CHILD ABUSE &

CHILD NEGLECT

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 CHILD ABUSE
 : It is defined as the non-accidental
physical injury , minimal or fatal , inflicted upon
children by persons caring for them . {Selwyn et al ,
1985}
It is an overt act of commission of a caretaker –
physical , emotional or sexual .

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 BATTERED BABY : It is a child

who shows clinical or radiographic
evidence of lesions that are frequently
multiple and involve mainly the
head , soft tissue , long bones, thoracic
cage and that cannot be
unequivocally explained. {Selwyn ,
1985 }
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 Battered child syndrome

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 NEGLECTED CHILD : It is one
who shows evidence of physical or mental ill
–health primarily due to failure on the part
of the parent or caretaker to provide
adequately for the child’s needs.

PERSECUTED CHILD : It is one

who shows evidence of mental ill – health
caused by deliberate infliction of physical or
psychological injury that is often continuous
in nature.
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 Historical Background
A review by Radbill (1973) indicated that historically
children were considered to be their parent’s
property , having a few rights of their own. It was
taken for granted that parents had every right to treat
their children as they wished.
The first documented & reported case of CA/CN
occurred in 1874 with a child named Mary Ellen.
In 1946 in a classic article by Caffey , some common
features of CA/CN were first described . It reported
the common association of subdural hematomas &
long bone pathosis.
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 In 1962 , the term battered child syndrome was
coined by Henry Kempe in his milestone article. It
was further elaborated by Kempe & Helfer in
1972.
In 1974 child abuse prevention & treatment act
was signed into law . For the first time , it
established within the federal government -
National Centre on Child Abuse & Neglect.
 The contribution of dentists to recognition of
CA/CN emerged during late 1960’s.

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 Type of child abuse & neglect
Physical abuse 31.8%
Sexual abuse 6.8%
Failure to thrive 4%
Intentional drugging or poisoning not specified
Munchausen syndrome by proxy not specified
Health (medical) care neglect including 8.7%
(Dental neglect)
Educational abuse 26.3%
Emotional abuse & neglect 27.8%
Physical neglect 7.8%
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 Statistics
At least 60% cases remain undetected.
The average age of detection of child abuse and
neglect is 7.4 years .
Reported cases in females is 51% and in males
49% .
Sexual abuse is more commonly seen in females
whereas physical abuse is more common in males
No age , sex , gender or socioeconomic status is
spared by child abuse .

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 Probable factors in child abuse
Stresses Ego weaknesses Vectors
Youthful parenthood Character disorders : Stresses created by child

Unwanted or unplanned Impulsive - aggressive Specific individual

parenthood psychodynamics
Low socio-economic status & Rigid - exacting Collusion or facilitation by
related variables such as partner
crowded and inadequate housing

Social isolation Immaturity, passive dependency Culture bound disciplinary

or inadequacy practice and beliefs
Long parenthood Depressive disorder Relative absence of other
need, satisfaction , frustrating
objects (social isolation)

Partner discord Psychic disorders

Responsibilities and Alcoholism

frustrations of parenthood
Altered physical or Non – specific ego defects
physiological status
10 Low self esteem , inability to
empathize & trust
 Physical abuse
It is probably the most important subtype of child
maltreatment because without intervention & services
it is potentially fatal.
Often the injury stems from an angry response of the
caretaker to punish the child for misbehavior.

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 Bruises in physical child abuse
1) Inflicted bruises : Occur at typical sites like :
• Buttocks & lower back
• Genitals & inner thighs
• Cheek { slap marks }
• Earlobe { pinch marks }
• Upper lip & frenum { forced feeding }
• Neck { choke marks }

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 Accidental bruises : All bluish discolorations
of the skin are not bruises.Most children acquire 1 or 2
bruises in daily activity like on knees or legs while
walking and on forehead on jumping.The
characteristics of these are similar to grab marks or
abuse marks however, the accidental bruises mostly lie
over bony prominences whereas the abuse marks are
on soft tissues.

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 Unusual bruises: Some common ethnic practices
can result in bruises that should not be confused with
child abuse. The Vietnamese can induce symmetrical
linear bruises from coin rubbing .

Pseudo bruises : Some skin conditions like

Mongolian spot or allergic periorbital discolorations ,
haemophilus influenza may give appearance of
abusive marks.

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 Color changes during healing of a
bruise :

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 Variables affecting the appearance of
bruises:
Vascularity of the tissue injured
Age
Metabolic rate
Medications
Normal skin color
Mass & velocity of the impact
Time of injury

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 Marks in physical child abuse
Human Hand Marks : They are prevalent in almost
22% of the cases & can leave various kinds of
bruises . The most common type is grab marks.

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 Grab marks or finger tip
bruise : They are oval shaped
bruises that resemble finger
tips . The most common site
is the upper arm or
shoulder . Lower extremities
are common until the child
learns to walk . Sometime
squeezing of the cheek
leaves a thumb or two -
three finger mark bruises .

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 Often linear grab marks occur due to the pressure
of the entire finger when capillaries at the edge
of the injury are stretched enough to rupture .

In slap marks to the cheek , 2 or 3 parallel linear

bruises at a finger width spacing will be seen to
run through a more diffuse bruise .

Crescent shaped bruising facing each other as a

result of pinch , primarily due to fingernail .

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 Strap Marks
Strap marks are 1 - 2 inches wide , sharp border
rectangular bruises of various length , sometimes
covering a curved body surface .
 lash marks : are narrow straight edged bruises or
scratches caused by a thrashing with a tree branch .
Loop marks : are secondary to being struck with a
doubled over lamp cord or a rope commonly
breaking the skin and loop - shaped scars because of
the force of distal-end .

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 Bizarre Marks
Bizarre – shaped bruises are always inflicted when
a blunt instrument is used in punishment with
the resulting bruise that will resemble it in shape.

The wide assortment of instruments used to abuse

children suggests that the caretaker who loses
temper grabs whatever object is handy .

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 Circumferential tie marks on ankle or wrist can
be caused when the child is restrained.
Circumferential cuts are due to narrow rope or
cord.

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 A frictional burn or rope burn may result due to
a large piece or strap of sheet used to restrain ,
presenting a large blister that encircles the
extremity .
 Gagging abrasion is due to restraining of the
crying or yelling children .

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 Injuries Of Dentition
Include:
Traumatized or avulsed teeth indicating
blunt trauma or pattern injury from
instruments.
Discolored teeth indicating repeated
trauma.

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 Child sexual abuse
This include contacts or interactions between a child
& an adult when the child is being used for
the sexual stimulation of the perpetrator or another
person .

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 Nutritional Neglect
It can be defined as an underweight , malnourished

condition who has a weight that is below the

third percentile & a height & head circumference
that are above third percentiles on growth curves.

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 Intentional Drugging or
Poisoning
It involves the administration of a prescription or
prescription drug that is harmful & not intended
for children .

Most common drugs are sedatives , hallucinogenic

drugs .

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 MUNCHAUSEN SYNDROME
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.

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 Munchausen Syndrome by
Proxy
A parent or caretaker attempts to bring medical
attention to themselves by injuring or inducing illness
in their children .
The term was first coined by Dr. Roy Meadow 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 signs & symptoms lead to unnecessary
medical investigations , hospital admissions &
treatment.
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 Factitious symptoms are often bleeding from
various sites.

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.

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 Health care neglect
It occurs when a child with a treatable chronic
disease has serious deterioration of the condition
because the parents or caretakers repeatedly ignore
health care recommendations.

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 Dental neglect
The Ad Hoc Committee on child abuse & neglect
of the American Academy of Pediatric Dentistry
has defined dental neglect as the failure by a
parent or guardian to seek treatment for visually
untreated caries, oral infections or failure of the
parent to follow through with treatment once
informed that the above condition exists.

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 Identification of neglect
Untreated,rampant caries that is easily detected by a
lay person.
Untreated pain,infection,bleeding,or trauma affecting
the orofacial region.
History of a lack of continuity of care in the presence
of previously identified dental pathology.

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 Safety neglect
It occurs when injury results from lack of
supervision.
These situations usually involve children younger than
4 years of age.
Lack of supervision leads to injuries like burns,
poisonings , falls

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 Emotional abuse & neglect
It can be defined as the continual scapegoating &
rejection of child by parent or caretaker.
Severe verbal abuses are also a part of emotional
abuse & so is the neglect by the teacher.

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 Educational abuse

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 Clinical assessment
History
Physical examination
Intraoral examination
Documentation
- written observation
1. Number
2. Type
3. Location
4. Resolution
5. Possible cause
6. Opinion
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 - Photographs
1. 35 mm color photograph
2. Various views
- Radiographs
- Bite-marks
- Saliva
 Treatment
 Parental consultation
 Reporting

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 The following histories are diagnostic in
evaluating non – accidental trauma :

 Eye - witness history

 Unexplained history
 Implausible history
 Alleged self - inflicted history
 Delay in seeking medical care

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 Examining Child Abuse &
Neglect
• The dentist & his staff should be educated to get a
visual impression of child as he enters the
reception room .

• He should note whether the child and parent has an

appropriate interaction .

• After evaluating the history in suspected cases , the

examination for such children should be
incorporated with a routine dental checkup .
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 Common sites to be observed &
examined
Many abused children , due to fear may
appear overly vigilant or display a frozen
watchfulness staring constantly .

There are no spontaneous smiles and almost

no eye contact .

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 The dentist should observe the child for lack of
cleanliness , for small stature with respect to age
and for evidence of malnutrition .

Typical signs of malnutrition include a posture of

fatigue with rounded shoulders , flat chest , a
protuberant abdomen & thinning of hair . The
face is pale , muddy & lacks luster.

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 Overdressed children should also be noted ,
long sleeves & high necked shirts or blouses
during hot summer months may be worn to
cover signs of physical abuse .

Face & neck should be examined for

periorbital ecchymosis , scleral haemorrhage ,
ptosis , deviated nasal septum , cigarette burn
marks & hand slap marks.

Corners of the mouth are reported with

binding marks from a gag tied in place for
hours to force the feed .
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 Sometimes , a spoon or fork applied with enough
force may result in fractured anterior teeth or
torn frenum.

If moving the child up in the dental chair or

lifting up motion results in pain , trauma is to be
suspected . Then belt marks , electric cord marks ,
bite marks , bruises or fracture of ribs or
clavicles should be suspected & dentist should
confirm by checking them.

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 Definitive CA/CN
examination
It requires a keen observation and detailed
documentation when suspicion exists . A
systemic approach should be followed and to
protect the examiner legally , the dental
assistant should be present in the room &
aware of the dentist’s suspicion , to verify
& record the findings .

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 Following areas should be examined carefully :

Detailed examination and palpation of the skull looking

for subgaleal hematomas & cephalomatomas
Positive sign of any battle like laceration , scar
bruises .
Body surfaces that are covered should be
examined by lifting up the clothes to the limit
they allow . Inner thighs , arm pits must be
checked .

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 Parent consultation
Once the suspicion is confirmed , the parent
should be informed that an injury has been
noticed .

The parental explanation of the cause of the

injury should be understood fully by the dentist
.

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 If the findings and explanation are not compatible
, or if suspicion still exists , the dentist is
mandated by law to contact the appropriate
CA/CN authority .

The dentist should contact suitable child protective

agency ensuring himself that parents’ influence
will not result in the dentist altering the decision .

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 Role of Pedodontist in Child
Abuse & Neglect
 To observe & 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 .
 To identify any dental injuries . Dentist should be
acquainted with management of injuries to both
primary & permanent dentitions .
 To establish & maintain a professional therapeutic
relationship with the family.
 To transfer the child to a physician or hospital for
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proper care.
 Child Protective Agencies
In India police is the concerned
authority .

NationalHuman Right Commission

{NHRC} have similar role .

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 Government organizations
(GO’s) and Non government Organizations
(NGO’s) Working Against Child Abuse

 UNICEF
 The Child line Organization , New Delhi
 Ummid Sanstha , New Delhi
 Shakti , Kolkata
 Asha Sevabhvi Sanstha , Mumbai
 NHRC , New Delhi
 Sparsh Seva Sanstha, Mumbai

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 Indian Laws Of Child Abuse
India has no law on/for child abuse per se.
 Physical abuse :
Violence in home : Indian Penal Code
{IPC}
323 / IPC 324.

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 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 .

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 Attempt to prevent child abuse
in India
In India child labor is the commonest type of abuse.
The government has made efforts to prohibit it by
enacting child labor laws which included 1986 Child
Labor ( Prohibition & Regulation ) Act .
It stated that children under 14 years of age could
not be employed in hazardous occupations.
It also attempted to regulate working conditions in
the jobs that it permitted , & put greater emphasis on
health & safety standards.

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 • Ministry of Labor has given notification on 5th
February , 1996 in New Delhi regarding Child
Labor Law .
• The working conditions of children have been
regulated in all employments which are not
prohibited under the Child Labor ( Prohibition &
Regulation ) Act.

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 PREVENTION OF CHILD ABUSE
DAY

19 th november.

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 References
Textbooks of pedodontics by Shobha Tandon
Textbooks of pediatric dentistry by Nikhil Marwah.

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 THANK YOU

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