Key points

  • Identifies the views of GDPs working in Greater Manchester with regards to their role in child protection.

  • Explores the well-known gap between suspicion and referral of children at-risk.

  • Discusses common barriers faced by GDPs to referring cases of suspected child abuse and neglect.

  • Highlights the need for further child protection training and support for clinicians.

Introduction

Child neglect and abuse unfortunately occur within our society and it is the responsibility of all dental practitioners to safeguard children. In the UK, 58,533 children were reported to be on child protection registers or subject to child protection plans as of 31 March 2017.1 This figure has been steadily increasing since 2002, with neglect being the most common form of abuse. In England there were 13,591 reported cases of child abuse in 2016/17, with a 4% increase in referrals to social services since 2015/16.2 These figures, however, only reflect the number of reported cases, with possibly many more unknown children suffering abuse or neglect.

Dental professionals play an important role in recognising and identifying children who are at risk. For many children and families, dental practices are the most regularly accessed health care service. Additionally, orofacial trauma, which may present to the dental practitioner, occurs in at least 50% of cases of physical abuse.3 Despite this, the literature suggests that there are barriers faced by dentists in identifying and referring children who are suspected to be at risk.

Prior to the paper by Welbury et al. in 2003,4 there was limited information about the views of general dental practitioners (GDPs) in the UK regarding their role in child protection. The authors highlighted that there was a lack of experience and confidence among GDPs when working in a multi-professional context and also a lack of potential support networks. GDPs also felt that they focused on clinical signs and symptoms but were less confident in a taking a holistic approach to a child's overall health. The inhibiting factors to referral were discussed including: difficulty identifying abuse; concern about the outcome; and getting things wrong, with consequences for themselves and the dental team.

Two other questionnaire studies5,6 were published based on the role of GDPs in child protection in Scotland. Both studies showed a gap between the suspicion of child abuse or neglect and onwards referral, with 29% (2005) and 37% (2013) of GDPs suspecting versus 8% (2005) and 11% (2013) referring for appropriate action. The increase in the number of dentists both suspecting and referring abuse in 2013 as opposed to the earlier study may reflect the increased awareness of child protection in the profession.7 The main factors preventing referral seemed to be lack of certainty of diagnosis and lack of knowledge of the referral process.

There is currently limited research into the roles and views of GDPs in the recognition and referral of suspected child neglect and abuse in England, and there has been change in practice over time. Therefore, this study aimed to assess the current experience of children's safeguarding reporting among GDPs and to investigate the barriers to the reporting of these safeguarding concerns in Greater Manchester, UK.

Methods

An electronic, 32-point questionnaire was devised using the Online Surveys tool (previously Bristol Online Survey tool) and was divided into sections investigating: participant demographics, history of safeguarding training, general safeguarding knowledge, previous safeguarding referrals, and barriers to referrals. The questionnaire was based on previous published questionnaire surveys,5,6 however it was expanded with further questions, particularly exploring the respondents' views regarding child protection training.

Ethical approval was gained from the University of Manchester research ethics committee before commencing the study. The questionnaire was piloted by inviting 25 GDPs working in the Greater Manchester area to complete it and this informed the final questionnaire design. In March 2018, the questionnaire was sent to the Manchester clinical commissioning group who then circulated an email invitation to their list of general dental practices in the Greater Manchester region. This gave a convenience sample of 100 GDPs. A reminder email was sent after six weeks and the questionnaire closed after 12 weeks. Fisher's exact test was used to test any association in contingency tables and explore any significant differences, with the significance threshold set at p <0.05.

Results

Demographics

Thirty-six questionnaires were completed, giving a response rate of 36%. All responses were included in the analysis of results. The average year of dental degree graduation was 1999 (range 1976-2017). Ninety-four percent of the respondents practised NHS dentistry (n = 34) and 89% held a basic dental degree only (n = 32).

Undergraduate training

Fifty-eight percent (n = 21) of respondents had undertaken some form of child protection training as part of their undergraduate programme. GDPs' perception of the usefulness of the training received in preparing them to identify, initially manage, get advice and report suspected cases of both child abuse and dental neglect is shown in Figure 1. Views towards undergraduate training were positive, with 86% (n = 18) and 81% (n = 17) of GDPs reporting that their undergraduate training helped them to identify signs of abuse and dental neglect, respectively.

Fig. 1
figure 1

GDPs views towards how undergraduate training helped to prepare them when dealing with different aspects of child safeguarding, n= 21

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Post-graduation training

Eighty-three percent (n = 30) of GDPs had received some form of child protection training following their basic dental degree. Of these respondents, 60% (n = 18) had funded the courses themselves, 30% (n = 9) had training as part of their dental foundation training, 37% (n = 11) had received deanery-organised training after their dental foundation training and 7% (n = 2) had completed training by other means.

Those respondents who did not receive post-graduation training reported barriers such as lack of course availability, lack of courses outside working hours and courses not being mandatory. Thirty-six percent (n = 13) of respondents were unaware of any child safeguarding courses in their local area and 81% (n = 29) felt that GDPs required more guidance and training in child protection. Those who had already been on a postgraduate child protection course had significantly more knowledge about the availability of any courses in their local area than those who had not undertaken any postgraduate training (p <0.05).

The most common recommendations by GDPs included a request for yearly child protection training and more accessibility to training for the whole dental team. Respondents' opinion on the usefulness of the post-graduation courses in preparing them to manage various aspects of child safeguarding is reported in Figure 2. Similar to the views of those obtaining undergraduate training, the respondents felt that their post-graduation courses had helped them to identify both signs of abuse and dental neglect, with 93% (n = 28) either agreeing or strongly agreeing with this statement. Previous training in child protection had no effect on participants' requests for further training in the area.

Fig. 2
figure 2

GDPs views towards postgraduate training and child safeguarding, n=30

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General knowledge regarding child safeguarding and practice

Table 1 shows the breakdown of responses to general questions regarding child safeguarding. Sixty-four percent of GDPs (n = 23) were familiar with the Child protection and the dental team8 document and there were no significant differences when comparing knowledge of the document to those undertaking child protection training courses.Of the respondents, 86% (n = 31) felt that the dental team were well placed to recognise child abuse or neglect and 100% (n = 36) were willing to get involved in detecting neglect.

Table 1 Responses to general questions about child safeguarding in practice
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Suspicions, referrals and contact

Fifty-eight percent (n = 21) of the GDPs had been suspicious of child abuse or neglect in practice. Of those, 95% had been suspicious of 0-5 cases in the past five years while 5% had been suspicious of 6-10 cases in the same timeframe. All respondents had documented their observations in the clinical notes with the exception of one GDP who documented his/her concerns in a separate observation book. Of all respondents, 28% (n = 10) had referred a case to social services, while 11 respondents were suspicious of a case but did not complete a referral. Of those who had been suspicious of a case of abuse or neglect, when directly questioned, 48% (n = 10) admitted to suspecting a case but not referring it onwards. Finally, 57% (n = 12) consulted someone outside of their practice when suspicious of a case. Previous child protection training had no effect on participants' level of suspicion of, and willingness to, refer cases of child abuse.

Barriers to reporting safeguarding concerns

All GDPs were asked about which, if any, factors influenced or would influence them to refer a case of suspected child abuse or neglect (Fig. 3). The most common reason was the fear of violence to the child with 78% of GDPs (n = 28) selecting this answer. Lack of certainty of diagnosis and lack of confidence in their suspicions were also commonly selected factors with 50% (n = 18) and 47% (n = 17) of respondents respectively. The least likely barrier to referral was due to reasons of confidentiality and data protection which was cited by 8% of the respondents (n = 3). Other reasons were documented as a fear of the parents making an official complaint.

Fig. 3
figure 3

Perceived barriers to GDPs' referral of suspected cases of child abuse or neglect

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The GDPs were invited to leave any further comments on their views towards paediatric safeguarding, the main themes included emphasis on the need for further training, up to date and concise guidance on referral pathways and the need for a dental contact to discuss concerns with before referrals.

Discussion

One of the main findings of this study was the demand for further child protection training and support for GDPs when dealing with this challenging subject. Fifty-eight percent of respondents reported that they had completed some form of child protection training at undergraduate level, which is considerably higher than in previous studies. Only 19% of GDPs in Scotland in 20055and 29% in 20136 reported receiving undergraduate training. The mean year of graduation in this study, however, was 1999, much later than in the previous papers, thus reflecting the changes in undergraduate teaching over time. This upward trend is promising and is predicted to continue, as a strong emphasis is currently placed on child protection training across dental schools in the UK.

Furthermore, 83% of respondents had undertaken postgraduate child protection training, which again is a vast increase from the 16% and 55% of GDPs in the previously described studies.5,6 The higher proportion of GDPs completing child protection postgraduate training should be welcomed and a continued emphasis should be placed to implement further courses.

Safeguarding children and vulnerable adults is a recommended continuing professional development (CPD) topic by the General Dental Council (GDC). Despite some views that it would be beneficial, the topic is not currently compulsory in line with current GDC enhanced CPD guidance.9

Despite the positive changes in education, there is still more to be done to increase exposure to child protection training among the dental profession. Education of healthcare staff is an essential aspect of safeguarding children and is often a key recommendation in serious case reviews.10 An intercollegiate document published by the Royal College of Paediatrics and Child Health alongside other agencies (revised in 2019), states that healthcare professionals should have child protection training every three years as a minimum.11 Our study supports the fact that more training is required to meet current guidance. This would also be well accepted as 81% of GDPs expressed a need for further child protection training, with some suggesting annual training. Finally, those who had previously undertaken training felt that this helped them to identify and manage suspected cases of abuse or neglect, further supporting its importance.

Reassuringly, the majority of respondents were aware of and knew how to access their local and practice child protection policies. In addition, all respondents knew who their safeguarding lead was and expressed willingness to get involved in detecting neglect. The Child protection and the dental team document,8 first published in 2006, has been hosted by the British Dental Association since 2016 and is freely available on their website. Sixty-four percent of respondents in this study were familiar with this document, which is an increase compared to 55% in 2013.6 The positive impact of this educational resource, particularly on practitioners' self-reported knowledge and confidence has been demonstrated;12 therefore, further emphasis on this document within practices would be beneficial.

Suspicion of at least one case of child abuse in this study was higher (58%) than that found in Scotland by both Cairns et al.5 (29%) and Harris et al.6 (37%), as well as in international studies.13,14 This result, however, was similar to that found in dentists with interest in paediatric dentistry by Harris et al. in 2009 (67%).15 In addition, the referral of cases was also higher in this study (28%) than the 8% and 11% referred in 2005 and 2013, respectively. The rise in the number of suspected cases and referrals may reflect the increased profile of child protection over time, improved education and vigilance of GDPs. Of the respondents in this study who were suspicious of at least one case of child abuse and or neglect, 57% had discussed their findings with someone outside their practice in the first instance and all respondents also wanted to discuss their findings with a dental colleague. Discussion and sharing concerns with appropriate persons where required should be supported and may have had an impact on decisions whether a referral was required.

The 30% gap between suspicion and referral found in this study is higher than the 21% and 26% reported in 2005 and 2013,5,6 but lower than 38% found by Harris et al.15 The gap between recognition and referral has been well documented in the literature on an international scale.14,16,17 It is the exploration of factors involved when reporting suspected cases and the reduction of the known barriers which may lead us to a reduction of this gap.

The most commonly reported barrier by GDPs in this study was a fear of violence to the child. As a profession dedicated to caring for patients and their wellbeing, GDPs may worry that negative repercussions could occur as a result of their actions. Such a mentality, however, needs to be avoided, as it has been concluded in serious case reviews, such as the Victoria Climbie inquiry,10 that it is often the failure to act that will result in the most significant consequences.

The second most stated barrier in this study was a lack of certainty in the diagnosis, similar to that of previous studies of GDPs5,6 and paediatric dental specialists.18 It should be stressed that dentists are not expected to diagnose child abuse before referral.19 It is the dental professional's responsibility to communicate appropriately, working together with others agencies to safeguard children.20 A lack of confidence in suspicions and a lack of knowledge regarding the referral procedure were commonly reported responses and are areas which could be tackled with further child protection training.

Documentation of suspicions was excellent among GDPs in this study (100%), which is encouraging and higher than the 81% of GDPs in 2013.6 The dental clinical records are particularly important in child protection, as they make up part of an overall picture for the patient and may be required during multi-agency working. Furthermore, practitioners should always 'keep contemporaneous, complete, accurate patient records' as per GDC guidance.21

A highly relevant topic that should always be considered when discussing child protection is dental neglect. Dental neglect was defined by the British Society of Paediatric Dentistry in a policy statement as 'the persistent failure to meet a child's basic oral health needs, likely to result in serious impairment of a child's oral or general health or development'.22 A child's basic oral needs include the maintenance of oral hygiene, access to a regular fluoride source, usually toothpaste, a stable diet and visits to a dentist for both preventive care and treatment when required.23 If oral needs are unmet, oral diseases can have great impacts on a child, including pain, loss of sleep and time off school. Untreated dental disease has also been linked to lower body weight, growth and quality of life,24 and is unfortunately a common finding. Sixty percent of dentists with an interest in paediatric dentistry, when asked in a UK survey, stated that they observed neglected dentitions on a daily basis.25 There is, however, only a small body of literature in this field26 and further research to explore the characteristics and impacts of dental neglect is required. GDPs in our study felt that child protection training helped them to identify and manage suspected cases of dental neglect. Child safeguarding education should cover the diagnosis of dental neglect and ensure that the dental team is aware of the stages of intervention, including preventive dental team and multi-agency management with child protection referrals when required.22 Further research into GDPs' views of dental neglect would be beneficial.

One of the limitations of this study was the low response rate of participants, which is a problem well documented in the literature regarding questionnaire-based research studies.27 The survey was sent electronically, which is a more cost-effective approach when compared to mail postage. There is some evidence, however, that these traditional methods of dissemination may be preferred, thus leading to higher response rates.28 The results of this study can, therefore, be regarded as exploratory in nature and justify a need for further research on a wider scale to review the opinions of GDPs on child safeguarding in the UK.

Conclusion

This study again highlights a gap between suspicion and referral of cases of child abuse and neglect, in addition to self-reported referral barriers among the dental profession. There is a demand for further training for GDPs to enable them to feel more supported and prepared to deal with such cases. Training should be a priority, particularly as the majority of dental care for children in the UK is provided by GDPs. Training should focus on common misconceptions within the area of child protection and discuss the barriers faced to try to alleviate and reduce the gap between identification and referral. Finally, there is also a need for further research on a larger scale to identify and explore the current views of GDPs in the UK, while analysing any shifts in beliefs over time.