvula. Additionally, lacerations are sometimes found in the floor of the mouth, which may be caused by forced bottle feeding.

Other soft tissue injuries

The examination for maxillofacial fractures is performed within the concept of overall patient care, including airway maintenance, control of hemorrhage, and neurologic examination.

In a significant number of jaw fractures there is also damage to associated structures, including the cribriform plate, nasal, and zygomatic bones. Intracranial lesions and skull fractures may also be present. The clinical examination includes both extraoral and intraoral palpation. Bilateral palpation is helpful to detect asymmetry. Swelling or ecchymosis in the lower

face is suggestive of fractures of the mandible

Fractures of jaws and associated structures

The role of the legal system in attempts to ensure the protection of children has attracted considerable attention of late. It should be borne in mind, at the outset, that the law alone cannot ensure adequate protection. Any approach to the problem must be multi-disciplinary, involving various other professions and community as a whole. What the legal system can do is to provide a framework- defining standards of protection, mechanisms by which they might be achieved and the roles of the parties involved.

THE LAW PROTECTING CHILDREN

An Act to protect children from offences of sexual assault, sexual harassment and pornography and provide for establishment of Special Courts for trial of such offences and for matters connected therewith or incidental there to.

THE PROTECTION OF CHILDREN FROM SEXUAL OFFENCES ACT, 2012

Goa Children's Act, 2003, was the only specific piece of child abuse legislation before the 2012 Act. Child sexual abuse was prosecuted under the following sections of Indian Penal Code:

I.P.C. (1860) 375- Rape

I.P.C. (1860) 354- Outraging the modesty of a woman

I.P.C. (1860) 377- Unnatural offences

I.P.C. (1860) 511- Attempt

In England, the National Society for the Prevention of Cruelty to Children, founded in 1884 and, in Scotland, the Royal Scottish Society for the prevention of Cruelty to Children, founded in 1889, are organizations whose sole aim is the protection of children

In the United States by 1967, all 50 states and the District of Columbia had child abuse reporting statutes, codifying a medical diagnosis into a legal framework which in many states defined official functions for the courts. Not until 1972, did a court decide that parents’ right to care, custody and control over their children was no longer absolute.

April has been designated Child Abuse Prevention Month in the United States since 1983. U.S. President Barack Obama continued that tradition by declaring April 2009 Child Abuse Prevention Month

As most of the abuse injuries occur in the head and neck, dentists can easily diagnose them and as a oral care professional it is our duty to detect such abuses at an early stage to prevent further harm to the child and counseling of abusive caretaker Reported cases of child abuse and corporal punishment, both new and under management and treatment, require continual monitoring.

Conclusion

The involvement of dentists in child protection teams would be beneficial in two ways:

Dentists would become aware of their role and would assist in the training of physicians and other professionals.

In turn, non-dental practitioners would benefit from consultations with dentists in the evaluation of physical and sexual abuse or neglect, especially those dentists who have experience or expertise with children.

1. Shobha Tandon, (2001) -Textbook of Pedodontics. Hyderabad: Paras Publishing

2. Child abuse and its detection in the Dental Office - J Indian Acad Forensic Med. October- December 2011, Vol. 33, No. 4

3. Barness, E.G. & Debich-Spicer, D.E. (2005) Handbook of Pediatric Autopsy Pathology. New Jersey: Humana Press

4. Mason, J.K. (1989)- Paediatric forensic Medicine and Pathology. New York: Chapman and Hall Medical

REFERENCES

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