While physical abuse may be identified by the nature and frequency of injuries, neglect is more elusive. Yet most oral healthcare providers will encounter cases of neglect - particularly dental neglect - sooner or later. An accepted definition of dental neglect is the failure of a parent or guardian to secure treatment for visually untreated caries, oral infections, or any other condition of the teeth and supporting structures that:

• makes routine eating difficult or impossible
• causes chronic pain
• delays or retards a child's growth or development
• makes it difficult or impossible for a child to perform daily activities such as playing, working or going to school.

Recognizing dental neglect is important because, in many cases, it has been associated with general healthcare neglect. One reason for dental neglect is that many parents are under the false impression that the deciduous teeth are unimportant, and that their care may be ignored. The ability to pay for treatment may influence the decision to seek care. Nevertheless, it is a mistake to confuse intentional neglect with poverty or ignorance.

For example, a public health dentist or dental hygienist may be screening a group of indigent children and observe a child with rampant caries, pulp polyps, and multiple abscesses who is in acute pain from oral infections. While the child may appear to be neglected, a discussion with the child's parents may reveal that they were unaware of the cause of the problems. Dental neglect becomes a reportable issue when the parent has been advised as to the extent of the child's oral condition and the consequences for failure to provide treatment, and, based on the family's resources, does nothing to resolve the situation for the child. The oral healthcare provider can go one step further by helping the parent find governmental assistance to treat the child. Contacting the Office of Oral Health at the Arizona Department of Health Services, (602) 542-1866, for a referral to a low-cost dental clinic is the first step in this process.

 
Behavioral Indicators of Child Abuse

Behavioral indicators also may help health professionals spot child abuse and/or neglect; however, these signs are considerably more difficult to assess. Look for the following behavioral signs to help make your determination if the child might be physically or sexually abused:

• Is the child wary of adult contact or does he or she display passive behavior to avoid conflict or seem frightened of their parents and afraid to go home? Does the patient avoid your touch?
  
• Does the child seem overly aggressive, violent, demanding or display abusive behavior? Does he or she exhibit dramatic mood changes?
  
• Do the parents seem extremely overprotective of their child?
  
• Does it seem the child is lying about any abuse so the parent will not retaliate? When talking to you, does the patient make indirect hints about abuse?
  
• Is the child's behavior consistent with that of other children at the same maturity level, based on your experiences in the dental setting?

 
Documentation

Proper documentation is a key to moving from suspecting abuse is taking place to taking action to protect the child. Complete and accurate descriptions must be recorded in the child's dental record. Begin with the size, shape, color, location and radiographic description (if applicable) of the injury. Identify the number of injuries present at each site. Sketch the injury and the body part where it is located, if necessary. Detail the child's behavior alone and as they interact with their parent, if it appears suspicious. Document all aspects of your interviews with the child and parent. Record verbatim the comments made by the child and parent explaining the injury. And sign and date the chart, and obtain the signature of a witness to the injuries and interviews.

 
Interviewing

Another key step in recognizing and reporting abuse is conducting and documenting interviews with the child and parents. Consider the explanation offered about the child's injuries. Is the parent vague when you say you have noted an injury or lesion, offering an improbable explanation? Does the reported history not fit in with the clinical presentation? Is the injury not in keeping with the history given or the developmental capabilities of the child? Does the explanation for the injury just not seem to make sense? Does it appear the child has been coached not to reveal information about the incident?

If possible, interview the child with a witness present, but without family members in attendance, so the child may speak freely without fear of reprisal. Use open-ended, non-threatening questions that require a descriptive answer rather than just a "yes" or "no" answer. For instance, the child could be asked "How did you knock your tooth out?" Do not suggest answers for the child or press the child for answers to questions he or she is unwilling to answer. Establish a trusting environment for the child and try to use his or her own words and terms while discussing the situation. Young children do not usually fabricate stories of abuse; however, they may decide not to volunteer information, believing that they will be separated from the parent, or that there will be retaliation. Is the child's explanation consistent with the parent's explanation?

Interview the parent separately from the child, ideally with a witness present. Tell the parent the reason for the interview, attempt to be objective, discuss your concerns regarding the child's injury or lesion, reassure the parent of your support, and do not attempt to prove abuse or neglect. A non-abusive parent will be willing to openly discuss the child's injury and provide all details when queried. Determine if the parent's story conflicts with the child's story before making your determination to report the case to the appropriate authorities.

In cases of severe abuse where you suspect the parents may abscond with the child, it is recommended to notify the appropriate authorities prior to informing the parents of your suspicions of abuse. However, the ideal situation is that the oral healthcare professional make an effort to gain as much information as possible, as well as the confidence of the parent.

 
Reporting

In Arizona, all members of the dental team are mandated to report suspected cases of child abuse and neglect, and have a professional and ethical responsibility to do so. In Arizona, as in many states, failure to report a suspected case is considered a misdemeanor. Keep in mind that you are only reporting a suspected case, you are not making a diagnosis or accusation of abuse. Additionally, Arizona law states, "A person furnishing a report...shall be immune from any civil or criminal liability by reason of such action unless such person acted with malice."

To report a case of child abuse or if you have any questions, contact Arizona's state-wide, toll-free Child Abuse Hotline at 1-888-SOS-CHILD.

 
Conclusion

Many children who have been severely abused will die as a consequence of reabuse if they are returned to their abusive environment without intervention by the appropriate professionals/therapists. All oral healthcare providers must assume a personal responsibility to the children they treat by becoming proactive and acquainting themselves with Arizona's rules regarding child abuse reporting and documentation.

If you suspect child abuse or neglect, make a report. The worst thing that can be done for an abused child is nothing!

 

The author of this article, Debby Kurtz-Weidinger, RDH, M.Ed, is a contractor with the Arizona Department of Health Services, Office of Oral Health, and is a part-time faculty member at the Phoenix College Dental Hygiene Program. She currently is assisting in the coordination of the P.A.N.D.A. (Prevent Abuse and Neglect through Dental Awareness) program in Arizona which will provide education on the issues of child abuse and neglect and the dental professional's responsibility in detecting and reporting it.

 
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