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In the UK, an estimated seven percent of young people will have experienced serious physical abuse, with six percent having suffered neglect and similar numbers having been subjected to emotional abuse and sexual abuse.1,2 Many of these children never come to the notice of professionals and may go on to suffer lasting consequences of their maltreatment. Dental practitioners, as universal providers of primary care, may be in a unique position to recognise and respond to concerns about possible child abuse and neglect. As well 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.3,4

Presentation

Abuse or neglect may present to the dental team in a number of different ways:5

  • Through a direct allegation made by the child, a parent or some other person

  • Through signs and symptoms which are suggestive of physical abuse or neglect; or

  • Through observations of child behaviour or parent-child interaction.

Orofacial trauma may be a particularly important marker of non-accidental injury, being found in at least 50% of physically abused children.6,7,8,9 Concerns may arise because of the site or extent of the injury, particular patterns of injury including finger-tip bruises, slap marks or grip marks, or because of inconsistencies between the history and examination. In assessing a child with an orofacial injury, it is always important to get a thorough history, preferably directly from the child, and to assess this against the clinical findings. The dental practitioner should be aware of the possibility of injuries elsewhere on the body, and it may be appropriate to refer the child for further examination by a paediatrician.

In contrast to physical abuse, neglect is insidious and may be harder to detect. It may present to the dental team through neglected dentition, or failure to take the child for appropriate dental care. Such markers may be just one manifestation of a wider picture of neglect with associated failure to thrive, developmental delay and poor hygiene. Severe untreated dental disease may lead to pain or other adverse consequences. A parent who fails to attend appointments, does not comply with planned treatment or ignores symptoms in their child, or a child who is displaying other features of more general neglect, should be a cause for concern and should lead to a further, multidisciplinary assessment of the child's needs.

Other children may present with behavioural disturbances, including the withdrawn, watchful or overly anxious child, or a teenager who is self-harming. These and other features may reflect underlying emotional or sexual abuse. Whilst it is not the role of the dental practitioner to make a diagnosis of abuse or neglect, all members of the dental team have a responsibility to respond to concerns and to share such concerns with their colleagues and with professionals in other agencies who are able to respond appropriately.

Taking action

Any member of the dental team who has concerns about a child's welfare should act on those concerns. The action taken will depend on the nature of the concerns and the context within which they have arisen. It is important first to assess the likelihood of any harm the child may have suffered or of any ongoing risk to the child. This will involve taking a thorough history, to include details of any injury or presenting complaint, the past dental and medical history and the family and social circumstances. A dental examination should be carried out and the findings clearly documented. Any injury or dental need should be dealt with appropriately; no child should be left untreated or in pain because of underlying concerns about abuse.

Child protection is always a shared responsibility. Having assessed the child, you should discuss the case with an appropriately experienced colleague: either a dental colleague, or a child protection nurse, paediatrician or social worker. If you remain concerned, then you should make a referral to your local social services team.10 Many dental practitioners are concerned that, if they make a referral, the process will be taken out of their hands, and often they want to be sure of the diagnosis before doing so.11,12 However, the individual practitioner only holds one part of the jigsaw of information on any one child; by sharing this information, other issues may come to light, whilst to hold back may put the child at risk of further harm. All referrals to social services should be backed up in writing within 48 hours. Once a referral has been made, social services will work with other agencies, including police and health, to assess the situation and plan how best to assess and respond to the concerns.3

In most situations you should explain your concerns to the child and parents, inform them of your intention to refer and seek their consent, unless to do so could put the child at increased risk of harm. An open, honest discussion, although potentially difficult at the time, will make it easier to work with the family to ensure the protection of the child, and to facilitate an ongoing relationship with the family.

Safeguarding children is not just about referring them when you have concerns but is about changing the environment to ensure that risks to their welfare are minimised. Much can be done within the dental team to achieve this, including identifying a child protection lead, ensuring you have appropriate policies and procedures in place, and that all members of the team are trained and know what to do if they have concerns.5

Drs Sidebotham and Harris will be speaking on this subject on Friday 25 May at the 2007 British Dental Conference and Exhibition, held at the Harrogate International Centre.