1. Saturday, April 15, 2017
CLINICAL PEDIATRIC DENTISTRY I DSV 441 CHAPTER 2 CHILD ABUSE AND NEGLECT (23-32) McDonald, Avery, Dean. Dentistry For The Child And Adolescent, 8th Ed. 21
PD is the specialized area of dentistry limited to the care of children from birth through adolescence, with additional focus in providing oral care to pts. with special needs
A young child is definitely more than just a miniature adult. Managing and convincing a child as a pt. for any dental procedures or treatment requires extra effort. So the dentist should master these skills and be in a position to manage children.
In the beginning the PD was mainly concerned with extraction and restorations. The trend changed from extraction to preservations. Presently the concept of PD practice is prevention and concentrating on minimal invasion.
Tuesday 17\3\2015
1:00 pm-2:00 pm
OTHMAN AL-AJLOUNI

2. CHILD ABUSE AND NEGLECT
LECTURE OUTLINE
CHILD ABUSE AND NEGLECT
IS IT CHILD ABUSE?
LEGAL REQUIREMENTS
WHO IS ABUSED?
IDENTIFICATION OF POSSIBLE CHILD ABUSE
EVALUATION
MANAGEMENT: DOCUMENTATION AND REPORTING

3. CHILD ABUSE AND NEGLECT
Health care and dental professionals are in unique positions to identify possibly abused child and must be knowledgeable in 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. Discussion of types of child maltreatment, clinical presentation and management of such issues, and documentation and reporting of suspected child abuse.

4. IS IT CHILD A B U S E?
Variety of experiences are on part of a responsible caretaker, includes physical or mental injury, sexual abuse, and negligent treatment or maltreatment of a child less than 18 years of age by a person responsible for child's welfare. No one individual is responsible for "deciding" what is abuse or neglect. Identification, treatment, and intervention are tasks of professionals from multidisciplinary backgrounds working together to provide care and evaluation in best interests of child. Anger expressed actively or passively against child is unplanned, but nonetheless can result in significant injury 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.

5. PHYSICAL ABUSE
Most easily recognized form of child abuse. Battered child syndrome was initially described Clinical picture of physical trauma or failure to thrive in which explanation of injury was NOT consistent with severity and type of injury. Not accidental; punishment that is inappropriate for 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 recognized by PATTERN of injury and/or its INCONSISTENCY with history. Bruises, welts, fractures, burns, and lacerations. 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 mouth.

6. SEXUAL ABUSE
Sexual abuse and sexual misuse are frequently interchanged terms that denote any sexually stimulating activity that is inappropriate for child's age, level of cognitive development, or role within the family. Trauma to mouth may result from sexual contact.

7. NEGLECT
Inattention to the basic needs of a child, such as food, clothing, shelter, medical care, education, and supervision. While 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 relate to periods of time without supervision, and responsibilities of child when 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."' 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 impact of such neglect on physical well-being of child.

8. EMOTIONAL ABUSE
It is difficult to demonstrate direct or causal link between emotional and verbal abuse, and harm to child. Such harm is usually seen as abnormal behaviors or mental health problems that are multifactorial in origin. Emotional and verbal abuses involve interactions or lack of interactions on part of caretaker that inflict damage on child's personality, emotional well-being, or development. Continuous isolation, rejection, degradation, terrorization, corruption, exploitation, or denials of affection are examples of behaviors that frequently have damaging effects on child.

9. FACTITIOUS DISORDER BY PROXY
Perhaps the most difficult form of child maltreatment to identify and treat is a factitious disorder—factitious disorder by proxy, Munchausen syndrome by proxy, or pediatric condition falsification. 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 present with persistent and recurrent illnesses that cannot be explained, signs and symptoms that do not make sense clinically, and problems that are rare, unusual, or bizarre. 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.

10. LEGAL REQUIREMENTS
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 abuse and one need NOT have proof. It is job of social and legal authorities to determine whether abuse has occurred and what intervention is legally necessary.

11. 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. Approximately 50% to 65% of child maltreatment encompasses neglect and 25% involves physical abuse; sexual abuse and emotional abuse account for majority of remaining cases. The average age of identification of maltreatment victims is 7. 4 years; 49% are male; and 68% are white, 21% are black, and 11% belong to other ethnic groups. 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; they are physically abused slightly more than average. Family characteristics overrepresented considered risk factors include female head of family, receipt of public assistance and thus lower income, presence of more children in home, and presence of spousal abuse, drug or alcohol abuse, or significant health or economic stresses. Risk factors play a role, but ultimately every child is a potential victim

12. IDENTIFICATION OF POSSIBLE CHILD ABUSE
One must be willing to consider diagnosis of abuse to make diagnosis. A number of characteristics of child, parent, or story given to explain 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. Many of signs or 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 child's age and developmental level and vary with child's experiences and resiliency.
Physical Indicators
Behavioral Indicators

13. IDENTIFICATION OF POSSIBLE CHILD ABUSE
PHYSICAL INDICATORS Pattern of injury is not consistent with account explaining it. A bruise in shape of a handprint on cheek does not result from a fall down stairs. Accounts from two or more individuals (such as parents or a parent and child) that conflict with each other or that change over time. Unexplained injuries on face, mouth, or lips; bruises; and scattered significant bruises on different surface areas at various stages of healing. Unexplained fractures of head, multiple fractures in varying stages of healing, injuries to growth centers in bone, and fractures in children younger than 2 years of age. Skull fractures may result from a fall from table to floor, but accompanying severe retinal hemorrhages or subdural hematoma with brain injury makes that explanation untenable. Burns are another form of recognizable child abuse; intentional cigarette and immersion burns.

14. IDENTIFICATION OF POSSIBLE CHILD ABUSE
BEHAVIORAL INDICATORS Include withdrawal, depression, poor school performance, regression in developmentally appropriate behavior, acting out, clinginess, and somatic complaints. Inappropriate affection toward others or extremely wary and distant in social interactions. Children who are afraid to go home, are frightened by their parents, or report injury by caretakers. Lack of concern or inappropriately high levels of concern in relation to severity of child's injury. Parents defensive and hostile when questioned or may refuse hospitalization and testing for child. Explanation for injury inconsistent with pattern or child's abilities, or explanation change when perpetrator realizes first story is not believed. Delay in seeking medical care for obvious injury, repeated ingestions of harmful substances, repeated hospitalizations, or excessive use of medical care for an apparently well child. Children whose basic needs for medical and dental care, food, clothing, shelter, or education are not being met.

15. EVALUATION
Trauma to the orofacial structures is a frequent manifestation of child abuse. Dental practitioner may be first person to identify abused child. Any evaluation requires a medical history and physical examination. History should be a complete dental and medical history. Details regarding any trauma should be complete and obtained separately from more than one source (i.e., parent and child) if possible. Open- ended questions should be used; those with a yes-no response must be avoided. Details should include who witnessed injury and who was with child when it occurred, where child and supervising adults were, and what exactly happened. Questions should include how and when incident occurred. Once enough information is obtained that the dentist is suspicious of child abuse or neglect, detailed questioning should be suspended.

16. COMMUNICATION WITH THE PATIENT
Professionals who are identifying and reporting suspected child maltreatment will have to talk to children in most circumstances to clarify a possible suspicion. They should not, however, be conducting investigative interviews of children to learn all the details or sort out truthfulness of comments. A suggested guideline is the following: if based on your knowledge and experience you have reason to believe child may have been abused or neglected, report it. Further detailed interviewing by a noninvestigating professional is neither necessary nor appropriate; that is job of child protective service agencies. If child is talking and wants to disclose more, it is appropriate to listen and provide support.

17. PHYSICAL EXAMINATION
Examination include entire body that is exposed without undressing child. Examination begins before patient is even back in operatory. Observe patient's posture, gait, and clothing. Dental staff should be trained in recognizing abuse and neglect so that they may alert dentist of their suspicions. Inappropriate dress may be an indication of neglect and/or abuse. For example, a child who appears with a long-sleeved shirt in middle of hot summer may be dressed in this manner to cover old injuries. Inappropriate Behavior. A lack of spontaneous smiling and avoidance of eye contact indicators. Start at top, beginning with hair and scalp, and systematically work down. Alopecia without an underlying medical cause may be an indicator of malnutrition or hair pulling. Continue by looking at nose and nasal septum. A deviated septum or clotted blood may be an indicator of previous trauma. Look for any periorbital ecchymosis, ptosis, and deviated or unequal pupils, which indicate significant facial trauma.

18. PHYSICAL EXAMINATION
If any question exists of possible abnormality, referred to a pediatrician or neurosurgeon familiar with child abuse as soon as possible. Any bruise in shape of an object, such as a belt, looped cord, handprint, or hanger. Varying color of bruises noted to identify several stages of resolution that would indicate ongoing trauma. Neck should be examined for evidence of rope burns or bruises that may indicate attempted strangulation. Severe shaking can result in large bruises on back of neck that may indicate brain damage. Physical trauma to child's chest or ribs may elicit a painful response from child if a lifting motion is used to slide child up to top of dental chair during examination.

19. PHYSICAL EXAMINATION
Presence of adult bite marks may be a sign of physical abuse, sexual abuse, or neglect. Documented and photographs taken, if possible, at time they are first observed, since they tend to fade rapidly. A forensic dentist or bite mark expert should be consulted as soon as possible when adult bite marks are suspected. Any visible patterns of injury should be photographed if possible. On completion of general physical examination, dentist should examine teeth and supporting structures. Note any missing teeth or previously traumatized teeth (avulsions, luxations, intrusions, or fractures) and pay especially close attention to any soft tissue injuries. Mandible should be examined for any deviation on opening, range of motion, trismus, and occlusion at rest. Maxilla should also be examined for any mobility indicating a facial fracture. Bleeding under tongue may indicate a fracture of body of the mandible.

20. PHYSICAL EXAMINATION
Note the maxillary labial frenum and lower lingual frenum. A torn maxillary frenum on a child who is too young to walk indicates possible trauma to mouth from a slap, fist blow, or forced feeding. A torn lingual frenum could be indicative of sexual abuse or forced feeding. Bruising or petechia of soft and hard palate may indicate sexual abuse. If any evidence of infection or ulceration is noted, specimens should be cultured for evidence of a sexually transmitted disease, such as gonorrhea, syphilis, or venereal warts. Child with extensive, untreated dental caries, untreated infection, or dental pain may be considered a victim of physical neglect. Taking a good medical and dental history and making repeated attempts to obtain appropriate treatment for child will help sort out these issues. Dental neglect can cause significant pain, discomfort, and possible disability.

21. 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. They must treat dental injuries. It is also important for dentists to know that they are legally mandated to report suspected child abuse or neglect. Reporting is initiated simply with a telephone call to the appropriate child protective service agency. Dentists are mandated to report based on "reasonable suspicion," and they are not responsible for any further investigation. Treatment
Documentation
Reporting
Parental Concerns
Obligation of the Dentist

22. MANAGEMENT: DOCUMENTATION AND REPORTING
Treatment
Any medical or dental treatment that is indicated by the child's 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, and so on). Medical evaluation should include assessment for medical conditions that can mimic or be confused with child abuse. A young child (younger than 18 months to 2 years) who has suffered a fracture should be examined by means of a skeletal survey to detect other fractures; children with bruising need to be examined for possible blood clotting disorders.

23. MANAGEMENT: DOCUMENTATION AND REPORTING
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. The child's name and the date of the photograph should be included in the picture. Most law enforcement officials will take photographs if requested to do so when suspected child abuse is reported. When suspected maltreatment is reported to authorities, the time, date, and method of reporting (phone or written report) should be documented in the medical and dental record.

24. MANAGEMENT: DOCUMENTATION AND 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.

25. MANAGEMENT: DOCUMENTATION AND REPORTING
PARENTAL CONCERNS
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. Health care professionals should not make any accusations about who may have caused the harm. Simple statements such as the following should be used: "Based on my training, I am concerned that this injury could not have happened this way. Because of this, I am required by law to make a report to Child Protective Services. In those situations in which a child is suspected to have been significantly harmed in the home, in which the parent is expected to be violent, or in which possible retribution against the child for having told is a concern, it may be more prudent to contact authorities and have them present to protect the child before parents are told. The dental professional has no legal obligation to inform parents that abuse or neglect is suspected or will be reported; some situations may best be handled by not telling them at the time a report is filed. The major concern must be for the welfare of the patient, and any 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 faith. When the dentist's action is presented to parents as motivated by concern for the child and by an attitude of "let' s figure out what is going on," many parents are eventually appreciative and will continue to seek support and care from the reporting professional. There should be no reluctance on the part of the dentist to report suspected child abuse because of concern that it will require a great deal of time. In most cases after the initial report has been filed no further involvement is necessary on the part of the dentist, and few cases require a court appearance. It is possible to report suspected child abuse anonymously, but it is preferred that you give your name so that the agency can contact you if there are any further questions.

26. MANAGEMENT: DOCUMENTATION AND REPORTING
OBLIGATION 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. Some state statutes stipulate that a mandated reporter who fails to make a report when abuse or neglect is suspected may be liable for proximate damages caused by the failure to report. Criminal liability is another possibility. The health care professional must remember that it is suspicions of child abuse or neglect that must be reported; proof is not required. It is the responsibility of child protective service agencies and law enforcement officials to investigate suspicions and determine if intervention is necessary. The health care professional can assist by providing as much information as possible through communication and coordination. Investigating professionals cannot do their jobs if the health care professional does not share detailed information regarding why the suspicions exist. Health care professionals unhappy with the outcome of system intervention (e.g., that nothing was done) are usually those who would not or did not provide the information available that would assist authorities in making the best informed decisions. If the health care professional feels that a bad decision is being made, a follow-up phone call to the assigned caseworker or caseworker's super-visor to clarify concerns and interventions is appropriate. Many misperceptions exist about what interventions are possible legally. Communication and coordination can improve everyone's knowledge and understanding about a child's needs and what can be done to meet them. 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.