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Children and youth in public care, i.e. child welfare institutions or foster homes, have the same rights as other children to privacy, protection, and care. Bufdir commissioned a review of the research that exists on the use of force and setting limits, and the relationship between these two, in welfare institutions and foster homes. Aims included exploring prevalence, types, understandings, consequences, preventative measures, and experiences with force and setting limits.
We conducted a systematic mapping review in which we categorized and described studies according to our research aims. We included twelve studies: one systematic review and eleven qualitative and quantitative studies. We assessed the methodological quality of each study.
Six studies were from Norway, two each from Sweden and the Netherlands, and one each from Denmark and Belgium. Samples included children and youth in welfare institutions and foster homes, employees and leaders in welfare institutions, foster parents, and auditors. Only two studies examined foster homes.
- Prevalence: two studies provided sparse data
- Types: three Norwegian qualitative studies described different types of force and the situations around them
- Understandings: one Dutch systematic review, three Norwegian qualitative studies, and two Swedish qualitative studies explored different perspectives on force and, to a lesser extent, setting limits
- Consequences: five qualitative studies (three from Norway) reported primarily negative consequences of force, related to damaged relationships and feelings of safety. Witnessing force was also explored
- Preventative measures: six studies described different methods to prevent the use of force; only one was an evaluation study
Auditing/monitoring: four Norwegian studies reported on the role of monitoring boards
Children and youth in child welfare institutions or foster homes have rights as all other children, to privacy, protection, and care. Child-rearing also includes setting limits, for which child welfare institution employees and foster parents are responsible. There are legal provisions in Norway for the use of force against children and youth in child welfare institutions, e.g. use of restraint or seclusion/isolation in acute situations. As the responsible executive body, the Norwegian Directorate for Children, Youth and Family Affairs commissioned a review of research that has examined both setting limits and force, and the overlap between these two, in the context of child welfare institutions and foster homes. Research questions included:
- What is the prevalence of force?
- What types of force are used?
- How are force and setting limits understood (by children and youth, foster parents, and employees of child welfare institutions)?
- What are the consequences of force (for children and youth)?
- How can force be prevented in child welfare institutions and foster homes?
- What are the experiences and opinions of children and youth, foster parents, and employees of child welfare institutions, regarding setting limits and force?
We conducted a systematic mapping review according to the Norwegian Institute of Public Health’s methods handbook and in alignment with international standards. A systematic mapping review describes research in a particular field. We first searched relevant databases and grey literature for studies (April 2020). We included systematic reviews and empirical primary studies, both qualitative and quantitative, that explored either force or setting limits in child welfare institutions or foster homes and were published 2000 or more recently. We limited our search for studies conducted in Norway, Sweden, Denmark, Finland, Belgium, and the Netherlands, as previous research has suggested comparable understanding and organization of child welfare in these countries.
Two researchers screened titles/abstracts and thereafter read studies in full-text to determine eligibility. Two researchers assessed the included studies’ risk of bias (for quantitative studies) or their methodological strengths and weaknesses (for qualitative studies). Two researchers then extracted data, which was sorted and summarized according to the research questions.
We included twelve studies: one systematic review and eleven primary studies. Of the primary studies, nine were qualitative and three were quantitative (one used mixed methods). Six studies were from Norway, two from Sweden, two from the Netherlands, and one each from Denmark and Belgium. Most studies involved child welfare institutions, and only two involved foster homes.
We assessed the studies’ risk of bias and methodological weaknesses. Seven of nine qualitative studies had small methodological weaknesses (corresponding to good methodological quality), while two had moderate methodological risks. Two of three quantitative studies had moderate risks of bias (moderate methodological quality), while one had a high risk of bias. The systematic review was of low methodological quality.
We sorted and presented studies’ results according to the research questions, and across study designs. Ten of the twelve included studies utilized qualitative data; they explored experiences and opinions of various aspects of force. We therefore chose to integrate findings related to experiences/opinions under each research question, as they provided substantial information. The last research question was changed to report distinctly on experiences with the function of monitoring boards.
1. What is the prevalence of force?
One Norwegian and one Danish study measured the use of force/sanctions, but most findings were not relevant to this review. Both studies reported the proportion of youth who had had their mobile phones taken away; about 40% in both. In the Danish study, this was more common for youth in foster homes than in institutions. No other types of force were measured.
2. What types of force are used?
Three Norwegian qualitative studies explored how different types of force were used. These types were force used in acute situations (typically restraint or seclusion/isolation), in addition to returning a child/youth who had run away; drug testing; limiting freedom of movement or assigning an adult to follow a child/youth; and denying access to mobile telephones or other electronic modes of communication.
3. How are force and setting limits understood (by children and youth, foster parents, and employees of child welfare institutions)?
Six studies explored different perspectives of force. In three Norwegian studies, a portion of participating youth understood force as the types of force that institutions were legally allowed to use, while others described it as “anything you yourself don’t want”. Employees of monitoring boards described force as both actions against the will of the child/youth, and actions regulated legally. Employees and leaders in institutions described force exclusively as the actions they were allowed to use. Some defined force as “physical limit-setting” or “robust care”. Two Swedish and one Dutch study explored further terms used to understand force, and to a lesser extent, setting limits.
4. What are the consequences of force (for children and youth)?
Four qualitative studies explored the consequences that force can have on children and youth living in child welfare institutions. Youth reported that force could end up being “normal” for institutional life, which made it difficult to see institutions as even temporary “homes”. This applied if one had experienced force directly or witnessed it used among others, and particularly if one witnessed physical, violent situations. Both youth and employees discussed how force was destructive for the relationships between the two parties, yet, many felt that force could be called for in certain situations. The Dutch study, which also included youth in secure and forensic institutions, reported consequences such as a powerlessness, loss of autonomy and meaning.
5. How can force be prevented in child welfare institutions and foster homes?
Six studies explored different aspects of preventing the use of force against children and youth in institutions or foster homes. One theme common to the majority of the studies was the importance of relationships. One suggestion was to include children and youth in designing preventative measures in institutions, for example by addressing prevention in house meetings or assessing force in client surveys. Another theme was employees’ need for guidance, and deliberations around ethics and their own feelings during acute situations. Three preventative measures were described in detail: Non-violent resistance, social work aimed at preventing use, and trauma-informed parenting/care.
6. What are the experiences regarding monitoring/auditing?
Four Norwegian studies explored the monitoring/auditing of the use of force within child welfare institutions, and the monitoring board’s roles, from the perspective of youth, employees, and the monitor. The extent to which youth understood their own rights varied greatly. Youth, employees, and monitors agreed that youth under-utilize their right to make formal complaints to the monitoring board. Employees of child welfare institutions, including leaders, had thorough understandings of the regulations surrounding force and its monitoring, but employees of the monitoring board were less confident in institutions’ knowledge. The extent to which the monitoring board provided training and guidance to institutions, instead of only monitoring/auditing, also varied.
Discussion and conclusion
This review was able to answer research questions regarding types of force, under-standings of force, and how children and youth as well as employees of child welfare institutions have experienced force. Findings highlight the overall negative experience of children and youth regarding force, both when experienced personally and as witnesses. Youth expressed interest in good relationships with opportunities for discussion in acute situations. We were not able to answer research questions regarding prevalence or consequences of force, reported quantitatively, from the included studies. Potential positive consequences of force appear rarely explored. Similarly scarce are data about setting limits in foster homes and the overlap between setting limits and using force. Finally, while several interventions to prevent or reduce the use of force were described, they were not evaluated.
We see a clear need for further research on numerous topics: measurements of the prevalence of different types of force, explorations of setting limits in foster homes and the relationship of setting limits and using force, and evaluations of preventative measures.