ORIGINAL RESEARCH

https://doi.org/10.5005/jp-journals-10077-3256
Journal of South Asian Association of Pediatric Dentistry
Volume 6 | Issue 1 | Year 2023

Dental Students Perception and Knowledge toward Child Abuse and Neglect in Dentistry: A Cross-sectional Study

Tanya Roy¹ https://orcid.org/0000-0003-0438-012X, Geetanjali Jadhav² https://orcid.org/0000-0002-3113-5675, Pritesh N Gawali³, Anand Shigli⁴, Rahul Hegde⁵ https://orcid.org/0000-0003-4904-2933, Roshni Rankawat⁶

^1,6Department of Pediatric and Preventive Dentistry, DY Patil Dental School, Pune, Maharashtra, India

^2,5,4Department of Pediatric Dentistry, DY Patil Dental School, Pune, Maharashtra, India

³Department of Pedodontics and Preventive Dentistry, Sinhgad Dental College & Hospital, Pune, Maharashtra, India

Corresponding Author: Tanya Roy, Department of Pediatric and Preventive Dentistry, DY Patil Dental School, Pune, Maharashtra, India, Phone: +91 9834393069, e-mail: dr.tanyaroy01@gmail.com

Received on: 01 December 2022; Accepted on: 11 March 2023; Published on: 22 April 2023

ABSTRACT

Aim: This study aimed to analyze the perception, attitude, knowledge, and experience of child abuse and neglect (CAN) among dental students in Pune, Maharashtra, India. The aim will help us come up with prevention strategies to help reduce the occurrence of CAN and also protect the children suffering.

Materials and methods: A total of 400 dental students were provided with a questionnaire. Descriptive analysis was carried out by using the obtained data.

Results: Dental students’ perception and knowledge about CAN are low and these professionals have poor attitudes and knowledge toward CAN by the code of conduct and law. The available information and education are also poor.

Conclusion: The results obtained from the study showed that there is a lack of knowledge and poor attitude and perception about CAN among dental students that prevents them from detecting and identifying suspected cases. Continuing dental education is required to enhance the ability of professionals to detect CAN cases. This study showed how we need to focus more on the training of dental professionals when concerned with cases of CAN.

How to cite this article: Roy T, Jadhav G, Gawali PN, et al. Dental Students Perception and Knowledge toward Child Abuse and Neglect in Dentistry: A Cross-sectional Study. J South Asian Assoc Pediatr Dent 2023;6(1):19-24.

Source of support: Nil

Conflict of interest: None

Keywords: Child abuse and neglect, Dental neglect, Dental students.

INTRODUCTION

Child abuse and neglect (CAN) is a grave issue our society faces. The physical, psychological, as well as social well-being of a child is of utmost importance. However, it is often overlooked by their primary caregiver. It could be in the form of negligence or even emotional, physical, or sexual abuse.

Child abuse and neglect (CAN) is defined by the Child Abuse Prevention and Treatment Act as “any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm.”¹

There are five subtypes of CAN—(1) physical abuse: in which a child potentially is physically harmed, such incidents may be single or multiple; (2) child sexual abuse: in which there is some sort of sexual activity where the child isn’t aware or cannot comprehend and is unable to give consent; (3) emotional abuse: where in the primary caregiver fails to provide an emotionally supportive environment for the child; (4) neglect: where the caregiver fails to pay attention to or omits the basic emotional, physical, health, and educational needs of the child; and (5) exploitation: where the child is exploited for work or other activities which benefits others such as child trafficking.²

Child abuse and neglect (CAN) have several short- and long-term effects on the child. These effects include post-traumatic stress disorder, aggression, emotional disturbances, and mental health concerns like anxiety, depression, etc. These effects also affect the child in their adulthood. According to the adverse childhood experiences study, an American research project established a strong relationship between bad experiences in childhood and adulthood physical and mental well-being.³

In a study done by da Fonseca et al., the children who had been physically abused showed >75% lesions on the head, neck, and face. Bite marks are good indicators of abuse as they are rarely accidental.⁴

It is a known fact that medical professionals are the first ones to come in contact with children affected by abuse and neglect. Dental professionals especially are the ones who would first notice any signs of CAN, since in maximum cases, the lesions are seen in the head, neck, mouth, and face region.

AIM

The aim was to assess dental students’ perception and knowledge of CAN in a pediatric dental setup.

Objectives

To assess the perception and knowledge of dental students toward CAN.
To assess perception and knowledge of CAN between male and female students.
To assess perception and knowledge toward CAN among final years, interns, and postgraduates.

Epidemiology

International Statistics

Nearly one in every four children, or 300 million children, aged 2–4 years are subjected to physical punishment and/or psychological violence at the hands of their parents or caregivers regularly.⁵
One in every five women and one in every 13 males report having been sexually molested as a child aged 0–17 years.
Forced sexual intercourse has occurred in 120 million girls and young women under the age of 20.⁵

Indian Statistics

In 2020, 1,28,531 occurrences of crime against minors were reported, a 13.2% reduction from the previous year (1,48,090 cases). Kidnapping and abduction (42.6%), and Protection of Children from Sexual Offences Act, 2012 (38.8%), including child rape, were the leading crime heads under “crime against children” in 2020. In 2020, the crime rate per lakh children population was 28.9, down from 33.2 in 2019 (India 2020 crime report).⁶

Over 24 million cases of online child sexual abuse were recorded in India between 2017 and 2018, with 80% of the victims being females under the age of 14.⁶

According to a Ministry of Women and Child Development [Government of India (GOI)] report on child abuse—India 2007, young children aged 5–12 are the most vulnerable to abuse and exploitation across all types of abuse. This includes physical, sexual, and emotional abuse (Table 1).⁶

**Table 1:** Signs of CAN
Signs of abuse	Signs of neglect
Physical abuse: Ecchymosis from slaps, bites, and fists. Bruises (battles sign). Lacerations. Contusions. Burns (cigarettes, cigars, lighters, and hot instruments). Traumatic alopecia. Lichenification of corners of mouth. Abrasions or lacerations of gingiva, tongue, palate, and floor of mouth. Fractures/dislocations/avulsions/pathologic mobility of teeth. Fractures of maxilla and mandibles. Lacerated lingual or labial frenum. Emotional abuse: Harsh treatment. Belittling or name calling the child. Ignoring. Shouting or speaking rudely. Comparison between siblings and other children. Sexual abuse: Unexplained injury or petechiae of palate, especially at the junction of hard and soft palate. Heightened defensive behavior of child. Ulcers or vesicles as a result of sexually transmitted diseases.	General neglect: Poor hygiene. Improper dressing according to cold weather for example lack of seater during winters. Visible medical condition which is untreated. Discrimination among siblings. Withholding food. Lack of parental attention. Leaving child for long stretches of time under dangerous conditions. Dental neglect: Delayed attendance and multiple missed appointments. Untreated dental infections, decay, trauma. No interest for oral hygiene. Failure to complete treatment plans. Poor dental status of child. Failure to access dental treatments.

MATERIALS AND METHODS

This study design was a descriptive cross-sectional survey. The study was set in DY Patil Dental School, Pune, Maharashtra, India, from which 400 participants were randomly selected. The study was conducted in November 2022. The participants selected were from the final year, internship, and postgraduation. The students of postgraduation were from all specialties and all years. The selection criteria of participants were based on their level of clinical exposure. The study tool is a questionnaire-based online survey based on observation and previous study articles. The questionnaire was submitted to experts (academicians and clinicians) who understood the topic, read through your questionnaire, and evaluated whether the questions effectively captured the topic under investigation. A pilot test of the survey on a subset of the intended population was conducted. A sample size of 50 was considered for the pilot. After collecting pilot data, enter the responses into a spreadsheet and clean the data. A standard test of internal consistency, Cronbach’s alpha (CA), was used to measure reliability which checks whether the responses were consistent. CA analysis gave a value of 0.8 which was well within the expected range. The ethical clearance was obtained by Institutional Ethical Committee. The number is E-115/IECDYPDS/2022.

The questionnaire data was self-collected using Google forms. A pilot study was initially done before proceeding to the main study. An online questionnaire form was designed with the help of Google forms. The questionnaire was divided into two parts—part I being participant information while part II contained questions analyzing the knowledge and attitude. The questions were mainly yes/no, except for a few. The informed consent and the Google form were then sent to the participants via WhatsApp. A gentle reminder was sent to fill out and send the form was sent every 3rd day for a week. It contained 400 records; each had 15 variables. One of the variables was the socioeconomic scale, for which we used the modified Kuppuswamy scale.⁷ This was recorded to analyze the knowledge of participants as it may be an important factor when CAN is concerned. Wilcoxon and Kruskal–Wallis nonparametric tests for continuous variables were used due to the different distribution of responses. Data entries were done in Microsoft Office Excel 2010 and analyses of results were done using Statistical Product and Service Solution (SPSS) version 22 IBM software. Descriptive statistics such as percentages/proportions were used to represent qualitative data. The Chi-squared test was used to compare qualitative data (Fig. 1).

Fig. 1: Questionnaire

RESULTS

Part I: Descriptive Statistics

Participant profile: group I—final year, group II—interns, group III—postgraduates. The results that we gathered through the questionnaire are as follows: maximum participation was from interns (group II) 44.5% followed by final years (group I) 44.25%, and least participation by postgraduates (group III) 11.25%.

Part II: Inferential Statistics

Group I—age-based comparison: maximum participation was from the age range 21–23 at 84.5%, while participants in the age range of 24–26 were 15.5%.
Group II—gender-based comparison: most of the participants in the study were females (83.3%), and the male participants were comparatively fewer (16.7%). There was no significant difference found (Table 2).
Group III—grade-based comparison: this is a comparison between the perception and knowledge of students from final years, interns, and postgraduates. As far as knowledge is concerned, there was a significant difference among the results from different years (p-value < 0.012). When the question about informing, the parents was asked there was a significant difference found among the years (p-value of 0.014); from the final years 96% said yes; from interns 89.9% answered yes, while from postgraduates 84.4% answered yes. Questions about perception showed significant differences over the years. As seen in Table 3, results show that postgraduates are in general, more aware than interns and final years. Also, interns are more aware than final years. The majority of participants showed that CAN is associated with low (66.3%) and lower middle socioeconomic strata (22%) (Table 4).

**Table 2:** Age- and gender-based distribution
	Frequency (n)	Percentage (%)
Age
21–23 years	338	84.5%
24–26 years	62	15.5%
Total	400	100%
Gender
Male participants	67	16.7%
Female participants	333	83.3%
Total	400	100%

**Table 3:** Year-based comparison
	Final year N (%)	Internship N (%)	PG N (%)	p-value
Knowledge
1. Dental practitioners are one of the first to suspect/report CAN	166 (93.8%)	165 (92.7%)	45 (100%)	p = 0.181
2. Could correctly identify an example of CAN	174 (98.3%)	171(96.1%)	40 (88.9%)	p = 0.012*
Perception
3. Are you aware of any forums to which you can report to about a suspected case of CAN	2 (1.1%)	5 (2.8%)	2 (4.4%)	p = 0.325
4. Are you aware of any helpline numbers you can use for a case of CAN	16 (9%)	15 (8.4%)	8 (17.8%)	p = 0.153
5. Are you aware of any app to report CAN	2 (1.1%)	8 (4.5%)	1 (2.2%)	p = 0.149
6. Are you aware of any non profit organizations who help with cases of child abuse and neglect	10 (5.6%)	15 (8.4%)	7 (15.6%)	p = 0.088
7. According to you will you report to the local police if a child is suspected of CAN	176 (99.4%)	175 (98.3%)	44 (97.8%)	p = 0.524
8. According to you will you inform the parents about your suspicions	170 (96%)	160 (89.9%)	38 (84.4%)	p = 0.014*

p > 0.05, no significant difference; *p < 0.05, significant difference

**Table 4:** Socioeconomic strata
	Frequency (n)	Percentage (%)
High	47	11.7%
Lower middle	88	22%
Low	265	66.3%
Upper middle	0	0%

DISCUSSION

The following are the findings we obtained through the questionnaire—interns had the highest involvement rate at 44.5%, followed by 4th years at 44.25%. Around 94% of respondents believe that dentists are the first to report or suspect child abuse. Around 92% of respondents did not know of any nonprofit groups where cases of CAN might be reported. Around 97.2% of people were unaware of any apps for reporting such incidents. Around 92% of respondents said they would notify the parents if they suspected child abuse or neglect. This could prove very detrimental to the child.

Based on the results of the study, it is sure that the students are to a great extent aware, of the warning signs shown by the child indicative of suffering CAN. However, it is also seen that the knowledge of reporting such cases or helping such children is minimal. As far as knowledge is concerned, there was a significant difference between the years. The reason might be that the students are not taught about CAN in detail as they should be. Further studies need to be carried out to find out the reason for this result.

Our study shows that postgraduates are more aware than the students who are interns and final years. This could be because of the practical experience in the dental setup. However, further studies need to be carried out to determine the exact reason for this. Interns were more aware than final years and once again could be because they have more experience. Not only did the participants not know who or how to report, but that they would inform the parents of their suspicions, which could lead to more harm to the child, as most often, the abuser is the primary caregiver or someone known.⁸ The fact that such a large number of future dental professionals were not aware of how or where to report such cases is alarming.

Most cases of CAN go unreported because of certain factors, which include:

Lack of awareness in recognizing signs of CAN.
Lack of knowledge as to what we can do to protect the child.
Lack of training provided in dental schools on the subject of abuse and neglect.
Hesitation to discuss such issues with the child as it may interfere with the parent-child relationship.
Reluctance toward taking legal action.⁹

The GOI has taken some measures to decrease the prevalence of CAN. However, it does not seem to be enough. Suspected cases of CAN can be reported via an online “E-Box”, which is provided by the GOI. E-Baal Nidan is a service provided by the government to register a complaint for violation of child rights, like abuse and neglect.

The most important resource while reporting CAN is the child helpline number 1098. It is a 24-hour helpline number for children by Childline India Foundation. There is also a toll-free complaint cell number launched in 2018 by Bachpan Bachao Andolan—1800-102-7222.

The nonprofit organization working toward the prevention of child abuse and protection of children is Save the Children, which in India is known as Bal Raksha Bharat, Child Rights and You, and Bachpan Bachao Andolan. Details of nonprofit organizations can be easily accessed through the online link—www.ngosindia.com

There are children-friendly police stations that aim to help the child feel comfortable reporting their problems without being scared to do so. Pune has 10 child-friendly police stations, which are located in the following areas—Lashkar, Vishrantwadi, Lakshmi Nagar, Yerawada, Range Hills, Khadki, Warje Malwadi, Kothrud, Uttam Nagar, Alankar, Dattawadi, and Sinhagad Road. This is a huge step toward preventing and protecting children from CAN.

In a study done among public health dentistry workers in Brazil, it was noted that notifications of CAN cases were mostly from dentists who may be due to the ability to identify signs, but even though these cases were suspected, there was underreporting.¹⁰ This data is consistent with data from other countries as well. The most common problem with CAN is not that there isn’t adequate knowledge about the signs, but there is fear of reporting and lack of knowledge on reporting.

Reporting cases of child abuse should be done when the dental practitioner suspects it. A quote by a pioneer in the field of child abuse prevention, Dr Henry Kempe, said he would rather apologize to a parent that he made a mistake in reporting the abuse than apologize to a brain-damaged child because he did not report it.

Dentists, dental schools, and other health professionals should be considered mandated reporters of CAN. If they fail to report such cases, they should be charged a penalty, as well as some strict action should be taken against them.

There are certain risk factors for CAN:

Children with special health care needs.
Unwanted children.
Ill-equipped knowledge of parenting and child health.
Depressed parent or partner violence within a family.
Dangerous neighborhoods or poor recreational facilities.
Poverty and associated burdens.
Social norms in different cultures.¹¹

However, it should be noted that children from all socioeconomic backgrounds are at risk of maltreatment.

There are many indicators of child abuse, such as:

Lack of concern for the child’s well-being.
Failure to provide for and recognize the child’s emotional needs.
Denying the problems of the child and blaming the child for it.
Belittling and berating the child.
Resorting to hard punishments such as denying food or recreational activities.
Demanding perfection from the child.¹²

These indicators can often be seen in the parent’s behavior during the visit to the dentist.

Talking to the child should always be done with open-ended questions such as “what happened to you?” or “how did you get hurt?” instead of “did your father do that?.” If the child’s behavior concerns, make sure to talk to them privately. Among younger children, more often than not, the child will disclose verbally about the abuse by accident, or the other child may tell you. Managing your emotional response and not judging them will make the child feel more comfortable talking to you. It is also important for a male dentist or dental student to always have a female colleague or dental assistant present while treating a female patient.

A study done by Manea et al., on dentists’ perception reported that perception about CAN is low and has a poor attitude toward confronting it.¹³ It is our ethical duty as a dentist, if not as healthcare professionals, to follow the four Rs—Recognize, Record, Report, and Refer when it comes to cases of CAN.¹⁴ Prevent Abuse and Neglect through Dental Awareness has been operatory in the United States of America, but no such program is available in India. A study on Danish dentists done by Uldum et al., findings suggests that there is a continuous need for awareness and training on the topic of child abuse and neglect.¹⁵

There should be a set guideline for reporting such cases, which should include topics on recognizing, talking to the patient, reporting, whom to report to, and organizations in your surrounding supporting the cause of prevention of children from CAN.

The reports of such cases should include the following:

Documentation—which includes details of the child and parents, findings of abuse, and neglect.
Witness—another individual should witness the examination, note, and cosign the documents.
Report to appropriate authorities as soon as abuse and neglect are suspected.
Necessary information to be included is the name and address of the child and parents or guardians, the child’s age, the nature of the child’s condition, and any other information that might be relevant to the case.¹¹

Government recommendations:

Current federal legislation is unsuccessful in combating certain cultural practices, such as child marriage, especially in regions with rural and tribal populations. State-specific laws should be prioritized.
Prioritize policies and safeguards for the most vulnerable children, including homeless or orphaned children, females from rural or tribal areas, and girls living in poverty or urban slums.
Improve social welfare frameworks for both home and school environments, including stronger safeguarding methods to identify vulnerable children or those who have experienced maltreatment.
Implement and enforce a prohibition on corporal punishment in all Indian states.

Ministry of Woman and Child Development:

Direct policy and research dollars toward eliminating corporal punishment as a normative cultural practice, such as focusing interventions on positive disciplining approaches in households and schools.
Encourage parents/caregivers to improve their behavior (positive parenting), to protect children from mistreatment at home.
Prioritize initiatives in schools that educate children about their rights and help them develop essential life skills (such as resilience and de-stigmatization).
Raise awareness of all safe, accessible, and available avenues for children of all ages to report abuse and neglect.¹⁵

Limitations of the Study

Since this was an online study, there is no real representation. This study has a majority of the students from one institution, one geographic location, and the results may vary if more population is considered. Hence, it cannot be generalized, and therefore, cannot be extrapolated. There is also no training available for students about cases of CAN. Further studies need to be conducted keeping the above points in mind.

CONCLUSION

To conclude, from the results, dental students in their final years, interns, and postgraduates are aware of the warning signs of CAN to a certain extent, but their knowledge of protecting the child and reporting suspected cases needs to be improved by leaps and bounds.

There should be a training program devised for people working in healthcare, especially dental professionals, to recognize warning signs of CAN; these professionals should be taught how to deal with suspected cases of CAN, right from identification to reporting the case and its legal aspects. Such a training program would benefit not only the practitioner in helping the child but also the child. It should be a mandatory course during the undergraduation for healthcare professionals; as we can see from the study; future dentists to be could identify the signs but did not have the proper knowledge on reporting and protecting the child. This is a failure on the part of the healthcare professional. Mandatory reporting of cases should be encouraged by adding a penalty or even jail time to the health professional who fails to report such cases.

ORCID

Tanya Roy https://orcid.org/0000-0003-0438-012X

Geetanjali Jadhav https://orcid.org/0000-0002-3113-5675

Rahul Hegde https://orcid.org/0000-0003-4904-2933

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