Year : 2005 | Volume
: 23 | Issue : 2 | Page : 92--95
Neglected child with substance abuse leading to child abuse: A case report
E M G Subramanian, B Subhagya, MS Muthu, N Sivakumar
Department of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, India
M S Muthu
Department of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Alapakkam Main Road, Maduravoyal, Chennai - 600095, Tamil Nadu
Child abuse and neglect is any interaction or lack of interaction between a caregiver and a child resulting in nonaccidental harm to the child«SQ»s physical and developmental state. Substance abuse is ingestion of any drug, which is capable of altering the mental functioning eventually leading to addiction. This paper presents a case report of a 12-year-old neglected girl with substance abuse for which she was physically abused by her mother.
|How to cite this article:|
Subramanian E M, Subhagya B, Muthu M S, Sivakumar N. Neglected child with substance abuse leading to child abuse: A case report.J Indian Soc Pedod Prev Dent 2005;23:92-95
|How to cite this URL:|
Subramanian E M, Subhagya B, Muthu M S, Sivakumar N. Neglected child with substance abuse leading to child abuse: A case report. J Indian Soc Pedod Prev Dent [serial online] 2005 [cited 2020 Sep 26 ];23:92-95
Available from: http://www.jisppd.com/text.asp?2005/23/2/92/16450
A child is defined as a young human being below the age of full physical development. The time spent by the child in this period is called childhood, which has no definitive or uniform scale to measure the happenings. The norms for a happy and satisfactory childhood are not laid down in words or texts but it should be felt and executed by parents or caretakers.
A child is dependent on his parents or caretakers for the entire physical and mental well being. Hence molding 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 nonaccidental 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. 
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.  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.
A girl aged 12 years reported to the Department of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College, Chennai, India, with her mother and two younger sisters with the complaint of pain in relation to her broken upper front teeth. Medical history revealed that the girl was deaf and dumb. 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) [Figure 1] 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 [Figure 2]. Tobacco stains were seen on the labial and buccal surfaces of 31, 32 [Figure 3], 36, and 37. Preoperative radiograph of 11, 21 was taken and it did not reveal any periapical pathology [Figure 4].
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 [Figure 5]. 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 [Figure 6].
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 counseled about child neglect and abuse.
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.  This interrelationship of hearing impairment and loss of speech skill was noticed in the cases. To compensate for this decreased ability to communicate verbally, like many other children the girl utilized lip reading and sign language.
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 neighboring 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 behavioral approaches that may be necessary to facilitate the provision of quality dental care to these individuals.  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 behaviors, namely overprotection and negligence.  In this case report, it was found to be negligence because the mother was reluctant about her daughter's unesthetic 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 (Child abuse).
Counseling 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 counseling of abusive caretakers. , 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. 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.
Now, it is within the scope of dentistry that the dentist is concerned with substance abuse also because such problems interact directly with the dental care of a patient. Hence obtaining and maintaining a satisfactory history is important during initial examination procedure. At subsequent visits, the dentist must consider the changes in general health history as well as answers to specific questions. 
Identification of substance abusers is difficult even for an experienced observer. Specific clues for identifying them include abrupt change in the behavior, 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 (in any form) may cause effects on soft and hard tissues of the mouth, such as bad breath, discolored teeth and restorations, gingival recession, leukoderma and 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.
|1||Zavras AL, Pai LH. Child abuse: Attitudes and perceptions of health profession students: A pilot study. J Clin Pediatr Dent 1997;22:23-7.|
|2||McDonald RE, Avery DR. Dentistry for the child and adolescent. 7th Ed. The C.V. Mosby Company; p. 17-8, 24-33.|
|3||Wei SHY; Pediatric Dentistry; Lea and Febiger: Total Patient Care; 1988. p. 572-3.|
|4||Tandon S. Textbook of Pedodontics. 1st Ed. Paras Publishing; 2001. p. 535-73.|
|5||Stewart RE, Barber TK, Troutman KC, Wei SHY. Pediatric Dentistry: Scientific foundations and clinical practice. The C.V. Mosby Company; 1982. p. 961-72.|
|6||Singh A, et al. Indian Penal Code|