Child abuse and neglect

Child abuse and neglect

• Introduction • Child protection
• Definitions teams
• Historical back • Legal aspects of child
ground abuse
• Types of abuse and • Dental neglect in
neglect children
• Incidence and age • Cultural health
distribution practices suspected
as child abuse
• Factors responsible
• Dentist as child
• Dental professional
abuser
responsibility
• Missing children
 Introduction:
• Maltreatment of children- major problem
• Religious sacrifice and abandonment of
children – Greek and Roman mythology
• Challenging social values- medico-social
problem
• National figures – 1,00,000 \yr of these
1,000 die each yr
• Pedodontist’s understand various aspects-
diagnosis, treatment, prevention and mgmt
• Responsibility- to report, treat and prevent
further complications
 Definitions:
• Abuse: make bad use of; ill-treat; misuse;
maltreatment; excessive use.
• Child abuse: (selwyn et al 1985)
• “Non-accidental physical injury, minimal or
fatal, inflicted upon children by person
caring for them”
• Child is considered to be abused if he\she
is treated in a way that is un-acceptable
for a certain culture at a given time
(welbury 1998)
• Any non-accidental physical ,sexual, or
emotional act against a child by a parent
or caretaker ,that is beyond the level of
child care.
 Neglect :
• Failure to take proper care of
• One who shows evidence of physical or
mental health primarily due to failure on
part of parents or caretakers to provide
adequately for child’s needs.
• Adverse consequences of inadequate or
negligent parenting.
• Child neglect occurs when a caretaker
either deliberately or by extraordinary
in-attentiveness permits the child to
experience present suffering and fails to
provide child with essentials for developing
his\her physical, emotional capacities.
• Battered baby: child who shows
clinical\radiographic evidence of lesions
that are frequently multiple and involve
mainly head, soft tissue, long bones and
thoracic cage that cannot be unequivocally
explained.
• Persecuted child: one who shows
evidence of mental ill-health caused by a
deliberate infliction of physical or
psychological injury that is often
continuous in nature.
 Historical background:
• 1874- first documented case of child abuse
reported- “ Mary Ellen chained to bed post”
• 1875- society of prevention of cruelty to
children was established.
• 1899- first Juvenile court began at
“ILLINOIS”
• 1946 Caffey- 6 infants with subdural
hematoma, and multiple # - “Medical
discovery of child abuse”
• 1957 Caffey - # in long bones of infants
have been often deliberately inflicted.
• 1961 first conference on “Battered child”
• 1962 Henry Kempe et al published -
“Battered child syndrome”- JAMA.
• 1966 – All 50 states passed laws-
reporting child abuse
• 1974 national center by congress. Child
abuse prevention and treatment act :
public law 93-247
• 1976- 79 no of reported cases rises to
71%
• 1977 child protection act
• 1992 PANDA (Prevent Abuse And Neglect
thru Dental Awareness) Missouri 1992
• 1995 no of reported cases – 1 million
approx- 2000 die\yr
• 1996 nearly all states had child death
review team. Mental injury ,passive
exposure to drugs other forms of abuse
Types of child abuse and neglect
and incidence: American Humane
association 1981
Types %
Physical abuse 31.8
Sexual abuse 6.8
Failure to thrive 4.0
Intentional drugging Not-specified
Health (Medical) neglect 8.7
Safety neglect Not-specified
Emotional abuse\neglect 26.3
Physical neglect 7.8
Educational neglect 27.8
Munchausen syndrome
by proxy
 Physical abuse:
• Defn: Injuries inflicted by a caretaker
• Potentially fatal.
• Injury stems angry attempt- child’s
misbehavior
• Dentist most likely to detect inflicted
injuries of face and mouth (slap, pinched,
bite marks)
 Physical

Mild Moderate Severe

Bruises ,welts, Numerous Large burns,
scratches, bruises, CNS injury,
cuts, scars minor burns, abdominal injury,
a single # Multiple #, life
threatening injury
• Since physical punishment is common in
our society- dentist’s, physicians need
guidelines
• Able to differentiate betn normal (Corporal)
punishment and physical abuse
• Reasonable physical punishment is not
illegal
 Any punishment that :
• Causes bruises
• Injury that needs medical\dental treatment
• Delivered by kicking\closed fist
• Reported – agencies- families can learn
safer ways of managing children
 Physical discipline techniques
guidelines : (Barton 1986)
• Parent\caretaker- only hand
• Child should only be struck on buttocks,
leg, arm not on face
• One strike hard enough to change
behaviour.> once more to relieve – anger
• Striking inappropriate before child has
learned to walk
• Physical punishment not more than 3
times
• Physical punishment not to be used for
aggressive misbehavior- biting, hitting
• Danger of subdural hematoma- vigorous
shaking
• Alternatives – removing privileges
 Sexual abuse:
• Defined as any sexual activity with a child
under age 18 by an adult.
• As prevalent as physical abuse, most
under diagnosed type- “last frontier”
• May include:
• Molestation (fondling or masturbation)
• Intercourse (vaginal, anal, or oral on non-
assaultive basis)
• Family related rape
• Child prostitution
• Most victimized is a girl child (90%)
• 50% below age of 12 yrs
• 99% offender always male
• Families are close-knit and secretive
• Vulvitis, vaginitis, vaginal bleeding or
venereal diseases – physician suspicious
• >50% no + physical findings or lab results
• Child’s explicit history – taken seriously
 Emotional abuse :
• Defined as continual scapegoating and
rejection of child by parents or caretakers
or teachers.
• Severe verbal abuse and berating often
part – attacks child feeling of “self worth”
• Psychological terrorism can occur- little
difficulty in identification.
 Cases of emotional abuse:
• Severe psycho logic and disturbed
behavior in child – unable to function and
cope as an adult
• Abnormal child rearing practices
• Continued refusal by parents of treatment
for child
• Depriving a child of needed mental health
care
• Situations presented with less evidence,
however if parent\caretaker floridly
psychotic or severely depressed- danger
to child
 Educational abuse:
• When a parent or caretaker
knowingly\intentionally keep the child in
home ,or fails to enroll child in school
 Neglect:
• Health care neglect
• Dental neglect
• Safety neglect
• Physical neglect
• Emotional neglect
• Failure to thrive due to nutritional neglect
 Health care neglect:
• Parents\caretakers ignore the treatment and
health recommendations of health
professionals for management of treatable
illness that a child has and that is becoming
worse.
• Situation arises due to parent’s denial that an
emergency exists or religious belief of
individual.
• Child’s constitutional right to life and
health must override parental beliefs and
control over child .
• If the disease is incurable ,parent’s\
caretakers wishes regarding non-
intervention are often respected.
 Dental neglect:
• (Ad Hoc committee on CA and CN AAPD)
Failure by a parent \guardian to seek Rx
for visually untreated caries , oral
infections, and oral pain or failure to follow
thru with Rx once informed that above
conditions exists.
• Specific type of health care neglect.
 Guidelines for identification:
Davis et al 1979
• Untreated rampant caries
• Untreated pain, infection, bleeding, or
trauma affecting oro-facial region
• History of lack of continuity of care
following identification of dental pathology
Issues that need to be addressed :
“Dental neglect policy”
• Law enforcement agencies must respond
• Child protection workers must have
resources
• Public\private agencies should support
neglected children
• Dentist must be able to identify and
manage
 Safety neglect:
• Defined as gross lack of direct\indirect
supervision of child that results in injury.
• Common in < 4 yr of age, when it is
important that parents\caretakers directly
supervise them.
• Too often burns, poisoning, falls, other
preventable accidents occur in children
because they were not being watched.
 Physical neglect:
• Defined as failure to care for child
according to accepted or appropriate
standards.
• Due to socioeconomic ills- poverty,
parental ignorance or unusual stress
• Best addressed by helping family obtain
needed services rather than reporting
• If associated with physical abuse – report
to appropriate authorities.
• Eg: lack of personal hygiene, inadequate
clothing ,diet or medical attention
• Such children should be evaluated for
presence\absence of emotional
disturbances.
 Emotional neglect:
• Emotional neglect includes inadequate
nurturance or affection or refusal to allow
needed remedial care for diagnosed
emotional problems
 Failure to thrive:
• Defined as underweight ,malnourished
condition.
• O\E: gaunt faces, prominent ribs, wasted
buttocks, and spindly extremities.
• Seen in <2yr children – rapid growth and
dependency of adult feeding.
• Mother neglects to feed- fells
overwhelmed with responsibilities or is
chronically depressed and hostile.
• Child should be hospitalized and placed
on unlimited feedings of regular diet for
that age
• Many of these infants also show signs of
emotional neglect.
 Intentional drugging or poisoning:
• Involves the administration of non-
prescription or prescription drug that is
harmful and not intended for children.
• Administration of sedatives, hallucinogenic
or other recreational drugs causing drug
addiction in children.
• Often parents have severe marital or
psychiatric problems or may be drug
abusers.
 Munchausen syndrome by proxy;
Meadow 1982
• Describes children who are victims of
parentally fabricated or induced illness.
• Children are too young to reveal the
deception (< 6yr)
• Fabricated illness lead to unnecessary
medical investigations, hospital
admissions, and treatment.
• Factitious symptoms are often bleeding
from various sites- if specimens are
requested mother adds her own blood .
• Recurrent sepsis from injecting
contaminated fluids, chronic diarrhea from
laxatives or rashes from rubbing the skin
or application of caustic substances
Abuse of children with disabilities: A
“dirty secret”
• Children with disabilities- 1.8 greater risk
for sexual abuse.
• Characteristics that make vulnerable:
• Dependency on others
• Lack of control over their own lives
• Lack of knowledge about sex
• Isolation and rejection- increases
responsiveness
• Inability to communicate experiences
 Incidence and age distribution:
• Male = Female
• Incidence rate of maltreatment of children
increases with age with 2 exceptions:
• In males physical abuse decreases with
increase in age.
• Incidence rate of physical neglect to male
and female from birth-2 yr remain constant
• Severe physical injuries occur during pre-
school age (0-5 yr) with 70% of fatalities.
• Adolescent males more likely to
experience educational and emotional
neglect.
• Incidence of sexual abuse are highest
among adolescent females, 50% of victims
are <11 yr of age.
• Not limited to any socioeconomic status,
religion, racial or geographic population.
• 1981, 68% of abuse- white families
22% in black in black families and
remaining in Hispanic families
• 95% of abusers are parents and not
caretakers.
• 50% of families are single parented of
which 49% are headed by a female.
 Factors responsible in child abuse:
Child abuse

Stress Ego weakness Vectors

Youthful parenthood Stress – child

Character Non specific
Unwanted\unplanned disorders ego defects Collusion by
partner
Low SE Impulsive
Low self
aggressive Cultural
Social isolation esteem
practices
Rigid
Responsibilities and Inability to
exacting Relative absence
frustration empathize
of other needed
Immaturity
Altered physical, or Inability to satisfaction
physiological status Depressive\ trust
psychic
Child itself disorders
 Dental professional responsibility:
• Numerous reports of child abuse in dental
literature
• Less severe injuries- undetected because
of lack of suspicion or knowledge
 Dental professional responsibility:
• Clinical diagnosis
• Treatment of oro-facial injuries
• Intervention and prevention
• Reporting to appropriate authorities
 Clinical diagnosis:
• Behavioral assessment
• History
• Examination
• Collection and documentation of data
 Behavioral assessment:
• Assess separately
• Speight (1989)
• Delay – medical care
• Story of accident – vague, varying
• Account of accident – not compatible with injury
• parent’s mood- preoccupied
• parent's behaviour
• Child’s appearance and interactions with their
parents abnormal
• Child may say concerning the injury
 Check list to increase one’s index
of suspicion:
• Child unduly afraid
• Child within confinement
• Evidence of repeated skin or other injuries
• Inappropriate treatment of injuries
• Undernourished
• Inappropriate dressing for weather
condition
• Poor overall care
 Check list to increase one’s index
of suspicion:
• Child is cranky or irritable
• Evidence of “role-reversal”
 Abusive parental characteristics:
• Poor self-esteem, coping skills
• Violent tempers or outbursts
• Unrealistic expectations
• Inappropriate responses
• Avoidance of looking or touching
• Reluctant to give history
• Request of treatment
• Appearance of confusion and embarrassment
• Immature, depressed or demanding
 Histories offered for inflicted
injuries:
• Eyewitness history
• Unexplained injury
• Implausible history
• Alleged self-inflicted injury
• Alleged sibling inflicted injury
• Delay in seeking care
 Eyewitness history
• Child readily states- true
• One parent \caretaker accuses the other-
accurate
• Partial confessions
 Unexplained injury:
• Some parent's deny
• Often parent’s\caretaker notice physical
findings- no explanation
• When stressed become evasive – vague
explanation
• Normal parents willingness to discuss
about accident
• Exact perpetrator identified “who was with
child”
 Implausible history:
• Parental history implausible or inconsistent
• Minor accident is described
• Often behaviour described as leading to
accident inconsistent with child’s level of
development
• Some parents make history implausible by
repeatedly changing it
 Alleged self-inflicted injury
• self-inflicted injury in a small baby is
dangerous
• Child who cannot crawl cannot cause a
self-inflicted injury
• History implying that child is masochistic
should raise questions
 Alleged sibling inflicted injury
• When difficulty in giving explanation-
project blame on sibling
• Number and seriousness of injury
contradicts explanation
 Delay in seeking medical care;
• Non-abusive parents seek immediate care
• Smyth 1972
• Adult who was with child at time of injury
does not accompany
 Examination:
• Inflicted bruises
• Accidental bruises
• Inflicted burns
• Inflicted bone injuries
• Inflicted eye injuries
• Inflicted head injuries
• Inflicted abdominal injuries
 Inflicted bruises
• Occur at typical sites and fit recognizable
patterns
• Eg: human hand marks, human bite
marks, strap marks or bizarre shape
Dating of bruises; Wilson 1977
Age Color
0-2 days Swollen and tender
0-5days Red, blue, purple
5-7days green
7-10days yellow
10-14days brown
2-4 weeks cleared
 Typical sites for inflicted bruises:
solsberg 1978
• Buttock and lower back – paddling
• Cheek-slap marks
• Ear lobe-pinch marks
• Upper lip and frenum – forced feeding
• Neck- choke marks
 Human hand marks;
• Grab marks\finger tip bruise- upper arm,
shoulder, lower arm ,cheek
• Linear grab marks-pressure from entire
finger- back
• Slap marks on cheek ,2-3 parallel linear
finger bruises at finger-width spacings
• Pinch marks: 2 crescent shaped bruises
facing each other
 Strap marks:
• 1-2” wide rectangular
bruises- belt
• Lash marks; narrow,
straight edged
bruises- thrashing
tree branch
• Loop marks; double-
covered lamp cord
,rope or fan belt -
loop-shaped scars
(sussman 1968)
 Bizarre marks:
• Always inflicted,
resembles the shape
of instrument
• Johnson 1985- angry
caretaker grabs
whatever object is
handy
• Eg: circumferential tie
marks, circumferential
sheet\strap marks,
gag marks
 Accidental bruises:
• Clinician should be able to differentiate
accidental and non-accidental injuries
• Common site; skin overlying bony
prominences
• Knee, lower leg, elbow, forehead(1-2 yr)
• Bruises from falling-circular with irregular
borders
 Accidental bruises:
• Unusual bruises
• Pseudo bruises
 Unusual bruises:
• Some common ethnic practices
• Yeatman 1976- Vietnamese induce linear
bruising- rubbing coin
• Passionate and prolonged kiss
• Vigorous sucking of candy-purpura on soft
palate
• Multiple petichiae of face and neck –
coughing, vigorous crying
 Pseudo bruises;
• Mongolian spots -95% of blacks
• Allergic periorbital discoloration – allergic
rhinitis, eye allergies
• H influenzae- bluish cellulitis of face
 Inflicted burns:
• Lenoski 1977 – account for 10%
• Without blister formation, only one surface
• Shape of burn often resembles agent
• Eg; cigarette burns (diff bullous impetigo)
• Hot water burns
• Immersion burns- parents places buttocks
in scalding liquids as punishment –
enuresis or resistance to toilet training
 Inflicted bone injuries;
• 10-20% -physical abuse
• Wrenching or pulling injuries that damage
metaphysis
• Common < 5 yr , radiographic survey
accomplished as soon as possible.
• Inflicted # of shaft – spiral
• Radiograph – multiple bones at different
stages of healing – repeated assaults
 Inflicted eye injuries;
• Mushin 1971-
hyphema, dislocated
lens, traumatic
cataract, and
detached retina
• >50% - permanent
loss of vision
• Inflicted periorbital
bruising – hit, large
bruise of forehead,
basilar skull #
 Inflicted head injuries:
• Includes- subdural hematomas,
subarachnoid hemorrhage, scalp bruises,
traumatic alopecia, subgaleal hematomas
 Inflicted abdominal injuries:
• Second common cause of death in abused
children (Touloukian 1968)
• Most common cause is punch, kick that
compress organs against spinal chord
• ( Gornall 1972) Most unique abdominal
injury intramural hematoma of duodenum-
projectile vomiting bile stained
 Inflicted abdominal injuries:
• Ruptured liver or spleen (commonly)
• Intramural hematoma
• Ruptured blood vessel – shock
• Kidney injury ( blow at back )
• Urinary bladder injury (blow to lower
abdomen)
• Intestinal perforation
• Pancreatic injury
• Chylous ascites
 References:
• Clinical management of child abuse and neglect
by Roger and Bross
• Mc Donald text book of Pedodontics
• Pinkham text book of Pedodontics
• Types of child abuse and neglect,Barton D
Schmitt, Ped dent May 1986
• Child abuse and neglect- Martin Ped dent Jan
1998
• Child sexual abuse Paul cassammimo Ped dent
May 1986
• Abuse of children with disabilities: A “dirty secret”
Steven Ped dent May 1999
• Ped dent reference manual 2004
• Scully colour atlas