Topic- Child Abuse And Neglect

Introduction - Child abuse and neglect is an international problem having victims of

all ages, races, religions and socioeconomic background. Formerly called battered child syndrome, child abuse and neglect have been recently

described as non-accidental injury { NAI}.

Definition• Child abuse and Neglect is defined “ as any interaction or lack of

interaction between a care giver and a child resulting in non-accidental harm to the child’s physical or developmental state”.

Battery is a term often associated with abuse, defined as an “unprivileged touching of another person’s body”.

Henry Kempe in 1962 first reported the term “battered child syndrome”. According to him, a child exhibiting the following features should be included under this syndrome.

1. Evidence of fracture of long bones 2. Subdural hematoma 3. Failure to thrive 4. Soft tissue swelling or skin bruising.

Types Of Abuse And Neglect

1. Physical abuse 2. Sexual abuse 3. Physical neglect 4. Emotional abuse and neglect 5. Failure to thrive 6. Intentional poisoning/drugging 7. Munchausen’s syndrome by proxy 8. Health care neglect 9. Safety neglect 10. Educational abuse.

Physical Abuse• IT forms 60% of the child abuse related fatalities. • It is a non-accidental means of trauma to the body of the child, which may result in

severe injury or even death.• These type of injuries may be inflicted by the parents, relatives or baby sitters.• Incidence of physical abuse is more in families of low socioeconomic status.• Abusers are most of the time unhappy, angry adults under stress. They injure their

children in anger for some misbehavior to relieve their frustration. The injuries sustained may vary form mild such as few bruises, scratches, etc to

severe ones such as burns, CNS injury, abdominal injury, multiple fractures or other life threatening injuries.

Evidence for suspecting physical abuse 1. Injury unusual for a specific age group (e.g. fracture in an infant) 2. History of previous/recurrent injury 3. Unexplained injury 4. Bruising in unusual areas with bruising patterns (buckle marks, etc.)

Sexual Abuse

The national center on child abuse and neglect defines sexual “to include contacts or interaction between a child and an adult”.

Evidence for suspecting sexual abuse are: A. Report by the patient or guardian B. Early and exaggerated awareness by the patient

about sex. C. Physical trauma, if present, tearing, bruising or

specific infection of the month, anus or genitals D. Pregnancy.

Physical Neglect

It consists of failure to provide the basic necessities such as adequate food, shelter, clothing and also health care needs.

Physically neglected children tend to exhibit at least several of these characteristics.

A. Dirty clothing and skin with foul smell, lice and unkempt appearance.

B. Undernourished. C. Rampant caries, abscess, periodontal lesions, etc. D. Uncared wounds. E. Failure maintain appointment. The reason for neglect may be parent’s illness, poverty,

ignorance, unusual stress on the family.

Emotional Abuse and Neglect

The child is emotionally attacked by parents, teachers or any caretakers. The child is harassed verbally and made to feel low either by direct abuse or by ridiculing the child in front of others. Severe forms may take the form of locking the child in a dark room.

Failure to Thrive

Some parents may not take care of the newborn and thus child may be malnourished and underweight. Common reason for such behavior is that the mother does not like or want the baby. Other reason may include depressed mother, recent separation of the parents, etc.

International Poisoning/Drugging

It is an uncommon lethal type of child abuse, involving administration of a harmful drug that is not intended to be used by the child. Parents who poison their children may have severe marital problems or may be drug abusers.

Munchausen’s Syndrome by Proxy

Parents fabricate or induce illness and subject the child to unnecessary medical investigation, hospital admission and treatment. Children are usually less than 6 years of age and too young to understand the deception. Parents may administer laxatives and complain to the doctors that their child is suffering from diarrhea.

Health Care Neglect

Parents ignore or do not provide the necessary medical or dental treatment to the child even until the condition proceeds to a serious or irreversible extent.

Safety Neglect

Includes gross lack of direct or indirect supervision of a child that result in an injury.

Educational Abuse

Parents do not educate their children or are not bothered about the chronic absenteeism of the child from school. They may intentionally keeps the child at home and do not allow him or her to attend school.

Injuries Associated With Abuse

Orofacial Injuries (Figs 18.1 to 18.3)• Parents hit the child on the mouth or lip to silence a

crying child leading to injuries on the lip or adjoining area.

• Hitting hard on the face over the eyes can lead to subcutaneous hemorrhage around the eyes or any kind of injury depending on the device used to hit.

• Sleeping leads to bruises on cheek, which – due to slap – where 2 or 3 parallel lines marking the finger marks may be seen.

Injury to Skin and Subcutaneous Tissues

• Marks seen on the skin are commonly due to holding the child’s hand tightly or due to rope or cloth used for restraining. Marks can also be seen when hit with an object.

• Burn injuries caused by cigarette buds or hot objects are common and the shape of the injuries due to hot water produces blisters or scalds over the area of injury.

• Bite marks are seen as elliptic or ovoid pattern formed by the upper and lower teeth on the skin.

Head Injuries

• Such injuries are seen in cases of severe cases of abuse.

• Injuries include subdural hematoma, subarachnoid hemorrhage, etc.

Bone Injuries

• Fractures are also associated with severe cases of abuse.

• Fractures of the ribs, upper and lower limb is seen.

Abdominal Injuries

• Caused by punch and kicks that compress the organs against the spinal column and forms the second most common cause of death in cases of abuse.

• Bruises or ruptured viscera – may result in massive hemorrhage – shock and death.

The Characteristics Of An Abused Child

• The child often has characteristics that make him/her provocative, such as negativism or a difficult temperament. Some of the more offensive misbehavior are intractable crying, wetting, soiling and spilling.

• The abuser describes the abused child as difficult to control, bad or selfish. Children are most of the time passive, afraid and presents with repeated skin or other injuries.

Features of Abused Child

1. Unduly afraid or passive 2. Evidence of prolonged confinement 3. Evidence of repeated skin or other injuries 4. Inappropriate treatment of injuries by parents. 5. Undernourished child 6. Inappropriate dressing 7. May be aggressive, demanding or hyperactive

or cranky, irritable or cries easily.

The Abuser Child abuse occurs in all cultural, occupational, socio-economic and ethnic groups. A

proportionately higher incidence of abuse is reported in minority and low income family. Father, mother or caretaker may be the abuser. The parents may have the following

characteristics indicative of abusive behavior. 1. Poor self esteem and coping skills. 2. Violent tempers or outbursts. 3. Unrealistic expectation of child’s behavior. 4. Inappropriate response to the seriousness of the child’s condition. 5. Over critical behavior toward the child. 6. Avoidance of looking at or touching the child. 7. Reluctance to give the history of the accident or giving an unrealistic explanation. 8. Request for treatment long after injury has occurred. 9. Appearance of confusion or embarrassment when discussing the child’s trauma. 10. Immature, depressed or demanding.

Role Of Dental Surgeon Dental surgeons are in a unique position of seeing patient that are victims of abuse and neglect. More than

50% of the abuse occurs to the head and facial area. Often the first medical professional to see these children routinely is a dentist. The ability to recognize the

sings and symptoms when such an incident presents itself can make a difference in the child’s physical, emotional and social well being and may even save a child’s life.

A dental surgeon has 3 main responsibilities towards abused children. 1. Detection 2. Reporting 3. Prevention. Numerous dentists fail to report suspected abuse and neglect, which may be due to: A. Lack of knowledge to identify B. Do not know where to report such cases C. Thinking “it is not our responsibility”. The usual controversy which exists among dental surgeon is whether they should inform the parents or

caretakers that they have reported the case. The law Enforcement Agencies stress that the parent or caretaker should not be told because of their concern for the protection of the child. If the alleged perpetrator is a member of the family, talking to the family may cause the child to suffer additional abuse or the family may move and the abuse will no doubt continue.

Once a dental surgeon is suspicious that an injury or lesion is of non-accident origin, the findings must be collected permanently and accurately documented and presented in the court. The records must be in the form of photographs, written documents, radiographs and diagnostic study casts.

Examination

It includes obtaining a general impression as to the child’s overall cleanliness, size and stature, interaction with the parent or caretaker and gait. A complete and thorough examination of the craniofacial area is essential, since these exposed areas are often involved in physical abuse.

Careful examination of the cranium and scalp can reveal battering lesions. Common finding include traumatic alopecia. Others being presence of lice, abnormalities of the ear, periorbital ecchymosis, scleral hemorrhage, ptosis, deviated gaze or unequal pupils, blood clots of the nose or presence of DNS (Deviated Nasal Septum).

Diagnosis The evidence of physical abuse is generally easily recognized. There are types and

sites of injury so common in child abuse that merely finding them is diagnostic. For example A child learning to walk may sustain injuries to shin, elbow, hands and forehead. But injuries to buttocks, lower back, genitals, inner thighs, etc. raise serious questions of non-accidental trauma. In addition, injuries to the cheeks, ears, upper lip, frenum, chest or abdomen should always be questioned.

The first step in diagnosis is talking a good history. A child’s statement that some one caused an injury is usually accurate. If one parent accuses the other of inflicting the trauma on the child, even this can be taken as eyewitness account unless the child is involved in custody battle. A partial confession such as admitting to only part of or one of the multiple injuries, can be just as diagnostic as a complete confession.

It is highly suspicious when a parent is unaware or he is unable to explain an obvious injury; because most non abusive parent know precisely how or when an injury occurred and willing to discuss it.

Prognosis

If abused children returned to their parents without any intervention about 5% will be killed or 25% seriously injured.

Children with repeated injuries to the CNS may develop mental retardation, organic brain syndromes, etc. Common emotional traits of abused children are fearfulness, aggression and hyperactivity or may turn out into next generation of child abusers.

Q1- The term “Battered Child Syndrome” is given by-

A- Henry Kempe in1962 B- Vandeven AM in 1962 C- Becker PT in 1962 D-McDonald KC in 1962

Q2- Dirty clothing and skin with foul smell, lice and unkempt appearance is characteristic of-

A- Physical Neglect B- Health care Neglect C- Sexual Abuse D- Safety Neglect

Q3-Bruises or ruptured viscera- may result in massive hemorrhage- is characteristic of- A- Head injuries B-Bone injuries C-Abdominal injuries D-Skin injuries

Q4- A proportionately higher incidence of abuse is reported in-A- Higher familyB- In minority and low income familyC-Educated familyD-Rich family

Q5-Poor esteem and coping skill, violent tempers or outbursts, unrealistic expectation of child behavior, inappropriate response to the seriousness of the child condition are

characteristics of a-

A-Abusive behavior of father B-Abusive behavior of mother C-Abusive behavior of care taker D-All of the above

Q6-Locking the child in a dark room is- A-Physical abuseB-Sexual abuseC-Emotional abuse and NeglectD-Health care neglect

Q7- “To include contacts or interactions between a child and an adult is called

A- Sexual abuse B- Physical abuse C-Emotional abuse D-Educational abuse

Q8-When parents fabricate or induce illness to the child by unnecessary medical investigation, hospital admissions and treatment is sign of-

A-Down syndrome B-Munchausen’ Syndrome by Proxy C-Health care safety D-All of the above

Q9-Educational abuse is called if parents -

A- Do not educate their children B- Are not bothered about the chronic absenteeism of child

from school C-Keeps child at home intentionally D- All of the above

Q10-Dental Surgeon has the main responsibility-A-Only DetectionB-ReportingC-PreventionD-All of above

Answers-

1-a 2-a 3-c 4-b 5-d 6-c 7-a 8-b 9- d 10-d