| Add RSS Feed

September 12, 2008

By Theresa S. Gonzales, DMD, MS, MS, and Patricia L. Blanton, DDS, MS, PhD

Maltreatment of children by their parents and/or primary caregivers has been with us for a very long time. Family violence can be traced back to biblical times. Extreme parental punitiveness has been recognized only relatively recently as a serious problem that demands intervention. While several U.S. court cases in the 19th century dramatized the plight of abused children (largely through the actions of the Society for the Prevention of Cruelty to Animals — SPCA) and established legal and social precedents for intervention on behalf of maltreated children, widespread public recognition of child abuse did not occur until 1962. That year, Dr. Henry Kempe published a landmark article titled "The Battered-Child Syndrome" and drew national attention to the abuse of children. Perhaps no single publication has had such a profound effect on the welfare of children. Since that time, we have implemented a variety of concepts and laws to combat this societal problem. By 1966, all 50 states had passed legislation regulating child abuse, all of which mandated reporting. By 1986, every state but one required reporting of neglect, and 41 states made explicit reference to reporting of emotional or psychological abuse. Initially, mandated reporting was limited to health-care providers, but this was eventually extended to include teachers, nurses, counselors, and the general public.

Child abuse as a social concept continues to evolve as children's rights are recognized by society. How we define "abuse" has a great impact upon our recognition of it. Child abuse is defined as nonaccidental, physical, emotional, or sexual trauma; exploitation; or neglect that is endured by a child younger than 18 years of age while under the care of a responsible person, such as a parent, sibling, teacher, or other person acting in loco parentis.(1) Approximately 3 million cases of child abuse are reported annually in the United States. Two thousand to four thousand of these cases will result in death. As a practical point, several nationally publicized child abuse/child homicide cases have occurred in Texas over the past several years. The United States has high rates of reported childhood homicide and higher teenage suicide rates than most industrialized countries of the world. Childhood homicide rates have more than doubled over the past 25 years, and there is no indication that this trend is abating. Since so many cases of abuse culminate in fatality, it is important to recognize the clinical indicators of abuse.

Oral aspects of child neglect and abuse are well known to the dental health-care team. The Prevent Abuse and Neglect through Dental Awareness (PANDA) coalitions have trained thousands of dentists and auxiliaries in the recognition and reporting of such injuries. Craniofacial injuries occur in more than 50% of the cases of child abuse. Often these are unexplained injuries that are inappropriately reported by the caregiver or the clinical presentation is inconsistent with the history provided. Other characteristics of orofacial injury in child abuse relate to the multiplicity and repetitive nature of the injuries. These injuries often appear in various stages of resolution. The face and the oral cavity in particular are frequent targets of abuse. Easy access to the child's head as well as the oral cavity's role in communication and nutrition make it particularly susceptible to abuse. Not surprisingly, the oral cavity is a frequent site of sexual abuse in children and oral gonorrhea in prepubertal children is pathognomonic of sexual abuse. Abusive trauma to the face and mouth include all the following:

• Laceration of the labial or lingual frenum — resulting from either being forcefully struck or forced feeding
• Repeated fractures or avulsions of the anterior teeth
• Facial bone and nasal fractures
• Bilateral contusions of the commissures of the lips
• Soft and hard palate ecchymosis/petechiae

Since many abusive-appearing injuries can also occur accidentally, a detailed history of the event should be sought. Parents attempting to conceal abuse often provide discrepant histories as to the nature of the presentation. Any time a discrepant history is given by a parent or caregiver, abuse must be suspected. Delay in obtaining medical and dental care, although not pathognomonic for abuse, should arouse suspicion. A past medical history of other unexplained or inadequately explained injuries should mandate a thorough review of emergency department and inpatient medical records. There are, however, some clinical findings that are virtually pathognomonic of abuse including patterned loop marks, adult human bite marks, immersion burns, and metaphyseal bone fractures often labeled as "bucket handle fractures." Nonorganic failure to thrive is characteristic of parental deprivation/child neglect.(2)

This pattern of injuries including multiple contusions in various stages of resolution combined with the discrepant history provided by the caregiver is characteristic of abuse.

Each week, there are reports in the local and national news of children who are injured or murdered by adults charged with their well being. Often these sensationalized stories are met with public outrage and force us to grapple with the question of why some parents intentionally harm their children. No doubt parenting is a demanding, challenging, and often physically exhausting job that taxes even the most capable person. For example, when a maternal or paternal characteristic such as poor impulse control is coupled with a toddler whose developmental goal is independence, the risk for abuse is great. Children represent our most valuable resource. Studies have shown that abuse occurs at all socioeconomic levels and when it comes to damage, there is no real difference between physical, sexual, and/or emotional abuse. All that distinguishes one from the other is the abuser's choice of weapons. In 2001, a report released from Prevent Child Abuse America estimated that the United States spends $258 million each day as a direct or indirect result of the abuse and neglect of our nation's children. Since conservative estimates were used, the actual annual cost could be higher than its estimate of $94 billion per year. This estimate includes the costs associated with intervening to help and treating the medical and emotional problems suffered by abused and neglected children, as well as the cost associated with the long-term consequences of abuse and neglect to both the individual and society at large.

A delay in seeking medical attention for this child's ruptured ear drum combined with demonstrable contusions suggests physical abuse. This child was well known to child protective services.

Mandated reporters are bound legally and ethically to have their reporting threshold activated when they have a "reason to suspect" that abuse has been committed. State reporting laws do not require mandated reporters to be convinced that child abuse or neglect has transpired in order to make the report. Physicians, dentists, and other mandated reporters are required to submit a report if they have "reasonable cause to suspect," "cause to suspect," or "cause to believe" that a child has been abused or maltreated. Mandated reporters are protected from civil and criminal liability for unsubstantiated reports if the reports were made in good faith. The etiology of child abuse is complex and the profile of the abuser is varied. In spite of these limitations, we need to consider abuse as a symptom of family dysfunction. If a parent feels as though he or she has abusive tendencies, the parent should be encouraged to voluntarily seek help from community advocacy programs. Educational programs to promote positive parenting are extremely beneficial to society at large.

Abuse represents a spectrum of behavior. It is repetitive in nature, and fatal abuse is often preceded by minor manifestations of maltreatment, which might be overlooked by physicians, dentists, teachers, social workers, and others who are in frequent contact with the child. The sad truth is that child abuse kills more children in the United States each year than do accidental falls, drowning, choking on food, suffocation, and fires in the home combined. Children should never die because of our inability to confront the possibility of abuse. Health-care providers must identify children at risk, educate the families we serve, and report suspected cases of abuse and neglect to the appropriate authorities. Our lack of understanding of the complex etiology of child abuse does not absolve our collective responsibility to protect those individuals at risk. As Dr. Henry Kempe so eloquently stated almost 34 years ago, "It is just not possible to worry about all of the children all of the time. There lies the frustration and total inaction as well. For each of us there must be only one child at a time."(3)

To raise awareness about the impact of child maltreatment and its prevention, the blue ribbon campaign is held each year during the month of April, Child Abuse Prevention Month. Throughout the month, the community is encouraged to wear a blue ribbon to symbolize their commitment to protect children and end child abuse and neglect. Anyone in the United States may make an anonymous report of abuse, neglect, or sexual abuse by reporting it to the emergency services by dialing 911 or calling the local police department. Abuse and neglect may only be reported at the state or local level, not to the U.S. government. Most states have a toll-free hotline staffed by trained call screeners. When contacted, they will either open the case for investigation or log the report. Depending on available resources and the department's legal mandate, one report may not be sufficient to open a case, but a detailed report about a potentially serious case, or multiple reports (by different reporters), may suffice. At that point, someone from a legally designated agency will investigate the report. The investigators may determine there is no evidence of maltreatment, that there is evidence enough to offer support to the family in the home, or that there is evidence enough to remove the child from the home. The National Child Abuse Hotline (1-800-4-A-Child) is another resource for citizens wishing to report abuse. Hotline counselors provide local reporting information and will stay on the phone while a three-way call is placed to local authorities.

Colonel Theresa S. Gonzales, DMD, DC, USA, returned to Fort Hood, Texas, after a recent tour as the director of orofacial pain management and a staff oral and maxillofacial pathologist at Tripler Army Medical Center in Honolulu, Hawaii. She graduated magna cum laude from the College of Charleston with a BS in chemistry and received her DMD from the Medical University of South Carolina. Col. Gonzales began her military career at Fort Jackson, South Carolina, as a resident in the Advanced Education in General Dentistry program. She then completed a residency training program in oral and maxillofacial pathology in 1992 at the National Naval Medical Center in Bethesda. In 2006, she completed a two-year fellowship in orofacial pain at the Naval Postgraduate Dental School and completed a master of science in health care from George Washington University in Washington, DC. She is an alumnus of the Naval Postgraduate Dental School, in the capacity of a resident, a fellow, and a faculty member. From 1994 to 1998, Dr. Gonzales taught in the Department of Diagnostic Sciences at Baylor College of Dentistry in Dallas. During her tenure at Baylor, she was a perennial favorite and was nominated for "Teacher of the Year" three times. Col. Gonzales has earned fellowship status with the American Academy of Oral and Maxillofacial Pathology, the American Academy of Oral Medicine, and the Academy of General Dentistry. She is a diplomate of the American Board of Oral and Maxillofacial Pathology and the American Board of Orofacial Pain. She holds diplomate status as well with the American Board of Forensic Examiners. She is a fellow of both the American College and International College of Dentists. You may contact her by e-mail at THERESA.GONZALES@us.army.mil.

Patricia L. Blanton, DDS, MS, PhD, has led a distinguished career in dentistry dating back to her first faculty appointment in 1967. The first female president of the Texas Dental Association, she received her PhD in anatomy from Baylor University in Dallas and her DDS from Baylor College of Dentistry. Dr. Blanton has spent most of her professional career at Baylor College of Dentistry, where she is currently a professor emeritus in the Department of Biomedical Sciences. In addition to her academic positions and numerous professional appointments, she currently has a full-time periodontics and implantology practice. Dr. Blanton is a Regent of The American College of Dentists, a member of the ADA Presidential Task Force to Study Commission of Dental Accreditation (CODA), a delegate to the American Dental Association, and a consultant for the Texas Dental Association. She has held numerous positions in the past with the American Dental Association, the Texas Dental Association, and the Dallas County Dental Society. Dr. Blanton has received many awards and recognitions in her field, including a nomination to the Texas Women's Hall of Fame in the Health/Health Research category, the Baylor College of Dentistry Distinguished Alumnus award, the Dallas County Dental Society Dentist of the Year award, the Dallas County Dental Society Lifetime Achievement Award, the American Association of Women Dentists 2008 Woman Dentist of the Year/Lucy Hobbs Taylor award, the Commanders Award from the Europe Regional Dental Command, and the naming in her honor of the Patricia L. Blanton Library at Baylor College of Dentistry. Dr. Blanton lectures internationally and has produced over 100 publications, including a book.

References

1. Herschaft EE. Forensic Dentistry, Oral and Maxillofacial Pathology, 2nd ed. Philadelphia, W.B. Saunders Company, 2002.

2. Sanger RG, Bross DC, eds. Clinical Management of Child Abuse and Neglect: A Guide for the Dental Professional. Chicago, Ill.: Quintessence Publishing Co., Inc.; 1984.

3. Kempe CH, Silverman FN, Steele BF, Droegenmueller W, Silver HK. The Battered Child Syndrome. JAMA; 181, 17-24.

| Add RSS Feed