By Katie Melko, RDH, MSDH
During my years as a mobile dental hygienist, I have seen some very sad things. Making the tough decision to call the appropriate agency (the Department of Children and Families [DCF] in Connecticut, where I practice) can be very intimidating as a mandated reporter. As clinicians, we are trained to pay attention to detail and to give our patients the best care that they deserve. When working with children, it can be difficult to determine which signs represent abuse and which do not. After all, children fall and get bumps and bruises and cuts. This is why it’s important to ask questions - but to do it in a way that is not intimidating, so that the child trusts you and feels comfortable talking to you.
It is a hard decision to pick up that phone and make that call. I know I have to make the call, and it’s better to be safe than sorry, but there is never a guarantee that I’m doing the right thing. I hate the thought of the child hating me, because children protect their parents even at a cost to themselves. It’s an emotionally difficult thing to process. In this article, I’m going to break down the process to help create some ease if you ever have to make the call.
How long do I have to make a report?
As a clinician and mandated reporter, you have 12 hours to make the oral report when you see a child who you think is being abused or neglected or who shows signs of fear. The DCF is mandated to record all reports. It is important to make the report as soon as possible to make sure that the facts are accurate and remembered in as much detail as possible. An important lesson I learned was to ask the operator taking my report to repeat what I said at the end to make sure my comments were being documented properly. In the state of Connecticut, the clinician also has to fax a written report within 48 hours of the incident.
If the abuse is recognized at a private or public facility, the mandated reporter must provide written notification to the head of the facility in which the alleged victim is enrolled. The facility may also have its own protocol that the mandated reporter has to follow. The mandated reporter can choose to be anonymous to the family but needs to give full disclosure of his or her identity for the DCF’s records. It is important to make sure your office has a protocol in place for mandated reporters to ensure that the process is completed in a timely and orderly manner.
What must be reported?
In Connecticut, “mandated reporters are required to report or cause a report to be made when, in the ordinary course of their employment or profession, they have reasonable cause to suspect or believe that a child under the age of 18 has been abused, neglected or is placed in imminent risk of serious harm.”1
The law continues, “Child abuse occurs where a child has had physical injury inflicted upon him or her other than by accidental means, has injuries at variance with history given of them, or is in a condition resulting in maltreatment, such as, but not limited to, malnutrition, sexual molestation or exploitation, deprivation of necessities, emotional maltreatment or cruel punishment . . . Child neglect occurs where a child has been abandoned, is being denied proper care and attention physically, emotionally, or morally, or is being permitted to live under conditions, circumstances or associations injurious to his well-being.”
The American Academy of Pediatric Dentistry (aapd.org) offers several resources for reporting child abuse or neglect discovered in the dental setting. The association, for example, defines dental neglect as the “willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral heath essential for adequate function and freedom from pain and infection.”
When making the call, you must know the following: the child’s name, date of birth, gender, address, and parents’ or guardians’ names. Other important information is the reason for the call, the approximate date the abuse occurred, who is suspected of doing the abuse, and where on the child’s body the signs of abuse, if any, are located. Also take note of the child’s general demeanor toward you (e.g., skittish, afraid, lack of eye contact, covering up their body, using a low voice).
Am I a mandated reporter?
As a registered dental hygienist, you are a mandated reporter. Failure to make a report in Connecticut can begin with a $500 fine; depending on the severity of case, the penalty can vary. If the DCF knows or feels that the reporter is making false claims of abuse, the person’s identity will be turned over to the police. The fine for failure to report within the appropriate amount of time can be from $500-$2,000 and may require additional education or training on being a mandated reporter.
I made the mandated report. What happens now?
According to the DCF’s website, it “is responsible for immediately evaluating and classifying all reports of suspected abuse/neglect/imminent risk.” (CT.GOV) If the DCF finds that the report needs to be investigated, the department works as hard as it can to start the investigation within two hours if it feels that the child is at risk of imminent danger. If there is not an immediate emergency, then the department must start investigation within three days from the day of the report. For all reports being made, DCF has 30 days to investigate the child’s case.
If the child’s case is pursued, the DCF needs parental consent to talk to the child unless the parents are suspected of abuse. In that case, the consent isn’t needed, but an unbiased person who has no direct interest in the child must sit in on an interview with the child and DCF counselor. After the interview, if serious physical or sexual abuse is noted, then the DCF has to notify police.
Some cases I’ve experienced
I still think about a case I witnessed last year. A six-year-old girl who came for a prophy presented with a cut on her lip. Initially, I thought that she bit her lip. When I inquired about the cut, I learned the difficult truth: her mother punched her in the mouth while yelling at her that morning and told her to tell anyone who asked that she bumped it while playing. I did my best to keep smiling and not to scare her, asking one question at a time in between cleaning her teeth. Toward the end she became nervous and kept repeating that it was an accident. It was a difficult decision to call, but I knew that I made the best decision for the well-being of that child. She may not understand it now, but in the future hopefully she will. I’ll never know exactly what happened to her, but all I can do is hope for the best.
Another case I had involved a seven-year-old girl who came for a prophy at school. She immediately sat down when she came into the room; when I asked her what her name was, she spoke so softly I barely heard her. When I turned around and asked again, a little louder, she repeated her name, but almost jumped out of the chair in fear. In that moment, I knew something wasn’t right. I asked her if she was nervous about getting her teeth cleaned; she said that she was in a lot of pain and was scared. Her appearance was ragged - she was dirty and looked malnourished.
When she opened her mouth for me to take a look, what I saw devastated me. The child presented with an eruption cyst, four abscesses, and multiple areas of suspicious cavitated lesions on her deciduous and permanent teeth. I asked if she had told her parents that she was in pain. She did not respond and looked down at her feet. I reassured her that I was just trying to find out so I could let her parents know if they were unaware. She looked up at me tearfully and said, “No, please don’t tell them. I don’t want to cause trouble.” I wiped her tears and said, “OK. Can I clean your teeth and teach you how to brush?” She replied, “No, I don’t want to bother you.”
The conversation broke my heart. I did clean her teeth and gave her some preventive items to take home with her. This was my first DCF case, and it was very difficult for me. I had no idea how to make the report. I had to call my supervisor and learn the company’s policy and the state requirements. I had to inform the social worker, principal, and nurse at the school. It was a long process and a delicate one as well. I found out that this wasn’t the first issue for this child either. I never found out what happened to her, but I do believe I did what was best for her well-being.
One last story I’ll share is about a 12-year-old boy who came in for a prophy with a swollen ankle, limping, and holding his arm strangely. His chart documented several areas of decay and several attempts to get this patient care over a two-year period. The patient acted normally as I was talking to him. He didn’t seem to care much about getting his teeth cleaned and he had a bit of an attitude. Throughout the appointment, I tried to engage the child. He slowly told me how he got injured by his father, who had pushed him down a flight of stairs in an argument. The patient said, “It was an accident. He just got too angry and I was standing too close.” The child wasn’t brought to a medical doctor and didn’t want to upset his father any more, so he said, “I’m just dealing with it. I’ll be fine, and it’s not the first injury I’ve gotten.” He had two abscesses and poor oral hygiene with gingivitis. The boy said, “We share one toothbrush in my house. That’s all we can afford, my parents say.” I knew in that moment that I had another case I had to report. I gave the child a toothbrush for each of his family members, educated him, and sent him back to class. Then it was off to the principal and the nurse to get some information on the family and discuss my findings. I called the report in and followed the protocols of the state, the facility where I was, and my company.
Some advice I have for new professionals is to go with your gut. If it doesn’t feel right, it probably isn’t! Abuse varies and will not present the same; sometimes it’s easily missed. That’s why I have a variety of questions I ask children when I treat them to see if there are red flags. These questions are friendly and inviting, but also tell a tale. It engages the child and helps build their trust in you. I hope you never have to make the call, but if you do, you can be prepared and know what needs to be done to fulfill the oath you took when you became a dental hygiene professional. RDH
Katie Melko, RDH, MSDH, is a public health hygienist at Community Health Center Inc. She graduated from Fones School of Dental Hygiene at the University of Bridgeport in 2016 with an MSDH. She sits on three workgroups, two for ADHA and one for NBDHE, and has practiced dental hygiene since 2009.
1. Conn Gen Stats §17a-101a.
2. Connecticut General Statutes §46b-120.
3. Connecticut Department of Children and Families. State of Connecticut website. http://www.ct.gov/DCF/site/default.asp. Accessed January 30, 2017.
If red flags are obvious, questions to ask
I ask children about what kinds of food they eat at home and how often they brush. This gives me an idea if there is anything unusual going on. Based on their responses, I’ll ask more detailed questions, particularly if they are not eating at home or don’t have a toothbrush.
If a child looks upset or sad, I’ll ask how their day is going, and why they seem sad. Again, based off answers I receive, I’ll have follow up questions. If a child has their coat on, I’ll ask if they want to take off their jacket to be more comfortable. If they have any visible bumps, bruises, or cuts, I’ll ask what happened in a casual voice, “Were you playing with friends?” Based on the response, I’ll probe further.
I often ask how their weekend was and if they did anything fun. This tells me a lot about their home life as well.