Reasons for reported suspicion of child maltreatment and responses from the child welfare - a cross-sectional study of Norwegian public dental health personnel

Child maltreatment

Being a victim of serious child maltreatment increases the risk of having developmental disturbances and reduces the possibility of having a normal and wholesome childhood. In fact, for many children, child maltreatment results in severe and lifelong challenges [1–3]. Child maltreatment is a widespread phenomenon worldwide [4]. There is a compelling body of research indicating that the maltreated children known to child welfare services (CWS) only represent the tip of the iceberg relative to the actual number of children being maltreated [4–7]. To prevent child maltreatment and its consequences, it is important to identify children at risk as well as children who are already victims. Such efforts require an interdisciplinary collaboration between the services working with children, and CWS is essential in this context.

Mandatory reporting, the role of dental services and child welfare services

Several countries have enacted legislation mandating reporting of maltreatment, with the goal of increasing the reporting frequency among designated personnel working with children [8–10]. Research has indeed shown an increase in reporting frequency as reporting becomes mandatory [11, 12].

All health personnel in Norway are mandated by the Norwegian Health Personnel Act, section 6 § 33, to report suspicion of severe child maltreatment to CWS [13]. The Norwegian public dental health service (PDHS) is mandated by the Dental Health Service Act to prioritize the prevention of dental disease and offer all children under the age of 19 free and regular dental treatments [14]. As a result, close to 100% of all children in Norway are regularly covered by the PDHS. This situation gives the PDHS an important and unique opportunity to detect and report suspicion of child maltreatment to CWS. Public dental health personnel (PDHP) in Norway are experienced reporters of child maltreatment, with a total of 60% having reported suspicion of child maltreatment to CWS during their career [15].

The assignment of the Norwegian CWS reflects the general reporting legislation and the fact that Norway is a social-democratic welfare state [16]. The CWS is mandated by the Child Welfare Act, section 6 § 6-7a, to provide a response to reporters within three weeks, although a response is not mandatory if the concern is clearly unsubstantiated. In cases for which an investigation has been opened, CWS provides the reporter with information on whether the case has been dropped or measures have been taken [17].

Previous research

Over the last decade, a number of studies have investigated the role of dental personnel in child maltreatment issues [15, 18–29]. High-quality research has focused on dental personnel, the frequency of reporting, failure to report, knowledge regarding child maltreatment and barriers to reporting [15, 18–20, 22, 24, 25, 28, 29]. However, little research has been focused on the reasons why dental personnel report to CWS [26, 30] and the associated responses from CWS. Additionally, to the best of our knowledge, no previous studies have explored how CWS responds to reports of concern from dental services and to what degree the Norwegian CWS fulfills the mandated response to designated reporters in this regard [17].

Although dental personnel’s barriers to and limited knowledge regarding reporting have been recognized and targeted in recent decades, the gap between suspecting child maltreatment and reporting seems to persist, implying that researchers have not succeeded in exploring all of the problems related to mandatory reporting [31]. To enhance our understanding and knowledge of the mechanisms involved in mandatory reporting in dental services, it is important to examine dental personnel’s reasons for sending a more thorough report of concern. Additionally, knowledge of how CWS responds to the different reports of concern sent by the PDHS should be obtained.

Aims

Focusing on a census of public dentists and dental hygienists in Norway, the objectives of this study were threefold. First, we assessed the reasons reported by PDHP for having sent a report of concern to CWS during the three-year period from 2012 to 2014. Second, we examined how CWS responded to these reports. Third, we assessed whether the different reasons for sending a report of concern were associated with a given response from CWS.

Study design and data collection

This national cross-sectional study was conducted by an electronic survey in a census of dental health personnel employed by the PDHS in Norway. Specifically, an email explaining the purpose of the study and providing a link to the electronic questionnaire, also containing an informed consent form, were distributed to all dental hygienists and dentists. The chiefs of the PDHS provided the names and e-mail addresses of their employees and gave their employees permission to answer the survey questions during their working hours. The estimated time required to complete the questionnaire was 30–40 min.

The survey contained questions regarding experience with suspecting and reporting child maltreatment, reasons for reporting and/or not reporting, experience with CWS, organizational questions regarding PDHS and the demographic characteristics of the respondents. A portion of the questions was derived from an Australian survey [32, 33], with certain necessary adjustments to tailor the questions to dental personnel in a Norwegian context. In particular, the questions from the Australian questionnaire were translated into Norwegian and then back translated into English to evaluate the semantic and content equivalence. The questionnaire was reviewed by PDHP with experience in survey research and clinical work at the PDHS before it was piloted among PDHP in one county. After certain small adjustments, the questionnaire was distributed to the 18 remaining counties in Norway. The Ombudsman, Norwegian Social Science Data Services (NSD), approved and registered the survey and was responsible for distributing the questionnaire and collecting the data. The main survey was distributed in November 2014, and follow-ups with reminders were sent to non-responders after two, four and seven weeks. The questionnaire is available in Norwegian, as an additional file (see Additional file 1).

Variables and their measurement

Experience with sending a report of concern to CWS was measured via the following question: ‘During your time as dental personnel, have you filed a report of concern due to suspicion of child abuse or neglect?’ The options were yes or no. Those answering yes were asked ‘Were any of the reports of concern sent in the time period from 2012 to this day?’ The response options were yes or no. If the respondent answered yes, they were asked ‘How many concerns have you filed since 2012?’ The response options ranged from one to ten or more concerns.

The respondents who had filed one or several reports of concern in the previous three years, from 2012 to 2014, were asked to provide the following information for each of the concerns that they reported having sent to CWS during this period: ‘The following questions regard the first report of concern that you sent in 2012–2014. What was the gender of the child in the first report of concern that you sent?’ The response options were boy or girl. ‘What was the age of the child in the first report of concern that you sent?’ The response options were 0–3, 4–7, 8–11, 12–15, and over 16 years. ‘What was the reason for the first report of concern that you sent? Multiple categories can be chosen.’ The response options were suspicion of physical abuse, suspicion of sexual abuse, suspicion of psychological abuse, suspicion of neglect, recurring missed appointment, grave caries, gingivitis, lack of hygiene, wounds and lesions in the oral cavity, trauma, other oral findings (please note), treatment refusal, cooperation with guardians, abnormal behavior, and other (please note). Wounds and lesions in the oral cavity and other oral findings were merged into one variable due to the low response frequency.

The background characteristics of the PDHP respondents that were assessed were gender, age (20–39 or 40+ years), occupation (dental hygienist or dentist), the number of patients treated in the last 12 months (0–500 or 501+ patients), the size of the municipality (0–10,000, 10,001–40,000, or 40,001+ inhabitants) and the geographical region where the dental clinic was located (north, central, west, south or east). More detailed information on the background characteristics can be found in a study by Brattabø et al., 2016 [15].

Regarding the responses from CWS, the PDHP were asked the following: ‘What response have you received from CWS regarding the first report of concern that you sent?’ The response options were as follows: ‘CWS has opened an investigation and taken measures’, ‘CWS has opened an investigation but dropped the case’, ‘CWS has opened an investigation but has not given me any feedback on whether measures have been taken or the case has been dropped’, ‘CWS has not opened an investigation, so the case has been dropped’, ‘CWS has not given any feedback’, ‘Other (please note)’, and ‘Do not know’.

The question battery described above regarding the reports of concern and corresponding responses from CWS was administered to each respondent repeatedly, the same number of times (1–10) that they had reported having sent a report of concern during the 2012–2014 period. Only the number of the report of concern mentioned in the questions was changed: ‘The following questions regard your [second, third, fourth, etc.] report of concern’.

Statistical analysis

Data were analyzed using the Statistical Package for Social Sciences version 22 (SPSS Inc., Chicago, IL, USA). Descriptive statistics, in terms of frequency % (n) and mean (SD) distributions, were calculated. The frequency of the independent variables relative to the dependent variables was calculated using multiple responses, frequencies and cross tables. Due to the layout of the questionnaire and because each respondent could have sent up to ten reports of concern, variables were restructured from multiple variables to groups of related cases. Repeated data had a multilevel structure, with observations nested within individuals or clusters. To account for clustering in repeated data, responses from CWS were regressed on reasons for concern across the numbers of reports (first report of concern, second report of concern and so on) using the binomial generalized estimating equation (GEE) [34]. After restructuring the original data file from wide (number as a variable) to long (number as a case) configuration, the binomial logit function and exchangeable working correlation matrix were employed. CWS responses by reasons for concerns across number of reports were estimated using odds ratios (ORs) and 95% confidence intervals (CIs). Both unadjusted and adjusted GEE analyses were performed, and the significance level was set to P < 0.05.

For model building, a series of unadjusted and adjusted GEE models were fitted. Initial models were built by adding children’s age and gender and the PDHP’s specific occupation, number of patients treated, municipality size and geographical region in addition to the range of reasons for concern. As both the unadjusted and the adjusted analyses revealed no significant effect of gender, the age of the child, the number of patients treated, the size of the municipality or the geographical region, those variables were excluded from the final GEE model to strengthen the analysis. The final GEE model included occupation as the only background variable in addition to the range of reasons for concern, as mutually adjusted.

Characteristics of the respondents

Of a total of 1542 questionnaire recipients, 1200 (77.8%) dentists and dental hygienists responded to the survey. As previously described [15], most of the 1200 respondents were women (80.3%) and dentists (68.9%), reflecting the present situation of the PDHS labor market in Norway [35]. The respondents had a mean of 11.9 (SD = 11.2) years of working experience, and 82.9% had examined more than 250 children under the age of 18 years during the previous 12 months. A total of 720 (60%) respondents had filed a report of concern during their career, with a mean of 3.6 (SD = 3.4) reports per experienced reporter, and 42.5% had filed a report during the three-year period from 2012 to 2014, with a mean number of 2.7 reports (SD = 2.0) per experienced reporter.

In the 2012–2014 period, the respondents reported having sent 1214 reports of concern to CWS, with 55.9% of the reports of concern regarding boys. The children had the following age distribution: 6.8% of the children were under the age of four, 35.6% were between 4 and 7 years, 31.6% were between 8 and 11 years, 20.5% were between 12 and 15 years, and 5.6% were between 16 and 17 years. Therefore, 74% of the children were under the age of 12 years.

Reasons for concern

Frequency distribution of responses given by CWS to PDHP’s reports of concern

Reasons for sending report of concern and associated responses from CWS

Responses from CWS according to PDHP’s reasons for sending report of concern

Dental personnel sending reports of concern due to the abnormal behavior of the child were less likely to have their reports opened and then dropped (OR 0.498, 95% CI (0.284–0.847), P = 0.015), and more likely to have their reports opened without being given any further information by CWS (OR 1.779, 95% CI (1.025–3.088), P = 0.041) compared with their counterparts sending reports of concern without this reason.