Child welfare removal of infants: Exploring policies and principles for decision-making in Nordic countries

1 Child welfare removal of infants: Exploring policies and principles for removal decision-making in Nordic countries Children and Youth Services Review 2020 https://doi.org/10.1016/j.childyouth.2019.104572 Senior researcher Anne-Dorthe Hestbæk* VIVE – The Danish Center for Social Science Research, Copenhagen. Herluf Trolles Gade 11 DK-1052 Copenhagen C., Denmark [email protected] Professor Ingrid Höjer, University of Gothenburg. Department of Social Work Box 720 SE 405 30 Göteborg, Sweden Ingrid.Hoje[email protected].se Professor Tarja Pösö, University of Tampere. Faculty of Social Sciences 33 014 Tampere University, Finland [email protected] Professor Marit Skivenes, University of Bergen, director of Centre for Research on Discretion and Paternalism. Department of Administration and Organization Theory University of Bergen, P.O. Box 7800 5020 Bergen, Norway [email protected] Funding The authors have obtained financial funding for the preparation of the article from the Norwegian Research Council grant no. 262773, and from VIVE – The Danish Center for Social Science Research. Further, the Centre for Research on Discretion and Paternalism, UiB, Norway, has supported the project by financing a research meeting in Bergen. The funders have no involvement, neither in study design, nor in collection, analysis or interpretation of data. Abstract This descriptive policy analysis examines the position of infants’ rights in the family service orientated child welfare systems of Denmark, Finland, Norway and Sweden when being placed in out-of-home care. Its focus is on the contexts of, and legal procedures for, removing babies from home into public care. Children under the age of one year are taken into public care mainly through voluntary and emergency This is the accepted manuscript of the article, which has been published in Children and Youth Services Review. 2020, 108, 104572. https://doi.org/10.1016/j.childyouth.2019.104572 2 measures. Analysis of the development over a decade displays big intra-country differences in the prevalence of infant removal, varying from 2 per 1000 to 8 per 1000. The scant prevalence of public policy, practice guidelines and research indicates that infant removal is in some ways an anomaly, an unspoken leaf in the Nordic child welfare systems, whereas the Nordic welfare states otherwise extensively support families with young children through universal interventions. The findings invite to a reexamination of the rights of infants and their specific needs in the welfare states in order to establish responsive and efficient child protection systems. Highlights o Despite a preventive focus, the prevalence of infant placements is relatively high o There prevalence of infant removal differ considerably across the Nordic countries o Infant removal in Nordic countries has little attention in legislation and policy o There is lack of research and guidelines for decisionmakers concerning infant removal Keywords: Removal; infant removal; out-of-home placement; Nordic child protection systems; care order. 1. Introduction and background Each Nordic country subscribes to a family service-oriented system of child protection. Such systems provide family services and are based on a therapeutic view of rehabilitation, in which it is possible for people to revise and improve their lifestyles and behaviors (Gilbert et al. 2011). A basic child protection principle is that it is part of a broader child welfare system, providing services that prevent harm and, consequently, prevent out-of-home placements. Thus, the sentiment has been that children placed out-of-home in the Nordic systems are predominantly adolescents and only rarely infants or young children (Pösö et al. 2014). In contrast, risk-oriented systems, such as those in the UK and America, have a higher intervention threshold and focus on mitigating serious health and safety risks (Gilbert et al. 2011). The goal of risk-oriented systems is not to provide services to prevent possible harm but rather to intervene in circumstances of serious risk of harm, with a goal of providing services leading to possible reunification. One consequence of this approach is that, compared with the Nordic systems, there are more infants and young children placed out-of-home in the American and the British system (Gilbert et al. 2011; Burns et al. 2017). However, without detailed information about child protection systems’ legislative basis and forms of removal, conclusions based on removal rates comparisons may be misleading (Thoburn 2007). If we focus on the removal of infants specifically, and then look at all forms of removal, we realize that these rates are not especially low in all Nordic countries. In fact, infants—not just teenagers—are removed from parental care at rates that appear to contest the principles of the family service-oriented child 3 protection systems and Nordic welfare state which, in principle, provide extensive parental services and benefits as to make removal unnecessary. Placement of an infant (age 0–11 months) in out-of-home care is especially challenging because infants are a particularly vulnerable group (Zeanah et al. 2011; Dozier et al. 2013); attachment research shows that infants need stable caregiver relationships to thrive. Therefore, it is important to examine critically the policies and procedures governing the removal of infants into out-of-home care. Herein, we examine the policies, legislation, research and expert reports from four Nordic countries—Denmark, Finland, Norway and Sweden—to shed light on their infant removal institution and rates. Our descriptive policy analysis focuses on the contexts and procedures for removing infants from their homes into public care. The focus of these analyses is to inform on the fundamental principles of these child welfare systems, their positions on infants’ rights and how frontline child welfare workers and public officials are instructed regarding handling and meeting the needs of vulnerable families with infants. First, we will detail the child protection and childcare contexts within these four countries. Then, we will examine the trends in rates of infant removal during a 10-year period. Next, we will describe legislation and guidelines for the public’s responsibility for at-risk infants. Finally, in the discussion and concluding sections, we summarize the different tendencies within these child welfare systems and highlight their emerging differences regarding infant removal. 2. The Nordic welfare state and family service child protection systems The philosophy behind the social-democratic welfare state and service-oriented child protection system provides a unique context in which to examine infant removal, a neglected research topic. For several decades, the universal Nordic childcare policy has supported parents in taking proper care of their young children (Eydal and Rostgaard 2011). Systematic, no-cost preand postnatal health care is accompanied by paid parental leave schemes, child benefits and subsidized daycare, including for infants. The overall success of these Nordic policies is reflected by frequent international comparisons. The Nordic countries also have relatively low infant mortality; measured per 1000 newborns, these rates are 1.7 in Finland, 2.1 in Norway, 2.3 in Sweden and 3.2 in Denmark (IndexMundi; UNICEF Office of Research). The Nordic countries have scored well in international child well-being and child deprivation indices and on the KidsRight Index and UNICEF Innocenti report cards (Deding and Forsen, 2013; UNICEF Office of Research 2016 & 2017). Most child welfare systems are based on the fundamental principle that removing a child from their birth parents is an intervention of last resort. In family service-oriented systems, such as in the Nordic countries, children are removed from their parents only when in-home services are determined to be insufficient to meet the child’s needs (Cameron and Freymond 2006; Gilbert et al. 2011). Whether providing longterm in-home services before more intrusive intervention may preferentially favor the parents and their rights over those of the children has been a matter of some debate (e.g., Pösö et al. 2014). These concerns are especially relevant for infants. Postponing a decision to remove a child from adverse family and living conditions may be detrimental to both their shortand long-term well-being (Ward 2006). Developmentally, young children require constant and immediate attention as well as secure attachment 4 to permanent caregivers (Howe 2005; Broberg et al. 2006; Ward et al. 2006; Bowlby 2010). Delaying infant removal may thus be more detrimental when viewed on the infants’ timescales, yet short-term information may be incomplete and rely heavily on predictions about the parents (Ward et al. 2006). The United Nations Convention on the Rights of the Child is ostensibly embedded in the child protection legislation of all four countries examined herein; however, they express this differently (Hestbæk 2011; Pösö 2011; Skivenes 2011; Svensson and Höjer 2017). Children’s rights should form the point of departure for all decisions directly concerning children, including all forms of removing them from their homes. While Norway and Finland have specific child protection legislation (Child Welfare Act 1992 and Child Welfare Act 417/2007, respectively), Denmark and Sweden have more general social services acts (Consolidation Act of Social Services and Social Services Act, respectively), which cover children, the elderly, the disabled and other groups needing public support. While the acts in Denmark, Finland and Norway cover all child protection decision types, Sweden has a specific act covering decisions without consent (Care of Young People Act) (Höjer and Pösö in press). 3. Main removal types In all four countries, the following criteria must be fulfilled in deciding on a care order: o There must be a need for an intervention. o There must be an obvious risk that the health and development of the child will suffer major harm. o The necessary care cannot be provided with in-home services. o The care order is in the best interest of the child. Across the four countries, there are three main removal types: o Voluntary placements, in which the parents (and, in some cases the child) consent to removal and can, at any stage, withdraw their consent and require that the child be returned to the home within a specific time frame. o Emergency placements, of limited duration, are performed when the child is in immediate danger. o Care orders, placements in which the parents’ rights are, to varying degrees, restricted; often characterized as “placement without consent.” An infant is typically placed in a foster home, sometimes following a voluntary or involuntary stay with the birth parents in a specialized residential home for observing and supporting the parent–child relationship. All placements are initially meant to be temporary and have a family reunification aim, though permanent placements are possible in Denmark and Sweden under certain conditions (Karmsteen et al. 2018; Höjer and Pösö in press). However, placement practice data from all four countries reveals that many children spend years or even their entire childhood in out-of-home care 5 (e.g., in Finland: Tilastoraportti 9, 2018; in Denmark: Local Government Denmark 2018). 3.1 Legal decision-making bodies The need for an authority qualified to assess children’s removal needs and make related decisions means that certain public authorities and bodies have been delegated the rights and duties to protect children and restrict parental rights (Dingwall et al. 2014). Removal proceedings differ somewhat across the four countries in terms of decision-making authority and involved professionals. However, they are all organized so that care orders without consent are prepared by the local child protection agency and then ruled on by a nonadministrative tribunal or court (Höjer, Forkby and Hultman 2017). Care orders and other removal proposals are initiated by social workers, suggesting that the impetus for removal legislation and policy derives from the social workers who are in close contact with these families. Differences across the Nordic decision-making systems define a spectrum. On one end, Finland’s system rests solely on professionals (e.g., judges, social workers, other experts); on the other end, Sweden delegates decision-making authority to laypeople. Denmark and Norway have systems that lie between these extremes (Hultman et al. 2018). 4. Trends in the use of out-of-home care of infants In 2015, there were 9.5 children per 1000 aged 0–17 years in Denmark who resided in any type of out-of-home placement. In Finland, this number was 13.9 per 1000 children, in Norway 13.2 per 1000 children and in Sweden 9.9 per 1000 children (Nordic Statistics database 2019). These figures reveal differences among the countries, with Denmark and Sweden having the lowest out-of-home care overall. When focusing explicitly on infants (see Figure 1), these rates are significantly smaller (from 3.5 to 7.7 per 1000 infants). Note that Figure 1 reflects “any type of out-of-home placement” (including all three placement types described in Section 3) and reflects the annual prevalence. Note too that within these data, an individual child may be placed in outof-home care more than once during the same year (e.g., starting with voluntary or emergency placement, returning home, then removal by a care order), thereby counting more than once in Figures 1 and 2. Figure 1. Prevalence of any type of placement (voluntary, emergency and care order) of infants 0‒11 months during the years 2007‒2016 (bar chart, left axis). Infants 0‒11 months old per 1000 in any type of care (horizontal graphs, right axis). 6 Note: None of these countries’ national statistics include the age category 0–11 months; rather, these data were requested from the national register agencies. We use the rate per thousand children within each reporting year. Danish registry data from Statistics Denmark were kindly analyzed by senior researcher Mette Lausten, VIVE. Data from Finland were provided by the child welfare register keeper THL, by request on November 7, 2018. Norwegian statistics were provided by the Directorate, National Statistics and Oslo municipality. Data from Sweden were provided by the child welfare register at the National Board of Health and Welfare, by request in November 2017. The rates of infants in any out-of-home care type vary among the four countries throughout the measurement period. Figure 1 shows that Norway has the highest prevalence (7.7 per 1000 in 2016), while Finland and Sweden are midrange with 6.0 and 7.0 per 1000, respectively, and Denmark has the lowest prevalence at 3.5 per 1000—half or less compared with the other countries. Throughout this 10-year period, the internal ranking between the countries remains relatively static, as illustrated by the line graphs, with Norway consistently highest and Denmark consistently lowest. Further, we note the trend of slowly increasing removal of infants during this period in all countries. 4.1 Care order removal Regardless of country, care order removal of infants, in which parental rights are distinctly restricted, is a low-frequency phenomenon (see Figure 2). Finland displays the lowest level of removal via care order (0.6 per 1000 infants in 2016) and in Norway, the rate is significantly higher with 2.3 per 1000 infants (see line charts). During the 10-year span shown in Figure 2, the removal trend was quite stable in Finland, starting with a rate of 0.7 per 1000 and ending at 0.6 per 1000. Sweden faced a decreasing trend during the final years, reaching 0.9 per 1000 in 2016. In reverse, Denmark went through an increasing trend, doubling the rate of infant removal in 10 years to also reach 0.9 per 1000 in 2016. The rates fluctuated in Norway and were generally considerably higher compared with the other three countries. 0 1 2 3 4 5 6 7 8 9 10 0 100 200 300 400 500 600 700 800 900 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 INFANTS 0‒11 MONTHS OLD PER 1000 INFANTS 0‒11 MONTHS ABSOLUTE NUMBERS YEARS Denmark Finland Norway Sweden Denmark Finland Norway Sweden 7 Figure 2. Prevalence of infants 0‒11 months removed by care order decision during the years 2007‒2016 (bar chart, left axis). Infants 0‒11 months old per 1000 removed by care order decision (horizontal graphs, right axis). Despite the intracountry differences, Figure 2 also reveals an essential feature regarding infant removal profiles in the Nordic countries: a relatively scarce proportion of care order removals. Most infants are admitted to care through voluntary or emergency placement. 5. Infant removal legislation, policy and research To examine the policy trends addressing this vulnerable population in the four Nordic countries, we systematically reviewed documents on the child protection systems’ responsibility for infants during the past 10 years. We included existing legislation, relevant background papers, new and proposed legislation, policy reports and programs, expert committees addressing child protection removal and national guidelines for social workers and decision-makers on removal decisions. Because our research team includes representatives from each of the four countries, these materials were examined in their original languages. 5.1. Legislation on infant removal In child protection legislation regarding child removal, infants are not an explicit category in Denmark, Finland or Sweden. This means that children under one year of age are considered indistinct from other children in these child protection systems. None of these three countries have any specific criteria within their child protection laws governing when to remove an infant into care. In contrast, Norway’s Child Welfare Act of 1992 has specific provisions related to newborns. Section 4-8 provides for protection intervention of a newborn within the maternity clinic. The legal threshold for 0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 0 50 100 150 200 250 300 350 400 450 500 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 INFANTS 0‒11 MONTHS OLD PER 1000 INFANTS 0‒11 MONTHS ABSOLUTE NUMBERS YEARS Denmark Finland Norway Sweden Denmark Finland Norway Sweden 8 removing a newborn is a high probability that they will experience a harmful situation, as defined by the criteria for a care order in §4-12 if they are sent home with their parents (cf Sandberg 2005). The lack of an infant-specific care order criterion in all four countries is also true for voluntary and emergency removals. Responsibility of the child protection systems begins in these countries only at birth. However, in both Norway and Denmark, recent policy discussions have raised the issue of giving the child protection system responsibility for the fetus (Prop. No. 745 [2015–2016]; Prop. 73 L [2016–2017]; Avisen.dk 2018), for example, in the form of taking measures to provide prenatal care without maternal consent. Currently, in Denmark, pregnant women with substance abuse problems can agree to a voluntary home separation to protect the unborn child. However, the woman can quit the contract at will and the method has scarcely been used. Since 1996, Norway has provided legal grounds for involuntary treatment of pregnant women experiencing substance abuse (Act on municipal health and care services, etc. [Health and Care Services Act] § 103; see Søvig 2004; Lundeberg et al. 2014). Further, all Norwegian health personnel shall, on their own initiative, report concerns that an unborn child may be hurt (health personnel law § 32). The Finnish Child Welfare Act (Section 25) addresses the unborn infants indirectly in its definition of “anticipatory notification.” This paragraph, introduced in 2010, expands mandatory reporting to cover unborn children. Child welfare notification should be given “if there are reasonable grounds to suspect that the child will need supportive child welfare measures immediately after birth.” The paragraph emphasizes supportive services for pregnant women but does not mention any form of removal. The current Social Welfare Act in Finland, introduced in 2014, obliges the municipalities to provide services to pregnant women with substance abuse problems. Pregnant women also have the right to request and receive services for substance abuse. 5.2. Guidelines and policies regarding infant removal We were unable to find national guidelines in any of these countries instructing social workers or other decision-makers specifically on infant removal. One exception, in Denmark, is The National Social Appeals Board, which in 2015 published a decision of principle (15–17) specifying the criteria for removing a newborn without their parents’ consent. However, there may be regional or local instructions in all countries, describing their agencyand municipality-based procedures, which we have not included here. Self-evidently, the general instructions and guidelines, regardless of child age, include infants. However, we did discover a variety of instructions on how to support parents and/or early parent–infant interactions. This emphasis on supporting families with infants is widely present in recent family and child policy programs, rather than those for child protection, in all four countries. Recent policy development in Norway, for example, shows an increased focus on situations for young children, particularly those considered vulnerable. Specific approaches such as early home visitation after leaving the hospital (i.e., within days 1–3, instead of 7–10) are suggested for at-risk families (NOU 2017:12, p. 121). Other aspects of the policy development include improved knowledge and information about young children’s developmental needs, living conditions and risk factors. Finally, Norway’s proposal for a new child welfare act discusses regulations for newborns and infants in relation to the thresholds for violating Human Rights Article 8, regarding the right to protection of family life and recent decisions by the European Court of Human Rights. The proposed law thus underscores 9 the importance of due process and professional expertise regarding newborns and their needs (NOU 2016:16). In Finland, there is a specific “infant family work” concept (vauvaperhetyö) in child welfare. This country offers multiprofessional assistance to families with infants in certain risk situations, introduced in 2007 as a key theme of the national development program of child protection (Bardy and Öhman 2007). This concept was based on research addressing infant development and families’ risks from poverty and other social factors. It aims to provide early support to families with infants, with a focus on in-home services. Other policy and practice initiatives have similarly drawn attention to therapeutic assessment and support of the parent–infant relationship (e.g., Kalland and Sinkkonen 2005) and supporting parents and expecting parents to cope with substance abuse problems (e.g., Holmila et al. 2008). Typical among both these practices and the Government Key Reform Program for Family and Child Services in Finland (2016–2018) is an emphasis on early and preventive services to support families. As such, infant removal is hardly ever mentioned. Consistent with Finland, the Swedish Social Service Act focuses on prevention, emphasizing consent and voluntariness. Social workers are provided evidence-based instructions and guidelines for working with children and young people at risk; however, age-specific information is scarce. Assessing infants, who have little capacity to participate or communicate, is not specifically mentioned. In a recent report (2018), the Swedish Research Council for Working Life and Welfare (FORTE) states that because infant attachment is closely connected to parents’ caregiving competence, which is not easily measured, it is vital that adequate methods to support parents are in place. They conclude that such methods need to be evaluated in a local context, to create a base for social and health care services recommendations (FORTE 2018). In 2009, new legislation on continuity came into force in Denmark, targeted at providing children placed in out-of-home care more stable lives with fewer changes in the caregiving environment. One of these changes specifically concerned infants. Cf § 62.5 in the Danish Consolidation Act of Social Services, The Children and Young Person’s committee may, in exceptional cases, stipulate that “[…] placement of a child who has not reached the age of one shall apply for three years if it is deemed highly probable that the conditions on which the decision of placement is based will prevail for this period of time.” However, six years after coming into force, only half of the 98 municipalities have applied this measure at least once in the case of an infant removed from home (Karmsteen et al. 2018). For years, Denmark has worked with so-called parallel placements, in which parents and their child are placed together for observation. 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