How to Spot Child Abuse Among Your Patients

Richard Gawel

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About 702,000 children were substantiated victims of child abuse or neglect in 2014, according to the Centers for Disease Control and Prevention (CDC). Additional data indicates that more than one in 10 children experienced abuse or neglect in the past year.

“Child abuse occurs at every socioeconomic level, across all ethnic and cultural lines, all religions, and within all levels of education,” said Camille Kostelac-Cherry, chief executive officer of the Pennsylvania Dental Association.

With these significant totals, the odds are strong that one of your pediatric patients may be a victim of child abuse. Also, state laws require dentists as well as other personnel in the office in many cases to report suspected abuse to the appropriate authorities.

Concerned groups are providing dentists with the tools they need to better identify these victims and get them help that could save their lives, as more than 1,500 children died in the United States from abuse and neglect in 2014.

Know the Physical Signs

The CDC defines physical abuse as the use of physical force against a child. Sexual abuse involves engaging a child in sexual acts. Emotional abuse refers to behaviors that harm a child’s self-worth or emotional well-being. And, neglect is the failure to meet a child’s basic physical and emotional needs.

“Most states have a child protective services law, and each of those laws will define child abuse very specifically,” said Kostelac-Cherry. “Most of those definitions will also define the age of a child. Generally, it’s from newborns up to 18 years of age.”

Dentists may begin to suspect neglect, for example, when pediatric patients have significant tooth decay that seems to have accumulated over a prolonged period of time. These cavities do more than cause substantial pain. They also may affect the child’s overall health.

“It will hurt to bite down. It will hurt to drink,” said Kostelac-Cherry. “That will affect their ability to thrive. It could lead to malnutrition, if the child is not able to get enough nutrients because of rampant caries. They are also more prone to infection.”

Dental neglect, then, is the willful failure of the parent or caregiver to follow through with any kind of dental treatment that is necessary to give the child a level of oral health essential to function adequately, free of pain and infection while eating enough to grow.

“Children who have rampant caries and more infection in their system tend to miss a lot more days of school,” Kostelac-Cherry added. “So dental neglect very much has an impact even on their educational progress.”

Additionally, dentists should look for indicators of physical abuse. According to Kostelac-Cherry, 75% of the injuries suffered by abused children occur to the face, head, neck, and mouth—all areas that dentists are trained to examine.

“There are very clinical indications of slap marks. You can see the handprint and you can see where a lot of the blood pools in between the spaces of fingers. You should look for the pattern of petechiae that form between the fingers of a slap mark,” said Kostelac-Cherry.

Dentists are advised also to look for ligature marks or handprints around the neck that could indicate choking. Pattern bruising may reveal impressions left behind by objects such as belt buckles and electrical cords. Plus, there are differences between accidental and intentional burns from cigarettes, curling irons, stovetops, and boiling liquids. Even bitemarks are suspect.

“The parent may say a bite was caused by the neighbor’s dog,” Kostelac-Cherry said. “But because of your experience, education, and expertise, you know the interarch distance shows that it was not an animal bite and that it likely is a human bite.”

Kids can be clumsy, and accidents are inevitable. But there are other important differences between accidental and intentional injuries. Children who fall on the playground or off of a skateboard, for instance, will see scrapes and bruises on bony protuberances such as their knees and chins. Injuries caused by abuse, though, happen elsewhere.

“As children get older, they tend to be bruised on the back and buttocks because they are more able to defend themselves, so they have defensive wounds as they are running away and their abuser catches them from behind,” Kostelac-Cherry said.

Dentists also may see signs of sexual abuse, which often involves oral contact. There may be symptoms of syphilis such as oral lesions. Genital warts in the oral cavity are another indicator. Dentists are advised to look for soft or hard palate bruising or torn frenums caused by repeated penetration as well.

Know the Behavioral Signs

Even when dentists can’t see the physical injuries, they may be able to infer abuse from the way the child is moving. For example, children who have trouble walking or who are uncomfortable sitting in the dental chair may have been injured in their legs, back, or buttocks. Attitude is another potential indicator.

“Look for a child who is either very compliant or overly compliant for their age, who appears to be fearful of upsetting their parents or making them angry,” Kostelac-Cherry said. “They want to please their parents so they don’t get hurt when they get home. Before they answer any question, they will look at the parent to see if it is okay to answer.”

Conversely, abused children may be overly aggressive since they tend to model the behavior that they have learned. Many times, their behavior is a product of a whole house that suffers from abuse and they are accustomed to violence and aggressive behavior.

While many kids feel anxiety in the dentist’s office, children who are abused also may display significant levels of fear by cringing when the dentist approaches them, for example. They may avoid eye contact and say very little as well, speaking briefly only when prompted.

“Children who have been sexually abused are very, very fearful of oral exams because of the horrible things that have happened to them,” said Kostelac-Cherry. “Look for kids who are socially withdrawn, melancholy, and shying away from physical contact.”

Parental behavior can be very revealing as well. While the dentist is in the operatory or office, personnel at the front desk have a good eye on the waiting room and can observe how parents treat their children there.

“We find that parents who are on absolutely their best behavior in the operatory while the dentist is there show a very much different side of themselves while they’re in the waiting room,” said Kostelac-Cherry.

Office personnel can look for parents who are verbally aggressive toward their children, including yelling at them, threatening them, trying to embarrass them, or using otherwise inappropriate discipline including hair and ear pulling. Or, abusive and neglectful parents may show a complete lack of interest in their child as they wait.

The Next Step

Dentists who see physical injuries should try to determine how they happened. Kostelac-Cherry suggests separating the child from the parent before asking the child about them, though. Otherwise, there is little likelihood of an honest answer. If parents are unwilling to leave the child alone, however, there are ways around it.

“You can separate the child from the parent by taking the child back for radiographs. ‘Sorry, Mom, you can’t come back here. We’re taking x-rays,’” Kostelac-Cherry said. “Then compare their stories to see if there is a difference.”

Kostelac-Cherry also says that dentists should try to have a witness present when they are asking children about their medical history, including the origins of suspicious injuries. Next, dental personnel should make an effort to document those injuries, including photographs.

“In Pennsylvania, we have a special provision under the law that allows mandated reporters of child abuse such as dentists to take pictures or radiographs without the parents’ permission,” said Kostelac-Cherry. “I would suspect that most states have a similar exception.”

Dentists who suspect abuse based on these observations are required to file a report with their appropriate authorities, such as local or state youth services agencies. Typically, dentists do not need physical evidence or any kind of confirmation from the child or parent to make these reports.

“In Pennsylvania, there are protections built into the law so that any mandated reporter who makes a report in good faith is immune from any civil and criminal liability,” said Kostelac-Cherry. “There’s also confidentiality, so their names will not be disclosed to the parents, to the guardian, to the media, and so on.”

In fact, many states have stiff consequences for mandated reporters who fail to act on their suspicions. In Pennsylvania, these penalties range from misdemeanors to felonies. They also are tied to the same penalty that the perpetrator gets for inflicting the abuse.

“If there’s substantial evidence to indicate the abuse has occurred and it’s a misdemeanor 3, a dentist who sees that and fails to report the suspicion could also be punished with a misdemeanor 3,” Kostelac-Cherry said. “And the penalties are increased if a pattern of failing to report emerges.”

Whether or not the dentist should confront the parent with these suspicions, though, is a trickier question. Kostelac-Cherry says that it depends on each individual case, and dentists should trust their own judgment based on how well they know their patients and their parents.

Questions about abuse could lead to a simple denial or to an angry or violent confrontation there in the office. Or, now knowing that they are under suspicion, parents may coach the child to lie in later interactions with protective services. Even worse, abusers may punish their children for telling the dentist about the abuse.

“Never question the parent if you believe that the parent may further retaliate against the child or harm the child for explaining how things happened, especially if in good faith you believe there’s a concern about the immediate safety of the child,” Kostelac-Cherry said.

Yet some good may come out of questioning the parent. Sometimes the child may be with the mother, and she is a victim of abuse at the hands of the child’s father too. Approaching these women may give them the opportunity they need to come forward.

“Sometimes, those caregivers are just waiting for somebody to ask,” Kostelac-Cherry said. “If this is a parent who seems to be a little bit meek and mild herself, she may actually welcome the opportunity to open up about any other domestic abuse that may be occurring.”

Additionally, dental neglect might not be the result of any kind of malice or indifference toward the child. Kostelac-Cherry notes that 30% of children who are abused or neglected nationwide come from families on public assistance, and another 14% come from families who lack the financial resources to meet the family’s daily needs.

“By questioning the parents, you are really opening up the door to allow them access to other social services that are available to them. You don’t need to do it in an adversarial style,” Kostelac-Cherry said. “You can find out that here’s a family that doesn’t even know that there are Head Start programs, parenting classes, transportation available to them so that they don’t need to neglect their children’s dental needs.”

To Learn More

Kostelac-Cherry encourages dentists and other professionals to investigate a program called Preventing Abuse and Neglect through Dental Awareness (PANDA). The regional organizations in this national coalition offer training programs and other resources about recognizing signs of neglect and abuse and intervening in those cases.

For example, the Delta Dental of Kansas PANDA Program notes that 24,000 reports of suspected child abuse and neglect were made in the state last year. Its website includes links to the Kansas Code for Care of Children and the Guide to Reporting Child Abuse and Neglect in Kansas as well as other downloadable materials.

Statewide dental associations offer training as well. The Pennsylvania Dental Association has a series of workshops and seminars scheduled throughout 2016 across the state. These courses will explore how the law defines abuse and neglect, indicators of abuse, clinical and intraoral pathologies, legal responsibilities, reporting procedures, and protections and penalties for reporters.

“These programs are critical, not only for dentists and dental professionals who are required to make these reports, but really for any citizen of the United States who suspects abuse against a child,” Kostelac-Cherry said. “It is a national epidemic.”

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