Child violence experiences in institutionalised/orphanage care

Figures & data

Figure 1. Flow chart: prevalence of abuse within institutional care systematic review – paper inclusion.

Figure 2. Peer violence within institutional care – paper inclusion.

Figure 3. Flow chart: cognitive/social development and institutional care – paper inclusion.

Table 1. Prevalence of abuse.

Study	Location	Sample	Measure of abuse	Prevalence
Abuse by staff
1. Rus et al. (2013)	Romania	1391 (648 female) children within institutional care. Age 7–20 years (M 12.86 [SD = 2.8])	Survey question: ‘Have you happened to be severely punished (beaten) by the staff?’ including both physical and emotional abuse. For ‘yes’, they were asked: how many times have you been severely punished by the staff? (Once/many times)	39.5% had been severely punished or beaten by the staff - 7.7% once and 31.8% reported many times. Males > severe punishment (OR = 1.79) than females (p < .001)
2. Euser et al. (2014)	The Netherlands	N = 329: 168 adolescents (38% female) in institutional care (age: 16.1 [SD = 1.43]) vs. 115 adolescents (53% female) in foster care (age: 15.1 [SD = 1.86])	Self- report questionnaire of 24 questions. Eight physical abuse where included (i.e. An adult in the residential care facility or foster family where I lived (1) hit me on the bottom with a hard object; (2) hit me with a fist or kicked me; (3) grabbed me around the neck and choked me; (4) beat me up; (5) burned or scalded me on purpose; (6) hit me on some other part of the body apart from the bottom with a hard object; (7) threatened me with a knife or gun; (8) threw or knocked me down)	Adolescents exposed to institutional care significantly higher risk of physical abuse than foster care (Risk Ratio – 1.9; 95% CI:1.2–3.0)
				Physical abuse not related to age for any out of home care settings. Males > physical abuse than females (31% vs. 18%)
				42% of those physically abused chose not to disclose the perpetrator. Of those who did disclose, (71%) abused by an employee- their perpetrators were other adults (e.g. teachers, security personnel, strangers; 26% in residential care). Two reported more than one type of perpetrator
Abuse by peers
3. Euser et al. (2014)	The Netherlands	N = 329: 168 adolescents (38% female) in institutional care (age: 16.1 [SD = 1.43]) vs. 115 adolescents (53% female) in foster care (age: 15.1 [SD = 1.86])	Same as 2 above	Institutional care significantly higher risk of exposure to physical abuse than foster care (Risk Ratio – 1.9; 95% CI:1.2–3.0)
				9% of the victims from residential care reported youths of 18 years or older from the residential care facility as perpetrator
Abuse, perpetrator not specified/measured
4. Hermenau et al. (2015)	Tanzania	28 (14 female) children within institutional care. Age 7–12 years (M 9.79y [SD = 1.45])	Physical maltreatment defined as being spanked or beaten. Emotional maltreatment as being screamed or yelled at. Maltreatment and abuse Chronology of Exposure was used to assess adverse childhood experience over 3 time periods	Physical Maltreatment: 93% reported physical maltreatment at baseline, 50% at time 1 and 18% at time 2. Emotional Maltreatment: 61% at baseline, 32% at time 1, and 79% at time 2. N analysed by age or gender
5. Gray et al. (2015a)	Cambodia	1053 (551 female) children in institutional care. Age 10–12 years	Potentially traumatic experiences were assessed using the Life Events Checklist (LEC), a self-report measure developed by the National Centre of Post-Traumatic Stress Disorder (PTSD)	50.3% [95% CI: 42.5, 58.0] of children within institutional care experienced physical or sexual abuse. Did not differ by gender however, incidence of abuse higher within younger adolescents (10–13 years) vs. (14–15 years). 6.6% of children within institutional care reported violence within the family or care setting within the previous 12 months compared to 9.1% of children within family based care
	Ethiopia
	India
	Kenya
	Tanzania
6. Gray et al. (2015b)	Cambodia	1053 (551 female) children in institutional care. Age 10–12 years	Potentially traumatic experiences were assessed using the Life Events Checklist (LEC), a self-report measure developed by the National Centre of Post-Traumatic Stress Disorder (PTSD). This study focused on gender comparisons	Gender specific estimates of abuse within groups were comparable. 50.3% [95% CI: 42.5, 58.0] of those children within institutional care reported physical or sexual abuse. Within the institutional care group the predicted prevalence of physical and sexual abuse at age 13 was 49.4% of males and 51.3% of females. Incidence of physical and sexual abuse within the last 12 months (age 13) was found to be 13.6% males and 12% of females
	Ethiopia
	India
	Kenya
	Tanzania
7. Hermenau et al. (2014)	Tanzania	N = 70–35 children who were institutionalised at birth-4 years of age (16 female) vs. 35 children institutionalised at 5–14 years of age (16 female). Interview age mean 10.5 years range 8–15 years)	Structured interview. Adverse childhood experiences were assessed using the Maltreatment And Abuse Chronology Of Exposure Paediatric Interview. This reflected the number of experienced and witnessed types of physical, emotional, and sexual maltreatment by caregivers toward children	62 (89%) children reported that they had least experienced one ACE type in institutional care. Children who were institutionalised at birth-4 years were more likely to experience abuse than those children aged 5–14 years
8. Hermenau et al. (2011)	Tanzania	38 children within institutional care (IC; 47% female, age: M = 8.56 years [R: 3–16 years])	Children were asked 41 questions about violence (http://www.vivo.org). At t1 children were asked about the violence they had experienced at home, school, in the neighbourhood and within the orphanage over their life time. At time 2, children were asked about the violence they had experiences in these settings over the past 6 months	At t1 children reported that they had experienced and average of M = 4.03 [SD = 3.99], different violent events within the orphanage over their lifetime. At t2 children reported that they had experienced an average of M = 1.93 [SD = 2.40], different violence event within the orphanage within the last 6 months. Findings aggregated by age and gender were not presented in this study
9. Pinto and Maia (2013)	Portugal	86 children in institutional care (IC) vs. 50 children in home based care (HBC) vs. 80 in the comparison group. 111 females, age: range 14–23 years (M = 17.05 years, SD = 1.8 years)	Children completed ACE study questionnaire - evaluates 10 categories of adverse childhood experiences including Emotional abuse: two items (e.g. ‘How often did a parent, stepparent, or adult living in your home swear at you, insult you, or put you down’). A response of often or very often to at least one of the items. Physical abuse: four items (e.g. ‘While you were growing up, that is, during your first 18 years of life, how often did a parent, stepparent, or adult living in your home push, grab, slap, or throw something at you?’). A response of often or very often to the first item or sometimes, often, or very often to the second item. Sexual abuse: four items (e.g. ‘During the first 18 years of your life, did an adult, relative, family friend or stranger ever touch or fondle your body in a sexual way?’). A response of yes to any of the four items. Emotional neglect: five reverse-scored items (e.g. there was someone in my family who helped me feel important or special). A response of never or once in response to one of the five items. Physical neglect: five items (two reverse-scored items) (e.g. ‘I didn't have enough to eat’; ‘I knew there was someone there to take care of me and protect me’.)	Children exposed to IC overall reported higher levels of abuse compared to those children in the HBC intervention on self-report measures (emotional abuse: IC [36%] vs. HBC [18%]; X = 11.36, p < .01; physical abuse: IC [34.9%] vs. HBC [14%]; X = 14.50, p < .01; emotional neglect: IC [57%] vs. HBC [42%]; X = 10.21, p < .01; physical neglect: IC [45.3%] vs. HBC [20%]; X = 22.59, p < .01; sexual abuse: IC [21%] vs. HBC [12.2%}; X = 2.16, n.s.). Based on documented abuse reported in official records children in IC greater amount of physical neglect, emotional neglect and sexual abuse when compared to the HBC intervention group (physical neglect: IC [94.1%] vs. HBC [76%], X = 9.39, p < .01; emotional neglect: IC [38.8%] vs. HBC [32%], X = .634, n.s.; sexual abuse: IC [9.4%] vs. HBC [6%], X = .49, n.s.)

Table 2. Interventions for violence/abuse in institutions.

Study	Location	Sample	Description of intervention	Measures	Findings	Comment
1. Hermenau et al. (2015)	Tanzania	28 children within institutional care (IC; 14 female; age: M 9.79 [SD 1.45])	Training for caregivers of children in IC. Aimed to prevent abuse and improve care quality. Mental health and exposure to abuse within IC assessed at 3 time points; 20 m prior, 1 m prior and 3 m following caregiver training	Structured interview. Maltreatment and Abuse Chronology of Exposure was used. Children’s Depression Inventory (CDI), The Strengths and Difficulties Questionnaire (SDQ) and the Reactive-Proactive Questionnaire (RPQ completed	A reduction in reported exposure to maltreatment over time. 93% reported physical maltreatment at t0, 50% at t1 and 18% at t3. Significantly less physical maltreatment at t3 compared to t1, χ^2(1) = 4.27, p = .018, and t0, χ^2(1) = 17.39, p < .001. Emotional maltreatment for 61% at baseline, 32% at t1, and 79% at t3. Depressive symptomology changed over time, F(252) = 15.00, p < .001 as did internalising and externalising problems, F(254) = 12.58, p < .001. RPQ scores reduced over time; t3 to t0, t(23) = 6.27, p < .001. Findings not aggregated by age or gender	Following the caregiver training intervention, children reported improved caregiving, less physical maltreatment by caregivers, improved mental health and reduced aggressive behaviour. The authors do not comment on the prevalence of violence in terms of gender or age
2. Pinto and Maia (2013)	Portugal	86 children in institutional care (IC) vs. 50 children in home based care (HBC) vs. 80 in the comparison group. 86 children in institutional care (IC) vs. 50 children in home based care (HBC) vs. 80 in the comparison group. 111 females, age: range 14–23 years (M = 17.05 years, SD = 1.8 years)	This study assessed psychopathology, childhood adversity, physical health and health risk behaviours among youths who received one of two different protective interventions which comprised movement from family into residential or foster care (HBC vs. IC). Comparisons were made between groups and with a comparison group	Social-demographic questionnaire, brief symptom inventory (evaluating psychological distress), Rotterdam symptom checklist (measure of physical and psychological symptoms), health risk behaviour checklist, ACE study questionnaire (evaluation of adverse childhood experience). Official records grid.	Children exposed to IC overall reported higher levels of abuse compared to those children in the HBC intervention on self-report measures (emotional abuse: IC [36%] vs. HBC [18%]; X = 11.36, p < .01; physical abuse: IC [34.9%] vs. HBC [14%]; X = 14.50, p < .01; emotional neglect: IC [57%] vs. HBC [42%]; X = 10.21, p < .01; physical neglect: IC [45.3%] vs. HBC [20%]; X = 22.59, p < .01; sexual abuse: IC [21%] vs. HBC [12.2%]; X = 2.16, n.s.). Documented abuse in official records IC > physical neglect, emotional neglect and sexual abuse than HBC (physical neglect: IC [94.1%] vs. HBC [76%], X = 9.39, p < .01; emotional neglect: IC [38.8%] vs. HBC [32%], X = .634, n.s.; sexual abuse: IC [9.4%] vs. HBC [6%], X = .49, n.s.). No significant differences on risk behaviours. IC group significantly > attempt suicide (IC [52.3%] vs. HBC [32%], X =5.28, p < .05)	Significantly higher levels of abuse were identified in the IC group compared to the HBC group. While only one significant difference was found between groups with regard to risk behaviours, attempted suicide was found to be greater in the IC group
3. Hermenau et al. (2011)	Tanzania	38 children within institutional care (IC; 47% female, age: M = 8.56 years [R: 3–16 years])	The intervention consisted of a new instructional system which included training for caregivers. Following an initial workshop, the implementation of the system was supervised for 6 months. Additionally, physical punishment was banned and any maltreatment would lead to dismissal. Children over 12 years were informed of ban and received sex education	Children were asked 41 violence questions (http://www.vivo.org). At t1 violence at home, school, neighbourhood and orphanage over their lifetime. At time 2, over the past 6 months. Plus socio-demographic information, physical health, mental health (SDQ), Post-traumatic stress disorder (UCLA PTSD Index for Children), depression and suicidality (Mini-International Neuropsychotic Interview kid for children and adolescence; section A and C) and aggression (reactive–proactive questionnaire).	Violence within the orphanage was found to reduce between t1 and t2 (t1: M 4.48[SD 4.14]; t2: M 1.93[2.40]; t[28] = 3.42, p < .01), with Cohen’s d indicating a large effect (d = .86)	Experiences of violence within institutional care were found to reduce dramatically after the implementation of a training intervention for staff and the introduction of a zero-tolerance policy concerning maltreatment

Table 3. Summary of studies noting cognitive effects (present, absent or indirect).

Cognitive deficit	No cognitive deficit	No cog. measure but yes social measure	Indirect association – cog. deficit
Sonuga-Barke et al. (2008)	Whetten et al. (2009)	Román et al. (2012)	Rutter et al. (2007)
Rutter + English/Romanian Adoptee Team (1998)	Wolff et al. (1995) – no cog. but social deficit	Fisher et al. (1997)	O’Connor et al. (2000)
Beckett et al. (2006)	Wolff and Fesseha (1999)	McLaughlin et al. (2012)	Croft et al. (2001)
Smyke et al. (2007)		Drury, Gleason, et al. (2012)	Smyke et al. (2010)
Nelson et al. (2007)		Lawler et al. (2014)
Pollak et al. (2010)		Kang et al. (2014)
McDermott et al. (2012)		Gabrielli et al. (2015)
Bos et al. (2009)		Simsek et al. (2008)
Güler et al. (2012)		Rus et al. (2014)
Loman et al. (2013)		Erol et al. (2010)
Govindan et al. (2010)		Simsek et al. (2007)
Bauer et al. (2009)		Davidson-Arad et al. (2003)
Tottenham et al. (2010)		Zeanah et al. (2009)
Mehta et al. (2009)		Lee et al. (2010)
Sheridan et al. (2012)		Daunhauer et al. (2005)
Hanson et al. (2015)		Andersson (2005)
Tottenham et al. (2011)		McGoron et al. (2012)
Vanderwert et al. (2010)
Vorria et al. (2003)
Dobrova-Krol et al. (2010)
Marcovitch et al. (1997)
Drury, Theall, et al. (2012)
Fox et al. (2011)
Ahmad et al. (2005)
Beckett et al. (2007)
Bos et al. (2010)
Ghera et al. (2009)
Miller et al. (2005)
Roy and Rutter (2006)
Vorria et al. (2006)
Cermak and Daunhauer (1997)
Chisholm (1998)
Johnson et al. (2010)
Kreppner et al. (2007)
Lin et al. (2005)
McLaughlin et al. (2010)
Stevens et al. (2008)
Slopen et al. (2012)
Merz et al. (2013)
Levin et al. (2014)
Cardona et al. (2012)
Berument (2013)

Table 4. Summary of studies showing presence or absence of social development issues linked with institutional care.

Social development issues	No social development issues
Ahemd et al. (2005)	Whetten et al. (2009)
Andersson (2005)
Beckett et al. (2007)
Cermak and Daunhauer (1997)
Chishom (1998)
Croft et al. (2001)
Daunhauer et al. (2005)
Davidson-Arad et al. (2003)
Dobrova-Krol et al. (2010)
Drury, Gleason, et al. (2012)
Erol et al. (2010)
Fisher et al. (1997)
Gabrielli et al. (2015)
Ghera et al. (2009)
Hanson et al. (2015)
Kang et al. (2014)
Lawler et al. (2014)
Lee et al. (2010)
Marcovitch et al.(1997)
McGoron et al. (2012)
McLaughlin et al. (2010)
McLaughlin et al. (2012)
O’Connor et al. (2000)
Román et al. (2012)
Rus et al. (2014)
Rutter et al. (2007)
Simsek et al. (2008)
Simsek et al. (2007)
Slopen et al. (2012)
Smyke et al. (2010)
Smyke et al. (2007)
Sonuga-Barke et al. (2008)
Tottenham et al. (2010)
Tottenham et al. (2011)
Vorria et al. (2003)
Vorria et al. (2006)
Wolff et al. (1995)
Zeanah et al. (2009)
Wolff and Fesseha (1999)
Kreppner et al. (2007)
Stevens et al. (2008)
Berument (2013)

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