Facial injuries in children and adolescents victims of aggression Lesões faciais em crianças e adolescentes vítimas de agressão Lesiones faciales en niños y adolescentes víctimas de agresiones

Child maltreatment may occur as the intentional use of power, effective or attempted, against children under 18 years old, that results or may result in actual or potential harm. It affects a vulnerable population, causing physical and/or emotional consequences persisting throughout their lives. This study aimed to characterize episodes of child maltreatment, with focus on facial injuries, in a Brazilian city (Teresina, PI). This is a retrospective study with a quantitative approach, carried out in the database at the Institute of Forensic Medicine in Teresina, between the years 2017 and 2019. All reports of bodily injury of children from 0 to 18 years were collected and statistically analyzed (SPSS 22.0). During the period analysis, 811 reports of bodily injury were identified. There was a predominance of female victims aged between 12 and 18 years old, the involvement of men with some family relationship with the victim was highly associated. Facial injuries represented 35.8% of the whole sample and 98.6% of those found in the head and neck region (41,6% of the total). The orbital (29.0%) was the most affected site, followed by the frontal (25.9%), malar (23.4%), labial (17.6%) and cheek area (11.4%). There is a high prevalence of injuries to the head and neck region, this fact emphasizes the importance of a trained professional, especially a dental surgeon, in the analysis and interpretation of these injuries during forensic examination.


Introduction
Child maltreatment is considered a social and public health problem that indiscriminately affects all countries. "It includes all types of physical and/or emotional ill-treatment, sexual abuse, neglect, negligence and commercial or other exploitation, which results in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power" (World Health Organization [WHO], 2014). In this context, physical violence is defined as the intentional use of power, effective or attempted, that results, or may result, in actual or potential harm (Pinheiro, 2006). Children are more vulnerable to this type of violence as they are still in the process of autonomy development (Salgado et al., 2016).
Several studies have indicated that physical violence is the most commonly type of violence against children observed worldwide. In Brazil, it is estimated that 18 thousand children are victims of physical aggression daily; 35% of them suffer recurrent episodes (Barreto, Araujo, Matins Júnior, Barreto Filho & Costa, 2018).
In a study carried out in Tanzania on the types of violence suffered in childhood, the prevalence of physical abuse was 82.1% (Mwakanyamale, Wande & Yizhen, 2018).
When it comes to violence against children, relevant issues are raised regarding the physical, psychological and social consequences in the short and long term. Some of these consequences are manifested through undesirable behaviors, including use of drugs, prostitution, involvement in abusive relationships, self-harm, and suicidal intentions (O'brien, White, Wu, & Killin-Farrel, 2016). The intervention requires an interdisciplinary and multidisciplinary approach, including direct health practitioners, social, legal, psychological, anthropological, religious support. During professional training, the topic "child maltreatment" must be always discussed beside prevention and citizenship promotion (Apostólico, Nóbrega, Guedes, Fonseca & Eggry, 2012).
In Brazil, when an episode of violence against children occurs, the victim is referred to the Institute or Department of Forensic Medicine for examination of bodily injury. This referral is carried out by the police officer or judicial authority, it can be requested to one of them directly by the Public Ministry (Lei n. 3.689, 1941). The forensic report is attached to the criminal process to be tried under the criminal law (Lei n. 3.689, 1941).
Studies on bodily injury associated to child maltreatment addressing the prevalence of facial injuries are scarce in the literature. This type of study is relevant to increase the issue visibility and promote effective public policy strategies to support the criminal process and the application of the criminal law, as well as emphasize the importance of a trained professional, especially a dental surgeon, at the Institute of Forensic Medicine. This study aimed to characterize episodes of child aggression, with focus on facial injuries, in a Brazilian city (Teresina, PI).

Methods
This is a retrospective study with a quantitative approach, carried out in the database at the Institute of Forensic Medicine, located in the city of Teresina-PI, which is responsible for conducting forensic exams in Teresina and 61 other cities in the state of Piauí.
The study was carried out through the collection of secondary data present in forensic reports stored in the database of the mentioned institution. Inclusion criteria were considered: all reports of bodily injury carried out from January 2017 to December 2019; whose victims were children from 0 to 18 years old. Reports resulting from reasons other than physical violence were excluded of the study; just as reports not concluded by the professional in charge or even canceled due to administrative mistakes.
Variables related to the victim's sociodemographic data (age and sex) and data from the violence episode (sex of the aggressor; involvement with the victim; location where the violence occurred; presence of injury; anatomical region of the body where the injury occurred, type of injury; instrument used to produce the injury) were collected. Only one investigator collected the data, thus ensuring a standardized record of all information presented.
Data was double checked using Microsoft Excel application and later exported and analyzed using the SPSS software, version 22.0. In order to characterize the sample, descriptive statistics of absolute and relative frequency were performed. Fisher's exact test was used to verify the association between qualitative variables, with a significance level of 5%. The Institutional Ethical Committee approved the study protocol (Process number 4.100.295).

Results
Between 2017 and 2019, 2,077 reports of violence against children were identified. Among these, 811 (39.0%) reports indicated physical violence. In this period, there has been a decrease in the number of reports over time, 379 in 2017, 221 in 2018, and 211 in 2019. Table 1 shows the distribution of reports according to sociodemographic and violence-related variables.
There was a predominance of female victims aged between 12 and 18 years old, the involvement of men with some family relationship with the victim is highly associated. The violence occurred most frequently at home, there was identification of bodily injury in most part of the reports, and the examination was performed within 24 hours of the occurrence of the violence. There was a predominance of lesions located in the head and neck region (41.6%), followed by the upper limbs (38.2%) ( Figure 1). Among the bodily injuries, those located in the facial region are noteworthy, they represented 35.8% of the whole sample and 98.6% of those found in the head and neck region. Table 2 shows the distribution of the facial injuries identified in the forensic reports of physical violence against children. The orbital region was the most affected site, followed by the frontal, malar, labial and cheek areas. 6 Among the forensic reports with identification of facial lesions, the most prevalent lesions were ecchymosis (31.8%), swelling (29.6%) and excoriation (22.2%) (Figure2). Blunt instruments were the most type of instrument recorded (Figure 3).  When analyzing the association of sex and age with variables related to injuries (Table 3), there is a significant difference between age and the presence of personal injury (p = 0.023), with a higher percentage of personal injury in the age group 12-18 years (teenagers) ; between age range and location of the lesion (p = 0.0001) with predominance of lesions in the trunk and lower limbs in children and in the head and neck and upper limbs in teenagers; and between sex and location of the lesion (p = 0.022), with a predominance of lesions in the trunks and genital region for males comparing to females. Table 3. Association between variables related to injuries and sex and age group of victims of violence. Teresina, 2020.

Variables related to injuries
Sex P * Age group P*

Discussion
The results of this study show that violence against children and teenagers at the Institute of Forensic Medicine in Teresina is a usual event, and most of the injuries affect the head and neck region, frequently in the facial area.
The reduction in the number of occurrences observed in the 3-year period of the investigation may be due to preventive policies promoted by government and non-government institutions that create protection networks to face the violence against children. Credits should also be given to the improvements in the cultural pattern of education against the violence and social Likewise, a study carried out at the same Legal Medical Institute between the years 2018 and 2020, found that the sex most victimized by sexual violence among children and adolescents was the female. This data reinforces the evidence of female fragility in gender relations, whether due to the condition of superior physical strength of the male gender, the inequality expressed in gender relations and the vulnerability and risk of women for victimization by violence, especially for children and adolescents (Trajano, Lyra, e Sá & Gomes, 2021).
Considering the age group, there was an increase in the number of victims as the age progress, with a higher percentage of bodily injury among teenagers (>12 years), corroborating the findings of other studies (Cavalcanti, 2010;Vidal et al., 2019;Almeida et al., 2017;Silva, Musse, Almeida, Marques & Costa, 2016). This can be explained by the fact that young people experience greater social exposure than children under 12 years, as well as the increased capacity and autonomy to make denunciations when older children are involved .
The profile of the suspects, for the most part, was not associated with family members, just as found in other studies where suspects were involved with victims' relatives, but they were not considered family (Cavalcanti & Martins, 2009;Vidal et al., 2019;Almeida et al., 2017;Silva et al., 2016). However, studies carried out in Haiti (O'brien et al, 2016) and Brazil (Rio de Janeiro) (Silva, Costa, Musse, Almeida & Vilas Boas, 2018) found that the aggression was more frequently committed by family members.
A quarter of the forensic reports evaluated did no have information about the victim's relationship with the suspect (25.8%) and the sex (26%) of the suspect. Information about the alleged perpetrator could assist the judicial authority in the process conduction including which law properly fit the fact. Unfortunately, there is no standard to collect this data, the professional responsible for collecting this data must be clearly defined and trained, the forensic examiner must double check this information.
When observing the time interval between the occurrence of the event and the performance of the forensic examination, most of the examinations occurred in the first 24 hours, which may explain the presence of injury in 87.1% of the cases, while some physical evidence might not last longer. In a similar study carried out in Portugal (Vidal et al., 2018), a longer time (2 days) between the aggression and the examination was observed. It is worth mentioning that in 15.4% of the exams there was no information about the time interval (between event and examination), allowing inconsistencies between the moment when the violence occurred and the evolutionary phase of the bodily injury (França, 2015).
Although the presence of injuries has not been observed during the forensic examination of some cases (12.9%), the occurrence of the violence is not excluded. The time between the event and examination may be too long or the intensity of the aggression was not enough to leave some evidence behing in the body of the victim. Blood congestions provoke some skin redness that may disappear in a few minutes (França, 2015).
Regarding the distribution of injuries in the victims' body, the head and neck are the most affected areas, followed by upper limbs. Studies have shown that 29% to 56.3% of cases of child maltreatment some trauma was present to the mouth, face and head (Cavalcanti, 2010;Vidal et al, 2018;Vidal et al., 2019;Rodrigues Júnior, 2009;Silva et al., 2018). The higher frequency of injuries in the head and neck areas is due to the fact that they are more exposed and accessible areas since the suspect is usually taller than the victim. While the injuries on the arms are associated with victims' attempts of defense (Vidal et al., 2018).
The face is usually affected due to the process of subjugation and humiliation inherent in the aggression act, due to its vulnerability and psychological impact (Cavalcanti, 2010). Other retrospective study carried out in Brazil (Campina Grande -PB), with similar methodology, pointed out a high prevalence of injuries to the facial region of physically abused children, with soft tissue lacerations being commonly found, mainly in the upper lip (Cavalcanti, 2010).
In this study, the orbital, frontal, malar, labial and cheek regions were the most affected, respectively. Other study carried out in Brazil (Recife-PE), found the face as the most affected site (20.1%) in cases of child maltreatment, with the eyes, mouth and nose the organs most likely to be affected (Vidal et al., 2018). Other investigation carried out in a children's hospital in South Africa (Naidoo, 2000), which analyzed injuries located on the head and neck, found that 59% of the total were facial and 11% intraoral. Taking a look only at facial injuries, 30% were located in the cheek, 25% in the orbital and 22% in the frontal region (Naidoo, 2000). Other investigation on the topic mentioned the numbers of 85.7% for facial and 25.7% intra-oral injuries (Banheiro, Escobar & Pereira, 2015).
Dental injuries in cases of child abuse usually include fractures, tooth luxation, subluxation and avulsions. In the present study, these types represented only 1.4% of all injuries in the face region, that is in contrast with the literature where intraoral injuries constitute a significant number over the sample, representing 30.8% of lesions on the face (Vidal et al., 2018).
Ecchymosis, swelling and excoriation were highly prevalent in the present study, differing from other study that points to cut-blunt (bruise trauma with some penetration in the tissue) injuries (Cavalcanti, 2010). According to the data in our study, the instrument most used in the production of facial injuries were blunt instruments. Other research performed in Brazil (Feira de Santana -BA) (Leite Filho, 2017), evaluated bodily injuries in children victims of physical violence, found the blunt instrument as the most prevalent (83.5% ), but sharping and piercing instruments were associated to injuries to the head and neck region (84.9%). . In another study in Belo Horizonte, also in Brazil, the "blunt" instrument was present in 91.9% of the cases of violence against children (Rodrigues Júnior, 2009).
As a limitation of this study, the retrospective assessment through forensic reports performed by different experts, in a poorly standardized way, is highlighted. However, despite this limitation, the results described the high prevalence of facial injuries resulting from physical violence against children. It is noteworthy that orofacial injuries are strongly associated with case of child maltreatment, the dental surgeon, especially those with expertise in forensic dentistry, is technically the most qualified professional to analyze and interpret such injuries during the forensic examination.

Final Considerations
The study shows a significant prevalence of physical violence against children and adolescents. There is a predominance of females, aged 12 to 18 years, male aggressor, the home was the most pointed place for the occurrence of violence.
Regarding the affected body region, there was a predominance of lesions located on the head and neck and, among these, those located in the bucofacial region. This fact emphasizes the importance of a trained professional, especially a dental surgeon, in the analysis and interpretation of these injuries during forensic examination.