Introduction

If you can’t trust your parents then who can you trust? Abuse by a primary caregiver damages the most fundamental relationship as a child—that you will safely, reliably get your physical and emotional needs met by the person who is responsible for your care. The most common cause in abusive families is the Substance abuse, poverty and economic strains, parental capacity and skills, and domestic violence.

Abuse and neglect of children are best considered in perspective in which the individual, family, social, and psychological influences are considered not separately but considered as a single factor to contribute to the problem. Kempe and Helfer termed this abusive pattern, in which the child, the crisis, and the caregiver's potential to abuse are components in the event of maltreatment.

If you think you are not physically abusing a child and a child is not being abused or neglected than you are probably wrong! Child abuse is not just the physical abuse; neglecting, rejecting, ignoring, terrorizing or criticizing a child is also a form a child abuse. Not being able to provide necessary health care to a child if needed is also an abuse. Let’s have a look over different forms of child abuse to have a better understanding and to take care of our little one’s in a better way.

Forms of Child Maltreatment/Abuse

Child maltreatment may occur either within or outside the family. The proportion of cases within or outside the family varies with the type of abuse as well as the gender and age of the child. Whether the abuse is a slap, a harsh comment, stony silence, or not knowing if there will be dinner on the table tonight, the end result is a child that feel unsafe, uncared for, and alone. Each of the following conditions may exist separately or concurrently. Neglect is the most commonly reported and substantiated form of child maltreatment and the person who is neglecting the child is most of the time unaware of the psychological trauma a child is undergoing by this neglect.

Physical Abuse

Physical abuse of children is most often inflicted by a caregiver or family member but occasionally by a stranger. The most common manifestations include bruises, burns, fractures, head trauma, and abdominal injuries. A small but significant number of unexpected paediatric deaths, particularly in infants and very young children (e.g. sudden unexpected infant death), are related to physical abuse.

Many physically abusive parents and caregivers insist that their actions are simply forms of discipline—ways to make children learn to behave. But there is a big difference between using physical punishment to discipline and physical abuse. The point of disciplining children is to teach them right from wrong, not to make them live in fear. These become very clear as the history provided by the child and parent may vary. The pattern of injury may not resemble a fall or accidental injury.

Sexual Abuse

Sexual abuse is defined as the engaging of dependent, developmentally immature children in sexual activities that they do not fully comprehend and to which they cannot give consent, or activities that violate the laws and taboos of a society. It includes all forms of incest, sexual assault or rape, and paedophilia. It's important to recognize that sexual abuse doesn't always involve body contact.

Exposing a child to sexual situations or material is sexually abusive, whether or not touching is involved. This includes fondling, oral-genital-anal contact, all forms of intercourse or penetration, exhibitionism, voyeurism, exploitation or prostitution, and the involvement of children in the production of pornography. Exploitation and enticement of children and adolescents via the Internet remains a growing trend.

These are small children and have their own share of rights to live a happy life. Treating them as individuals and not as objects may help treat the problem. A child who has suffered sexual abuse has inevitable marks on the psyche and as the child grows into an adult they are deep rooted in the psychology.

For a child with sexual abuse, counselling is must so that these incidents do not hamper the normal development of the child.

Emotional Abuse & Neglect

Emotional or psychological abuse has been defined as the rejection, ignoring, criticizing, isolation, or terrorizing of children, all of which have the effect of eroding their self-esteem. The most common form is verbal abuse or denigration. Children who witness domestic violence should be considered emotionally abused. The most common feature of emotional neglect is the absence of normal parent-child attachment and a subsequent inability to recognize and respond to an infant's or child's needs. A common manifestation of emotional neglect in infancy is nutritional (nonorganic) failure to thrive.

Physical Neglect

Physical neglect is the failure to provide the necessary food, clothing, and shelter and a safe environment in which children can grow and develop. Although often associated with poverty or ignorance, physical neglect involves a more serious problem than just lack of resources. There is often a component of emotional neglect and either a failure or an inability, intentionally or otherwise, to recognize and respond to the needs of the child.

Warning signs of neglect in children: Clothes are ill-fitting, filthy, or inappropriate for the weather. Hygiene is consistently bad (not bathed, matted and unwashed hair, noticeable body odor).

Medical Care Neglect: Medical care neglect is failure to provide the needed treatment to infants or children with life-threatening illness or other serious or chronic medical conditions untreated illness and physical injuries.

Munchausen Syndrome by Proxy

Munchausen syndrome by proxy is a relatively unusual disorder in which a caregiver, usually the mother, either simulates or creates the symptoms or signs of illness in a child. The disorder has recently been termed factitious disorder by proxy. The child can present with a long list of medical problems or often bizarre, recurrent complaints. Persistent doctor shopping and enforced invalidism (e.g. not accepting that the child is healthy and reinforcing that the child is somehow ill) are also described in the original definition of Munchausen syndrome by proxy. Fatal cases have been reported.

Examining child abuse/ neglect

1. The dentist should observe the lack of cleanliness, for small stature with respect to age and evidence for malnutrition. Typical sign for malnutrition include a posture of fatigue with rounded shoulder.
2. Face and neck should be observed for periorbital edema ecchymosis, scleral hemorrhage, ptosis, deviated nasal septum, cigarette burn marks and hand slap marks.
3. Corner of the mouth with binding mark from a gag tied for hours to force the feed.
4. Fracture anterior teeth or torn frenum
5. Belt marks, electric cord mark, bite mark and bruises on back and chest

Facial injuries prevalence

The table below shows the percentage of the injury occurrence

Prevention

Physical abuse is preventable in many cases

1. Parent education and anticipatory guidance are also helpful, with attention to handling situations that stress parents (e.g. colic, crying behaviour, and toilet training), age-appropriate discipline, and general developmental issues.
2. Prevention of abusive injuries perpetrated by nonparent caregivers (e.g. babysitters, nannies, and unrelated adults in the home) may be addressed by education and counselling of mothers about safe child care arrangements and advocating for affordable day care for all families.
3. The prevention of sexual abuse is more difficult. Most efforts in this area involve teaching children to protect themselves and their "private parts" from harm or interference.
4. The age of toilet training is a good time to provide anticipatory guidance to encourage parents to consider this discussion.
5. The most rational approach is to place the burden of responsibility of prevention on the adults who supervise the child and the medical providers rather than on the children themselves.
6. Promoting Internet safety and limiting exposure to sexualized materials and media should be part of this anticipatory guidance.
7. Efforts to prevent emotional abuse of children have been undertaken through extensive media campaigns. No data are available to assess the effectiveness of this approach. The message that parents are role models for a child's behaviour is important. As a responsible citizen whenever you see such a situation report the case to your nearest child protection officer.

References

1. Adams JA et al: Guidelines for medical care of children who may have been sexually abused. J PediatrAdolescGynecol 2007; 20:163. [PMID: 17561184]
2. American Academy of Pediatrics, Hymel KP; Committee on Child Abuse and Neglect; National Association of Medical Examiners: Distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics 2006;118:421. [PMID: 16818592]
3. American Academy of Pediatrics, Hymel KP; Committee on Child Abuse and Neglect: When is lack of supervision neglect? Pediatrics 2006;118:1296. [PMID: 16951030]
4. American Academy of Pediatrics: Clinical report: The evaluation of sexual abuse of children. Pediatrics 2005;116:506. [PMID: 16061610]
5. DeBellis MD: The psychobiology of neglect. Child Maltreat 2005;10:150. [PMID: 15798010]
6. Johnson CF: Child sexual abuse. Lancet 2004;364:462. [PMID: 15288746]