Child Abuse and Neglect: An Overview

1PG Student, Department of Pediatric and Preventive Dentistry, Bhojia Dental College and Hospital, Bhud (Baddi), Solan, Himachal Pradesh 2Professor & Head, Department of Pediatric and Preventive Dentistry, Bhojia Dental College and Hospital, Bhud (Baddi), Solan, Himachal Pradesh 3Reader, Department of Pediatric and Preventive Dentistry, Bhojia Dental College and Hospital, Bhud (Baddi), Solan, Himachal Pradesh 4Senior Lecturer, Department of Pediatric and Preventive Dentistry, Bhojia Dental College and Hospital, Bhud (Baddi), Solan, Himachal Pradesh 5Senior Lecturer, Department of Pediatric and Preventive Dentistry, Bhojia Dental College and Hospital, Bhud (Baddi), Solan, Himachal Pradesh 6PG Student, Department of Pediatric and Preventive Dentistry, Bhojia Dental College and Hospital, Bhud (Baddi), Solan,Himachal Pradesh Abstract Child abuse and neglect are serious global problems and can be in the form of physical, sexual, emotional or just neglect in providing for the child’s needs. These factors can leave the child with serious, long-lasting psychological damage. Child maltreatment is a complex life experience occurs when a parent or caregiver does an intentional or potential damage to a child, including acts of commission and omission. Child abuse is not an uncommon event, but it is not always recognized. Identifying the real number of maltreated children is a challenge because of the large variability in reported prevalence data across studies. It is associated with important economic and social costs (such as physical and mental health, productivity losses, child welfare, criminal justice and special education costs) due to its high prevalence and its long-term and short-term consequences.

nic, religious and professional strata. 1 World Health Organisation defines Child abuse and neglect (CAN) as "Every kind of physical, sexual, emotional abuse, neglect or negligent treatment, commercial or other exploitation resulting 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". 2 Child maltreatment has been associated with poor emotional, cognitive, and physical health functioning both during childhood and later in life. 3 According to the United Nations Convention on the Rights of the Child (UNCRC), children are entitled to basic rights of protection, including protection from abuse, neglect, exploitation, and violence. 10 Maltreatment is all forms of physical and/or emotional ill-treatment, sexual abuse neglect or negligent treatment or commercial or other exploitation, resulting 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 The clinical report from the American Academy of Pediatrics (AAP) entitled "The Evaluation of Suspected Child Physical Abuse" provides additional guidance (Christian CW) that is useful in the medical assessment of suspected physical abuse includes the following:

TYPES OF CHILD ABUSE
• Standard history including medical, developmental, and social history.
• Family history, especially of bleeding, bone disorders, and metabolic or genetic disorders.
• Familial patterns of discipline. Child temperament: Whether the child is easy or difficult to care for; whether there is excessive crying in an infant; parents" expectations of the child"s behaviours and development. • Substance abuse by any caregivers or people living in the home; mental health problems of parents; past arrests, incarcerations, or interactions with law enforcement; and domestic violence (which may be necessary to ask of each parent or caregiver individually).
• Social and financial stressors and resources.
Sexual abuse 9,10,11 Sexual abuse is inappropriate sexual behaviour with a child. It includes fondling a child's genitals, making the child fondle the adult's genitals, intercourse, incest, rape, sodomy, exhibitionism and sexual exploitation. Oral and perioral gonorrhea in prepubertal children (which is diagnosed with appropriate culture techniques and confirmatory testing) is pathognomonic of sexual abuse but is rare. Rates are higher in sexually abused adolescents (12% with gonorrhea; 14% with Chlamydia).
When oral-genital contact is confined by history or examination findings, universal testing for sexually transmitted infections within the oral cavity is controversial; the clinician may consider risk factors (e.g. chronic abuse or a perpetrator with a known sexually transmitted infection) and the child"s clinical presentation when deciding whether to conduct such testing.
Accuracy to diagnose sexually transmitted infections of the oral cavity is increased if evidence is collected within 24 hours of exposure in prepubertal children (Girardet R, Bolton K) and within 72 hours in adolescents.
Bite Marks: Acute or healed bite marks may indicate abuse. Human bites compress flesh and can cause abrasions, contusions, and lacerations but rarely avulsions of tissue. An intercanine distance (i.e., the linear distance between the central point of the cuspid tips) measuring more than 3.0 cm is suspicious for an adult human bite.35 Bite marks should be suspected when ecchymoses, abrasions, or lacerations are found in an elliptical, horse shoe shaped, or ovoid pattern.
Bullying 12,13 Thirty percent of children in the sixth to 10th grades report having been bullied and/or having bullied. Children with orofacial or dental abnormalities (including malocclusion) are frequently subjected to bullying and as a result, may suffer serious psychological consequences, including depression and suicidal ideation. Children who reported physical abuse, intimate partner violence, forced sex, and bullying were found to also report poor oral health. Health care providers (including dental providers) can ask patients about bullying and advocate for antibullying prevention programs in schools and other community settings.

Human trafficking 14
Human trafficking is a serious child health issue involving medical and dental ramifications, among others. The US Department of State defies human trafficking as "The recruitment, harbouring, transportation, provision, or obtaining of a person for labour or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. Often these, children most commonly experience sex trafficking, "in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age".
Human trafficking in India: According to the National Crime Records Bureau (NCRB) study (YEAR), the common causes of trafficking were forced marriages, child labour, domestic help and sexual exploitation, among others.
Emotional Abuse 15,16 Childhood emotional abuse is a more hidden form of childhood maltreatment, which can be characterized as degrading, terrorizing, isolating, denying/rejecting and exploitive/corruptive caregiving. Emotional abuse itself is associated with a myriad of neuropsychosocial problems including disturbance in brain limbic systems, dissociative symptoms, anxiety, depression, low self-esteem, hostility and delin-

CURRENT MEDICAL RESEARCH AND OPINION
quency.
WHO has defined emotional abuse as: "Emotional abuse includes the failure to provide a developmentally appropriate, supportive environment, including the availability of a primary attachment figure, so that the child can develop a stable and full range of emotional and social competencies commensurate with her or his personal potentials and in the context of the society in which the child dwells.

TYPES OF CHILD NEGLECT
WHO 1999 defines child neglect as the failure to provide for the development of the child in all spheres: It is defined by the AAPD, as the "wilful failure of parent or guardian, despite adequate access to care, to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection." This neglect is seen at each and every step of life with different reasons involved with it.
Salient features of dental neglect include failure to seek or delay in seeking dental treatment, to comply with treatment plan, and failure to implement. Early lesions that progress to cavity in 2-3 years and these cavities can further give rise to symptoms such as pain and swelling, which are also considered to be features of neglect. c. The anticipated benefit of the treatment is significantly greater than its negative adverse effects, ensuring that reasonable caregivers would choose treatment over non treatment.
d. Access to health care is available but not used.

Supervisory neglect 19
It is a serious health concern. Unintentional injury is the leading cause of death in children between the ages of 1to 15 years. (The American Academy of Pediatrics defines supervisory neglect as whenever a caregiver's supervisory decisions or behaviours place a child in his or her care at significant ongoing risk for physical, emotional, or psychological harm.

Nutritional Neglect 20
The PNP may also be confronted with nutritional neglect at both ends of the spectrum: failure to thrive and obesity. Both types most often result from a combination of nutritional and psychosocial factors. Failure to thrive is defined as weight falling below the 5th percentile for age.

Consequences of Child Abuse and Neglect
Aside from the immediate physical injuries children can experience through maltreatment, a child's reactions to abuse or neglect can have lifelong and even intergenerational impacts Types of consequences: Physical Health Consequences, Psychological Consequences, Behavioural Consequences and Societal Consequences 21

Physical Health Consequences
Some long-term physical effects of abuse or neglect may occur immediately (e.g., brain damage caused by head trauma), but others can take months or years to emerge or be detectable. There is a straightforward link between physical abuse and physical health, but it is also important to recognize that maltreatment of any type can cause long-term physical consequences. Childhood maltreatment has been linked to higher risk for a wide range of long-term and/or future health problems. 22

Psychological Consequences
Child abuse and neglect can cause a variety of psychological problems. Maltreatment can cause victims to feel isolation, fear, and distrust, which can translate into lifelong psychological consequences that can manifest as educational difficulties, low selfesteem, depression, and trouble forming and maintaining relationships. 23

Behavioural Consequences
Victims of child abuse and neglect often exhibit behavioural difficulties even after the maltreatment ends. The following are examples of how maltreatment can affect individuals' behaviours as adolescents and adults. Unhealthy sexual practices, Juvenile delinquency leading to adult criminality, Alcohol and other drug use. 24

Societal Consequences
Although the physical, psychological, and behavioural consequences of child abuse and neglect weigh heavily on the shoulders of the children who experience it, the impact of maltreatment does not end there. Society pays a price for child abuse and neglect in both direct costs (e.g. hospitalizations, foster care payments) and indirect costs (e.g. longterm care, lost productivity at school, juvenile and criminal justice systems costs). 23

Laws
The Constitution of India provides that the state, as a directive principle of state policy, must seek to ensure "that children are given opportunities and facilities to develop in a healthy manner and in conditions of freedom and dignity and that childhood and youth are protected against exploitation and against moral and material abandonment.

Federal Laws
A federal government is a system of government that separates the power between central and state government of the country. It delegates certain responsibilities to each sector so that the central government has its own task to do and state government has its own.
• Schemes and Programmes on Child Protection Some of the existing child protection schemes and programmes include: 3. Childline Service for children in distress, especially children in need of care and protection so as to provide them medical services, shelter, rescue from abuse, counselling, repatriation and rehabilitation. Under this initiative, a telephone helpline, number 1098, runs in 74 urban and semi-urban centres in thecountry.115 4. Shishu Greha Scheme Scheme for care and protection of orphans/ abandoned/destitute infants or children up to 6 years and promote in-country adoption for rehabilitating them.

Prevalence in India
Children, under the age of 18, contribute to 37% of India's population165 with large proportions experiencing great deprivations such as lack of access to basic education, nutrition or health care. 28 The first nation-wide study in India on child abuse by the Ministry of women and child development (2007) found high prevalence particularly among young children (5)(6)(7)(8)(9)(10)(11)(12) year group) who were the most at risk of abuse and exploitation. Majority (55%) of physically abused (69%) were boys. Most (boys-53%, girls-47 %) of the abuse happened in the family environment by parents (89%).
Physical abuse was more in juvenile justice institutions (70 % of children in conflict with law and 53% of children in need of care and protection) also. Family members and other people were the perpetrators of physical abuse of children living on the street (66 % of boys and 68% of girls