Neglected child with

substance abuse leading to

child abuse: A case report
SUBRAMANIAN E., SUBHAGYA B., MUTHU M. S.,
SIVAKUMAR N.
Journal of Indian Society of Pediatric and Preventive
Dentistry (2005)
• A child is dependent on his parents or caretakers for the entire
physical and mental well being.

• Hence moulding the child into a good human being is the total
responsibility of the parents/caretakers.

• Any aberration in the parents’ attitudes towards the child results

in abuse and neglect of the child.
Abuse is defined as
‘the non accidental commission of any act by a care-taker upon a child under age 18
years which causes or creates a substantial risk of serious physical or emotional injury,
or which constitutes a sexual offense (such as rape or molestation).’

A caretaker may be a child’s parent,

stepparent, guardian, or any person entrusted with the
responsibility for a child’s health or welfare’.
Neglect is defined as
‘a failure by a caretaker, either deliberately
or through negligence or inability, to provide a child
with minimally adequate food, clothing, shelter, medical care,
supervision, emotional stability and growth, or other essential
care provided that such inability is not solely due to
inadequate economic resources or to a handicapping condition

Zavras AL, Pai LH. Child abuse: Attitudes and perceptions of

health profession students: A pilot study. J Clin Pediatr Dent
1997;22:23-7.
Abuse is to commit a forbidden act on a child and neglect is omission of concern for the child.

However, both lead to the disaster of the physical and mental built up of the child.

Abuse may be of many types like physical, emotional, mental, sexual, or verbal.

Substance abuse or drug abuse is the usage of psychoactive drug, which is capable of altering
the mental functioning.

Commonly used drugs from the past till today are marijuana, alcohol, amphetamines, solvents,
inhalants like typewriter correction fluid, smokeless tobacco, gasoline and glue, etc.

McDonald RE, Avery DR. Dentistry for the child and adolescent. 7th Ed. The C.V. Mosby Company; p. 17-8, 24-33.
Among them, ingestion of tobacco is considered to
be the most common and addictive of all and is
more prevalent in India.

The objective of this article is to present a case of

child neglect leading to substance abuse and ended
in child abuse.
Patient Medical History
❏Age: 12 Years
❏Gender: Female
❏Location: Chennai
❏Medical History-
Deaf and Dumb
● She reported with her mother and two younger sisters with the complaint of pain in
relation to her broken upper front teeth.

● History regarding trauma revealed that the mother had physically abused the girl by
hitting with a long spoon a month earlier and hence the teeth fractured.

● After repeated questioning about the reason for hitting the girl, the mother said that the
girl used ‘Hans’, a tobacco that is squeezed and placed in the oral mucosa mostly on
the mandibular labial vestibule or buccal vestibule close to the molars as quid.
● The girl also used to ingest various other tobacco products available in the market. All
the attempts by her parents (including burn on the oral mucosa with a hot spoon 2
months back) to revive the girl from the habit, failed.

● The mother seemed to be very reluctant about this girl and was not much worried
about the fractured anterior teeth (Dental neglect). The girl looked very depressed and
anxious.

● On further questioning it was found that the girl was totally neglected by parents and
she used to move closely with some neighbouring elderly women who used to chew
pan and had acquired the habit from them.
● Intra-oral examination revealed fracture of both the maxillary central incisors (11, 21) with
the involvement of pulp (Class-III Ellis and Davey).

● Soft tissue examination showed rough and inflamed mandibular labial mucosa and white
patches at the left retromolar area where she usually places the quid.

● Tobacco stains were seen on the labial and buccal surfaces of 31, 32, 36, and 37.
● Preoperative radiograph of 11, 21 was taken and it did not reveal any periapical
pathology.

● A thorough prophylaxis was performed. Access opening was done in 11 and 21 and pulp
tissue remnants were extirpated.

● Root canal treatment was completed in the subsequent visits.

● Light cure composite restoration was done on 11 and 21 to restore the morphology of the
teeth and to improve the self-image of the girl.

● Consequences of using tobacco were explained to the girl with verbal expression and
descriptions (without a mask so that she can read the lips), which she can understand.

● The pictures of precancerous lesions and cancerous lesions from an oral pathology atlas
were showed to the child and the mother. Mother was counselled about child neglect and
abuse.
DISCUSSION
● The interrelationship of hearing impairment and loss of speech skill was noticed in this
case.

● The decreased ability to communicate through speech influences adversely the

psychological development and social integration of children with hearing impairment.

● This was true in this girl who was not moving around with her peer group, but she was
close to neighbouring elderly women.
● It is important for the dentists to be aware of the characteristics of such hearing impaired
individuals, as well as the psychological and behavioural approaches that may be necessary
to facilitate the provision of quality dental care to these individuals.

Tandon S. Textbook of Pedodontics. 1st Ed. Paras Publishing;

2001. p. 535-73.

● The mother of the girl aided us by being present in the operatory. Since the girl was more
sensitive to dental surroundings, presence of her mother minimized her anxiety and she
became very cooperative in the succeeding visits.
● Parents have feelings of sorrow, guilt, anger and self-pity when they have a child with
disabilities like this patient whose hearing is impaired and speech skills are lost.

● The family has been emotionally, physically and financially tied up with the patient’s
medical conditions, which makes them difficult to get interested in dental needs of the
child.

● The attitude of the parents influence the dental service based on two types of
behaviours, namely overprotection and negligence.

● In this case report, it was found to be negligence because the mother was reluctant
about her daughter’s anaesthetic appearance of fractured 11 and 21.
● They reported only after she developed pain. Her father is a labourer and history
revealed that even he uses the same substance (Hans).

● In this case, the girl was totally neglected by her parents and she moved with elderly
neighbouring women who chew pan.

● Substance abuse by children is mostly associated with rebellion against parents and
society especially due to neglect and child abuse. With this substance abuse they get a
momentary feeling of independence and power because they have disobeyed the rules
of their parents and society as a revenge for their neglect.
● This satisfaction obtained through rebelling against parents can give the children and adolescents a
reinforcing motive for persisting in substance abuse and ending up in addiction.’

● This was also true with this case, as many attempts by the mother including placing hot spoon in the
girl’s mouth to stop the habit failed and finally the mother hit the girl’s teeth with a spoon and
fractured them.

● Counselling was carried out with the mother and the girl and they were asked to report after a month

for review.

● Mother reported with the girl after 1 month and the mother revealed that the girl completely stopped

the habit of taking pan.

● The mother was also found to be caring towards the girl. Intra-oral examination revealed the
disappearance of white patches on the left buccal mucosa and tobacco stains on the mandibular
incisors.

● The girl was rewarded for the withdrawal of the habit.

● As most of the abuse injuries occur in the head and neck, dentists can easily diagnose them and as a
oral care professional it is our duty to detect such abuses at an early stage to prevent further harm to the
child and counselling of abusive caretakers.

McDonald RE, Avery DR. Dentistry for the child and adolescent.7th Ed. The C.V. Mosby Company; p. 17-8, 24-33.
Stewart RE, Barber TK, Troutman KC, Wei SHY. Pediatric Dentistry: Scientific foundations and clinical practice. The C.V. Mosby Company;
1982. p. 961-72.
● Although dentists are aware of child abuse and neglect in the western countries and many cases have
been reported, in India, it is comparatively less.

● This can either be due to the cause that the child abuse and neglect cases are rare or may be due to the
unwillingness of the dentists to report.

● Indian law (Indian Penal Code No. 317) states that exposure and abandonment of child under 12
years, by parent or person having care of it is punishable.
Singh A, et al. Indian Penal Code

● It also states that leaving such child, in any place with the intention of wholly abandoning such child,
shall be punished with imprisonment of either description for a term which may extend to 7 years, or
with fine, or with both.
● However, the reported cases are less in India. Pediatric dentists should diagnose child
abuse cases and report to the concerned authorities and work to prevent such cases.

● Identification of substance abusers is difficult even for an experienced observer.

● Specific clues for identifying them include abrupt change in the behaviour, social
interaction, depression, moodiness, loss of interest in opposite sex, desperate need for
money and loss of appetite and weight.

● Deviant social background, school dropout, prostitution, broken relationships,

inability to retain a job and low self esteem are some of the traits observed in
substance abusers.
● Intra-oral placement of smokeless tobacco quid may cause effects on soft and hard
tissues of the mouth, such as bad breath, discoloured teeth and restorations, gingival
recession, erythema of soft tissues, ulceration, leukoplakia (white patches) and
eventually may lead to cancer.’

● Hence dentists should identify such substance abusers and counsel them and take
measures to stop them from the habit.
RELEVANT
PUBLICATION
-1
Child abuse and neglect-
A Case Report

Kiran K
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE
DENTISTRY | December 2011 | Supplement 2 | Vol 29 |
● A 3-year-old girl presented with her mother and her 6-year-old elder sister to the
pediatric dental department at the Kamineni Institute of Dental Sciences, Narketpally,
Andhra Pradesh, India, for routine dental evaluation and treatment.

● The mother had visited the department for the dental treatment of her elder daughter
while the younger daughter had only accompanied her mother and sister.

● The author accidentally saw the accompanying 3-year-old child and requested a check-
up for her.
The 3-year-old girl had a very poor oral hygiene and almost all the teeth were affected with dental caries.

In spite of her parents being educated and financially sound, the girl was
malnourished.

On questioning the child and the mother, it was evident that the child was not
given adequate medical and dental care.
● The child was suffering from abuse and neglect as she was an “unwanted” baby girl.

● The child was severely malnourished and performed miserably in all parameters of growth and
development.

● On further questioning, the mother revealed that the father was an alcoholic and the mother
admitted to the lapses of not providing adequate nutritious food and medical/ dental care to her
child.

● The parents were expecting their second child to be a baby boy.

● However, when that did not happen, the parents neglected the needs and concerns of this girl,
leading to the existing poor medical and dental condition.
● The author reported the case to a social worker and counselling of the patient’s mother was
carried out.

● The mother was educated and counselled about the negligence and the detrimental effects on
the wellbeing of the child.

● The child is now being treated for complete general health by the paediatricians and paediatric
dentists for oral rehabilitation
RELEVANT
PUBLICATI
ON - 2
CHILD ABUSE PRESENTED
AS OROFACIAL INJURY
Afshan Bey, Nazia Ashfaq and Syed
S.Ahmed
Curr Pediatr Res 2011; 15 (2): 73-76
An 8 year old male child was referred to the department for the management of swollen lips
and bleeding gums.

It was observed that he had bruises and cuts on his face specially around his mouth and
nose.

His lips were swollen and the gums were lacerated and bleeding. He had bruised nasal
bridge and forehead.
The intraoral examination revealed Ellis type III fracture in right upper central incisor
and Ellis type II fracture in left upper central incisor.

The child appeared frightened and disturbed.

The father told the child sustained trauma due to fall on the floor while running in the
house.

However, on repeated questioning, it was found that he was allegedly beaten up by his
father and it was a usual happening.
The father was called, and then referred to the psychotherapist for
counselling.

During the interaction with the psychotherapist, the father revealed

certain acts of his child which irritated him and consequently he beat or
tortured the child to relieve his anguish.

The acts were excessive use of computers for game and chatting and
mobile phone, for calling his friends and gossiping and spending lot of
time which he (father) accounted as wastage of time.
He was of the opinion that the child was ‘wasting’ lot of time on these modern gadgets
and believed that computers and mobiles should be used at the time of need only and
not to pass the time.

Later on the child was sent to pediatric counsellor who helped him to alter his behaviour
which irritated his father.

The father was also counselled for his thinking and irresponsible behaviour.

During the course of follow up visits, the child enlightened the changes and helpful
attitude of father.
THANK
YOU!
● Hearing impairment may be present congenitally at birth or may be acquired
adventitiously in the postnatal period and this impairment will have an effect on the
development of speech and verbal communication skills, as they are interrelated.

● Only after the sounds have been heard can these sounds be imitated, grouped to form
speech, understood to learn language and then transmitted as communication.

Wei SHY; Pediatric Dentistry; Lea and Febiger: Total Patient Care; 1988. p. 572-3.