Child abuse and neglect are serious global problems and can be in the form of physical, sexual, emotional or just neglect in providing for the child's needs. These factors can leave the child with serious, long-lasting psychological damage. Child maltreatment is a complex life experience occurs when a parent or caregiver does an intentional or potential damage to a child, including acts of commission and omission. Child abuse is not an uncommon event, but it is not always recognized. Identifying the real number of maltreated children is a challenge because of the large variability in reported prevalence data across studies. It is associated with important economic and social costs (such as physical and mental health, productivity losses, child welfare, criminal justice and special education costs) due to its high prevalence and its long-term and short-term consequences.
Child abuse is prevalent in every segment of the society and is witnessed in all social, ethnic, religious and professional strata.
Child maltreatment has been associated with poor emotional, cognitive, and physical health functioning both during childhood and later in life.3 According to the United Nations Convention on the Rights of the Child (UNCRC), children are entitled to basic rights of protection, including protection from abuse, neglect, exploitation, and violence.10 Maltreatment is all forms of physical and/or emotional ill-treatment, sexual abuse neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.4
I.
According to WHO: Physical abuse, Sexual abuse, Emotional abuse
According to AAPD
i. Physical abuse- oral injuries, bite marks
ii. Sexual abuse – oral and peri-oral injuries, bite marks
iii. Bullying
iv. Human trafficking
v. Dental neglect
Physical abuse is the inflicting of physical injury upon a child. This may include burning, hitting, punching, shaking, kicking, beating or otherwise harming a child. Craniofacial, head, face, and neck injuries occur in more than half of child abuse cases. Oral injuries may be inflicted with instruments such as eating utensils or a bottle during forced feedings, hands, fingers, scalding liquids, or caustic substances. This form of abuse may result in contusions; burns or lacerations of the tongue, lips, buccal mucosa, palate (soft and hard), gingiva, alveolar mucosa, or frenum; fractured, displaced, or avulsed teeth; or facial bone and jaw fractures. Some serious injuries of the oral cavity, including posterior pharyngeal injuries and retropharyngeal abscesses, may be inflicted by caregivers who fabricate illness in a child (Levin AV) to simulate hemoptysis or other symptoms requiring medical care.
The clinical report from the American Academy of Pediatrics (AAP) entitled “The Evaluation of Suspected Child Physical Abuse” provides additional guidance (Christian CW) that is useful in the medical assessment of suspected physical abuse includes the following:
Standard history including medical, developmental, and social history.
Family history, especially of bleeding, bone disorders, and metabolic or genetic disorders.
Pregnancy history: Wanted/ unwanted, planned/unplanned, prenatal care, postnatal complications, postpartum depression, delivery in nonhospital settings.
Familial patterns of discipline. Child temperament: Whether the child is easy or difficult to care for; whether there is excessive crying in an infant; parents‟ expectations of the child‟s behaviours and development.
History of abuse to child, siblings, or parents and previous and/or present CPS involvement with the family.
Substance abuse by any caregivers or people living in the home; mental health problems of parents; past arrests, incarcerations, or interactions with law enforcement; and domestic violence (which may be necessary to ask of each parent or caregiver individually).
Social and financial stressors and resources.
Sexual abuse is inappropriate sexual behaviour with a child. It includes fondling a child's genitals, making the child fondle the adult's genitals, intercourse, incest, rape, sodomy, exhibitionism and sexual exploitation. Oral and perioral gonorrhea in prepubertal children (which is diagnosed with appropriate culture techniques and confirmatory testing) is pathognomonic of sexual abuse but is rare. Rates are higher in sexually abused adolescents (12% with gonorrhea; 14% with Chlamydia).
When oral-genital contact is confined by history or examination findings, universal testing for sexually transmitted infections within the oral cavity is controversial; the clinician may consider risk factors (e.g. chronic abuse or a perpetrator with a known sexually transmitted infection) and the child‟s clinical presentation when deciding whether to conduct such testing.
Accuracy to diagnose sexually transmitted infections of the oral cavity is increased if evidence is collected within 24 hours of exposure in prepubertal children (Girardet R, Bolton K) and within 72 hours in adolescents.
Bite Marks: Acute or healed bite marks may indicate abuse. Human bites compress flesh and can cause abrasions, contusions, and lacerations but rarely avulsions of tissue. An intercanine distance (i.e., the linear distance between the central point of the cuspid tips) measuring more than 3.0 cm is suspicious for an adult human bite.35 Bite marks should be suspected when ecchymoses, abrasions, or lacerations are found in an elliptical, horse shoe shaped, or ovoid pattern.
Thirty percent of children in the sixth to 10th grades report having been bullied and/or having bullied. Children with orofacial or dental abnormalities (including malocclusion) are frequently subjected to bullying and as a result, may suffer serious psychological consequences, including depression and suicidal ideation. Children who reported physical abuse, intimate partner violence, forced sex, and bullying were found to also report poor oral health. Health care providers (including dental providers) can ask patients about bullying and advocate for anti-bullying prevention programs in schools and other community settings.
Human trafficking is a serious child health issue involving medical and dental ramifications, among others. The US Department of State defies human trafficking as “The recruitment, harbouring, transportation, provision, or obtaining of a person for labour or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. Often these, children most commonly experience sex trafficking, “in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age”.
Human trafficking in India: According to the National Crime Records Bureau (NCRB) study (YEAR), the common causes of trafficking were forced marriages, child labour, domestic help and sexual exploitation, among others.
Childhood emotional abuse is a more hidden form of childhood maltreatment, which can be characterized as degrading, terrorizing, isolating, denying/rejecting and exploitive/corruptive caregiving. Emotional abuse itself is associated with a myriad of neuropsychosocial problems including disturbance in brain limbic systems, dissociative symptoms, anxiety, depression, low self-esteem, hostility and delinquency.
WHO has defined emotional abuse as: "Emotional abuse includes the failure to provide a developmentally appropriate, supportive environment, including the availability of a primary attachment figure, so that the child can develop a stable and full range of emotional and social competencies commensurate with her or his personal potentials and in the context of the society in which the child dwells.
WHO, 1999 defines child neglect as the failure to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter, and safe living conditions. Typically, neglect involves omissions that are repeated over time, and it is the pattern of omissions that makes the behaviour neglectful (if a child misses one single feeding, true harm is difficult to determine; however, repeated missing feedings can result in failure to thrive or even more serious health concerns, including death).
The child might show the following general indicators of abuse
i. Be afraid or reluctant to go home, or might run away
ii. Show unusual aggression, rages, or tantrums
iii. Flinch when touched
iv. Have changes in school performance and attendance
v. Withdrawl from family, friends, and activities previously enjoyed
vi. Have poor self-esteem (e.g., describe himself or herself as bad, feel punishment is deserved, be very withdrawn) or
vii. Have suicidal thoughts or exhibit self-destructive behaviour (e.g. self-mutilation, suicide attempt, extreme risk-taking behaviour).
WHO 1999 defines child neglect as the failure to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter, and safe living conditions. Neglect involves acts of caregiver omissions, whereas abuse involves acts of commission.2
Medical: Failure/delay in seeking medical care, Noncompliance with plan of care
Supervision/safety: Car seats/seat belts, Ingestion, Guns/other weapons, Intimate partner violence
Education: Truancy, Noncompliance
Dental: Failure to seek care, Caries
Nutrition: Failure to thrive, Obesity, Noncompliance to prescribed diet
Prenatal drug exposure
Shelter/home: Homelessness, Safe, Clean
Hygiene/clothing
Nurturance and affection/love: Abandonment, Ignoring/apathetic care
It is defined by the AAPD, as the “wilful failure of parent or guardian, despite adequate access to care, 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.”
This neglect is seen at each and every step of life with different reasons involved with it.
Salient features of dental neglect include failure to seek or delay in seeking dental treatment, to comply with treatment plan, and failure to implement. Early lesions that progress to cavity in 2-3 years and these cavities can further give rise to symptoms such as pain and swelling, which are also considered to be features of neglect.
Dental caries, periodontal diseases, and other oral conditions can lead to pain, infection, loss of function, and worse if left untreated.
To accurately diagnose medical neglect, the following criteria are necessary
a. The child is harmed or at risk of harm because of lack of health care.
b. The recommended health care offers significant benefit to the child.
c. The anticipated benefit of the treatment is significantly greater than its negative adverse effects, ensuring that reasonable caregivers would choose treatment over non treatment.
d. Access to health care is available but not used.
It
The PNP may also be confronted with nutritional neglect
Aside from the immediate physical injuries children can experience through maltreatment, a child’s reactions to abuse or neglect can have lifelong and even intergenerational impacts
Types of consequences: Physical Health Consequences, Psychological Consequences, Behavioural Consequences and Societal Consequences21
Some long-term physical effects of abuse or neglect may occur immediately (e.g., brain damage caused by head trauma), but others can take months or years to emerge or be detectable. There is a straightforward link between physical abuse and physical health, but it is also important to recognize that maltreatment of any type can cause long-term physical consequences. Childhood maltreatment has been linked to higher risk for a wide range of long-term and/or future health problems.22
Child abuse and neglect can cause a variety of psychological problems. Maltreatment can cause victims to feel isolation, fear, and distrust, which can translate into lifelong psychological consequences that can manifest as educational difficulties, low self-esteem, depression, and trouble forming and maintaining relationships.23
Victims of child abuse and neglect often exhibit behavioural difficulties even after the maltreatment ends. The following are examples of how maltreatment can affect individuals’ behaviours as adolescents and adults. Unhealthy sexual practices, Juvenile delinquency leading to adult criminality, Alcohol and other drug use.24
Although the physical, psychological, and behavioural consequences of child abuse and neglect weigh heavily on the shoulders of the children who experience it, the impact of maltreatment does not end there. Society pays a price for child abuse and neglect in both direct costs (e.g. hospitalizations, foster care payments) and indirect costs (e.g. long-term care, lost productivity at school, juvenile and criminal justice systems costs).23
The Constitution of India provides that the state, as a directive principle of state policy, must seek to ensure “that children are given opportunities and facilities to develop in a healthy manner and in conditions of freedom and dignity and that childhood and youth are protected against exploitation and against moral and material abandonment.”25
The government of India ratified the United Nations (UN) Convention on the Rights of the Child on November 12, 1992.On April 26, 2013, the government of India adopted a new National Policy for Children, 2013, which replaced the 1974 child policy.26
History
The adoption of the National Policy for Children (NPC) in 1974 was the first such major comprehensive initiative taken by the Government. The policy had set out action commitments to address and honour the national standards and obligations enshrined in the Constitution.
National Commission for the Protection of Child Rights (NCPCR) (2005), the Prohibition of Child Marriage Act (2006), the Right of Children to Free and Compulsory Education Act (2009), the Protection of Children from Sexual Offences (POCSO) Act (2012), and Child Labour (Prohibition and Regulation) Amendment Act, 2016.
Federal Laws
A federal government is a system of government that separates the power between central and state government of the country. It delegates certain responsibilities to each sector so that the central government has its own task to do and state government has its own.
Schemes and Programmes on Child Protection
Some of the existing child protection schemes and programmes include:
A Programme for Juvenile Justice
An Integrated Programme for Street Children without homes and family ties. Under the scheme NGOs are supported to run 24 hours drop-in shelters and provide food, clothing, shelter, non-formal education, recreation, counselling, guidance and referral services for children. The other components of the scheme include enrolment in schools, vocational training, occupational placement, mobilizing preventive health services and reducing the incidence of drug and substance abuse, HIV/AIDS etc.
Childline Service for children in distress, especially children in need of care and protection so as to provide them medical services, shelter, rescue from abuse, counselling, repatriation and rehabilitation. Under this initiative, a telephone helpline, number 1098, runs in 74 urban and semi-urban centres in thecountry.115
Shishu Greha Scheme Scheme
Children, under the age of 18, contribute to 37% of India's population165 with large proportions experiencing great deprivations such as lack of access to basic education, nutrition or health care.28
The first nation-wide study in India on child abuse by the Ministry of women and child development (2007) found high prevalence particularly among young children (5-12 year group) who were the most at risk of abuse and exploitation. Majority (55%) of physically abused (69%) were boys. Most (boys-53%, girls-47 %) of the abuse happened in the family environment by parents (89%).
Physical abuse was more in juvenile justice institutions (70 % of children in conflict with law and 53% of children in need of care and protection) also. Family members and other people were the perpetrators of physical abuse of children living on the street (66 % of boys and 68% of girls). Every two out of three school children reported facing corporal punishment.29
Several types of abuse were reported to be more prevalent among school children. This include ridiculing in the name of caste, family status or physical disability (22%), sexual abuse (24%), harsh punishment at home, including inflicting of minor burns and being tied up (40%), "punishment and blame from parents and teachers" for not scoring marks to their expectations (68%), constant reprimand (71%) etc.30
An analysis of Demographic and Health Surveys (DHS) data showed that spousal violence had been experienced in the previous 12 months by more than 10% of girls aged 15 to 19 in India. The husband‟s relatives remain the main perpetrators of violence and abuse.31
Increased attention in the public discourse and activism around child protection led to the Government of India passing the, „The Protection of Children from Sexual Offences (POCSO)‟ law in 2012. This act criminalizes a range of acts including rape, harassment, and exploitation for pornography involving a child below 18 years of age and mandates the setting up of Special Courts to expedite trials of these offences. However, the issue of CSA (child sex abuse) remains a taboo in India.32
National Commission for Protection of Child Rights (NCPCR) and State Commission for Protection of Child Rights (SCPCRs), who are mandated to monitor the implementation of the POCSO Act, have developed and circulated information, education and communication (IEC) material on POCSO Act.33
All types of child abuse and neglect leave the affected child with long-lasting scars that may be physical or psychological. The exposure by the child to violence during childhood can increase vulnerability of that child to mental and physical health problems like anxiety disorder, depression, etc. and make victims more likely to become perpetrators of violence later in life.
Prevention efforts and policies must directly address children, their caregivers and the environments in which they live in order to prevent potential abuse from occurring and to deal effectively with cases of abuse and neglect that have taken place.
As a moral responsibility to care for children and young people, members of the dental team have both professional and legal requirements to work with other agencies to safeguard and promote the welfare of children.