Family Abuse:

Nov. 1, 2000
As health-care professionals. hygienists have a moral ? and legal ? obligation to report suspected abuse.

Do ask ... Do tell!

As health-care professionals. hygienists have a moral ? and legal ? obligation to report suspected abuse.

Cathy Terhune Alty, RDH

Accidents are a part of everyday life: A bump into the door jamb, a slip and fall on loose gravel, a burn from being too close to a hot skillet. We?ve all had them. But what about that perfectly round burn on little Katie?s arm? That bruise on Mrs. Smith?s cheek? The torn frenum you saw in 8 year- old David?s mouth? Or the look of fear you see in 80 year-old Mrs. Turner?s eyes when her son-in-law, not her daughter, arrives to take her home after the appointment? Could it be abuse? How do you know? Who do you ask? What do you say? What are the legal ramifications? Should you get involved?

Family violence incidents, including child abuse, elder abuse, and spousal abuse/domestic violence, are on the rise in our country. The statistics are compelling. Child protective agencies confirm that 14 out of 1,000 children ? more than 1 million ? were abused in the United States. in 1993. More than 3 million children each year are at risk from exposure to parental violence. Studies also substantiate that as much as 25 to 66 percent of girls and 25 to 50 percent of boys will be sexually molested by age 18. Violence will occur at least once in two-thirds of all marriages in the United States, while 15 to 20 percent of all pregnant women are battered. Fifty percent of men who assault their wives also abuse their children. A study by the U.S. Department of Health and Human Services reveals that more than 425,000 elderly persons experienced abuse and/or neglect in 1996. An equally frightening statistic: Less than one in five incidents of abuse are ever reported. The true measure of the problem can only be estimated.

As healthcare professionals, hygienists are considered mandatory reporters. Thirty eight states require by law that hygienists report suspected abuse; dentists are are mandatory reporters in all states. Failing to report suspected abuse can have serious consequences, according to Kimberly Hart of the National Child Abuse Defense and Resource Center. Hart states that because of this, dental professionals tend to err on the side of caution.

ODefinitions of abuse differ from state to state, and there is no national standard,O says Hart. She adds, OHealth-care professionals are in a position of assumed credibility, which means their suspicions are given more credence than that of a nonprofessional. The problem is that most dentists and hygienists, although required by law to be mandatory reporters, have no training to recognize abuse.O

Providing training to dental professionals in spotting the signs of abuse has been the mission of Lynn Douglas Mouden, DDS, MPH, who is the director of Office of Oral Health at the Arkansas Department of Health. He is also associate clinical professor at the University of Missouri ? Kansas City School of Dentistry. In 1992, Dr. Mouden was instrumental in the creation of the P.A.N.D.A. (Prevention of Abuse and Neglect through Dental Awareness) Coalition in Missouri. P.A.N.D.A. is a public/private partnership designed to increase awareness in the dental community and help prevent abuse and neglect. Dr. Mouden noticed that out of the 46,000 to 48,000 cases of abuse reported in Missouri, dentists made fewer than 10 total reports per year.

OWe knew the majority of physical abuse cases involved injuries to the head, neck and mouth, but we didn?t know why dentists weren?t reporting more frequently,O says Dr. Mouden. OWeren?t they recognizing the signs, or did they not know what to do when they did see the signs?O After P.A.N.D.A. Coalition training, the statistics showed an encouraging 160 percent increase in reports from dentists in the first year.

Dr. Mouden reports that 42 states and six international locations now offer P.A.N.D.A. Coalition training. The coalition educates professionals on how to recognize and report suspected abuse, and shares resources to support professionals and victims of domestic violence.

The sole aim of mandatory reporting legislation is to ensure the person is better off than before the intervention. Dr. Mouden emphasizes that protective agencies exist to protect the victim from further abuse and strengthen the family. Caseworkers strive to keep families intact, and the majority of cases have a positive outcome. Counseling improves parental coping skills, allowing children to remain in the home.

If you suspect abuse, Susan Orr, director of marriage and family at the Family Research Council in Washington, D.C., recommends gently questioning patients immediately, rather than waiting until after they leave the office. OAsk! Investigate! Mandatory reporting means you must report if you have suspicion, not confirmation, of abuse,O she advises.

Orr recognizes, however, that there is often a fine line between abuse and errors in parental judgement. She has seen unfortunate cases where well-meaning parents were found guilty of abuse and subsequently stigmatized. OThere can be a perfectly rational explanation for the injuries you see,O she states. OSome things are obvious abuse. But there is a serious dispute about what is good parenting. I have seen cases that of parental judgement errors where child welfare found them guilty of abuse. They were put on a registry ? a permanent record. They can never volunteer at school. They can never be a den mother. Today?s computer technology can track them.O

Orr therefore urges caution and a little common sense during questioning.

Hart advises sticking to open-ended, nonleading questions: ODo the questioning in good faith, staying neutral, without leading or hiding anything.O Hart also advises dental offices to store a signed release form in every patient?s file that explains mandatory reporting and what will be done should abuse be suspected. A signed release alleviates patient confidentiality concerns and informs each patient up-front of a practice?s procedures. Hart further advises that if you see an injury, take pictures and document it. OGet more than one person in the office to support the position for professional protection.O Doing so, explains Hart, protects the child if there is abuse, helps those who are falsely accused, and demonstrates that the the reporter?s actions are in good faith.

Many experts advise taping a questioning session; however, Dr. Mouden feels tape recorders are too intimidating for the patient. You must also inform the individual and obtain consent. Instead, he suggests questioning with a witness. ORemember, it?s not our job to interview patients; that?s a job for social services. We don?t say, ODid Dad hit you?? That gives a person only three choices: yes, no, or silence. Since we are the authority figure, if we do this, we are suggesting the right answer. Instead, we need to ask general, open-ended questions: What happened? When did it happen? How did it happen? Where did it happen? Did you tell anybody else about it?O

To increase our own awareness of domestic violence, Dr. Mouden has very specific recommendations: OFirst, get training. Not just in the dental signs of abuse, but in the legal and liability aspects as well. Next, do your homework. Read the literature and educate yourself on the signs and symptoms. (See the reading list at the end of this article for suggestions). Be sure to talk to your local child protective service organization. They have good information that includes specific steps for mandated reporters.O

Mouden also urges hygienists to network with other professionals and the rest of the staff. OThis is not a solo effort,O he says, adding, OThe entire team needs to be aware. Then, if an issue arises, you can compare notes. Another staff member could be aware of a situation that can put a suspicion to rest or bring a suspicion forward.O

What about the liability issues to the hygienist who does report? Dr. Mouden says that anyone who reports abuse or neglect is immune from any criminal or civil liability if the report is made in good faith. What about the dentist who wants to ignore a suspicious injury on a child for fear of losing the family as patients when confronted? Failure to act, apart from the obvious moral implications, can result in serious civil and even criminal liability. OYou can lose a patient, or literally lose a patient (meaning the child could be killed) if you don?t report it. What?s more important ? money, or a child?s safety?O asks Mouden.

The P.A.N.D.A. Coalition has developed an outline to help professionals recognize the signs and symptoms of abuse. These may indicate the need for further inquiry of the patient, parent or caregiver. The report, OScreening for Family ViolenceO from Columbia University recommends including questions about physical abuse when taking a health history from adults.

The report also cautions, OErrors in diagnosing abuse are of great concern because of the serious emotional, legal and societal implications of either failing to take action in cases of abuse or incorrectly accusing innocent persons.O Obtaining adequate training and being keenly observant will help ensure the accuracy of our suspicions.

Suggested reading:

Ambrose, Julia B. OOrofacial Signs of Child Abuse and Neglect: A Dental Perspective.O Pediatrician; 16(3-4); 1989: 188-92.

American Medical Association. OAMA Diagnostic and Treatment Guidelines Concerning Child Abuse and Neglect, Council on Scientific Education.O JAMA; 254(6); Aug 9 1985: 796-800.

Becker, David B.; Needleman, Howard L.; Kotelchuck, Milton. OChild Abuse and Dentistry: Orofacial Trauma and its Recognition by Dentists.O JADA; 97(1); July 1978: 24-8.

Bernat, Joseph E. OChild Abuse and Neglect: Dentistry`s Role.O New York State Dental Journal; 55(3); Mar 1989: 34-7

Blain, Stephen M.; Kittle, Paul E. OChild Abuse and Neglect ? Dentistry`s Intervention.O Update in Pediatric Dentistry; 2(2); Apr 1989: 1-7.

McDowell, John D.; Kassebaum, Denise K.; Stromberg, Shelly. ORecognizing and Reporting Victims of Domestic Violence.O JADA; 123(9); Sep 1992: 44-50.

Mouden, L.D. OThe Role for Dental Professionals in Preventing Child Abuse and Neglect.O Journal of the California Dental Association; 26(10); October 1998: 737-743.

Poston, Carol. OChildhood Abuse Linked to Dental Fears.O CDS Review; 83(9); October 1990: 24-25

Sopher, Irwin M. OThe Dentist and the Battered Child Syndrome.O Dental Clinics of North America; 21(1); Jan 1977: 113-22.

Von Burg, Mary M.; Hibbard, Roberta A. OChild Abuse Education: Do Not Overlook Dental Professionals.O Journal of Dentistry for Children; 62(1); Jan-Feb 1995: 57-63.

Monteleone, JA. ORecognition of Child Abuse for the Mandated Reporter.O GW. Medical Publishing; St. Louis, Missouri; 1994; 231 pp.

Monteleone, J.A. OChild Maltreatment: A Comprehensive Photographic Reference Identifying Potential Child Abuse.O GW. Medical Publishing; St. Louis, Missouri; 1994: 266 pp.

Compiled by Lynn Douglas Mouden, DDS, MPH, FICD, FACD. For copies, or a complete bibliography, contact Dr. Mouden at: 4815 W. Markham Street, Slot 41, Little Rock, AR 72205.

Cathleen Terhune Alty, RDH, is a frequent contributor to RDH. She is based in Clarkston, Michigan.

Steps in reporting suspected abuse:

* Documentation: Carefully document any findings of suspected abuse or neglect in the patient?s record.

* Witness: Have another individual witness the examination, note and co-sign the records concerning suspected child abuse or neglect.

* Report: Call the appropriate child protective services (CPS) or law enforcement agency in your area, consistent with state law. Make the report as soon as possible without compromising the child?s dental care.

* Necessary information: Have the following information available when you make the report:

- Name and address of the child and parents or other persons having care and custody of the child

- Child?s age

- Name(s) of any siblings

- Nature of the child?s condition, including any evidence of previous injuries or disabilities

- Any other information that you believe might be helpful in establishing the cause of such abuse or neglect and the identity of the person suspected of causing it.

(c) Lynn Douglas Mouden, DDS, MPH, FICD, FACD

States that do not requiring mandatory reporting from RDHs include:

- Alabama

- North Dakota

- Arkansas

- Oregon

- Conneticut

- Rhode Island

- Georgia

- South Dakota

- Kansas

- Massachusettes

- Wisconsin

Helpful resources:

Child abuse:; 1-800-4-A-CHILD

Family Research Council: 1-800-225-4008

Elder abuse:

Domestic violence:


The P.A.N.D.A. Coalition?s recommended outline for

recognizing signs and symptoms of abuse and neglect:

Physical Abuse:

Unexplained bruises and welts: (face, lips, mouth, torso, back, buttocks, thighs) in various stages of healing; clustered, regular patterns reflecting shape of article used to inflict (exg. buckle) on several different areas; regularly appears after absence, weekend, or vacation

Unexplained burns: cigarette, cigar burns, (especially on soles, palms, back, buttocks); immersion burns (sock or glove-like); circular or patterned (electric burner, iron); rope burns on arms, legs, or torso

Unexplained fractures: skull, nose, facial structures in various stages of healing

multiple or spiral fractures

Unexplained laceration or abrasion: to mouth, lips, gingiva, eyes, or external genitalia

wary of adult contacts; apprehensive when others cry

Behavioral extremes: aggressive; withdrawn

Frightened of parents; wary of adult contacts; apprehensive when others cry; afraid to go home reports injury by parents

Physical Neglect:

Constant hunger; poor hygiene; inappropriate dress; consistent lack of supervision, especially in dangerous situations or for long periods; unattended physical problems or medical/dental needs


Begging, stealing food

Extended stays at school; early arrival, late departure

Constant fatigue, falling asleep in class

Alcohol or drug abuse

Delinquency (exg.? thefts)

Says there is no caretaker

Sexual abuse:

Difficulty in walking or sitting; torn, stained, bloody underwear; pain or itching in genital area; bruises or bleeding of external genitalia, vaginal, or anal areas

Venereal disease, esp. in pre-teen


Unwilling to change for PE

Withdrawal, fantasy, or infantile behavior

Bizarre, sophisticated sexual knowledge or behavior

Poor peer relationship

Delinquency; runaways

Reports sexual assault by caretaker

Emotional maltreatment

Speech disorders

Lags in physical development

Failure to thrive

Habit disorders (sucking, biting, rocking, etc.)

Conduct disorders (antisocial, destructive)

Neurotic traits (sleep disorders, inhibited play)

Psychoneurotic behaviors (hysteria, phobia, obsession, compulsion, hypochondria)

Behavior extremes: compliant, passive; aggressive; demanding

Overly adaptive behavior: inappropriately adult; inappropriately infantile

Developmental lags (physical or mental)

Attempted suicide