Keywords
Attitudes - child abuse - dentists - knowledge - training
Introduction
Children are one of the most vulnerable groups in our society. Child abuse is currently considered a significant public health problem.[[1]] The World Health Organization defines child abuse as “every kind of physical, sexual, emotional abuse, neglect or negligent treatment, commercial or other exploitation resulting in actual or potential harm to the child’s health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power.”[[2]]
Child abuse victims can be very easily identified with the help of a multidisciplinary team – one of whom are dentists, as research has proven that parents or guardians who abuse their children frequently change their child’s physicians, but very rarely change their dentists.[[3]] In addition, approximately 50%–75% of all reported cases of child abuse involved trauma to the head, face, and mouth;[[3]] this is an area that dentists routinely assess. These facts make dentists in the most ideal position to identify physical abuse in children. However, dentists still seem to be reluctance to do so.[[4]] The reluctance to report such cases may be due to their lack of knowledge in this particular area, but some other reasons include feeling unprepared, not knowing where to report, the impact of making a referral on their practice – in terms of finance and time, concern of making an inaccurate accusation resulting in the disruption of the dentist’s relationship with the family, and fear of what the child may go through from the intervention of statutory agencies.[[4]],[[5]],[[6]],[[7]]
Unfortunately, dentists fail to understand their legal duties when it comes to reporting child maltreatment even though they recognize the signs of abuse in a children.[[8]] Dentists are seen to be the most inactive group in recognizing and reporting child abuse, in comparison to other health professionals.[[9]] According to Ferrara et al.,[[10]] the likelihood of a dentist to report a child abuse case was associated with their exposure to continuing education and having seen such cases in practice. In 2002, all dental schools in the US and Canada added the education of child abuse in their curricula. However, this does not necessarily indicate that the students were provided with any clinical experiences with child abuse and neglect.[[3]]
The United Arab Emirates (UAE) officially implemented a child protection law in 2016. This law named – Wadeema’s law – has now redefined child protection in the UAE, where it obligates any doctor, teacher, and other professionals working with children to report any suspected child abuse. Not doing so can result to fine penalties and imprisonment.
The aim of this study is to assess the level of knowledge and experience reported by dental practitioners in Dubai regarding the identification of child physical abuse, to identify the barriers that prevent the reporting of suspected cases, and to assess the need for additional training in child protection.
Materials and Methods
This study was conducted at the Dental College of Ajman University. Therefore, the ethical approval was obtained from the research ethics committee in that university. The current study targeted randomly selected dentists working in private clinics in Dubai and dentists with <1 year of experience were excluded. All information received from the dentists remained anonymous, as neither the dentists’ names nor the names of their practices were mentioned. Dentists contributed voluntarily to this study.
The questionnaire was written in English based on previous similar studies.[[3]],[[4]],[[11]] It was reviewed by two pediatric dentistry specialists with knowledge in this area. The content validity of the questionnaire was tested by conducting pilot survey of dentists (n = 10) working in the Dental College of Ajman University. Those dentists were asked to assess the clarity of the questions and the response formats.
The questionnaire used comprised 16 close-ended questions, which was divided into four main parts: the first section of the questionnaire contained information about the dentists’ gender, age, type of degree, and the number of pediatric patients they see every week. The second section focused more on the dentists’ knowledge about child abuse – both generally and pertaining to the law of UAE. The third part of the survey was more subjective, asking the practitioners whether they felt they needed further training to recognize any signs of child abuse. The fourth and final sections directly asked about the dentists’ exposure to any child abuse cases, whether they reported the case when they suspected one, where they do report it once they come across a child who is victimized by abuse? It also requested the respondents to identify the barriers that prevented them from reporting such cases and whether or not they ever received any information or training in the diagnosis of child abuse.
The questionnaires took no more than 5 min to fill. All the data entered into the MS-Excel 2013 version 15.0 (Microsoft Office Suite, Washington, USA), and then transferred into SPSS windows version 21.0 (SPSS Inc., Chicago, IL, USA). Data were analyzed using descriptive analyses for responses to each question.
Results
A total of 124 dentists agreed to participate in this study. [[Table 1]] shows the characteristics of the participants in addition to information regarding the number of pediatric patients they see per week. It can be observed that the majority of the dentists who filled the questionnaires were female (59.7%). The largest number of the dentists fell in the age group of 26–35 years (46%). When asked about the type of degree the dentists hold, the majority stated they have BDS/DDS (73.4%). The highest percentage of dentists saw 11–20 pediatric children per week (81.5%).
Table 1:
Characteristics of the participants, their academic degree, and number of children seen every week
|
Frequency (%)
|
|
Gender
|
|
|
Male
|
50 (40.3)
|
|
Female
|
74 (59.7)
|
|
Age
|
|
|
25 years
|
38 (30.6)
|
|
26-35 years
|
57 (46.0)
|
|
36-45 years
|
20 (16.2)
|
|
46-55 years
|
5 (4.0)
|
|
>56 years
|
4 (3.2)
|
|
Type of degree
|
|
|
BDS/DDS
|
91 (73.4)
|
|
MSc
|
26 (21.0)
|
|
PhD
|
7 (5.6)
|
|
Number of pediatric patients seen per week
|
|
|
10
|
15 (11.3)
|
|
11-20
|
101 (81.5)
|
|
21-30
|
3 (2.4)
|
|
31-40
|
4 (3.2)
|
|
>41
|
1 (0.8)
|
Out of the 33 dentists who suspected child abuse in their careers, only 10 actually reported their concerns. When the dentists were asked if they are legally required to report child abuse cases in the UAE, a high percentage (84%) agreed on that. However, when the dentists were asked whether there are any legal consequences for not reporting child abuse cases, almost one-quarter of the participants thought that there are no legal consequences for not doing so. The majority of the dentists felt that they need further training on recognizing child abuse (88%). [[Table 2]] shows the participants’ attitudes toward reporting of child abuse and their perceived need for training program in child protection.
Table 2:
Knowledge and attitudes of the respondents toward reporting abuse cases and their perceived need for training programs of child protection
|
Yes (%)
|
No (%)
|
I don't know (%)
|
|
Have you suspected any cases of child abuse during your career?
|
33 (27)
|
91 (73)
|
|
|
If yes, have you reported your concerns about those child abuse cases?
|
10 (30)
|
23 (70)
|
|
|
Do you think that dentists are legally required to report child abuse cases in the UAE?
|
104 (84)
|
18 (15)
|
1 (1)
|
|
Are there any legal consequences for not reporting child abuse?
|
93 (75)
|
30 (24)
|
1 (1)
|
|
Do you feel that you need further training on how to recognize child abuse?
|
110(88)
|
14 (12)
|
|
UAE - United Arab Emirates
The most common barrier that prevents dentists from reporting child abuse cases was uncertainty about their diagnosis (33%). Lack of knowledge regarding referral procedures proved to be the second-most common barrier that precludes the dentists from reporting, followed by the fear of violence in the family toward the child (17.7%). When the participants were asked where they should report child abuse cases in the UAE, more than one-third of the dentists did not know the answer (36.7%) (n = 48). However, 30% of the dentists agreed that the family protection department is the appropriate place to report child abuse. The majority of the participants (78.0%) received their information regarding child abuse from their dental schools; surprisingly that only 3.2% received this information through continuing education programs. Dentists’ knowledge about child abuse referral procedures and factors preventing their reporting of those cases are presented in [[Table 3]].
Table 3:
Barriers to reporting suspected cases of child abuse and places of reporting perceived by the respondents
|
Frequency (%)
|
|
What barriers preclude you from reporting child abuse cases?
|
|
|
Uncertainty about your diagnosis
|
41 (33.0)
|
|
Fear of violence in that family toward the child
|
22 (17.7)
|
|
Lack of knowledge regarding referral procedures
|
33 (26.6)
|
|
Not wanting to interfere
|
8 (6.4)
|
|
Negative impact on your practice
|
7(5.6)
|
|
Where do you have to report child abuse and neglect in the UAE?
|
|
|
Family protection department
|
38 (30.6)
|
|
Local police
|
36 (29.0)
|
|
The nearest hospital
|
2 (1.6)
|
|
I don't know
|
48 (38.7)
|
|
Where did you get your source of information on child abuse, if you have received any?
|
|
|
Dental school
|
97 (78.0)
|
|
Dental journals and literature
|
3 (2.6)
|
|
Continuing education courses
|
4 (3.2)
|
|
National dental meetings
|
20 (16.1)
|
UAE - United Arab Emirates
Discussion
Every child worldwide has the right of a loving environment, and child protection is the duty of every member of the society.[[8]] However, millions of children around the world are victims of violence.[[12]] As mentioned earlier, the majority of lesions reported due to child abuse involve the craniofacial regions. Therefore, dentists are in an exceptionally favorable position to recognize child abuse.
The finding of the current study indicates that there was a lack of knowledge in many areas related to child physical abuse, as has been reported by other researchers in similar studies.[[13]],[[14]] The current study indicates that 25% of the dentists had encountered suspected incidences of child abuse at least once in their career. However, the percentage was higher in Jordan (42% and 50%, respectively) as reported by Owais et al.[[14]] and Sonbol et al.[[15]] The lower percentage of dentists that encountered child abuse case may not represent the actual incidence of child abuse, but rather undiagnosed cases of child maltreatment, or it might reflect the low percentage of pediatric dentistry specialists who contributed to this study.
The lack of knowledge in the area of child abuse might hamper dentists from reporting those cases. In a study conducted by Al-Dabaan et al.[[16]] among dentists in Saudi Arabia, it was found that the rate of reporting child abuse cases was extremely low, and lack of knowledge to recognize such cases was one of the main factors affecting their decision not to report suspected cases. This study demonstrated that only 30% of the participants reported suspected abuse cases.
The findings of this study regarding the legal responsibility toward child abuse were quite impressive compared to what has been reported previously,[[14]] which indicates that dentists practicing in UAE are aware of their role in this regard. Unfortunately, inadequate training in child protection is evident in this study, similar findings were reported by Habib.[[17]] Having these findings in hand emphasize the importance of providing training for the dentists practicing in the UAE. However, the majority of the respondents (88%) felt that they need further training on how to make accurate diagnosis of child abuse. Similar findings were reported by AlBuhairan et al.[[13]] and Al-Dabaan et al.[[16]] This finding indicates that the dentists in UAE are keen in protecting child abuse victims.
The main barrier to reporting suspected abuse cases in the present study was the uncertainty about the diagnosis (33%). Health-care professionals are responsible for reporting child abuse and they must seek the necessary knowledge in reporting procedures if needed. In addition, uncertainty about referral procedure was reported as a barrier to report suspected cases; nevertheless, similar findings have been reported by previous studies done by Al-Dabaan et al.[[16]] in Saudi Arabia and Sonbol et al.[[15]] in Jordan. Fear of violence toward the child is considered one of the barriers to reporting by 17.7% of the participants. This percentage is way lower than what has been cited by Al-Habsi et al.[[18]] and Al-Dabaan et al.,[[16]] in which they reported it as 66% and 87.7%, respectively. Conversely, the least reported barrier to the reporting of child abuse cases included: “not wanting to interfere;” fear of litigation and reporting child abuse might have a negative impact on their practice.
The current study findings showed that more than one-third of the participants did not know where to report suspected cases of child abuse. This finding was consistent with the finding of Hashim and Al-Ani [[19]] and Owais et al.[[14]] Abuse is most likely a continuous occurrence rather than a single event, and cases are usually reported after various medical evaluations.[[20]] Therefore, if a dentist witnesses multiple injuries, injuries that are in different stages of healing, or a history that does not sound valid, he/she must be suspicious of child abuse.[[21]]
More than three-quarters of the dentists reported that they learned about child abuse in their dental school. However, it is very essential to consider that this topic covered mainly theoretically in the classroom setting, which is different than the clinical scenario.
The main limitation of this study is the sample size, which was limited to dental practitioners working in private sector only, involving dentists from the public sector in future studies will be recommended. Another limitation was that the study was based only on self-report of the health professionals and did not include observations of their actual practice. Nonetheless, the results provide valuable insights into a very important issue and significantly contribute to our knowledge related to the attitudes and experience of dental practitioners regarding child abuse in the UAE.
Child abuse in the majority of cases is a traumatic experience that leads to many advance effects including anxiety difficulties in concentration, low self-esteem, and even suicide.[[22]] Therefore, the support of multidisciplinary team is highly recommended. Training should be tailored to the specific needs of dental professionals in order to achieve a better outcome.
Conclusions
Child abuse is an ongoing public health problem that seems to be overlooked by dentists. This research highlighted the main barriers facing dentists when they encounter suspected child abuse incidence in the UAE. Since many dentists are willing to receive more training, it would be highly recommended if the Ministry of Health provide continuing education program, which highlights the issue of child abuse to help the UAE society to overcome this problem.
