The aim of this article is to inform the reader of types of child abuse exist, how to recognise these, how to respond to suspected child abuse and the responsibility of the dental team.
Everyone has a responsibility in society to ensure that children are kept safe from harm and dental professionals have the responsibility to act on any concerns they may have about the safety of a child. This article gives information on types of child abuse and how to deal with suspected abuse based on the information produced by COPDEND (2006) in respect to child protection and the dental team.
What is child abuse?
According to COPDEND (2006) a “child is considered to be abused if he or she is treated in a way that is unacceptable in a given culture at a given time”. The threshold beyond which actions or omissions become abusive or neglectful is, to a certain extent, socially and culturally defined. For example, physical punishment of children has become progressively less acceptable in the UK in recent years. Most child abuse occurs within a child’s own family by persons known to the child. However, children may be abused in institutional or community settings by those known to them or, more rarely, by a stranger.
Types of abuse
Physical abuse means causing physical harm to a child which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning or suffocating. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately causes illness in a child.
According to COPDEND (2006) “emotional abuse is the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development.” Emotional abuse may involve conveying to children that they are worthless or unloved and inadequate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child’s developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve causing children frequently to feel frightened or in danger, or the exploitation or corruption of children.
Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening.
The activities may involve physical contact, including penetrative (e.g. rape, buggery or oral sex) or non-penetrative acts (oral sex). They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways.
Neglect is defined by HM Government (2010) as “the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development.” Neglect may occur in pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to provide adequate food and clothing, shelter (including exclusion from home or abandonment), failing to protect a child from physical and emotional harm or danger, failure to ensure adequate supervision (including the use of inadequate care-takers) or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.
There is a spectrum of child abuse in terms of type and severity. At one end of the scale are children who are suffering extreme harm as a result of severe, persistent or malicious abuse.
In Britain, at least 1 child per 1000 under 4 years of age per year suffers severe physical abuse; for example, fractures, brain haemorrhage, severe internal injuries or mutilation. An estimated one to two children die each week in England and Wales as a result of abuse or neglect.
• In 2004, there were 26,300 (or 24 per 10,000) children on child protection registers in England (Department for Education and Skills, 2005)
• Neglect accounted for 42% of registrations
• Children in the youngest age groups (aged 0 to 4) were assessed to be most in need of protection
• Infants under 1 year had the highest rate of registration (51 per 10,000 in England)
Recognising Child Abuse
Abuse or neglect may present to the dental team in a number of different ways:
• through a direct allegation (sometimes termed a ‘disclosure’) made by the child, a parent or some other person
• through signs and symptoms which are suggestive of physical abuse or neglect
• or through observations of child behaviour or parent-child interaction.
Because of the frequency of injuries to areas routinely examined during a dental check-up, the dental team has an important role in intervening on behalf of an abused child. In some instances, the diagnosis of child abuse is clear. However, there are occasions when evidence is inconclusive and the diagnosis merely suspected. Members of the dental team are not responsible for making a diagnosis of child abuse or neglect, just for sharing concerns appropriately. COPDEND (2006) urge that if in doubt, always take advice.
Recognising Physical Abuse
Orofacial trauma occurs in at least 50% of children diagnosed with physical abuse. (Becker et al 1978, Da Fonseca et al 1992). A child with one injury may have further injuries that are not visible. Where possible, arrangements should be made for the child to have a comprehensive medical examination. It is important to state that there are no injuries which prove child abuse although some injuries or patterns of injury will be highly suggestive of it.
The assessment of any physical injury involves three stages:
evaluating the injury itself, its extent, site and any particular patterns
taking a history to understand how and why the injury occurred and whether the findings match the story given
exploring the broader picture (e.g. the child’s behaviour, the parent-child interaction, underlying risk factors or markers of emotional abuse or neglect).
Recognising Emotional Abuse
Emotional abuse causes unhappiness and damage to the child’s developing personality that may be irreversible. According to COPDEND (2006) it often accompanies other forms of violence and neglect and may be missed if the child appears well nourished and well cared for.
The main clues are found in:
the emotional state and behaviour of the child. For example, they may be clingy and become distressed when a parent is not present or, alternatively, they may be agitated, non-compliant and unable to concentrate, or withdrawn, watchful and anxious. Older children may self-harm, abuse drugs and alcohol, exhibit delinquent behaviour, run away from home and often have educational problems.
their interaction with parents. For example, the parent may ignore the child or use abusive or inappropriate language; they may threaten the child or have unrealistic expectations of the child’s abilities to cope with dental treatment.
Recognising Sexual Abuse
Sexual abuse is an abuse of power and may be perpetrated by male and female adults, teenagers and older children. Unless there are intraoral signs of sexual abuse or the child discloses abuse, the dental team are most likely to detect the problem through emotional or behavioural signs. The intraoral signs associated with sexual abuse include erythema, ulceration and vesicle formation arising from gonorrhoea or other sexually transmitted diseases, and erythema and petechiae at the junction of the hard and soft palate which may indicate oral sex.
Presentation of sexual abuse
Sexually transmitted infection
Emotional and behavioural signs
o delayed development
o anxiety and depression
o psychosomatic indicators
o soiling or wetting
o inappropriate sexual behaviour or knowledge
o running away
o drug, solvent or alcohol abuse
COPDEND (2006) recognises that neglect adversely affects a child both physically, educationally, psychologically, socially and medically. Failure of the parent to recognise or meet their child’s needs and comply with professional advice is a common factor in many sorts of neglect. Failure to take a child for appropriate health care when required and necessary dental care is neglectful.
In infancy, neglected children are often recognised by their poor physical state, failure to thrive and delay in achieving developmental milestones such as walking. Older children may have behavioural problems, difficulty forming relationships and emotional problems. A neglected child may present to the dentist with unmet dental needs and may subsequently fail repeated appointments.
What is the responsibility of the dental team?
The Department for Education and Skills (2006) states that “all health professionals working directly with children should ensure that safeguarding and promoting their welfare forms an integral part of all stages of the care they offer.” and the General Dental Council’s Standards Guidance (2005) clearly states that the dental team have an ethical obligation to find out about local procedures for child protection. Registrants should make sure they follow these procedures if they suspect that a child may be at risk because of abuse or neglect. Additional to this, registrants must maintain appropriate boundaries in the relationships they have with patients and must not abuse those relationships to ensure that children are not at risk from members of our own profession and to take action to prevent this e.g. by safe staff recruitment. It is your responsibility as a GDC registrant to raise any concerns that you may have about colleague in regards to the safety of children. Details of local safeguarding boards (in England and Wales) can be found HERE Local services telephone number can be found by looking up “social services and children’s services” in the local telephone directory, alternatively use an internet search engine to search for “LSCB” followed by the local council.
What to do if you suspect abuse
According to Harris et al 2006, “Members of the dental team are not responsible for making a diagnosis of child abuse or neglect, just for sharing concerns appropriately”. They go on to say that “the most important thing to remember when you are faced with a child who may have been abused is that you do not need to manage this on your own”
In the first instance:
assess the child
take a history
talk to the child
discuss with an appropriate colleague
decide if you still have concerns
If you still have concerns…
provide urgent dental care
talk to the child and parents
explain your concerns
inform of your intention to refer
seek consent to sharing information
keep full clinical records
refer to social services
confirm referral has been acted upon
If you no longer have concerns
provide necessary dental care
keep full clinical records
provide information about local support services for children and families
arrange dental follow-up
As a member of society and as a GDC registrant, dental professional have the responsibility to help protect children. If a dental professional suspect a child is being abused they must assess their level of concern, raise any concerns with the appropriate agencies and make a direct referral to child protection services where this is absolutely necessary. They should be aware of their local safeguarding children procedures and refer to them if they have any concerns. It is important to keep up to date on the recommendations and training in recognising child abuse to help protect children. Further information and resources can be found on the Child Protection and the Dental Team website here.