A dental perspective on child maltreatment
Sammanfattning: Children who are exposed to child maltreatment are at risk of developing physical and mental ill-health and of expressing risk-taking behaviors. International studies describe associations of child maltreatment with caries, head and neck injuries and intra- oral injuries. Similar studies in a Swedish context are scarce, and little is known. The present thesis analyzed associations of oral health and oral health behaviors among children exposed to child maltreatment, as well as among children who were enrolled at the Social Services because of suspected child maltreatment. The thesis studies also describe the clinical management of suspected child maltreatment within dental health services concerning mandatory reports (decision-making, prevalence, and characteristics). Study I investigated – among 5,940 Grade 9 compulsory school and second-year high school pupils – the association between self-perceived oral health and (i) self-reported experiences of physical abuse, (ii) intimate partner violence, (iii) forced sex, and (iv) bullying. The following items were included: socio-demographic variables, abuse variables, and self-perceived oral health. Adolescents who reported poor self-perceived oral health also reported experience of physical abuse, intimate partner violence, bullying and forced sex (aOR 2.3–14.7). The likelihood of reporting poor oral health increased from aOR = 2.1 for a single incident of abuse to aOR = 23.3 for multiple incidents. Study II investigated the management of suspicions of child maltreatment among specialists in pediatric dentistry. Four focus groups with a total of 19 informants were formed. Discussions were video-recorded, transcribed verbatim, and analyzed with thematic analysis. There was common agreement on the meaning of child maltreatment, such as poor oral health, lack of tenderness and love in the family and a child being exposed to various kinds of violence or ill treatment. The main theme for decision-making in mandatory reporting was identified and labeled as “the dilemma of reporting suspicions of child maltreatment”. The dilemma occurred in three subthemes: (1) to support and report, (2) to differentiate between poor well-being and child maltreatment, and (3) the supportive or the unhelpful consultation. Study III included all mandated dental reports to the Social Services concerning suspicions of child maltreatment in one municipality during the study period. The study analyzed age, gender, and socioeconomic status; main cause for the report; the content of the report; and concurrences with other mandated reports or own applications. The results showed that 111 children had been reported a total of 147 times from dental care services between January 2008 and December 2014. During 2008–2011 a significant increase from 6 to 37 reports per year occurred (p<0.001). Most reports originated in low socio-economic areas (p=0.043), and 86% of the reports concerned a child who had had prior contact with Social Services. The main reasons for reporting were (i) failure to attend to regular dental check-ups (without known treatment need), and (ii) dental neglect (p<0.001). Study IV evaluated oral health, oral health behaviors, and parental factors among 86 children investigated by the Social Services because of suspected child maltreatment and for whom a dental record had been requested. The findings were compared with those in 172 controls. Children in the study group were shown to have increasingly severe dental treatment needs compared with controls. Missed appointments and dental health service avoidance occurred more often because caregivers did not bring their children, than for legitimate reasons. Furthermore, children suspected of experiencing maltreatment are more likely to lack parental support in maintaining good oral health and to have been referred for specialist pediatric treatment. Conclusions: Poor self-perceived oral health, presence of dental neglect, and dental health service avoidance- may indicate broader social problems and possible child maltreatment. Thus all dental health professionals should ask questions about the child’s social situation when dental disease and/or attendance behaviors cannot be reasonably explained. Pediatric dental care at a specialist clinic is a particularly important setting where children and their families’ social situation should be assessed. Dental neglect as a diagnosis or a suspicion should be used more often; it should be documented in the dental records and subsequently reported to the Social Services. A report from dental professionals may help children and their families receive, from other sources, supportive interventions that are unavailable in the dental health services. Furthermore, the Social Services should acknowledge oral health when investigating children’s needs according to the Social Services Act.
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