- FORENSIC DENTISTRY
Sowndarya Gunasekaran1a* , Mallikarjun Bhuthanahosur Shanthala1b , George Babu1c , Vidhya Vijayan1d
1Department of Pediatric and Preventive Dentistry, Coorg Institute of Dental Sciences – CIDS, SH 88B, Kodagu Coorg District, Virajpet, Karnataka 571218, India
aBDS, MDS, Post Graduate Student; e-mail: Sowndaryagunasekaran@gmail.com; ORCIDiD: https://orcid.org/0000-0002-3503-4927
bBDS, MDS,PhD, Professor and Head; e-mail: email@example.com; ORCIDiD: https://orcid.org/0000-0001-7566-6294
cBDS, MDS, Reader; e-mail: firstname.lastname@example.org; ORCIDiD: https://orcid.org/0000-0002-5474-1299
dBDS, MDS, Post Graduate Student; e-mail: Vidhu.email@example.com; ORCIDiD: https://orcid.org/0000-0002-7410-2398
Background Child Abuse & Neglect is a worldwide social and public health problem, which has a multitude of short- and long-term effects on children.
Objective Pediatric dentists are often the ones who, after a pediatrician, come to identify a child abuse victim, so this article addresses the importance of the pediatric dentist in identifying the oral health issues that can be associated with child abuse victims.
Data sources Web of Science, PubMed, Google Scholar were databases researched for peer review articles in indexed journals.
Method Literature search was conducted and articles were selected according to the data provided regarding child abuse and neglect and the relevant data were summarized.
Result Some medical providers may receive less education pertaining to oral health and dental injury that are related to abuse or neglect as readily as they detect those involving other areas of the body.
Conclusion Pediatric dentists are encouraged to collaborate with pediatricians to increase the prevention and detection of child abuse and neglect in children.
Child Maltreatment, Child Mistreatment, Child Neglect, Dentists, Pediatric Dentists.
Child abuse and neglect is a problem that pervades all sections of society. Many children are denied the right to grow in a supportive and loving family environment, which promotes a person’s development to his / her full potential. In 1997, three million children were reported to Child Protective Services (CPS) for some form of child abuse, and about 1 million cases were proven after the CPS investigation . Statistics show that 1000 children die every year as a result of some form of child abuse, 78% under the age of five, 38% under the age of one year . This makes the role of infant oral health care provider extremely essential for early detection of child abuse and neglect and proper management of the same. According to “Save the Children”, a non profitable NGO, the recent statistics regarding child abuse in India are .
• The number of cases registered for child abuse rose from 8,904 in the year 2014 to 14,913 in the year 2015, under the POSCO act. Sexual offences and kidnapping account for about 81% of crime against minors.
• Preventive measures designed to ward off strangers were found to be ineffective as most of the offenders were either relatives, acquaintances or somebody they trust.
• Uttar Pradesh emerged as the state with the highest number of child abuse cases (3,078), followed by Madhya Pradesh (1,687), Tamil Nadu (1,544), Karnataka (1,480) and Gujarat (1,416).
There are reports of child abuse and neglect cases, but there are no definite guidelines to follow. Delay in reporting abuse or neglect in young children usually results in an arrest of the normal developmental process. Attitude and behavioural consequences depend on the time at which the child’s developmental process is interrupted. The degrees of impact of such developments are the results of factors such as maltreatment of children, lack of a supportive home environment, peer pressure, and other immediate family members and outside support from individual children . This paper attempts to explain the importance of reporting when such a situation is encountered in the dental setup.
2. RECOGNIZING THE DIFFERENT TYPES OF CHILD ABUSE
2.1. Types of child abuse
2.1.1. Emotional abuse includes failure to provide the children with an appropriate and sympathetic environment, and actions that have negative consequences on mental health and development. Children are most vulnerable; they need constant support from the family and mainly during their developmental period . Mental abuse of children can be very harmful, disrupting their mental and physical health as well as their social and cognitive development. Despite evidence that child emotional abuse can cause long-term and serious harm to a child’s development, health and safety, little attention has been paid to how best to protect children from child psychological abuse.
2.1.2 Child neglect is the most common form of child abuse, a pattern of failing to meet a child’s basic needs, including inadequate food, clothing, hygiene or supervision . Detecting child neglect is not always easy. Sometimes, parents may not be able to care for the child physically or mentally, for example a serious illness or injury, or untreated depression or anxiety. At other times, alcohol or drug abuse can impair judgment and the ability to keep a child safe.
2.1.3. Physical abuse involves physical injury or trauma to a child. It may be the result of a deliberate attempt to harm a child or excessive corporal punishment . Many parents who are physically abusive emphasize that their actions are just disciplinary forms and ways for children to learn to behave. But there is a big difference between using corporal punishment for discipline and physical abuse.
2.1.4. Sexual abuse Child sexual abuse is a complex form of abuse caused by layers of guilt and shame. It is important to recognize that sexual harassment does not always involve physical contact . Exposing a child to a sexual situation or subject is subject to sexual harassment, even without touching.
• Children who have been abused often suffer from shame and guilt. They think they are the cause of the abuse or have somehow been brought it upon themselves. It can lead to self-loathing and sexual and relationship difficulties as an adult.
• The shame of sexual abuse makes it very difficult for children to come forward. They think that others will not trust them, that they will be angry with them, or that it will break up their family. Because of these difficulties, false allegations of sexual harassment are not common. If a child confides in you, take them seriously.
2.2. Indicators of abuse in infants
2.2.1. Physical abuse
• Craniofacial, head, face and neck injuries .
• Children in Foster care should be screened for oral trauma, tuberculosis, gingivitis and other oral health problems because some authorities believe the oral cavity is a central focus of physical abuse because it is entangled in communication and nutrition .
• Oral injuries with utensils such as bottle during forced feeding, hands, fingers, or stained liquids or caustic substances.
• Tongue, lips, buccal mucosa or pharynx, broken displacement or avalanche teeth or fractures of the facial bone and jaw.
• Appliance applied to the mouth can cause bruising, lichenification or scarring in the corners of the mouth.
• Physical Bite marks on a child’s body are an indicator of a child’s physical abuse. Dentists trained as forensic odontologists can help detect and diagnose bite marks related to physical or sexual abuse.
• Adult handprints or bilateral injuries are indicators of suspicion of child abuse.
The common site according to a study  for inflicted oral injuries was the lip (54%) (Fig.1) followed by oral mucosa, teeth, gingivae and tongue.
2.2.2. Sexual Abuse
The oral cavity is a frequent site of sexual abuse in children  but oral lesions or infections are very rare.
• Diagnosis of oral and peripheral gonorrhoea in prepubertal children with appropriate culture methods and diagnostic testing sexual harassment [10-12].
• Unexplained injury or petechiae of the palate, especially at the junction of the hard and soft palate, may be evidence of forced oral sex.
2.2.3. Emotional abuse
• Extreme withdrawal, fear or anxiety to do anything [13-17].
• Extreme behaviour – Fig. 2 (very compliant, deman-ding, passive, aggressive).
• The parent or guardian does not seem to be attached [18-20].
• Acts either as an inappropriate adult (taking care of other children) or an inappropriate.
2.2.4. Child neglect
• Clothes may not fit properly, be dirty, or be unsuitable for the weather.
• Hygiene is consistently bad (matted and unwashed hair, noticeable body odour).
• Untreated illnesses and physical injuries.
• Often left unattended or left alone or allowed to play in unsafe conditions [21-23].
• Always often late or miss school.
3. THE ROLE OF THE PEDIATRIC DENTIST IN CHILD ABUSE AND NEGLECT
Whenever a pediatric dentist assesses a child, there is an intimate interaction between the child and the caregiver (parent or guardian) and every opportunity to see signs of child abuse and neglect. Most cases of child abuse involve oral exploration, which is provided as evidence .
3.1. Child Abuse Victim Reporting
Mandatory reporting of child abuse and neglect should be recommended. Reporting by required / designated professionals (including pediatric dentist)
to the appropriate authorities regarding suspected cases of physical and sexual child abuse and neglect should be mandatory [33-37]. In the case of false reporting, they are protected by law as long as they are in good faith. They will be legally fined if they fail to report. Under this law, no evidence is required to report and what is reported is only suspicious abuse. In India, such regulations have not yet been introduced.
3.1.1. Who to report to? India has a wide range of laws to protect children and child protection is recognized as a major factor in social development. Enforcement of laws is challenging due to inadequate field human resource capacity as well as inadequate quality prevention and rehabilitation services. As a result, millions of children are subjected to violence, abuse and exploitation. In the absence of ‘mandatory reporting’ regulations and child protection services in India, this is an important decision [38,39]. Repor-
ting can usually be done to the police, the local child welfare committee and even the ChildLine. However, even after reporting, networking between different professionals is usually required to follow the case to its conclusion.
3.1.2. Childline. Launched by the Government of India, the service is a 24-hour free phone service that can be accessed by a distressed child or by dialling 1098 on his or her behalf on an adult telephone. Childline provides emergency assistance to children and then, depending on the needs of the child, the child is referred to the appropriate institution for long-term adoption and care. It calls for medical help, asylum, repatriation, missing children, protection from abuse, emotional support and guidance, information and service referrals, calls related to death, and so on.
Child helpline contact details in India:
– Karnataka State – (080-47181177 (will operate from 10 am to 5pm)
– CHILDLINE India Foundation, Tamilnadu – 04328 276 745
– Child helpline, Punjab -093175 05759
International Child helpline
– Japan Childline – 0120-99-7777
– Malaysia Child line – 12999, 15999
– South Korea – 1577-1391 (Child Protection Hotline)
The reporting of child abuse and neglect cases can be done directly to the local bodies, there are child helplines and child protection Commission available in every state of India. (Fig.3)
3.1.3. Child Welfare Committee. Under the Juvenile Justice Act, which allows the Juvenile Justice Board, which includes psychologists and sociologists to determine the adoption process of orphaned, abandoned and surrendered children, the bill introduced concepts from the Hague meeting on child protection and cooperation. Inter-Country Adoption was missing in the previous action, 1993. This bill requires the Child Welfare Committee to notify any parent or guardian who severely abuses a child, or fails to protect a child from being abused; such persons are disqualified and an order is issued to remove the child from the custody of such persons. Crimes under this law are detectable and a person can be arrested without a special police officer or his subordinate needing a warrant and the premises can be searched without a warrant.
3.1.4. National laws and amendments to prevent child abuse and neglect . The legislative framework for children’s rights is being strengthened with the formulation of new laws and amendments to existing laws. These include the Food Safety Act (2013), the Protection of Children from Sexual Offenses (POCSO) Act, 2012, the Free and Compulsory Education Act (2009), the Child Marriage Prohibition Act (2006), and the Commissions for the Protection of Children. The Right to Information Act (2005), Juvenile Justice (Child Protection and Protection) Act 2000, amended in 2006, Right to Information Act (RTI) 2005, Goa Child (Amendment) Act 2005, Child Labor (Prohibition & Control) Act, 1986 (2006 & Two notifications in 2008), Prohibited and Dangerous Procedures and Expansion of Professional List) and Information and Technology (Amendment) Act 2008. In addition, there are new laws such as the HIV / AIDS Bill. Telephone helplines (Childline 1098) and Child Welfare Committees (CWCs) were established under the Juvenile Justice Act (2000), where child abuse or harm to children can be reported and help sought.
3.1.5. National programs for the rights and protection of children . The Government of India has implemented a number of programs on social inclusion, gender sensitivity, children’s rights, participation and protection. This approach is based on the UN CRC and the Millennium Development Goals (MDGs). These programs include: Integrated Child Development Services (ICDS), the Sabla Scheme for Adolescent Girls, and the Evidence Project for Adolescent Boys; Rajiv Gandhi Creche Scheme for Children of Working Mothers, Domestic Helping Scheme for Promoting Adoption in the Country (Shishu Greh), Dhanalakshmi-Conditional Cash Transfer Schemes for Girls, Program for Juvenile Justice, Child Line (24 Hour Toll-Free Telephone Helpline (No.1098), Integrated Child Protection Scheme (ICPS), Integrated Program for Street Children, Ujjawala (Trafficking and Rescue Prevention Scheme, Rehabilitation, Reunification and Repatriation), School Education Campaign National Program for School Education, National Rural Health Mission (NRHM), Mid-Day Meal Scheme, Jawaharlal Nehru National Urban Renewal Mission (JNNURM), Universal Immunization Program (UIP) and Neonatal & Childhood Illness (IMNCI) Integrated Management.
4. DISCUSSION – LONG-TERM CONSEQUENCES OF CHILD ABUSE AND NEGLECT.
Children with a history of neglect or physical abuse are at risk of developing mental health problems or a chaotic attachment style. In addition, 59% of the children who experience child abuse or neglect are arrested as children, 28% as adults, and 30% are more likely to commit violent crimes . When some of these children become parents, especially if they suffer from post-traumatic stress disorder (PTSD), dissociative symptoms and other sequels of child abuse, they may experience difficulties when dealing with their infant and toddler needs and general distress, which can lead to negative consequences for their child socio-emotional development [32-38]. In addition, children may find it difficult to feel empathy for themselves or others, which can make them lonely and unable to make friends. Despite these potential difficulties, psychosocial intervention can be effective, at least in some cases, in changing the way abusive parents think about their young children. Outcomes for each child can vary widely and are affected by a combination of factors, including the age and developmental status of the child at the time of abuse; type of abuse, frequency, duration and severity, and the relationship between the child and the offender. In addition, children who experience abuse are often affected by other negative experiences (e.g., parental substance abuse, domestic violence, poverty) that make it difficult to distinguish specific effects of abuse.
Child abuse affects society as a whole, and the future well-being of any nation depends on children. It is the responsibility of everyone to ensure that they have atraumatic upbringing. Pediatric dentists are among the front-line professionals trained to detect child abuse and they play an important role in reporting such cases. The dentist should not continue the investigation, but is responsible for notifying the appropriate authorities, who will determine if a child has been abused or neglected. If not intervened, 50% of time abuse will be repeated and more severe [10,42].
Statistics of child abuse and neglect will continue to rise if mandatory reporting is not followed and health care professionals fail. It is high time that professionals (pediatricians, pediatric dentists, general dentists and other health care workers) who come in close contact with children during examination and concerned regulatory bodies should join hands to protect today’s children from any kind of child abuse. Health care professionals are especially required to report cases of child sexual abuse under the “Protection of Children from Sexual Offenses Act (POCSO), 2012″.
Conflict of Interest
The authors declare no conflict of interest.
SG: have made substantial contributions to conception and design and have been involved in drafting the manuscript and revising it critically for important intellectual content; SBM: has made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data and has given the final approval of the version to be published; GB: has made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data and have given the final approval of the version to be published; VV: has made substantial contributions to conception and design and revisited it critically for major intellectual content.
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