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Recognizing Signs of Child Maltreatment

Dental hygienists play an important role in identifying child abuse and neglect, and need to know effective strategies for assessment and reporting.

PURCHASE COURSE
This course was published in the March 2024 issue and expires March 2027. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.

AGD Subject Code: 155

EDUCATIONAL OBJECTIVES

After reading this course, the participant should be able to:

  1. Identify the types of child maltreatment and understand the risk factors associated with each type.
  2. Discuss strategies for assessing suspected cases of child maltreatment during dental hygiene appointments.
  3. Note the mandatory reporting laws and resources available for suspected victims of child maltreatment.

Child abuse and neglect have no boundaries, impacting those of all cultural, socioeconomic, and ethnic backgrounds. Dental hygienists should be prepared to recognize the signs and symptoms of abuse and neglect, due to the unique nature of their patient relationships and their close proximity to the head and oral cavity, where most traumatic injuries occur.1

Typically, dental hygienists build trusting relationships with their patients; this may enable patients to open up about abuse. Generally, victims return to the same dental practice, giving the clinicians an opportunity to recognize signs and symptoms of abuse relatively sooner than other healthcare professionals.1

The term child maltreatment may be used to describe all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role such as clergy, coach, or teacher.1­–3 Child maltreatment encompasses physical abuse, sexual abuse, and emotional/​psychological abuse, and neglect.

Children with disabilities have a 3.44 times greater risk of maltreatment than children without a documented disability.4 Additional factors increase the risk of child maltreatment, such as having young parents or single parents, caregivers who may have experienced abuse or neglect themselves, personal or family stress, intimate partner violence, mental health issues, and substance use disorder.3

Current Statistics

In 2021, the United States Department of Health and Human Services estimated that more than 588,000 children were victims of child maltreatment in 51 states.2 Victims younger than age 1 encompass 15.1% of all abuse victims. Children between birth and age 2 account for more than 27% of victims impacted by maltreatment.

Gender and ethnicity also impact rates of maltreatment. Although the victimization rate for girls is higher than boys, the actual percentage of child victims by gender is not statistically different. Statistics from 2021 revealed the highest rate of abuse was found among American-Indian or Alaska Native children followed by African-American children.2

Family status also affects abuse/​neglect rates. Research shows that unmarried partners are more likely to physically abuse their partner’s child than biological parents; this is referred to as the “Cinderella effect.”5

Types of Abuse

Physical abuse is the use of physical force to mistreat or harm a child, which may include shaking, biting, striking, kicking, burning, beating, and punching.1,3,6 Sexual abuse is adult engagement in sexual acts with underage participants who cannot give consent.6 Sexual abuse can include, but is not limited to oral, anal, or vaginal penetration; fondling; exposure to sexually explicit materials; or sexting/posting pictures of a child.3,6

Emotional and/​or psychological abuse is the use of words or actions to mistreat a child. This includes verbal abuse, humiliation, or terrorizing a child.6 Such behavior can make a child feel worthless, unloved, and unwanted, resulting in low self-esteem.3

Neglect is the failure by a parent, caregiver, or guardian to provide basic needs, such as food, shelter, clothing, education, healthcare, or supervision.1,6 Dental neglect may present as poor oral hygiene, untreated dental caries, rampant dental decay, untreated pain or infection, or oral lesions due to nutritional deficiency. Diagnosing dental neglect in children can be challenging as it isn’t always deliberate; in fact, in some cases it is unavoidable. Factors, such as poor oral health literacy, access-to-care issues, and financial limitations, may all contribute to dental neglect.1,7

Assessing Child Abuse and Neglect

When identifying suspected cases of child maltreatment, clinicians must be tactful in their efforts to confirm whether abuse is occurring. As with any recare appointment, a thorough medical, dental, and social history should be taken. Performing the intraoral and extraoral examination on all patients, even children, will make it less obvious to the caregiver that the clinician is suspecting some form of child maltreatment is occurring. All clinicians should have their own method for observing patient behaviors and any unexplainable injuries to the head, neck, and oral cavity.8 Table 1 provides signs and symptoms of each category of abuse and neglect.

One of the most critical signs of child maltreatment is discrepancy in the history surrounding the injury and how that injury presents clinically. Additionally, the clinician should make note of any recurring injuries and those in various stages of healing, ranging from red to purplish to green/​yellow, or even brown.9,10 If child maltreatment is suspected, the clinician should offer the child the opportunity to provide an explanation for the injuries without the caregiver present. However, discretion is advised when trying to obtain information from a child. Questioning should be kept to a minimum allowing the appropriate officials to lead a more in-depth interview.9

The following must be considered when obtaining information from a child:9

  • Confirm how the injury occurred and who was present and/​or involved
  • Ask open-ended questions in a way that makes the child comfortable enough to be honest with you
  • Give the child your undivided attention
  • Speak to the child in age-appropriate language
  • Listen clearly to what the child is telling you
  • Report only the exact words of the child, not what you think he or she meant

Table 2 provides examples of questions to ask children specific to the type of abuse suspected. These should be modified based on the patient’s age.

Other Impactful Factors

Although dental professionals have a duty to report signs of abuse and neglect, conditions that mimic abuse should be considered. Three common conditions that may be mistaken for physical abuse due to their similarities are Sturge-Weber syndrome, Ehlers-Danlos syndrome, and idiopathic thrombocytopenic purpura.1

Sturge-Weber syndrome is a rare, neurological disorder that presents with a port-wine stain birthmark, usually on the forehead and/​or upper eyelid.1,11 Ehlers-Danlos syndrome is a group of genetic connective tissue disorders that leads to easily bruised skin.1,12 Idiopathic thrombocytopenic purpura is a platelet disorder that can cause easy bruising and bleeding in the mouth. It may also present as a skin rash with petechiae spots.1,13

Dental hygienists often serve diverse patient populations, and other cultures have different views on discipline.3,14 Some cultures believe in the importance of corporal punishment. In some circumstances, corporal punishment may include whipping, burning, or even scalding. Many cultures practice alternative medicine including coining and cupping that may cause bruising, which could be confused with physical abuse. Examples of unintentional neglect may be due to cultural beliefs. Some religious groups do not believe in seeking medical attention for potentially fatal childhood illnesses,which, legally, is a form of medical neglect. Furthermore, some caregivers refuse to have their children vaccinated for personal or religious reasons, also a form of medical neglect.3

Documentation

Thoroughly documenting all potential cases of child maltreatment is key for the dental professional. Accurately describing the size, shape, color, and location of all injuries is crucial. Any photographs taken of lesions and/​or injuries should be captured with a millimeter device, such as a probe, and included in the dental record. Also of importance are any statements given to the clinician by the caregiver and child regarding the injury and/​or lesion. It would behoove the clinician to have a witness present during the interviewing process for both the caregiver and child. The names of any professional interpreters and witnesses should be documented and expedited to the proper authorities.8

Dental professionals, as healthcare providers, are required to follow mandatory reporting laws in all 50 states.9,15 These reporting laws vary by state, including requirements for continuing education courses on abuse, as well as identification and reporting training.16 Children, as minors, are more susceptible to abuse and neglect. This makes it critical for dental professionals to act when signs of abuse and neglect are seen.

Resources

Prevent Abuse and Neglect through Dental Awareness (P.A.N.D.A.) was created to educate dental professionals on recognizing and reporting cases of abuse and neglect.17,18 Child protection acts in certain states mandate any individual suspecting child abuse or neglect to report it to the state’s Department of Health and Human Services.18 Dental professionals have a duty to protect their pediatric patients from further abuse and neglect and are critical in identifying signs of potential abuse and neglect.

Every dental team member should know what resources are available to suspected victims of child maltreatment. Below are a few national resources:19

  • Child Welfare Information Gateway provides access to information and resources designed to help protect children and strengthen families. Website: childwelfare.gov
  • FRIENDS National Resource Center is a federally mandated training and technical assistance provider for agencies working to prevent child abuse. Website: friendsnrc.org
  • Childhelp USA is a nonprofit dedicated to siding victims of child maltreatment. 
Hotline: 1-800-4-A CHILD, available 24 hours a day, 7 days a week
  • STOP IT NOW! prevents sexual abuse of children prior to it actually happening by preparing adults, families, and communities to take measures that protect children before they are actually harmed. Hotline: 1-888-PREVENT

If there is immediate suspected danger or an emergency, 911 should be called.

Conclusion

Dental professionals play a unique role in identifying child abuse and neglect. A thorough extraoral and intraoral examination must be completed and documented at every dental hygiene visit. Even for states that do not require specific abuse and neglect training, clinicians should make it their priority to attend continuing education courses that help prepare them for potential situations that may arise as well as fostering relationships with law enforcement and social service agencies.

Oral health professionals have the opportunity to make a difference for children experiencing maltreatment.


References

  1. Bowen DM, Pieren JA. Darby and Walsh Dental Hygiene Theory and Practice. 5th ed. New York: Elsevier Inc; 2020:1053.
  2. United States Department of Health and Human Services. Child Maltreatment. Available at: acf.hhs.gov/​sites/​default/​files/​documents/​cb/​cm2021.pdf. Accessed March 4, 2024.
  3. Pekarsky AR. Overview of child neglect and abuse. Available at: merckmanuals.com/​home/​children-s-health-issues/​child-neglect-and-abuse/​overview-of-child-neglect-and-abuse. Accessed March 4, 2024.
  4. Traisman E. Recognizing maltreatment in children with special needs. Pediatr Ann. 2016;45:e273–277.
  5. Block K, Kaplan J. Testing the Cinderella effect: measuring victim injury in child abuse cases. Journal of Criminal Justice. 2022;82:101987.
  6. Gonzalez D, Mirabal A, McCall J. Child abuse and neglect. Available at: ncbi.nlm.nih.gov/​books/​NBK459146/. Accessed March 4, 2024.
  7. Costacurta M, Benavoli D, Arcudi G, Docimo R. Oral and dental signs of child abuse and neglect. Oral Implantol (Rome). 2015;8:68–73.
  8. Jones M, Francisco E. Recognize the signs. Dimensions of Dental Hygiene. 2014;12(2):48–52.
  9. Wright F, Johnson J, MacLean J. Child maltreatment: the role of a dental professional. Available at: dentalcare.com/​en-us/​ce-courses/​ce599. Accessed March 4, 2024.
  10. Swiner C. Anatomy of a bruise. Available at:webmd.com/​first-aid/​ss/​slideshow-bruise-guide. Accessed March 4, 2024.
  11. National Institute of Neurological Disorders and Stroke. Sturge-Weber Syndrome. Available at: ninds.nih.gov/​health-information/​disorders/​sturge-weber-syndrome. Accessed March 4, 2024.
  12. Miklovic T, Sieg V. Ehlers-Danlos syndrome. Available at: ncbi.nlm.nih.gov/​books/​NBK549814/. Accessed March 4, 2024.​
  13. National Heart, Lung, and Blood Institute. Immune Thrombocytopenia. Available from: https:/​/​Available at: nhlbi.nih.gov/​health/​immune-thrombocytopenia. Accessed March 4, 2024.
  14. Child Welfare Information Gateway. Cultural responsiveness: child abuse and neglect. Available at: childwelfare.gov/​topics/​systemwide/​cultural/​can/​#:~:text=Culture% 20shapes%20the%20way%20individuals,be%20considered%20acceptable%20in%20another. Accessed March 4, 2024.
  15. Mandated Reporter. Are You a Mandated Reporter of Child Abuse? Available at: mandatedreporter.com/​child-abuse. Accessed March 4, 2024.​
  16. Concord Seminars. State CE Requirements for RDHs. Available at: concordseminars.com/​State-CE-Requirements-RDHs.asp. Accessed March 4, 2024.
  17. Mid-Atlantic P.A.N.D.A. We Prevent Abuse and Neglect Through Dental Awareness. Available at:​midatlanticpanda.org/. Accessed March 4, 2024.
  18. Northeast Delta Dental. Prevent Abuse and Neglect through Dental Awareness. Available at: nedelta.com/​providers/​resources/​prevent-abuse-and-neglect-through-dental-awareness/. Accessed March 4, 2024.​
  19. United States Centers for Disease Control and Prevention. Child Abuse and Neglect Resources. Available at: cdc.gov/​violenceprevention/​childabuseandneglect/​resources.html. Accessed March 4, 2024.

From Dimensions of Dental Hygiene. March 2024; 22(2):32-35

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