Violence and alternative care: a rapid review of the evidence

Abstract

This paper focuses on the mechanisms through which international policy and practice relating to the safeguarding of children and young people living in alternative care is being implemented in national policy and practice. It is based on a rapid review of the evidence regarding the violence experienced by children and young people living in different forms of alternative care internationally. The evidence base indicates that children living in alternative care are especially vulnerable to violence and abuse, prior to and during their care experience and also in the longer term. The introduction of the UN Guidelines for the Alternative Care of Children has encouraged greater attention to this issue. The paper concludes that progress is variable according to a range of political, economic and social factors, and that greater attention to practice at national and community levels is required if more effective safeguarding practice is required. A more sophisticated evidence base is required to support this.

Keywords:

• Children
• violence
• alternative care
• international policy

Introduction

The numbers of children and young people living in different forms of alternative care throughout the world are impossible to estimate with accuracy; between two and eight million children live in some form of institutional or residential care, and as many or more again will live in family based care (Pinheiro, 2006; United Nations, 2014; United States Government, 2012). It has been widely recognised in international legislation and policy that different forms of violence are experienced disproportionately by children and young people living in alternative care, and that strong measures are required to ensure their protection and welfare.

This paper has emerged from a rapid review of the evidence relating to violence experienced by children and young people living in different types of alternative care internationally. It is based on a rapid review of the literature undertaken as part of the Know Violence in Childhood initiative, in partnership with the Better Care Network (www.bettercarenetwork.org). The review aimed to examine seven questions relating to children and young people’s experience of violence. These covered three areas: progress in implementing the United Nations Guidelines for the Alternative Care of Children in terms of the provision of safe and high quality alternative care; evidence relating to the relationship between experience of alternative care and experience of violence, both pre-entry and during the experience of alternative care; and evidence relating to the rebalancing of alternative care, including the development of more family-based options.

This paper will focus on the first of these areas, namely the distance travelled in the implementation of the UN Guidelines for the Alternative Care of Children, and the challenges and opportunities associated with this. Conceptually, this is linked to questions about the drivers for policy and practice change in relation to alternative care, and the conditions and resources necessary to trigger such change. Methodologically it raises questions regarding the value of addressing these questions in an international context, and the implications for further development of the evidence base.

It begins with a brief description of the methodology that informed the overall review. It then considers the broad research findings relating to violence experienced by children and young people living in different types of alternative care, and the international policy framework. The discussion then focuses on the question of how this international framework can be translated into action at the level of individual nation states.

Review methods

Rapid reviews of the literature can be distinguished from systematic and scoping reviews by dint of their policy or practice focus, and their emphasis on provide an overview of the topic, often within a short timescale (see, for example, Academy Health, 2015; Gannan, Gliska and Thomas, 2010; National Foundation for Educational Research, 2011; Polisena et al., 2015). The questions that inform rapid reviews can take many different forms, and tend to relate to problems, options or issues relating to implementation, rather than the impact of a single intervention, and can involve a range of different types of evidence.

The flexible nature of rapid reviews also makes them methodologically problematic, in that they can suffer from problems of definition and the diversity of methodologies applied (Academy Health, 2015; Gannan, Gliska and Thomas, 2010). Unlike systematic reviews, they tend not to involve the weighting of different forms of evidence, which can generate bias. These advantages and disadvantages are significant in the context of alternative care, where information generated by NGOs and governments are often as relevant as peer-reviewed research, but where more emphasis may be given to the policy relevance of findings, rather than methodological transparency. Rapid reviews may therefore be best seen as an interim measure, providing ‘best available’ evidence but by no means replacing more comprehensive and robust review methodologies.

Inclusion and exclusion criteria were applied in relation to date of publication, type of publication, language and scope. Conceptually, the research questions for this review are wide-ranging, and search terms were therefore identified according to individual questions, rather than for the review overall. There has been some disciplinary bias towards social care and social work sources. This is notable in that other disciplinary perspectives – for example, in economics, development studies and anthropology –are equally important in understanding the landscape of alternative care internationally, and this has not been fully exploited. The search process took account of the wide range of language used to describe different forms of alternative care. Violence was provisionally defined for the purposes of searching in accordance with the UN Guidelines on Alternative Care and the United Nation’s Committee on the Rights of the Child General Comment No. 13 (2011; see also United Nations, 2014).

Peer reviewed literature was searched using bibliographic databases including the University of Bedfordshire’s Discover; SocIndex; ASSIA; Google; Googlescholar and key research repositories. The search also benefited from two existing databases previously undertaken by the International Centre and with relevant content, though both required updating (Shaw et al., 2010 regarding private foster care; SOS International & the University of Bedfordshire, 2014 regarding violence alternative care). Additionally, reference harvesting provided further material and a small number of key journals were hand searched.

Violence and alternative care

There are well-established methodological difficulties associated with understanding the nature and scale of violence experienced by children and young people living in alternative care. These include a lack of official data collected by states; the associated dependence on data provided by NG0s, which may be of variable quality or methodological transparency; and significant problems of definition (Bronsard et al., 2011; Mann, Lang, Delap, & Cornell, 2012; Meinck, Cluver, Boyes, & Ndhluvu, 2013; Ohara & Matsuura, 2016; Thoburn, 2007). These problems make it difficult to establish how many children live in alternative care, and in which kind of settings, quite apart from exploration of the quality of their care or outcomes from this.

In the present review there are definitional problems associated with both alternative care and violence. The literature demonstrates clearly the multitude of definitions that have been and are attached to different forms of alternative care (McLean, Price-Robertson, & Robinson, 2011) andto what constitutes a child living in alternative care, especially in relation to extended family or kinship care. The definitional issues are equally problematic in relation to violence (Haarr, 2011), Further work is needed to develop to develop tools for measuring the nature and prevalence of different forms of abuse (Stoltenborg, van IJzendoorn, Euser, & Bakermans-Kronenberg, 2011) and there is a lack of replication across research studies. There are a number of issues that help explain this: not all types of violence are recognised in all countries; some definitions of violence may subsume violence against children within other categories, such as domestic violence; some measures may concentrate on referred cases of maltreatment while others on substantiated cases; in some countries reporting of maltreatment is mandatory while in others this is not the case. Violence is also a matter of intrinsic shame and fear, with the result that it may be difficult or impossible to research aspects of the problem, and sophisticated methods are used by care providers to hide the extent of violence, particularly sexual violence against children (Gilbert, Parton and Skivenes, 2011).

The evidence is strong that large numbers of children throughout the world, whether or not living in alternative care, experience high levels of all types of violence (Pinheiro, 2006; UN, 2014). In turn these experiences of violence have been linked to a range of negative outcomes for children and young people. Equally, many of these outcomes are associated with experience of alternative care, and include child mortality and morbidity, physical, emotional and mental health problems, low educational achievement, involvement with the criminal justice system and difficult transitions to adulthood (Gilbert et al., 2009). The overlap between vulnerability and violence is also reflected in studies of other groups – for example, children living on the street (for example, Meinck et al., 2013; Walakira, Nyanzi, Lisham, & BAizerman, 2014; Wlodarczyk & Makaruk, 2013), children living with HIV/AIDS (Thurman & Kidman, 2011) and children experiencing domestic violence (Haarr, 2011). Children who are disabled are also more likely to experience harsh discipline and violence at home (Hendricks et al., 2014).

The literature also emphasises the need to recognise ‘polyvictimisation’, or multiple experiences of violence in different contexts, including the home, peer group, and school as well as different forms of alternative care (Finkelhor et al., 2013). For example, a Polish survey of children and young people’s experience of violence found that 71% of children and teenagers had experienced one form of violence, while one in ten had experienced six or more forms of victimisation (Wlodarczyk and Makamuk, 2013). Awareness and recognition of overlapping and multiple experiences of violence is important in identifying risk and intervening to prevent violence. For example, experience of domestic abuse carries with it many of the same risk factors as other forms of childhood abuse, will often take place within the same household, and is often legitimated by the same social norms (see, for example, Guedes and Colombini, 2016; Haarr, 2011). The pattern of violence will vary according to geographic and cultural context, but overall the striking feature of the evidence is the range and levels of different forms of violence reported by children (see, for example, Pinheiro, 2006; Ruiz-Casares et al., 2013).

An important question has been the extent to which different placement types affect the extent to which different types of violence are likely to be known to be present. There is extensive evidence of abuse in large-scale institutions, usually defined as establishments caring for more than 10 children (Canadian Law Commission, 2000; Colton, 2002; Government of Ireland, 2009; Mathews, Rosenthal, Ahern, & Kurylo, 2015; Senate Community Affairs References Committee, 2004). This evidence has emerged both through historical enquiries illustrating the abuse of power by institutions such as the Roman Catholic Church (Death, 2015) and a significant body of evidence emerging from regions such as Eastern Europe where large institutions continue to play a significant role. A Romanian study found that 38% of 7 to 18-year-olds in residential care reported severe punishments or beatings (see also Popescu, 2016). A report for the Committee on the Rights of the Child in Kyrgyzstan found that children living in institutional settings were beaten, forced to do physical exercise and deprived of sleep (Utesheva, Votslava, & Medetov, 2013). Violence is not confined to institutional care. Violence in formal family foster care is under-researched, but where information exists it is clear that there is also evidence of different types of violence and abuse (Euser et al., 2013). Research relating to extended-family care indicates significant levels of violence and abuse (see, for example, Kulyuni, Alhassan, Tollend, Weld, & Hanna, 2009; Shibuya & Taylor, 2013).

However, the evidence does not suggest that violence is inevitable in alternative care settings, and indeed, there is considerable evidence – albeit not from a sufficiently wide range of cultural and national contexts – that care can be provided in a way that protects children and promotes their welfare (Connolly et al., 2013; Forrester, 2008; Morgan, 2010; Rahilly & Hendry, 2014). Studies asking older children and adolescents for their views have also found that while children continue to miss their birth families and struggle with the impact of separation, they value the safety of the foster care environment (Ahmed, Windsor, & Scott, 2015; Johnson, Yoken and Voss, 1995; McSherry, Malet, & Weatherall, 2013). Rather, the specific vulnerabilities associated with alternative care settings should be considered, firstly, in terms of the wider socio-political and cultural context, including war and conflict and disease, and cultural beliefs regarding different forms of violence. Secondly, there is the question of the alternative care economy, which includes the history of alternative care, the relative role of the state in providing and regulating alternative care, and the mix of placements available.

The international framework

The Guidelines for the Alternative Care of Children were introduced in 2009 in response to this kind of evidence. The Guidelines are underpinned by the United Nations Convention on the Rights of the Child (1989). This asserts a view of children as individuals bearing rights regardless of context, including their right to safety, welfare and to be listened to. More specifically, Article 20 states that a child temporarily or permanently deprived of his or her family environment, or in whose own best interests cannot be allowed to remain in that environment, shall be entitled to special protection and assistance provided by the State. States should ensure that alternative care for children in these situations should be provided, and this could include any of a range of options, including foster placement, kafala in accordance with Islamic law, adoption or placement in an institution suitable for the care of children. When considering solutions, due regard shall be paid to the desirability of continuity in a child’s upbringing and to the child’s ethnic, religious, cultural and linguistic background.

States therefore have a fundamental role in implementing children’s rights in all aspects of legislation, policy and practice, and this should be reflected in support and services to all children who require alternative care (CELCIS, 2012). This should include the establishment of independent bodies such as children’s ombudsmen or commissioners to monitor children’s rights; the promotion of children’s rights through the media and other awareness campaigns; consideration that the rights of all children are upheld regardless of status or circumstances, including poverty, ethnicity, religion, sex, mental and physical disability, HIV/AIDS or other serious illnesses whether physical or mental, birth outside of marriage and socioeconomic stigma. For children in alternative care, this will mean allowing participation in activities that reflect wider social practices.

The development of the guidelines, even before their implementation, served to highlight the evidential gaps associated with the experiences of children living in alternative care. More generally, it takes place in a context where there has been growing interest in the nature of social work and care internationally, and in the challenges and opportunities presented by comparative data.

Attitudes towards what is meant by ‘violence’ towards children changes over time and at a different rate according to cultural and social context. Thus, the use of corporal punishment may be viewed as a matter of normal ‘discipline’, or children with disabilities may be subject to treatment that is violent, including different forms of incarceration (Mathews et al., 2015). In some countries certain groups will be discriminated against, with the result that violence against children in these groups is not recognised or is legitimated, for example in regard to Roma children and young people in Bulgaria (D’Arcy & Brodie, 2015; Petrova-Dimitrova, 2005). Equally, there may be powerful social assumptions about who is most vulnerable to violence – girls rather than boys, younger children rather than older, children living in residential care rather than foster care. This can mean that the violence experienced by some groups – for example, boys’ experience of child sexual exploitation – is underestimated.

Distance travelled in the implementation of the guidelines

The search process demonstrated that the Guidelines provided an important backdrop to descriptions of developments and in providing a common international framework for what states were trying to achieve (Milligan, 2012; Muhamedrahimov & Grigorenko, 2015). In a review of progress and guide to future directions, CELCIS (2012) suggests there have been ‘big steps’ evidenced by a more coherent international policy framework. Arguably the Guidelines have also provided the basis for an international dialogue on the nature of alternative care, and for examination of the extent to which messages regarding good practice are transferable (Berridge, 2016; Kornbeck, 2013).

Regionally and nationally, it is important to note that ratification of international frameworks will co-exist, sometimes uneasily, with other legal systems. The Guidelines are intended to enhance children’s rights, and are complementary to the UNCRC. The extent to which states demonstrate a commitment to the UNCRC, for example through the embedding of children’s rights in domestic law, is therefore important in evaluating progress in respect to implementation of the Guidelines. This is regularly monitored by the UN. Studies reveal that progress has been made in the development of legal provisions, data collection, and the embedding of the UNCRC in domestic law (Lundy, Kilkelly, Byrne, & Kang, 2012). Some examples of promising developments have been identified within the literature. For example, in relation to the development of legal frameworks, Namibia’s Child Care and Protection Act explicitly recognises the role and status of kinship care as an alternative care form (Assim & Sloth-Nielson, 2014). The work undertaken by NGOs in individual countries is important in monitoring progress in these areas.

The UN Guidelines are clear that family based interventions which can help avoid the child’s removal from their family should be a priority in state intervention and there is support internationally for family based alternatives to care. At the same time, it is clear that there are counter-drivers, in the form of disease, war, displacement and migration, and poverty. An extensive body of research attests to the way in which HIV/AIDS epidemic has placed existing systems of support via the extended family under stress in Africa (see, for example, Miller, 2007; Wallis, Dukay, & Mellins, 2010; Sherr, 2008).

Gale (2015), in a comparative study of deinstitutionalisation in Bulgaria and Ukraine, argues that differing socio-political contexts have helped – in the case of Bulgaria – or hindered – in the case of Ukraine – progress in implementing successful policy aimed at reducing the number of institutions. She also notes that political change takes time, and the impact of the shadow of history should not be underestimated. In the case of Eastern Europe, the legacy of state paternalism and autocracy continues to exercise considerable influence. The relationship with other institutions is likely to be important – for example, Jurgena and Mikainis (2005; see also Ivanova and Bugdanov, 2013) note the significance of accession to the European Union in generating discussion about family based care in Latvia. In Armenia, and evaluation of the developing family support (VistAAPlus & Mathematica Policy Research, 2015) found that the development of capacity in the child protection system, including professional training and increasing the number of personnel, were important issues. Relationships between state governments and NGOs will also be important (Rosenbery, Hartwig, & Merson, 2008).

Drivers of change

So, the evidence on violence is discouraging, and it is clear that progress is patchy at best in taking forward policy and practice that support children better with their families, and seek to prevent violence. There are important indicators of the drivers that support change and which indicate that, notwithstanding the methodological difficulties, there is value associated with examining alternative care through a comparative or international lens (see, for example, Kendrick, Steckley, & McPheat, 2008; Thoburn, 2007).

The recognition and awareness of violence as is fundamental to driving change in alternative care and should be prioritised. Underlying this principle is recognition of the relationship between different forms of violence in different social settings, and for all groups of children (Bosnjak, 2009; Pinheiro, 2006; see also Cloward, 2016). This will include an appreciation of levels of violence in the society more generally. There are a number of fora and mechanisms through which such awareness can be generated, including international policy actors (for example, the UN, international NGOs), regional political organisations, historical abuse enquiries, police investigations, parliamentary enquiries, academic reports, national fora in highlighting the issues and the scale of the problem (see, for example, Kendrick, 2014). Wider social interventions will include awareness raising about the nature of abuse, parenting and corporal punishment.

Nevertheless, it will prove difficult to assess children’s experiences of violence when living in alternative care without the generation of more general data concerning the child population and their experiences of violence for comparison. Understanding of the characteristics of the population living in alternative care and the levels of abuse and maltreatment experienced prior to care is important in the design of interventions and identification of areas of policy and practice that need to change. This will include information about sub-groups of children who are especially vulnerable and those who are marginalised, including children who are disabled, minority ethnic groups, and others who may be discriminated against or stigmatised.

This will require developing a better understanding of the context of children’s lives at home, school and in the community. As children have become recognised as individuals who actively create and contribute to their environment, so the richness and complexity of their lives has become apparent. This includes aspects of their lives that are positive and protective, but also those that may be associated with violence or danger for the young person. Some factors, such as the significance of friendships and peers, may involve both benefits and risks (Barter, Renold, Berridge, & Cawson, 2004; Thakkar, Mepukari, Henschel, & Tran, 2015). Research that explores the everyday lives of children and young people can help develop understanding of these issues – for example, a study by young people in Bangladesh which identified interactions with visitors to family homes as something that exposed them to risk of sexual abuse (Aparajeyo Bangladesh & ECPAT International, 2010).

These conceptual issues should not imply a downplaying of the importance of structural developments, specifically the development of systems for the protection of children. This may be linked to the development of other welfare services, including services for pregnant women, ante- and postnatal care, early years care and education, and other health and education services. Stevens, Connelly, and Milligan (2013) found that even where resources, policy and legislation sympathetic to the development of family based care existed, there may be problems of lack of capacity in the system to establish alternative forms of are.

Adapting the analytical framework for understanding violence in alternative care

The complexity of the issues involved in understanding the scale and nature of violence in alternative care can appear overwhelming. In this context, it is important to consider the different levels at which change occurs, and the significance of more informal processes. A key element of this will be less a focus on an ‘international’ picture, and greater emphasis on the regional and local. An appreciation of the extent of difference and of alternative care in cultural and historical context is also needed (Kendrick, 2014; Tobis, 2000), such as the legacy of colonialism or communism (Gale, 2015).

This question of the relationship between local cultures and changes to alternative care runs through debates on measures to reduce violence. Cultural barriers, for example in terms of attitudes to discipline and corporal punishment, have also been highlighted (Frankenberg et al., 2010; Hendricks et al., 2014; Lardhi, 2016). Cloward (2016) discusses the question of the tension between international policy and local norms, and the factors that lead to local practices being abandoned. A number of strategies are available to achieve this, including coercion, material incentives and efforts to influence ‘community leaders’, whose changed behaviour may encourage emulation by the rest of the community. Overall, she suggests, much greater attention needs to be given to the dynamics of local relationships and the mechanisms by which non-state actors absorb international policy messages (p. 10), and the extent to which state bureaucracies have the capacity to communicate new messages. This is highly relevant to the question of violence in the context of alternative care, which also reflects beliefs regarding appropriate discipline and attitudes towards violence. It may also help explain variation in practice within countries. The policy implications of this are not easily deduced in relation to alternative care, but there is little evidence that progress can be made in preventing violence without an appreciation of beliefs about children, family, parenting practices and violence itself. This reflects much thinking in international development more generally; a greater challenge is to translate such thinking into funding and the practice of state governments, international and regional NGOs, and academic research.

Conclusion

This review has both positive and challenging implications in terms of the state of current knowledge regarding the experience of children and young people living in alternative care, though its conclusions should also be viewed as tentative in the light of the limitations of the methodological approach. There is much greater academic interest in this area and this has revealed more about the relationship between history, culture and the political and socio-economic context in shaping children’s lives and experiences of violence. This greater visibility of children living in alternative care, and the trajectories of violence that have characterised many of their lives, is positive. There is also evidence of progress in the development of legal and policy structures within nation states that have the potential to protect children and enhance their welfare. There continue to be major barriers resulting from high levels of child poverty, conflict, displacement and the political relationships between the providers of child care and state governments.

The gaps in evidence have also become apparent within this review. There is a need to identify the mechanisms through which states and NGOs can work together to improve basic data gathering and analysis, both in terms of the population of children living in alternative care and their experiences of violence. This will require the development of research capacity and expertise in different national and regional contexts to meet the needs of policy makers, child welfare services and individual professionals. This should include evaluation of individual programmes or interventions which aim to prevent or mitigate the effects of different types of violence.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by the Know Violence in Childhood and the Better Care Network.