Maltreatment and neglect in societal

care of children and young people

- an overview of research data

Carl Göran Svedin,

Professor

Documentation for the Swedish Government Official Report SOU 2011:9:

Inquiry on Redress for Past Abuse, February 2011
Contents
1. Introduction ........................................................................................................................................ 3
1.1 Commission .................................................................................................................................. 3
1.2 Approach ...................................................................................................................................... 3
2. The vulnerability of children in general - in Sweden and internationally .......................................... 4
2.1 Sweden ......................................................................................................................................... 4
2.2 Norway ......................................................................................................................................... 5
2.3 Iceland .......................................................................................................................................... 5
2.4 Denmark ....................................................................................................................................... 5
2.5 Ireland ........................................................................................................................................... 6
2.6 Wales ............................................................................................................................................ 6
2.7 Australia ........................................................................................................................................ 7
2.8 Canada .......................................................................................................................................... 7
2.9 Summary ....................................................................................................................................... 7
3. Presence of neglect, physical abuse and sexual abuse before placement ......................................... 8
4. Symptoms and behavioural problems of children and young people in social care .......................... 9
5. Neglect, physical abuse and sexual abuse of children and young people in social care .................. 14
5.1 Occurrence ................................................................................................................................. 14
5.2 Events ......................................................................................................................................... 18
5.3 Perpetrators ................................................................................................................................ 19
5.4 Victims ........................................................................................................................................ 20
5.5 Risk factors for maltreatment in social care ............................................................................... 21
5.6 Summary ..................................................................................................................................... 21
6. Survivors - retrospective victim surveys ........................................................................................... 22
7. Program for avoiding harmful treatment in social care ................................................................... 26
8. Children's own accounts ................................................................................................................... 31
9. Summary and conclusions ................................................................................................................ 32
10. Viewpoints and proposals .............................................................................................................. 34
References ............................................................................................................................................ 37
1. Introduction
1.1 Commission

The commission was to collect as much knowledge as possible from literature searches regarding
children and young people who have been victims of maltreatment or negligence when placed in a
foster home or institution for children and young people, nationally and internationally.

The commission is structured in the framework of the committee directive "Redress procedure for
individuals who have been victims of maltreatment and neglect in the social services' children and youth
care" (dir. 2010:15). This commission has its origins in the previous investigation "Neglect in social
services' childcare in the twentieth century" (SOU 2009:99).

1.2 Approach
Literature searches

Data searches were carried out by a systematic review of the Scopus databases, which contain
publications in the areas of research, technology and medicine and include around 18,000 journals
from 5,000 publishers (www.info.sciverse.com/scopus/about/); PubMed, containing bibliographical
references to approximately 19 million journal articles in medicine, nursing, odontology, veterinary
medicine, health care and pre-clinical subject areas since 1948 (www.ncbi.nlm.nih.gov/pubmed/ );
Web of Science, published by the major American company ISI (Institute for Scientific Information)
mediated by Thomson Reuters, which indexes more than 10,000 peer-reviewed journals in natural
science, the humanities and social sciences, (http://apps.isiknowledge.com.lt.ltag.bibl.liu/ ); CSA
Social Services Abstracts, which is a database mainly in social work and sociology since 1979,
www.csa.com and ERIC Education Resources Information Center, which covers large parts of
educational research since 1966 and currently has approximately 1.3 million articles,
www.eric.ed.gov.

The search words in the databases were limited to Swedish, English, Danish and Norwegian. The
search words for care were: Institutional care, orphanage/s, children’s home/s, foster home/s, foster
care, institutionalized child/children, residential care, young offender institution/s, youth detention
center, juvenile detention center, juvenile hall, youth custody, youth center. Concerning
vulnerability: Child abuse/s, abuse of child, child neglect, child molestation, child harassment, child
maltreatment, sex offences, physical abuse, sexual abuse
As regards persons: Child/children, adolescent/s, teenager/s, young people, adult survivors of child
abuse

The years searched were 1990-1999 and 2000-10.

In Scopus: 940 hits.

In PubMed: 714 hits.
In PsychINFO: 720 hits
In Web of Science: 316 hits
In SCA: 1,433 hits
In ERIC: 576 hits
In total there were 4,699 hits using the above search words.

In addition to this, a manual search was made after reference to the references in the databases
searched. A large part of the literature was found in several of the databases.

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There were nearly 40 articles that directly concerned poor conditions during a placement in a foster
home or in an institution, and this compilation discusses these articles in sections 5 and 6. On top of
these there are about 50 articles that indirectly affect children placed in homes, mainly in sections 5
and 7. These articles concern principles, discussions, prevention and policies regarding the abuse of
children in foster homes or institutions. The delimitations are not as clear here, since discussion
articles about different countries' earlier government Inquiries, for example, have been left out of the
compilation. In addition to these, certain articles, usually overview articles, have been used to describe
areas such as the occurrence of maltreatment and neglect in society and its effects on health, the
background and health of children placed in homes, and risk factors involved in taking children into
care and placing them in out-of-home care, in sections 2, 3, 4 and 8.

Many of the publications searched through describe different aspects of children placed in
institutions or foster homes, but there are few that discuss their situation and experience during the
placement. The majority of the publications are from English-speaking countries, with only a few
from Sweden or the Nordic countries.

Studies and reports that are listed and described in the government study on "Neglect in social child
welfare in the 1990s" (SOU 2009:99) are not described, since this has already been done. For reasons
of space, we have not included purely theoretical articles with more political or administrative
descriptions of quality, or rather lack of, in the care of children and young people outside the home.
The review focuses on what we know about the children in research and reports.

Percentages in the referenced materials have been rounded to the nearest whole number.

Definitions

The term children refers to everyone from 0 - 18 years old unless otherwise stated. The concept of
child abuse includes neglect, physical maltreatment and sexual abuse, unless otherwise stated. In
Anglo-Saxon literature, child maltreatment is often used as a collective term, which in the Swedish
original text became roughly malicious treatment of children or child abuse. When only physical child
abuse is involved, this is stated specifically as physical child abuse.

2. The vulnerability of children in general - in Sweden and

internationally
2.1 Sweden

From a number of Swedish studies, we know that among 18 year-olds, 25% of girls and 7% of boys
have been subjected to sexual abuse at some time during their childhood. According to these studies,
10-13% of girls and 3-6% of boys have been the victim of penetrative sexual abuse (Priebe & Svedin,
2009; Svedin & Priebe, 2009). As regards physical abuse, 15% (boys 14% and girls 17%) of school
children in Sörmland stated that they had been hit at some point by a guardian, of which 6% (boys 6%
and girls 7%) on two or more occasions (Annerbäck, Wingren, Svedin & Gustafsson, 2010). These
figures correspond well with the study carried out by Allmänna Barnhuset (Children's Welfare
Foundation) and Karlstad University of pupils in school years 4, 6 and 9, in which 13% of the students
stated that they had been hit by their parents or another adult in the home, of which more than 1% on
many occasions (Svensson, Långberg & Janson, 2007). Of those who had been hit, 19% said they had
been hit hard with a hand or with an object, which was 3% of the total number of pupils in the study.
Of note in the studies on sexual abuse (Priebe & Svedin, 2009; Svedin & Priebe, 2009) was that only 7-
10% of abuse of

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girls and 3-4% of abuse of boys were reported to the authorities. In the study of physical abuse, 7% of
the pupils said that the abuse had been reported to the authorities (Annerbäck, Wingren, Svedin &
Gustafsson, 2010). Those children who came to our attention over a period of one year through the
number of suspected cases of child abuse reported to the police (10,460 cases age 0-15 in 2008) and
sexual abuse (3,816 cases age 0-15 in 2008) only represent a fraction of all children who are abused
physically or sexually in Sweden, which is partly reflected in the low reporting rate as shown in a study
from Swedish daycare centres, where only 37% of suspected cases were reported to the social services
(Sundell, 1997), and the generally low reporting rate from childcare and general psychiatry (Cocozza,
2007).

The international perspective is limited to those countries which, like Sweden, have had similar
studies of neglect in public childcare - Norway, Iceland, Denmark, Ireland, Wales, Australia and
Canada.

2.2 Norway

Norway has carried out a number of studies on children's vulnerability, in particular the occurrence of
sexual abuse. Mossige and Abrahamsen (2007) used the same questionnaire as Svedin and Priebe
(2004) used in the Swedish study, within the framework of the Baltic Sea Regional Study on
Adolescents' Sexuality. Of the 3,363 responses, 14% of girls and 9% of boys aged 17-19 had
experienced enforced penetrative sexual abuse while growing up. In another study, also with a
representative sample of 7,033 school-leavers (18-19 years old), Mossige and Stefansen (2007) stated
that 22% of girls and 8% of boys had experienced milder forms of sexual abuse, while more serious
abuse was reported by 15% of girls and 7% of boys. In this study the respondents were also asked if
any adult in the family had hit them during their childhood. 11% of girls and 7% of boys stated that
they had been hit on one occasion, while 8% of girls and 6% of boys stated that they had been hit
between 2 and 20 times. 2% of the girls and the boys had been hit on more than ten occasions.

2.3 Iceland

There have been few studies on child abuse carried out in Iceland. An epidemiological study
concerning sexual abuse was recently presented (Gault-Sherman, Silver & Sigfúsdóttir, 2009). The
study showed that of 8,618 young people aged 16-20, 18% of the girls and 6% of the boys reported
that they had experienced enforced sexual abuse, meaning physical contact. The most serious form of
sexual abuse was defined as intercourse, which had been experienced by 4% of girls and 2% of boys.

2.4 Denmark

There have been a number of studies in Denmark on sexual abuse while growing up. In one of the first
random sample surveys from 1987 with 2,000 adult respondents (Leth, Stenvig, Pedersen, 1988) 14%
of women and 8% of men stated that they experienced sexual abuse during their childhood (up to the
age of 18). In 2000, the Danish National Institute of Public Health carried out a study of 10,319 adults,
aiming to determine on the basis of a simple question whether they had been forced into sexual
activities, either when they were under 13, between 14-17 or as an adult (Helweg-Larsen, 2002). In
summary, 8% of girls and 2% of boys had experienced forced sexual activities or an attempt at forced
sexual activities.

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Helweg-Larsen and Larsen (2002, 2006) conducted a computer-based study of 6,203 pupils in grade 9
that focused on sexual abuse. In this study, 16% of girls and 7% of boys stated that before the age of 15
they had experienced sexual acts which are punishable under Danish legislation.

Those who had been abused in the Danish school survey had more frequently had an insecure
childhood with parents who had separated, had more often had accommodation outside the family,
found it difficult to talk with their mother when there was a problem and had experienced domestic
violence more frequently. Of all the pupils, 9% of the girls and 12% of the boys had been hit in the last
year. 5% of the girls and 4% of the boys had been hit by their parents during the last year. 9% of girls
and 6% of boys had experienced physical violence against their mother, while 3% of girls and 2% of
boys had experienced violence towards their father during the last year.

Helweg-Larsen, Schütt and Larsen (2008) carried out one further survey in 2008, in which the
methodology of the 2002 study was repeated. A total of 3,976 students from grade nine participated.
In this study, 22% of girls and 5% of boys stated that they had had unwanted sexual experiences with
peers or adults. 7% of girls and 3% of boys stated that they had been hit in their homes.

2.5 Ireland

McGee et al (2003, 2009) carried out telephone interviews with 3,120 adults from the Irish
population. Of the men, 16% said that they had been subjected to sexual abuse with body contact
and 7% without body contact before the age of 17. The corresponding rates for women were 20%
and 10% respectively.

2.6 Wales

There are no separate statistics for Wales, but there have been studies in the UK as a whole and, in
contrast to many other countries, there is also a Child Protection Register which continuously record
all cases of child abuse.

The National Society for the Prevention of Cruelty to Children (NSPCC) carried out the first population-
based study in the UK, in which 2,869 young people aged 18-24 took part (Cawson, 2000; May-Chahal
& Cawson, 2005). In this study, 7% serious physical child abuse was reported, 3% abuse that could
cause concern and 14% abuse that could be described as relatively serious. In the case of sexual abuse
(under 16), 1% had experienced abuse by a parent or guardian, 3% by a relative, 11% by a known
person but not a relative and further 5% by a previously unknown person. The report contained cases
of abuse with and without physical contact. In the case of neglect, 6% of participants reported
deficient care, 5% lack of supervision and 6% emotional abuse. In a subsequent processing of the
material, Cawson (2002) found that 16% of all children in the survey had been exposed to serious
maltreatment by their parents, of which one third had experienced more than one type of
maltreatment. If relatively serious cases are included, occurrence increases to 38% of all the
interviewees who had experienced any form of malicious treatment (serious + relatively serious).

On 31 March 2006, 31,919 children were registered in the Child Protection Registers in the UK. Of these,
2,163 children were registered in Wales. It was estimated that about 700 children were registered each
week in the UK.
2.7 Australia

A number of studies have been carried out in Australia on the occurrence of sexual abuse during
childhood. In a survey in which only women participated, (Mullen et al. 1996), 11% of the respondents
reported sexual abuse (7% penetrative abuse and 4% repeated genital contact). Physical abuse had
occurred among 8% and 12% reported emotional abuse. Altogether, 22% of respondents had
experienced some form of child abuse before the age of 16.

In a smaller study of 427 students, Goldman and Padayachi (1997) examined the occurrence of sexual
abuse in Queensland, Australia. In this study, slightly under 40% of women and 13% of the men
reported that they had been subjected to some form of sexual abuse with physical contact.

Dunne et al (2003) conducted telephone interviews with a random selection of the population (1,784
individuals between 18 and 59). They found that the occurrence of non-penetrative abuse under the age
of 16 was twice as common among women (34%) as men (16%). Of the women, 12% reported that they
had been subjected to penetrative sexual abuse during childhood, compared with 4% among men.

2.8 Canada

The frequency of child abuse and neglect has been studied in Canada through reports to the
authorities in the Ontario Incidence Studies of Reported Child Maltreatment in 1993 and 1998
(Trocmé, Fallon, MacLaurin & Neves, 2003). The number of investigations increased during the period
by 34% from 21/1000 children in 1993 to 28/1000 children in 1998. The number of confirmed cases of
maltreatment of children increased during the same period from 6/1,000 children to 10/1,000
children. The forms of abuse which increased in the reported cases were physical abuse, neglect and
emotional abuse, while investigations of sexual abuse decreased.

In another study from Ontario, 9,953 people were asked about their experience of sexual abuse and
physical abuse (Macmillan et al., 1997). Of the men, 31% reported that they had been subjected to
physical abuse (11% serious abuse) and 4% that they had been subjected to sexual abuse during
childhood. Of the women, 21% reported that they had been subjected to physical abuse (9% serious
abuse) and 13% that they had been subjected to sexual abuse during childhood.

2.9 Summary

There are always difficulties and limitations in comparisons of the occurrence of child abuse and sexual
abuse in different studies, not least regarding studies from different countries. This relates to purely
methodological issues, study design, how the questions are formulated and how one defines sexual
abuse. Added to this, in comparisons between countries, are cultural differences and differences in
legislation. One advantage of later studies is that researchers have begun to realise the benefits of
having identical questions for repeated studies. Accordingly, we can say with relative certainty that the
occurrence of self-reported sexual abuse in Sweden between 2000-2010 is fairly constant; e.g. 10-13%
of girls and 3-6% of boys had experienced penetrative sexual abuse during childhood, i.e. before the
age of 18. There is also reasonably close uniformity in respect of children and young people being hit
by one of their parents, despite slightly different study design (13-15% say they were hit at some time).
This contrasts with the fact that reports, both regarding sexual abuse and physical abuse against
children under 15, have continuously increased during the same period. This has been interpreted by
the Swedish Council for Crime Prevention as an increasing

7
tendency to report such occurrences. If this is the case it is gratifying, since the hidden statistics are
large and less than 10% of perceived abuse and sexual abuse during childhood comes to the attention
of authorities or professionals. In an international comparison, there is a fairly stable pattern that
three times the number of girls report sexual abuse compared with boys, while the picture regarding
physical abuse shows a more equal gender balance. Other comparisons are more difficult for the
reasons mentioned above, but the similarities are larger than the differences particularly among the
Nordic countries and the Australian study, in which 12% of women and 4% of men reported
penetrative sexual abuse during childhood (Dunn et al., 2003).

3. The occurrence of neglect, physical abuse and sexual abuse

before placement
Several studies have indicated that children who are placed in a foster home or an institution are at
particular risk because they have been abandoned, subjected to abuse, neglect or received inadequate
care at home (Benedict, Zuravin, Brandt & Abbey, 1994; Bolton, Laner & Gai, 1981). Ball estimated that
66% of children in social care had previously been abused and Chernoff et al (1994) studied 1,407
children over a two-year period (1989-1991, Maryland, USA) who had come in for a medical
examination in connection with their first placement. They found that the children in care had a
background of abuse in 81% of cases (neglect 51%, physical abuse 25%, sexual abuse 4%).

In another American study of 6,177 children who during a four-year period started a foster home
placement (2001-2004, Utah), 38% were placed due to neglect, 11% due to physical abuse and 4%
due to sexual abuse (Steel & Buchi, 2008).
In a Finnish study of 109 children placed in institutional care, 16% of children in common institutions
and 46% of those placed in specially designed institutions had previously been subjected to sexual
abuse (Hukkanen et al., 1997).

In a summary of twelve studies published between 1999 and 2009, in which Steel and Buchi's study is
included, it was noted that 18-78% of children had been placed in a foster home due to neglect, 6-48%
due to physical abuse and 4-35% due to sexual abuse (Oswald, Heil & Goldbeck, 2010).

Some groups of children placed in care are considered to be more vulnerable to abuse and neglect.
Such groups consist of children with disabilities and children with behavioural and/or emotional
problems (Utting, 1997). It was also noted that while more children receive care and support at
home or in a foster home, the remaining group receiving care in institutions have the greatest
difficulties (Polnay, Glaser & Rao, 1996).

In the report on ADAD (Adolescent Drug Abuse Diagnosis) interviews with children placed in special
juvenile homes by SiS (Swedish National Board of Institutional Care), it emerged that more than half
of the girls had been subjected to physical abuse and 61% to psychological abuse (SiS, 2009). 12% of
the girls had been subjected to sexual abuse by a person they were dependent on. Of the boys, 28%
had been subjected to physical abuse, 25% to psychological abuse and 1% to sexual abuse.
In conclusion it can be stated that a high proportion of children who are placed in a foster home or
institution are exposed to some form of child abuse. From the literature, it can be concluded that
some form of maltreatment of children is two to three times more likely among children placed in
care, with variations between the different categories of abuse depending on the age of the children
and the type of placement. Since this background is associated with mental symptoms and
behavioural disorders to a very large extent, it is not surprising that studies of children placed in care
show high frequencies of both physical and mental ill-health. Criminality and substance abuse are also
widespread among older children placed in care. In Steel and Buchi's study (2008), crimes were
committed by 36%, and substance abuse by parents or children aged 13-18 occurred in 56% of cases.
See also Swedish National Board of Institutional Care (2009).

4. Symptoms and behavioural problems among children and

young people in social care
Children's birth data and early development have been studied in two large register studies. In a Finnish
study, data from the Finnish medical birth register and social register (Child Welfare register) for 1,668
children were analysed and compared with data for all children born in Finland in 1997 (Kalland et al.,
2006). They found that new-born babies placed in a foster home had worse health than other children.
Foster home children had a lower birth weight, were shorter when born and were born prematurely in
comparison with average Finnish new-born babies. The Apgar score one minute after birth was also
lower and the children stayed in the maternity ward longer than other children.
A study from California used a similar method (combination of birth records and social records) to
study data on 26,460 children placed in foster homes and compared them with 68,401 other children
(Needell and Barth, 1998). They found that children placed in homes had lower birth weights, more
birth abnormalities, less preventive obstetric care and came from poorer circumstances.

Other studies have focused on more specific areas of children's early development, such as cognitive,
motor, language and social skills. Pears and Fischer (2005) compared 99 children placed in homes with
a comparison group of 54 children who had not been exposed to abuse or other maltreatment. Both
groups of children were aged three to six, and a significantly higher proportion of foster home children
were shorter and had a smaller head circumference. Foster home children showed lower sensory-
motor and visual-spatial skills, had poorer memory and cognitive abilities and poorer language
development. In another study by the same research team, 117 children placed in foster homes were
studied with respect to the type of maltreatment they had been exposed to and the symptoms they
displayed (Pears et al., 2008).
Poorer cognitive performance was related to neglect and/or physical abuse, while aggressive
behaviour (externalizing) was highest in the group who had experienced both neglect, physical abuse
and sexual abuse, while introverted symptoms (internalization) was related to physical abuse and/or
sexual abuse.

Both American and European studies have shown that the health of children placed in foster homes is
poorer and they are not cared for during their placement (Hjern & Vinnerljung, 2002; Oliván, 2002;
Simms, Dubowitz, and Szilagyi, 2000).

Leslie et al. (2005) studied 1541 children between three months and almost six years old. Of these
children, just prior to their first placement, 87% had some physical ailment (skin problems and
respiratory problems were the most common). Using various psychological test scales, it was shown
that 43- 51% of the children had slightly delayed language development, while 7-13% had

9
significantly delayed language development. Similar findings were noted when non-verbal abilities
were studied using other scales.

Becker-Weidman (2009) studied 57 children placed in foster homes and adopted children who had
experienced chronic maltreatment in their early life and developed reactive attachment patterns.
Using the Vineland Adaptive Behavior Scales-II, it emerged that there was a large and significant
difference in the study group between the children's chronological age (9.9 years) and their
developmental age (4.4 years).

Regarding the mental health of children placed outside the home, the incidence of ill-health has been
studied either through registers or general questionnaires or more targeted, specific questionnaires or
interviews.

In two registry studies based on clinical assessments it was possible to study mental ill-health among
children placed in foster homes, and it was found that among children aged 0-18 this ranged from
32% (Burge, 2007) to 44% (Steel & Buchi, 2008). The incidence of ADHD varies between 10-21%,
Conduct Disorder (CD) 2-8%, Oppositional Defiant Disorder (ODD) 4-10%, depression 5-15%, mood
disorder 2-15% , anxiety disorder 3-12%, attachment disorder 4-17% and adjustment disorder 0.4 -
21%.

When using a more general form, so-called screening forms, it emerges that children placed in foster
homes screened with the Child Behavior Checklist for Children (CBCL; Achenbach, 1991), between 36-
61% of such children are above the threshold for behavioural problems (Baker et al., 2007; Clausen et
al., 1998 ; Hukkanen et al., 1997; Hukkanen et al., 2005; Holtan, Ronning, Handegard & Sourrander,
2005; Sawyer et al., 2007; Tarren-Sweeney & Hazell, 2006).

The most interesting studies from the Swedish perspective, i.e. those that are most comparable to
Swedish conditions, include the Norwegian study by Holtan et al. (2005), and two by Hukkanen et al.
(1997, 2005). Holtan et al. studied 214 children placed in foster homes, either with an unknown
family or with relatives. The children placed in homes were between 4 and 13 years old and had
been placed in homes for more than five years at the time of the survey. Among the children who
were placed in normal foster homes, according to the foster parents' assessment 52% of children
were above the threshold for problem behaviour, while the corresponding figure for children placed
in a relative's family was 36%.
Both groups showed significantly more symptoms compared to the norms for the test. One
explanation for the differences between the two groups was that children who were placed with
relatives had fewer previous placements, were more often placed within their municipality of origin
and had more contact with their biological parents.

In the first Finnish study (Hukkanen et al., 1997) 109 children in institutions were observed. Of these,
47 children (43%) had total values for the CBCL test above the limit for problem behaviour (clinical
area). Boys were more often in the clinical area (55%) compared to girls (26%). Children who had been
sexually abused before being placed in foster homes and children who lived in special institutions had
higher scores on the subscale of externalization as well as internalization. In the other Finnish study
(Hukkanen et al., 2005) 140 children were divided into three study years: 1993, 1996 and 1999. It
could be seen that the overall points on CBCL increased during these years and the number of children
on the subscale of internalisation was over the limit for problem behaviour (clinical area) at 35%, 45%
and 61% respectively for the three years. In 1999, 70% of children also had clinical values on the
subscale of externalisation.

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In a study from the Odyssey Project Population, developed by the Child Welfare League of America,
children in Residential Treatment Centers, RTC, were compared to those in Therapeutic Foster Care,
TFC. The study involved 2,274 children from 22 authorities in 13 states. In the comparison between
RTC and TFC, it was noted that the proportion of children in the clinical part of the CBCL
(measurements taken 90 days after registration) was approximately the same in both groups (RTC 55%
and TFC 52%), while there was a clear statistically significant difference in the case of externalisation
(RTC 60%, TFC 48%) and criminality (RTC 37%, TFC 25 %) as well as a slightly weaker difference in
internalisation (RTC 40%, TFC 36%), anxiety/depression (RTC 17%, TFC 13%) and aggression (RTC 24%,
TFC 21%). In all these areas, the children in RTC had more problems and symptoms than those in TFC.
Only attention problems were significantly more common among children placed in foster care (RTC
17%, TFC 22%). The results support those who argue that institutionalised children have more
problems, in particular the externalisation category, than children placed in foster homes - also found
in an English study (Meltzer et al., 2003)

Another screening form, the Strengths and Difficulties Questionnaire (SDQ, also used in Sweden), was
used in a study in Scotland of 182 children aged 5-16 placed in foster homes. In this study, 64% of
children were estimated to be above the limit for problem behaviour on the overall scale, according
to their foster home parents' assessment (Minni et al., 2006). The children also had high scores on the
subscales: hyperactivity 54%, emotional problems 45%, conduct problems 66%, friend problems 63%
and on the pro-social scale 38% had difficulties, scoring above the cut-off score.

In a separate study from England, Scotland and Wales, 1,453 children in care were compared with
10,438 children from the normal population (Ford et al., 2007). It was found that 45% of the children in
care had mental problems and 71% of those placed in an institution had more problems compared
with those who were placed with relatives (71% and 32% respectively).

In an Australian study in which children placed in foster homes estimated their own health using the
Youth Self-Report (YSR, Achenbach, 1991), 35% of children (aged 6-17) were over the limit for problem
behaviour (Sawyer et al., 2007). The children placed in foster homes had more attention problems, more
social problems, more criminal and aggressive behaviour, more anxiety and depression symptoms and
reported more physical problems than the comparison group.

In a Turkish study (Erol, Simsek, & Münir, 2010) 350 children (aged 11 - 18) placed in institutions were
compared with a group of children of the same age living at home with their parents (n = 2,206). In
addition to the self-assessment form YSR and the parental form CBCL, the survey also used a Teacher's
Report Form (TRF, Achenbach, 1991). The children placed in an institution reported four times more
mental health problems than their peers living at home, and parents and teachers reported twice as
many symptoms and problematic behaviour in the institution group. The symptoms exhibited were
over a broad range and the authors concluded that the real situation regarding mental ill-health is far
more complicated than the stereotyped picture of children in institutions mainly showing externalised
problems of aggression and criminality.
The authors stated how remarkable it was that only 2% of the children placed in institutions had
received any kind of specialised psychological/psychiatric help for their problems during their stay in
care.

A number of studies have observed specific disturbances using specific forms for children placed in
care. The most commonly studied symptoms/problems were attachment disorders. In three
different studies, higher proportions of children with attachment disorders were found through

11
interviews (Zeanah et al., 2004) or by using the Reactive Attachment Disorder Questionnaire (RAD)
(Minnis et al., 2006; Milward, Kennedy, Towlson & Mannis, 2006).

Indiscriminate friendliness has previously been associated mainly with institutional children (Chisholm,
1998). However, this behaviour has also been noted in foster home children in several studies (Pears
et al., 2010), and it was associated with both the number of placements and a lack of impulse control
(Pears et al., 2010).

Post-traumatic stress has been reported to be almost twice as common (19% versus 11%) among
children in foster homes who came under investigation due to child abuse, compared with children
not placed in homes (Kolko et al., 2010). Four factors contributed to the higher frequency of PTS
symptoms: younger children, assault by non-biological parents, family violence and the child's
depression. Dubner and Motta (1999) studied PTSD in 150 children aged 8-19 placed in foster homes.
PTSD was diagnosed in 64% of children subjected to sexual abuse, 42% of children subjected to
physical abuse and 18% of children neither sexually nor physically abused.

The occurrence of substance abuse has been studied using American registers (National Household
on Drug Abuse, 2000) in which 464 children placed in foster homes were compared with the total
register of 19,430 young people aged 12-17 regarding their use of alcohol and drugs (Pilowsky & Wu,
2006). Foster home children used alcohol more often and were two to four times more likely to have
another form of abuse, i.e. poly-drug abuse.

Allen et al. (2000) studied the occurrence of depression by asking 160 foster home children aged 8-16 to
answer the self-assessment form Children's Depression Inventory (CDI). No difference in symptoms
presented was found between foster home children, published norm data or a comparison group of
peer children.

Eating disorders have also been studied among children placed in foster homes. In an Australian study
of 347 children aged 4-9, 25% were identified with eating disorders (Tarren-Sweeney, 2006). Two
types of pattern could be identified: overeating without weight gain and pica-like behaviour (fixation
on eating certain things not normally considered as nutritive) which was also correlated with self-
harm.

In a study from Kurdistan (Ahmad, 1996) children placed in foster homes were compared with
children placed in orphanages on two occasions, with a one-year interval. CBCL and two instruments
that measured post-traumatic stress syndrome (PTSD) were used in the assessment. The
competency scales in CBCL improved during the year of the study in both groups, but while the
children in the orphanage group showed increased symptoms, children placed in foster homes
exhibited decreased symptoms during the same period. Orphanage children also had a higher
frequency of post-traumatic stress syndrome than children in foster homes.

Few studies have used diagnostic interviews as a method of measuring mental ill-health/psychiatric
diagnoses among children placed in foster homes. In one study of 17 year-olds, 373 children placed
in foster homes were interviewed using the Diagnostic Interview Schedule for DSM-IV with the
sections that measure post-traumatic stress (PTSD), depression, mania, ADHD, ODD and CD
(McMillen et al., 2005). 61% of children had a psychiatric diagnosis during their childhood, and 62%
of these had a diagnosis before they were placed in a foster home. In descending order, the
diagnoses were CD/ODD (47%), depression (27%), ADHD (20%) and PTSD (14%) and mania (6%).
Comorbidity was common and 32% had had more than one psychiatric diagnosis during their

12
upbringing. The number of different types of maltreatment was the strongest predictor for a
psychiatric diagnosis.

Teplin et al. (2002) found that the most common diagnoses among boys and girls placed in institutions
were substance abuse, conduct disorder and defiant disorder, followed by anxiety disorder, mood
disorders and ADHD. Similar results were found by Fazel, Doll and Långström (2008) in a meta-analysis
of 25 different studies. A tenfold increase in psychotic disorders was also found compared to the
normal population.

A Swedish study of 100 young people placed in institutions (SiS) in south-west Sweden observed the
occurrence of various diagnoses using DSM-IV (Ståhlberg, Anckarsäter & Nilsson, 2010). In this study
(92 boys and 8 girls, average age 16), it was found that 73% of these young people had at least one
psychiatric diagnosis. 48% of the young people met the diagnostic criteria for ADHD under DSM-IV,
17% for autism spectrum disorder and 17% had delayed development.

In conclusion, the Swedish National Board of Institutional Care (SiS, 2009), using ADAD interviews,
reported on health and behaviour problems of young people who had initially been placed in care in
2008. 1,437 cases of care were started in 2008 and ADAD interviews were carried out on 1,264
occasions. In total, 830 interviews (66%) were carried out, but 84 of those interviewed chose not to be
included in the research register, the interview was too late in 28 cases and the subjects had been
interviewed several times in 49 cases.
The report finally included 669 young people: 36% girls and 64% boys.
Of the interviewees, 42% were 15 or under, 40% were 16-17 and 18% were 18 or over. Placement was
the result of an acute situation for 58% of the subjects. Many of the young people had come from
broken homes. The most common situation was that they had grown up with either both parents or
only their mother. Just over half of the young people interviewed had previously been placed in an
institution for treatment. 23% of them had repeated a year in school and just over half had been in
special education. 12% had gone to special schools and 45% had been suspended from school at some
point. Two thirds of the young people spent time with friends who had committed crimes and 61% of
young people had close friends who had problems with the police due to substance abuse.
The most common health problem among young people was poor sleep (68% girls, 52% boys). One
third had backache (42% girls, 28% boys) and 28% often had headaches (48% girls, 17% boys). Half of
the young people interviewed said that they had problems with severe worry/tension/ or with their
concentration. Almost half had undergone severe depression at some point. A larger proportion of
girls compared with boys stated that they had experienced some of these mental disorders. 46% had
problems with violent behaviour, more commonly girls (56% compared with 41% of the boys). 35% of
the subjects had been given out-patient care and 14% in-patient care for mental health problems. A
significantly larger proportion of girls had been given care in one of the two forms. The most common
offence was shoplifting, which two-thirds of the young people had been involved in. The second most
common offence was assault (68% of the boys and 46% of the girls). Theft and vandalism were the
next most common crimes, which almost half of the young people had committed. Boys had
committed more types of crime and were more criminally active than girls. The crime debut age for
boys was generally a little lower than that for girls. Most of the young people interviewed had drunk
alcohol at some time, and 56% had used marijuana or cannabis. Just over one third had used
amphetamines and a quarter had used pain killers. 27% of the subjects stated that they had used
pharmaceutical products and 14% said that they had used heroin/opiates.

In conclusion it can be said that children placed in care have a significantly higher risk of exhibiting
symptoms and behavioural problems of a more generalised type as well as more specific symptoms,

13
both in conjunction with being placed in care and during the time they are in care. With the support of
the above literature and other studies, we can conclude that 40% - 70% of all children placed in care
have mental problems and behavioural disorders of significant clinical importance. These problems are
largely explicable by neglect and potentially traumatising experiences during childhood, but other
factors such as neuro-biological vulnerability, their age when first placed in care, the number of places
providing care and the quality of the placements are also significant. The increased presence of
symptoms, behavioural disorders and clinical diagnoses are also accentuated among institutionalised
children, who generally have more problems than children placed in foster families.

5. Neglect, physical abuse and sexual abuse of children and young

people in social care
5.1 Occurrence

Before continuing with the review, it should be pointed out that placing a young child in an institution
per se involves considerable risks for the child's development and health. It is now avoided in Sweden
if at all possible, as in a number of other countries. Instead of infants' homes and children's homes in
the years before school starts, placement in a foster home with relatives or other families is
preferred. This is to avoid the more or less inevitable side effects that placement in an institution
often results in, as well documented in research.

Johnson, Browne and Hamilton-Giachritsis (2006) made an overview of 27 studies that examined the
consequences of early institution placement (before the age of five) on children's bonding, social and
behavioural development and cognitive development. The impact on the development of children's
attachment capacity was studied in 12 of the 27 studies, and the authors summarized that "even
seemingly 'good' institutional care can have an adverse impact on the ability of the children to form
relationships later in life. The lack of a warm and continuous relationship with a sensitive guardian can
result in children who are in desperate need of adults' attention and love". Even though there are
exceptions, such as the staff's favourite child, children living in an institution generally have few
chances to really bond with a person when compared with children in a foster family. This is
particularly the case in institutions where there are many children, few staff and a lack of consistent
and continuous care due to scheduling and staff turnover.

From the 17 studies that examined social and behavioural difficulties among institutionalised children,
it could be concluded that children brought up in institutions had more difficulties or problems with
their behaviour and poorer social skills, as expressed in their games and interactions with friends and
siblings. The authors found that early placement in an institution predisposed children to behavioural
and social problems later in life. Much behaviour among severely under-stimulated institutionalised
children, such as stereotypical behaviour and eating disorders, improve rapidly after transfer from
institutional care to a supportive family environment. Placing children in such an environment,
however, is still not sufficient to overcome these difficulties. A poor outcome for some children who
return to their biological families indicates that the quality of the subsequent family environment is an
important factor in how children develop after being placed in an institution. Hodges & Tizard (1989a)
showed that placement in a supporting family after staying in an institution may result in close
bonding within the family, but that many institutionalised children continue to have problems outside
the family with friends and adults.

The third part of the survey consisted of the 13 studies that analysed the cognitive development of
children placed in institutions. Twelve of the studies showed that this had a negative impact on the
children's cognitive development. A good institutional environment with high standard may compensate
for this, however (Hodges & Tizard, 1989b) and later adoptions of Romanian children
14
from institutions have shown that there is good potential for recovering a large part of their cognitive
potential (Rutter et al., 1998; O'Connor et al., 2000).

Irrespective of whether children placed in care are subjected to abuse or neglect, Young (1990) states
that foster home children feel oppressed and controlled. Young says that the oppression they feel can
be described in five different forms: exploitation, marginalisation, helplessness, cultural imperialism
and violence. Bruskas (2008) refers to Young's categorisation and says that children in foster homes
do not feel only one of these forms, but all five.

Gallagher (2000) defined institutional-related abuse as "sexual, physical or emotional abuse of

children (under 18) by an adult who works with the child. The offender may be an employee or a
volunteer, in the public, voluntary or private sector, not necessarily at an institution, and may work
directly with children or have some support function". Thus, Gallagher's definition did not include the
abuse that may take place between children placed in a foster family or institution.

The fact that children suffer from neglect or different forms of abuse while in social care for various
reasons is not a new phenomenon, but in many countries around the world this was particularly noted
in the late 1990s. This could apply to children in general, but in several cases also children from specific
minority groups such as indigenous peoples in the United States, Canada and Australia. The abuse
reported around the world may have occurred in various environments where other persons than
parents were responsible for the children. This may have taken place in organisations engaged in social
care, such as foster families, children's homes, reformatories and prisons, but also in voluntary
organisations such as boarding schools, with or without specialisation, religious or other non-profit-
making organisations such as sports and scouts. In short, this type of abuse has occurred whenever
children are looked after by other people.

At an early stage, Gil (1982) described three different forms of maltreatment in institutions. The first
was an open or direct form, including all forms of sexual, physical or emotional abuse of a child by an
employee, i.e. very similar to the forms of abuse which take place in society or within a family. The two
other forms were unique for institutional environments, though. What she calls "program
maltreatment" consisted of the institution's habits, procedures or treatment programs, and even
though it was accepted by the staff, an outsider would consider it to be abuse. Unlike sexual abuse,
which staff know is punishable, perpetrators of physical abuse sometimes believe that their conduct is
a legitimate part of the treatment program. The third form described by Gil is "system maltreatment",
which is not perpetrated by an individual or special treatment program, but which consists of the
extensive and complex system of social care of children. As such it is difficult to manage and does not
meet the child's needs of safety and protection.

Wolfe et al (2003) state that maltreatment in an institution from an individual perspective is usually more
an on-going process than an isolated event and involves the abuse of power and loss of trust, and may
include physical abuse, sexual abuse or emotional abuse/neglect.

In a broader perspective, we can see at a more systemic level that abuse within an institution involves
both the authorised use of special means of upbringing and handling of children as well as
shortcomings in the management and control systems for protecting children (Stein, 2006).

Attempts have been made to estimate the prevalence of maltreatment of children in public institutions
and among children placed in foster homes.

The only document regarding child abuse in Swedish social care is by the National Board of Health and
Welfare (1997). One survey was made by county administrative boards during the period 1988-1993,
when a total of 18,526 children were placed in foster families at any one time. The report showed that

15
there were 86 cases of suspected sexual abuse in the foster family during these years. Reports to the
police were made of 73 suspected perpetrators, of which 47 investigations were closed down. Legal
action was taken against 34 perpetrators, of which 32 were sentenced for criminal offences. Of the 86
cases reported, nine out of ten were girls, just over half were in compulsory care, 27% had immigrant
backgrounds and 15 girls were described as slightly delayed in their development. No less than 62 of the
86 children had previously been placed outside the home and 24 had previously been suspected victims
of sexual abuse. In 70% of cases the suspect offender was the father of the foster family and in 20% of
cases it was foster family sons, boys placed in the family or persons known to the victims. Four foster
home mothers were reported as suspects.

In an early survey by Hennepin County Community Service (Minneapolis, USA), 125 reported cases of
maltreatment and neglect were examined in 570 foster homes in the catchment area during an 18-
month period (May 1980 - November 1981). This corresponds to a frequency of approximately 22%, on
the assumption that each family only had one child placed with them (Cavara & Ogren, 1983). The high
frequency was assessed as partly due to the municipality developing a clear action plan for the
processing of complaints concerning child abuse. The frequency of investigations was four times more
than in municipalities that did not emphasise the importance of rigorous investigation procedures,
comparisons being made with a study by Bolton, Laner and Gai (1981) among others.

In Bolton, Laner and Gai's survey (1981) from Maricopa County, Arizona, reports of maltreatment in
foster families were compared with reports from all other types of families. Foster families were more
frequently reported for suspected maltreatment of children placed in their care (7%) compared with
other families (2%).

A survey of national data from USA by Nunno & Rindfleisch (1991) found 158 reports per 1,000 children
concerning maltreatment of children placed in care and thus separated from their parents (16%). It was
estimated that of these, 27% were confirmed - leading to the conclusion that 42 per 1,000 children per
year had probably been maltreated. By way of comparison, the proportion of confirmed cases among
all American children was 26 per 1,000 children (United States Department of Health and Human
Services, 1988).

Rindfleisch and Rabb (1984) carried out one of the first extensive surveys to describe the occurrence of
maltreatment (respondents' own definition) in institutions in 48 US states in 1980. Information from
1,700 institutions was collected, with a response rate of 65%. On average there were 39 reports of
maltreatment per 1,000 children. It could be confirmed that abuse had occurred in 10 cases per 1,000
children. On a follow-up visit to 12 institutions in four states, significantly more cases were noted and
only one in five cases led to a report to the supervisory authority/social authorities.

The New York State Commission on Quality of Care (1992) reported a rate of maltreatment as high as 87
reports per 1,000 children in its institutions. This figure was in marked contrast to the frequency of 28
reports per 1,000 non-institutionalised children in New York State.

Spencer and Knudsen (1992) made an analysis of five years' reports (1984 - 1990) to the Indiana
Department of Public Welfare related to physical maltreatment and sexual abuse. The authors noted
that reports from the different types of institutions and foster families were few, but on the other
hand the number of reports per 1,000 children were significantly higher for institutionalised children

16
(120/1,000) and foster family children (17/1,000) compared to children who were living in their own
families (112/1,000). All forms of round-the-clock care had higher rates of reporting than those of
daytime organisations such as schools, daycare centres etc.

Zuravin, Benedict and Somerfield (1993) studied 296 foster homes in Baltimore City Department of
Social Services over a period of five years (1984 - 1988). They found that 62 foster homes (21%) had at
least one report of maltreatment during that period. The families without any reports became the
control group when studying the differences between the two groups regarding risk factors; refer to
description below. In another study from the same material (Benedict, Zuravin, Brandt & Abbey, 1994),
which took place over three years (1985-1987) and compared reports between foster homes and other
families in society, 15% of foster homes had been reported for neglect, physical maltreatment or sexual
abuse compared with 4% of other families, i.e. a three to four times higher risk for children living/cared
for in a foster home.

Hobbs, Hobbs and Wynne (1999) studied reports from paediatricians to social authorities (157 episodes
for 133 children placed in foster homes and 34 episodes for 25 institutionalised children) regarding
alleged physical child abuse and sexual abuse over a period of six years (1990 - 1995) in Leeds. In their
study, it was seven to eight times more common that children placed in foster homes and six times more
common that children placed in institutions were investigated by paediatricians for alleged physical
maltreatment or sexual abuse compared to children in the general population.

Poertner, Bussey and Fluke (1999) studied reports of maltreatment and neglect to the Illinois Department
of Children and Family Service over a period of five years (1993-1997). They found that about 2% of all
children placed in care per year were reported to have been subjected to maltreatment or neglect. In
their material, there were more reports of physical maltreatment among children placed with relatives,
while reports of sexual abuse were most common in institutional care, including group accommodation.

Gallagher (2000) reviewed reports of sexual abuse to the social services or police in eight geographical
areas in England and Wales over five years (1988 - 1992). The survey had unusually wide criteria for
inclusion, and in addition to institutions, boarding schools and foster homes it included a wide range of
local organisations such as schools, children's clubs and child-minders' homes. When reviewing
documentation on some 20,000 cases, a total of 65 cases of confirmed sexual abuse were found,
corresponding to approximately 13 cases per year in the catchment area. The authors extrapolated
these data to the whole of England and Wales and stated that they would correspond to around 920-
930 cases, or approximately 185 cases per year. The 65 cases were equivalent to 1% of all reports to the
social services and 3% of all reports to the social services concerning sexual abuse. The corresponding
figures for reports to the police were 1% and 2% respectively. About half of the 65 cases were related to
municipal-based organisations (52%) while foster care (34%) and institutions (14%) made up the
remainder. The most common occurrence was maltreatment in public sector organisations (62%), while
private organisations (19%) and voluntary organisations, including religious organisations, (19%)
accounted for the rest of the cases.

In an Israeli study that compared 360 young people aged 13-19 placed in reformatory institutions and
7,012 normal school children, it was found that institutionalised children were subjected to more
maltreatment by staff compared to school children in normal schools (Davidson - Arad, Benbenishty &
Golan, 2009). This applied mainly to being pushed, sworn at, kicked/hit or subjected to sexual comments.
Boys at institutions had also been exposed to unwanted molesting more often.

In a study from the Odyssey Project Population (see above) it was found that 399 of the 1,321 children
(30%) in registered therapeutic communities (RTC) had been subjected to sexual abuse (Baker, Curtis &
Papa-Lentini, 2006).

17
5.2 Events

In the previously mentioned survey by Hobbs, Hobbs and Wynne (1999), physical maltreatment was the
reason for reports in 32% of cases and sexual abuse in 57% of cases. The remaining 11% of cases
consisted of a combination of physical maltreatment and sexual abuse. In the group of institutionalised
children, the distribution of physical maltreatment was 50%, sexual abuse 25% and mixed forms a further
25%.

Rosenthal et al (1991) went through 290 reports of physical maltreatment, sexual abuse and neglect
among children placed in foster homes, group homes, treatment institutions and other institutions.
Their study was based on an analysis of cases over four years (1983-1987) that were reported to a
special investigation team within the Colorado State Department of Social Services. Physical
maltreatment was the most common cause of reports at 55% (49-64%). Sexual abuse accounted for
24% (20-29%) and neglect for 21% (16-22%) of the reports. This order was not correlated with the type
of placement.

In Spencer and Knudsen's study (1992), the most common occurrence was physical maltreatment in
a foster home, while sexual abuse was most widespread among institutionalised children and neglect was
most common in state institutions.

Blatt (1992) studied 510 reports of maltreatment of institutionalised children reported to the New York
State Child Abuse and Maltreatment Register over a 16-month period (1986-1988). In a comparison of
reports concerning institutionalised children and reports relating to other children, scratches and cuts
were considerably more common among reports of institutions (35% compared with 18%) while neglect
was much rarer (5% compared with 27%). There was a significant difference when maltreatment
occurred. It was more common that institutionalised children were subjected to maltreatment or abuse
during periods of the day when they were awake and fewer staff were on duty, in this case between 5
p.m. - 11 p.m. and 7 a.m. to 8 a.m. The authors concluded that low numbers of staff was a factor that
increased the risk of abuse.

In the study by Benedict et al (1994), physical maltreatment (60%) was the most common cause of
reports concerning instances of poor conditions in foster care, while neglect accounted for 17% and
sexual abuse 11% (in 11% of cases there was a combination of the different forms). Even though reports
relating to foster care only accounted for just over 1% of all reports, they were almost four times higher
compared with reports for all other family types. Reports of physical maltreatment, which were seven
times more common, was the type with most variation between the groups. Reports relating to
suspected sexual abuse were slightly over four times more common and reports relating to neglect
around twice as common in foster care. Continued processing of the material (Benedict, Zuravin,
Somerfield, Brandt, 1996), showed that children who are victims of sexual exploitation in foster care
were more frequently placed outside the family and relatives, i.e. in an unknown foster home. They had
more mental health problems and development problems than other children in the study. Neither
physical maltreatment nor neglect during a stay with a foster family was related to the children's health
or level of functioning.

18
Nunno, Holden and Tollar (2006) described 45 deaths among institutionalised children between 1993-
2003 in the United States due to so-called restraint (holding the body with or without technical aids).
The most common cause of these deaths was suffocation.

5.3 Perpetrators
The suspected perpetrators in Hobbs, Hobbs and Wynne's study from Leeds (1999) were one of the foster
home parents in the case of children placed in foster homes (41%), one of the biological parents in
conjunction with rights of access (24%), and other children (20%). With regard to the children placed in
institutions, the perpetrators were a staff member (32%), another child at the institution (16%), and
another child outside the institution (52%).

In the study by Rosenthal et al (1991), 64% of the perpetrators were men, and this tendency was even
clearer in the case of sexual abuse, where 77% of the perpetrators were men. The majority of the
perpetrators were staff and foster home parents, but in the case of sexual abuse, 21% of the
perpetrators came from foster family siblings.

In Blatt's study (1992), 77% of the suspected perpetrators were men, and reports from institutions
indicated that younger staff (< 35 years old) were taken up more often in such reports.

In the study of foster homes by Benedict et al, foster home parents made up 80% of the suspected
perpetrators of physical maltreatment and neglect, but only 40% of the cases of suspected sexual
abuse. In the case of sexual abuse, the perpetrator was more frequently a sibling or another person.

Studies from England and USA show that children placed in institutions have an increased risk of being
maltreated by other children at the institution than by staff (Spencer & Knudsen, 1992; Farmer &
Pollock, 1998; Sinclair & Gibbs, 1998; MacLoad, 1999). One of the studies analysed responses from 223
children in 48 different institutions (Sinclair & Gibbs, 1998). 13% of children reported that they had been
sexually abused and 40% said that they had been bullied by a contemporary at the institution. One of
the problems and thus the risk of abuse between peers, which Farmer and Pollock (1998) point out, is
that sexually abused children are placed with young people who have committed sexual offences.

In an interview study of 71 children (6-17 years old) from 14 different English institutions, Barter et al
(2004) found that no less than 62 of the 71 children had experienced violence between children at the
institution (87%). Some had experienced physical violence, either as victims (40) or perpetrators (25) of
violence, or as witnesses of physical violence (15). Twenty-one children described serious violence in
the form of knife attacks, kicks or fist fights. About half had experienced violence that did not involve
physical contact, such as damage to personal property, physical threats or being controlled by threats
from someone else. In nine cases (13%) there had been sexual violence with forced physical contact,
such as molesting, and in one case, rape. There were a further nine cases of sexual behaviour without
physical contact, usually in the form of sexual humiliation. It was most frequently girls that were
affected in cases of sexual violence. All children had experienced verbal violence in the form of
harassment and insults.

In the study of reports made to the social services concerning sexual abuse in England and Wales
(Gallagher, 2000), in 92% of cases the perpetrator was alone in carrying out abuse of children, and in
96% of cases the perpetrator was a man.

In two studies, Cameron (2003, 2005a, 2005b) examined how common it was that foster home parents
who had sexually abused children were homosexual. Through searches in the Lexis Nexis Academic
Universe, an internet-based search engine mainly for American newspapers, Cameron found that among

19
6,444 articles over the period 1989-2002 there were 33 articles about foster homes where a child was the
a victim of abuse. In 25 of these cases the perpetrator was a foster home parent and 15 cases (60%) were
homosexual abuse (2003, 2005a). The same article analysed all registered cases of physical or sexual
abuse over the period 1997-2002 in Illinois. During this six-year period, 270 parents had abused foster
home children, including those adopted later. Sixty-seven of 97 foster home mothers (69%) and 148 of
the 173 foster home fathers (86%) had abused girls. Thirty of the foster home mothers (31%) and 25
foster home fathers (14%) had abused boys. In total this means that in 92 cases (34%), a foster home
parent had abused a child of the same sex.

Another article which searched newspaper articles between 1980-2003 found that 175 foster parents
had sexually abused children in their care (2005b). The sex of the child was known in cases concerning
169 perpetrators. Of these, 149 of the perpetrators were men and 20 were women. In 76 cases of male
abuse, the victim was a boy (51%) and in 14 cases female abuse the victim was a girl (70%).

5.4 Victims

In Hobbs, Hobbs and Wynne's study (1999) of reported cases of sexual abuse and physical child
maltreatment, 56% of the foster family group were girls and 68% of the institution group were boys. Of
the cases reported in the foster family group, 60% of cases of sexual abuse were girls and 60% of cases
of child maltreatment were boys. Of the cases reported from institutions, the proportion of girls who
had been sexually abused was 33% and the proportion of boys who had been physically maltreated was
67%. The average age of children placed in foster homes was lower than those placed in institutions
where abuse was suspected: just under 7 and just over 12 respectively. In the foster home group, the
most common reasons for cases being noticed were the child disclosing the situation (usually to his/her
social worker) in 43 cases, suspicions were aroused in 29 cases due to behavioural problems and in 29
cases the child had sustained injuries. The situation was noticed due to concerns reported by the school
in only eight cases, and due to regular visits to the doctor in seven cases.

In the study by Rosenthal et al (1991), boys were in the majority regarding reports of maltreatment
(64%). Girls dominated in the group of sexual abuse (60%) while boys were more frequent in both the
groups of physical maltreatment (71%) and neglect (76%). Children in foster families were younger than
children in different types of institutions.

In the Gallagher study from 2000, there was generally only one victim involved in the reports of sexual
abuse (54%). Two children were concerned in 22% of reports, and in the rest of the cases (23%) there
were three or more children in each case. In total, girls were slightly more frequent among victims of
abuse, and were considerably more frequent in foster homes (62% of girls), whereas boys were more
frequent in terms of reports from institutions (78%). 17% of children were judged to have special needs
due to their behaviour or various forms of disabilities. In about half the cases, children placed in a foster
home or institution had already been exposed to some form of maltreatment before they were placed.
The most common forms of maltreatment were sexual abuse (52%) and neglect (43%).

20
5.5 Risk factors for maltreatment in social care

Risk factors or risk situations for maltreatment of children in care are linked to the organisation of
social care and the institution itself, as well as factors related to the child's vulnerability.

Westcott (1991) describes the characteristics of institutional environments that may impede or prevent
accusations being noticed:

- Maltreatment which takes place in an institution is seen as the staff's individual problem and
not that of the institution or care system - i.e. maltreatment is seen as a personal and not a
professional problem
- The institution is like a closed system - it is reluctant to allow independent reviews due to the
fear of losing credibility - it tries to deal with the accusations internally
- In the system of values within social care, especially institutional care, the care provided is
considered to be better than what the parents provided earlier, so the working methods of the
institution are not called into question

Hobbs, Hobbs and Wynne (1999), on the basis of their own and others' studies, identified an increased
risk of maltreatment within social care if the child was a girl, if the child was placed in an unknown
family (not with relatives) or in an institution if the child suffered from emotional or behavioural
problems, if the child had developmental problems or a disability, if the child was young, if its parents
were far away, e.g. in another part of the world, if the child was placed in an institution with fewer than
four children, and if the child was in prison.

In the study by Zuravin, Benedict and Somerfield (1993), it was found that foster homes reported to the
authorities for maltreatment of at least one child placed in the home had four characteristics that
separated them from other foster homes. These characteristics were that the foster home mother was
younger than mothers in the comparison group; that children more often shared a bedroom with other
foster family members; that the social worker had doubts about the home; and the home had
restrictions to receive certain categories of children. Being placed in a relative's home was a protective
factor.

5.6 Summary
In summary, the initial review shows that reports of irregularities in foster homes or institutions in the
form of maltreatment (neglect, physical maltreatment or sexual abuse) are 2 to 7 times more frequent
than reports concerning children who live at home. Most of the studies are from USA and it is difficult to
make comparisons between the various studies since they have different inclusion criteria, such as type
of institution, definition of different types of maltreatment (mental/emotional, physical, sexual or
neglect), as well as access to data. There are no Nordic studies in this area and care must be taken when
comparisons are made with studies from USA. In the absence of studies in Sweden, on the other hand, we
must assume that maltreatment of children in social care has also been more common than among
children in the general population.

As regards the characteristics of cases where children have been subjected to maltreatment in care, we
can generally see that younger children and girls are more vulnerable compared with other children in
care. This could possibly be a result of the willingness to report being greater in the case of small children

21
and girls. Older children and boys may be perceived as tougher, or get what they deserve. The forms of
maltreatment also appear to differ in that boys are over-represented in the figures for physical
maltreatment, and girls are over-represented in the category of sexual abuse. Children placed in foster
homes were younger than children placed in institutions, which may possibly be explained by the fact
that younger children are more often placed in foster homes while older children with more serious
problems are placed in an institution. Children having problems or various types of disabilities also
constitutes an increased risk, as well as the distance to their biological family. The latter can possibly be
explained by decreasing transparency for the family, but also for the authority that places the child, which
in many cases has a greater distance to the foster home or institution.

6. Survivors - retrospective victim surveys

There are a limited number of surveys which study people who volunteer information a long time
after their childhood in a foster family or institution. Some of these victim surveys with a scientific
approach are described below.

Colton, Vanstone and Walby (2002) interviewed 24 people about the maltreatment and neglect they
experienced in their childhood institutions. Since this target group was made up of people who gave
evidence in court, the respondents' pictures of their past included complex feelings and strategies for
dealing with the events. The authors found that the main motivation for the "survivors" to come
forward was their desire to see the perpetrators given a trial, and to a lesser extent to obtain financial
compensation. The authors also found that there was sometimes a conflict between the desire that the
investigations would lead to convictions and the "survivors' " need for support to work through their
experiences during their childhood. Many survivors felt that receiving a public apology was also
important. The majority also emphasised the importance of long-term professional advice and
psychiatric help.

During the period between 1950 and 2002, more than 11,000 accusations of sexual abuse were
levelled at over 4,000 Catholic priests in the United States (U.S. Conference of Catholic Bishops, 2004).

Wolfe, Francis and Straatman (2006) followed up 76 men who had been maltreated and abused during
their childhood in religious/church-run institutions. The men participating in this study came forward
with their allegations after an advertising campaign in the American media between 1997 and 1999. The
abuse had taken place from the early 1960s until the late 1980s. These were validated in court and
more than two thirds of the men were found to be victims of serious and long-term physical and sexual
abuse, including one or more of the following categories: oral sex, anal sex, penetration with fingers, hit
repeatedly, hit with a fist or object, thrown against solid objects. In addition, these acts were
accompanied by intimidation or other life-threatening conditions. The men’s age at the time of the
investigation was between 23 and 54 ( M = 39.17). Clinical interviews, a structured interview for DSM-IV
and psychological tests were used.

Over half of the men (60%) were given a current Axel I diagnosis according to DSM-IV, and 88% had
been given an Axel I diagnosis at some point. The most common current diagnoses were PTSD (42%),
alcohol abuse (21%) or major depression (25%). Many also exhibited comorbidity, i.e. were given
several diagnoses, the most common being PTSD in combination with major depression (50%). On the
Personality Assessment Inventory (PAI; Morey, 1991) there were two clinical scales: Anxiety-related
disorders and Borderline, raised in comparison with the standardised instrument. On the Trauma
Symptom Inventory (TSI; Briere, 1996) the men showed raised levels on the subscales of Depression,
Intrusive Experiences, Defensive Avoidance and Dissociation, as well as on Trauma and Dysphoria.

22
In the interviews, 28% of the men described previous confusion in relation to sexual orientation
(usually during their late teens) but at the time of the survey 22% also experienced sexual confusion.
Two thirds (66%) described earlier sexual problems and 46% still had these at the time of the survey.
These took the form of hypersexuality (8%) and hyposexuality (32%) or feelings of inadequacy (7%). Of
those who had had a partner for at least one month, 49% stated that they had verbally or physically
abused their partner. About half of the men had been arrested for crimes against property (51%) or
crimes related to substance abuse (49%).

Almost all the men in the survey expressed a sense of betrayal and lack of trust that went beyond the
loss of their faith and a devaluation of the church. They described a general loss of trust that spread to
other social institutions such as schools and workplaces. Many men expressed anger towards the
institution and the extended legal process for damages, and had a lack of respect for the authorities
and poor faith in their own future which they ascribed to the years of silence and inactivity about their
earlier experiences of being abused.

The authors conclude their study by emphasising the need to make comparisons with a group of
matched individuals without the experience of abuse during childhood or without the experience of
institutional abuse. This is required to study the unique phenomenon of institutional abuse better and
the impact it has on the individual, as well as the individual's earlier history.

In the mid and late 1990s there were repeated accusations of child abuse levelled at Irish institutions,
not least those run by a religious association called the Christian Brothers (Coldrey, 2000), resulting in
the Irish Government eventually appointing a commission, "Commission to Inquire into Child Abuse
(CICA)". In the final report of the commission (Brennan, 2007; Ryan, 2009), it was stated that physical
and sexual abuse and neglect within institutions affiliated to the church had been commonplace. The
commission also initiated a number of research projects.
From the total pool of individuals who participated in the Commission to Inquire into Child Abuse (CICA)
until 2005 (n = 1,578) 247 were to be included in the subsequent interview surveys conducted by the
research group run by Alan Carr and the School of Psychology, University College Dublin. Of the
individuals participating, there were 135 men and 112 women; their average age at the time of the
interviews was just over 60. The participants were 5.4 years old on average when they were placed in an
institution and they stayed in the institution for an average of 10 years. Over 90% had experienced
physical and/or emotional abuse or neglect, while 47% had been subjected to sexual abuse during their
stay in the institution. 98% of the participants had experienced three or more of the five different
categories of maltreatment. Many of the cases of maltreatment were serious, both in the case of
physical abuse and sexual abuse. No less than 47% of cases of serious maltreatment and 10% of the
most serious cases of sexual abuse had taken place more than 100 times. Only 121 individuals had
enough recollections of their childhood in a family to fill in the family part of the Childhood Trauma
Questionnaire (CTQ; Bernstein & Fink, 1998). Of these, 38% had experienced maltreatment in the
family.

All participants underwent clinical interviews (SCID I and SCID II; First et al., 1996; First et al., 1997) to
obtain a diagnosis according to Axel I or Axel II in the DSM-IV system. The current diagnosis was given at
the time of the interview and the lifetime diagnosis was given if the person had met the criteria for the
diagnosis earlier, but not at the time of the interview. When current and lifetime diagnoses were added
together, no less than 82% either had an anxiety diagnosis, a depression diagnosis, alcohol or drug
abuse or a diagnosed personality disorder. At the time of the survey, 45% had an anxiety diagnosis,
which can be compared with population-based studies from Europe where 6% had this diagnosis and
from USA where the figure was 18%. Just over 26% had a depression diagnosis, compared with 4% in
Europe and 10% in USA. Substance abuse during the last year was at 5%, compared with 1% in Europe
and 4% in USA, while 30% had some sort of personality disorder, which was significantly more than in
both Europe (13%) and USA (15%). On the Trauma Symptom Inventory (TSI; Briere, 1996) the subjects

23
scored considerably higher than standardised data (< 2 standard deviations), indicating post-traumatic
stress in various forms. The subjects' attachment styles were assessed using the Close Relationship
Inventory (ECRI; Brennan, Clark, & Shaver, 1998). No less than 83% were judged to have an insecure
attachment style, in which anxiety/avoidance was the most common style (44%). The group with the
most secure attachment (17%) were the most positive profile while the with a anxiety/avoidance profile
had the most negative profile (Carr et al., 2009). The more diagnoses subjects had according to DSM-IV,
the higher/worse were their scores for trauma symptoms (TSI), Global Assessment of Function Scale,
quality of life (World Health Organization Quality of Life 100 scale) and marital satisfaction (Kansas
Marital Satisfaction scale).

The links between child abuse, as measured with CTQ before being placed in an institution and during the
time in an institution, and adaptation during adult life as measured by the outcome of diagnoses
(lifetime) and test results at the time of the survey, were studied in more detail. Significant correlations
were obtained between trauma symptoms measured with TSI and total maltreatment (r =.38), sexual
abuse (r =.35) and emotional abuse concerning maltreatment at institutions measured with CTQ. In other
words, subjects who had been exposed to more maltreatment during their stay in an institution,
particularly sexual abuse and emotional abuse, exhibited more trauma related symptoms as adults. There
was no such correlation found among those who stated they were maltreated prior to being placed in an
institution.

There were relatively few differences between institutionalised men and women as regards diagnoses,
but the women had more lifetime diagnoses of panic anxiety with agoraphobia, while men more often
had a lifelong dependency on alcohol. When comparing those subjected to abuse both before and
during placement in an institution (46/121) with those only abused during their stay in an institution
(75/121), it emerged that those who had been abused in both environments had significantly more TSI
symptoms than those only maltreated in the institutional environment (p < .025). They also had a less
secure attachment style as measured with ECRI (p < .05).
The research group also developed a new psychometric instrument with the above group (The
Institutional Child Abuse Process and Coping Inventory, ICAPCI) to evaluate the psychological processes
that may be associated with institutional maltreatment and coping strategies for dealing with the
maltreatment people are subjected to (Flanagan-Howard et al., 2009).

In Canada there was widespread attention and dismay when the abuse of children placed in orphanages
at an early age and later in asylums became known to the public at the end of the 1990s and the
beginning of the 2000s. These institutions were run by the Catholic Church until 1980, after which the
public sector took over responsibility for them. Children were often placed there as infants and most of
them spent most or all of their childhood in these institutions. There were as many as 20,000 children in
such institutions in the province of Quebec between 1949 - 1950. Much has been written about these
children, called "Les Enfants de Duplessis/Orphans of Duplessis", including a number of research
reports.

In a first pilot study (Sigal, Rosignol & Perry, 1999) 32 people were studied (selected in alphabetical
order) from a list of 112 members of a self-help group. These were compared with a random sample
of 446 individuals from the population register with an annual income of less than CAD 30,000. They
filled in a version of Dupuy's General Wellbeing Schedule (Dupuy, 1980) as modified by Kovess (1982).
The scale consists of 14 questions on health and wellbeing. Two additional instruments were used for
measuring stress-related symptoms (Ilfeld, 1988) and chronic health problems in the form of 28

24
different questions. The orphanage group had a significantly lower level of education and more of
them had never been married. They reported less wellbeing and higher levels of physical and
psychological stress, and had a higher frequency of health problems.

In a second study (Sigal et al., 2003) 81 survivors were studied: 40 men aged 43-73 and 41 women aged
47-72. Of these, more than 80% had been placed in an orphanage immediately after birth. Participants
were randomly selected from a list of 185 members of one of the larger self-help groups. The
participants were interviewed and asked to fill in the two instruments for measuring chronic illness and
the Psychological Symptom Inventory (PSI, Ilfeld, 1976; Kovess, 1982). As a comparison there were
three matched control groups for each participating former orphanage child from the province of
Quebec's health survey, which is conducted every 5 years.

The group studied, i.e. the former orphanage children, showed a statistically significant lower
frequency of marriage: men 48% compared with 22%, women 44% compared with 14%). They were
more often alone (men 38% compared with 14%, women 37% compared with 13 %), experienced more
psychological discomfort (men 73% compared with 45%, women 72% compared with 47%), had more
frequently contemplated suicide (men 44% compared with 2%, women 30% compared with 25%) and
more had attempted suicide (men 31% compared to 2%, women 34% compared with 3%) than the
control group. Orphanage children also had significantly more often (9 of 12 cases) had different forms
of chronic illness than the control group.

In the third processing of the material of the 81 former orphanage children (see above), early
experiences of traumatic events were studied further (Perry et al., 2005a). Methods used included the
Traumatic Antecedents Interview TAI; Herman, et al., 1989), a specially developed instrument, the
Traumatic and Protective Antecedents Interview TPAI). The interviews take up different traumatic
events in five different age intervals of the individual's past life, mainly childhood, attachment and
relations, and twelve different strengths or what we sometimes call health factors. The age intervals
were 0-6, 7-12, 13-18, 19-24 and 25+. The interviews were recorded on tape and the audio content was
assessed by one or two researchers whose consensus was good.

Eight different types of maltreatment were reported by more than half of the 81 participants. Physical
maltreatment by staff had been experienced by 96% and sexual abuse by 57%. There were only two
gender differences: sexual abuse, where men reported considerably greater frequency of exposure
(p<.0003) while women reported more emotional abuse than men (p<.003). The most vulnerable
periods were when children were 7-12 and 13-18.

Former orphanage children reported that they had not had any significant carer for one or two of the
time intervals, and 51% said that they had had trusted contact with an adult during at least one of the
age intervals. Having at least one talent during at least one of the age intervals was the only strength
that more than half of the subjects reported. The mean value of the scale of strengths was low and most
subjects only stated a few strengths during one or two age intervals. Children who had strengths while
growing up also had them as adults (correlation r = .71) and those who had relationships while growing
up also had them in later life (r = .45).

In a third study (Perry et al., 2005b) the relationship between early childhood experience and
functioning levels and mental health as adults was studied. In addition to the Traumatic and Protective
Antecedents Interview (TPAI), three additional instruments were used. The first instrument, the Social
and Occupational Functioning Scale (SOFAS), is an abbreviation of the GAF scale used in Sweden to
measure the functioning level of psychiatric patients. SOFAS measures only the social and labour
functioning levels. The second instrument, the Modified Psychiatric Symptom Scale (MPSS), consists of
14 questions which measure depression, anxiety, aggression and cognitive difficulties. The third
instrument, the Defense Mechanism Rating Scale (DRMS), is based on an interviewer assessing 30
different defence reactions if and when they arise during the interview (Perry & Lanni, 1998). The

25
interview results in three different assessments. The first is an Individual Defense Score, which is the
total number of detected defence reactions registered during the interview divided by the number of
possible defence reactions. The second assessment is the Defense Level Score, which has seven
different hierarchical levels based on how functional these are for the individual. The third is called
Overall Defensive Functioning, ODF, where individuals are given a score between one and seven.
It is stated in the study summary that the average SOFAS score was 58, which indicates moderate
difficulties in social and working life, but only 22% of the 81 former orphanage children
in the study had over 71 points, i.e. had slight difficulties (14%), or functioned well socially and in
working life (9%).

Psychiatric symptoms were significantly more common than corresponding measurements of the
population (see above, Perry et al., 2005a). In the assessment of the Overall Defense Reaction (ODF) a
neurotic/inhibited functioning level was noted. Both the total trauma strain and strengths during
childhood predicted outcomes as an adult. The authors concluded that if children must be placed in an
institution, there must be a built-in security system in organisations that prevents the occurrence of
child abuse in all its forms, not least in the case of children with few strengths. It is also necessary to
support the development of individual strengths in order to avoid future functional impairments as
adults.

In a further study on "Les Enfants du Duplessis" a deeper description and analysis of seven former
orphanage children's lives and accounts was made (Perry et al., 2006). This article gave rise to seven
different comments in the journal (Fritsch, 2006; Stein, 2006; Low & Eth, 2006; Michels, 2006; Cozza,
2006; Shaw, 2006; Putnam, 2006).

In conclusion, the "survivors' " accounts and the researchers' reports make heavy and poignant reading.
They describe many years of suffering, with daily humiliations interspersed with physical maltreatment
and sexual abuse, which make the reader think more of medieval punishment than social care for
growing children's best interests. Throughout the reports, the high level of ill health is measured by
attachment difficulties, social problems, symptoms and psychiatric diagnoses which these "survivors"
have had to live with during both childhood and adulthood. The small rays of hope are that certain
personal strengths and some important relationships during formative years have had some effect on a
small group.

The weakness of the above studies is the low number of participants (26% in the CICA studies) and thus
the representativeness of the investigations carried out. Was it children who experienced less serious
maltreatment and abuse who chose not to participate in the survey, or is it the converse - those who
suffered the most serious outrages - who are missing? Regardless of which may be true, the participants'
accounts are fully sufficient to understand the extent of the maltreatment and negligence.

7. Program for avoiding harmful treatment in social care

Part of the literature tries to explain and understand how institutional abuse can take place and at the
same time describes either deficiencies in the general public responsibility for children in care or the
more concrete need for improved procedures. This applies to the recruitment of staff for both foster
homes and institutions, their need for support and guidance and giving the children in care a voice
and better supervision.

Using Bion's affective theory as a starting point, Shield (2006) analyses and discusses institutional abuse in
Ireland. He says that one can view these institutions' inner world as a closed room in which children
experience projected identifications and intrusions from adults as passive victims. The task of providing

26
care to vulnerable children became a claustrophobic and at times a perverse meeting. The lack of
knowledge-based care and lack of clarity regarding the limits, roles and responsibilities in the internal
world of the institution between the state's children, religious children, adult carers and religious parents
created overwhelming practical, psychological and emotional demands on both children and carers. At
the same time, the adult group of leaders in the church and/or the state failed, from the external world,
to intervene or address the concerns, which led to systematic exploitation.

In institutional care, Shield also sees an opportunity for staff to take the dual role of victims and
perpetrators, in the absence of knowledge-based care. Boundaries may be crossed and things fall
apart in the physical and emotional environment as a result of unlikely responses to external and
internal concern. To maintain a high level of integrity within the health care sector regarding
selection, training, supervision and management of staff, a parallel process is required. This process
should be characterised by critical thinking, communication and regular external assessment of the
quality of the primary tasks, with supportive management at all levels. Knowledge and understanding
are needed for the emotional reality of the job and the ability to intervene before hatred becomes
harmful.

Paul and Cawson (2002) state that one of the problems is that children placed in an institution are less
likely to get help from the social services or carers due to the barriers which institutions set up around
themselves. Among other things, these barriers mean that complaints remain within the institution, that
they investigate complaints and that the social services fail to ensure that staff at the institution have
access to professionals with expert knowledge of children's needs.

Even if the difficulties described by Paul and Cawson (2002) are overcome and a report is made, there
are a number of obstacles in the decision-making process (DePanfilis & Girvin, 2005). DePanfilis and
Girvin went through the complaints that came in to the New Jersey Department of Youth and Family
Service over a period of four years (1999-2002). Of the 1,295 complaints, a random selection of 158
cases was made, of which 129 were studied in detail. Four categories of deficient decisions were
studied: (1) placing children in foster homes with a previous record of child abuse; (2) decisions
concerning the discovery of new reports on child abuse; (3) evaluation of child safety after a report on
child abuse, and (4) decisions regarding permits and penalties. The results showed that explanations of
deficient or incorrect decisions could be attributed to a lack of knowledge, shortcomings in the
information process, shortcomings in the work environment, perceptual blocks, i.e. the investigator
defines the problem too narrowly or ignores alternative explanations, deficiencies in the written
descriptions of situations and the organisation and communication of information.

Wolfe et al (2003) see four factors or areas which can contribute to the understanding of the situation
of a child in an institution, and thus the scale of the damage that can be caused by institutional
maltreatment. Firstly, they say that many institutions which contribute with teaching, have religious
affiliations or where society places the child have a high status in society that make it difficult to criticize
or question them. Educational and religious institutions have often been selected by the parents and
responsibility is given to the institution, so people are not keen on questioning their methods or type of
care. This means that children placed in care find it difficult to complain to any adult. Who would
believe the child? Revealing maltreatment also involves more public exposure, so children are very
reluctant to complain. When the social services place a child in care, the biological family is often in a
precarious position and if contact between child and parents is not encouraged either, there is a risk
that transparency decreases. Who should the child contact? Secondly, staff at institutions have a status
that may be difficult to question. This applies in particular to religiously managed institutions, where
people are not usually encouraged to question leaders or practitioners. In the field of sports, the
teacher or leader may become a sort of idol. Disclosure may then be twice as difficult, when the
whistle-blower must also come to terms with the image of their idol and risk being left out of the team.
Thirdly, the authors believe that the child's role in the institution may also make disclosure difficult.

27
If a child is involved in different activities in the institution, such as theatre and sport or music, (s)he
may hope for more time with the teacher in order to practise their interest, and once again it makes it
more difficult to disclose abuse. Finally, a child will be worried about what happens after they disclose
abuse. Partly the child fears that (s)he will not be believed when they tell someone, and partly it is
about the child's concern that they will not be believed later on and will be humiliated during
questioning in an investigation; including, perhaps, a criminal investigation. Who would believe a child -
especially an orphanage child?

Wolfe et al (2003) state in their overview that the effects of maltreatment and abuse reported in
international literature tend to be accentuated due to the special circumstances in which the
institutional abuse takes place. For example, trust in other people risks deteriorating further and may
spread to other areas than the person or persons who carried out the abuse. For example, the accounts
from the "Children of Duplessis" have spread so far and wide that trust in the church and other social
institutions has either been dramatically reduced or completely removed.

Finally, Wolfe et al (2003) stress that there is still a lot left to do in preventing institutional maltreatment
and abuse. This applies to improvements when selecting staff, supervision and clear action
programmes. Municipal officials, i.e. those who place children in institutions or offer institutional places,
need to understand the vulnerability and powerlessness involved in being placed outside the home. This
means there is a need for better training and awareness raising, both among adults and young people,
as well as policy documents and written procedures for how to act if abuse is disclosed. Cooperation
needs to be developed and strengthened between the social services, police and judiciary, as well as
those who help children to recover after abuse.

As early as 1983 Cavara and Ogren described a structured model for how to investigate suspected
abuse in a foster home. In their conclusions, Cavara and Ogren (1983) write that every unit that places a
child in care must have procedures for how to act on any suspicion that the child has been subjected to
maltreatment or neglect. In more specific terms they state that:

1. The investigation must be carried out by an objective party who does not have any
previous commitments in the case (a third party), i.e. has not had any responsibility for
either the placement or for follow-up/supervision.
2. The procedures need to be well established and have the support of the local administration.
3. One person or unit should be responsible for collecting all the information on the case.
4. Legal support is needed during the process to ensure that all relevant legislation is complied with.
5. A standardised form should be developed on how the final statement should be
formulated, including clear definitions of terms and concepts.

Nunno and Motz (1988) take the idea of independent third parties one step further and propose special
investigation units which are independent from the placing authority, and Bearup and Palusci (1999)
describes the work and the benefits of an independent "children's ombudsman" in Michigan.

Based on two years of experience with the structured investigation model, Cavara and Ogren (1983)
proposed the following preventive steps to reduce the risk of maltreatment and neglect during a
placement:

1. Screening of prospective foster home parents.

Screening should include home visits, personal interviews with all members of the family
including their social background, own experiences of abuse and neglect during childhood,
evaluation of the motives for receiving a foster child, principles of child upbringing and family
relationships. The use and abuse of alcohol must be checked. References should be taken,
including an opinion from the family doctor and school. All prospective foster home parents
should also provide an extract from the criminal records.

28
29
 2. Frequent and continuous contact with the foster home.
The responsible social secretary needs to have close contact with the foster home and be
attentive toward any changes in family life which could add further stress.
The authors recommend at least one contact per quarter.
3. Avoid high-risk placements.
Information on the family's background needs to be paired with details of the child to be placed
in care. The child's previous background and history of maltreatment and neglect are important.
4. Avoid giving the foster home parents too much work.
5. The prohibition of corporal punishment/beating.
6. Requirements on education and training for both foster home parents. Foster home
parents who have received children subjected to sexual abuse in the past need training
in how to deal with sexualized behaviour (see Kjellgren, 1995), receive training in dealing
with disruptive aggressive behaviour which some physically abused children exhibit, and
how to best respond to clinging or apathetic behaviour that children may exhibit when
they have been neglected.
7. Make people aware of the stress that is sometimes part of being a foster home parent and
examining how this stress can be eased.
8. Be the child's lawyer.
Social secretaries need to develop their roles toward children to include being their lawyer. A
confidential contact is needed for the child placed in care.
9. Offer help.
Foster home parents need to be encouraged to contact services and ask for help if they have
difficulties.
10. The social worker must be able to decipher signs of child abuse and neglect and be aware that
this can also happen in a foster family.
11. The social worker must have the opportunity of meeting the child alone.
12. The social worker must be able to make unannounced visits to the foster home.
13. The social worker should consult the child's parents and they should be encouraged to
participate and have viewpoints on the placement.
14. The social worker must have "exit" interviews with the child when it leaves the foster home to
gather feedback on his/her experience of the foster home.
15. Any person who discovers that a child is the victim of abuse or neglect must act immediately.

Bloom (1992) states that an authority is responsible for three different tasks when a staff member is
suspected of sexual abuse at an institution. The first is to protect the child, the second is to support
staff, and the third is to ensure the functioning of the organisation. The main responsibility is to protect
the child. Bloom feels it is important to get the message across to children at an institution that "it can
happen here". It is necessary to say that the accusation will be taken seriously and the suspect will be
suspended on pay during the initial investigation. It is also important to prevent any retribution from
staff or other children at the institution and to give the child support and treatment.

Daly and Dowd (1992) state that an environment that does not create any damage when a child is
placed outside his/her home is an environment free from abuse and neglect which complies with laws
and regulations. It is also an environment that promotes the rights of the child and offers children a
chance to receive care and treatment which help the child's mental, emotional, intellectual and
physical growth.

30
They also believe that children need something more than an environment which does not further
damage the child, i.e. a well-integrated and effective childcare programme. Such a programme or
system should be characterised by support for carers, a care model, focus on positive behaviour,
consumer orientation, training, evaluation of health and health programmes, and an internal audit.

Kehan (1994) and Barter (1997) describe proposals for improvement for children in care institutions,
which Barter (2003) summarises in a number of points:
- The child's rights and involvement, meaning that children need to be involved and
consulted on decisions that affect them.
- Regular contact between children and families (if appropriate), independent
visits, children's rights representatives and the local community.
- Better procedures for staff recruitment, which involve a probationary period and the
involvement of young people in the selection.
- Training in the form of national accreditation and qualifications for staff working in child
welfare.
- Regular, open, supportive supervision of adequately trained supervisors that is
systematically recorded and evaluated.
- Regular monitoring and evaluation of staff with visits by the social and legislative
authorities.
- Guarantee of protection for those who disclose abuse/neglect.
- Staffing procedures that ensure there are superior staff present at sensitive times, - early
mornings and late evenings - and an adequate ratio of staff to children.
- A leadership style based on consultation and respect, where there is a clear picture of the
unit's goals shared between management and staff.
- Complaints must be processed independently in a child-friendly way and clearly recognised.
- The organisational factors which cover the establishment of inter-union work, the development
of open, effective and participating management structures, including contact with children and
young people, the supply of outside professions, a placement policy that allows every child's
needs to be met and a good mix of children can be achieved.
- The counteracting of a "macho", hierarchical youth culture based on inequality.

Staff manning in the form of suitability, quantity, quality and stability is important in the treatment
process at children's institutions and when this is not sufficiently good it contributes strongly to the
occurrence of institutional child abuse and neglect (Shaughnessy, 1984). The above factors were
identified in an article by Colton (2002).

Education and training programmes for institution staff have been found to reduce the risk of harmful
treatment of children during their stay in an institution (Zuckerman, Abrams & Neuring, 1986; Gil, 1982).
For example, in a study by Groze (1987) it was found that there was a reduced number of confirmed cases
of maltreatment of children by staff that had been given training in crisis management.

Wolff and Fesseha (1999) compared orphanage children with a group of children at other children's
homes. They found that in orphanages which encouraged collective responsibility, had strong ties with
staff, encouraged conversation and interaction during meals with children, gave children responsibility
in households, organised activities after school and shaped the children's personal identities, the
children functioned better in behavioural and cognitive terms compared with children growing up in
more authoritarian orphanages.

Finally, Wolfe et al (2010) presented a guide for the investigation of allegations of past abuse as well
as the assessment of damage and needs. The guide is aimed mainly at expert opinions in connection
with trials for damages.

31
In conclusion there are five areas that recur in ideas and suggestions for improvements in preventing
maltreatment and abuse when children are placed in social care. These are:
1. Selection and checks on staff and foster home parents.
2. Adequate staffing of institutions and not overloading foster home parents.
3. Training and guidance for staff and foster home parents.
4. Counteract tendencies towards closed institutions or foster homes through frequent visits
from the placement unit, frequent contact with parents and external supervision.
5. Procedures for an independent party to investigate complaints.

8. Children's own accounts

There is remarkably little written about children's own experiences of being in care and placed in some
form of social care. Studies that ask children to comment on their experience of being placed outside
the home are a potentially important source of information for social services. Fox and Berrick (2007)
believe that children have a unique insight that can and should contribute to the development of child
welfare, both in practical terms and its design. One of the reasons why there are so few studies which
take up children and young people's own viewpoints is probably our preconceived notions of placement
outside the home being inherently bad, and that when it is sometimes necessary we do not really want
to know how children feel about it. In the studies that do exist, they report that the majority of children
and young people have a positive experience of their stay outside their own home (Courtney, Piliavin,
Grogan-Kaylor & Nesmith, 2001; Fox, Berrick & Frasch, 2008; Johnson et al., 1995; Kufeldt, Armstrong, &
Dorosh, 1995; Wilson & Conroy, 1999). They are generally satisfied with their current life situation, they
feel safe and better treated in their placement home. However, this does not mean that the children
have no criticisms; they still feel outside the decision-making process by the social services, they miss
their original family and they have poor contact with their biological parents. In addition, there is a small
number of children who are completely dissatisfied with their situation. Two other studies apart from
that mentioned above deserve a more detailed review.

In a comprehensive study, Chapman, Wall and Barth (2004) tried to describe what factors affected
children's satisfaction with being placed in care outside their home, in this case in foster families in
USA. From a group of 6,231 children, a random selection was made of 316 children who were at least
six years old and had been placed in care for twelve months. The children were placed in relatives'
families (relative placement), other families or in group homes (small institutions). Of these children,
90% were satisfied with the family they stayed with and 36% wanted to be adopted; approximately half
wanted the current family to become their permanent home. On the other hand, 11% had tried to
leave their foster home. When comparing the different forms of placement, the children who lived
with a relative's family or in a normal foster home were more satisfied than those who lived in a group
home. They more often wished that their placement would become permanent, while children in
group homes had tried to leave the home more often than those placed with relatives and foster
families.

In a randomized study, interviews were made of 180 children aged 9-11 who had been placed outside
the home due to maltreatment (Dunn, Culhane & Taussig, 2010). They were placed in care between
2002-2006 and were still in care at the time of the survey. The distribution of answers to the question,
"what do you think about being placed outside your home?" was fairly even. Approximately one third in
each case replied that it was "very good", "OK" or "very difficult". The most difficult thing was missing
their mother (34%) or missing the family (28%). What was best/most help was that they had a better
home (39%). Children who had been sexually and emotionally abused, children who were satisfied with
their current family and placement and girls more frequently said that their lives would be worse if they
had remained in their original family. Physically abused children more frequently said they believed that
life would have been the same, i.e. no difference if they lived at home or in another home.

32
Children who lived in a group home, compared with other forms of placement, felt more often that life
would have been better if they had lived at home.

As an expression of children not being listened to, we can look at research on why children run away
from placements outside the family. Courtney and Zinn (2009) note that there are three predictors that
can explain why children run away from care outside the home. These three were the children's
characteristics (age, sex, behavioural problems), family characteristics (composition of the family, family
conflicts) and factors related to the society that places children in care (type of placement, treatment
plan, attitude of staff). From clinical experience one should always ask: what is the child running away
from and what is the child running to? In none of the investigations is the question raised - what is the
child running away from? Courtney and Zinn (2009) reviewed 14,282 cases of children running away
from care in the Illinois Department of Children and Family Service without the question ever being
asked why they were running away and whether they were running away from an intolerable situation
involving maltreatment and neglect.

9. Summary and conclusions

The current literature review has been extensive, although there are few articles describing the
maltreatment of children in social care. One of the difficulties was delimiting the problem using search
words: children and young people subjected to maltreatment and abuse when in social care. There is
much literature about children who risk being taken into care, e.g. due to parents' substance abuse, the
background of the child, symptoms and behavioural disorders of children placed in care, treatment
outcomes when placement in social care is used as an outcome parameter. Few studies follow children
placed in care during the time they are in care, even fewer ask questions about the quality of the care
and almost none ask the children themselves! On top of this, Swedish and Nordic publications, with few
exceptions, are conspicuous by their absence in international databases on this subject.

This summary should be seen as both a summary of what the literature tells us about child maltreatment
and maltreatment in general and specifically when it occurs in a foster home or institution, and the
author's overall viewpoints on the shortcomings and needs that become clear after reading the literature.
Suggestions for improvements regarding children in Swedish social care supplement the above aspects.

From the literature we can draw the conclusion that the majority of children in care outside the home
receive good care. Most children placed in care are satisfied with their placement, even though we can
see differences between the types of placement. Children who are placed with relatives or in ordinary
foster homes are more satisfied with their placement and feel better than children who are placed in
institutions.

However, there are significant exceptions. It is precisely in the case of these exceptions or shortcomings
that the authorities' understanding of how children's vulnerability in care is put to the test. Whose needs
and whose accounts should the authorities be guided by? Obviously it should be the children's needs and
how these needs are monitored in accordance with the UN Convention on the Rights of the Child. The
adult world has a duty to ensure that those children who have had and still have the most difficult
situation in our society are offered the best and the most qualified care in accordance with science and
practical experience.

From a Swedish perspective, it is sad that awareness of the issue and the resulting government
commission did not take place until the 2000s, triggered by children's accounts in a TV documentary
called "Stolen childhood" (Stulen barndom). It is easy to believe that maltreatment of children placed in a
foster home or institution took place "then" and not now. That this is not the case is shown by the review
of international research which drew attention to these problems in the early 1980s and the list of

33
current cases in the mass media during the past two years is long (e.g. news programme Ekot
24/06/2009 on "Isolation used as punishment", newspaper DN Debatt 15/12/2009 "Serious mistakes
made in institutional youth care", radio news P4 in Kalmar 24/10 "Suspected of kicking foster children",
Borås newspaper 26/03/2010 "Re-placement of foster children examined", Norrköping newspaper
21/03/2009 "Prison sentence upheld for maltreatment of foster child").

In Sweden nearly 4,000 complaints are made annually to the police regarding sexual abuse of children
under the age of 15 and around 11,000 reports of physical child abuse. We know from Swedish and
international research that maltreatment and sexual abuse seriously affect children's health and
development, both during their continued childhood and in later life.

The compilation of scientific literature shows that children who are put into social care run a two to three
times greater risk of being exposed to neglect, physical maltreatment and sexual abuse than other
children not placed in care and that their development and mental health is seriously compromised.
Children in institutional care also appear to have more problems than children placed in foster homes.

For children in social care, there is an increased risk of further abuse by foster home parents, staff at
institutions and other children placed in care. It also appears that children who were abused before
being placed in care and were then abused during social care show the worst adaptation later in life
and the most symptoms of mental ill health, including psychiatric diagnoses.

Despite the number of studies being small and the difficulties that arise from limited material, which can
rarely claim to be representative of the whole group and which usually has a retrospective design, thus
making it difficult to compare with material from different countries and cultures, we can nevertheless
say with some support that the above review is like a ladder or pyramid, fig. 1.

Fig. 1.

Increasing difficulty Maltreated children

- at an institution
- - in a foster home
-
Previously maltreated children
- at an institution
- in a foster home

Children at an institution
Children in a foster home

Maltreated children

Non-maltreated children

At the bottom is the majority of all children who live at home and who have not been exposed to
neglect, physical maltreatment or sexual abuse. At the top is the small group of children who have been
placed in care and who have been abused in some way during care, of which the most vulnerable are
the group who were abused both before and during the placement (Carr et al., 2009).

34
This latter fact indicates added suffering on top of all the previous life events and is relevant to the
issue of redress and compensation. In one study, the importance of redress was emphasized (Colton,
Vanstone & Walby, 2002).

10. Viewpoints and proposals

It is currently the exception rather than the rule that children who are placed in social welfare, be it in a
foster home, therapeutic care, home for care and living (HVB) or an institution run by the Swedish
National Board of Institutional Care (SiS), are systematically investigated before they are placed in care.
This is not reasonable in a child-friendly and evidence-based western society. It is thus impossible to
systematically evaluate the results that society achieves through placing children in care.

Proposal 1. Every child who is taken into care and placed outside the home shall be investigated in a
uniform and systematic manner, both before and during placement. Such a systematic investigation
must include both standardised assessments of physical and mental health, any relevant diagnoses such
as DSM-IV, and a thorough review of previous life events and trauma.

Proposal 2. The social welfare board that decides in these cases must ensure that systematic
assessments are carried out and that these are gathered in a national quality register that can serve as a
basis for future quality assurance of care in foster homes and institutions.

A high proportion of children placed in foster homes or institutions have experienced neglect and
directly traumatising actions such as physical maltreatment and sexual abuse. These traumas are
associated with a variety of problems such as attachment-related issues, psychosomatic symptoms,
depression, self-injury behaviour, easily aroused over-activity, aggression, sexualized behaviour and,
not least, post-traumatic stress syndrome. It is thus surprising that so few children are offered
professional help to work through their earlier traumas before being placed in care (which could
maybe have been avoided) but even more remarkable that so few children are offered such help
during their placement in care. It is even more urgent since research shows that children who have
been exposed to trauma have an increased risk of being exposed to it again, i.e. they have increased
vulnerability to being exposed to trauma during their stay in a foster home or institution, as well as
later in life.

Proposal 3. Children with traumatic childhood experiences should be offered evidence-based

treatment if they show symptoms of clinical or sub-clinical post-traumatic stress syndrome or other
clinical symptoms that can be considered as trauma-related. Today there are good opportunities for
help with Trauma Focused Cognitive Behaviour Therapy (TF-CBT), Eye Movement Desensitization and
Reprocessing (EMDR), or in the case of self-injury behaviour, Dialectical Behaviour Therapy (DBT).
These treatments can be provided by Child Advocacy Centres (Barnahus) in Sweden, child and
adolescent psychiatry clinics and by some institutions.

The summary shows that children placed in a foster home or institution constitute a risk group since to
a large extent they have experienced a traumatic earlier childhood with neglect, witnessed violence,
physical maltreatment and sexual abuse. Children placed in care also show a high degree of psycho-
social ill health. Placing these children in a foster home or institution with insufficient preparation,
inadequate training and supervision creates a situation where the most vulnerable children in society
run the risk of further abuse - contrary to the intention of the placement. It is therefore of the utmost
importance, for both foster homes and institutions, via placing authorities or themselves, to ensure
that there are procedures to prevent abuse from taking place during care. A major theme in this
investigation, in particular for institutions, is that openness and transparency should be complete,
since institutions by their very nature tend to close ranks on outsiders. Children's voices need to be
35
heard and their needs must be visible. It is also apparent that neither the social worker who decides on
placing children nor the person who then has responsibility for the placement is the right person for
investigating any suspected malpractice.

Proposal 4. Children in social care need continuous contact with an independent person whose only
task is to monitor the best interests of the child and be in constant contact with the child. This
"mentor" should be appointed in conjunction with the placement and could be recruited from
members of an existing voluntary children's organisation such as Save the Children, or by a guardian
being appointed under the Parental Code in the same way as for unaccompanied refugee children in
some municipalities, e.g. Åtvidaberg municipality (Act on Legal Guardian for Unaccompanied Minors,
2005:429).

Proposal 5. Lex Children. In the same way that elderly care has a special law, "Lex Sarah" that states
the obligation to report any suspicion of malpractice, those who work with children in social care
should also have an obligation to safeguard the quality of care and report any serious wrongdoing, in
addition to the obligation to report any suspected child abuse. Although this was carried out in
principle through an extension of Lex Sarah from 1 July 2011, it is important that protection for
children placed in care is made visible and is strengthened. The Swedish National Board of Health and
Welfare launched a 020 number in 2010 that children and young people placed in care could call to get
advice on their rights and to give their viewpoints. Every child who is placed in care should have a
folder containing this number and other information. The regional units of the National Board of
Health and Welfare are currently responsible for supervision, but this party's competence and
capabilities need to be strengthened for the units to function as a "third party" in reality.
The Children's Ombudsman should also be given a special mandate to follow and monitor the interests
of children placed in care.

Proposal 6. To increase competence, it should be compulsory for staff at foster homes and institutions
to be given guidance in the work carried out. As regards guidance at institutions, the supervisor should
be independent from the organisation in order to reinforce transparency outwards.

The review shows that the investigation's core group, those who were victims of neglect, physical
maltreatment and sexual abuse in a foster home or institution many years ago, are in great need of
redress and rehabilitation. This redress in the form of a public apology does not replace other needs
for compensation, however. The amount of compensation in financial terms should be discussed,
since it needs to be calibrated with the compensation given by the Swedish Crime Victim
Compensation and Support Authority to children who have suffered witnessed violence, physical
maltreatment or sexual abuse. It should also be taken into account that children who now give their
accounts of neglect, physical maltreatment or sexual abuse do not have their cases tried in court. For
a large majority of those affected, there is a continuing need of psycho-therapeutic help and support.

Proposal 7. In the same way as many countries have previously done, when malpractice in social care
are revealed, a public apology should be given to those affected, which includes persons who step
forward and are interviewed and persons who have chosen not to express themselves for different
reasons.

Proposal 8. On the basis of its experience, the Swedish Crime Victim Compensation and Support
Authority should be given the task of producing a model for financial compensation.

Proposal 9. Those who stepped forward in the investigation of maltreatment in social childcare
during the twentieth century and who still need psychotherapeutic help and support should be
offered that support by society without any charges.

36
The review shows that there is very little Swedish research and few publications in international
journals about the situation of children and young people and how they feel about being placed in a
foster home or institution. This is an important area to develop and strengthen.

Proposal 10. As one way of a drawing attention to the suffering of children previously placed in care,
highlighting the seriousness of children being maltreated during social care and the need for knowledge
and development, earmarked funds should be allocated for future research in this area. Such funds
could be administered by the Children´s Welfare Foundation of Sweden and applied for through their
regular calls for research funding.

37
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