CHAPTER 2 Child Abuse and Neglect
Child abuse and neglect affect millions of children in the United States each year. The health harms from child maltreatment are long reaching and clearly correlate with morbidity in adulthood. 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.1 This chapter includes 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.
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 or psychological abuse, and neglect in its many forms. Children living in violent homes are increasingly recognized as victims of maltreatment. Many gray areas exist in the determination of threat or harm, and disagreements about the “abusive” nature of some experiences 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 backgrounds working together to provide care and evaluation in the best interests of the child.
Maltreatment is not always willful; that is, the harm or injury inflicted is not always the intent of the act. Emotion expressed actively or passively against the child is often unplanned, but nonetheless can result in significant harm or death. Education and prevention efforts may teach parents to redirect their actions and explore more appropriate discipline techniques and ways to manage anger or frustration.
Physical abuse is often the most easily recognized form of child maltreatment. The battered child syndrome was initially described by Kempe and colleagues in 1962 and elaborated further by Kempe and Helfer in 1972 as the clinical picture of physical trauma in which the explanation of injury was not consistent with the severity and type of injury observed.2,3 These injuries are inflicted and not accidental; some result from punishment that is inappropriate for the child’s age, condition, or level of development. Some result from a parent’s frustration and lack of control in acting out anger. Physical abuse is usually recognized by the pattern of injury and/or its inconsistency with the history related. Bruises, welts, fractures, burns, and lacerations are commonly inflicted physical injuries. Approximately 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 and sexual misuse are frequently interchanged terms that denote any sexually stimulating activity that is inappropriate for the child’s age, level of cognitive development, or role within the family. Many definitions incorporate the desire for sexual gratification on the part of one of the participants. In the spectrum of child sex play, sexual experimentation, and parent-child physical-sexual contact, it may be difficult to distinguish normal behavior from lustful intrusion. Sexually abusive acts may range from exhibitionism or kissing to fondling, intercourse, 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. Practitioners should be aware that there are differences in state definitions.
Inattention to the basic needs of a child, such as food, clothing, shelter, medical care, education, and supervision, may constitute neglect. Whereas physical abuse tends to be episodic, neglect tends to be chronic. Determination of neglect also depends on the child’s age and level of development as it relates to periods of time without supervision, the parents’ whereabouts, parental intention, and responsibilities of the child when the child is not supervised or not attending school. The American Academy of Pediatric Dentistry defines dental neglect as “willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.”4 Level of medical and dental care, adequate nutrition, and adequate food and clothing must be considered in light of cultural and religious differences, poverty, community requirements and standards, and the impact of such neglect on the physical well-being of the child.
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 the emotional and verbal abuse and the harm to the child. Such harm is usually seen as abnormal behaviors or mental health problems that are multifactorial in origin. Emotional and verbal abuse involve interactions or lack of interactions on the part of the caretaker that inflict damage on the child’s personality, emotional well-being, or development. Harm to the child generally occurs in various ways over a prolonged period. Continuous isolation, rejection, degradation, terrorization, corruption, exploitation, or denial of affection are examples of behaviors that frequently have damaging effects on the child.
Perhaps the most difficult form of child maltreatment to identify and treat is a factitious 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, produces false signs or symptoms, and fabricates illnesses in the child that result in extensive medical evaluations, testing, and often prolonged hospitalizations. The fabrication may be deliberate to gain medical attention, the result of parental psychosis, or simply fraudulent to obtain money or services. Because health care providers are often dependent on the parental history of the child’s illness, it takes some time for the practitioner to realize the inconsistencies and possibly fabricated or exaggerated nature of the complaints. These children may present with persistent and recurrent illnesses that cannot be explained, with signs and symptoms that do not make sense clinically. The bizarre nature of many of these cases makes them almost unbelievable to professionals involved, and an unbelieving social and legal system has considerable difficulty protecting a child.
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 suspicions of child maltreatment and one need not have proof. Once reported it is the responsibility of social and legal authorities to determine the needs of the child and family, whether maltreatment has occurred, and what intervention or service is legally allowable or necessary.
Children from all walks of life may be victims of child abuse or neglect-no age, race, gender, or socioeconomic level is spared. Statistics on child abuse reflect only those cases known or suspected, and all studies struggle with the component of the unknown. In 2006, the U.S. Department of Health and Human Services reported almost 65% of child maltreatment encompasses neglect, 16% involves physical abuse; 9% involves sexual abuse, and 7% involves 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.
Sociodemographic characteristics of maltreated children vary somewhat by type of abuse or neglect. The average age of identification of maltreatment victims is 7.4 years; 48% are male; 49% are white, 23% are black, and 18% are Hispanic. Females are slightly overrepresented as abuse victims because sexual abuse is more prevalent among females. The youngest children (infants to 2 years) tend to be neglected most often and sexually or emotionally abused least often. Older children (12 to 17 years) are the least neglected, but the most sexually and emotionally abused. Family characteristics overrepresented among families of maltreated children and therefore considered risk factors include the presence of more children in the home, lower socioeconomic status, spousal abuse, drug or alcohol abuse, and significant health or economic stresses. Risk factors play a role, but ultimately every child is a potential victim.
As stated earlier, child abuse and neglect are not identified if they are not considered as a diagnostic possibility. One must be willing to consider the diagnosis of abuse to make the diagnosis. A number of characteristics of the child, parent, or story given to explain the child’s condition may lead a professional to suspect child maltreatment.
Indicators of child abuse and neglect are those signs or symptoms that should raise one’s suspicions of the possibility of child maltreatment. The presence of such indicators does not “prove” maltreatment, but should lead one to be more thorough in thinking through a medical versus abusive or neglectful etiology. Many of the signs and symptoms are nonspecific and may be present for a variety of reasons-child abuse is only one of those reasons. Indicators of abuse and neglect often depend on the child’s age and developmental level, and vary with the child’s experiences and resiliency.
Situations raising the strongest suspicions and the most easily recognized maltreatment cases are those in which the pattern of injury is not consistent with the account history offered to explain it. The history should be consistent with the injury as it relates to mechanism of the injury, the timing of the injury, and the developmental level of the child. For example, a 3-month-old (nonambulatory) child is not going to sustain a spiral femur fracture from crawling. A bruise in the shape of a hand print on the cheek does not result from a fall down the stairs (Fig. 2-1). Accounts from two or more individuals (e.g., parents or a parent and child) that conflict with each other or that change over time are also very suspicious. Any significant injury that is reportedly “unwitnessed” should raise concerns of possible abuse.