Detection of child maltreatment, the role of dental health personnel – A national cross-sectional study among public dental health personnel in Norway

Introduction: Research has revealed that child maltreatment is an extensive and global problem. It is argued that the known victims of child maltreatment represent only the tip of the iceberg. Child maltreatment has far-reaching consequences for the victims, their families and the society. To hinder or reduce the consequences of child maltreatment, it is important to detect children at risk and those already being victimized as early as possible. In Norway, the PDHP are in a special position to prevent and detect child maltreatment, as all children up to the age of 19 receive free dental health care on a regular basis at the PDHS. International research has revealed that dental personnel are in an excellent position to suspect and report child maltreatment. However, a gap between suspicion of child maltreatment and reporting to CWS or other statutory agencies has also been found, indicating that underreporting of child maltreatment is a challenge in the dental health service. Aim: The overall aim of the present study was to gain more knowledge regarding the role and potential of dental health personnel in the preventive and detective work of child maltreatment. This knowledge was gained by assessing the following: 1) PDHPs’ frequency of reporting and failing to report suspected child maltreatment to the CWS, 2) PDHPs’ reasons for sending a report of concern to CWS, 3) how CWS responded to the reports from PDHP, and 4) whether the different reasons for sending a report of concern were associated with a given response from CWS. Finally, 5) an empirical test of the reasoned action approach (RAA) in predicting PDHPs’ intention to report suspicion of child maltreatment was provided. Method: The present thesis and papers are built upon a national descriptive crosssectional study including a census of dentists and dental hygienists working in the PDHS in Norway in autumn 2014. A total of 1542 dentists and dental hygienists received the survey, of which 1200 (78%) responded. Results: A total of 60.0% of the respondents reported to have sent reports of concern to the CWS during their dental career, while 32.6%, had suspected child maltreatment but failed to report it to CWS in the same period. A total of 42.5% had sent reports of concern to CWS during the period from 2012 to 2014. The majority of the reports from PDHP were sent to CWS for multiple reasons. The most frequently reported reasons for concern were “did not attend dental appointment”, grave caries, lack of hygiene and suspicion of neglect. Suspicion of physical abuse, sexual abuse and/or psychological abuse were reported more rarely. In total, 24.5% of the reports from PDHP resulted in measures being taken by CWS, 20.7% were dropped either directly or after investigation, while 29.4% lacked information from CWS on the outcome. For the remaining 25.5% of reports, the dental personnel did not know or remember the outcome. Reports of concern due to suspicion of sexual abuse, grave caries and suspicion of neglect had higher likelihood of being opened and substantiated by the CWS compared with reports of concern without any of those reasons. In contrast, reports of concern due to missed appointments were less likely to be opened and substantiated by CWS. The present study provided support for the utility of the RAA across males and females in predicting dental health personnel’s intention to report suspicion of child maltreatment to the CWS. The model revealed that instrumental attitude and perceived behaviour control (capacity and autonomy merged) were the strongest predictors of intended reporting behaviour, followed by descriptive norm, injunctive norm and experiential attitude, explaining 63.6% of variance in PDHPs reporting intention. Conclusion: The findings from this study imply that PDHPs in Norway suspect and report most forms of child maltreatment and play an important role in the preventive and detective work of child maltreatment. However, the failures to report among PDHP, the relatively low number of measures being taken by CWS and the number of reports that lack a response to reporters from the CWS suggest that there is a potential and need for improvement to fulfil the Health Personnel Act and the CWS Act. The findings reveal a need for closer cooperation between the services, as this would be in the best interest of the child and benefit the services. Moreover, this study offers a thorough understanding of the socio-cognitive factors underlying PDHPs’ intention to report suspected child-maltreatment to the CWS. Focusing on these factors in future training and education might strengthen the reporting intention among dental personnel and bring us one step further in the preventive work of child maltreatment. In closing, to succeed in the important, complex and challenging work of child maltreatment prevention and detection, a collective and research-based approach is needed. The present study represents only a small fraction of the whole picture