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CHILD ABUSE AND NEGLECT
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INTRODUCTION
Childhood should be a carefree time of life filled with love, new world to explore,
and with joy of mastery of oneself and the environment.
However, for many children, this is only a dream, not reality.
Child abuse and neglect (CA/CN) is an increasing social problem not limited to
medical, legal or social service professions.
The dentist treating the child must also be able to detect , document, report, and often
help to manage these needy patients and their families.
CHILD ABUSE
“According to Gill 1968,it is defined
as the non accidental physical injury,
minimal, or fatal, inflicted upon
children by persons caring for them.
It is an overt act of commission of a
caretaker- physical, emotional, or
sexual”
NEGLECTED CHILD
-It is the one who shows evidence
of physical or mental ill health
primarily due to failure on the part
of the parent or caretakers to
provide adequately for the childs
need.
WHAT IS CHILD ABUSE AND NEGLECT…!!??
Historical background
-A review by Radbill (1973) indicated that historically,
children were considered to be their parents property, having
a few rights of their own. It was taken for granted that parents
and guardians had every right to treat their children as they
wished.
- The first documented and reported case of CA/CN
occurred in 1874 and with a child named Mary Ellen.
- In 1946, in a classis article by Caffey, some common
features of CA/CAN were first described, and it reported
the common association of subdural hematomas and long
bone pathosis.
-In 1962, the term battered child syndrome was coined
by Henry Kempe in his milestone article. It was further
elaborated by Kempe and Helfer in 1972
-In 1974, Child Abuse Prevention and Treatment Act
was signed into law. For the first time, it established
within the federal government-National Center on
ChildAbuse and Neglect.
-The contribution of dentists to recognition of CA/ON
emerged during late 1960s. Initially, dentistry focused
on the forensic aspects of battered child syndrome and
homicide. Only recently has the dental profession
seriously considered its role in detecting and reporting
CA/CN.
FACTORS RESPONSIBLE FOR CHILD ABUSE
CHARACTERISTICS OF CHILD ABUSE
The abused child
 Unduly afraid or passive child
 Evidence of prolonged confinement like
delay in speech.
 Evidence of repeated skin or other
injuries.
 Child is undernourished and is given
inappropriate food or drink
 Evidence of poor overall care
 Child is cranky irritable or cries easily
 Physically abused children were more
aggressive than neglected.
The abuser
Child abuse can occur in any cultural , occupational ,
socio-economic and ethnic group but a higher
incidence is found in minority and low income
families
The parent often has a history of being abused
personally, so this practice is passed down for one
generations to other
Parents may have following characteristics, which
may indicate abusive behaviour
 poor self esteem
Overly critical behaviour toward the child
Avoidance of looking at or touching the child.
Types of child abuse Types of neglect
 Physical abuse
 Nutritional
 Educational abuse
 Healthcare
 Emotional abuse
 Sexual abuse  Dental

 Failure to thrive  Safety

 Intentional drugging or poisoning  Emotional
 Munchausen syndrome by proxy
 Physical

TYPES OF CHILD ABUSE AND NEGLECT

PHYSICAL ABUSE
 Physical abuse is the most important subtype of child maltreatment ,because
without intervention and services it is potentially fatal.
 Often the injury is from an angry response of the caretaker to punish the child
for misbehaviour.
 Physical abuse is the second most frequently reported form of child abuse,
accounting for 30% of all cases of child abuse.
 Physical child abuse is physical injury inflicted upon the child with cruel
and/or malicious intent. Physical abuse can be the result of punching, beating,
kicking, biting, burning, shaking, or otherwise harming a child physically.
 The parent or caretaker who abused the child may not have intended to hurt
the child, but rather the child's injury may have resulted from overly harsh
discipline or physical punishment.
Physical abuse symptoms include:
• Bruises
• Broken or fractured bones
• Burns or scalds
• Bite marks
It can also include other injuries and health problems, such
as:
 Scarring
 The effects of poisoning, such as vomiting, drowsiness or
seizures
 Breathing problems from drowning, suffocation or
poisoning.
Head injuries in babies and toddlers can be signs of abuse so
it's important to be aware of these… Visible signs include:
 being extremely sleepy or unconscious
 breathing problems
 seizures
 vomiting
Shaken Baby Syndrome
 Shaken Baby Syndrome (also known as Shaken Impact Syndrome) is a serious form
of abuse inflicted upon a child.
 It usually occurs when a parent or other caregiver shakes a baby out of anger or
frustration, often because the baby will not stop crying.
 Babies have very weak neck muscles that cannot fully support their proportionately
large heads.
 Severe shaking causes the baby’s head to move violently back and forth, resulting in
serious and sometimes fatal brain injury. These forces are exaggerated if the shaking
is interrupted by the baby’s head hitting a surface.
 Subdural hematoma

 Subarachnoid hemorrhage

 Direct trauma to the brain ,when the brain strikes the inner surfaces of the skull.

 Shearing off or breakage of nerve cell branches

 Irreversible damage to the brain substance from the lack of oxygen if the child stops breathing during shaking.

 Damage to the brain cells when injured nerve cells release chemicals that add to oxygen deprivation to the brain.

 Retinal hemorrhages
Skull fractures resulting from impact when the baby is thrown against a hard or soft surface.

 Fractures to other bones, including the ribs, collarbone and limbs; bruising to the face, head and entire body.
Battered child syndrome (BCS) refers to non-
accidental injuries sustained by a child as a result of physical abuse,
usually inflicted by an adult caregiver.
 Severe form of physical abuse

-Defined “as the child who shows clinical/radiographic evidence of

lesion that are frequently multiple and involve mainly the head , soft
tissue , long bones, thoracic cage and that cannot be unequivocally
explained.
-Described by Kempe and collegues in 1972
 Characterized by …..
-Tragic cause of oral injuries in young children resulting from severe physical abuse.
-Head or facial trauma is often principal reason for admission to a hospital.
-Oral injuries due to blow to the mouth to silence screaming or crying child.
-In children usually less than 3 years of age.
-Physically/mentally challenged, step children and adopted children are more prone to this.
-Bruises ,belt mark, fracture, burns, and lacerations are commonly inflicted physical abuse.
BRUISES IN PHYSICAL CHILD ABUSE
Bruise, also called a contusion, happens when a part of the body is
injured and blood from the damaged capillaries (small blood vessels
leaks out. With no place to go, the blood gets trapped under the skin,
forming a red or purplish mark that's tender when you touch it.
-Typical sites for inflicted bruises
- Buttocks and lower back (patting)
-Genitals and inner thighs
-Cheek (slap marks)
-Earlobe (pinch marks)
-Upper lip and frenum (forced feeding)
-Neck (choke marks).
BRUISES
DATING BRUISES……
Marks in Physical Child Abuse
Human hand marks: These are classified here. The most common type is grab marks which is
oval-shaped bruise that resemble fingerprints due to holding of child in violent shaking.

-Some of the non abusive grab marks are when the parent holds the child's legs to help him
walk or on the cheeks, if an adult squeezes it in an attempt to get food or medicine into his
mouth leaving a thumb mark bruise on one cheek and two to four fingermark bruises on the
other cheek.

Strap marks: These are 1-2 inches wide, sharp- bordered, rectangular bruises of various lengths,
and sometimes covering curved body surface often caused by a belt.

Lash marks: These are narrow, straight, edges bruises, or scratches caused by thrashing with
tree branch or switch
Loop marks: These are secondary to being struck with a doubled over lamp cord, rope, or fan
belt. The distal end of the loop strikes with the most force, commonly breaking the skin and
leaving loop-shaped scars.

Bizarre marks: These are always inflicted when a blunt instrument is used in punishment with the
resulting bruise that will resemble it in shape.

Circumferential tie marks: These are present on the ankles or wrists and are caused, when a child
is restrained. If a narrow rope or cord is used, the child will be left with circumferential cut.

-If a strap or piece of sheet is used to restrain a child about the wrists or ankles, a friction burn or
rope burn may result, usually presenting as a large blister that encircles the extremity.

Gag marks: Seen as abrasions that appear near the corner of the mouth. Children may be gagged
because of screaming or yelling.
CHILD SEXUAL ABUSE
This has increased dramatically over the last decade. An estimate of
the incidence of the number of sexual assaults on children at 3 lakhs
annually but authorities agree that these estimates are probably low, due
to underreporting as a result of a number of factors…
• Cultural morals make sexual abuse a stigma for victim, perpetrator,
and family.

• Victims are often young children whose fear, lack of awareness, or

lack of language skills make them easy prey and victims who may
not ready or believable witnesses.

• Health professionals may be unaware of the signs or symptoms of

child sexual abuse.

• Child sexual abuse often is hidden with no visible physical

manifestations.
• Health professionals may be unwilling to report cases of sexual abuse where clear physical evidence is
lacking for fear of error, reprisal, or loss of patients.

• Verification of sexual abuse by physical examination may be beyond the legal extent of practice of many
professionals.

• Lack an accepted definition of sexual abuse.

Federal statues define sexual abuse in the context of child abuse and includes act like child pornography,
rape, molestation, Incest, and child prostitution.

National Center on Child Abuse and Neglect offers a more general definition of child sexual abuse to include
contacts or interactions between a child and an adult when the child is being used for the sexual stimulation of
the perpetrator or another person.

It can also be defined as any sexual activity with a child under age 18 by an adult.
VICTIM
•The sexually abused child is most often a female, with the
ratio of victimized females to males of 9:1.
•Children of all ages are abused sexually but those in the early teens seem
to be most at risk.
•Most offenders are family-related, some are family acquaintances, and the
least common are strangers.
•This close relationship between victim and perpetrator compounds the
problem of reporting which leads to a victim who may be abused
repeatedly.
•The psychological profiles of sexually abused children vary widely and to
have some relation to age, closeness to perpetrator, and the type of abuse.
Some of the features that are noted are:
 Emotional effects
 Functional disturbances such as retention of feces.
 Frequent masturbation
 Preoccupation with the genital area
 Regression in behavior
 Guilt and anxiety.
PERPETRATOR
 The perpetrator of sexual abuse is no longer considered to
be the impersonal stranger who victimizes an unknown
child.
 The numbers of sexual assaults by those familiar to the
child have increased dramatically.
 The type of abuse may characterize the perpetrator.Incest
most often is committed by a male parent against a female
child.
 The father may have one of several profiles like, he may
be abusive or shy or withdrawn; sexual problems with
spouse or alcoholism.
 Mother-son, or father-son incest is less common, but
indicates psychological pathosis.
Act
 Types include molestation (fondling or masturbation) intercourse (vaginal, anal,
or oral intercourse on a nonassaultive basis), or family-related rape.
 Pregnancy or venereal disease may be the sequelae of repeated
 sexual abuse.
 The act of sexual abuse is rarely a singular event, if perpetrated by someone
familiar to victim. In many cases, abuse may involve repeated fondling of genitals
or other body parts.
 Of interest to dentists is the association of oral features with child sexual abuse
due to kissing or oral penetration.
EMOTIONAL ABUSE

• It involves lack of interactions, on the part of care taker that inflict damage on the child’s
personality, motional wellbeing or development.

• Continuous isolation, rejection , degradation, terrorization, corruption, exploitation, denial of

affection, are examples of behavior that have damaging effect on child.
CHILD NEGLECT
NUTRITIONAL NEGLECT

 Failure to thrive can be defined as an underweight, malnourished condition who has a weight that is
below the third percentile and a height and head circumference that are above third percentiles on
growth curves.
 On physical examination, the infants have gaunt faces, prominent ribs, wasted buttocks, and spindly
extremities and is expressed in first 2 years of life.
 The causes of failure to thrive are estimated as 30% organic, 20% underfeeding due understandable
error, and 50% underfeeding from parental neglect.
 The mother may neglect to feed her baby because she feels overwhelmed with responsibilities or is
chronically depressed and hostile toward the baby.
Healthcare Neglect
 When a child with a treatable chronic disease
has serious deterioration of the condition
because the parents or caretakers repeatedly
ignore healthcare recommendations, health care
neglect occurs.
 Healthcare neglect may occur in situations
where an emergency exits and the parents or
caretakers will not acknowledge it as much
 Refusals because of religious beliefs also lead to
healthcare neglect.
Safety Neglect
 Safety neglect, has occurred when injury
results from lack of supervision.
 These situations usually involve children
younger than 4 years of age, when it is
important that parents directly supervise
them.
 This leads to injuries like burns, poisonings,
and falls because children are not being
watched.
Emotional Neglect
 Emotional abuse can be defined as the continual
rejection of child by parent or caretaker.
 Severe verbal abuses are also apart of emotional abuse
and so is the neglect of student by teacher.
 Emotional abuse is often difficult to detect and involves:
o Severe psychopathology and disturbed behavior in
child of a degree making it unlikely that he will be
able to function and cope as an adult.
o Abnormal child rearing practices of the parent that
has caused behavior disturbances in child.
o Refusal by the parent to get the treatment for the child.
Dental neglect
 Ad Hoc Committee on Child Abuse and
Neglect of the American Academy of
Pediatric Dentistry defined “dental
neglect as the failure by a parent or
guardian to seek treatment for visually
untreated caries, oral infections and/or
oral pain, or failure of the parent or
guardian to earlier condition(s) exists”
Physical Neglect
• Failure to care for children according to accepted or appreciated standard.
• This is usually coaxial with physical abuse and involves presentation of child with dirty hair, dirty
or insufficient clothing, inadequate lunches, incomplete immunization, unsanitary home
environment, and inadequate after school supervision.
MUNCHAUSEN SYNDROME BY PROXY
 Munchausen syndrome was first described by Dr Richard Asher in 1951.
 He reported adults who fabricated symptoms about themselves and produced signs
of illnesses. They presented themselves for medical care but did not inform the
medical professional about the deception.
 On the other hand in cases Munchausen syndrome by proxy “a parent or caretaker
attempts to bring medical attention to themselves by injuring or inducing illness in
their children”
 Dr Roy Meadow first coined the term "Munchausen Syndrome by proxy" to describe the
preservation of the deception in regard to the child.
 This describes children who are victims of parentally fabricated or induced illness. The
fabricated symptoms and signs lead to unnecessary medical investigations, hospital admissions,
and treatment.
 The mother often is a nurse or has a similar illness herself. Factitious symptoms are often of
bleeding from various sites.
 If specimens are requested, the mother adds her own blood to the material.
Factitious signs include recurrent sepsis from injecting contaminated fluids, chronic diarrhea
from laxatives, fever from rubbing thermometers, or rashes from rubbing the skin or applying
caustic substances.
RECORDING OF CHILD ABUSE/NEGLECT
HISTORY
Each dental practitioner should develop an examination protocol to aid in
screening and reporting of suspected cases of child abuse and neglect.
Clinical Assessment
• History
• Physical examination
• Intraoral examination
• Documentation

- Written observation
1. Number
2. Type
3. Location
4. Resolution
5. Possible cause
6. Opinion
Photographs
1. 35mm color photograph
2. Various views
- Radiographs
- Bite-marks
- Saliva

• Treatment
• Parental consultation
• Reporting

The following histories are diagnostic or extremely suspicious in evaluating

non-accidental trauma:
 Eye witness history
 Unexplained history
 Implausible history
 Alleged self-inflicted history
 Delay in seeking medical care
Eyewitness history
1. The child himself states that injury is caused by parent
2. One parent accuses the other about the injury
3. Parents accepts that one of the many injuries is caused by
him but not all.
Unexplained injury
-Some parents or caretakers deny knowledge of the injury,
but others can tell about the injury but cannot offer any
explanation as to how the injury happened.
-They often give a vague explanation.
Implausible history
Many parents offer an explanation for the injury, but one
which is inconsistent with common sense while describing a
minor injury whereas the marks on the child prove otherwise.
Alleged self inflicted injury
In a small baby it is the most serious. In general ,if a child
cannot scrawl, he cannot cause self injury.\
Delay in seeking medical care
Some abused children are not presented for care for a
considerable length of time even in major and they may not
accompany the child to the health care facility.
EXAMINING CHILD ABUSE/NEGLECT
• The dentist and his staff should be educated to get a visual impression of the
child as he enters the reception room. The practitioner should note whether
the child and parent or guardian has an appropriate interaction.
• After evaluating the history in suspected cases of child abuse/neglect, the
examination for such children should be incorporated with a routine dental
checkup.
Common Sites to be observed and Examined

• Many abused or neglected children, due to fear they may appear overly
vigilant or display a "frozen watchful-ness" staring constantly.

• There are no spontaneous smiles and almost no eye contact.

• Should observe the child for lack of clean-liness
 Typical signs of malnutrition include a
posture of fatigue with rounded shoulders,
flat chest, a protuberant abdomen and
thinning of hair.
 The face is pale, muddy.
 Overdressed children should also be noted,
long sleeves and high necked shirts or
blouses during hot summer months may be
worn to cover signs of physical abuse.

 Face and neck should be examined for

periorbital ecchymosis, scleral
hemorrhage, deviated nasal septum,
cigarette burn marks and hand slap marks.
 Corners of the mouth are reported with
binding marks from a gag tied in place
for hours to force the feed.
 Sometimes, a spoon or fork applied with enough force or determination, may result in fractured
anterior teeth or torn frenulum.
 If moving the child up in the dental chair in a supine position or lifting up motion results in pain,
trauma is to be suspected.
 Then belt marks, electrical cord marks, bite marks bruises or fracture of ribs or clavicles should be
suspected and dentist should confirm by checking them.
 The dentist, however, must train himself to be vigilant.
ROLE OF PEDODONTIST IN CHILD ABUSE AND NEGLECT

 If the initial examination reveals trauma including oral cavity and it is within the scope of
the attending dentist, the definitive treatment should begin. In suspected cases of child
abuse, follow-up dental care may not be possible because of lack of familial compliance or
delay in disposition of the case by the investigating agency.
The dentist's role in identifying and preventing child abuse is as follows:
 To observe and examine any suspicious evidence that can be ascertained in office.
 To record according to the law, any evidence which may be helpful in the case
 Dentist should be acquainted with management of injuries to both primary and
 permanent dentitions.
 To establish and maintain a professional therapeutic relationship with the family.
 To transfer the child to a physician or hospital for proper care.
Intervention and Prevention
Once a case of child abuse is suspected and reported, the multidisciplinary
team of the institution initiates the screening process. A pedodontist can
contribute towards prevention of this criminal act by understanding various
issues related to child abuse and applying them at different levels.
 Primary level: Dentist should follow approaches, which are applicable to a
population in general, without targeting a particular high-risk group.
 Greater attention should be given toward screening children at a higher
risk of maltreatment.
 Parents at risk for abusing children are frequently very needy themselves,
so they need to be screened and counseled.
 Comprehensive evaluation of child and family situation should be done
assisted by a social worker and mental health professional
 Secondary level:
Concerns and effects directed to those who are to be especially at high-risk.
 The pedodontist must recognize his limitation and assume responsibilities for
applying an interdisciplinary approach.
 Goal of intervention should be to enhance parenting capabilities to enable them
to a morem adequate care for their children and avoid possible maltreatment.
 Tertiary level: It refers to intervention after the condition is already identified.
Prevention is considered , as the goal is to prevent recurrence of the condition.
 Pedodontist should ensure that child is referred to a designated child
protection agency
 He should not make the report and disengage, as he often has valuable
information, which might help in treatment and monitoring the situation.
Legal Aspects…..
 A dentist should be well versed with current legal system
for child protection. A separate doctrine "Parens Patriae"
is important in understanding laws developed to protect
children.
 Dentists should know the definitions of child abuse
and existing related laws proposed under the Draft Model
Child Protection Act 1977, to protect himself and apply it
correctly in such cases.
 Dentist Should be fully aware of legal standards of care and legal
responsibilities.
 Records should be made in presence of patients.
 Should keep legibly written, accurate case records.
 Should keep knowledge update
 Diagnostic tools like radiographs should always be used.
 Should always consult a legal or medico legal expert to
 review insurance policies or any financial or legal matter.
Child Protective Agencies
• In India police is the concerned authority
National human right commission (NHRC) also have
similar role.
Indian Laws for Child Abuse
• India has no law on/for child abuse per se.
Physical abuse:
- Violence in home: Indian Penal Code(IPC) 323/IPC 324
Sexual abuse:
- Girls: statutory rape : IPC 376
- Boys: unnatural sexual offence : IPC 377
-There is no law which protects child from other types
of abuse like emotional and educational abuse .
Government Organizations (GO's) and Non- government Organizations
(NGOs)Working Against Child Abuse
• The United Nations International Children's Education Fund (UNICEF),
www.unicef.org
• The Childline Organization, New Delhi,
• Organization for children at risk in India, Mumbai
• Asha Sevabhavi, Mumbai
MANAGEMENT OF A CHILD ABUSE PATIENT

 Many institutions, especially schools and hospitals, teams have been setup to discuss
management of cases and whether or not a report to the states agency ought to be filed.
 Ideally, such teams consist of representatives of different disciplines and different ethnic
groups. A team offers the ideal approach to deal with the complex and frequently painful
situations.
 This evaluation generally includes meeting with key family members, a home visit, and
contact with professionals involved with the family such as a physician, dentist, or
teacher.
 The social worker needs to assess the
degree of the child's immediate risk so
as to determine the appropriate
placement.

 In the majority of cases, the child will

remain in the home, but when there is
serious concern about the child's safety,
he will be removed.

 When children are placed out of home

reunion is always the ultimate goal.
 A comprehensive social service plan should be developed as soon as possible that identifies the
needs of the family and implements the appropriate services to meet these needs.
 In addition, clear goals should be articulated to the family in a supportive
but for the right manner.
 These include payments for disabled children, or nutrition supplements
for pregnant women, infants, and young children.
Situation In India….
 Though in India child is considered to be the gift of God, child abuse is still common
specially in tribal and remote areas. It is presumed that 50% of the cases are not
reported.
 Out of 3.8% cases reported majority of the girls are prime victim for sexual abuse
and boys for physical abuse.
 It is observed that child abuse cases are not reported due to unusual problem and lack
of awareness. However, media exposure has taken a footstep to awaken the people.
Attempt to Prevent Child Abuse in India
In India child labor is the commonest type of abuse for which Ministry of Labor has given notification on
5th February, 1996 in New Delhi regarding Child Labor Law in India.
 The working conditions of children have been regulated in all employments which are not prohibited
under the Child Labor (Prohibition and Regulation) Act. Following up on a preliminary notification
issued on October 5, 1993, the government has also prohibited employment of children in occupation
processes like slaughterhouses, printing, cashew nut descaling and processing, and soldering.

-Children perform a variety of jobs: some work in factories, making products such as carpets and
matches; others work on plantations, or in the home.
-For boys the type of work is very different because they often work long hours doing hard physical labor
outside home for very small wages.
 The government in India has made efforts to prohibit child labor by enacting child labor laws in India
including the 1968 Child Labor ( Prohibition and Regulation ) Act that stated that children under
fourteen years of age could not be employed in hazardous occupation.
REFERENCES
1.TEXTBOOK OF PEDIATRIC DENTISTRY
NIKHIL MARWAH
2.TEXT BOOK OF PEDIATRIC DENTISTRY
SOBHA TANDON
THANK YOU...