Art-7-4-2020
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FORENSIC DENTISTRY
CHILD ABUSE AND NEGLECT: UNDERSTANDING THE
Review Article
ROLE OF A PEDIATRIC DENTIST
Sowndarya Gunasekaran1a* , Mallikarjun Bhuthanahosur Shanthala1b , George Babu1c , Vidhya Vijayan1d
1
Department of Pediatric and Preventive Dentistry, Coorg Institute of Dental Sciences - CIDS, SH 88B, Kodagu Coorg District, Virajpet, Karnataka
571218, India
a
BDS, MDS, Post Graduate Student; e-mail: Sowndaryagunasekaran@gmail.com; ORCIDiD: https://orcid.org/0000-0002-3503-4927
b
BDS, MDS,PhD, Professor and Head; e-mail: shanthalapedo@cids.edu.in; ORCIDiD: https://orcid.org/0000-0001-7566-6294
c
BDS, MDS, Reader; e-mail: georgebabu@cids.edu.in; ORCIDiD: https://orcid.org/0000-0002-5474-1299
d
BDS, MDS, Post Graduate Student; e-mail: Vidhu.sainidhi@gmail.com; ORCIDiD: https://orcid.org/0000-0002-7410-2398
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(4).art.7
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.
KEYWORDS
Child Maltreatment, Child Mistreatment, Child Neglect, Dentists, Pediatric Dentists.
1.INTRODUCTION of the same. According to “Save the Children”, a non
profitable NGO, the recent statistics regarding child
Child abuse and neglect is a problem that pervades abuse in India are [3].
all sections of society. Many children are denied • The number of cases registered for child abuse rose
the right to grow in a supportive and loving from 8,904 in the year 2014 to 14,913 in the year
family environment, which promotes a person's 2015, under the POSCO act. Sexual offences and
development to his / her full potential. In 1997, three kidnapping account for about 81% of crime against
million children were reported to Child Protective minors.
Services (CPS) for some form of child abuse, and • Preventive measures designed to ward off strangers
about 1 million cases were proven after the CPS were found to be ineffective as most of the offenders
investigation [1]. Statistics show that 1000 children were either relatives, acquaintances or somebody
die every year as a result of some form of child abuse, they trust.
78% under the age of five, 38% under the age of one • Uttar Pradesh emerged as the state with the highest
year [2]. This makes the role of infant oral health care number of child abuse cases (3,078), followed
provider extremely essential for early detection of by Madhya Pradesh (1,687), Tamil Nadu (1,544),
child abuse and neglect and proper management Karnataka (1,480) and Gujarat (1,416).
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Gunasekaran S, Shanthala MB, Babu G, Vijayan V. Child abuse and neglect: understanding the role of a pediatric dentist. Stoma Edu J.
2020;7(4):286-293.
Received: August 26, 2020; Revised: September 18, 2020; Accepted: September 23, 2020; Published: October 10, 2020
*Corresponding author: Dr. Sowndarya Gunasekaran, BDS, MDS, Post Graduate Student, Department of Pediatric and Preventive Dentistry
Coorg Institute of Dental Sciences - CIDS, SH 88B, Kodagu Coorg District, Virajpet, Karnataka 571218, India
Tel: +91 9994506721; Fax: +91 9448500451; e-mail: sowndaryagunasekaran@gmail.com
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
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Review Articles
Figure 1. Bruising seen in the lip area indicating physical abuse. Figure 2. Emotional abuse.
There are reports of child abuse and neglect cases, anxiety. At other times, alcohol or drug abuse can
but there are no definite guidelines to follow. impair judgment and the ability to keep a child safe.
Delay in reporting abuse or neglect in young 2.1.3. Physical abuse involves physical injury or
children usually results in an arrest of the normal trauma to a child. It may be the result of a deliberate
developmental process. Attitude and behavioural attempt to harm a child or excessive corporal
consequences depend on the time at which the punishment [6]. Many parents who are physically
child’s developmental process is interrupted. The abusive emphasize that their actions are just
degrees of impact of such developments are the disciplinary forms and ways for children to learn to
results of factors such as maltreatment of children, behave. But there is a big difference between using
lack of a supportive home environment, peer corporal punishment for discipline and physical
pressure, and other immediate family members abuse.
and outside support from individual children [4]. 2.1.4. Sexual abuse Child sexual abuse is a complex
This paper attempts to explain the importance of form of abuse caused by layers of guilt and shame. It is
reporting when such a situation is encountered in important to recognize that sexual harassment does
the dental setup. not always involve physical contact [7]. Exposing a
child to a sexual situation or subject is subject to
2. RECOGNIZING THE DIFFERENT TYPES OF sexual harassment, even without touching.
CHILD ABUSE • Children who have been abused often suffer from
shame and guilt. They think they are the cause of
2.1. Types of child abuse the abuse or have somehow been brought it upon
2.1.1. Emotional abuse includes failure to provide themselves. It can lead to self-loathing and sexual
the children with an appropriate and sympathetic and relationship difficulties as an adult.
environment, and actions that have negative • The shame of sexual abuse makes it very difficult for
consequences on mental health and development. children to come forward. They think that others will
Children are most vulnerable; they need constant not trust them, that they will be angry with them,
support from the family and mainly during their or that it will break up their family. Because of these
developmental period [4]. Mental abuse of children difficulties, false allegations of sexual harassment
can be very harmful, disrupting their mental and are not common. If a child confides in you, take them
physical health as well as their social and cognitive seriously.
development. Despite evidence that child emotional
abuse can cause long-term and serious harm to 2.2. Indicators of abuse in infants
a child’s development, health and safety, little 2.2.1. Physical abuse
attention has been paid to how best to protect • Craniofacial, head, face and neck injuries [8].
children from child psychological abuse. • Children in Foster care should be screened for oral
2.1.2 Child neglect is the most common form of trauma, tuberculosis, gingivitis and other oral health
child abuse, a pattern of failing to meet a child's basic problems because some authorities believe the oral
needs, including inadequate food, clothing, hygiene cavity is a central focus of physical abuse because it
or supervision [5]. Detecting child neglect is not is entangled in communication and nutrition [6].
always easy. Sometimes, parents may not be able to • Oral injuries with utensils such as bottle during
care for the child physically or mentally, for example forced feeding, hands, fingers, or stained liquids or
a serious illness or injury, or untreated depression or caustic substances.
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Review Article Table 1. Recommendations for child abuse and neglect management.
What to do if you suspect a child is being Child abuse is difficult to accept and even difficult to talk about, for the dentist and
abused? Or if a child is confiding to you? children. When talking to abused children, the best way to encourage them is to show
calm reassurance and unconditional support[24-28].
Avoid rejection and stay calm. Rejection is a general response to the news, which is as offensive and shocking as child
abuse. However, if the dentist exhibits rejection or disgust at what they are saying, the
child may be afraid to continue and shut down. No matter how hard it is, stay calm and
reassured.
Do not question Let the child explain what happened in their own words, but do not ask the child any
leading questions. This can confuse the child and make it harder for them to continue
their story.
Reassure the child that they have not done It takes a long time to come forward about child abuse. Assure them that you take
anything wrong. what they say seriously and that it is not their fault[29-32].
Security comes first. If you feel that your safety or the safety of the children may be threatened if you try to
intervene, leave it to the experts. You can provide more support later.
• Tongue, lips, buccal mucosa or pharynx, broken 3. THE ROLE OF THE PEDIATRIC DENTIST IN
displacement or avalanche teeth or fractures of the CHILD ABUSE AND NEGLECT
facial bone and jaw.
• Appliance applied to the mouth can cause bruising, Whenever a pediatric dentist assesses a child, there
lichenification or scarring in the corners of the is an intimate interaction between the child and the
mouth. caregiver (parent or guardian) and every opportunity
• Physical Bite marks on a child's body are an indicator to see signs of child abuse and neglect. Most cases
of a child's physical abuse. Dentists trained as of child abuse involve oral exploration, which is
forensic odontologists can help detect and diagnose provided as evidence [11].
bite marks related to physical or sexual abuse.
• Adult handprints or bilateral injuries are indicators 3.1. Child Abuse Victim Reporting
of suspicion of child abuse. Mandatory reporting[10] of child abuse and neglect
The common site according to a study [8] for inflicted should be recommended. Reporting by required /
oral injuries was the lip (54%) (Fig.1) followed by oral designated professionals (including pediatric dentist)
mucosa, teeth, gingivae and tongue. to the appropriate authorities regarding suspected
2.2.2. Sexual Abuse cases of physical and sexual child abuse and neglect
The oral cavity is a frequent site of sexual abuse in should be mandatory [33-37]. In the case of false
children [9] but oral lesions or infections are very reporting, they are protected by law as long as they
rare. are in good faith. They will be legally fined if they
• Diagnosis of oral and peripheral gonorrhoea in fail to report. Under this law, no evidence is required
prepubertal children with appropriate culture to report and what is reported is only suspicious
methods and diagnostic testing sexual harassment abuse. In India, such regulations have not yet been
[10-12]. introduced.
• Unexplained injury or petechiae of the palate, 3.1.1. Who to report to? India has a wide range of
especially at the junction of the hard and soft palate, laws to protect children and child protection is
may be evidence of forced oral sex. recognized as a major factor in social development.
2.2.3. Emotional abuse Enforcement of laws is challenging due to inadequate
• Extreme withdrawal, fear or anxiety to do anything field human resource capacity as well as inadequate
[13-17]. quality prevention and rehabilitation services. As a
• Extreme behaviour – Fig. 2 (very compliant, deman- result, millions of children are subjected to violence,
ding, passive, aggressive). abuse and exploitation. In the absence of ‘mandatory
• The parent or guardian does not seem to be reporting’ regulations and child protection services
attached [18-20]. in India, this is an important decision [38,39]. Repor-
• Acts either as an inappropriate adult (taking care of ting can usually be done to the police, the local child
other children) or an inappropriate. welfare committee and even the ChildLine. However,
2.2.4. Child neglect even after reporting, networking between different
• Clothes may not fit properly, be dirty, or be professionals is usually required to follow the case to
unsuitable for the weather. its conclusion.
• Hygiene is consistently bad (matted and unwashed 3.1.2. Childline. Launched by the Government of
hair, noticeable body odour). India, the service is a 24-hour free phone service that
• Untreated illnesses and physical injuries. can be accessed by a distressed child or by dialling
• Often left unattended or left alone or allowed to 1098 on his or her behalf on an adult telephone.
play in unsafe conditions [21-23]. Childline provides emergency assistance to children
• Always often late or miss school. and then, depending on the needs of the child, the
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Review Articles
CHILD ABUSE VICTIM
Examination of sibling (if Separating the potential
any) for abuse offender from the child
Life threatening injuries
No yes
Medical / dental Management of emergency
management of injuries by physician.
Is the child safe at home?
No
Yes
Admit/call ChildLine 1098/report Report to police
counselling
to CWC*. Help from trustworthy
family member
Monitor and Assess
1. Has abuse stopped?
2. Has parenting and environment improved?
3. Is the child’s development normal?
Yes
No No
Yes
Figure 3. Flow chart describing recommenda-
call ChildLine
tions for dental management and reporting of
Continue follow up. child abuse. (*Child Welfare Committee; Child-
1098/report to CWC*.
line (phone number 1098)).
child is referred to the appropriate institution for abandoned and surrendered children, the bill
long-term adoption and care. It calls for medical help, introduced concepts from the Hague meeting on
asylum, repatriation, missing children, protection child protection and cooperation. Inter-Country
from abuse, emotional support and guidance, Adoption was missing in the previous action, 1993.
information and service referrals, calls related to This bill requires the Child Welfare Committee to
death, and so on. notify any parent or guardian who severely abuses
Child helpline contact details in India: a child, or fails to protect a child from being abused;
- Karnataka State - (080-47181177 (will operate from such persons are disqualified and an order is issued
10 am to 5pm) to remove the child from the custody of such persons.
- CHILDLINE India Foundation, Tamilnadu - 04328 Crimes under this law are detectable and a person
276 745 can be arrested without a special police officer or his
- Child helpline, Punjab -093175 05759 subordinate needing a warrant and the premises can
International Child helpline be searched without a warrant.
- Japan Childline - 0120-99-7777 3.1.4. National laws and amendments to prevent
- Malaysia Child line - 12999, 15999 child abuse and neglect [40]. The legislative
- South Korea - 1577-1391 (Child Protection Hotline) framework for children's rights is being strengthened
The reporting of child abuse and neglect cases can with the formulation of new laws and amendments
be done directly to the local bodies, there are child to existing laws. These include the Food Safety
helplines and child protection Commission available Act (2013), the Protection of Children from Sexual
in every state of India. (Fig.3) Offenses (POCSO) Act[41], 2012, the Free and
3.1.3. Child Welfare Committee. Under the Juvenile Compulsory Education Act (2009), the Child Marriage
Justice Act, which allows the Juvenile Justice Board, Prohibition Act (2006), and the Commissions for the
which includes psychologists and sociologists Protection of Children. The Right to Information
to determine the adoption process of orphaned, Act (2005), Juvenile Justice (Child Protection and
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Protection) Act 2000, amended in 2006, Right to can be effective, at least in some cases, in changing
Review Article Information Act (RTI) 2005, Goa Child (Amendment) the way abusive parents think about their young
Act 2005, Child Labor (Prohibition & Control) Act, children. Outcomes for each child can vary widely
1986 (2006 & Two notifications in 2008), Prohibited and are affected by a combination of factors,
and Dangerous Procedures and Expansion of including the age and developmental status of the
Professional List) and Information and Technology child at the time of abuse; type of abuse, frequency,
(Amendment) Act 2008. In addition, there are new duration and severity, and the relationship between
laws such as the HIV / AIDS Bill. Telephone helplines the child and the offender. In addition, children
(Childline 1098) and Child Welfare Committees who experience abuse are often affected by other
(CWCs) were established under the Juvenile Justice negative experiences (e.g., parental substance abuse,
Act (2000), where child abuse or harm to children domestic violence, poverty) that make it difficult to
can be reported and help sought. distinguish specific effects of abuse.
3.1.5. National programs for the rights and
protection of children [40]. The Government of 5. CONCLUSION
India has implemented a number of programs on
social inclusion, gender sensitivity, children's rights, Child abuse affects society as a whole, and the future
participation and protection. This approach is based well-being of any nation depends on children. It is
on the UN CRC and the Millennium Development the responsibility of everyone to ensure that they
Goals (MDGs). These programs include: Integrated have atraumatic upbringing. Pediatric dentists
Child Development Services (ICDS), the Sabla are among the front-line professionals trained to
Scheme for Adolescent Girls, and the Evidence detect child abuse and they play an important
Project for Adolescent Boys; Rajiv Gandhi Creche role in reporting such cases. The dentist should
Scheme for Children of Working Mothers, Domestic not continue the investigation, but is responsible
Helping Scheme for Promoting Adoption in the for notifying the appropriate authorities, who will
Country (Shishu Greh), Dhanalakshmi-Conditional determine if a child has been abused or neglected. If
Cash Transfer Schemes for Girls, Program for not intervened, 50% of time abuse will be repeated
Juvenile Justice, Child Line (24 Hour Toll-Free and more severe [10,42].
Telephone Helpline (No.1098), Integrated Child Statistics of child abuse and neglect will continue
Protection Scheme[42] (ICPS), Integrated Program to rise if mandatory reporting is not followed and
for Street Children, Ujjawala (Trafficking and Rescue health care professionals fail. It is high time that
Prevention Scheme, Rehabilitation, Reunification professionals (pediatricians, pediatric dentists,
and Repatriation), School Education Campaign general dentists and other health care workers)
National Program for School Education, National who come in close contact with children during
Rural Health Mission (NRHM), Mid-Day Meal Scheme, examination and concerned regulatory bodies
Jawaharlal Nehru National Urban Renewal Mission should join hands to protect today's children from
(JNNURM), Universal Immunization Program (UIP) any kind of child abuse. Health care professionals
and Neonatal & Childhood Illness (IMNCI) Integrated are especially required to report cases of child sexual
Management. abuse under the "Protection of Children from Sexual
Offenses Act (POCSO), 2012"[40].
4. DISCUSSION - LONG-TERM CONSEQUENCES
OF CHILD ABUSE AND NEGLECT. CONFLICT OF INTEREST
The authors declare no conflict of interest.
Children with a history of neglect or physical abuse
are at risk of developing mental health problems or AUTHOR CONTRIBUTIONS
a chaotic attachment style. In addition, 59% of the
children who experience child abuse or neglect are SG: have made substantial contributions to conception and
arrested as children, 28% as adults, and 30% are more design and have been involved in drafting the manuscript and
likely to commit violent crimes [34]. When some of revising it critically for important intellectual content; SBM:
these children become parents, especially if they has made substantial contributions to conception and design,
suffer from post-traumatic stress disorder (PTSD), acquisition of data, analysis and interpretation of data and
dissociative symptoms and other sequels of child has given the final approval of the version to be published; GB:
abuse, they may experience difficulties when dealing has made substantial contributions to conception and design,
with their infant and toddler needs and general acquisition of data, analysis and interpretation of data and have
distress, which can lead to negative consequences given the final approval of the version to be published; VV: has
for their child socio-emotional development [32- made substantial contributions to conception and design and
38]. In addition, children may find it difficult to feel revisited it critically for major intellectual content.
empathy for themselves or others, which can make
them lonely and unable to make friends. Despite ACKNOWLEDGMENTS
these potential difficulties, psychosocial intervention None.
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Sowndarya GUNASEKARAN
BDS, MDS, Post Graduate Student
Department of Pediatrics and Preventive Dentistry
Coorg Institute of Dental Sciences - CIDS
Virajpet, Kodagu, Karnataka, India
CV
Dr Sowndarya Gunasekaran (DOB: 28th of March, 1995) obtained her bachelor’s degree in Dental Surgery at the Sri Ramakrishna
Dental College and Hospital, India (2012-2017). She is currently purusing her Master’s in Pediatric and Preventive Dentistry (final
year), Coorg institute Of Dental Science, India (2018-2021). Her academic interests include preventive health and child care.
She strongly believes that every child should be given the right to live a happy and healthy childhood, it is very distressing to
see children of young age suffer from abuse which affects their growth and development, as well as their confidence because
of negligence and inadequate education about Child abuse and neglect and the consequences of ignoring the needs of the
children.
292 Stoma Edu J. 2020;7(4): 286-293 pISSN 2360-2406; eISSN 2502-0285
Child abuse and neglect: the role of a pediatric dentist
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Questions
Review Articles
1. Which of the following is a sign of neglect?
qa. Display unusual sexual knowledge;
qb. Extremely or overly compliant;
qc. Regularly upset stomach;
qd. Lacks hygiene and appropriate clothing.
2. A parent who continually teases a child in a mean way is committing which type of
abuse?
qa. Physical;
qb. Emotional;
qc. Sexual;
qd. Neglect.
3. What is the term for people who are required by law to report suspected child abuse?
qa. ECE professionals;
qb. Police officer;
qc. Child welfare agents;
qd. Mandated reporter.
4. When should teachers report abuse?
qa. Once they have a suspicion;
qb. Once they have proof;
qc. Once the child tells them;
qd. Once it has happened twice.
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