The objectives of the present study were to explore PDHP’s reasons for sending a report of concern in the three-year period from 2012 to 2014, to assess how CWS responded to the reports of concern and to examine whether the different reasons for concern were associated with a given response from CWS. This study showed that Norwegian PDHP report on several types of suspected child maltreatment, including neglect and physical, psychological and sexual abuse. Thus, the majority of reports were sent due to multiple reasons for concern. Only one-fourth of the reports from the Norwegian PDHS led to a measure being taken and the PDHP lacked information regarding the outcome in approximately one third of the reports, while one-fifth were dropped either directly or after investigation. Reports due to suspicion of sexual abuse, grave caries and suspicion of neglect were most strongly associated with a response from the CWS in terms of having opened an investigation and implemented measures.
The most frequently reported reasons for concern were repeated failure to attend dental appointments, grave caries, a lack of hygiene and suspicion of neglect which is in accordance with findings in a Swedish study . Repeated failure to dental attendance, could be attributed to forgetting, an address change, a lack of time, illness or dental anxiety [36,37,38]. This finding indicates also that PDHP and the PDHS are alerted when children continuously forfeit their legal right to free dental care according to the Public Dental Health Service Act . In addition, when children repeatedly fail to attend their dental appointments, PDHP are placed in a position in which they are unable to fulfill their obligation to determine whether there is a need for dental treatment or oral health guidance. Previous studies have demonstrated associations of failure to attend a dental appointment, an absence of dental care routines, caries and poor dental health with families struggling with their everyday life and children having adverse childhood experiences [30, 36, 39,40,41,42,43]. This implies that that continuously missed dental appointments and dental neglect could be indicators of child maltreatment and could be used as a tool for the early identification of struggling children and families.
In the present study, children of all ages were reported to CWS, with close to three-quarters being under the age of 12 years. These findings indicate that dental personnel are in a position to detect children at risk especially those at a younger age. Concerning early detection of vulnerable children, this finding is of particular importance.
Regarding the reports of concern due to grave caries, it is important to be aware that recent statistics in Norway reveal that 82% of 5-year-olds and 60% of 12-year-olds had no experience with caries . The good oral health of the majority of Norwegian children increases the conspicuousness of the children with extensive oral health problems. The present study suggests that PDHP are concerned for their patients with oral health deficiencies and suspect that these children may be neglected.
The results of the present study indicate competence and awareness among PDHP in Norway regarding the different forms of child maltreatment, even though potential cases of physical, psychological and sexual abuse were rarely reported. Increased focus during the recent years on child maltreatment-related issues in the PDHS, educational institutions, the media and among the authorities may be contributing factors in this regard. Present findings differ somewhat from findings in Sweden, where all the reports from dental service regarded concerns due to parental deficiencies (failure to attend appointments) and neglect (dental neglect), while concerns due to suspicion of psychological, sexual and/or physical abuse were absent . However, the present findings are partly in accordance with findings from Greece, where dentists suspected several forms of child maltreatment, although they had very low reporting frequency . In addition, studies from Denmark, the UK and Scotland have also shown that dental personnel reports child abuse and neglect, although without specifying what kind of child abuse and neglect is being reported [19, 20, 22]. The discrepancy with previous studies could be due to differences in sample size and study design. Small sample sizes reduces the chance of rare concerns being detected. Further, due to recall biases, social desirability, differences in definitions, reporting and registration there might be discrepancy between studies based upon self-reports and case-reports.
Only one-fourth of the reports from the Norwegian PDHS led to a measure being taken. Moreover, the PDHP lacked information regarding the outcome in approximately one third of the reports while one-fifth were dropped either directly or after investigation. This might be attributed to large workload of CWS as the numbers from Statistics Norway reveal a general increase in reports to CWS over the last few years . Other plausible explanations might be overreporting or insufficient reports of concern from PDHP [45, 46]. One might further wonder if the frequency of measures being taken and the lack of information to PDHP is a result of unclear response procedures within CWS or lack of knowledge within CWS regarding dental neglect and its consequences. Specifically, in light of the good oral health in Norwegian children, it might be difficult for a CWS worker to fully understand the consequences that a lack of oral hygiene and treatment could have for a child. At present, however, this is only speculation, so additional research is needed.
According to the present findings, the odds of an investigation being opened and measures taken was 98% higher for reports of concern due to suspicion of sexual abuse compared with reports not due to this suspicion. Furthermore, suspicion of neglect and grave caries also showed increased odds of 65% and 63%, respectively for cases being opened and measures taken. The present findings suggest that CWS consider these concerns the most serious. In contrast, non-attendance at dental appointments seemed to be recognized as less serious reasons, with 33% lower odds of cases being opened and measures being taken compared with reports due to other suspicions. Hence, it may be reasonable to assume that CWS considers non-attendance more of an indication than a serious suspicion of child maltreatment. Meanwhile, reports including concern about abnormal behavior in the child had 50% lower odds of being dropped when first opened compared with reports without behavioral concerns, implying that CWS takes the behavior of children seriously. This study further show that, with the exception of abnormal behavior, no reason for concern was significantly associated with a case being dropped immediately or after investigation, which might indicate that CWS considers all types of reports from the PDHP.
The current findings might indicate that PDHP need to improve their reports of concern and clarify the severity of the consequences that a lack of oral hygiene and continuous missed appointments might have for a child. Furthermore, the present findings, with close to one third of the reports lacking information from CWS on the outcome, indicate that CWS should improve its feedback frequency to fulfill its obligation stemming from the Child Welfare Act. Overall, improvement of the cooperation and information flow between services will increase the knowledge of PDHP and CWS regarding the circumstances and needs of vulnerable children and will strengthen the wellbeing of these children.
For future research, there is a need to pinpoint whether continuously missed dental appointments and dental neglect are indicators of child maltreatment, serving as a tool for the early identification of struggling children and families. Furthermore, there is a need for research focusing on CWS and its experience with reports from and cooperation with PDHP. The present findings thus have implications for CWS, dental services, the authorities and future research.
Certain limitations of the present study should be noted. First, the findings mainly rely on self-reports of PDHP, which may undermine the study of the responses. Data were not collected from CWS, and hence, the perspective and experiences of CWS regarding reports of concern coming from PDHP and the response of CWS to reporters are not reflected. Second, the present study builds upon the experiences and recollections of PDHP regarding their contact with CWS during the three previous years. Therefore, there is a possibility of recall bias. In contrast, reporting to CWS is a challenging and rare event for most PDHP, likely increasing the likelihood of recall.