Shades of Blue: Recognition and Responsible Reporting of Child Abuse

Mary Machowski, BS, Patricia L. Blanton, DDS, PhD and Theresa S. Gonzales, DMD, MS, MSS

Maltreatment of children by their parents and /or primary caregivers has been
with us for a very long time. Family violence can be traced back to biblical times.
Extreme parental punitiveness has been recognized a serious problem that demands
intervention only relatively recently. While several court cases in the United States in
the 19th-century dramatized the plight of abused children (largely through the actions of
the Society for the Prevention of Cruelty to Animals- SPCA) and established legal and
social precedents for intervention on behalf of maltreated children, widespread public
recognition of child abuse did not occur until 1962. That year Dr. Henry Kempe
published a landmark article entitled the battered child syndrome and drew national
attention to the abuse of children. Perhaps, no single publication has had such a
profound effect on the welfare of children. Since that time, we have implemented a
variety of concepts and laws to combat this societal problem. By 1966 all fifty states had
passed legislation regulating child abuse, all of which mandated reporting. By 1986,
every state but one required reporting of neglect, and forty-one states made explicit
reference to reporting of emotional or psychological abuse. Initially, mandated reporting
was limited to health care providers but this was eventually extended to include
teachers, nurses, counselors, and the general public.

Child abuse as a social concept continues to evolve as children's rights are

recognized by society. How we define abuse has a great impact upon our recognition
of it. Child abuse is defined as the non-accidental, physical, emotional or sexual trauma;
exploitation; or neglect that is endured by a child younger than 18 years of age while
under the care of a responsible person, such as a parent, sibling, teacher or other
person acting in loco parentis. Approximately 3 million cases of child abuse are reported
annually in the United States. Two thousand to four thousand of these cases will result
in death. As a practical point, several nationally publicized child abuse/ child homicide
cases have occurred in South Carolina over the past several years. The United States
has high rates of reported childhood homicide and higher teenage suicide rates than
most industrialized countries of the world. Childhood homicide rates have more than
doubled over the past 25 years, and there is no indication that this trend is abating.
Since so many cases of abuse culminate in a fatality, it is important to recognize the
clinical indicators of abuse.

Oral aspects of child neglect and abuse are well-known to the dental health care
team. The Prevent Abuse and Neglect through Dental Awareness (PANDA) coalitions
have trained thousands of dentists and auxiliaries in the recognition and reporting of

Page | 1
such injuries. Craniofacial injuries occur in more than 50% of the cases of child abuse.
Often these are unexplained injuries that are inappropriately reported by the caregiver
or the clinical presentation is inconsistent with the history provided. Other
characteristics of orofacial injury in child abuse relates to the multiplicity and repetitive
nature of the injuries. These injuries often appear in various stages of resolution. The
face and the oral cavity in particular are frequent targets of abuse. Easy access to the
child's head as well as the oral cavitys role in communication and nutrition make it
particularly susceptible to abuse. Not surprisingly, the oral cavity is a frequent site of
sexual abuse in children and oral gonorrhea in prepubertal children is pathognomonic of
sexual abuse. Abusive trauma to the face and mouth include all the following:

Laceration of the labial or lingual frenum- resulting from either being

forcefully struck or forced feeding.

Repeated fractures or avulsions of the anterior teeth.

Facial bone and nasal fractures.

Bilateral contusions of the commissures of the lips.

Soft and hard palate ecchymosis/petechiae

Since many abusive appearing injuries can also occur accidentally, a detailed
history of the event should be sought. Parents attempting to conceal abuse often
provide discrepant histories as to the nature of the presentation. Anytime a discrepant
history is given by a parent or caregiver - abuse must be suspected. Delay in obtaining
medical and dental care, although not pathognomonic for abuse, should arouse
suspicion. A past medical history of other unexplained or inadequately explained
injuries should mandate a thorough review of emergency department and inpatient
medical records. There are however, some clinical findings that are virtually
pathognomonic of abuse including patterned loop marks, adult human bite marks,
immersion burns and metaphyseal bone fractures often labeled as bucket handle
fractures. Non-organic failure to thrive is characteristic of parental deprivation/child
neglect.

Page | 2
 This pattern of injuries including multiple contusions in various
stages of resolution combined with the discrepant history provided
by the caregiver is characteristic of abuse.

Each week, there are reports in the local and national news of children who are
injured or murdered by adults charged with their well-being. Often these
sensationalized stories are met with public outrage and force us to grapple with the
question of why some parents intentionally harm their children. No doubt, parenting is a
demanding, challenging, and often physically exhausting job that taxes even the most
capable person. For example, when a maternal or paternal characteristic such as poor
impulse control is coupled with a toddler whose developmental goal is independence,
the risk for abuse is great. Children represent our most valuable resource. Studies have
shown that abuse occurs at all socioeconomic levels and when it comes to damage,
there is no real difference between physical, sexual and/or emotional abuse. All that
distinguishes one from the other is the abusers choice of weapons. In 2010, a report
released from Prevent Child Abuse America estimated that the United States spends
$258 million each day as a direct or indirect result of the abuse and neglect of our
nation's children. Since conservative estimates were used, the actual annual cost could
be higher than its estimate of $94 billion per year. This estimate includes the costs
associated with intervening to help and treating the medical and emotional problems
suffered by abused and neglected children, as well as the cost associated with the long-
term consequences of abuse and neglect to both the individual and society at large.

Page | 3
 A delay in seeking medical attention for this childs ruptured ear
drum combined with demonstrable contusions suggests physical
abuse. This child was well known to child protective services.

Mandated reporters are bound legally and ethically to have their reporting
threshold activated when they have a reason to suspect that abuse has been
committed. State reporting laws do not require mandated reporters to be convinced that
child abuse or neglect has transpired in order to make the report. Physicians, dentists
and other mandated reporters are required to submit a report if they have reasonable
cause to suspect, cause to suspect or cause to believe, that a child has been
abused or maltreated. Mandated reporters are protected from civil and criminal liability
for unsubstantiated reports if the reports were made in good faith. The etiology of
child abuse is complex and the profile of the abuser or is varied. In spite of these
limitations, we need to consider abuse as a symptom of family dysfunction. If a parent
feels as though he or she has abusive tendencies, they should be encouraged to
voluntarily seek help from community advocacy programs. Educational programs to
promote positive parenting are extremely beneficial to society at large.

Abuse represents a spectrum of behavior. It is repetitive in nature and fatal

abuse is often preceded by minor manifestations of maltreatment, which might be
overlooked by physicians, dentists, teachers, social workers and others who are in
frequent contact with the child. The sad truth is that child abuse kills more children in
the United States each year than do accidental falls, drowning, choking on food,
suffocation and fires in the home combined. Children should never die because of our
inability to confront the possibility of abuse. Healthcare providers must identify children
at risk, educate the families we serve and report suspected cases of abuse and neglect
to the appropriate authorities. Our lack of understanding of the complex etiology of child
abuse does not absolve our collective responsibility to protect those individuals at risk.
As Dr. Henry Kempe so eloquently stated almost 34 years ago, It is just not possible to

Page | 4
worry about all of the children all of the time. There lies the frustration and total inaction
as well. For each of us there must be only one child at a time.

To raise awareness about the impact of child maltreatment and its prevention,
the blue ribbon campaign is held each year during the month of April, Child Abuse
Prevention Month. Throughout the month, the community is encouraged to wear a blue
ribbon to symbolize their commitment to protect children and end child abuse and
neglect. Anyone in the United States may make an anonymous report of abuse, neglect
or sexual abuse by reporting it to the emergency services by dialing 911 or calling the
local police department. Abuse and neglect may only be reported at the state or local
level, not to the U.S. government. Most states have a toll-free hotline staffed by trained
call screeners. When contacted, they will either open the case for investigation or log
the report. Depending on available resources and the department's legal mandate, one
report may not be sufficient to open a case, but a detailed report about a potentially
serious case, or multiple reports (by different reporters), may suffice. At that point,
someone from a legally designated agency will investigate the report. The investigators
may determine there is no evidence of maltreatment, that there is evidence enough to
offer support to the family in the home, or that there is evidence enough to remove the
child from the home. The National Child Abuse Hotline (1-800-4-A-Child) is another
resource for citizens wishing to report abuse. Hotline counselors provide local reporting
information and will stay on the phone while a three-way call is placed to local
authorities. In South Carolina cases of suspected abuse can reported by accessing the
Department of Social Service(DSS) website :
https://dss.sc.gov/content/about/contact.aspx and by calling the specific resources in
the county where you reside or practice. If you or any member of your staff believes that
a child has been or is being harmed or is at significant risk of being harmed you should
call the county DSS office where the child resides.

Street Address:

South Carolina
Department of Social Services
1535 Confederate Avenue Extension
Columbia, SC 29202-1520

Mailing Address:

South Carolina
Department of Social Services
P.O. Box 1520
Columbia, SC 29202-1520

General Contact Numbers:

Page | 5
TANF/SNAP, Client Services (800) 616-1309
(Temporary Assistance for Needy Families)

General Information (803) 898-7601

Office of the State Director (803) 898-7360

Emergency Hotlines & Toll Free Numbers

Abuse & Neglect

Abbeville

Childrens Helpline (for foster children) and (800) 645-9789

Out of Home Abuse and Neglect (OHAN)

Child Abuse Hotline (National) (800) 422-4453

Child Support Enforcement (800) 768-5858

Parents Anonymous 24-Hour Hotline (800) 326-8621

Sistercare Hotline (800) 637-7606

Women, Infants & Children (800) 868-0404

Statewide Abuse, Neglect and Exploitation Reporting System

ADD STATE MAP AND PHONE NUMBERS

This reporting system is provided for your convenience to report instances of

abuse or neglect that do not require an emergency response. An emergency is a
situation where a child or elderly/disabled person appears to face an immediate risk of
abuse or neglect that could result in death or serious harm.

Call your local law enforcement agency or 911 if the situation is an emergency.

Page | 6
 South Carolina Code: 63-7-20

Child abandonment occurs when a parent or guardian willfully deserts a child or willfully
surrenders physical possession of a child without making adequate arrangements for
the childs needs or the continuing care of the child.

Child abuse or neglect occurs when the parent, guardian, or other person
responsible for the childs welfare:

Inflicts or allows to be inflicted upon the child physical or mental injury or engages in
acts or omissions which present a substantial risk of physical or mental injury to the
child, including injuries sustained as a result of excessive corporal punishment, but
excluding corporal punishment or physical discipline which:
a. Is administered by a parent or person in loco parentis
b. Is perpetrated for the sole purpose of restraining or correcting the child
c. Is reasonable in manner and moderate in degree
d. Has not brought about permanent or lasting damage to the child
e. Is not reckless or grossly negligent behavior by the parents

Commits or allows to be committed against the child a sexual offense as defined by the
laws of this State or engages in acts or omissions that present a substantial risk that a
sexual offense as defined in the laws of this State would be committed against the child.
Abandons the child
Encourages, condones, or approves the commission of delinquent acts by the child and
the commission of the acts are shown to be the result of the encouragement, or
approval
Fails to supply the child with:
o Adequate food, clothing, shelter, or supervision appropriate to the childs age and
development
o Education as required by law. A childs absences from school may not be considered
abuse or neglect unless the school has made efforts to bring about the childs
attendance, and those efforts were unsuccessful because of the parents refusal to
cooperate.
o Health care; though financially able to do so or offered financial or other reasonable
means to do so and the failure to do so has caused or presents a substantial risk of
causing physical or mental injury. For the purpose of this chapter "adequate health
care" includes any medical or nonmedical remedial health care permitted or authorized
under state law
o Has committed abuse or neglect as described in in previous paragraphs, such that a
child who subsequently becomes part of the persons household is at substantial risk of
one of those forms of abuse or neglect.

Page | 7
References

C. Henry Kempe and Ray E. Helfer, editors: The Battered Child. 1st edition, 1968. 2nd edition, Chicago:
Chicago University Press, 1974. 3rd edition, 1980. 5th edition by M. E. Helfer, R. Kempe, and R.
Krugman, 1997.

C. H. Kempe, Frederic N. Silverman, Brandt F. Steele, William Droegemuller, Henry K. Silver: "The
Battered Child Syndrome." Journal of the American Medical Association, 1962, 181: 17-24. Tardieu's
syndrome. Also called Caffey-Kempe syndrome.

A Good Knight for Children: C. Henry Kempe's Quest to Protect The Abused Child by Annie Kempe.
Booklocker.com, Inc. 2007.

Child Abuse Review

Volume 24, Issue 6, pages 389394,November/December 2015

Child Welfare Information Gateway (2006). Preventing abuse of children with disabilities. Retrieved June
29, 2007.
The National Center on Addiction and Substance Abuse at Columbia University (CASA). (2005). Family
matters: Substance abuse and the American family. New York: CASA.
th
Herschaft, EE. Forensic Dentistry, Oral and Maxillofacial Pathology, 4 ed. St. Louis Elsevier, 2016.

National Childrens Alliance 2013 and 2014 national statistics collected from Childrens Advocacy Center
members and available on the NCA website: http://www.nationalchildrensalliance.org/cac-statistics7-24.

U.S. Department of Health and Human Services: Administration for Children & Families. Child
Maltreatment 2013. http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2013

U.S. Department of Health and Human Services, Administration on Children, Youth, and Families.
(2007). Child maltreatment 2005. Washington, DC: U.S. Government Printing Office.

U.S Department of Health and Human Services, Childrens Bureau. (2003). Child welfare information
gateway: A bulletin for professionals. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect.
(1996). Third national incidence study of child abuse and neglect (NIS-3). Washington, DC: U.S.
Government Printing Office.

Stmger RG, Bross DC, eds. Clinical Management of Child Abuse and Neglect: A Guide for the Dental
Professional. Chicago, IL: Quintessence Publishing Co, Inc; 1984

Page | 8