The use of force and limit-setting for children and youth in residential childcare and foster care: systematic scoping review (update)
The aim of this systematic scoping review was to map out research related to occurrence, types of force used, understanding of use of force/limit-setting, consequences, prevention and experience with use of force and limit-setting.
Children and young people in child welfare institutions and foster homes have the right to be protected and looked after and to have The aim of this systematic scoping review was to map out research related to occurrence, types of force used, understanding of use of force/limit-setting, consequences, prevention and experience with use of force and limit-setting.their personal integrity respected.
We included eight studies: six qualitative, one non-randomized controlled pre-post study and one longitudinal cohort study. The studies' methodological limitations were assessed.
There were three studies from the Netherlands, three from Norway and two from Sweden. The samples included young people and employees in institutions. None of the studies dealt with foster homes.
- We found no studies that addressed prevalence of use of force, exercise of use of force or consequences of use of force.
- Understanding of use of force: a Dutch study addressed professionals' and young people's understanding of the term seclusion.
- Prevention of use of force: three studies highlighted different ways of preventing the use of force.
- Experiences with limit-setting and use of force: six studies addressed experiences regarding limit-setting and use of force from different perspectives, with relationships being a particularly salient topic. Use of digital communication can illustrate dilemmas concerning the use of force.
The current review found that youth and institutional staff in residential childcare regard positive relationships as important in preventing conflicts and violence. We found little research on limit-setting and use of force in residential childcare institutions and foster homes.
Children and young people who live in a child welfare institution or foster home have, just like other children and young people, the right to have their personal integrity protected and the right to protection and care. Limit-setting is an important part of the care and support that all parents must provide, including foster parents and staff in child welfare institutions. In Norway, laws and regulations also allow the use of specific coercive measures against children and young people in child welfare institutions, for example physical coercion and isolation in acute dangerous situations, body searches and examination of their room and their belongings. This is regulated in the rights regulation, which has now been partially incorporated into the new Child Protection Act.
The purpose of this review was to conduct a systematic scoping review of the research on use of force and limit-setting in child welfare institutions, limited to studies carried out in Norway, Sweden, Denmark, Finland, Belgium and the Netherlands. The information may be used to identify knowledge gaps and to aid the authorities’ work with foster homes and child welfare institutions. The review is an update of a previous systematic scoping review published by the Norwegian Institute of Public Health in 2020. The research questions in the original review were also used in the current update:
- What is the prevalence of use of force?
- How is the use of force exercised?
- How is limit-setting and the use of force understood?
- What consequences does the use of force have?
- How is the use of force prevented in child welfare institutions and foster homes?
- What are children and young people's, foster parents' and institutional staff's experiences with and views on limit-setting and the use of force?
We carried out a systematic scoping review in line with the Norwegian Institute of Public Health's methods handbook, which follows international standards. A systematic scoping review is a type of review that maps and narratively describes the research literature that exists in a specific field. A research librarian designed our search based on the original search from 2020, but made some adjustments based on experience from the previous review, such as reducing the number of databases, adding search terms and removing the geographical limitation of the search. The database search was conducted in November 2022 in Scopus, APA PsycINFO and Sociological Abstracts & Social Services Abstracts. In addition, searches were carried out in other sources, including Bielefeld Academic Search Engine, Google, Google Scholar and the websites of relevant organisations, in addition to citation searches and searches in OpenAlex.
The project members independently screened titles and abstracts against the inclusion criteria. We utilized priority screening, a machine learning function based on a ranking algorithm to provide a faster overview of the most relevant references. Full-text publications were then retrieved and screened by one project member and checked by another project member. We then extracted data from the studies (design, research question, country, characteristics of the sample, setting and results), in addition to assessing the studies’ methodological limitations and risk of bias.
The literature search identified 2 738 references within the relevant time frame and were screened on title and abstract. We reviewed 71 publications in full-text and included eight studies: six qualitative, one non-randomized controlled pre-post study and one cohort study. Three studies were from Norway, three from the Netherlands and two from Sweden. All studies concerned child welfare institutions.
We assessed the studies' risk of bias and methodological limitations. One of the six qualitative studies had minor methodological limitations, two had moderate methodological limitations, two had severe to moderate methodological limitations and one had severe methodological limitations. The one non-randomized controlled pre-post study had a high risk of bias and the one longitudinal cohort study had a high risk of bias.
We grouped the results for each study according to the six research questions. Three of the research questions (prevalence, practice and consequences) were not addressed by any of the included studies. In contrast, six of the studies addressed the research question about experiences with limit-setting/use of force, three addressed the question of prevention and one addressed the question of understanding.
Question 1. What is the prevalence of use of force?
None of the included studies addressed this question.
Question 2. How is the use of force exercised?
None of the included studies addressed this question.
Question 3. How is limit-setting and the use of force understood?
A Dutch study explored the concept of seclusion, with the aim of achieving a shared definition between leaders, staff and residents of youth care institutions. They settled on defining seclusion is “an involuntary placement in a room or area the client is not allowed or able to leave”. This definition served as the basis for a shared monitoring system of seclusion in all residential youth care institutions in the Netherlands.
Question 4. What consequences does the use of force have?
None of the included studies addressed this question.
Question 5. How is the use of force prevented in child welfare institutions and foster homes?
Prevention of use of force and violence was investigated in three included studies: one qualitative and two quantitative. The qualitative study interviewed professionals in Norwegian child welfare institutions who believed that a good relationship with youth was important to prevent the use of violence. On the other hand, some were concerned that their demanding work made relationship-building difficult. The one quantitative study used a non-randomized controlled pre-post design to evaluate whether a program aimed at the staff's cognitions could change how they related to the youth. This study found a positive effect on repressive behaviour. The second quantitative study used a longitudinal cohort design to investigate the prevalence of seclusion after the introduction of a monitoring and feedback system. This study found a reduction in the use of seclusion over time. It should be pointed out, however, that both of these quantitative studies had a high risk of bias.
Question 6. What are children and young people's, foster parents' and institutional staff's experiences with and views on limit-setting and the use of force?
Experiences with, and views regarding limit-setting and force, were investigated in six qualitative studies. A consistent theme in several studies was how employees who behaved with care, understanding and flexibility had a better relationship with the youth than employees who were concerned with strict enforcement of the rules. Two of the six studies focused particularly on the use of digital communication technology in an institutional setting. It was evident that mobile phones and social media were important for the youth's social connections and sense of security. On the other hand, they could be associated with adverse behaviors such as self-harm, nude photos, drug use and sharing of violent incidents. The staff were therefore keen to discuss the challenges of promoting children’s well-being while at the same time protecting their rights.
Discussion and Conclusion
This review has addressed understanding, prevention and experience of use of force in child welfare institutions among youth and staff. There is weak or limited evidence for several aspects of this topic. However, the studies demonstrate how a good relationship between children and professionals can be important for preventing conflicts and violence. At the same time, working in an institution can lead to exhaustion, which exacerbates relationship-building. Several studies highlight youth's use of digital communication and help illustrate dilemmas related to the use of force. The limited evidence may be due to a lack of research on the topic. It may also reflect that our inclusion criteria may have been narrower than they ideally should have been.
We see a need for further research in several areas, especially studies on foster homes and limit-setting. There is also a lack of research into the occurrence, understanding and long-term consequences of the use of force, as well as the consequences of seeing others being exposed to use of force. Future research may explore professionals and foster parents who use force and similar actions. Furthermore, we would like to see more quantitative studies on the effect of preventing use of force.