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OPINION Richard Welbury and Christine M Park DOI: 10.1308/rcsfdj.2016.141
Is child safeguarding safe in our hands? by Richard Welbury and Christine M Park Dental teams have been involved with child protection for more than 40 years. In this article, we summarise their involvement in the detection of the various types of child abuse and discuss the ‘gap’ between the number of dental professionals who suspect child abuse or neglect and those who ask for advice on how to obtain help in such cases. Current child protection legislation and responsibilities for the dental team will also be outlined.
Author: *Professor Richard Welbury, Clinical Lead Paediatric Dentistry, School of Dentistry, University of Central Lancashire, Preston Christine M Park, Clinical Lecturer, Paediatric Dental Dept, Glasgow Dental Hospital and School, Glasgow *Corresponding author E:
[email protected] Keywords: Child abuse, education, professional role
FACULTY DENTAL JOURNAL July 2016 • Volume 7 • Issue 3
OPINION
FACULTY DENTAL JOURNAL July 2016 • Volume 7 • Issue 3
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OPINION Richard Welbury and Christine M Park
Historical aspects of child protection The first documented case of child maltreatment was that of Mary Ellen in 1874 in New York State.1 Her father was killed in 1864 at the first battle of Cold Harbor in the American Civil War and her mother was unable to support her. She was chronically abused by her guardians but, in the absence of any laws to protect children, her case was brought to the American Supreme Court by The American Society for the Prevention of Cruelty to Animals, on the basis that Mary Ellen was a member of the animal kingdom. This led to the formation of the New York Society for the Prevention of Cruelty to Children in 1875. The United Kingdom Society for the Prevention of Cruelty to Children was founded in 1884. Severe chastisement of children by parents and teachers was accepted in Victorian society and it took significant work by Wilberforce, Shaftesbury and Barnado to influence social legislation and social attitudes towards children. Since the Second World War, ideologies underpinning child care legislation in the UK have fluctuated between the ‘welfarist approach’, which is against state intervention and has an emphasis on the ‘blood tie’ and keeping families together and, at the other extreme, the ‘interventionist approach’, where the state adopts a child rescue approach for abused, rejected and neglected children. The enquiry into the death of Maria Colwell in 1974 led to the Children Act 1975 and the establishment of: • a child protection system with interagency structures to coordinate services for children in each local authority area, with agreed interagency procedures; • child protection registers and child protection conferences to assess risk and plan for children’s welfare; and • categories for defining abuse. The Children Act 1989 remains the legislative framework governing child care and child protection in the UK. It introduced the concept of ‘parental responsibility’ rather than ‘parental right’, and required local authorities to plan corporately for the welfare of children in need, including children in care (‘looked after and accommodated’ children) and those in need of child protection. The first National Child Protection guidelines, Working together under the children Act 1989, were issued in 1991, and the latest version of this document, Working together to safeguard children, provides our guidance today.2 It was reported in 2014 that some 50,000 children in the UK were identified as needing protection from abuse or neglect, and it is estimated that 1 in 10 UK children experience neglect.3 Statistics and numbers are difficult to interpret, as official statistics only identify those who have been identified as needing protection FACULTY DENTAL JOURNAL July 2016 • Volume 7 • Issue 3
or support. The NSPCC estimate that, for every child identified as needing protection, there are another eight who are suffering.4 Children who are abused or neglected do not always have the ability to ask for help themselves. They may be too young, scared or ashamed to report what is happening to them, and many may not realise that what they are experiencing is not normal. Social and cognitive development of children, as well as their physical and emotional health, is damaged in the short term. However, damage persists in the long term, and adults who were neglected as children have higher rates of arrest, suicide and major depression, as well as health issues such as diabetes and heart disease. Child protection is an activity undertaken to protect specific children who are suffering, or at risk of suffering, significant harm. There are 45,000 children in the UK at any one time subject to child protection interventions. Children in need are those children who require additional support or services to achieve their full potential. It is estimated there are 300,000–400,000 children in the UK in this category at any one time. Dental teams and child protection The involvement of the dental profession in child protection and safeguarding began to be reported in the scientific literature in the 1960s and 1970s, not long after C. Henry Kempe’s landmark paper in 1962 ‘The battered child syndrome’.5 He suggested nonaccidental causes should be considered in any child with a fracture, subdural haematoma, failure to thrive, soft-tissue swellings, skin bruising or sudden death where the degree and type of injury was at variance with the history given. Kempe quoted radiologist John Caffey’s pivotal work in 1946,6 in which he observed that children with subdural haematomas sometimes showed changes in their long bones that were suggestive of previous trauma. When a dental team has concerns about a child’s wellbeing, the situations can be complex. Understanding the thoughts, feeling, motivations, inhibitory factors and decision-making processes involved is essential in helping to resolve situations. There are a number of potential factors affecting referral: concerns relating to the impact on the practice; fear of violence to the child; fear of violence to the general dental practitioner (GDP); fear of litigation; fear of consequences to the child from statutory agencies; lack of knowledge of referral procedures; and lack of certainty of the diagnosis. However, we don’t fully understand which reasons are most important or crucial in the decision to report. This review will explore this history of the dental teams’ involvement in child protection and safeguarding, as well as explain the current responsibilities of dental teams, with a glimpse into the future and how this may well change.
OPINION
Dental signs of abuse Early dental papers concentrated on the physical abuse of children, finding that and 50%–75% of abused children have orofacial signs of abuse.7–11 These include bruising of the soft tissues (especially those that do not overlie a bony contour), abrasions, multiple injuries, bruising of different vintages, scarring of the lips, dento-alveolar injuries, fractures, burns and ‘tattoo’ injuries, which reflect the shape of the offending object. The history, as well as the site of the injury, may distinguish them from accidental injuries. If the explanation for the injury does not fit with the clinical picture, then the dental team should have a high index of suspicion. Accidental injuries commonly involve bony prominences and should be in keeping with the development of the child, whereas injuries to soft tissues or injuries that would be unusual for the child’s developmental stage are suspicious. Dental teams are critical to the recognition of neglect and, specifically, dental neglect.12–14 Neglect is defined as ‘the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development’ and it remains the most common form of child abuse in the UK.2,4 The UK’s first dental guideline on child protection,12 and the British Society of Paediatric Dentistry’s document,13 define dental neglect as ‘the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development’. Dental teams may also see children who have been sexually abused. Recorded sexual offences against children in the UK have increased in the past year, as have contacts regarding sexual abuse to both the NSPCC and ChildLine helplines.4 The general features that the dental team should be aware of are the oral manifestations of sexually transmitted infections and what tests may be required. Some of these manifestations may not be particular to sexual abuse. Sudden changes in eating and sleeping patterns, becoming withdrawn, nightmares, being fearful of adults not previously feared, precocious sexual interest, self-harm and low self-esteem are also recognised as sequelae of child sexual abuse and are an alert for referral to medical colleagues.15 The National Collaborating Centre for Women’s and Children’s Health reminds dentists that, if they discover that any of their child patients aged 13 years or younger are pregnant, this may also be a sign of child maltreatment and they should share their concerns.16 Emotional abuse is now recognised as a component in all categories of abuse.2,4 Signs and symptoms include babies who are demanding/clingy or irritable, who may have feeding difficulties and who cry a lot. In school-aged children, there may be developmental delays, soiling or wetting problems, poor behaviour, non-attendance at school or rejection by their peers. Teenagers who have suffered emotional abuse may
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50%–75% of abused children have orofacial signs of abuse
exhibit problems with drugs or alcohol, behavioural issues, self-harming, eating disorders or depression.2 The gap between those who suspect and those who refer Nationally and internationally, there is a gap between the numbers of dental professionals who suspect child abuse/neglect and those who actually refer cases.17–22 Prior to 2003, it was unknown whether GDPs in the UK accepted they had a role in child protection or if they felt they had needs in developing their role further.23 However, the General Dental Council made the safeguarding of children a recommended continued professional development (CPD) topic for dental professionals in April 2015, although it is still not mandatory. Since the 2003 paper, there have been two further papers in Scotland looking at the role of GDPs in child abuse.19,22 Both were based on questionnaires sent to a quarter of the Scottish GDP workforce, and both demonstrated that the gap between those who suspect and refer was still apparent, although the 2013 paper revealed that there was a larger proportion of GDPs who both suspected (37%) and referred (11%) child abuse than in the 2005 paper (29% and 8%, respectively). This perhaps reflected an increasing awareness of the problem. Additionally, a larger proportion of GDPs in 2013 had had undergraduate (29%) and postgraduate (55%) training in child abuse. Despite this apparent increase in awareness and an increase in training uptake, it is clear that efforts so far have not tackled the ‘gap’. The two main issues appear to be fear (of potential outcomes) and confidence (in how to refer, and a lack of confidence in suspecting a diagnosis). FACULTY DENTAL JOURNAL July 2016 • Volume 7 • Issue 3
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OPINION Richard Welbury and Christine M Park
Disabled children are 3.4 times more likely to have been maltreated than their non-disabled peers
Despite 40 years of dental involvement in child protection, there remains a gap between the number of dental professionals who suspect abuse or neglect in a paediatric patient and those who actually ask for advice on how to help a family. All local authorities have websites dedicated to child protection issues. These have the contact numbers and names of children’s services and safeguarding team personnel (child protection nurses). We are now able to discuss our case in confidence with the local safeguarding team and then take advice on how to proceed. The days have gone where we would have to communicate only with a faceless telephone number or via the address of a ‘social services’ office. Although potential barriers to referral have been identified and targeted in training courses, the gap does not really seem to change. However, dental teams are not the only healthcare professionals for whom this gap exists, and we must strive to overcome the gap to get help to the families with a need. Safeguarding means taking measures to minimise the risks of harm to children. These include:
Kvist and colleagues attempted to examine which factors cause specialists in paediatric dentistry to suspect child abuse or neglect, and to determine what influenced their decisions to report.24 Their results drew parallels with those in GDPs in 2003,23 in that there was a need for certainty of the diagnoses, which suggests that the decision to report is not always easy, even for those who are widely regarded as experts in paediatric dentistry. Becoming a safe safeguarding practice Kempe’s original formula for assessing those at risk of child abuse included: something wrong with the parents; something wrong with the marriage; something wrong with the child; life stresses; and parents who have no access to lifelines. Parental factors that may increase the risk of child abuse included: young parents of low intelligence (who have often been abused themselves); mother divorced/single and cohabiting with person responsible for the violence; disability; criminal record; and emotional immaturity.5 Additionally, we now recognise, on the part of the adult, that drugs, alcohol, mental illness, poverty, social isolation, unemployment and domestic violence may all contribute and, where the child is concerned, that crying, soiling, disability and being an unwanted pregnancy may be important. Disabled children are 3.4 times more likely to have been maltreated than their non-disabled peers,25 and are judged more vulnerable because they experience greater physical and social isolation, a lack of control over their life and bodies, greater dependency on others and problems in communication.26 FACULTY DENTAL JOURNAL July 2016 • Volume 7 • Issue 3
• protecting children from maltreatment; • preventing impairment of children’s health or development; and • ensuring that children grow up in a safe and caring environment. We all need to know our responsibility to safeguard because of the availability of the United Nations Convention on the Rights of the Child, government guidance and General Dental Council standards, and the work of the Care Quality Commission. We are in a good position to recognise the signs of abuse and neglect, thanks to our skills and our significant contact and work with children and families. We need to observe, record, communicate and get advice, and refer children for assessment by children’s services, if necessary. We are NOT expected to diagnose. The purpose in seeking help is to ensure the health, development and safety of the child, and not to blame the parents. In the majority of cases, intervention means building up social supports for the family, rather than looking to child protection or legal systems to intervene.
OPINION
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Schwartz S, Woolridge E. Child Abuse. In: Cottone JA, Standish SM, eds. Outline of Forensic Dentistry. Chicago: Year Book Medical Publishers, Inc, 1982. pp128–1342. Department for Education. Working together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children. London: HM Government; 2015. The NSPCC. Child protection register statistics UK: 2010 – 2014. https://www.nspcc.org.uk/globalassets/documents/statisticsand-information/child-protection-register-statistics-unitedkingdom.pdf (cited June 2016). Jütte S, Bentley H, Tallis D et al. How safe are our children? The most comprehensive overview of child protection in the UK. London: The NSPCC; 2015. Kempe CH, Silverman FN, Steele BF et al. The battered-child syndrome. JAMA 1962; 181: 17–24. Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Am J Roentgenol Radium Ther 1946; 56: 163–173. Becker DB, Needleman HL, Kotelchuck M. Child abuse and dentistry: orofacial trauma and its recognition by dentists. J Am Dent Assoc 1978; 97: 24–28. Malecz RE. Child abuse, its relationship to pedodontics: a survey. ASDC J Dent Child 1979; 46: 193–194. da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatr Dent 1992; 14: 152–157. Jessee SA. Physical manifestations of child abuse to the head, face and mouth: a hospital survey. ASDC J Dent Child 1995; 62: 245–249. Cairns AM, Mok JY, Welbury RR. Injuries to the head, face, mouth and neck in physically abused children in a community setting. Int J Paediatr Dent 2005; 15: 310–318. Harris J, Sidebotham P, Welbury R et al. Child Protection and the Dental Team: An Introduction to Safeguarding Children in Dental Practice. Manchester: Committee of Postgraduate Dental Deans and Directors; 2006. Harris JC, Balmer RC, Sidebotham PD. British Society of Paediatric Dentistry: a policy document on dental neglect in children. Int J Paediatr Dent 2009; PMID:19470009 Balmer R, Gibson E, Harris J. Understanding child neglect. Current perspectives in dentistry. Prim Dent Care 2010; 17: 105–109. Casamassimo PS. Child sexual abuse and the pediatric dentist. Pediatr Dent 1986; 8: 102–106. National Collaborating Centre for Women’s and Children’s Health. When to suspect child maltreatment. NICE clinical guideline 89. London: National Institute for Health and Clinical Excellence; 2009. Saxe MD, McCourt JW. Child abuse: a survey of ASDC members and a diagnostic-data-assessment for dentists. ASDC J Dent Child 1991; 58: 361–366. Kilpatrick NM, Scott J, Robinson S. Child protection: a survey of experience and knowledge within the dental profession of New South Wales, Australia. Int J Paediatr Dent 1999; 9: 153–159. Cairns AM, Mok JY, Welbury RR. The dental practitioner and child protection in Scotland. Br Dent J 2005; 199: 517–20; discussion 512; quiz 530. Harris JC, Elcock C, Sidebotham PD et al. Safeguarding children in dentistry: 1. Child protection training, experience and practice of dental professionals with an interest in paediatric dentistry. Br Dent J 2009; 206: 409–414. Uldum B, Christensen HN, Welbury R et al. Danish dentists’ and dental hygienists’ knowledge of and experience with suspicion of child abuse or neglect. Int J Paediatr Dent 2010; 20: 361–365. Harris CM, Welbury R, Cairns AM. The Scottish dental practitioner’s role in managing child abuse and neglect. Br Dent J 2013; 214: E24. Welbury RR, MacAskill SG, Murphy JM et al. General dental practitioners’ perception of their role within child protection: a qualitative study. Eur J Paediatr Dent 2003; 4: 89–95. Kvist T, Wickström A, Miglis I et al. The dilemma of reporting suspicions of child maltreatment in pediatric dentistry. Eur J Oral Sci 2014; 122: 332–338. Sullivan PM, Knutson JF. Maltreatment and disabilities: a population-based epidemiological study. Child Abuse Negl 2000; 24: 1,257–1,273. Westcott HL, Jones DP. The abuse of disabled children. J Child Psychol Psychiatry 1999; 40: 497–506. FACULTY DENTAL JOURNAL July 2016 • Volume 7 • Issue 3
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