Evaluation of factors influencing child abuse leading to oro-facial lesions in Isfahan, Iran: A qualitative approach.

BACKGROUND: Since child abuse and neglect are serious conditions which can potentially lead to inappropriate dental health, we conducted this qualitative study to define the factors influencing child abuse and neglect, which lead to oro-facial lesions.
MATERIALS AND METHODS: Qualitative semi-structured interviews were conducted by social services employees. Purposive sampling was used to recruit participants to capture a range of experiences such as the physical abuse, sexual abuse, role of family in child abuse, age, and gender.
RESULTS: Participants demonstrated a range of perceptions which lead to child abuse including hitting on the head and slapping. Often subsidiary to this view, several factors were mentioned that occasionally influenced child abuse. These factors appeared to be idiosyncratic but could be drawn together into three categories: Cultural lacks which includes poverty, cruelty of parents and addiction, psychological disorders, and separation in the family which was seen in most of the children.
CONCLUSION: This study has identified a variety of factors influencing the incidence of child abuse. Therefore, dentists should meticulously pay attention to children who have these risk factors in order to discover child abuse events. Quantitative research would reveal the extent of these factors. Dentists' knowledge of their roles in managing cases suffering from abuse might need to be assessed to see if dentists need further education in this important area.

INTRODUCTION

Despite the fact that most of children grow in desirable environments, unfortunately a minority suffer from child abuse and neglect by their parents, caregivers, or others. Child abuse is treating a child in a culturally unacceptable manner at a certain time,[1] However, child neglect is defined as ‘the persistent failure to meet a child's basic physical and/ or psychological needs, likely to result in the serious impairment of the child's health or development’.[2] Abuse is defined in three categories; physical abuse, emotional abuse, and sexual abuse. There are signs of physical abuse which manifest in the oro-facial area. It is obvious that dentists not only are extensively knowledgeable about this area, but also have access to this region. While dentists can potentially report and stop physical abuse, there is still a reluctance to do so.[3] Undoubtedly, dentists are morally responsible for following local child protection procedures and for making sure that children rights are not disrespected.[4]

While there are several reports in the literature showing the prevalence of child abuse, there is no epidemiological study conducted in Iran aimed to assess the prevalence and the causes of child abuse. However, it seems necessary to define the factors influencing on this event to provide a standard guideline for dental professionals about child abuse. The aim of this qualitative study was to investigate the causes of child abuse and child neglect which lead to oro-facial lesions using the records of Isfahan social emergency services from 2007 to 2012.

MATERIALS AND METHODS

Qualitative semi-structured interviews were conducted by social services employees in the past, and we studied the records related to 2007-2012. The social emergency services are legally eligible to separate the victims of child abuse from their families as well as interview the children and their families in order to solve their problems. Purposive sampling was used to recruit participants to capture a range of experiences such as the physical abuse, sexual abuse, role of family in child abuse, age, and gender. Sampling continued until ‘saturation’ when no new codes appeared in the data. The saturation was obtained after 25 interviews. Interviews were loosely structured and comprised open-ended questions related to the area to be explored. The original interview guide was based on preliminary discussions between researchers and social services’ lawyer. This study was ethically approved by the ethics committee of Isfahan University of Medical Sciences.

The principle approach was qualitative content analysis. Data were then analyzed using line-by-line coding and then codes with common themes were brought together. The themes were then grouped into categories. All categories originated in the data and provided insights into, and explanations of, factors that might influence the prescribing patterns and thus child abuse. Deviant case analysis was also undertaken to ensure that any emergent explanations or theories were redefined to embrace all cases.[5]

The emergent categories are neither discrete nor mutually exclusive but are the constructions of the researchers to group and understand the data. Therefore, the results are presented as themes that emerged from the data rather than as coherent categories described by participants. However, quotes are used to illustrate key categories. Cases were identified by initials in order to consider ethical aspects.

RESULTS

Participants demonstrated a range of perceptions as to the factors influencing type of child abuse. Qualitative data are primarily concerned with identifying the range of ideas and categories within the data and are not suited to describing how frequent is a particular view. Often subsidiary to this view, several factors were mentioned that occasionally influenced child abuse. These factors appeared to be idiosyncratic but could be drawn together into three categories: Cultural lacks which includes poverty; cruelty of parents and addiction, psychological disorders, and separation in the family which was seen in most of the children [Figure 1].

Figure 1

Factors influencing child abuse leading to oro-facial lesions

Cultural lacks

Three sub-categories of Cultural lacks were identified in this category: Cruelty of parents, poverty, and addiction.

Cruelty and maltreatment of parents was seen in most of the children in this study. There was wide variation in views on aggressive behavior of parents specially fathers. Potential barriers in law inhibited social service emergency to sue parents with violent behavior. Potential barriers were concerns about social services roles and responsibilities.

“My father died after an accident. My stepfather smacks me”.

In this child, signs of trauma and bruising were visible in his thorax, face, and extremities which were subsequent to hitting by belt. Erosions of right cheek and posterior of left earlobe were also sensible.

“My dad breaks the glasses and hits me as he gets angry, then I scream and break everything”.

Poverty is a prevalent issue in the society which can make the parents neglect their children and may lead to a lot of problems.

“My parents live in a desert. My mother begs for money, and her friends smack me and my brother. So we decided to escape”.

Addiction was another issue mostly observed in the family of children abused either physically or sexually, and it seemed to be an important factor in the child abuse events. Addiction of parents and even the children was observed prominently in the records:

“My mother uses drugs. She sends me to my grandmother as she wants to use drugs. Arrest my mother! Tell that she has burnt my body to the police”. A 4 year-old boy.

“His father is addicted. His parents are divorced. We have to take care of him. His father smacked him as he gets angry”. Grandparents of a 2.5 year-old boy.

Psychological disorders

Psychological disorder was another factor which was commonly seen in the records.

This section details a very variable theme in child abuse. Factors related to psychological disorders included parents’ and child’ attitudes and parents characteristics such as the complexity of disorders, behavior of the parent and child, poor follow up treatment, socio-economic status, age, and medical problems. These factors were distinct from the general ‘type’ of children.

Participants expressed a range of views about parental behaviors.

“I hate the repetition of words. Everything annoys me and then I shout at Narges or hit her. I have problem with sleeping”.

Case complexity included different psychological disorders, dimensions such as the volume or nature of psychological disorders, disease levels, anxiety, medical history, age, and socio-economic status of the parents.

Separation of parents

Divorce, death of parents, and being in jail are factors which lead to separation and second marriage. Our results have shown that it makes the children more vulnerable to any kind of abuse.

“My parents are divorced. My mother married again and she cannot take care of me. My stepmother smacks me”. A 12 year-old boy.

DISCUSSION

This is the first study to assess the factors influencing on child abuse which lead to the facial and oral lesions using the records of Isfahan social emergency services in 2007-2012. Qualitative data are primarily concerned with identifying the range of ideas and categories within the data and are not suited to describing how frequent is a particular view. Often subsidiary to this view, several factors were mentioned that occasionally influenced child abuse. These factors appeared to be idiosyncratic but could be drawn together into three categories: (1) Cultural lacks which includes poverty, cruelty of parents, and addiction, (2) Psychological disorders, (3) Separation in the family.

In this study, incidence of child abuse was found to be influenced by different financial situations and poverty. This finding is compatible with earlier research on social services’ views about child abuse occurrence.[6]

The findings from the systematic review and other quantitative studies that considered the incidence of child abuse triangulated with the results of our qualitative study, in which poverty was mentioned as one of the key reasons influencing child abuse.[7]

Participants in the present study suggested that parental problems such as addiction and poverty were a possible factor. Needleman studied the addiction problem of parents influencing child abuse[89] and recommended that both government and dentists could be involved in promoting greater influence on reduction of incidence of child abuse.

Indeed, many dentists who regularly treat children report that managing dental neglect is a part of daily practice.[10] However, previous research has shown that dentists feel unprepared to take on a child protection role and are unsure what to do if they suspect that a child has been maltreated.[31112]

CONCLUSION

In conclusion, this study has identified that a variety of factors may influence the incidence of child abuse. Quantitative research would reveal the extent of these factors. Dentists’ knowledge of their roles in managing cases with abuse might need to be assessed to see if dentists need further education in this important area.