CONTENTS

Introduction
Definitions
Classification of child abuse and neglect
Types of child abuse
Types of child neglect
Statistics
Probable factor in child abuse
Recording of child abuse/neglect history
Clinical assessment
Examining child abuse/neglect
Definitive child abuse/child neglect examination
Parent consultation
Inflicted bruises
Human hand marks
Strap marks
Bizarre marks
Facial injuries
Injuries of dentition
Child protective agencies
Indian laws for child abuse
Government organizations (GOs) and non government organizations (NGOs) working against child

abuse
Situation in India
Attempts to prevent child abuse in India
Management
Reference

INTRODUCTION
Child abuse has existed since the dawn of history. The health harms from child maltreatment are long reaching
and clearly correlate with morbidity in adult hood . Health care and dental professionals are in unique positions
to identify the possibly abused child and must be knowledgeable in the recognition,documentation,treatment
and reporting of suspected child abuse cases . To appropriately intervene,professionals must be willing to
consider abuse or neglect as a possibility if it is not considered,it cannot be diagnosed . Child abuse and neglect
include a discussion of the types of child maltreatment frequently encountered,the clinical presentation and
management of such issues,and the documentation and reporting of suspected child abuse.
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DEFINITIONS

CHILD ABUSE : It is defined as the non accidental physical injury,minimal or fatal ,inflicted

upon children by persons caring for them(Sclwyn et al,1985).

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 caretakers to provide adequately for the childs needs.

CLASSIFICATION OF CHILD ABUSE AND NEGLECT

Types of child abuse:
1.
2.
3.
4.
5.
6.
7.

Physical abuse-31.8%
Educational abuse -26.3%
Emotional abuse-23.3%
Sexual abuse- 6.8%
Failure of thrive -4.0%
International drugging or poisoning- not specific
Munchausensyndrome by proxy -not specific

TYPES OF CHILD NEGLECT

Neglect is an act of emission or the failure to provide food,shelter,clothing,health care,safety need,dental care
and supervision . These may be broadly categorized into the following types:

Emotional neglect-27.8%
Health care neglect including dental neglect-8.7%
Physical neglect-7.8%

Choffin et al (1966) reported depression as a strong risk factor for physical abuse,which in turn was
strongly related with the onset of substance abuse.
Some instances of child abuse fall with in a gray zonebetween the pure-accident and negligent
homicide,due to possible sub-conscious desires of the mother or guardian to injure the infant. However

the repetition of non-fatal injuries should alert the attending clinicians that some instances of accident
prone-ness in children may be a subliminal form of child abuse.

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 where as physical abuse is more common in

males.
No age,sex,gender or socioeconomic status is spared by child abuse.

PROBABLE FACTOR IN CHILD ABUSE

1. The condition attributed to parents.
2. The condition attributed to child.
3. The condition attributed to social,cultural religious practices.

RECORDING OF CHILD ABUSE/ NEGLECT HISTORY

Each dental practitioner should develop an examination protocol to aid in screening and reporting of suspected
cases of child abuse and neglect.

HISTORY
The dentist who suspects child abuse or neglect needs to complete a thorough dental and general physical
examination. The combination of information is what influences or creates the suspention of possible child
maltreatment. The history should be a complete dental and medical history. Details regarding any trauma should
be complete and obtained seperatly from more than one source (eg.parent and child) if possible open ended
questions should be used yesor no questions should be avoided. Often the best question is what happened
.The dentist need only ask for a level of detail that would indicate suspicion of abuse or neglect that

would be reported. Details might include who witnessed the injury and who was with child when the injury
occurred,where the child and supervising adults were,and what happened. Questions should include how and
when incident occurred.
CLINICAL ASSESSMENT

History
Physical examination
Intra oral examination
Documentation
1. Number
2. Type
3. Location
4. Resolution
5. Possible cause
6. Opinion
Photographs
a) 35mm color photograph
b) Various views
Radiograph

Bite marks
Saliva
Treatment
Parental consultation
Reporting

The following histories are diagnostic or extremely suspicious in evaluating non-accidental trauma:

Eye witness history

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

IS IT CHILD ABUSE
Child abuse and neglect encompass a variety of experiences that are threatening or harmful to the child and are
the result of acts of commission or omission on the part of a responsible caretaker. Child maltreatment is usually
divided into categories of physical abuse,sexual abuse,emotional,psychological abuse and neglect in its many
forms. Children living in vident homes are increasingly recognized as victims of maltreatment. Many gray areas
exist in the determination of threat or harm and disagreement about the abusive natures of some experience
are common. No one individual is responsible for deciding what is abuse or neglect. Identification, treatment
and intervention are the tasks of professionals from multidisciplinary back-grounds working together to provide
care and evaluation in the best interests of the child.

PHYSICAL ABUSE:
Physical abuse is often the most easily recognized form of child abuse. The battered child syndrome was
initially described by Kempe et al in 1962 and elaborated further by Kempe and Helfer in 1972 as the clinical
picture of physical trauma or failure to thrive in which the explanation of injury was not consistent with the
severity and type of injury observed. These injuries are inflected and not accidental; some result from
punishment that is appropriate for the childs age,condition,or level of development . Approximatly 50%of
physical abuse results in facial and head injuries that could be recognized by the dentist,25% of physical abuse
injuries occur in or around the mouth.

SEXUAL ABUSE:
Sexual abuse and sexual misuse are frequently interchanged terms that denote any sexually stimulating activity
that is inappropriate for the childs age, level of cognitive development, or role with in the family. Sexually
abusive acts may range from exhibitionism or kissing to fondling,intercource,pornography,or rape. Trauma to
the mouth may result from sexual contact. In some states, statutes may include age criteria or an age differential
in the legal definition of some forms of sexual abuse.

NEGLECT
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In attention to the basic needs of a child, such as food,clothing,shelter, medical care, education and
supervision ,may constitute neglect. While as physical abuse tends to be episodic ,neglect tends to be chronic.
Determination of neglect also depends on the childs age and level of development as it relate to period of time
without supervision, the parents where about parental attention ,and responsibilities of child when the child is
not supervised or not attending school.

EMOTIONAL OR PSYCHOLOGICAL ABUSE

Emotional abuse has been a concern for many years ,but definitions and standards for identifying such abuse
have been extremely difficult to establish. It is often difficult to demonstrate the direct or causal link between
emotional and verbal abuse and harm to the child. Such harm is usually seen as abnormal behavior or mental
health problems that are multifactorial in origin. Continous isolation, rejection, degradation, terrorization,
corruption, exploitation or denial of affection are examples of behaviors that frequently have damaging effects
on the child.

CHILD ABUSE IN THE MEDICAL SETTING

Perhaps the most difficult form of child maltreatment to identify and treat is a facitious disorder. Initially called
munchausen syndrome by proxy, then pediatric condition falsification, the problem is one of child abuse in the
medical setting. These are conditions in which the perpetrator (usually the mother) relates a fictitious history,
produce false signs or symptoms, and fabricates illnesses in the child that result in extensive medical
evaluations, testing, and often prolongeal hospitalization.

LEGAL REQUIRMENTS
Every state has legal statutes requiring that suspected child abuse or neglect be reported to authorities. Statutes
vary somewhat from state to state regarding detailed definitions of child abuse and neglect, but all states
mandate that health care providers( including dentists) report child abuse or neglect when it is suspected. It is
important to emphasize that one is required to report suspicious of child abuse and one need not to have proof.
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WHO IS ABUSED
Children from all walks of life may be victims of child abuse or neglect, no age, race ,gender or socioeconomic
level is spared. statistics in child abuse reflect only those cases known or suspected, and all studies struggle with
the components of the unknown. In 2006, the U.S. department of health and human services reported almost
65% of child maltreatment encompasses neglect ,16% involve physical abuse, 9% involve sexual abuse and 7%
involve emotional abuse. A little more than 2% of victims experienced medical neglect. Children who are
victims of one form of maltreatment often are maltreated in other ways as well.

EXAMINING CHILD ABUSE/NEGLECT

The dental and his staff should be educated to get a visual impression of the child as he enters the reception
room. The practitioner should notes whether the child and parent or guardian has an appropriate interaction.
After evaluating the history in suspected cases of child abuse/neglect the examination for such children should
be incorporated with a routine dental checkup.

COMMON SITES TO BE OBSERVED AND EXAMINED

Many abused or neglected children, due te fear may appear overly vigilant or display a frozen
watchfulness staring constantly. There are no spontaneous smiles and almost no eye contact.
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 and thinning of hair.
Over dressed children should also be noted, long sleeves and high necked shirts or blouses during hot
summer months may be worn to cover signs of physical abuse.
Face and neck should be examined for periorbital echymosis, sclera hemorrhage, ptosis, deviated nasal
septum, cigarette burn marks and hand slap marks.
Corners of the mouth are reported (McNees et at, 1975) with binding marks from a gag tied in place for
hours to force the feed.

 Sometimes, a spoon or fork applied with enough force or determination, may result in fractured anterior

teeth or torn frenum.

If moving the child up in the dental chair in a supine position or lifting up motion results in pain, trauma
is to be suspected.

DEFINITIVE CHILD NEGLECT/CHILD ABUSE EXAMINATION

The head and neck being most often involved in abuse cases, dentist is in a unique position to identify child
abuse in routine examination. The definitive child neglect/child abuse examination requires a keen observation
and detailed documentation when suspicion exists.

FOLLOWING AREAS SHOULD B EXAMINED CAREFULLY:

Detailed examination and palpation of the skull looking for subgaleal hematomas and cephalomatomas.
Positive sign of any battle like laceration, scar, bruises.

Body surface that are covered should be examined by lifting up the clothes to the limit they allow. Inner
thighs, arm pits must be checked. The only areas that are not in the purview of the dentist are the
genitalia and buttocks.

PARENT CONSULTATION
Once the suspicion is confirmed, the parent should be informed that an injury has been noticed. If the findings
and explanation are not compatible, or if suspicion still exists, the dentist is mandated by law to contact the
appropriate child abuse/child neglect authority.

INFLICTED BRUISES:Color changes in a bruise during healing.

Cleared

Brown

00

Yellow
Green

RE

Red

Blue
G

Purple
1.2

Swollen
Tender
0-5
5-7

Days

Days

7-10
Days

10-14
Days

2-4

Days

Weeks

Color changes during healing of a bruise:

HUMAN HAND MARKS

TIME

SIGN

Hand marks are prevalent in almost 22%of the cases and can leave various kinds of bruises.

Grab marks or finger tip bruises. Most common are grab marks or squeeze marks, oval shaped bruises
0-2Days

swollen,tender

that resembles finger tips. Sometime squeezing of the cheek leaves a thumb or two three finger mark
0-5Days

red,blue,purple

bruise.
5-7Days
green
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.
7-10Days

yellow

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 bruises.

Crescent shaped bruising facing each other as a result of pinch, primarily due to fingernail.

STRAP MARKS
Strap marks are 1-2 inches wide, sharp border rectangular bruises of various length, sometimes covering
a curved body surface.
Often, 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.

BIZARRE MARKS

Bizarre-shaped bruises wih borders are nearly always infected when a blunt instrument is used resulting

in a belt or a bruises.
The wide assortment of instrument used to abuse children suggests that the caretaker who loses temper

grabs whatever object is handy

Circumferentia tie marks on ankle or wrist can be caused when the child is restained.
Circunferential cuts are due to narrow rope or cord.
A frictional burn or rope burn may result due to a piece or strap of sheeting used to restrain, presenting a

large blister that encircles the extremity.

Gagging abrasion is due to restraining of the crying or yelling of children.

FACIAL INJURIES PREVALENCE IN PHYSICAL CHILD ABUSE

SITE

PERCENTAGE

Scalp

79

Neck

59

Forehead

52

Cheek

49

Lower jaw

48

Upper lip

45(Cameron et al 1986)

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Facial injuries include( in order of decreasing frequency):

Contusions and ecchymosis

Abrasions and laceration
Burns
Bone fractures
Bite marks

INJURIES OF DENTITION INCLUDE

Traumatized or avulsed teeth indicating blunt trauma or pattern injury from instruments.
Discolored teeth indicating repeated trauma.

CHILD PROTECTIVE AGENCIES:

In india police is the concerned authority.
National human right commission (NHRC) also have similar role.
INDIA LAWS FOR CHILD ABUSE:
India has no law on/for child abuse per se
Physical abuse
Violence in home:India penal code(IPC) 323/IPC 324
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.

GOVERNMENT ORGANISATION (GOs) AND NON-GOVERNMENT ORGANIZATION

(NGOs) WORKING AGAINST CHILD ABUSE

The united nations international childrens education fund (UNICEF)

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The child line organization, new delhi.

Ummid sanstha, new delhi.
Asha sevabhav sanstha, Mumbai.
Shakti, Kolkata
National Human Right commission, GOI, new delhi
Organization for children at risk in India, Mumbai
Sparsh Seva Sanstha, Mumbai

SITUATION IN INDIA
Though in India child is considered to be the gift of god, child abuse is still common specially in tribal and
remote areas. It is presumed that 50% of the cases are not reported. Out of 3.8% cases reported majority of
the girls are premi victim for sexual abuse and boys for physical abuse. It is observed that child abuse cases
are not reported due to unusual problem and lack of awareness. However , media exposure has taken a
footstep to awaken the people.

ATTEMPTS TO PREVENT CHILD ABUSE IN INDIA

In India child labour is the commonest type of abuse for which ministry of labor has given notification on
5th February, 1996 in new delhi regarding child labor law in india.
The working condition of children have been regulated in all employments which are not prohibited under
the child labor (prohibition and regulation) Act. Following up on a preliminary notification issued on
October 5,1993 the government has also prohibited employment of children in occupation processes like
abattoirs/slaughter houses, printing, cashew nut descaling and processing and soldering.

Children performs a variety of jobs: some work in factories, making products such as carpets and

matches; Other work on plantation, or in the home.

For boys the type of work is very different because they often work long hours doing hard physical

labor outside home for very small wages.

The government has made efforts to prohibit child labor by exacting child labor law in India
including the 1986 child labor (prohibition and regulation) Act that stated that children under
fourteen years of age could not be employed in hazardous occupations.
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This act also attempted to regulate working conditions in the jobs that is permitted, and put greater
emphasis on health and safety standards.

MANAGEMENT:DOCUMENTATION AND REPORTING

Clinical and medicolegal management of suspected child abuse and neglect involve several basic steps;
medical and dental management, documentation (including photographs) and reporting. As health care
professionals, dentists should be especially sensitive to the need for protecting children from abuse or
neglect. They must, ofcource, treat dental injuries.

TREATMENT

Any medical or dental treatment that is indicated by th childs condition should be provided. A
referral for a complete pediatric history taking and physical examination will assist in identifying

and treating other possibly associated conditions (failure to thrive, anemia).

Medical evaluation should include assessment for medical conditions that can mimic or be confused
with child abuse.

DOCUMENTATION

All data collected in the medical history and physical examination must be documented in a

complete and objective manner. Pertinent positive and negative findings should be included.
Actual comments and behaviors should be recorded, opinions about those behaviors should be
avoided. For visible injuries, photographs should be taken if possible.

REPORTING
The dentist is obligated by law to report suspected findings of child abuse to the appropriate authorities, that
is, child protective service agencies and/or law enforcement officials. Failure to do so may result in the
filing of civil or criminal charges against the dentist. With increased public awareness and inclusion of
courses on child abuse in the dental curriculum, ignorance of the laws of child abuse is not an acceptable
excuse.

PARENTAL CONCERNS
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In most situations, parents should be told of the concerns about possible child abuse or neglect and the legal
requirement to report it to local authorities. This can help maintain the relationship with the patient and
family. It also can be helpful to ask the parent if there has ever been a concern that some one might have
hurt the child. Health care professionals should not make any accusations about who may have caused the
harm.
The major concern must be for welfare of the patient, and may concerns about losing a patient from a
practice should be secondary. Individuals are protected from civil and criminal liability if the report is made
in good

OBLIGATIONS OF THE DENTIST

The privileged quality of communication between the caretakers or the patient and the practitioner is not
grounds for excluding evidence in a judicial proceeding resulting from a report or for failing to make a
report as required by law. Strict confidentiality of records is maintained. Reports and any other information
obtained in reference to a report are confidential and available only to persons authorized to examine them
by the juvenile code. Child abuse and neglect are identifiable in the dental office. Knowledgeable
practitioners must be able and willing to identify, document and report suspicions of child maltreatment.
Awareness, of local child protective community resources and professionals, can facilitate interaction with
the legal system and improve the ability to appropriately protect abused or neglected children.

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REFERENCES
1.Text book of pedodontics(Shobha tondon)-2nd edition.
2.Dentistry for the child and adolescent(Mc Donald).

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