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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 83-92

Child Abuse: Should we have conscious awareness? A study to assess cognizance of dentists concerning child abuse in Ludhiana City

Department of Pedodontics and Preventive Dentistry, Christian Dental College, Ludhiana, Punjab, India

Date of Submission25-Jan-2020
Date of Decision06-Feb-2021
Date of Acceptance05-Jul-2021
Date of Web Publication18-Oct-2022

Correspondence Address:
Nishita Rana
Department of Pedodontics and Preventive Dentistry, Christian Dental College, Brown Road, Ludhiana - 141 008, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_5_20

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Introduction: Child abuse is an increasing social problem with serious lifetime impact. Almost half of the violence cases affect the head-and-neck region, so dentists can play a proactive role in identifying and reporting possible cases of child abuse. Aim: This study aims to assess the knowledge and attitude about physical and social indicators, legal aspects, and barriers in reporting mechanisms toward child abuse among dentists in Ludhiana city. Methodology: With prior consent, a self-administered structured questionnaire comprising 21 questions was distributed to 100 state-registered dentists of Ludhiana city. The data collected were descriptively analyzed using Pearson Chi-square test. Results: A total of 92 dentists responded to the questionnaire, with a response rate of 92%. Among them, 43% were females, while males were 57% and 64.4% of dentists were specialists, out of which 21% were pedodontists. A moderate proportion of the dentists (68%) had knowledge about indicators. The knowledge of indicators was more among pedodontists. However, no significant difference was seen between other respondents and pedodontists. Almost 79% knew their legal duty to report the suspected case. Forty percent of the dentist had encountered with child abuse cases with a significant difference among pedodontists when compared to other respondents, but only 23% reported a case. Fear of litigation, lack of referral knowledge, and uncertainty of diagnosis were major barriers in reporting. Ninety-two percent showed a positive attitude for further training in identification and reporting mechanisms for suspected cases. Conclusion: The respondent dentists had moderate knowledge regarding child abuse, positive attitude toward dealing with child abuse, but they were diffident and unaware of the appropriate authority to report. Considering this fact, a systematic educational program in diagnosis and reporting of child abuse is advised to provide adequate knowledge than lecture-based learning.

Keywords: Barrier in reporting, child abuse, legal aspect, systematic educational program

How to cite this article:
Rana N, Singh N, Shamsher S, Thomas AM. Child Abuse: Should we have conscious awareness? A study to assess cognizance of dentists concerning child abuse in Ludhiana City. CHRISMED J Health Res 2022;9:83-92

How to cite this URL:
Rana N, Singh N, Shamsher S, Thomas AM. Child Abuse: Should we have conscious awareness? A study to assess cognizance of dentists concerning child abuse in Ludhiana City. CHRISMED J Health Res [serial online] 2022 [cited 2022 Dec 8];9:83-92. Available from: https://www.cjhr.org/text.asp?2022/9/1/83/358822

  Introduction Top

Childhood and adolescence are particular stages of human life as they shape one's personality. Adulthood mental health is largely dependent on the quality of education and life during this time. Consequently, a successful transition from childhood to adulthood requires family and community support.[1],[2]

Children are always more vulnerable than other community members due to their young age and lack of sufficient skills. Child abuse and infanticide are existing over the centuries. Child abuse was revealed in 1962, with the term “battered child syndrome” which was used to identify infants presenting with multiple unexplained severe injuries.[3] The WHO has defined child abuse as “Child maltreatment is the abuse and neglect that occurs to children under 18 years of age. It includes all types of physical and/or emotional ill-treatment, sexual abuse, neglect, negligence, and commercial or other exploitation, which results 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],[5]

The consequences of child abuse cascade throughout the life. Various studies reported that psychological ailments such as anxiety, depression, alcohol dependence, posttraumatic stress disorder, and suicidal behaviors are more prevalent among these children.[6],[7] UNICEF estimated that 41,500 children lose their lives annually from violence and maltreatment.[8]

According to the survey reported by the Indian Ministry of Women and Child Development 2007, two-third of children in the country are physically abused, including 72.2% of children in the age group of 5–12 years.[9] Approximately 50%–70% of injuries due to child abuse occur in the orofacial region and almost 15% of these injuries are confined to the head region.[10] Since, a multitude of these injuries involve orofacial region among all health professionals dentists hold a strategic position to detect signs of physical abuse, sexual abuse, health care neglect, and dental neglect.[11] American Academy of Pediatric Dentistry cited that the upper lip and maxillary labial frenum injuries are distinctive in severely abused children. Furthermore, poor oral hygiene, gingival inflammation, and avulsed and decayed teeth have also been witnessed in the abused children group.[12]

The actual data on offenses against children are still lacking. This might be due to unreported crimes against children. The American Dental Association reported the first documented proof of dentists failing to report child abuse in 1967, stating that among 416 cases of child abuse reported in New York State, none had been reported by a dentist. Lack of dentist knowledge in this sector has been reported as the reason for underreporting.[13] To better counter the horrendous acts of sexual abuse and sexual exploitation of minors, the Protection of Children from Sexual Offenses (POCSO) Act, 2012, was formulated by Indian parliament. This gender neutral Act provides protection to any individual below 18 yr from sexual abuse and stipulates harsh punishments that are tiered according to the severity of the offence, with a maximum sentence of life imprisonment and a fine. In all cases of child sexual assault, it is now mandated that health professionals should file a medicolegal case. Failure of reporting could result in 6 months imprisonment and/or a fine under Sec 21 of the POCSO Act, 2012.[14]

Despite child abuse being a vital issue, most of the professionals still ignore the correct attitude toward suspicious cases of abuse. Hence, the present study addresses on the knowledge and attitudes about indicators, legal issues, professional responsibilities, barriers in reporting, and educational needs regarding child abuse among dentists in Ludhiana city in Punjab.

  Methodology Top

The study was conducted after obtaining approval from the ethical committee by dental post graduate institute.

A self-administered questionnaire was prepared in English version based on previous studies. The validity of the questionnaire was performed with eight pediatric dentists, and the comprehensive final version of questionnaire was based on the recommendations. The dental practitioners with active state dental licensure were included in this study. Prior to the distribution of questionnaire, written consent was obtained stating that responses would be kept confidential. A 21 question survey was distributed to 100 state-registered dentists of Ludhiana city. The questionnaire consisted of multiple-choice as well as dichotomous yes–no questions.

The questionnaire was composed of five parts: The first part of the questionnaire consisted of questions on the demographics and qualification of the responding practitioner. The second part included knowledge regarding physical indicators and social indicators of child abuse. The third part included attitude and knowledge related to legal and ethical responsibilities. The fourth part determined their experience with child abuse and barriers in reporting. The fifth part included training in recognizing and reporting on child abuse. The average time given to answer the questionnaire was 10 min [Questionnaire].

Statistical analysis

The data collected were tabulated, and descriptive statistics were performed using Statistical Package for the Social Sciences software version 20.0 for Windows (SPSS Inc., Chicago, IL, USA) for analysis. The influence of demographic characteristics and qualification was analyzed statistically Pearson Chi-square test. The level of significance was set at 0.05.

  Results Top

A total of 92 responders returned the complete questionnaire, yielding a response rate 92%. Among them, 43% were females, while males were 57% and 58.6% of participants were between 25-35 years. About 64.4% of dentists were specialists, out which 21% (20) were pedodontists [Table 1].
Table 1: The summary of the distribution of respondents by gender, age, and qualification

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Knowledge about physical and social indicators of child abuse

Most of the respondents were able to identify the physical and social indicators of child abuse [Figure 1] and [Figure 2]. Majority of them (94.9%) had knowledge of all forms of child abuse. They recognized that the bruises on the cheek (60.8%) and on bony prominences (25.30%), avulsed or discolored teeth (48%), burns in the shapes of hot objects (48%), and bite marks (68%) are often associated with child abuse. Conversely, only 36.7% answered correctly that there is correlation between poor oral health and physical neglect. Sixty-eight percent believed that child abuse is more prevalent in low socioeconomic groups. Forty-six percent believed that child's psychosomatic complaints and unusual knowledge about sexual matter could be a sign of child abuse. Nearly 35.4% were of view that abuser is child known in most cases. The knowledge of indicators was more among pedodontists. However, Pearson Chi-square test did not show any significant difference between general/specialist dentists and pedodontists.
Figure 1: Response rate regarding knowledge about physical indicators of child abuse

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Figure 2: Response rate regarding knowledge about social indicators of child abuse

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Attitude and knowledge related to legal and ethical responsibilities

Seventy-nine percent were of opinion that they are required by law to report suspected cases of child abuse or neglect, whereas very few of them (21%) do not know. The majority of them (70%) think that identity of a dentist reporting child abuse should remain confidential. However, only 40% knew the Indian law and exact mechanisms for reporting child abuse [Figure 3].
Figure 3: Response rate regarding attitude and knowledge related to legal and ethical responsibilities

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Cases observed by dentists and barriers in reporting child abuse

Forty-percent of respondents had encountered cases of child abuse with significant difference among pedodontists (70%) when compared to other respondents. The cases observed were more in boys than girls almost. However, only 23% of dentists reported the observed cases [Figure 4]. Fear of litigation (27%), lack of knowledge (23%), and uncertainty of diagnosis (22%) were identified as the major barriers in reporting [Figure 5].
Figure 4: Response rate regarding cases of child abuse encountered and reported by dentists

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Figure 5: Response rate regarding barriers in reporting child abuse

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Attitude toward further education and training in recognizing and reporting child abuse

Three percent of respondents were confident enough to identify the case of child abuse, while 92% felt that they need further training regarding identification and reporting mechanisms for suspected cases [Figure 6]. However, 5% of respondents were satisfied with knowledge. Seventy-four percent of dentists were of view that formal training in diagnosis and reporting of child abuse should be part of dental college curriculum
Figure 6: Response rate regarding attitude toward formal training in identifying suspected cases

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  Discussion Top

Child abuse is a globally prevalent medicosocial problem, and multidisciplinary approaches are the best ways for protection from maltreatment. It was found that 61% of the deaths caused by child abuse were preventable.[15] The worldwide statistics shows that underreporting of suspicious cases is one of the foremost reasons for the global burden of child abuse and neglect. This may be attributed to the apparent lack of diagnostic information and knowledge of the obligation for documenting suspected cases by various health professionals.[16] Thus, a cross-sectional study was conducted in Ludhiana city to obtain the knowledge and attitude of issue of child abuse and to assess their educational needs regarding child abuse.

Response rate of the present study was comparatively higher (92.6%) to previous studies (38% and 68%) in different parts of world.[6],[17],[18] However, studies by Kaur H and et al. and Bandi et al. yielded comparable response rate to the present study.[13],[19]

Identifying child abuse is the first and most essential step for helping children who are being maltreated. Sixty-eight percent of the dentists were able to identify the physical indicators of abuse. Sixty-eight percent of current respondents also conveyed at abuse and neglect were confined to low socioeconomic classes, while 46% believed that child's psychosomatic complaints and unusual knowledge about sexual matter could be possible indicator of child abuse. This indicates that they had moderate knowledge of physical and social signs of abuse. The knowledge of indicators among respondents was higher than the similar studies conducted in Iran, Scotland, Turkey, and other states of India.[2],[20],[21],[22],[23],[24] Hashim and Al-Ani et al. also reported similar responses as the present study regarding the indicators of child abuse among the United Arab Emirates dental students.[25] The knowledge about indicators on child abuse found to be varying with experience. This can be attributed to the fact that respondents included were also from the specialist category (59%) and thus may have greater exposure to the literature on child protection. Similarly, a Jordanian study found that indicators of child abuse were recognized by almost 97% of dentists.[26] Malpani et al. and Hobbs and Wynne previously reported that low socioeconomic status, poverty, and temporary housing are highly and consistently linked to the incidence of abuse and neglect.[24],[27]

Similar to this study, a survey in California testified that <50% of dental professional knew that there is a strong correlation between poor oral hygiene and dental and physical neglect.[28] Agreeing to Naido, in the current study, 35.4% affirmed that the abuser is child known in most cases. It has been reported that parents to be the most probable abusers followed by relatives.[29] The overall knowledge about the indicators was more among specialists, out of which the maximum were among pedodontists. However, no statistically significant difference was seen.

Majority of the dentists (79%) in the current study were aware of their legal responsibility toward protecting a child from abuse and 21% of the respondents did not know. This indicated that dentists understand their legal obligation to report the suspected case. Similarly, a past survey in Texas revealed that majority of the correspondents (84%) were aware of their legal duty to report suspected cases of child abuse.[17] However, dental professionals are not always aware of their legal obligations to report child abuse, according to the studies in Ramos-Gomez et al. and Deshpande et al.[28],[22] About 75.9% of current respondents thought that identity of a dentist reporting child abuse remains confidential; nonetheless, only 40% knew the mechanism to report suspected cases. A similar study conducted in South India among dental resident yields the comparable findings.[19] This could be attributed as their unfamiliarity with child protection policies in India.

Merely 40% of current respondents had encountered cases with child abuse study, out of which only 23% reported a case of child abuse which was comparable to results reported by Owais et al. and by Dalledoneet al. et al.[26],[30] In the present study, pedodontists had a statistically significant encounter with child abuse cases as compared to the other respondents. It is rational that pedodontists are more likely to encounter these cases due to the greater number of child patients being referred to them. Similarly to the previous studies by Naidoo and United Kingdom National Society, the present survey showed that boys are more susceptible to maltreatment than girls.[29] In contrast, H. Kaur et al. reported that girls are more vulnerable to child abuse.[13] In a survey by Al-Dabaan et al., it was found that a large proportion had experienced a case of child abuse in their practice, but only about 10% of these were reported. Their reasons for not reporting suspected cases were fear of family and lack of precision about the diagnosis.[5]

Fears of a negative impact on dental practice, fear of litigation, lack of adequate knowledge on legal requirements, and reporting mechanisms followed by uncertainty of diagnosis were cited as the most common barriers in identifying and reporting abuse in the present study. Eleven percent of current respondents were afraid of family violence against them. Azevedo et al. reported fear of litigation as one of the major barriers in reporting.[18] Similarly, Bsoul et al. concluded inadequate knowledge on legal and reporting procedures as one of the obstacles.[17] Uncertainty about diagnosis, as an influencing factor for dentists, has been reported in Australia and the UK.[31],[32]

In comparison to the prior study by Al-Buhairan et al., 69.3% of the respondents wished to attend child protection training;[33] in the aforesaid survey, 92% of the respondents felt that they need further training regarding identification and reporting mechanisms for suspected cases. Most of them did not receive proper training in recognition and reporting child abuse except mere lecture-based learning. A greater proportion of dentists were of view that formal training in diagnosis and reporting of child abuse should be part of dental college curriculum.

As indicated by the results, regarding child abuse, dentists in Ludhiana city had moderate knowledge and optimal attitude. However, it needs to be improved, especially for the pedodontists as the odds of encountering child abuse cases are high. In the dental profession, underreporting child abuse is still a major problem. Most of them did not recognize or report a case because of lack of knowledge and fear of litigation. Therefore, a systematic educational program on identification of multiple signs of child abuse, the significance of identifying the cases of physical and psychological child abuse, how to report various cases, how to take a history of injuries, etc., is necessary rather than lecture-based learning.

  Conclusion Top

Children experiencing violence are at greater risk of becoming abusers themselves. When it comes to descrying child neglect and abuse, dentists are at a pivotal juncture. Thus, dentist's adequate knowledge and vigilant attitude could be valuable in breaking this vicious cycle of violence.

It is suggested that more efforts be made to improve knowledge, attitude, and skills of dentists in relation to child abuse cases for their timely intervention and management. Efforts should be made by educational and government institutes to implement comprehensive training in diagnosis and reporting of child abuse as a part of a dental college curriculum.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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