Child abuse and neglect

1. CHILD ABUSE & NEGLECT
Submitted by
Dr. Arnold Boban

2. CONTENTS
 INTRODUCTION
 DEFINITIONS
 CHILD ABUSE –
CHARATERISTICS
TYPES
FACTORS CONTRIBUTING
PHYSICAL CHILD ABUSE
CHILD SEXUAL ABUSE
INDICATORS

3.  CHILD NEGLECT
 MUNCHAUSEN SYNDROME BY PROXY
 BATTERED CHILD SYNDROME
 SHAKEN BABY SYNDROME
 INTENTIONAL DRUGGING
 ROLE OF DENTIST
 INTERVENTION & PREVENTION
 LEGAL ASPECT
 MANAGEMENT
 REFERANCE

4. INTRODUCTION
 Childhood should be a care free time of life filled with
love , new world to explore and with joy of massery of
oneself and environment . However for many children
this is only a dream , not reality .
 Child abuse &neglect is an increasing social problem
not limited to medical , legal or social service
professions
 The dentist treating children also must be ale to
detect, document ,repost and often help to manage
needy patient and their families

5. DEFINITIONS
 Child abuse –Non accidental physical injury , minimal
or fatal, inflicted upon children by person caring for
them. It is an overt act of commission of a caretaker
physical, emotional or sexual
-Grill 1968
 Battered baby – A child who shows clinical or
radiographic evidence of lesions

6.  Neglected child – It is one who shows evidence of
physical or mental health primarily due to failure on
parent or caretaker to provide adequately for child’s
needs
 Sexual abuse – Include contact or interaction child &
an adult when child is being used for sexual
stimulation of perpetrator or another person

7.  Dental neglect – Failure by a parent or guardian to
seek treatment for visually untreated caries , oral
infection and oral pain or failure of parent or guardian
to follow through with treatment once informed that
above condition exist

8. CHILD ABUSE
CHARATERISTICS
 Abused child –
 Distribution between male & female are equal in all
forms of child abuse
 Identifying features of child abuse are
1. Unduly afraid or passive child
2. Evidence of prolonged confinement like delay in
speech
3. Evidence of repeated skin or other injuries

9. 4.Child is undernourished and is given inapproprite
food or drink
5. Evidence of poor overall care
6.Child is cranky irritable or cries easily
7. Physically abused child is more aggressive than
neglected

10.  Abuser –
▪ Child abuse can occur in any cultural , economic , or
occupational group but higher incidence in minority &
low income families
▪ Parent often has history of being abused personally

11.  Parent charateristics
1.Poor self esteem
2.Violent temper or outbursts
3.Overly critical behaviour towards child
4. Embrassment when discussing childs trauma

12. TYPES OF CHILD ABUSE
1) Physical abuse (31.8%)
2) Emotional abuse (23.3%)
3) Educational abuse (26.3%)
4) Sexual abuse (6.8%)
5) Failure to thrive (4%)
6) Intentional drugging or poisioning
7) Munchausan syndrome

13. FACTORS THAT CONTRIBUTING TO ABUSE
1. Stress
2. Unemployment
3. Poverty
4. Overcrowded living conditions
5. Lack of support network
6. Substance or alcohol abuse
7. Children exposed to drug inutero have
developmental problem and difficult to manage.
Hence increased chance of being abused

14. Physical child abuse
 Most common type of child abuse
 Potentially fatal
 Injury stems from angry response of caretaker to
punish child for misbehavior

15. BRUISES IN PHYSICAL CHILD ABUSE
 Inflicted bruises –
occur at atypical sites or fit in recogniable patterns
 Accidental bruises –
all bluish discolorations are not bruises
Children acuire bruise on daily activity like on knee
and leg while walking and on head while jumping
Lie mostly on bony prominences

17.  Unusual bruises –
Common ethnic practices can cause bruises
Vietnamese can indue symmetrical, linear bruise from
coin rubbing . For symptoms of fever , chills or
headache back & chest are covered with oil & then
massaged in downward strokes with edge of coin

19.  Pseudo bruises-
Skin condition like mongolian spot or allergic
periorbital discolarations , haemophilus influenza may
give appearance of appearance of abusive mark

21. TYPICAL SITE OF INFLICTED
BRUISES
1. Buttocks & lower back(patting)
2. Genital &inner thigh
3. Cheek(slap mark)
4. Ear lobe (pinch mark)
5. Upper lip & frenum (forced feeding)
6. Neck (choke mark)

22. DATING OF BRUISES
AGE COLOR
 0-2 days
 0-5 days
 5-7 days
 7-10 days
 10-14 days
 2-4 weeks
 Swollen , tender
 Red, blue, purple
 Green
 yellow
 Brown
 cleared

23. TYPE OF ABUSE
LOCATION OF BRUISE INDICATIVE OF
 Genital or inner thigh
 Cheek
 Earlobe
 Upper lip /labial frenum
 Neck
 Circumferential bruise on
ankle /wrist
 Corner of mouth
 Toilet mishaps or sexual
abuse
 Slapping of child
 Pinching or pulling
 impatient or forceful feeding
 Strangulation
 Placement of restraints
 Gagging of child

24. MARKS IN PHYSICAL CHILD ABUSE
1. Human hand mark
 Oval shaped bruise –finger print due to holding of
child in violent shaking
 When parent hold childs leg to help him walking
2. Lash mark
 Narrow, straight, edge bruises or scratches caused by
thrashing with tree branch or switch

26. 3. strap mark
1-2 inch wide
Sharp borderd ,rectangular ,bruise of various length
,sometimes covering curved body surface often caused
by belt
4. Bizzare mark
Blunt end instrument used to punish

28. 5.Circumferential tie mark
⮚Present on ankles or wrist
⮚Caused by when child is restrained
6.Gag marks
⮚Seen as abrasions
⮚Appear near corner of mouth

30. CHILD SEXUAL ABUSE
 VICTIM
Most often female (f:m=9:1)
Children of all age are abused .Those in early teen are
at more risk
Most offenders are family related ,some are family
acquaintances & least common are strangers

31.  Features
1. Emotional effects
2. Functional disturbances like retention of feces
3. Frequent masturbation
4. Preocupation with genital area
5. Regression in behaviour
6. Guilt & anxiety

32.  PERPETRATOR
Incest most often committed by male parent against
female child
Father may have one of several profile like , he may
have be abusive or shy or withdrawn , sexual problem
with spouse or alcoholism

33.  ACT
Types include molestation (fondling or masturbation
),intercourse or family related rape
Pregnancy or veneral disease may be sequelea of
repeated sexual abuse

34. Indicators of sexual abuse
1) Compulsive masturbation
2) Excessive curiosity about sex
3) Bruises or bleeding from external genitalia
4) Difficulty in sitting or walking
5) Sexually transmitted disease
6) Any signs of forced oral sex
7) Pregnancy in early adolescence

35. CHILD NEGLECT
NUTRITIONAL NEGLECT
 Failure to thrive can be defined as an underweight
malnourished condition who has weight that’s below
3rd percentile and height & head circumference that
are above 3rd percentile on growth curves
 Physical examination findings
Gaunt face
Prominent rib
Wasted buttock
Spindly extremities

36.  Cause
30% organic
20% underfeeding due to understandable error
50% underfeeding due to parental neglect

37. HEALTH CARE NEGLECT
 When a child with treatable chronic disease has
serious deterioration of condition because parents or
caretaker repeatedly ignore health care
recommendation
 Refusals because of religion belief

38. DENTAL NEGLECT
 When a parent or caretaker deliberately or
unintentionally permit child to experience suffering or
falls to provide necessities for childs physical
,emotional & intellectual developments

39. SAFETY NEGLECT
 If injury results from lack of supervision
 In case of children younger than 4yrs
 Leads to injuries like burns, poisioning , falls because
children are not being watched

40. EMOTIONAL NEGLECT
 Defined as continual scapegoating & rejection of child
by parent or caretaker
 Severe verbal abuses are also a part of emotional abuse
& so is neglect of student by teacher
 Difficult to detect

41. PHYSICAL NEGLECT
 Failure to care for children according to accepted or
appreciated standard
 Presentation of child with dirty hair, dirty or
insufficient clothing, inadequate lunch, incomplete
immunization, unsanitary home environment and
inadequate after school supervision

42. MUNCHAUSEN SYNDROME BY PROXY
 Munchausen syndrome – Dr. Richard Asher
 Adults who fabricated symptoms about themselves &
produced signs & illness. They presented themselves
for medical care but did not inform medical
profesional about deception

43. MUNCHAUSEN SYNDROME BY PROXY
 Parent or caretaker attempt to bring medical attention
to themselves by injury or inducing illness in their
children
 Term coined by Dr. Roy meadow
 Fabricated symptoms & signs lead to unnecessary
medical investigation ,hospital admission & t/t

44.  Factious symptoms – bleeding from various
site
 Factious signs –recurrent sepsis from injecting
contaminated fluid
-chronic diarhea from laxatives
-fever from rubbing thermometr
- rashes from rubbing skin

46. BATTERED CHILD SYNDROME
 Dr. C. Henry Kempe – article
 Impact of Dr. Kempes publication led to passage of
laws in all states requiring health professional to
report to welfare departments & or police departments
. However it is imp to realize that battered child
syndrome is only one small ,eventhough severe
portion of physical abuse of children

48. SHAKEN BABY SYNDROME
 1st reported by Guthkelch in 1971
 Occurs primarily in children 18 months of age or
younger
 Infants head is shaken vigorously forward & backward
hitting chest & shoulders
 Most often associated with infants less than 1yr
because their neck lack muscle control & and head is
heavier than rest of body

49.  Symptoms –seizure
-retinal hemorhage
-subdural or subarachinoid
hematoma
- absence of other external signs
abuse
-breathing difficulty
- unconsciousness

51.  Most cases no skull fracture & no external signs of
trauma
 Collection of injuries associated with shaken baby
sometimes seen in toddlers ,it is rare & is always a sign
of extremely violent & severe action against child

52. INTENTIONAL DRUGGING /POISIONING
 Less common
 Potentially life thretening form of child abuse
 Involve variety of toxic substance
 No clinical presentation
 Mortality rate of nonaccidental poisioning -17%
 Intentional drugging may recurr .so need to remove pt
from care taker is management option

53. ROLE OF PEDODONTIST
 If initial examination reveal trauma including oral
cavity & it is within scope of attending dentist
,definitive t/t should begin
1. To observe & examine any suspicious evidence that
can be ascertained in office
2. To record according to law ,any evidence which may
be helpful in case

54. 3. If any dental injuries ,dentist should be acquainted
with management of injuries to tooth primary &
permenent dentition
4.To establish & maintain proffessional therapeutic
relationship with family
5. To transfer child to a hospital for proper care

55. INTERVENTION & PREVENTION
 Once a case of child abuse is suspected & reported
multidisciplinary team of institution initiate screening
process
 Pedodontist can contribute towards prevention of this
criminal act by understanding various issues related to
child abuse & applying them at different levels
 Primary level
 Secondary level
 Tertiary level

56.  PRIMARY LEVEL
1. Greater attention should be given towards screening
children at high risk of maltreatment
2. Parents at risk for abusing children are frequently
very needy themselves , so they need to be screened
& counseled
3. Comprehensive evaluation of child & family situation
should be done assissted by social worker & mental
health professional

57.  SECONDARY LEVEL
1. Pedodontist must recognize his limitation & assume
responsibilities for applying interdisciplinary
approach
2. Goal of intervention should be to enhance parenting
capabilities to enable them to a more adequate care
for their children & avoid possible maltretment

58.  TERTIARY LEVEL
 Intervention after condition is identified
1. Pedodontist should ensure child is reffered to a
designated child protection agency
2. He should not make report & disengage as he often
has valuable information ,which might help in t/t &
monitoring situation

59. Meassures for prevention
1. Dental professional against violence
 Initiated by californian dental association in 2001
 Consist of both train the trainer & direct provider
training programs designed to assist dental
professional & their terms in recognizing &
responding to child abuse & neglect ,intimate
partner violence ,elder abuse & neglect

60. 2.Prevent Abuse & Neglect through Dental Awareness
(PANDA)
 Objective :-educate professional & dental auxillaries
about their role & responsibility in recognition
,reporting & prevention of child abuse & neglect

61. 3.Other preventive meassures
a. Identification of high risk families in antenatal &
prenatal period
b. Preventive supportive program for parent with infant
c. Education of parents in school
d. Counseling before marriage & during pregnency
e. Any meassure taken to reduce stress in families
below poverty line

62. LEGAL ASPECTS
 Dentist should know definitions of child abuse &
existing related laws proposed under draft model child
protection act 1977, to protect himself and apply it
correctly

63. PRINCIPLES IN FORENSIC PEDODONTICS
1) Should be fully aware of legal standards of care &
legal responsibilities
2) Record should be made in presence of pts
3) Should keep legibly written ,accurate case records
4) Should keep update knowledge

64. 5) Diagnostic tools like radiograph should always be
used
6) Should always consult a legal or medicolegal expert
to view insurance policies or any financial or legal
matter

65. GUIDELINES ON IDENTIFICATION
OF CHILD ABUSE
1.Unusual dressing which is not suitable for season may
be intentional to cover existing physical injuries
2.A gross physical examination from head to toe without
undressing to observe any signs of injuries
3.Any bruise in shape of an object like belt , hangar

66. 4. Presence of any bite mark
5. Frenal tears may indicate forced feeding
6. Bruising & petechia of soft palate indicate sexual
abuse
7.A 4 month old child with femur fracture
8.Bruise in shape of handprint on cheek
9. Any bruise in neck region may be an attempted
strangulation

67. MANAGEMENT
 Meeting with key family members , home visit &
contact with professional involved with family such as
physician ,dentist or teacher
 Assess degree of childs immediate risk so as to
determine appropriate placement
- Majority of cases child will remain at home
- When child is placed out of home ,reunion of family is
ultimate goal

68. - At 1st supervised by social worker , then increase
frequency &duration of visit
- If visit presents major difficulties in child , it might be
shortened & become less frequent
 A comprehensive social service plan should be
developed as soon as identifying needs of family .
Social worker helps in family in obtaining services like
payments for disabled children , nutrition for pregnant
,infant & young children

69. - Advocate suitable school program
- Monitoring family situation & coordinating services

70. Conclusion
⚫ Indicators are not proof that abuse or neglect actually
exists. Rather, they are indications that a child may have
a problem and that further exploration may be necessary
to determine what is happening in that child's life.
Abuse and/or neglect are not the only causes of these
specific behaviors or indicators.
⚫Neglect in the early years can have a long-standing
impact across the whole spectrum of children's
development, and throughout the life span. Early
intervention and support for families where neglect is
identified is therefore of utmost importance in
safeguarding children from harm.

71. Referance
 Text book of pediatric dentistry –Nikhil Marwa
 Pediatric dentistry –shobha tendon
 Pediatric dentistry –principles & practice MS Muthu