Child Abuse 1/23/11 10:02 PM

Objectives
1. Describe the dental professionals responsibilities regarding indentification,
documentation and reporting of suspected maltreatment
2. List the types and frequency of maltreatments encountered in pediatric
dentistry
3. Describe the clinical presentation and management of maltreatment

Child Abuse and Neglect

 Physical Injury
 Emotional Injury
 Sexual Abuse
 Negligent Treatment
 Factitious Disorder by Proxy

Problems with Defining

 Disagreement about the “abusive” nature of some experiences
o Cultural
o Religious
o Sociologic
 Question of premeditation
 Maltreatment is not always willful or planned
 Economic
  Emotion
 Education and prevention may help caregivers to reconsider and/or
redirect their actions to more appropriate options in childcare

History
 Through the early 1900s the United States was much like modern
third world countries in consideration for and protection of children.
 Children were considered property and treated poorer than farm
animals.

Physical Abuse
 1946, John Caffey, a radiologist noted a correlation between long
bone fractures and what he postulated was physical abuse.
Journals of the day refused to publish his essays.
 At that time injuries were often excused as punishment for
misbehaving ‘children were property.’
 Battered Child Syndrome was first described and published in 1962
by Kemp
 Some injuries were more severe than could be explained by the
reported history.
 Some punishments are inappropriate for the age, condition, or level
of development.
 Injuries are often the result of caregiver frustration and/or lack of
anger management.
 Today, physical abuse is one of the most easily recognized forms of
abuse .

Mary Ellen Wilson

 9 yr old living with foster parents since age 2
 Looked like she was 5 years old
 Foster situation was not monitored
 Neighbors had heard beatings and crying
  Mary never left apartment with foster parents
 Etta Wheeler, a mission worker and Henry Bergh, Founder of ASPCA
They asked for church and police assistance
 Mary was carried into court wrapped in a horse blanket, Henry
asked that she be treated as a “dumb animal” and placed into the
care of the ASPCA
 Lived to 92 with 2 natural and 1 foster child
 Reportedly she was not much of a disciplinarian

What is the dentists responsibility?

 Dentists are in a unique position to identify child maltreatment
 Dentists must be knowledgeable in the recognition of the signs of
maltreatment
 Dentists must be willing to consider maltreatment or they cannot
diagnose it
 Dentists must know how to speak with child and caregiver in cases
of suspicion
 Dentists must know how to document and report suspected
maltreatment
 abuse must be included in differential diagnosis - cant diagnose if
unwilling to consider

Physical Abuse
 History inconsistent with injury
 Failure to Thrive
 Injuries in Various Stages of Healing
 Bruises
 Welts
 Fractures
  Burns
 Lacerations
 50% of physical abuse results in facial and head injuries
 25% of these are in or around the mouth

Emotional Abuse
 Interactions or lack of interactions with care giver which are
demonstrated to have harmed the child
 Usually seen as abnormal behaviors or mental health problems
 Difficult to demonstrate the direct or causal link between emotional
and verbal abuse and harm to the child

Sexual Abuse
 Sexual Abuse / Misuse - any sexually stimulating activity that is
inappropriate for the child’s age, level of cognition, or role within
family
 May include the desire for sexual gratification on the part of one of
the participants
 May be difficult to distinguish normal behavior....
 child sex play / sexual experimentation....from lustful intrusion
 parent - child physical sexual contact
 exhibitionism kissing fondling
 intercourse pornography rape

Neglect
 Chronic inattention to the basic needs of a child
  ‘Willful failure of 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’ AAPD
 Consider in light of cultural, religious, economic, community
requirements and standards as well as the impact on the physical
well-being of child
 Any child whose basic needs for medical or dental care, food,
clothing, shelter or education are not being met may be victim of
neglect

Factitious Disorder By Proxy

 Perhaps the most difficult form of maltreatment to identify
 Perpetrator relates fictitious history, false signs or symptoms, and
fabricates illness
 Fabrication may be deliberate, the result of parental psychosis, or
fraudulent
 Results in extensive medical examinations, testing, and prolonged
hospitalizations
 Indicated by a childs history of persistent and recurrent illnesses
that cannot be explained, signs and symptoms that do not make
sense clinically, and problems that are rare, unusual or bizzare
 The nature of these cases makes it hard to convince social and legal
system of the danger to the child

Who is Maltreated?
 No segment of society, age, race, gender or socioeconomic is
spared from maltreatment
 50-65% of reported cases of maltreatment are classified as Neglect
 Physical abuse is reported in 16% of cases
 50% of physical abuse in head and neck related
 Sexual and Emotional abuse account for the majority of other cases
(9% and 7% respectively)

Sociodemographics
 Average Age of Identification of Maltreatment 7.4years
  Male 49%, Female rate higher in case of abuse
 White 68%, Black 21%
 Neglect is more common among infant to 2 year olds
 Sexual and Emotional abuse is more prevalent in 12-17 year olds
 Physical abuse rate increases with age of victim
 Summarizing highest probability factors gives a worst situation for
abuse as previously spousal abused female head of household
receiving public assistance for multiple children in home where drug
or alcohol has been abused or there is other significant health or
economic stress.

Identification
 Cannot identify that which we are unwilling to consider
 There are characteristics of the child, parent, and history given that
may lead to suspicion
 Indicators of maltreatment may present in a variety of ways
 - indicators do not prove maltreatment
 Health care providers are required to report suspicion
 - proof is the responsibility of officials
 Failure to report suspicion may lead to serious injury and even
death of a child
 - often results in sactions to the non reporting healthcare provider

Legal Requirements
 Statutes and definitions of abuse or neglect vary
 All states mandate that health care providers report suspicion to
authorities
 Includes Dentists
  One is only required to report suspicions
 Social and Legal authorities are charged with determining whether
abuse has occurred and what intervention is necessary

Physical Indicators
 Easiest to recognize are those for which the account is inconsistent
with the injury
 Suspicion raised whenever:
o Clustering of injuries
o Unwitnessed significant injury
o Accounts that change over time
o Conflicting accounts from two or more individuals
o Injury inconsistent with normal developmental pattern or
child’s abilities
 Unexplained injury to face, mouth, and lips
 Bruises reflecting shape of instrument
 Injuries in various stages of healing - bruises and fractures
 Any fracture in child under 2 years
 Burns
 Immersion
 frontal injuries in toddlers = ok due to falling - while back injuries
uncommon
Behavioral indicators
 Withdrawal
 Depression
 Regression
 Acting Out
 Clinginess
 Poor Performance
 Somatic Complaints
 Inappropriate affection towards others
 Extremely wary / distant in social interactions
 Child or child history that may raise suspicion:
o Frequent Hospitalizations
o Repeated Ingestation of Harmful Substances
o Emergency Room Shopping
o Excessive Medical Care for apparently well child
 Take seriously ANY child who:
o is afraid to go home
o is frightened by parents
o reports injury by caregiver
 Caregiver displays that raise suspicion:
o Lack of Concern - delay in seeking treatment
o Refuse hospitalization or testing for child
o Defensive or Hostile when questioned
o Unusually High Level of Concern
 o Poor Judgement
o Jealous of Child
o Extreme Protectiveness
o Child Abandonment
o Violent Behavior
o Erratic Behavior

Evaluation
 Abusive caregivers are often less guarded when visiting the dentist
 Dentist may be the first to identify a maltreated child
 When abuse or neglect is suspected the child must undergo a
thorough dental and general physical examination
 Details regarding any trauma should be complete and obtained
separately from multiple sources if possible ( child and parent )
 Use open-ended questions ( not yes / no )
 Seek detailed history about injury. Document witnesses, what
happened, how, when, description of any past injuries and child’s
developmental abilities

Child Interview
 The child is asked open-ended questions to clarify details about
injury
 This is not an interrogation or spanish inquisition
 Once the health care provider has reason to believe that the child
has been maltreated the interview is suspended and the suspicion is
reported

Physical Examination
  Physical examination begins when the patient is first visible to office
staff
 Staff is trained to recognize irregularities in posture, gait, clothing
and behavior
 Any visible pattern of injury should be photographed if possible
 Law enforcement will dispatch photographer if requested
 Dentist examination should systematically work from head to toe
examining the entire exposed body without undressing the child:
o Clothes
o Smile
o Hair / Scalp
o Nose and Nasal Septum
o Eyes and Periorbital
o Head
o Neck
o Back of Neck
o Chest / Ribs
o Bite Marks
Dental Examination
 Evaluation of teeth and supporting structures
 Take note of any:
o Missing or Traumatized Teeth
o Mandibular movements: deviation, range of motion, trismus,
and Occlusion at Rest
o Maxilla mobility
 o Soft Tissue Injuries: frenum, hard and soft palate
o Gross Caries / Infection

Management: Documentation
 Dentist have legal mandate to report “reasonable suspicion” of
abuse
 A phone call to appropriate child protective agency is all that is
usually required
 Ideally call is followed with a written report
 Refer for pediatric medical history, exam, and evaluation
 All activity regarding the reporting should be documented in patient
record

Parents / Caregivers
 How do we approach parents /caregivers?
 There is no requirement to inform them about the suspicion nor of
the plan to report
 The welfare of the child should be the predominant motivator, not a
concern over possible loss of a patient or family
 Without accusation simply let them know that health care
professionals are required to report concerns about child well being
to authorities
 If parents are suspected as being the perpetrator, not telling them
may be abvisable
01/24/2011
01/24/2011