Child abuse

Child
abuse
INDIAN DENTAL
ACADEMY
Leader in continuing
Dental Educationwww.indiandentalacademy.com

CONTENTS
1. Introduction
2. Definition
3. Different types of child abuse & types of
neglect
4. Description of each type of abuse
5. Dental neglect
6. Reporting & documentation
7. References
www.indiandentalacademy.com

 Greeks, Egyptians, Persians and other ancient
civilizations considered “Every child to be a charge of
the state”
 Early English law stated that "paternal power should
consist of kindness, not cruelty”
 Child abuse is a violation of the basic human rights of a
child and is an outcome of a set of inter-related familial,
social, psychological and economic factors
 The problem of child abuse and human rights violations
is one of the most critical matters on the international
human rights agenda

 Child abuse and neglect issues are common in
almost all countries at the global level
 Largest population of children in the world live in
South Asia and majority of these children lack access
to proper health care, nutrition and education
 Only 2.4% of the world's children are legally
protected from corporal punishment in all settings

Child abuse in India:
 19 % of the world's children live in India.
 According to 2001 Census, 440 million people in the
country are aged below 18 years and constitute 42 %
of India's total population i.e., 4 out of every 10
persons.
 The National Policy for Children, 1974, declared
children to be a 'supreme national asset'.
 The National Study on Child Abuse undertaken by the
Ministry of Women and Child Development,
Government of India, in 2005

Child Survival:
 2.5 million children die in India every year
 1/6 children die before they attain 1 yr of age, and
1/11 die before they attain 5 yrs of age
 Child abuse is second to SIDS, (Sudden Infant
Death Syndrome) which is the leading cause of
death in children under 1 yr of age.
 In older children it is second to accidents

Sudden Infant Death Syndrome:
 Sudden and unexplained death of an infant.
 It's a frightening prospect because it can strike
without warning, usually in seemingly healthy babies.
 Deaths are associated with sleep ("crib death") and
infants show no signs of suffering.
 Most SIDS deaths happen when babies are between
2 - 4 months of age

Potential risk factors:
 Smoking, drinking, or drug use during pregnancy
 Poor prenatal care
 Prematurity or low birth-weight
 Mothers younger than 20
 Tobacco smoke exposure following birth
 Overheating from excessive sleepwear and bedding
 Babies who are placed to sleep on their stomachs
(Stomach sleeping) or sides are at higher risk for
SIDS than babies who are placed on their backs to
sleep.

Definitions

Abuse – The non-accidental commission of any act by
a care-taker
upon a child under age 18 yrs which causes or creates
a substantial
risk of serious physical or emotional injury, or which
constitutes a
sexual offense
Care-taker – Child’s parent, stepparent, guardian, any
person
entrusted with responsibility for a child’s health or
welfarewww.indiandentalacademy.com

‘‘Child abuse or maltreatment constitutes all forms of
physical and/or emotional ill-treatment, sexual abuse,
neglect
or negligent treatment or commercial or other
exploitation,
resulting in actual or potential harm to the child’s
health,
survival, development or dignity in the context of a
relationship
of responsibility.’’
- WHO, 1999

Child abuse has been defined as ‘Nonaccidental
physical
attack or physical injury, including minimal as well
as fatal
injury, inflicted upon children by persons caring for
them.’
- GIL D.
G,1968.
Child abuse & Neglect
The Portion of harm to children that results from
human
action that is Proscribed, Proximate & Preventable
Proscribed - One that is not acceptable
Proximate – Occurs within immediate environment

According to Federal Law, 2004
“ The physical or mental injury, sexual abuse or
exploitation,
negligent treatment or maltreatment
 Of a child under the age 18, or except in the
case of sexual abuse, age specified by child
protection law of the state
 By a person (including any employee of a
residential faculty or any staff person providing
out-of-home care ) who is responsible for the
child’s welfare
 Under circumstances which indicate that the

Any willful act or threatened act that results in any
physical, mental, or sexual injury or harm that causes
or is
likely to cause the child’s physical, mental, or
emotional health
to be significantly impaired.
2004, Orlando Regional Healthcare, Education &
Development
According to CAPTA, 2007 – Recent act or failure to
act that
results in death, serious physical or emotional harm,
sexual abusewww.indiandentalacademy.com

Child abuse refers to the intended, unintended and
perceived
maltreatment, whether habitual or not, of the child,
including any
of the following:
 Psychological and physical abuse, neglect, cruelty,
sexual and emotional maltreatment.
 Any act, deed or word which debases, degrades or
demeans the intrinsic worth and dignity of a child as a
human being.
 Unreasonable deprivation of his/her basic needs for
survival such as food and shelter; failure to give timely
medical treatment to an injured child resulting in
serious impairment of his/her growth & development
or in his/her permanent incapacity or death.

Types of Child Abuse & Child
Neglect

Types of child abuse & neglect
1. Physical abuse
2. Sexual abuse
3. Emotional abuse
4. Neglect
- Physical
- Emotional
- Educational

Physical neglect - not providing adequate food or
clothing,
appropriate medical care, supervision, or proper weather
protection (heat or cold)
Emotional neglect includes the lack of any emotional
support and
love, never attending to the child, substance abuse
including allowing
the child to participate in drug and alcohol use.
Educational neglect - failure to provide appropriate
schooling orwww.indiandentalacademy.com

Risk factors
Child characteristics:
 The child was born prematurely
 The child has disabilities or abnormalities
 The child exhibits certain behavior problems
 Nonbiologic relationship to the caretaker
 One of multiple births
 Medical fragility

Family & environmental factors :
 Violence in the home (in particular, the father abuses
the mother or siblings abuse one another)
 Substance abuse, including alcohol abuse, by the
parents or caretakers
 Parents or caretakers lack the necessary maturity to
care for the child
 Parental expectations are inconsistent with the
child’s developmental abilities
 Caretaker is socially isolated (i.e., has no external
support systems)
 Unwanted pregnancy

 High local unemployment rates
 Criminal history of the parents
 Mental health history
 Family is experiencing high levels of stress from
events such as loss of a job, increased financial
burdens, serious illness, death in the family,
separation or divorce
 Long parenthood
 Ego-defects – low self-esteem, inability to
empathize

Physical abuse

 Physical abuse is the inflicting of physical injury upon
a child.
 This may include burning, hitting, punching, shaking,
kicking, beating or otherwise harming a child
 Parent or caretaker may not have intended to hurt
the child.
 The underlying belief is that physical punishment
encourages discipline in children and is for their
betterment in the long-run

Child abuse can have the following consequences:
 It will encourage child to lie, fear, and insult, instead of
loving, trusting, and listening
 It will alienate your child from you and the rest of your
family & make him/her a recluse.
 It will lower your child's self esteem, and affect your
child's psychological development and usual behaviour
 When your child grows up, your child could
probably carry on the family tradition, and abuse
his/her children.
 Your child may exclude you from his/her adult life.

“Any force or action that exceeds the force considered
reasonable for
disciplining a child and that results in non-accidental
injury.”
Most commonly are inflicted with blunt trauma with an
instrument,
eating utensils, hands, or fingers or by caustic
substances.
J Can Dent Assoc 1999; 65:387-
91
“Hitting, shaking, throwing, poisoning, burning or
scalding,
drowning, suffocating or otherwise causing physical

 Abuse may result in contusions, lacerations of the
tongue, buccal
mucosa, palate, gingiva alveolar mucosa or frenum,
fractured,
displaced, or avulsed teeth; facial bone, jaw fractures
& burns
 Gags applied to the mouth may leave bruises, or
scarring at the corners of the mouth

Ministry of Women and Child Development, Government of
India, 2007
Highe
st

India, 2007

 Characterize a clinical condition in children, usually
younger than 3 years old, who suffer from serious
physical abuse
 Children typically show fractures, subdural
hematomas, failure to thrive, and multiple soft tissue
injuries.
 Skeletal injuries in several locations in different stages
of healing are key diagnostic criteria
 A Radiologist, Frederic N. Silverman,1953 - claimed
that “spontaneous” fractures in a child with a normal
bony structure are caused by unrecognized trauma
Battered child syndrome

Shaken baby syndrome
 The child is held around the chest and violently
shaken back and forth
 This causes the extremities and the head to wave
back and forth in a whiplash movement
 Intracranial injury occurs as a result of severe
angular acceleration, deceleration and direct impact
as the head strikes a solid object.
 The chest is compressed resulting in rib fractures.
 Arms and legs move about in a whiplash movement
resulting in the typical 'corner' or 'bucket-handle'-
fractures in the metaphyseal region.

 A remarkable feature of SBS is the lack of external
evidence of trauma.
 The combination of shaking with striking of the infant
against a hard object is termed as shaken impact
syndrome

 Consequences of SBS include lifelong disability from
neurological damage, varying degrees of visual
impairment e.g., blindness, motor impairment e.g.
cerebral palsy and cognitive impairments
SIGNS & SYMPTOMS
 Retinal hemorrhages
 Subdural hematomas
 Oxygen deprivation
 Swelling of brain

 No outward physical signs of trauma
 Change in the child's behavior such as irritability,
lethargy, pale or bluish skin, vomiting, and
convulsions.
 Breathing difficulty, seizures & dilated pupils

 Bone fractures of the skull from impact injury
 Long bone fractures (arms and legs)
 Retinal detachment (inner-most layer of the eye
detaching from the rest of the eyeball)
 Tearing of the child’s brain tissues (Axonal
shearing)
 Complete loss of vision
 Cerebral palsy
 Death

Sexual Abuse

India, 2007
Highest

Out come in Childhood
 Emotional disturbances in the form of fear, anxiety,
depression, anger, and low self-esteem
 Various anxiety disorders (fearfulness, nightmares,
phobias), post-traumatic stress disorder (PTSD),
hysterical reactions,depression, suicidal behaviour,
substance abuse etc.

Emotional abuse

Emotional abuse is also known as verbal abuse, mental
abuse, and
psychological maltreatment.
 This can include parents, caretakers using extreme
and/or strange forms of punishment, such as
confinement in a dark room or being tied to a chair for
long periods of time or threatening a child.
 Emotional and psychological maltreatment of children
is the most complex type of abuse - invisible and
difficult
- WHO,1999

CAPTA, 2007 - defines emotional abuse as an abuse
that results in
demonstrable harm (e.g. impaired psychological growth
&
development) of a child.
There are several types of emotional abuse
1. Rejection
2. Isolation
3. Terrorism
4. Ignorance
5. Psychological unavailability
6. Corruption

Deprivational Syndromes
when the basic needs of the child are not being met -
adequate
nutrition, clothing, shelter, emotional support, love,
education, safety, and medical & dental care
Historical Findings
 Lack of appropriate well-child care, including
immunizations
 Lack of appropriate medical care of chronic illness
 Absence of necessary health aids such as
eyeglasses or hearing aids
 Absence of appropriate dental care

Physical Findings
 Under nutrition (on examination or as evidenced
by plotting on appropriate growth curves)
 Poor hygiene
 Developmental delay
 Untreated medical conditions
 Rampant dental caries

Behavioral Findings
 Depression
 Anxiety
 Enuresis (involuntary urination)
 Sleep disturbances
 Impaired interpersonal relations
 Discipline problems, aggressive behavior
 Poor school performance

Dental neglect
“The 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, 2005

 High proportion of abused children suffer injuries to
the face and head, including the oral and perioral
regions.
 These injuries may be observed during the course of
dental treatment and in some cases even before the
child is seated in the dental chair.

Indicators of dental neglect include:
 Untreated rampant caries that can be easily detected;
 Untreated bleeding or trauma affecting the orofacial
region;
 Lack of continuity of care in the presence of previously
identified pathoses.
 Present injury is one of a series of injuries that the
child is experiencing
 There has been an extraordinary delay in seeking care
for the injury.
 Family does not want to discuss the circumstances of
the injury.
 Family offers an explanation that is not compatible
with the nature of the injury.www.indiandentalacademy.com

• Eye witness
• History
• Physical Examination

At reception:
1. Routinely observe children for unusual behavior
2. Frozen watchfulness – staring look
3. Evaluate hygiene, outward signs of proper
nourishment, and general health
4. Child’s clothing appropriate for the present weather
5. Are there any wounds or bruises on the child’s face
or body
6. How does child respond to others

When interviewing the child:
 Sit near the child, not across a desk or table, and at
the child’s eye level
 Attempt to establish an empathic, trusting relationship
 Conduct the interview in private and without the
caretaker being present
 Use the child’s own words and terms in discussing the
situation whenever feasible
 Always ask the child if she/he has any questions and
answer them

Do not:
 Suggest answers to the child
 Press the child for answers that she/he is
unwilling to give
 Criticize the child’s choice of language
 Make the situation that the child feel blame or
guilt
 Leave the child unattended or with unknown
persons
 Display shock or horror concerning the child or
the situation
 Offer rewards to the child

When interviewing the caretakers:
 Tell them the reason for the interview
 Conduct the interview in private or, when indicated,
with appropriate personnel (e.g., child protection
service personnel)
 Explain further actions that will be required

Do not:
 Attempt to prove abuse or neglect
 Display anger, horror, or disapproval of the caretakers
or situation
 Place blame or make judgments
 Give feedback on the caretakers’ explanation of how
the injury occurred since this will permit them to
change the explanation, based on your feedback

Physical Examination
Should be
 Conducted with the consent of the child
 Take sufficient time for the child to be
comfortable
 Conducted in a gentle and sensitive manner

 Visual observation,
 Radiographic studies,
 Manipulation of the jaws,
 Pulp vitality tests, and percussion
 Transillumination

General Physical Findings:
 Child's nutritional state
 Extraoral injuries (various stages of healing,
indicating the possibility of repeated trauma)
 Head and neck for asymmetry
 Bruises or abrasions – shape, reflects the offending
object,
- color, indicates different
stages of healing
 Bite marks, bald patches (where hair has been
pulled out), injuries on extremities or on the face,
eyes, ears, or around the mouth & corners of the
mouthwww.indiandentalacademy.com

 Bruises from hand slapping are common - produce
the outline of the hand
 Multiplanar injuries occur accidentally as a result of
tumbling falls (e.g., falling down stairs) or trauma
during automobile accidents.

Ageing of Bruises and Abrasions: -
• Red – Blue – Purple :- 0-1 days.
• Blue – Black :- 1-3 days.
• Green – Blue :- 3-6 days.
• Brown – Yellow – Green :- 6-10 days.
• Tan – Yellow :- 14 days.
•Faded :- More than 14 days.

Burns
 Patterned burns resembling an electrical appliance
(e.g., iron, burner, grill)
 Cigar or cigarette burns, especially on the soles, palms,
back, or
buttocks
 Most common cause of burns in children is hot liquid.

Fractures
 Fractures caused by abuse are commonly seen in the
metaphyseal (growing ends of bone), ribs, scapula, clavicle,
vertebrae, and fingers
 Rib fractures are rare in young children because of the
cartilaginous flexibility of the bones

Bite marks
 Bites pose a threat of infection and should be taken
very seriously
 Healthcare provider must confirm whether the bite
was human or animal in origin
 Bites produced by dogs and other carnivorous
animals tend to tear flesh, whereas human bites
compress flesh and can cause abrasions,
contusions, and lacérations

 Human bites tend to have a circular mark with
crescent-shaped bruising, Individual tooth marks
may be evident.
 Human bites also tend to tear or crush due to the
large surface area, where as animal bites cause
puncture wounds from their sharp teeth
 Normal distance between the maxillary canine teeth
in child is approx. 2.5cms

 Suspicion of child abuse - when new injuries are
present
along with older
injuries.
- Scars, particularly on the
lips,
are evidence of
previous trauma
- Darkened and/or nonvital
teeth
- Missing teeth
 Tongue of an abused child may exhibit abnormal
anatomy or function due to scarring - result from a
burn or other traumawww.indiandentalacademy.com

Typical Oral Lesions:
 Oral and facial injuries of child abuse may occur
alone or in conjunction with injuries to other parts of
the body
 Oral lesions associated with child abuse are usually
bruises, lacerations, abrasions, or fractures.

Intraoral Examination
 Burns or bruises near the commissures of the mouth
- gagging with a cloth or rope
 Scars on the lips, tongue, palate or lingual frenum -
forced feeding
Tears of the labial or lingual frenum:
 Frequently seen in child abuse cases
 Result from - Forced feeding
- blunt force trauma (e.g., when a hand
or blunt
object is forcibly applied to the upper lip to
silence the child)

Oral mucosa torn from gingiva:
 Blunt force trauma to the lower face may cause the
mucosal lining of the inner surface of the lip to be torn
away from the gingiva. (e.g.,forceful slap)
 Location and extent of the injury will depend on the
magnitude of force and the location and direction of
the blow.

 Trauma to the mouth may also cause ulceration of
the palate or uvula.
 Lacerations in the floor of the mouth, which may be
caused by forced bottle feeding.

Loosened, fractured, or avulsed teeth:
 Severe trauma to the lower face
 Common for root fractures to occur, confirm with
radiographs.
 Traumatic injuries, may be accidental rather than
abusive
 Therefore, always determine whether the injury is
compatible with the explanation given.
 If the dental injuries resulted from a fall, for example,
usually also find bruised or abraded knees, hands, or
elbows. When these additional injuries are not
present, further inquiry is appropriate.

Fractures of jaws and associated structures:
 Fractures of the maxilla, mandible, and other cranial
bones may be found in cases of child abuse.
 Radiologic study - signs of old & new fractures, if a
pattern of repeated trauma has been found, needs to
be investigated with reference to possible child
abuse.
 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.
 Other sign include abnormal mobility of bony
structures & Crepitation
 Swelling or ecchymosis in the lower face is

In evaluating and reporting dental injuries, Andreasen's
classification, based on a system adopted by WHO:
 Crown infraction - incomplete fracture (crack) of
enamel
 Uncomplicated crown fracture - confined to enamel or
enamel and dentin, pulp not exposed
 Complicated crown fracture - pulp is exposed
 Uncomplicated crown-root fracture - involves enamel,
dentin, and cementum, but does not expose pulp
 Complicated crown-root fracture - involves enamel,
dentin, cementum, and exposes pulp

 Concussion - injury to supporting structures without
abnormal loosening or displacement of the tooth
 Subluxation (loosening) - injury to supporting
structures with abnormal loosening, but without
displacement of the tooth
 Intrusive luxation - tooth displaced into alveolar
bone, injury accompanied by comminution or
fracture of alveolar socket
 Extrusive luxation - tooth partially displaced out of its
socket
 Lateral luxation - tooth displaced in a direction other
than axially, with comminution or fracture of alveolar
socket
 Exarticulation (complete avulsion) - tooth completely
avulsed from socket

 Fracture of alveolar socket wall - fracture confined to
the labial or lingual socket wall
 Fracture of mandible or maxilla - involves the base
of mandible or maxilla and often the alveolar
process, may or may not involve alveolar socket
 Laceration of gingiva or oral mucosa - shallow or
deep wound in mucosa resulting from tear, and
normally produced by sharp object
 Contusion of gingiva or oral mucosa - bruise usually
caused by blunt object, no break in mucosa, usually
causes small submucosal hemorrhage
 Abrasion of gingiva or oral mucosa - superficial
wound produced by rubbing or scraping mucosa,
leaving raw, bleeding surfacewww.indiandentalacademy.com

 Injuries to the face may include trauma to the eyes,
ears, and nose.
 Blunt force trauma to the eye
- Periorbital bruises (black eyes),
- Acute hyphema (blood in anterior chamber of
eye),
- Retinal and subconjunctival hemorrhage,
- Ruptured globe,
- Dislocated lens,
- Optic atrophy,
- Traumatic cataract, and
- Detached retina.www.indiandentalacademy.com

 Direct trauma to the nose
- Deviated septum due to cartilage injury
- Hematoma formation
- Nasal fractures
 Injuries to the ear
- Bruising,
- Repeated blows result in a "cauliflower ear"
- Rupture tympanic membrane
- Hemorrhage and hematoma formation

Differential Diagnosis of Physical Abuse
INJURY DIFFERENTIAL DIAGNOSIS
BRUISES
Accidental or nonaccidental bruise, dermatologic disorders,
genetic disorders (e.g., Ehlers-Danlos syndrome), hematologic
disorders, Henoch- Schönlein purpura, mongolian spots
BURNS
Accidental burn, dermatitis, inflicted burn, skin infection,
Stevens-Johnson syndrome
FRACTURES
Accidental or intentional fracture, birth trauma, congenital
syphilis, leukemia, osteogenesis imperfecta, osteomyelitis,
physiologic changes, rickets, scurvy
HEAD
TRAUMA
Accidental or inflicted trauma, birth trauma, hemorrhagic
disease, infection, intracranial vascular anomalies, metabolic
disease

Diagnosis
 Are the history, signs, and symptoms of disease
credible?
 Is the child receiving unnecessary and harmful or
potentially harmful medical care?

 Child who has multiple medical problems that don't
respond to treatment or that follow a persistent and
puzzling course
 Physical or laboratory findings that are highly
unusual, don't correspond with the child's medical
history, or are physically or clinically impossible
 Short-term symptoms that tend to stop when the
perpetrator isn't around

During the diagnostic process, the physician should:
 Assess the child’s immediate medical needs
 Obtain the past medical and social history of the
child and family members
 Determine the level of risk to the child if she/he
returns home

Documentation
Records should be kept in a precise, professional
manner and should
include the following
 A standard, thorough health assessment, including a
medical history and relevant social history
 Statements made by the child and caretaker, including
any taped interviews
 Observed behavior
 A detailed description of the injuries, including type,
number, size, degree of healing, possible causes,
explanations given, and location recorded on a body
chart or drawingwww.indiandentalacademy.com

 An opinion on whether the injuries were adequately
explained
 Results of all pertinent laboratory and other diagnostic
procedures
 Photographs and imaging studies, if applicable
 Any other significant facts or materials that address
the who, what, where, when, and why of the injuries

It is important to realize that all members of the dental
team have a unique opportunity and a legal obligation
— to assist in the struggle against child abuse.
In diagnosing and treating victims of child abuse or
neglect, every
Dentist should:
 Have a thorough knowledge of the reporting laws in
her/his state of practice
 Be aware of the “Battered child syndrome”
 Be aware of behavioral signs that suggest abuse,
 Be aware of populations at high risk for abuse and
psychosocial risk factors for abuse
 Arrange for physical examinations and interviews as

 If uncomfortable with a situation, request a specialist
to examine or interview the child
 Get a second opinion in unclear situations
 Provide follow-up medical care for the child
 Be sensitive to the problems of abusive parents
 Be familiar with related abuse problems

Prevent Abuse and Neglect through Dental Awareness
(P.A.N.D.A.)
 PANDA Coalition was started in Missouri in 1992 to
address a lack of child abuse and neglect reporting by
dental professionals.
 PANDA, provides training courses and materials to
dental professionals and others regarding how to
recognize, report, and prevent suspected child abuse
and neglect.

References
 Dentistry for the Child and Adolescent,
McDonald, Avery, Dean 8th Ed
 Pediatric Dentistry :Total patient care
Stephen H.Y Wei
 Child Abuse: Approach and Management
American Family Physician ,Volume 75, Number 2 ,
January 15, 2007
 Oral and Dental Aspects of Child Abuse and Neglect
Joint statement of the American academy of
Pediatrics and the
American academy of Pediatric
Dentistrywww.indiandentalacademy.com

 Detecting Child Abuse and Neglect — Are Dentists
Doing Enough?
J Can Dent Assoc 1999; 65:387-91
 Beyond Munchausen Syndrome by Proxy:
Identification and Treatment of Child Abuse in a
Medical Setting
PEDIATRICS, Vol. 119 No. 5 May
2007
 Oral and Dental Aspects of Child Abuse and Neglect
PEDIATRICS, Vol. 116 No. 6
December 2005
 Child Sexual Abuse in Clinical Practice: Identification
and Management - JIACAM Vol. 1, No. 2, Article 6
 The work of Ambroise Tardieu: The first definitivewww.indiandentalacademy.com

There is never an excuse to hurt
a child!!!!

Child abuse

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