National Clearinghouse on Family Violence Publication
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Family Violence Handbook for the Dental Community

ERRATUM

FAMILY VIOLENCE HANDBOOK FOR THE DENTAL COMMUNITY
Please note: the telephone number listed on page 48 for the Children's Help Line is incorrect.
The correct telephone number is 1 - 800 - 668 - 6868  

Prepared by
Donna Denham and Joan Gillespie

For

Mental Health Division and Health Service Systems Division
Health Services Directorate
Health Canada

December 1994

Our mission is to help the people of Canada maintain and improve their health.
Health Canada

Additional copies are available from:

National Clearinghouse on Family Violence
Ottawa, Ontario Postal Locator 1907D1
K1A 1B4 
Tel: (613) 957-2938 (Ottawa-Hull) or call Toll Free: 1-800-267-1291
Fax: (613) 941-8930

TDD (telephone device for the deaf)
(613) 952-6396 (Ottawa-Hull) or Toll Free: 1-800-561-5643

Permission is granted for non-commercial reproduction related to educational or clinical purposes.
Please acknowledge the source.

The views expressed in this publication are those of the authors, and do not necessarily represent those of Health Canada.

Également disponible en français sous le titre :
Guide sur la violence familiale a l'intention des spécialistes de la dentisterie

© Minister of Supply and Services Canada
Cat. No. H72-21/136-1995E
ISBN 0-662-23474-X

Foreword

Section 1: Raising Awareness

Introduction Principles & Assumptions Myths and Facts Respecting Differences and Diversity

Section 2: From Recognition to Response

Abuse and Neglect of Children

Definition The Role of the Dental Team Indicators of Child Abuse Asking Questions About Child Abuse What About Reporting Documentation

Abuse of Women

Definition The Role of the Dental Team Indicators of Woman Abuse Asking Questions About Woman Abuse What About Reporting Documentation

Abuse and Neglect of Older Adults

Definition Competency The Role of the Dental Team Indicators of Abuse and Neglect of Older Adults Asking Questions About Abuse and Neglect of Older Adults What About Reporting Documentation

Treating Survivors of Child Sexual Abuse

Section 3: Moving to Action

Dental Team Initiatives Individual Actions The Role of Professional Associations

Section 4: Resources

References

Appendices:

1. Implementation Steps 2. Abused Children: Physical Indicators of Abuse 3. Abuse Indicators for Women 4. What You Can Do To Help An Abused Woman 5. Types of Abuse and Neglect of Older Adults 6. Family Violence Community Resource List 7. Display Poster 8. List of Members of Advisory Group

With the help of resources provided through the Federal Family Violence Initiative, the Mental Health Division of Health Canada has been working in collaboration with the health community to help health professionals develop an enhanced awareness of the family violence issue and greater sensitivity in responding to people affected by violence in their lives. Over a four-year time frame, the Division's objectives have been to facilitate better access to information, programs, and approaches, as well as to develop and expand resource materials.

The work of the Mental Health Division has spanned the broad issue of family violence - violence in relationships of kinship, intimacy, dependency or trust - while recognizing the special vulnerability of women, children, older adults and people with disabilities. Special attention has been given to prevention, early intervention and effective screening approaches, as well as to appropriate responses to the needs of people critically affected by violence in their everyday lives.

Practice guidelines and curriculum approaches have been developed through collaboration with professional health associations, educators, service providers, voluntary organizations, and Health Canada programs. In addition, the Division's attention to the issue of abuse and neglect of older adults has resulted in enhanced resource and reference materials relating to both community and institutional settings.

The Fami1y Violence Handbook for the Dental Community is a guide for all members of the dental team. It deals with how to address the family violence issue in dental practice, the educational setting, the professional association, and the community at large. Funded through the Federal Family Violence Initiative, this publication is the latest outcome of a series of activities over the past three years.

The Ad Hoc Advisory Group on the Dental Community's Response to Family Violence Issues met quarterly over a one year period, beginning in the fall of 1992. This group, initiated by the Mental Health Division and the Health Service Systems Division of Health Canada, had as its purpose to foster the dental community's awareness of and interest in the important issue of family violence. The Canadian Dental Association, the Canadian Dental Assistants Association and the Canadian Dental Hygienists Association nominated representatives to sit on this ad hoc group and to act as advisors in planning initiatives with the dental community.

Activities stimulated by this group include articles in professional journals, the November 1993 family violence theme issue in The Journal of the Canadian Dental Association, initiatives with respect to curricula and accreditation, an annotated bibliography of resource materials. and initial consideration of practice guideline development. Our first publication, Family Violence Resource Materials for the Dental Community: An Annotated Bibliography, published in early 1993, was prepared for Health Canada by the Library of the Canadian Dental Association.

Subsequently, two advisory groups were convened in the winter and spring of 1994. The February 1994 advisory group included representatives from academic and practice settings; it undertook the broad planning with respect to the specific role of the dental community in relation to family violence issues, and set the direction for specific resource materials. The May 1994 advisory committee was selected to represent more fully the range of practice areas, and was given the responsibility to plan and oversee the development of the Dental Handbook. This group established the framework for the publication, identified resource materials and people, and reviewed draft text; members' contribution to the development of the handbook was critical. The writers of the handbook participated in the May advisory group meeting; these contractors continued to work with committee members until the final text was submitted to Health Canada in December 1994.

The names of the members of the three advisory groups are listed in Appendix 8. Many others reviewed the draft handbook and provided recommendations throughout the process. We thank all those who contributed to the overall initiative. The impact of this work will be substantial.

In addition, we would like to particularly acknowledge the Canadian Nurses Association (CNA) for their December 1992 publication: Family Violence - Clinical Guidelines for Nurses, which provided the foundation for development of Family Violence Handbook for the Denial Community. These Clinical Guidelines, developed by a CNA advisory committee in conjunction with the Health Services Directorate of Health Canada, have been recognized worldwide, and have been an important resource for many health professions. A representative of the CNA advisory group participated in the development and review process noted above.

We would also like to acknowledge the support of the National Clearinghouse on Family Violence, Health Canada for editing and publication costs.

The dental community has made a strong contribution to the issue of family violence in relation to practice guidelines and to interdisciplinary curriculum development. Other health disciplines are encouraged to build upon these resources as well as the collaborative process used, to develop materials appropriate for their professions.

Joan Simpson Mental Health Division Health Services Directorate Health Canada

Sharon Amer Health Service Systems Health Services Directorate Health Canada

February 1995

Introduction

In recent years family violence has been recognized as a major health problem as well as a serious social issue. The need for all health care professionals to recognize the impact of family violence on patient care has become a reality. Members of the dental community - practitioners, academics, leaders of professional associations in the dental field - are acknowledging that they too are in a position to take a proactive role to end violence in the family.

Violence in the family is not new. What is new is that family violence, most particularly violence against women by their partners, has been named and made public. As a result, Canadian laws and institutional practices are beginning to change to support the belief that violence against anyone is unacceptable. The term family violence refers to abuse that takes place in the family, in an intimate relationship, or in a situation of dependency or trust.
The abuse may be:

• physical
• emotional
• sexual

In Canada it is women, children, older adults and people with disabilities who are most at risk of abuse by members of their family or trusted caregivers. It also needs to be recognized that boys and men are also at risk.

Research shows that all forms of family violence are interrelated. Studies also demonstrate that violence in the family does not stop unless there is outside intervention. Prevention, identification and subsequent intervention in situations of family violence must be a part of all health care service delivery.

'The dental community is a key partner in the network of health care providers. The particular skills, ongoing relationships with patients/clients, and interactions with all age groups make it possible for members of the dental team - office receptionists, dental assistants, dental hygienists, dental therapists, and dentists - to provide concrete assistance to patients who are being abused.

This handbook has been prepared specifically for members of the dental community to:

• heighten awareness of the existence of family violence among patients and colleagues
• increase understanding of some of the basic facts about family violence.
• increase identification and referral skills.
• outline the contributions dental teams, individuals and professional associations can make to end family violence.

Principles

• Everyone has the right to live a life free of violence.
• No one deserves to be abused physically, sexually, emotionally or financially.
• Understanding and naming the issues of power and control are fundamental to the task of ending family violence.
• No one has the right to control another person by threat, coercion, intimidation or by any other misuse of power.
• Ending family violence is everybody's responsibility.

• Physical, emotional, sexual and financial abuse within families, or within relationships of intimacy, dependency and trust, are major social and health problems. All people affected by family violence should have access to appropriate help at any point in which they come in contact with health care and social service providers.
• Family violence is not a private family matter. It is a criminal offense which demands that abusers, not their victims, be held responsible for the violence.
• It is the responsibility of every person in the dental community to be an advocate on behalf of any patient/client suspected of being a victim of abuse.
• Adults are the best experts on their own lives. With accurate information, true choices and practical support, people can make decisions that are best for them.

Family violence is a complex issue. Most people have been socialized to believe certain truths about men and women, about marriage and family life, about the privacy of the home, about ownership of children and about the expression of powerful emotions. Outlined below are some of the commonly held myths which need to be challenged, along with some factual information which can help the dental community increase their own awareness.

• Myth Family violence isn't as serious as we are being led to believe.

  Facts

  The recent Violence Against Women Survey by Statistics Canada (1993) revealed that: - almost one-half of the 12,300 women surveyed reported violence by men known to them.

  - one-quarter of all women in Canada have experienced violence at the hands of a current or past marital partner (includes common-law unions). The Report of the Committee on Sexual Offenses Against Children and Youths (the 1984 Badgley Report) claims that: - 53% of females and 31% of males have been victims of one or more unwanted sexual acts.

  - approximately four out of five of these incidents happened to the victims when they were children or youths. The National Survey on Abuse of the Elderly in Canada: The RyersonStudy (1989) indicates that: - 4% of older adults (approximately 98,000 people) living in private dwellings are abused.

  - financial abuse is the most prevalent type of abuse, There can be no escaping the reality that family violence is a widespread problem. People at risk of abuse are being seen by dental professionals every day. To ignore the seriousness of the problem of abuse means that the dental community is not providing some of their patients/clients access to appropriate health care resources.

• Myth Violence is usually caused by alcohol or drugs.

  Facts

• Myth Abuse occurs more frequently in certain racial, cultural or economic backgrounds.

  Facts

  Family violence occurs in all ethnic, racial, economic., social and age groups. There are no exceptions. However violence in more affluent groups is often hidden. It is important that all victims of family violence be identified, regardless of their backgrounds.

• Myth Women enjoy the violence. If they were really bothered by it they would leave.

  Facts

  Thousands of women have now publicly told their stories. All talked about their horror, helplessness and terror as they tried to survive the violence. Fear of losing their children, fear of being killed, lack of affordable housing, financial instability, rejection by their communities and families are just a few of the realities women face which may prevent them from leaving an abusive partner.

  The Statistics Canada Violence Against Women Survey indicates that over 60 percent of all female homicides in Canada are committed by husbands or live-in partners. The most dangerous time for a woman is when she chooses to leave her abuser or when she moves to end the relationship. Women are wise to take threats by partners very seriously.

  Members of the dental community who understand the realities of women 's lives and themselves of community resources can help to open and expand the choices available to women.

• Myth Abuse is a private family matter and should be dealt with in the privacy of the home.

  Facts

  Many abusers themselves grew up in abusive homes. Children who witness abuse between parents are at a much greater risk of growing up to abuse others or be abused by others than are children who grow up in non-abusive homes. Breaking the intergenerational cycle of family violence is everyone's responsibility.

• Myth Women and older adults provoke their abusers into abusing them. They deserve what they get.

  Facts

  No one ever deserves to be abused. Provocation is an excuse abusers use to escape accepting responsibility for their own emotions and actions. There is no excuse for abuse.

• Myth Men who assault their wives, parents who abuse their children and individuals who abuse older adults are mentally ill.

  Facts

  All forms of family violence are too widespread to be explained away by mental illness. Most abusers confine their violence to the privacy of their own homes. They often aim the physical blows at areas of the body where bruises do not show. The systematic and controlled nature of family violence is not consistent with the characteristics of mental illness involving violent outbursts.

All the communities in which we work and live are becoming increasingly diverse. With family violence, working with diversity means recognizing that while many experiences of victimization and survival are shared, there are many differences based on culture and race.

Areas which affect the provision of dental services:

• Communication with the patient or patient's family

  Communication at any time can be difficult with the pressures of a busy practice and the discomfort many of the dental team may have in discussing financial or family matters. Communication may be all the more difficult when there are racial or cultural differences. You may not be sure whether the patient fully understands or whether the patient is agreeing or consenting out of deference to your perceived authority.

• Understanding and respecting different social and cultural practices

  Many cultures have different child rearing practices which may affect the dental team's understanding or recognition of abuse. They may have varying levels of respect for older adults which will determine how they are treated.

  Understanding these differences is important in order to develop a relationship of trust and respect and to question patients more sensitively if abuse is suspected. Cultural differences should never be an excuse for inaction.

• Understanding and respecting health values and beliefs of the patient

  Many cultural groups have different health practices which may impact on the understanding or recognition of abuse.

Refer to Section 4 of this publication for further information. The resource Family Violence Resource Materials for the Dental Community: An Annotated Bibliography, provides a useful starting point.

As your awareness of the issue of flarnfly violence increases, there will be an effect on how you observe your dental practice. You will begin to see many of your patients/clients through new eyes and to develop a better understanding of their lives outside the dental office. You will also be in a better position to treat them, support them, and link them to community resources if they are survivors of family violence.

To assist you in this work, the sections that follow - Abuse and Neglect o Children, Abuse of Women, Abuse and Neglect of Older Adults, Treating Survivors of Child Sexual Abuse - outline some of the indicators of abuse and neglect, treatment implications, and resources for patients/clients who have been abused. Please note, treatments modifications suggested in Treating Survivors of Child Sexual Abuse may be important in other situations.

Abuse and Neglect of Children

Definition:
Child abuse is the mistreatment or neglect of a child by a parent,guardian, caregiver, or person in a position of trust that results ininjury or significant emotional or psychological harm to the child.

It may involve:

• physical abuse
• sexual abuse
• emotional abuse
• neglect

Dental professionals are in a special position to detect and support an abused child.

Consider that:

• Over 50% of injuries associated with child abuse are to the face and head. An aware dental team is in a good position to detect abuse.
• Dental health care professionals may be the only health care providers to see an abused child on a regular basis. An abusive parent or caregiver may move from one doctor to another but continue treatment with the same dental professional.
• The dental team has the opportunity to view evidence of trauma, parent-child interactions and changes in a child's behaviour over a period of time.

As health care providers, members of the dental team have a moral and professional obligation to:

• increase their awareness of the issue of child abuse
• recognize the indicators of child abuse
• understand the legal requirements for reporting child abuse
• know how to access the community support services for children and their families

All injuries to children should raise suspicions but a diagnosis of abuse can not be made on a single indicator.

Principal face and head injuries

• fractured teeth
• oral lacerations
• fractures of the jaw
• bruising to the face
• adult bite marks

Behavioural indicators

• overly sullen or withdrawn child who appears to do anything to avoid conflict and to keep the adult from noticing them.
• overly watchful, fearful child who instinctively cowers when an adult, including a dental professional, shows displeasure.
• excessively nervous, anxious or eager to please child.
• uncharacteristically aggressive, violent child who shows uncontrolled, rage-like behaviour.
• overly frightened or overly stoic responses to being hurt during dental treatment.
• excessive gagging when objects are placed in the mouth.
• parent-child interactions in which the parent is striking or verbally abusing a child.

• Is the injury consistent with the given history or explanation of the cause?
• Is the parent's or caregiver's explanation of the injury evasive or inconsistent with the physical findings?
• Is there evidence of previous or repeated trauma?
• Are there multiple skin lesions or bruises which are strongly suggestive of abuse?
• Does the parent or child show inappropriate behaviour?
• Is there evidence of neglect or poor supervision?
• Is there hesitation in history taking as if wanting to say more?
• Are there language or cultural differences which cause communication difficulties?

None of the indicators on their own can tell you if a child has been abused but rather they should alert you to the possibility. Your own awareness that child abuse is extensive and occurs in families of all backgrounds is the single most important factor in recognizing abuse.

Some suggestions:

• Have someone from your dental team with you if you are interviewing a child about possible abuse.
• Interview parents or caregivers away from the child and if possible have another staff person present.
• Use a straightforward approach when speaking with adults about a potential abuse or neglect situation.
• Ask questions in a supportive rather than an accusatory manner. The adult you are speaking with may be unaware of the abuse or may be the abuser. In either case the discussion needs to be conducted in a non-judgmental manner.
• Use open-ended rather than close-ended questions: Tell me again howMary's teeth were broken? instead of Did you break Mary's teeth? Whowas with you when you burned your hand? instead of Did someone burnyour hand?

  Remember: There is no set of questions or particular technique which is guaranteed to lead to disclosures of abuse. The purpose of your questions is to collect data and establish rapport, not to become the accuser.

I notice some bite marks on Linda's neck. Could you tell me howthese occurred? Who was looking after her at the time of the injury? Who else was present? What was happening just before she got hurt?

Is there anything you can tell me about why Trevor has so manybruises on his face?

What About Reporting?

It is required by child protection law in all jurisdictions in Canada except the Yukon that persons must report cases of alleged or suspected child abuse or neglect to a child and family services authority. There is no liability for a person making a report as long as it is not made maliciously. In the Yukon, cases may be reported but it is not mandatory. One should note, however, that mandatory reporting provisions for teachers/principals and child care employees are contained in separate pieces of legislation in the Yukon.

It is important to remember that the purpose of reporting is to help, not to punish. Protection for the child, and resources and support for the family, is the intent of the legislation.

While the legislation is straight-forward, the situations in the dental office are not always so clear cut. The following three scenarios illustrate the different choices you may face.

Scenario 1: No cause to report In many suspected cases the child's injury or condition is consistent with the explanation given. Your assessment and examination provide no evidence indicating the child was harmed or neglected. The injury or condition that initially aroused suspicion should be documented in the chart and dental treatment should be continued as planned.

Scenario 2: Reporting required In some cases you strongly suspect abuse and/or the evidence is so clear-cut that a report must be made. Contact the child welfare agency, provincial/territorial social services department or police force in your community to make the report. In all cases, the person reporting is protected from any kind of legal action as long as the report is not made out of malice. When advising a parent or caregiver that you are making a report about suspected abuse tell them that you are required by law to report your observations to the authorities. Remember - reporting is not an accusation but a way of getting help.

Scenario 3: Consultation recommended The most difficult situation and the one most frequently encountered by members of the dental team is the situation in which you are still unsure of whether to report after considering all aspects of the case. Consultation with another colleague, physician, or social worker is useful at this point.

Local child welfare abuse and neglect teams have extensive training and assessment skills. Make use of their expertise by involving them in discussions about the situation. It is not necessary to reveal your patient's name in these preliminary discussions. You are just asking for suggestions on possible directions in which to go.

Documentation

it is very important to document precisely the findings of all dental team members, whether child abuse and neglect is reported or not. Detailed observations should be made in the dental record to include:

• the size, shape, location, colour, degree of healing of the injury
• reported cause of problem detailed notes of behavioural indicators
• pictures drawn of the injured area and labelled accordingly
• photographs of suspicious pathology
• radiographs of affected teeth
• record of the date of consultation with other professionals
• record of the date and time of reporting if this was required

• Include a standard question on abuse in the medical history.
• Ensure that the history taking can occur in a confidential setting.
• Use a chart to record the locations and the state of abrasions, bruising, lacerations etc.
• Record symptoms that may be initial indicators of abuse. If the patient returns with more symptoms you can then confidently relate the earlier appearances and behaviours and seek more information.
• Use the dental specific additional indicators to assist in recognition
• Include observations of all members of the dental team where relevant.

Definition The term, abuse of women, includes woman abuse, physical or sexual assault, emotional/psychological intimidation, degradation, deprivation or exploitation of women by their partner in an intimate relationship. The abuse may be:

• physical
• sexual
• psychological
• financial

As a member of the dental team, you can play an important role in supporting abused women through:

• increasing your own awareness of the impact of woman abuse on your patients, colleagues, family and friends
• recognizing indicators of abuse
• offering resource materials and referrals to community agencies which support abused women
• providing support and resources in your workplace for colleagues who are being abused by their partners

Principal face and head injuries:

• broken teeth
• black eyes
• injuries to bone or soft tissue
• hair loss
• lacerations or bruising of head or face
• insomnia
• fractured or dislocated jaw
• severe periodontal disease - especially in adolescents or young women.
• enamel erosion which may result from the effects of bulimia or prolonged sperm containment in the mouth.

• depression
• financial difficulties
• delay of treatment
• reluctance to obtain treatment
• poor self-care

  Taken alone, none of these indicators mean that a woman is being abused. What they should do is alert you to the possibility of abuse.

Asking Questions About Woman Abuse

Asking questions about abuse on a routine basis is a positive step for dental professionals to take. Survivors of abuse have said repeatedly that they are often too scared or too ashamed to mention the abuse to anyone. Women who have been abused may strongly deny the abuse when first asked about it. However they have also said that the fact that they were asked was a turning point for them when they knew the health professional:

• understood the issue
• was comfortable talking about it
• would be a source of helpful information if and when the woman decided to talk.

Sometimes patients who have this type of problem (bruising, brokenteeth etc.) are having family problems. If this is true for you and you want to talk about it, I may be able to help with some resources.

I know that many women are experiencing physical and emotionalabuse in their relationships. I also know that it is very hard to talkabout it. We have resources in the office to support women, so ifyou or someone you know is being abused, we could pass on the information. Barriers to involvement

One of the barriers for many dental professionals in asking questions about abuse is the fear that they then have to 'solve the problem.' This is not true. Adults are the best experts on their own lives. With accurate information, true choices and practical support, women can make decisions that are best for them. There is no single or simple solution to woman abuse.

What dental professionals can do to support abused women:

• Give clear messages about abuse: - Violence is never okay or justifiable.

  - The safety of the woman and her children is always the most important issue.

  - Wife assault is a crime.

  - The woman did not cause the abuse and she is not to blame for her partner's behaviour.

• Know the key resources for abused women in your community. Look in the front pages of your phone book to find the emergency numbers for your area.

  Appendix 6 "Family Violence Community Resource List" will help you identify and have accessible the names and telephone numbers of key resources in your community.

Having a variety of newspaper and magazine articles on violence against women, information pamphlets and telephone resource numbers available in your waiting room is an important way to reach these women. Staff at your local transition house for abused women and children can help you put together a good collection. The Resource Section at the end of this handbook will also provide you with ideas.

What About Reporting?

Wife assault is a crime under the Criminal Code of Canada. There are no legislated requirements for health professionals to report woman abuse. The decision to report the abuse or to lay charges against the abuser does not rest with the dental professional. Women are presumed competent and capable of making decisions for themselves.

Documentation

While there are no legislated requirements for professionals to report woman abuse, it is very important that dental professionals document any findings which would indicate that abuse has occurred. Similar to child abuse documentation (see earlier section), this might include:

• detailed drawings of facial injuries
• photographs of suspicious pathology
• radiographs of affected teeth
• notes of discussions with the patient/client if she talks to you about her abuse.
• This documentation may be of assistance to the woman if she decides to lay charges or to leave the relationship.

Definition Abuse and neglect of older adults refers to any action or inaction that threatens the well being of an older person. Abuse may be:

• physical
• emotional
• sexual
• financial

Older adults may be vulnerable because of frailty, poor health and financial and emotional dependency. Neglect is commonly associated with abuse. With passiveneglect the caregiver does not intend to injure the dependent older adult; with activeneglect the caregiver consciously fails to meet the needs of the older adult.

Passive dental neglect may be described as a failure to meet the basic necessities and care of the oral cavity of an older adult who is unable to meet them herself/himself, but without making a conscious attempt to inflict distress. In institutions, abandonment or denial of services linked to oral health occurs primarily because of a lack of experience, resources, time, or training in this specialized field of health on the part of the daily care providers.

Examples of passive dental neglect:

• neglect of daily personal oral hygiene
• failure to replace or adjust poorly fitting or broken dentures
• failure to provide the necessary access to a yearly screening examination for oral cancer

Competency

Most older persons who are victims of abuse and neglect are mentally competent. Competency can be defined as a person's ability to understand the situation he or she is in, and the decisions he or she has to make. Competency is not a single ability but rather a series of abilities, some of which a person may or may not have. For example, he/she may not be capable of making financial decisions, but may be competent to consent to medical treatment. Consult with the family physician with respect to competency issues.

The Role of the Dental Team

Because of the continuing prevalence of dental disease and the consequent need for dental care for older adults, dental health professionals may be in periodic contact with them. As dental professionals receive increasing numbers of older adults in their practices and as some expand the scope of their practices to include nursing homes and homebound patients, the potential for encountering abused and/or neglected older adults will keep on increasing.

As health care providers, members of the dental team have a moral and professional obligation to:

• increase their awareness of the issue of abuse and neglect of older adults.
• recognize the signs of abuse and neglect.
• know how to access the community support services for older adults.

Each of the following categories of indicators cites examples seen most frequently in the dental office when discussing abuse and neglect:

• physical abuse: non-accidental use of physical force that results in bodily injury, pain or impairment - lip trauma

  - fractured, loose or missing teeth

  - Injuries to the eye and surrounding soft and hard tissues

• psychological abuse: any verbal or non-verbal act which may diminish the sense of identity, dignity and self-worth - confinement, isolation

  - verbal assault, humiliation, infantilization

  - withdrawn, passive affect

  - change in behaviour of patient

  - depression, agitation, anxiety

• material abuse: financial exploitation; unauthorized use of funds, property or any resource of an older person - lack of dental care

  - unpaid dental bills

  - ill fitting dentures, excuses as to why new ones not obtained

• neglect (intentional or unintentional): deprivation of services that are necessary for maintaining physical or mental health - untidy appearance, body odours, halitosis

  - malnutrition

  - not assisted with medical and dental visits

Asking Questions About Abuse and Neglect of Older Adults

• As in questioning about other forms of abuse and neglect, it is important to remain objective, non-judgmental, supportive.
• If it is possible, discuss the situation with the patient/client alone, without the presence of the family member or caregiver.
• State directly your concerns about the older adult's well-being, affirm that you understand the many different stressors impacting on his or her life and if possible offer choices of resources and support services.

I've noticed that you have some bruises on your face, Mr. Levin. Sometimes this is an indication to us that a person is not being treated properly at the nursing home. If this is happening lo you, I hope you can talk about it with me, so we can find a way to help.

We notice in the office that your daughter seems to be very angry and yells at you a lot, Mrs. Frenz. Does this happen at home as well? I'd be happy to talk about it with you. Maybe we can find some ways to make it easier for everybody. What About Reporting?

Abuse of older adults is a crime under the Criminal Code of Canada. In some provinces, there are legislated requirements for health professionals to report abuse and/or neglect of older adults. In other parts of Canada there are no reporting requirements, although many provinces and territories are currently exploring the issue.

For example, Nova Scotia adult protection legislation includes a clause for mandatory reporting of abuse and neglect of older adults. Newfoundland makes reporting of neglect mandatory. Prince Edward Island, British Columbia and New Brunswick have policies of voluntary reporting. Inform yourself about the legislation and reporting procedures in your own jurisdiction.

Both mandatory and voluntary reporting are ineffective if there is no public education program to inform people about the rights of older adults, the potential for abuse of those rights and the moral responsibility toward abused or neglected people.

Dental professionals do have an ethical responsibility if they suspect abuse:

• to assess the situation thoroughly
• to consult with other involved service providers - in particular the family physician
• to make appropriate referrals to community resources and support services
• to involve the older adult and to respect her/his choices in all steps of the decision making process
• when mental competency of older adult is an issue, consult with family physician

While there may be no legislated requirements for dental professionals to report abuse and neglect of older adults, it is very important that they document any findings that would indicate that abuse has occurred. Similar to child abuse documentation, (refer to earlier section), this might include:

• detailed drawings of facial injuries
• photographs of suspicious pathology
• radiographs of affected teeth
• notes of discussions with the patient/client if he or she talks to you about abuse
• record of consultations with other service providers

There is a growing awareness and understanding of the difficult issues faced by both child and adult survivors of child sexual abuse. These issues may be relevant for other victims of abuse. While there has not been a lot of research into the implications for dental practice, some issues have been identified which could help you in your treatment of all abuse survivors.

• The dental experience may cause the patient/client to remember the powerlessness of past abuse and loss of control.

  The dental care provider: - often is male and an authority figure

  - usually is in close contact with the patient/client, who may be in a reclining position

  - often has his/her hands in the patient's/client's mouth The patient/client: - may have difficulty breathing

  - may anticipate pain

  - may be fearful and anxious

• Communication with the patient/client about what makes her/him comfortable or uncomfortable is essential. Suggestions on how to do this include: - agree on a non-verbal signal the patient/client can use to stop the procedure/take a break, e.g., raising a hand

  - keep the door open

  - have a female member of the dental team in the room

  - position the chair in a more upright position

  - avoid use of the rubber dam

  - plan shorter visits

The obligation of the dental community to address the issue of family violence extends beyond the confines of the dental practice. The work to end family violence takes place on many different levels. Recognizing abuse and offering resources and support to individual patients is important but only one part of the solution. The responsibilities of each member of the dental community are much broader. As a member of the dental team, as an individual and as a member of a dental professional association, there are many different ways you can get involved and assume a leadership role.

Dental Team Initiatives

Recognizing and responding to family violence requires a total team effort. Receptionists., office staff., dental assistants, dental therapists, dental hygienists and dentists all need to work together to develop the awareness and define the procedures that will guide their practice. Linking to the wider network of' community organizations working with survivors of abuse is also very important.

Some members of the team may find it very difficult to discuss the issue of family violence, while others may be very comfortable with the materials, questions and responses. Find the best person on your team to be the contact and then work together to increase the whole team's comfort level.

Some of the steps you can take as part of the dental team:

• Discuss the issue of family violence at staff meetings.
• Organize staff training for all members of the dental team on family violence issues such as: - child abuse legislation and reporting procedures

  - recognition of abuse indicators

  - communication skills for talking about abuse

  - treatment implications for patients/clients who are survivors of abuse

  - community resources for survivors of abuse

• Include routine questions about abuse as part of the medical history.
• Establish a protocol for documenting suspected abuse.
• Develop a list of support services and counsellors in your community and post it in your office.
• Place pamphlets, posters, resource material and contact phone numbers for community agencies in your waiting room.
• Invite someone from a shelter, a counselling agency or a seniors' organization to a staff meeting as part of your awareness raising and community networking.
• Participate in community committees of service providers who are working to end family violence.

• Educate yourself on an ongoing basis about family violence. - Subscribe to a newsletter on family violence.

  - Watch television documentaries relating to family violence.

  - Attend workshops, community information sessions, public lectures on family violence issues.

  - Read professional journals, magazine articles, books concerned with family violence.

• Volunteer to work with one of the organizations in your community concerned with family violence issues. - Sit on the board as a member of a community agency serving seniors or people with disabilities.

  - Raise funds for your local women's shelter.

  - Volunteer to work on the youth crisis line.

  - Write letters to the newspaper protesting funding cuts to community support services.

  - Involve your children's school, your community association, or your religious organization in organizing a family violence awareness event.

• Subscribe to a newsletter on family violence;
• Establish contact with the National Clearinghouse on Family Violence at Health Canada;
• Obtain Family Violence Resource Materials for the Dental Community: An Annotated Bibliography from Publications, Health Canada, or Canadian Dental Association Library.
• Offer workshops on family violence at dental conferences.
• Include information on family violence and the dental community as part of display tables at conferences or workshops.
• Support research on recognition and treatment of abuse in dental practice.
• Develop or encourage the use of existing resource materials and training packages to help assist dental care providers address family violence issues.
• Consider the diversity and/or special needs of patients/clients and persons with disabilities and encourage adaptation of training approaches as appropriate, e.g. - aboriginal communities

  - immigrant population

  - ethnocultural groups

  - people with disabilities

• Develop policies, procedures and resources to support colleagues who are living in abusive relationships.
• Support the integration of family violence issues into the education programs for all dental health professionals.
• Include articles dealing with family violence issues on a regular basis in professional journals.
• Organize special mailings to highlight important information on family violence, e.g., new resources, conferences, training sessions.
• Inform association members when new resources on the topic of family violence and the dental community are available, e.g., updates to annotated bibliography Family Violence Resource Materials for the Dental Community.
• Build interdisciplinary links with other professional associations addressing family violence issues.
• Organize events for the dental association in collaboration with the community during family violence awareness activities or fundraising events, e.g., transition homes, children's services.
• Set up a Speakers Bureau of resource people from the dental community who are knowledgeable about family violence issues as they relate to dental practice.

1. Family Violence Resource Materials for the Dental Community: AnAnnotated Bibliography (1993)

   Copies available from:

   Publications, Health Canada
   13th Floor, Brooke Claxton Building
   Tunney's Pasture
   Ottawa, ON K1A 0K9
   Postal Locator 0913A
   Tel: (613) 954-5995 : Fax: (613) 941-5366

   This publication also includes a listing of organizations and departmentsacross Canada dealing with resource materials on family violence issues.

   A 1995 update to the bibliography will be available as an insert. Contact the Mental Health Division of' Health Canada or the Library of the Canadian Dental Association .for more information.

2. National Clearinghouse on Family Violence, Health Canada

   Health Canada
   Ottawa, K1A 1B5
   Postal Locator 0201A2
   1-800- 267-1291 : Fax: (613) 941-8930

   The National Clearinghouse on Family Violence (NCFV) is an excellent source qf materials on all forms of family violence. Resource materials are available free of charge in either French or English from NCFV

• Family Violence Overview Papers

  Each fact sheet provides a brief but comprehensive overview of the key issues relating to a specific topic.

  The following fact sheets would be particularly useful for awareness raising in the dental community: - Child Abuse and Neglect

  - Child Sexual Abuse

  - Wife Abuse

  - Wife Abuse - The Impact on Children

  - Elder Abuse

  - Family Violence and Substance Abuse

  Fact sheets on many additional topics are also available.

• Family Violence: Clinical Guidelines for Nurses

  This booklet provides an easy to use guide for all health practitioners. All ,forms of violence in families are discussed and guidelines for identification are included

• Wife Abuse - A Workplace Issue: A Guide for Change

  The Guide provides practical resources, training ideas and workshopoutlines adaptable for use in any workplace setting, including dentalpractices. It would he very useful for anyone wanting to make theirworkplace more supportive for colleagues who are being abused bypartners.

• Community Awareness and Response: Abuse and Neglect of Older Adults

  This resource provides community service providers with an introductionto the issue of abuse and neglect of older adults and suggests constructiveways for communities to deal more effectively with the needs and concernsof older adults.

• Awareness Information for People in the Workplace - Family Violence

  - Abuse and Neglect of Older Adults

  - Child Abuse and Neglect This series of guides was developed for use by people interested inmeeting to discuss a range of family violence issues. The goal of thesesessions is to help people develop a greater awareness about the issue,practical steps./br help, and the range of resource available in their own community.

3. Vis-à-vis... A National Newsletter on Family Violence

   Vis-a-vis is published quarterly in both French and English by the Family Violence Program of the Canadian Council on Social Development. It provides up-to-date information on new resources, programs, conferences and research in the field of family violence.

   Recent issues which might be of interest to those developing workplace awareness sessions in their dental practice include: - When Racism Meets Sexism: Violence Against Immigrant and Visible Minority Women, Summer 1994

   - Stopping Violence Against Women: Men Can Be Part of the Solution, Spring 1994

   - Family Violence: Aboriginal Perspectives, Spring 1993 Subscriptions to Vis-à-vis are available from:
   Family Violence Program
   Canadian Council on Social Development
   441 MacLaren Street
   Ottawa, Ontario
   K1Y 4G1

4. Cross-Cultural Caring: A Handbook for Health Professionals in WesternCanada

   Edited by N. Waxler Morrison, J. Anderson and E. Richardson, University of British Columbia Press, 1990.

   This handbook describes several recent immigrant groups in western Canada, among them Vietnamese, South and Southeast Asians, Chinese, Japanese, Central Americans, West Indians and Iranians. The final chapter offers specific guidelines for cultural assessment, including strategies for negotiating a plan of care that will he acceptable to both the clinician and the patient.

5. Violence Issues: An Interdisciplinary Curriculum Guide for HealthProfessionals (1995)

   Mental Health Division, Health Canada

   Every health professional needs to understand violence issues and develop basic skills. This Guide has been developed for use by a variety of health disciplines, including dentists and dental hygienists. Preparing future health professionals to address violence issues in all practice settings is an essential role for all educators.

6. Course Materials for Ethics In Dentistry

   by Mariel J. Bebeau, Centre for the Study of Ethical Development, University of Minnesota: 141 Burton Hall, 178 Pillsbury Drive S.E., Minneapolis, Minnesota, U.S.A. 55455 - Cost $75

   The materials address the issues of ethics for all the health professions. The Brian Conlin case is related to family violence and a visit to the dental office. The Sandy Johnson case occurs in a dental office and concerns an eating disorder. There is a Dental Ethical Sensitivity Test and the case studies are scored. These materials should be useful resources for educational programs for dental health professions as well as for continuing education courses.

7. For additional information, contact your provincial or territorial government, for example:

• Ministry of Health
• Ministry of Social Services
• Women's Bureau or Commission on the Status of Women
• Ministry of Justice
• Ministry of Attorney General
• Ministry of Education

Canadian Nurses Association. Family Violence Clinical Guidelinesfor Nurses. 1992. (available from the National Clearinghouse on Family Violence, Health Canada (NCFV)

Denham D. and Gillespie J. Wife, Abuse - A Workplace Issue: A Guide For Change 1992. (available from NCFV)

Denham D. and Gillespie J. Workplace Learnings About Woman Abuse: A Guide for Change II. 1994 (available from NCFV)

Mental Health Division, Health Canada:

• Community Awareness and Response : Abuse and Neglect of Older Adults. 1993. (available from NCFV)
• Resource and Training Kit for Service Providers: Abuse and Neglect ofOlder Adults. 1995. (available from NCFV)
• Abuse and Neglect of Older Adults in Institutional Settings: DiscussionPaper Building From English Language Resources. 1995. (available from NCFV)
• Violence Issues: An Interdisciplinary Curriculum Guide for HealthProfessionals. 1995. (available from NCFV)
• Family Violence Resource Materials for the Dental Community: AnAnnotated Bibliogrqphy. 1994 (available from Publications, Health Canada)

Podnieks, E.K. et al, National Survey on Abuse of the Elderly in Canada: The Ryerson Study. 1990

Statistics Canada, "Violence Against Women Survey". 1994

"Theme Issue on Family Violence", Journal of the Canadian Dental Association, Vol 59 No. 11, November 1993.

Wilson, M., "Family Violence: A Problem with Relevance for the DentalHygienist ", Probe, Vol 27, No 5, Sept/Oct 1993 pp. 173-175

1.    Become familiar with the issues Have each member of your dental team review the material in the Family Violence Handbook for the Dental Community. Ask everyone to think about the role he or she can play in recognizing and assisting those who have been victims/survivors of violence in the family. Remember that there may be members of the dental team who have experienced abuse or are themselves perpetrators.

2.    Gain knowledge through sharing After each person has had the chance to review the material, hold a staff meeting to discuss family violence. Important topics to include:

• identifying indicators of abuse
• improving communication skills. Learning to ask questions about abuse in a caring and sensitive way.
• incorporating a response to family violence into the practice: how to do it? who should do it? what further training or resources are needed?
• identifying the key resource people in your community network of family violence services.

In the dental practice:
• Include questions about abuse in the medical history.
• Develop a chart to record location and state of abrasions, lacerations.
• Ensure that history taking takes place in a confidential setting
• Record any symptoms that may be initial indicators of abuse. If the patient returns with more symptoms, you can then confidently relate the earlier appearances/behaviours in order to get more information or to confirm your suspicions.
• Use the dental specific indicators outlined in the Handbook to assist in recognition.
• Keep a supply of family violence pamphlets and resource lists in your waiting room.

In the community
• Get involved with the health and human services network so that they see you as a resource in your community.
• Get to know and support the shelter staff in your area.
• Seek out referral agencies and individuals that offer sensitive and appropriate support services for survivors of family violence.

Teeth

• missing teeth in unexpected areas
• empty areas of avulsion, broken roots or teeth
• trauma to teeth where explanation doesn't fit the injury

• bruises to hard and soft palate (possibility of forced feeding or oral sex)
• burns, scars and sloughing of tissue inside the mouth (can be from scalding foods, cigarettes or other implements)
• signs of infection gonorrhea, venereal warts, syphilis, herpes, moniliasis, trichomonas
• tears of the lingual frenum (not an unusual injury in a young child learning to walk but should arouse suspicion in a nonambulatory infant or an older child)
• tear of the maxillary frenum, especially in young infants. May be indicative of slap across the face.

• scarring of the lips
• burns from chemicals, hot food, cigarettes
• rope burns that indicate gagging
• bruises from forced feeding, slapping, forcing of pacifiers
• signs of infection with venereal warts

• marks showing hand or belt buckle bruises may indicate underlying fractures

• bruises, cuts
• cauliflower ear indicating pulling or twisting
• perforated tympanic membrane

• broken or bruised
• deviated septum
• blood clots in nose

• bald or sparse spots that indicate malnutrition or hair pulling
• lack of hygiene (scabs, excessive dandruff, lice)

• bruises or burns in various stages of healing

• bruises on the neck may suggest an attempt to strangle
• rope burns, hand marks from choking

• 65% of all bite marks can be seen without disrobing

• chronic throat infections
• overall dental neglect and lack of dental care may be an indicator of physical or emotional abuse
• poor oral hygiene concurrent with low self-esteem in the adolescent may be an indicator of abuse

Physical

• Injuries to bone or soft tissues - lacerations to head or face
  - hair loss
  - broken teeth
  - fractured or dislocated jaw
  - black eyes
  - perforated eardrums
• Bite marks
• Unusual burns caused by - cigarettes
  - top of stove
  - hot grease
  - acids
• Injuries sustained do not fit the history given - client appears after hours
  - client may delay coming for treatment
• Client may show evidence of old or new injuries
• Visits to facilities may increase and severity of injuries become more serious over time
• Nutritional/sleep deprivation

• Depression - low self-esteem
  - withdrawn
  - unkempt appearance
  - may discuss or attempt suicide
  - anorexic or bulimic behaviour
  - alcohol or drug abuse
  - insomnia
  - psychosomatic illness (may be non-compliant)
  - anxiety attacks
  - feelings of helplessness
  - cries frequently
  - indecisive behaviour
  - avoids eye contact
• Loss of family and peer contact - feels isolated
• Poverty (may be due to economic entrapment by partner)
• May minimize or delay treatment of injures for self or child
• May refuse further investigation or intervention with self or child
• May feel abuse is her fault ("I asked for it.")
• Fears reprisal
• May show detachment or hostility toward children
• May have unrealistic expectations of children's development and capabilities

• Sexually transmitted disease
• Miscarriages
• Stillbirths
• Pregnancy
• Pre-term babies
• Low birth weight babies (abused women have an increased tendency to deliver low birth-weight babies).

• Believe her
• Listen and let her talk about her feelings,
• Give clear messages: - Violence is never okay or justifiable.
  - Her safety and her children's safety are always the most important issues.
  - Wife assault is a crime.
  - She does not cause the abuse.
  - She is not to blame for her partner's behaviour.
  - She cannot change her partner's behaviour.
  - Apologies and promises will not end the violence.
  - She is not alone.
  - She is not crazy.
  - Abuse is not loss of control. It is a means of control
• Talk with her about what she can do to plan for her and her children's safety. Encourage her to make her own decisions.
• Help her find the good things about herself and her children.
• Know the key resources in the community and how to contact them.
• Get her a copy of a community resource list
• Respect her confidentiality

• Don't tell her what to do, when to leave or when not to leave.
• Don't tell her to go back to the situation and try a little harder.
• Don't rescue her by trying to find quick solutions.
• Don't suggest you try to talk to her husband to straighten things out.
• Don't tell her she should stay for the sake of the children.

Physical Abuse Non-accidental use of physical force that results in bodily injury, pain or impairment. Sexual assault

	Examples		Presenting Indicators in a Dental Practice
	•	punching, hitting	•	lip trauma, fractured, subluxated or avulsed teeth
	•	trauma to oral/perioral structures	•	fractures of the mandible or maxilla
	•	cuts, lacerations or abrasions	•	bruising of the edentulous ridges or the facial tissues
	•	hemorrhaging beneath the scalp	•	evidence of prior trauma to dental or orificial structures
			•	fractures of the zygomatico-maxillary complex
			•	eye injuries, orbital fractures
			•	missing teeth
	•	pulling hair	•	unexplained alopecia
	•	physical restraint	•	rope marks - pressure areas (head)

Psychological Abuse Wilful infliction of mental or emotional pain by verbal or non-verbal abusive conduct

	Examples		Presenting indicators in a dental practice
	•	humiliation, scolding, intimidation, threatening (eg. of institutionalization), infantilization	•	change in behaviour
			•	withdrawn, passive affect
			•	depression, agitation, anxiety
			•	caregiver appears hostile, unconcerned regarding patient
	•	belittling, contradictory statements, controlling	•	receptionist may hear arguing between caregiver and older person when on the phone or in the office
	•	withholding affection	•	diminished self-esteem

Material Abuse Financial exploitation, unauthorized use of funds, property or any resource of an older person

	Examples		Presenting indicators in a dental practice
	•	absence of government funding to needy older person	•	lack of dental care
	•	theft of pension cheque, money or property	•	unpaid dental bills
	•	deceit, fraud	•	older person poorly dressed
			•	ill fitting dentures, excuses as to why new ones notobtained
			•	caregiver questions dentist on necessity of dental work for older person, e.g., "at her age?"
			•	disappearance of older person's possessions in an institutional setting

Neglect (intentional or unintentional) Deprivation of basic necessities or services that are necessary for maintaining physical or mental health

	Examples		Presenting indicators in a dental practice
	•	withholding nutrition fluids	•	malnutrition, emaciation, absence of dentures, glossing, dehydration, xerostomia, angular cheilitisconfusion
	•	poor hygiene, personal care	•	impaired skin integrity, rashes, unkempt appearance, body odours, halitosis, poor oral hygienerampant dental disease
	•	withholding medical/dental services/treatment or medication	•	not taken to the dentist, doctor or therapist
			•	appointments frequently cancelled
			•	difficulty in arranging appointments
			•	caregiver states that there is "no time" to take older person to dentist.

Source:

Chart titled "Types of Elder Abuse", from Podnieks, E., Elder Abuse and Neglect: A Concern for the Dental Profession, Journal of the Canadian Dental Association 59(11), 1993.

Source:

Family Violence: Awareness Information for People in the Workplace. Mental Health Division, Health Canada. 1995. (available from the National Clearinghouse on Family Violence, Health Canada)