How Forensic Dentistry Can Help in Fighting Child Abuse

Content

1 Introduction

2 Historical Background and Incidence

3 Child Abuse in India

4 Etiology

5 Child Abuse Types & Prevention

6 Consulsion

7 Bibliography

Acknowledgement

This book would not have been possible without the guidance and the help of several individuals who in one way or another contributed and extended their valuable assistance in the preparation and completion of this book. First and the foremost, my utmost gratitude is to offer my sincere thanks to the Almighty, the Creator and Preserver.

I can never forget the invaluable contribution of my Wife, Dr.Charvi Gupta Mankel, without whom this treatise would never have been materialized. Her willingness to help me out of any problem faced during the writing of this book stands out in itself.

In countless ways, my PARENTS, have contributed to this effort. I shall always remain indebted for carrying me across any rough tide that I faced throughout these years. They have been and shall always remain my pillars of strength & moulding me into the person I am today and for their relentless prayers, sacrifices and choicest blessings. Their mere presence made me realize the existence of God.

I am thankful to my parents, M r . Ganesh Prasad Mankel and Mrs. Pushpa Mankel and brother Er Ankit Mankel fo r their caring and supportive attitude & and for their unflinching moral support.

A note of thanks and appreciation to all my friends for being with me and helping me directly or indirectly.

Thank you all

Dr. Hemant Mankel

CHILD ABUSE AND FORENSIC DENTISTRY

Henry Kempe and his colleagues (1962) first coined the phrase “Battered-Child Syndrome”.⁵,¹⁸,¹⁹,²⁰,²¹,²² Battered Child Syndrome is a disease in which children are physically abused.A child is dependent on his parents or caretakers for the entire physical and mental wellbeing. Hence molding the child into a good human being is the total responsibility of the parents/caretakers. Any aberration in the parent’s attitudes towards the child results in abuse and neglect of the child.¹⁹,²³

Abuse is defined as ‘the non-accidental commission of anyact by a care-taker upon a child under age 18 years whichcauses or creates a substantial risk of serious physical oremotional injury or which constitutes a sexual offense (suchas rape or molestation). Childabuse is anything that causes injury or puts the childunder threat especially physical injury (ranging from minorbruises to severe fractures or death) as a result ofpunching, beating, kicking, biting, shaking, throwing,stabbing, choking, hitting (with a hand, stick, strap orother object), burning or otherwise harming a child.Such injury is considered abuse regardless of whetherthe caretaker intended to hurt the child. A caretaker may be a child’s parent,stepparent, guardian or any person entrusted with theresponsibility for a child’s health or welfare.²³,²⁴

Neglect is defined as ‘a failure by a caretaker either deliberatelyor through negligence or inability to provide a childwith minimally adequate food, clothing, shelter, medical care,supervision, emotional stability and growth or other essentialcare provided that such inability is not solely due toinadequate economic resources or to a handicapping condition.Abuse is to commit a forbidden act on a child and neglect isomission of concern for the child. However, both lead tothe disaster of the physical and mental built up of the child.Abuse may be of many types like physical, emotional, mental, domestic, spiritual,sexual or verbal. Substance abuse or drug abuse is the usage of psychoactivedrug, which is capable of altering the mental functioning.Commonly used drugs from the past till today are marijuana,alcohol, amphetamines, solvents, inhalants like typewritercorrection fluid, smokeless tobacco, gasoline, glue etc.²³,²⁵

Historical Background and Incidence-

Child abuse and neglect issues are common in almost all countries at the global level such as physical abuse, sexual abuse, emotional and psychological abuse, abandonment and increasingly, problems of street children. Child abuse and the harsh corporal punishment of children have been historically documented through the ages, the presently recognized magnitude of the problem and the increased awareness among the medical and paramedical sciences, law enforcement agencies and judicial system have fostered recent efforts to correct this blight upon our modern civilized societies.¹⁸

Early civilizations regularly abandoned deformed or unwanted children and the ritual sacrifice of children to appease the gods took place in the Egyptian, Carthaginian, Roman, Greek and Aztec societies. In Roman society the father had complete control over the family, even to the extent that he could kill his children for disobedience. Sexual abuse of children was common in both Greek and Roman societies. Children were also sold as prostitutes. Women often participated in abuse. Petronius, a Roman writer, recorded the rape of a 7 year old girl witnessed by a line of clapping women.²⁶

During the Middle Ages (350-1450) in Europe, healthy but unwanted children were apprenticed to work or offered to convents and monasteries. Infanticide or the murder of babies was also common. The Roman Catholic Church contributed to infanticide when it declared that deformed infants were omens of evil and the product of relations between women and demons or animals. In another example of religious support for what would now be considered child abuse, the archbishop of Canterbury in the seventh century ruled that a man could sell his son into slavery until the child reached the age of seven.Children were beaten not only by their parents but also by their teachers. In a poem written around 1500, a schoolboy admitted that he would gladly become a clerk, but learning was such strange work because the birch twigs used for beating were so sharp. The children at an Oxford school must have felt justice was served when their schoolmaster, out early one morning to cut willow twigs for a switch to beat them, slipped, fell into the river and drowned.²⁶

In sixteenth and seventeenth-century Europe fathers commonly placed their children in apprenticeships to provide inexpensive labor. The apprentice system was the major job training method of pre-industrial Western society. The apprentice who trained with a master frequently worked under conditions that, by today's standards, would be considered severely abusive. The practice of paternal control was brought to the American colonies and the father ruled his wife and children. The mother however was also expected to discipline her children, inflicting corporal punishment as she saw fit. A child was little more than the property of the parents. At the same time, the child was an asset that could be used to perform work on the farm.²⁶

In the early 1870s, child abuse captured the nation's attention with news that an eight-year-old orphan named Mary Ellen Wilson was suffering daily whippings and beatings at her foster home. With no organization in existence to protect abused children, the orphan's plight fell to attorneys for the American Society for the Prevention of Cruelty to Animals (ASPCA). These attorneys argued that laws protecting animals from abuse should not be greater than laws protecting children. Mary Ellen Wilson's case went before a judge, who convicted the foster mother of assault, battery and gave her a one year sentence. More significantly, the orphan's case generated enough outrage over child abuse that in 1874, citizens formed the New York Society for the Prevention of Cruelty to Children.²¹,²⁷,²⁸

Current interest in the recognition of child abuse has been attributed to the report by Caffy describing the common association of chronic head injuries and multiple fractures of the long bones in children. In 1953, Silverman related the roentgenologic manifestations of unrecognized skeletal trauma in infants. Eight years later Adelson published a study of 46 homicides involving child victims. In 1962 Kempe et al. termed the phrase “Battered Child Syndrome” to apply to non-accidental injuries inflicted upon the young. Others have chosen “The Unprotected Child” in application to the complex child-guardian interaction resulting in such injuries.¹⁸

Child abuse captured attention again in 1962, when an article appearing in the Journal of the American Medical Association described symptoms of child abuse and deemed child abuse to be medically diagnosable. Within ten years, every state had statutes known as "Mandatory Reporting" laws. Mandatory reporting laws require certain professionals like doctors and teachers to report to police suspected child abuse situations.²⁷

As a result of nonsystematic reporting practices, the true incidence of child abuse in our population is difficult to establish. Estimates have indicates that more than 1,00,000 children are severely injured as a result of child abuse each year in the United States.Other reports have indicated that the incidence may be considerably greater, even approaching 5,00,000 cases yearly. The fact the incidence has increased in recent successive years is a reflection of increased community awareness and improved reporting practices. It is generally accepted that in hospital admission of victims of child abuse an approximate 10 percent mortality rate exists. In a recent survey of child abuse admission at San Francisco General Hospital, it was stated that child abuse accounted for the years 1969, 1970 and 1971. Other centers have reported that 10 percent of child trauma emergency room admissions are the result of child abuse.A 1974 federal law further bolstered efforts to eliminate child abuse by funding programs to help individuals identify and report child abuse and to provide shelter and other protective services to victims.¹⁸,²⁷

In 1999, there were an estimated 28,22,829 investigated reports of child abuse and neglect in the United States (U.S. Department of Health & Human Services, 2001). Of these reported cases, 25.4 per cent were substantiated. “Substantiated” means that a report of suspected abuse was made and investigated and child protection authorities determined that there was a reasonable cause to believe that the abuse or neglect had occurred. In 1999, the overall victimization rate in the United States was 11.8 per 1,000 children, but increased to 12.4 per 1,000 children in 2001.²⁹

According to the Australian Institute of Health and Welfare (AIHW, 2004) the rate of child abuse in Australia ranged from 0.9 per 1,000 in Tasmania up to 7.4 per 1,000 in Queensland. There were 1,98,355 reports of suspected cases of child abuse and neglect made to the Australian state authorities during 2002-2003. During the year from 1st April 2002 to 31stMarch, 2003, the National Society for the Prevention of Cruelty to Children in the United Kingdom documented 4,109 reported offences of “Cruelty to or neglect of children” and 1880 of “Gross indecency with a child under the age of 14” in England and Wales respectively (Home Office, 2004). Trocme and Wolfe (2001) reported that the Social Service Agencies in Canada investigated an estimated 1,35,573 cases of child abuse in 1998.²⁹

The US Department of Health and Human Services reports the rate of child victimization was 12.4 victims per 1,000 children in 2003. Neglect accounted for 60.9% of cases, physical abuse 18.9%, sexual abuse 9.9 %, psychological abuse 4.9% and medical neglect 2.3 %. In 2004 there were 2,906 children identified as victims of one or more forms of child maltreatment in Rhode Island. The Rhode Island Kids Count reports die rate of child victimization was 7.0 victims per 1,000 children in Rhode Island in 2004 Neglect accounted for 71% of cases, physical abuse 17%, sexual abuse 5%, psychological abuse 1% and medical neglect 2%.30

Child Abuse in India-

Nineteen percent of the world's children live in India. According to the 2001 Census, some 440 millionpeople in the country today are aged below eighteen years and constitute 42 percent of India's totalpopulation i.e. four out of every ten persons. This is an enormous number of children that the country hasto take care of.Ministry of Women and Child Development (MWCD) has taken significant steps to address the issue of child protection by setting up a National Commission for the Protection of Child Rights, amending the Juvenile Justice (Care and protection of Children) Act 2000 and the Child Marriage Restraint Act 1929, launching the Integrated Child Protection Scheme (ICPS) and started a National Study on Child Abuse in the year 2005 which gives the data on incidence of crime committed on children as follow-30

Incidents of Crimes against Children and % change in 2015 over 2014

Abbildung in dieser Leseprobe nicht enthalten

According to the NCPCR (National Commission for Protection of Child Rights) report, child abuse in India increased to 763 for 2009-10 from 35 in 2007-08. As per the NCPCR report, in India, the maximum number of child abuse complaints was received from Uttar Pradesh which stood at 179. Uttar Pradesh was followed by Delhi 127, Orissa 58, Bihar 46, Madhya Pradesh 42 and West Bengal 39 cases were received respectively. North eastern states of India like Sikkim, Meghalaya and Tripura reported no child abuse complaints. To deal with the child abuse or child exploitation in India, the protection of Children from sexual offences bill, 2010 has been drafted. The draft bill describes a boy or a girl below the age of 18 as a child. The draft bill also describes any kind of physical contact with sexual intent as sexual assault.³¹

Etiology:

Child abuse is a complex phenomenon with multiple causes. Understanding the causes of abuse is crucial to addressing the problem of child abuse. Parents who physically abuse their spouses are more likely than others to physically abuse their children. However, it is impossible to know whether marital strife is a cause of child abuse or if both the marital strife and the abuse are caused by tendencies in the abuser.³²,³³

Substance abuse can be a major contributing factor to child abuse. One U.S. study found that parents with documented substance abuse, most commonly alcohol, cocaine, and heroin were much more likely to mistreat their children and were also much more likely to reject court-ordered services and treatments. Another study found that over two thirds of cases of child maltreatment involved parents with substance abuse problems. This study specifically found relationships between alcohol and physical abuse and between cocaine and sexual abuse.³²

In recent year, much research has focused on the psychopathology and behavioral characteristics attributed to abusive parents. Such studies have revealed a complex panel of psychiatric and demographic characteristics considered to be related to the offender’s behavior. In some instances, reports have disclosed conflicting data. Whereas some investigators have related an increased incidence of child abuse to the lower socioeconomic strata, others have noted its occurrence in parents of higher socioeconomic standing and still others have stated that child abuse is psychodynamically determined and is independent of education, race and socioeconomic level. In a paper by Green et al. (1974) who observed the patterns of family interaction encountered in 60 cases of child abuse, conclude that etiology is based upon an interaction between the personality trait of the parents, the child’s characteristics which enhance scapegoating and the environmental conditions resulting in increased demand for child care. The author further stated that the wide variation in behavioral characteristics, personality traits and psychiatric symptoms among abusive parents suggest that a specific “Abusive” personality does not exist.¹⁸

Numerous studies have indicated that the mother tends to be the most frequent perpetrator of child abuse. However, the father, stepparents, foster parents, babysitter, paramour, distant relative or sibling may also be offenders. Brown (1976) in his study of 531 hospitalized abused children, found that only a few offenders were overtly psychotic, mentally retarded or acted under the influence of drugs or alcohol. Many of the abuser possessed backgrounds of frustration and chronic stress fostered by issues such as inadequate housing and finances, absence of a father figure or husband in the family constellation, illicit sex relations, too many young or unwanted children.¹⁸

Often the offenders themselves were abused as children. The behavior pattern of the abuser may be one of chronic stress with a sudden loss of mental control of the situation denoted by a child’s crying spell or messed diaper. On the other hand, the offender may possess rather harsh sadistic tendencies resulting in repetitive, premeditated of episodes of physical torture. Various cases shows that they were bounded and subsequently burned by cigarettes, beaten with metal chains and suspended upside down from ceiling fixtures. One of case is severely burned on the buttocksdue to placement on a hot stove represented punishment meted out by the mother for diaper wetting.¹⁸,³³

Some instances of child injury fall within a “Gray Zone” between pure accident and negligence due to possible subconscious desires of the mother or guardian to injury the infants. Incident of this nature are often difficult to categorize as to intent, since the mother may be of low intelligence and proof of intent may be difficult if not impossible to establish. Examples are the mother who “Inattentively” allows her infants to roll off a bassinette or who allows the toddler to amble near an open fireplace resulting in burns. Hopefully, the repetition of nonfatal injuries would alter attending clinicians that some instances of accident proneness in children may be a subliminal form of child abuse.¹⁸

Religion provides specific directives for positive moral action and the promotion of human welfare. It may be difficult to realize that religious beliefs can also foster, encourage and justify abusive behavior. Physical abuse is sometimes perpetrated by parents or by religious leaders or teachers who believe they are helping to deliver children from sin. Because of media attention, the public is generally aware of cases in which fringe religious groups and isolationalist cults practice beatings in the name of Godly discipline. When discovered, such cult’s abusive practices and even their particular religious beliefs are immediately highlighted in the news media and criticized and rejected by society with much self-righteousness. Yet “Cult” beliefs and practices may differ only in degree from those of mainstream religious groups such as Methodists, Baptists and Catholics who believe the physical punishment of children is religiously sanctioned, especially those who are Biblical literalists. Also, many of their cases of physical abuse were quite extreme for example, they reported one case in which an "Eyeball was plucked out of a youth's head during an exorcism ceremony" and another in which a “Father performed an exorcism on his children by dismembering and then boiling them”.³⁴

Children are vulnerable to abuse from many different individuals. Of the women who were abused prior to the age of 18 by males outside the family, Russell et al; (2000) found that 15 percent were molested by strangers, 40 percent by acquaintances, 14 percent by friends of the family, 2 percent by unclassified authority figures and 18 percent by a friend or date of the victim. Of those women who reported being abused by females, 2 percent named acquaintances and 2 percent cited friends of the family or of the respondent.³⁵

Unemployment and financial difficulties are associated with increased rates of child abuse. In 2009 CBS News reported that child abuse in the United States had increased during the economic recession. It gave the example of a father who had never been the primary care-taker of the children. Now that the father was in that role, the children began to come in with injuries.³²

Abuse is not within the parent’s frame of reference . Parents who have had no experience with abuse or who blocked the memoryof their own experiences do not expect other adults to sexually abuse children. NativeAmerican families, for example give children a great deal of freedom on the reservation,not expecting that they will come to any harm. Parents whose children use the Internet maynot recognize how potentially dangerous unmonitored use can be for children. Because ofcurrent media attention, parents may be more cautious, but even cautious parents often tellthemselves their fears are groundless.³⁵

Parents may not provide adequate supervision for several reasons: They may feeltheir children can care for themselves. Parents who allow children freedom in walkinghome from school or playing in the neighborhood may not even consider the danger of potentialabuse or may feel that the children can take care of themselves. Some parents haveunrealistic expectations about their children’s ability to care for themselves. In this era ofthe Internet, some parents may not realize that children need supervision when they are online.Today, the Internet provides an opportunity for children to be seduced into futureabuse while they are on the computer in their own homes. Parents may feel unable to providesupervision. Latchkey children, who come home to an empty house and remain aloneuntil the parents return from work, are becoming the trademark of two- career families.Child care is expensive and some parents feel financially unable to provide an alternative.In addition, the parents may not be able to find a program or a sitter to supervise. Or parentsmay be unaware of unsupervised periods. The child, who misses a ride or for somereason is left unsupervised, is vulnerable despite the parent’s good intentions. Some parentsmay be otherwise occupied.Caring for a child is a demanding and full-time job. Forsome parents the responsibility is sometimes overwhelming. Others may be so involved intheir own crises or conflicts that they are not able to concern themselves with their children’swhereabouts. And finally, the child may initiate the separation. Children who wanderoff, run away or become distracted sometimes separate themselves from supervisingcaregivers.³⁵

The major risk factors for child abuse include:

- Alcoholism
- Drug abuse
- Being a single parent
- Lack of education
- Poverty

However, it is important to note that cases of child abuse are found in every racial or ethnic background and social class. It is impossible to tell abusers from non-abusers by looking at their appearance or background.³³

The recognition of child abuse at its earliest occurrence permits the institution of corrective social, psychotherapy and the temporary or permanent removal of the injured child and his siblings from the hostile family setting. Recognition, reporting and treatment of child abuse represent the ideal in holomedicine and constitute the rationale for an interdisciplinary approach by the medical paramedical field, social and welfare agencies and law enforcement personnel. The objective is to correct or ameliorate the etiology factors in order to restore the family constellation or at least to protect the heretofore unprotected and defenseless child.¹⁸

Types of Child Abuse-

Child abuse involves a complex and dangerous set of problems that include-¹⁹,²⁵

- Domestic abuse
- Economic abuse
- Emotional or psychological abuse
- Neglect
- Physical abuse
- Sexual abuse
- Spiritual abuse
- Verbal abuse

1. Domestic abuse-

Domestic abuse also known as domestic violence orspousal abuse orfamily violence orintimate partner violence (IPV) can be broadly defined as a pattern of abusive behaviors by one or both partners in an intimate relationship such as marriage, dating, family, friends or cohabitation.Domestic abuse is the attempt, act or intent of someone within a relationship, where the relationship is characterized by intimacy, dependency or trust, to intimidate either by threat or by the use of physical force on another person or property.²⁵,³⁶

Domestic violence has many forms including physical aggression (hitting, kicking, biting, shoving, restraining, slapping, throwing objects) or threats thereof; sexual abuse; emotional abuse; controlling or domineering; intimidation; stalking; passive/covert abuse (e.g.neglect) and economic deprivation. Alcohol consumption and mental illness can be co-morbid with abuse and present additional challenges when present alongside patterns of abuse. The purpose of the abuse is to control and/or exploit through neglect, intimidation, inducement of fear or by inflicting pain. Abusive behavior can take many forms including: verbal, physical, sexual, psychological, emotional, spiritual, economicaland the violation of rights. All forms of abusive behavior are ways in which one human being is trying to have control and/or exploit or have power over another.²⁵,³⁶

Types of violence identified by Johnson:³⁶

- Common couple violence (CCV) is not connected to general control behavior but arises in a single argument where one or both partners physically lash out at the other. Intimate terrorism is one element in a general pattern of control by one partner over the other. Intimate terrorism is more common than common couple violence, more likely to escalate over time, not as likely to be mutual and more likely to involve serious injury.
- Intimate terrorism (IT) may also involve emotional and psychological abuse.
- Violent resistance (VR) sometimes thought of as "Self-defense" is violence perpetrated by victims against their abusive partners.
- Mutual violent control (MVC) is rare type of intimate partner violence occurs when both partners act in a violent manner, battling for control.
- Situational couple violence which arises out of conflicts that escalate to arguments and then to violence. It is not connected to a general pattern of control. Although it occurs less frequently in relationships and is less serious than intimate terrorism, in some cases it can be frequent and/or quite serious, even life- threatening. This is probably the most common type of intimate partner violence and dominates general surveys, student samples and even marriage counseling samples.

Types of male batterers identified by Holtzworth-Munroe and Stuart (1994) include "Family-only", which primarily fall into the Common Couple Violence type, who are generally less violent and less likely to perpetrate psychological and sexual abuse. Intimate Terrorism batterers include two types: "Generally-violent-antisocial" and "Dysphoric-borderline". The first type includes men with general psychopathic and violent tendencies. The second type are men who are emotionally dependent on the relationship. Support for this typology has been found in subsequent evaluations.Others, such as the US Centers for Disease Control, divide domestic violence into two types: reciprocal violence in which both partners are violent and non-reciprocal violence in which one partner is violent.³⁶

Effects-

Physical -

Bruises, broken bones, head injuries, lacerations and internal bleeding are some of the acute effects of a domestic violence incident that require medical attention and hospitalization. Some chronic health conditions that have been linked to victims of domestic violence are arthritis, irritable bowel syndrome, chronic pain, pelvic pain, ulcers and migraines. Victims who are pregnant during a domestic violence relationship experience greater risk of miscarriage, pre-term labor and injury or death of the fetus.³⁶

Psychological-

Among victims who are still living with their perpetrators, high amounts of stress, fear and anxiety are commonly reported. Depression is also common, as victims are made to feel guilty for ‘Provoking’ the abuse and are constantly subjected to intense criticism. It is reported that 60% of victims meet the diagnostic criteria for depression either during or after termination of the relationship and have a greatly increased risk of suicidality. In addition to depression, victims of domestic violence also commonly experience long-term anxiety and panic are likely to meet the diagnostic criteria for Generalized Anxiety Disorder and Panic Disorder. The most commonly referenced psychological effect of domestic violence is Post-Traumatic Stress Disorder (PTSD). PTSD is characterized by flashbacks, intrusive images, exaggerated startle response, nightmares and avoidance of triggers that are associated with the abuse. These symptoms are generally experienced for a long span of time after the victim has left the dangerous situation. Many researchers state that Post Traumatic Stress Disorder is possibly the best diagnosis for those suffering from psychological effects of domestic violence, as it accounts for the variety of symptoms commonly experienced by victims of trauma.³⁶

Financial-

Once victims leave their perpetrator, they can be stunned with the reality of the extent to which the abuse has taken away their autonomy. Due to economic abuse and isolation, the victim usually has very little money of their own and few people on whom they can rely when seeking help. This has been shown to be one of the greatest obstacles facing victims of domestic violence and the strongest factor that can discourage them from leaving their perpetrators. In addition to lacking financial resources, victims of domestic violence often lack specialized skills, education and training that are necessary to find gainful employment and also may have several children to support. In 2003, thirty-six major US cities cited domestic violence as one of the primary causes of homelessness in their areas. It has also been reported that one out of every three homeless women are homeless due to having left a domestic violence relationship. If a victim is able to secure rental housing, it is likely that her apartment complex will have “Zero Tolerance” policies for crime; these policies can cause them to face eviction even if they are the victim (not the perpetrator) of violence. While the number of shelters and community resources available to domestic violence victims has grown tremendously, these agencies often have few employees and hundreds of victims seeking assistance which causes many victims to remain without the assistance they need.³⁶

Long term-

Domestic violence can trigger many different responses in victims, all of which are very relevant for any professional working with a victim. Major consequences of domestic violence victimization include psychological/mental health issues and chronic physical health problems. A victim’s overwhelming lack of resources can lead to homelessness and poverty.³⁶

Vicarious trauma-

Due to the gravity and intensity of hearing victim’s stories of abuse, professionals (police, counselors, therapists, advocates, medical professionals) are at risk themselves for secondary or vicarious trauma, which causes the responder to experience trauma symptoms similar to the original victim after hearing about the victim’s experiences with abuse. Research has demonstrated that professionals who experience vicarious trauma show signs of exaggerated startle response, hyper vigilance, nightmares and intrusive thoughts although they have not experienced a trauma personally and do not qualify for a clinical diagnosis of Post Traumatic Stress Disorder. Researchers concluded that although clinicians have professional training and are equipped with the necessary clinical skills to assist victims of domestic violence, they may still be personally affected by the emotional impact of hearing about a victim’s traumatic experiences. Iliffe et al. found that there are several common initial responses that are found in clinicians who work with victims: loss of confidence in their ability to help the client, taking personal responsibility for ensuring the client’s safety and remaining supportive of the client’s autonomy if they make the decision to return to their perpetrator. It has also been shown that clinicians who work with a large number of victims may alter their former perceptions of the world and begin to doubt the basic goodness of others. Iliffe et al. found that clinicians who work with victims tend to feel less secure in the world, become “Acutely Aware” of power and control issues both in society and in their own personal relationships, have difficulty trusting others and experience an increased awareness of gender-based power differences in society.³⁶

The best way for a clinician to avoid developing vicarious trauma is to engage in good self-care practices. These can include exercise, relaxation techniques, debriefing with colleagues and seeking support from supervisors. Additionally, it is recommended that clinicians make the positive and rewarding aspects of working with domestic violence victims the primary focus of thought and energy such as being part of the healing process or helping society as a whole. Clinicians should also continually evaluate their empathic responses to victims, in order to avoid feelings of being drawn in to the trauma that the victim experienced. It is recommended that clinicians practice good boundaries and find a balance in expressing empathic responses to the victim while still maintaining personal detachment from their traumatic experiences.³⁶

Burnout-

Vicarious trauma can lead directly to burnout, which is defined as “Emotional exhaustion resulting from excessive demands on energy, strength and personal resources in the work setting”. The physical warning signs of burnout include headaches, fatigue, lowered immune function and irritability. A clinician experiencing burnout may begin to lose interest in the welfare of clients, be unable to empathize or feel compassion for clients and may even begin to feel aversion toward the client. If the clinician experiencing burnout is working with victims of domestic violence, the clinician risks causing further great harm through re-victimization of the client. It should be noted, however, that vicarious trauma does not always directly lead to burnout and that burnout can occur in clinicians who work with any difficult population – not only those who work with domestic violence victims.³⁶

Cause-

There are many different theories as to the causes of domestic violence. These include psychological theories that consider personality traits and mental characteristics of the perpetrator as well as social theories which consider external factors in the perpetrator's environment such as family structure, stress and social learning. As with many phenomena regarding human experience, no single approach appears to cover all cases.There are many theories regarding what causes one individual to act violently towards an intimate partner or family member there is also growing concern around apparent intergenerational cycles of Domestic Violence. In Australia where it has been identified that approximately 75% of all victims of Domestic Violence are children.³⁶

Responses that focus on children suggest that experiences throughout life influence an individual’s propensity to engage in family violence (either as a victim or as a perpetrator). Researchers supporting this theory suggest it is useful to think of three sources of Domestic Violence: childhood socialization, previous experiences in couple relationships during adolescence and levels of strain in a person's current life. People who observe their parents abusing each other or who were themselves abused may incorporate abuse into their behavior within relationships that they establish as adults.³⁶

Cause of domestic abuse are-³⁶

Psychological-

In general, about 80% of both court-referred and self-referred men in these domestic violence studies exhibited diagnosable psychopathology, typically personality disorders. The estimate of personality disorders in the general population would be more in the 15-20% range.As violence becomes more severe and chronic in the relationship the likelihood of psychopathology in these men approaches 100%. Psychological theories focus on personality traits and mental characteristics of the offender. Personality traits include sudden bursts of anger, poor impulse control and poor self-esteem. Various theories suggest that psychopathology and other personality disorders are factors and that abuse experienced as a child leads some people to be more violent as adults. Studies have found high incidence of psychopathy among abusers.

Dutton has suggested a psychological profile of men who abuse their wives, arguing that they have borderline personalities that are developed early in life.Gelles suggests that psychological theories are limited and points out that other researchers have found that only 10% (or less) fit this psychological profile. He argues that social factors are important, while personality traits, mental illness or psychopathy are lesser factors.

Behavioral-

Behavioral theories draw on the work of behavior analysts. Applied behavior analysis uses the basic principles of learning theory to change behavior.Behavioral theories of domestic violence focus on the use of functional assessment with the goal of reducing episodes of violence to zero rates. Often by identifying the antecedents and consequences of violent action, the abusers can be taught self-control. Recently more focus has been placed on prevention and a behavioral prevention theory.

Social stress-

Stress may be increased when a person is living in a family situation with increased pressures. Social stresses, due to inadequate finances or other such problems in a family may further increase tensions. Violence is not always caused by stress but may be one way that some people respond to stress. Families and couples in poverty may be more likely to experience domestic violence, due to increased stress and conflicts about finances and other aspects. Some speculate that poverty may hinder a man's ability to live up to his idea of "Successful Manhood", thus he fears losing honor and respect. Theory suggests that when he is unable to economically support his wife and maintain control; he may turn to misogyny, substance abuse and crime as ways to express masculinity.

Power and control-

In some relationships, violence is posited to arise out of a perceived need for power and control, a form of bullying and social learning of abuse.Abuser’s efforts to dominate their partners have been attributed to low self-esteem or feelings of inadequacy, unresolved childhood conflicts, the stress of poverty, hostility and resentment toward women (misogyny), hostility and resentment toward men, personality disorders, genetic tendencies and sociocultural influences, among other possible causative factors.

A causalist view of domestic violence is that it is a strategy to gain or maintain power and control over the victim. This view is in alignment with Bancroft's "Cost- benefit" theory that abuse rewards the perpetrator in ways other than or in addition to, simply exercising power over his or her target. He cites evidence in support of his argument that, in most cases abusers are quite capable of exercising control over themselves but choose not to do so for various reasons.

An alternative view is that abuse arises from powerlessness and externalizing/projecting this and attempting to exercise control of the victim. It is an attempt to gain or maintain power and control over the victim but even in achieving this it cannot resolve the powerlessness driving it. Such behaviors have addictive aspects leading to a cycle of abuse or violence. Mutual cycles develop when each party attempts to resolve their own powerlessness in attempting to assert control.

Mental illness-

Psychiatric disorders are sometimes associated with domestic violence like Borderline personality disorder, Antisocial personality disorder, Bipolar disorder, Schizophrenia, Drug abuse and Alcoholism. In past medical knowledge, untreated Attention Deficit Hyperactive Disorder and Conduct disorders in childhood was associated with domestic violence in adulthood.

Gender aspects of abuse-

Women are subjected to domestic violence more often and more severely than are men. According to a report by the United States Department of Justice, a survey of 16,000 Americans showed 22.1% of women and 7.4% of men reported being physically assaulted by a current or former spouse, cohabiting partner, boyfriend, girlfriend or date in their lifetime. A 2001 survey of over 22,000 residents of England and Wales by the UK Home Office showed four percent of women and two percent of men were victims of domestic violence in the last year. Of the most heavily abused group 89% were women³⁶.

Women are much more likely than men to be murdered by an intimate partner. Of those killed by an intimate partner about three quarters are female and about a quarter are male. In 1999 in the United States 1,218 women and 424 men were killed by an intimate partner and 1,181 females and 329 males were killed by their intimate partners in 2005. InEngland and Walesabout 100 women are killed by partners or former partners each year while 21 men were killed in 2010.The UN Declaration on the Elimination of Violence against Women (1993) states that “Violence against women is a manifestation of historically unequal power relations between men and women, which has led to domination over and discrimination against women by men and to the prevention of the full advancement of women and that violence against women is one of the crucial social mechanisms by which women are forced into a subordinate position compared with men.”³⁶

The relationship between gender and domestic violence is a controversial topic and there continues to be debate about the rates at which each gender is subjected to domestic violence and whether abused men should be provided the same resources and shelters that exist for women victims. In particular, some studies suggest that men are less likely to report being victims of domestic violence due to social stigmas. Other sources, however, argue that the rate of domestic violence against men is often inflated due to the practice of including self-defense as a form of domestic violence.³⁶

Some researchers have found a relationship between the availability of domestic violence services, improved laws and enforcement regarding domestic violence and increased access to divorce and higher earnings for women with declines in intimate partner homicide by women. Murders of female intimate partners by men have dropped but not nearly as dramatically. Men kill their female intimate partners at about four times the rate that women kill their male intimate partners. Research by Jacquelyn Campbell, PhD RN FAAN has found that at least two thirds of women killed by their intimate partners were battered by those men prior to the murder. She also found that when males are killed by female intimates, the women in those relationships had been abused by their male partner about 75% of the time.³⁶

Theories that women are as violent as men have been dubbed "Gender Symmetry" theories. On the other hand, Michael Kimmel of the State University of New York at Stony Brook found that men are more violent inside and outside of the home than women. Estimates show that 248 of every 1,000 females and 76 of every 1,000 males are victims of physical assault and/or rape committed by their spouses. A 1997 report says significantly more men than women do not disclose the identity of their attacker. A 2009 study showed that there was greater acceptance for abuse perpetrated by females than by males. Several studies have confirmed that women’s physical violence towards intimate male partners is often in self-defense.³⁶

[...]

---

¹ Dr. Loveleen Kacker IAS, Srinivas Varadan, Pravesh Kumar. Study on Child Abuse. India: Ministry of Women and Child Development, Government of India; 2007.

² Manciaux M, Gabel M, Girodet D, Mignot C, Royer M, Enfances en danger. Paris: Édition Fleurus Psycho-Pédagogie 1997.

³ Facchin P. Regional policies in Veneto Region. Proceedings of the European Conference on Reducing Social Inequalities in Health among Children and Young People; Dec 9–10; Copenhagen, Denmark, United Nations; 2002.

⁴ Halperin DS, Bouvier O, Jaffé P, Mounoud RL, Pawlak C, Laedemach J, et al. Prevalence of child sexual abuse among adolescents in Geneva: results of a cross sectional survey.” BMJ 312: 1326–29, 1996.

⁵ 1. Dr. Loveleen Kacker IAS, Srinivas Varadan, Pravesh Kumar. Study on Child Abuse. India: Ministry of Women and Child Development, Government of India; 2007 study within Oxfordshire. Child Abuse Negl 20: 477–85, 1996

⁶ Lopez F, Carpintero E, Hernandez A, Martin MJ, Fuertes A. Prevalence and sequelae of childhood sexual abuse in Space. Child Abuse Negl 19: 1039–50, 1995.

⁷ Heikki S, Antti V. The prevalence of child sexual abuse in Finland. Child Abuse Negl 18: 827–35, 1994.

⁸ Wattam C. The comparative study of child abuse in Europe. Proceedings of the 4th European Conference about Maltreated Child; 28–31 March; Padua, Italy. Cleup. 1993.

⁹ Creighton S. An epidemiological study of abused children and their families in the United Kingdom between 1977 and 1982. Child Abuse Negl 9: 441–48, 1985.

¹⁰ Committee on Child Abuse and Neglect. Oral and Dental Aspects of Child Abuse and Neglect. Pediatrics 104: 348–50, 1999.

¹¹ Pinheiro, P. S. (2006): World Report on Violence against Children; United Nations Secretary-General's Study on Violence against Children; United Nations, New York http://www.violencestudy.org/r25

¹² http://family.findlaw.com/child-abuse/child-abuse-history.html

¹³ Mary Ellen Wilson, Mrs. Connolly, the Guardian, Found Guilty, and Sentenced to One Year’s Imprisonment at Hard Labor, N.Y. TIMES, Apr. 28, 1874, at 8.

¹⁴ American Academy of Pediatric Dentistry. Definition of dental neglect. Pediatr Dent. 1997; 19:24.

¹⁵ Becker DB, Needleman HL, Kotelchuck M. Child abuse and dentistry: Orofacial trauma and its recognition hy dtnusts. J Amer Dent Assoc. 1978;97:24 -28

¹⁶ Radbill, S.X. (1974), “A history of child abuse and infanticide”, in C.H. Kempe & R.E. Helfer (eds)The Battered Child (2nd edn), University of Chicago Press, Chicago.

¹⁷ da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatric Dentistry 1992; 14: 152–157.

¹⁸ McDonald RE, Avery DR. Dentistry for the child and adolescent, 7th Ed. The C.V. Mosby Company; p. 17-8, 24-33.

¹⁹ Shobha Tondon, text boof of pedodontics 2nd Ed. Pg=883-860

²⁰ C Henry Kempe.M.D,Denver,Frederic N,Silverman,M.D,Cincinnati, Brandt .Steele,M.D,William Droegemueller, M.D, And Henry K. Siver, M.D, Denver. The Battlered – Child Syndrome. Child abuse and neglect . vol 9 ,pp143-154. 1985

²¹ Jill S. Levenson .Experiences of non offending parents and caretakers in child sexual abuse Cases. The Southwest Journal of Criminal Justice, Vol. 8(2)

²² R. R. Welbury,R. S. Hobson,J. J. Stephenson, and N. J. A. Jepson, Evaluation of a computer-assisted learning programme on the oro- facial signs of child physical abuse (Nonaccidental Injury) By General Dental Practitioners. British Dental Journal, Volume 190, No. 12, June 23 2001

²³ Samer A. Bsoul, BDS, MS Diane J. Flint, DDS S. Brent Dove, DDS, MS David R. Senn, DDS Marden E. Alder, DDS, MS. Reporting of Child Abuse: A Follow-up Survey of Texas Dentists. Pediatric Dentistry – 25:6, 2003

²⁴ M. Cairns,J. Y. Q. Mok & R. R. Welbury.Injuries to the head, face, mouth and neck in physically abused children in a community setting. International Journal of Paediatric Dentistry 2005;15:310–318310

²⁵ B Muthu M. S.,Subramanian E. M. G.,A Subhagya B., C Sivakumar N. Neglected child with substance abuse leading to child abuse: A case report. J Indian Soc Pedod Prev Dent- June 2005

²⁶ Nancy Kellogg, MD; and the Committee on Child Abuse and Neglect. Oral and Dental Aspects of Child Abuse and Neglect. Pediatrics 2005;116;1565-1568

²⁷ Marji Harmer-Beem. The Perceived Likelihood of Dental Hygienists to Report Abuse Before and After a Training Program . Journal of Dental Hygiene, Vol. 79, No. 1, Winter 2005

²⁸ John E. Thomas, BA Lloyd Straffon, DDS, MS Marita Rohr Inglehart, Dr. Phil Habil Knowledge and Professional Experiences Concerning Child Abuse: An Analysis of Provider and Student Responses. Pediatric Dentistry – 28:5 2006

²⁹ S. Manea, G. A. Favero, E. Stellini, L. Romoli, M. Mazzucato, P. Facchin. Dentists’ Perceptions, Attitudes, Knowledge, and Experience about Child Abuse and Neglect in Northeast Italy. The Journal of Clinical Pediatric Dentistry. 2007. Volume 32, Number 1/

³⁰ P. D. Sidebotham1 and J. C. Harris Protecting children. British Dental Journal Volume 202 No. 7 Apr 14 2007

³¹ Maguire SA, Hunter B, Hunter LM, Sibert J, Mann MK, Kemp AM. Torn labial frenum in isolation not pathognomonic of physical abuse; Diagnosing abuse: a systematic review of torn frenum and intra-oral injuries. Arch Dis Child 2007; 27.

³² S. T. McDonnell and I. C. Mackie An urgent referral of a suspected case of child abuse. British Dental Journal Volume 205 No. 11 Dec 13 2008

³³ Ana Flávia Granville-Garciai Maria Jackeline Freitas Silvaii Valdenice Aparecida De Meneze Abuse of Children and Adolescent: A Study in the City of São Bento do Una, PE, Brazi. Pesq Bras Odontoped Clin Integr, João Pessoa, 8(3):301-307,. 2008

³⁴ Nancy Valencia-Rojas, DDS, MSc; Herenia P. Lawrence, DDS, MSc, PhD; Deborah Goodman, MSW, RSW, PhD. Prevalence of Early Childhood Caries in a Population of Children with History of Maltreatment. American Association of Public Health Dentistry. Vol. 68, No. 2, Spring 2008.

³⁵ B.L. Chadwick, J. Davies, S. K. Bhatia, C. Rooney and N. McCusker. Child protection:training and experiences of dental therapists. British Dental Journal2009: 1-4

³⁶ J. C. Harris, C. Elcock, P. D. Sidebotham and R. R. Welbury Safeguarding children in dentistry: 1. Child protection training, experience and practice of dental professionals with an interest in paediatric dentistry. BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009