Abuse

The Role for Dental Professionals in Preventing Child Abuse and Neglect

Dr. Mouden will present "The Role for Dental Professionals in Preventing Child Abuse and Neglect" at the ADA Annual Session in San Francisco, on Sunday, Oct. 25, From 8:30 am - 11 am in the City Room at the ANA Hotel.

    The topic of child maltreatment is difficult because all practitioners wish that child abuse and neglect did not happen. Also, we would rather not have to deal with some of the emotions these cases evoke in us. Cases of family violence are difficult to deal with because we know they are not the result of some disease process nor some accident. Instead, we know that these injuries are deliberate and preventable.

Figure 1. Adult hand prints from a case of Shaken Baby Syndrome. Figure 2. Adult bite marks reported as a dog bite Figure 3. Laceration of labial frenum from forced feeding. Figure 4. "Slap mark" on a child's face. Figure 5. Multiple, bi-lateral injuries to the face, consistent with the use of force over a period of time. Figure 6. Injuries from an open-handed slap to the mouth. Injuries include lacerations of the upper lip and labial frenum, contusions in the vestibule and suluxation of the permanent right central incisor.

    Dealing with child maltreatment sometimes is similar to the way we deal with death. Many people prefer to deny these problems, or to say that it only happens in someone else's neighborhood. They are angry about child abuse, and what abusers do to children should make them upset, but anger by itself will not solve the problem. They bargain about their involvement, saying that if they get involved with child abuse prevention, they won't need to be concerned with other forms of family violence. They get depressed, feeling that our small victories are inconsequential to fight the huge epidemic of abuse. However, we can show every dental professional that a thorough understanding of their involvement can lead them to a feeling of acceptance -- an acceptance that we can do something to stop this awful epidemic.

    Child abuse and neglect truly are epidemic in proportion. In 1996, approximately 2.9 million children were reported to child protection services agencies as victims of maltreatment, with over 7,300 cases reported every day.1,2 To help prevent the growing number of these cases, every state has passed legislation to increase the reporting of suspected abuse and neglect. Under these laws, several classes of individuals are listed in state statutes as "mandated reporters." As mandated reporters, these individuals are required, under penalty of law, to report any child within their purview suspected of being abused or neglected. Although dentists are mandated reporters in every state, they have done a remarkably poor job of living up to that obligation.

    An analysis of 260 documented cases of child abuse at Children's Hospital Medical Center in Boston found that 65 percent of all cases of physical abuse involve injuries to the head, neck, or mouth.3 Therefore, dentists are in a perfect position to see signs of child maltreatment. However, in states that track cases by the profession of the reporter, dentists have made only 0.32 percent of all reports.4 If dentists are in the best position to see these injuries, why don't they recognize them? If they recognize child abuse, why don't they report it?

    Child abuse and neglect are not new to society. Society's attitude toward protecting children has changed dramatically over the centuries. The Greeks, Egyptians, Persians and other ancient civilizations considered every child to be a charge of the state. Somewhat later, Roman law reversed that thinking by conceding to the father absolute dominion over his children. English common law came to a compromise between these two extremes. Under that law, the parent had absolute control of the child, subject to the power of the King under the concept of parens patriae, the sovereign's right to protect the child. As attitudes have changed, so has the treatment of children.

    In this country, early attitudes toward child maltreatment seemed to have been based on denying the very existence of abuse or neglect. No mention of child maltreatment appeared in the literature until 1874. It was in that year that the case of "Mary Ellen" brought the issue of child maltreatment to light. While visiting an elderly parishioner, a church social worker learned about Mary Ellen, a child who had been beaten, bound, and neglected by her foster parents. The social worker found that she could do nothing to have the child removed from the home, so the church sought changes in the law to protect such children.

    Following the legal efforts to help Mary Ellen, the New York Society for the Prevention of Cruelty to Children (now called the ASPCC) was formed. It is a sad commentary that the NYSPCC was formed years after the beginning of the New York Society for the Prevention of Cruelty to Animals (now known as the ASPCA). The Mary Ellen case was even championed under the auspices of the SPCA because she was deemed to be a "human animal".

    Current attitudes toward child maltreatment arise from the publication of "The Battered-Child Syndrome" by Dr. C. Henry Kempe in 1962.5 Dr. Kempe's message, directed to his medical colleagues, was clear: battered-child syndrome should be considered in every differential diagnosis involving injuries to children. Specifically, he advocated that "abuse should be considered in any child exhibiting evidence of fracture of any bone, subdural hematoma, failure to thrive, soft tissue swelling, or skin bruising." He later expanded the list of symptoms of child maltreatment to include retinal hemorrhages, hand print bruises, human bite marks, genital injuries, intraoral hematomas, and lacerations of the mouth.6

    Kempe's article immediately heightened awareness in the medical community. Because of the article, the problems of child abuse also gained public recognition for the first time. Within six months the popular press had picked up on the story and spread it to the masses as in Life, 1963, "Cry Rises from Beaten Babies" and Good Housekeeping, 1964, "The Shocking Price of Parental Anger." Further evidence of the effect of the Kempe article was that the federal Children's Bureau authored model legislation in 1963 for the states to address the problems of child maltreatment.

    The impact of the Kempe landmark article was admittedly a stroke of luck. For ten years Dr. Kempe had talked about child abuse, non-accidental injuries, and inflicted injury, but no one had paid attention. He coined the phrase "battered-child syndrome" despite its provocative and anger-producing nature to finally get the attention of the medical profession. He got much more attention than he expected.

Etiology

Child maltreatment can undoubtedly be considered a breakdown in the parenting skills of the child's caregivers. Many factors can lead to this failure to parent properly. It is most useful to understand that child abuse and neglect may be among many symptoms of a dysfunctional family. One theory holds that parents' unrealistic expectations for the child and for themselves can contribute to the abuse. Another theory is that the abuser's attitude toward children is based on the conviction that children exist to satisfy parental needs. For these parents, it follows that children who do not satisfy those needs should be physically punished in order to make them behave properly.7 Some mothers are simply not satisfied by the unresponsiveness and lack of feedback from an infant. One young mother's tragic lament shows her self-justifying reasons for abusing her baby:

I've waited all these years for my baby, and when she was born she never did anything for me. When she cried, it meant that she didn't love me; so I hit her.7

Other abusers explain the maltreatment of children as a suitable means of parenting. In one notable study, Dietrich et al interviewed abusers about their feelings subsequent to the abuse. Of those adults interviewed, 62.5 percent felt justified in injuring the child, 58.9% felt no remorse for their actions, and 50.7 percent blamed the victim for the abuse. Combining the three factors studied, fully one-third of the adults felt justified, blamed the victim, and felt no remorse.8

Dr. Kempe noted that parental attitudes have long been influenced by what he referred to as the "three almost sacred sayings." "Spare the rod and spoil the child" is a time-honored admonition that condones corporal punishment. "Be it ever so humble, there's no place like home" reminds us of the primary importance of parents, even flawed parents.

Unfortunately, places far better than home do exist for children in certain situations. "A man's home is his castle" reinforces the widespread belief that parents have ultimate control over their children, and can rear their children without outside intervention.

Most parents would agree that parenting is often difficult and trying. All parents can feel anger toward their child at some time. Mothering can be even more fraught with broken promises based on our cultural perceptions of the ideal mother. Dr. Kempe said, "The idealized view of the mother as Madonna, sweetly smiling on her child, is in the mind's eye of many people today. However, it is unlikely that any mother or father can be loving and generous 24 hours per day, seven days per week.7 The difference between abusers and non-abusers is that non-abusers find less violent methods to deal with their anger and frustration.

The prevention of child maltreatment would be expedited if one could develop a model for identifying potential abusers. While it would certainly be helpful to be able to identify the perpetrators before they abuse their children, attempts to develop a "personality profile" of the potentially abusive parent have shown little success.9 Current efforts are aimed at identifying risk factors that may lead to child abuse or neglect. Factors such as brief time of residence in a location, families with more than three children, parents with less than average years of education, and age of the parents at the time of the child's birth are all known to affect the risk of abusive behavior.10 Parents who have one or more of these risk factors may then be targeted for preventive interventions.

Demographics

Early surveys of child abuse cases inaccurately reported that child abuse and neglect occurred mostly in minority and lower socio-economic class families. It is now known that child maltreatment occurs in families in all economic levels and from every ethnic background,3 although it has been suggested that the poor are more likely to be reported, accused and convicted of child abuse and neglect.7

National statistics, compiled from the 47 state agencies that completed the 1992 survey of the National Center on Child Abuse Prevention, show that from over 2.5 million reported cases:

    (1) 65 percent of cases involve Caucasian families;

    (2) reports cover every socio-economic level; and,

    (3) 54 percent of reports are of families in rural settings.11

Therefore, no one should assume that child abuse only occurs in poor, minority, or inner-city families. The data clearly show otherwise. The prevalence of child neglect is even higher. For every child seen who is abused, probably ten more children have been neglected.12 People in health care need to be especially aware of the prevalence of child maltreatment across ethnic, geographic and economic strata. It is said to be highly unlikely that health care professionals in any area have not seen abused children in their practice.11

Recent widely reported news stories have highlighted certain high-risk environments for children. Even though court cases involving day care centers have received much attention, less than 1 percent of substantiated cases occur in the day care setting.12 Divorce proceedings with allegations of child abuse leveled by one or both parents are common in the popular press. However, less than two percent of divorce custody disputes involve allegations of abuse. Unfortunately, more than half of the allegations made, although incidental to the divorce, are nevertheless reported to have been founded.13 It is unknown whether the abuse is a cause for the divorce, or whether the stresses of divorce are a contributing factor in the abuse, or both.

Sexual abuse is also widespread. At least one in six women and one in 10 men report having experienced intrafamilial sexual abuse before the age of 18.14 A 1988 Los Angeles Times poll revealed that 22 percent of Americans reported being victims of child sexual abuse.15

Legal Issues

Under the provisions of the federal Child Abuse Prevention Act of 1974, passed 100 years after the Mary Ellen case, every state is required to have legislation aimed at protecting children from abuse and neglect. All 50 states have the legislation in place. Each state statute is slightly different, but all cover the same basic areas. In every state, certain citizens are specifically listed as mandated reporters -- those individuals required to report suspected cases of child abuse and neglect.

Every state reporting statute contains similar provisions defining child abuse, who must report, immunity for reporting and abrogation of privileged communication. The definition of reportable conditions varies widely between jurisdictions. Some statutory definitions are extremely circuitous, as in the case of Tennessee's statute, which defines abuse and neglect as "... failure to protect a child from conditions of brutality, abuse or neglect ."16 Most states, including California, use a definition based on federal law, that refers to "any physical injury inflicted by other than accidental means, sexual abuse, and unjustifiable punishment.17

State laws differ widely on situations that may constitute child neglect. Such varying definitions of child neglect underscore the cultural issues inherent in labeling children as neglected. Factors including socioeconomic conditions and access to care have influenced legislative thinking on the definition of neglected children.

Much variation exists in the listing of mandated reporters, those required by law to report suspected cases. Nineteen jurisdictions require that "any person" is required to report suspected child maltreatment. Other states, such as Illinois, list so many specific individuals (including homemakers)18 that the listing should be "any person." California statute list includes teachers, day care workers, health practitioners (defined as physicians, dentists, podiatrists, chiropractors, nurses, dental hygienists, etc.), coroners and medical examiners.19

Every state statute contains language to protect mandated reporters from criminal and civil liability arising from good-faith reports. However, such immunity does not apply to liability arising from willful misconduct or gross negligence.20 Forty-seven of the states that specify mandated reporting (including California) also provide for criminal penalties for failure to report suspected cases.21 It is important for mandated health care professionals to note that malpractice insurance does not cover criminal acts. Because failure to report can be a crime, subsequent injuries resulting from failure to report might open a health care professional to exposure to uninsured professional liability.

The abrogation of privileged communication provisions is of paramount importance to the reporting process. From the beginning of their professional education, health care providers are told that what is learned within the doctor-patient relationship is confidential. Therefore, violation of privileged communication is anathema to many providers. Child abuse reporting laws systematically remove doctor-patient confidentiality in suspected abuse cases, and state that patient confidentiality can not be used as an excuse for failure to report.

Clinical Aspects of Child Abuse and Neglect Related to Dentistry

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. Other types of injuries are pathognomic to child abuse and easily identified by the dentist. Injuries of this type include those that appear simultaneously on multiple body planes.22 Injuries that exhibit patterned marks of implements or the adult's hand, or bilateral injuries to the face, carry a high index of suspicion of abuse,23 and can occur on easily observable areas of the child's body.

The mouth is sometimes injured due to the abuser's desire to silence a crying child.24 Surveys of dentists who have reported cases to CPS agencies show a trend in the type of oral injuries encountered in child abuse cases. In an American Board of Pedodontics survey of 155 pediatric dentists throughout the nation, the principal dental injuries reported in cases of child abuse include missing and fractured teeth (32 percent of reported cases), oral bruises (24 percent), oral lacerations (14 percent), jaw fractures (11 percent), and oral burns (5 percent).25

Even the youngest victims of abuse can have oral injuries. Lacerations and contusions of the oral mucosa, particularly around the anterior alveolar ridge, are seen in cases of forced feeding when the bottle is shoved forcefully against the child's mouth. In older children, gags used to silence or punish a child can leave bruises at the corners of the mouth.26

Human bite marks should be easily identifiable by all dental professionals and these injuries carry a high index of suspicion of child abuse.27 Dentists should be able to see most abuse-related bite marks. Forty-three percent of all abuse bite marks are located on the head and neck,28 and 65 percent of all abuse bite marks can be seen while the child is clothed.29 Human bites are painful and represent an assault with a weapon that carries a significant possibility of morbidity or even mortality. It must be remembered that the infection potential of the human bite is significant and serious.

Many of the physical signs of child sexual abuse are also within the purview of dentistry. The presence of oral or perioral gonorrhea, syphilis, or chlamydia in prepubertal children is pathognomic of sexual abuse.30 The behavioral indicator of exaggerated gag reaction to any oral intrusion with an instrument has been found in cases of oral sexual abuse.31

Dental neglect has been defined as lack of care that makes routine eating impossible, causes chronic pain, delays or retards a child's growth, or makes it difficult or impossible for a child to perform daily activities.25 It is well accepted in health care that untreated dental problems are as serious as an untreated wound in any other part of the body, because neglecting treatment can lead to complications affecting the entire body.29

Just as attitudes toward neglect in general vary among states, the practical definitions of dental neglect between particular dental settings may also differ. The American Academy of Pediatric Dentistry has defined dental neglect as the failure to seek treatment for untreated, rampant caries, trauma, pain, infection or bleeding. Also included is the failure to follow through with treatment once the parent has been informed that the above conditions exist.32 The failure to follow up on treatment needs is probably more germane to dentists. Many practitioners have had parents express that they were totally unaware of conditions in their child's mouth before the dentist's diagnosis. Once the caregiver knows about the child's condition, failure to provide necessary care, within the bounds of their resources, can be reported as child neglect.

The Academy's definition serves neither as law nor as a standard of practice. It is a guideline for those dentists evaluating their patients' oral health in light of societal norms. It is up to the dental professional to weigh the guidelines and legal definitions against regional or local norms and access to care issues.

Attitudes of Dental Professionals About Child Abuse and Neglect

The attitude of dental professionals about child maltreatment has been slow to change. The dentist's role in preventing child abuse and neglect was first addressed by organized dentistry in the 1970s. It was not until 1993 that the American Dental Association (ADA) added required recognition and reporting of perioral signs of child abuse to its Principles of Conduct and Code of Ethics. Under a resolution passed by the ADA House of Delegates, the Code now states: Dentists shall be obliged to become familiar with the perioral signs of child abuse and to report suspected cases to the proper authorities consistent with state law. (House Resolution 23S-1B.)33

The resolution goes on to "urge the constituent dental societies to inform their members of applicable state laws relating to reporting of suspected cases of abuse and neglect." Another ADA Resolution (HR 141-RC) reinforces the Association's official policy by saying that members should "become familiar with and report all physical signs of child abuse observable in the normal course of the dental visit."33 It is hoped that the ethical responsibility to recognize and report child abuse, along with increased awareness of statutory requirements, will encourage dentists to perform their legal duties.

While many dentists report being leery of bureaucratic entanglements, it is important to remember that the dentist is only required to notify the proper authorities, not pursue any investigatory aspects of the case.34 All too often practitioners try to be detectives. They waste time trying to find out "who did it?" when the important question for the practitioner to answer is "did something happen?" Dentists also are often unaware that the aim of child protective service agencies is to protect the victim from further abuse and to strengthen the family. In fact, the vast majority of investigated cases result in the family's remaining intact.35

Dentistry's Involvement in Preventing Child Abuse and Neglect

If dentists' failure to report suspected cases of abuse and neglect can be considered an indicator, dentistry's level of awareness of child maltreatment is abysmal, because the most important factor in recognizing child abuse is to be aware.36 Diagnosing suspected abuse or neglect is only the first step -- dentists must be prepared to take immediate remedial action on behalf of the victim.37 Specifically, they must be willing to make the required report to aid the victim. All members of the dental profession must be informed of the health, social, and legal aspects of child abuse and neglect, and they must inform other professions that dental abuse and dental neglect are serious components of child maltreatment.38    

Recognition of child maltreatment is filled with frustration for most health care professionals. The problem with recognition is the initial, awful realization that parents and care-givers do hurtful things to defenseless, vulnerable children.39 Educating professionals to recognize child abuse and neglect is only half the battle. Encouraging them to make required reports is the other half.

Conclusion

Awareness programs such as the Prevent Abuse and Neglect through Dental Awareness (P.A.N.D.A.) coalitions may help relieve anxieties of the reporters. P.A.N.D.A's educational and awareness message can alleviate fear of the unknown that may await a practitioner who follows the law. Dental professionals can be expected to perform their duty to help protect our children only after receiving appropriate education about their role in identifying and reporting suspected cases of maltreatment .

Dentists must become more aware of their moral, legal, and ethical responsibilities in recognizing and reporting child abuse and neglect. All dental professionals need to understand the seriousness of the problems of child maltreatment and realize that children do not just get hurt in abuse and neglect -- they often die as a direct result of their maltreatment. Dentistry must do its part to help stop the pain, suffering, and death that result from child maltreatment; it has been said that victims of child abuse and neglect fall into only two categories -- those who lived through it and those who did not.40

Author

Dr. Mouden is the Associate Chief, Missouri Bureau of Dental Health and an Associate Clinical Professor at the University of Missouri Kansas City School of Dentistry. He is the ADA's National Spokesperson on Child Abuse Prevention.

References

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