Uncertain Legacies: Resilience and Institutional Child Abuse - A Literature Review

6 Institutional Child Abuse

Introduction

6.1 All abuse of children, in whichever context it occurs, is damaging, dangerous and distressing to those who are subjected to it. However, aspects of particular forms of abuse can present specific difficulties and challenges for individuals who struggle to recover (Collishaw et al, 2007; Lev-Wiesel, 2008; Wolfe et al, 2003). This section outlines what is meant by institutional child abuse (ICA), and discusses the way in which some of the distinctive features of abuse which takes place in residential childcare settings might affect the development of resilience across the lifespan of those who experience it, with reference to some of the factors discussed in Chapter Five.

6.2 As previously outlined, the Scottish Government identifies five categories of harm which constitute child abuse: physical injury; physical neglect; emotional abuse; sexual abuse; and non organic failure to thrive (Scottish Government, 2002). When these harms are inflicted on children in any of a range of care settings provided by the public, voluntary or private sector, they are defined as institutional abuse. Wolfe et al (2003) highlighted an acute lack of research material relating to ICA, pointing out that:

...governments have had to rely on public enquiries to gain a better understanding of the causes and consequences of child abuse in nonfamilial settings, to reduce the likelihood of future incidents, and to address the needs of survivors of past abuse (p180).

6.3 This continuing knowledge deficit means that there is limited data relating to the recovery processes and resilience of survivors of ICA. Seven of the papers reviewed here related to ICA, four of which were based on primary research, but none directly discussed resilience and ICA. Nevertheless, it is possible to draw out some inferences from that literature, and to relate these to the concept of resilience.

6.4 There has been significant reform of social work, childcare and institutional practice and structures in recent years, and many of the papers reviewed highlighted the positive benefits institutional care can bring into children's lives. Children who are in residential care often come from already disrupted and often abusive family backgrounds, and are more likely to suffer from higher levels of emotional, behavioural and social difficulties as a result (Daniel, 2008; Hobbs et al, 1999; Jackson and Martin, 1998; Lösel and Bliesener, 1990; Rutter, 2000). Residential institutions can - and frequently do - provide a stable environment and consistent care to children and young people (Daniel, 2008; Gilligan, 2008). They might offer opportunities to build close trust relationships with staff members who recognise and respond to their needs appropriately and sensitively, as well as providing a safe, secure base from which to develop wider social networks (Houston, 2010; Roman et al, 2008). In such instances, the experience of residential care can prove to be a positive, resilience-enhancing turning point in the lives of vulnerable children (Rutter, 2000).

6.5 However, there are grounds for some reservations when assessing the contribution to children's wellbeing made by residential care. It would be wrong to assume that residential settings are inevitably safe, secure and nurturing. Those whose wellbeing has already been compromised by their experiences, including abuse, in "adverse environments, often seriously risky ones, before coming into care" (Rutter, 2000, p686) are at higher risk of experiencing further maltreatment once in State care (Hobbs et al, 1999; Gallagher, 2000). Known rates are, once more, elusive - Gallagher (2000) suggests it is a "small but significant problem" (p797), while highlighting an acute lack of research. Revelations in recent years regarding child abuse in formal institutions, in Scotland and around the world, have clearly demonstrated that there may be distinct risk associated with residential childcare, and as a consequence there can be no certainty that such care settings will be "benign and protective" (Rutter, 2000, p687).

6.6 Lev-Weisel suggested that resilience involves a process of transitional identities: from initial denial, to the acceptance of an identity as a victim, towards that of a survivor (2008). This might occur over an unpredictable period of time, but depends on an individual's cognitive and emotional abilities to contextualise, analyse and understand abuse experiences (ibid). For many children, the impacts of abuse take years to surface, emerging only once they are mature enough to recognise and articulate the corruption of power and rupture of trust which underpinned their experiences: there is therefore a link between childhood abuse and adult maladjustment. This was evidenced in several primary studies reviewed here, for example Flanagan-Howard et al's study of 247 survivors of childhood abuse in Irish institutions (2009), Losel and Bliesner's interviews with 244 adolescents in Germany (1990), and Perry et al's work with 81 Canadian participants who had been raised in institutions from birth (2005).

6.7 When this abuse occurs within a residential childcare setting, there are particular aspects which cause acute problems for survivors, and which have direct implications for the development of resilience. These are discussed at length by Wolfe et al (2003), who referred to them as "dimensions of harm": betrayal and diminished trust; shame, guilt and humiliation; fear of or disrespect for authority; avoidance of reminders; and injury and vicarious trauma (pp184-187). Some of these might apply to adult survivors of childhood abuse in other settings. However, also discussed in the paper are unique circumstantial aspects of residential care which might contribute to these particular impacts in specific ways. Wolfe et al point out that these dimensions of harm are only proposed rather than empirically tested and therefore should be approached with caution. Nevertheless, there is resonance with the other literature reviewed, including primary studies, which offers some corroboration to Wolfe et al's ideas and which can be correlated with aspects of resilience and its development in survivors of ICA.

Internal/personal factors

• Self Image: Children who are in residential care are often already victims of various forms of maltreatment (Hobbs et al, 1999), and feelings of shame, guilt and humiliation are common among children who are subjected to all types of abuse. Consequently those who enter the residential care system may already be trying to cope with the impacts of those earlier experiences, a process potentially complicated by ambivalent feelings towards admission and the stigma associated with being a 'young person in care' (Gilligan, 2008; Colton et al, 2002). Participants in Wolters' (2008) small study of ten counsellors working with survivors of ICA reported a perception among their clients that damage was caused by institutionalisation in the first instance, and abuse experiences once in care compounded that harm. Hobbs et al's (1999) retrospective survey of paediatricians' records relating to the institutional abuse of 158 children between 1990 and 1995 found that 80% had been abused prior to admission, demonstrating the pre-established vulnerability of many who enter the care system (Jackson and Martin, 1998; Daniel, 2010). Those who have been harmed prior to admission may therefore already be suffering the common, well-documented emotional and psychological outcomes associated with abusive trauma as outlined in paragraphs 4.2 to 4.5 above. As a result, self esteem and confidence might already be eroded, and a sense of control diminished: subsequent admission to care and exposure to abuse in an institutional setting might further compound and reinforce this negative self image.
• Control: In Chapter Five, aspects associated with control were described, including agency and self determination, both of which relate to the ability to make autonomous decisions and act effectively upon them. The literature reviewed emphasized the need for professional childcare practice to facilitate the empowerment of those in care (for example, Dearden, 2004; Gilligan, 2008). However, child abuse in any context is associated with a shift of the locus of power and control away from the victim so that it becomes concentrated in the hands of the perpetrator, in order that the child can be effectively entrapped into an abusive situation, isolated from sources of support and intervention (Gallagher, 2000; Wolfe et al, 2006). This might be more easily achieved in residential care settings, where contact with family and community sources of support can be more easily restricted (Gallagher, 2000). Wolfe et al (2006) found in their study of 76 male adult survivors of childhood sexual and physical abuse in Irish religious institutions that perpetrators often invoked God's will as a means to ensure compliance, thereby presenting victims with a conflict between a desire to self protect with that of accepting what God had apparently ordained. Unchecked power and authority, and therefore control, is often invested in residential care institutions by society, communities, individual families, and the child itself, and the literature suggests that this is one aspect which explains some of the specific difficulties experienced by ICA survivors as they grow into adulthood (Wolfe et al, 2006; Colton et al, 2002; Gallagher, 2000).
• External attribution of blame and disclosure: The potential for longer term traumatisation of abuse survivors was widely documented in the literature and, as has already been pointed out, there is an extensive body of research relating to the negative outcomes of childhood abuse. It was suggested in Chapter Four that disclosure might be a key moment in recovery journeys, enabling access to and utilisation of support which helps with the process of projecting blame outwards onto the perpetrator rather than inwards towards oneself. However, disclosure processes of ICA might be associated with heightened risks of retraumatisation. Colton et al (2002) interviewed 24 survivors of child abuse in residential institutions, all of whom had taken part in large-scale retrospective investigations into ICA. The researchers found that there may be a public dimension to disclosure absent in other forms of abuse: revelations of persistent abuse of children at particular care homes, for example, may threaten the privacy of prior residents who may or may not have suffered abuse, and prompt defensive denial or forced disclosure from those who were victims. At the very least, revelations may force long-buried memories to the surface, provoking unpredictable responses among those who have been abused (ibid).

In a discussion paper, Wolfe et al (2003) suggest specific dangers in revealing ICA: if the abuse occurred in a respected institution or was inflicted by highly regarded individuals, disclosure may spark accusations of fabrication or explicit community hostility, reinforced by institutional retraumatisation if claims are met with disbelief and rebuffed by public bodies such as the police or criminal justice services. This assertion was reinforced by Colton et al's (2002) participants, some of whom cited fear of disbelief or recounted experiences of outright rejection when disclosure had previously been attempted. The nature of child abuse, the full impacts of which may not be fully comprehended by the survivor until later in life, often leads to delayed disclosure, fuelling public reservations about their veracity (Wolfe et al, 2003). Some authors acknowledge the inherent difficulties of reflecting upon memories of abuse in childhood from the perspective of adulthood, highlighting the risk of "distortion and memory biases" (Wolfe et al, 2006) at the very least, and the danger of "the social construction of memories of abuse" (Smith, 2010, p313) at worst. However O'Leary (2009) conducted a survey among 147 adult men who had experienced sexual abuse in childhood, and noted higher rates of post traumatic stress disorder in those whose claims of abuse were negatively received, and therefore it might be reasonable to surmise that, despite the challenge and complexity associated with disclosure, initial responses from those listening to narratives of abuse are critical, affecting recovery processes and the longer term development of resilience.

Nevertheless, there are documented benefits to disclosure. Lev-Weisel (2008) drew on the work of Forward (1990) to illustrate that by analysing and understanding the personality of the perpetrator of their abuse, survivors can more effectively externalise blame and this might be one outcome of participating in formalised investigations into ICA, where experiences are contextualised with those of other survivors. Although some of the 24 participants in Colton et al's (2002) study, all of whom had taken part in public investigations of ICA, reported feeling significant distress as a result of their participation, others overcame initial ambivalence and gained benefit, seeing it as an altruistic act, for example, whereby the sharing of their experiences contributed to the future protection of children. The researchers assert that:

The stories of survivors bring into sharp relief the fact that historical investigations into child abuse are finely balanced between, on the one hand, addressing the harm that has been caused, and on the other hand, causing further harm. (2002, p548).

There is a need therefore for particular attention to the process of disclosure from those responding to revelations of ICA, especially within public institutions and bodies, as its impacts might be unpredictable. Wolfe et al (2006) found extremely high levels of distress among their 76 participants who had been subject to particularly severe abuse in residential care, suggesting sensitivity in responses is paramount. However, differential experiences of survival indicate that the impacts of abuse may recede and resurface over a period of years, suggesting there is a need for the provision of ongoing, freely available, reflexive and responsive support services for survivors (Hall, 2003) according to need at any given time. The literature therefore points to the potential significance of disclosure in recovering from abuse experiences, as well as diverse outcomes for individuals possibly as a consequence of their disclosure, and the role sensitive, supportive responses might play in nurturing resilience.

• Meaningfulness: Wolfe et al (2006) interviewed 76 male survivors of institutional abuse and found that the majority displayed a "global loss of trust" (p209), whereby feelings of distrust extended beyond individual perpetrators to the organisations in which abuse occurred, radiating out towards other community institutions and perpetuating into adulthood. The extremity of abuse both experienced and witnessed by clients of Wolters' (2008) counsellors had contributed to a conviction that no-one and nowhere was safe. One outcome of the betrayal of an unspoken contract of care between child and institution, ruptured when individuals who have authority within that contract inflict abuse, might be that:

What once made sense no longer makes sense and what was once safe is no longer safe. Abuse survivors have explained that this loss of a sense of safety causes the world to seem chaotic or unstructured. (Wolfe et al, 2003, p185).

This might consequently jeopardise a belief in social order and stability, a sense that the environment - and correspondingly, one's own life - is regulated and relatively predictable, one of the factors associated with higher levels of resilience. Moreover, trust is associated with the ability to function in terms of relationships at every level - intimate, social and professional - and a lack of trust can have an acute affect on individual lives in both private and public spheres, an issue which is further discussed in a following section.

• Spirituality: Three of the four primary studies involved participants from Ireland, where large scale institutional abuse often took place in a religious context, with many of the care facilities being operated by the Catholic Church (Wolfe et al, 2006; Wolters, 2008; Flanagan-Howard et al, 2009). All three reported loss of religious faith in the aftermath of abuse, with anger and disillusionment towards the Church perpetuating into adulthood. Wolfe et al (2006) emphasise the role of the Church as a focal point for community, as well as individual identity, demonstrating the potential rupture between the survivor and their wider social networks, reinforcing their isolation into adulthood. This might be particularly acute as the Church could be seen as an organisation invested with "implicit trust" (Wolfe et al, 2003, p183), its faith-based care believed by most to be loving, benign and inherently trustworthy.
• Hope: Wolfe et al (2006) found that many male survivors of various forms of childhood abuse in religious organisations who took part in their primary study had a bleak view of the future, which they associated with "the years of silence and inaction regarding their abuse" (p209). An inability to envisage a positive future was echoed in Wolters' (2008) study, where counsellors reported that clients who had experienced abuse in institutional settings demonstrated higher levels of hopelessness compared to those who had been abused as children in familial settings. However, in Wolters' paper, this was attributed to a profound and diffuse inability to trust others on a personal, social or professional level. Relationships with others, therefore, known to be critical in establishing and sustaining faith in the future (Werner, 1992), were severely compromised by participants' childhood experiences of abuse in care.

External/social factors: looked-after children and relationships

6.8 For looked-after children, the quality of parental or familial relationships is often compromised (Rutter, 2000), but the literature showed that other non-related adults can provide adequate support to offset this deficit, alongside the good peer relationships which are equally critical for looked-after children (Daniel, 2008; Dearden, 2004). What is important is the existence of "a sensitive, consistent, and safe care-giving environment" (Heller et al, 1999, p322), and care staff were seen as playing a central role in providing supportive relationships (Daniel et al, 1999; Daniel, 2008; Dearden, 2004; Gilligan, 2008). The 23 at-risk young people interviewed in Laursen and Birmingham's study (2003) repeatedly expressed a need to spend time with adults, to be listened and responded to, appreciated and valued. Relationships which provide this have positive impacts on self worth, and empowering practices such as active consultation and shared decision making between young people and care workers are likely to build self confidence and instil a sense of autonomy and control in looked-after children (Daniel, 2008; Laursen and Birmingham, 2003), thus promoting the development of resilience in the longer term.

6.9 Several authors, however, highlighted the tendency for residential settings to focus on structured, practical care - ensuring school attendance, for example - while the importance of informal support - of spending time with residents, talking and listening to them - is often overlooked (Daniel, 2008; Gilligan, 2008; Jackson and Martin, 1998). Although supportive relationships may occur informally and routinely, they are often absent from formal care plans, and consequently simply spending time with young people can become a neglected aspect of residential care (Gilligan, 2008) and may subsequently run the risk of being under-valued and under-resourced (Daniel, 2008). Ungar (2001) conducted secondary analysis on a piece of primary research which involved double interviews with 43 youths in care, and highlighted a tendency to focus on the "problem-saturated identities" (p138) of participants, while Daniel et al (1999) drew on a participatory study with 11 social workers to argue that adopting a resilience framework would allow a shift of emphasis from problem based approaches, to one which works with the existing and potential strengths of individuals in order to develop their resilience. Moreover, Dearden (2004) used data from a small qualitative study with 15 young people to argue that concentrating on reducing risk factors, many of which are embedded at socioeconomic and structural levels, is impossible for both local authorities and practitioners, and therefore it is pragmatic to prioritise practice which reinforces protective factors such as relationship-building. These arguments chime with current developments in health policy, in particular assets-based approaches, premised on the notion that channelling efforts to mobilise and fortify pre-existing personal, community and social strengths and resources can offset the negative impacts of larger, structural problems in developing overall health and wellbeing (Sigerson and Gruer, 2011). Contemporary work with children in residential care settings may already be resilience-enhancing, building on the work of NCRRI and influenced by GIRFEC. Daniel (2008) therefore proposed that developing frameworks with the purpose of identifying and invigorating resilience in young people in the care system would enable formal integration of such practices, an approach congruent with strengths-based theory.

The impact of institutional child abuse on relationships

6.10 The literature reviewed points out that there is currently scope for the development of good, healthy, nurturing relationships between looked-after children and adult care staff. Contemporary policy responses, underpinned by the work of the NRCCI and CELCIS, promote safer recruitment practices, registration of care workers, and closer monitoring and inspection of residential homes than occurred in the past. However, there remains an increased opportunity for perpetrators of institutional abuse to groom or forcibly inflict harm on children and young people living in residential care, and to escape subsequent detection particularly in light of the power dynamics of the child/care worker relationship. The reviewed literature consistently highlighted the long-term impact experiences of childhood abuse have on adult relationships. Abuse by figures of respect and authority is much more likely to result in longer term fear and/or disrespect for those in authority in later life (Wolfe et al, 2003; Wolfe et al, 2006; Wolters, 2008). Feelings of powerlessness and impotence may translate into mistrust and disengagement with authority figures and formal public institutions, for example in educational or workplace environments (Wolfe et al, 2006). There has been historical concern about the overall educational attainment rates of looked-after children - although there has been some improvement in recent years - which may be lower than those of non-looked after children, increasing the likelihood of experiencing poverty later in life (Jackson and Martin, 1998; Rutter, 2000). This suggests possible intergenerational implications, both in terms of the difficulties associated with raising children in poverty, but also because mistrust and disengagement may affect relationships with those who teach survivors' children, increasing the possibility of cyclical disadvantage (Wolfe et al, 2003).

6.11 This loss of trust might also impact on longer term recovery, and affect both the ability to build and maintain healthy relationships with other adults, as well as with healing professionals such as counsellors. For example in Wolters' (2008) study, which examined therapists' experiences of working with survivors of ICA, participants reported that it was harder to build trust relationships with this group of clients, compared to those who were abused in non-institutional settings. An acute lack of trust, referred to repeatedly in the literature, can impact on survivors in every domain of their life, and hamper access to resources and support that might help to aid recovery and contribute to the development of resilience.

Structural factors

6.12 Colton et al (2002) conducted a study comprising interviews with 24 survivors of institutional abuse who had taken part in large scale public investigations. The authors highlight the "long-standing anxiety about the threat to social order represented by troubled and troublesome youth" (p549) arguing that the demographic background of many of those in care - drawn overwhelmingly from the poorest and most disadvantaged homes and communities - shade experiences of abuse, shaped as they are by the "deeply embedded social attitudes and associated structures of social injustice" (p549). Just as the process of resilience itself is multifaceted and dynamic, so too are the parallel political discourses which shape attitudes towards specific social groups. Therefore the stigmatisation of sections of society on socioeconomic grounds - the 'underclass' discourse - as well as negative attitudes based on race or disability might prompt ambivalence in public attitudes towards children who have been in care, and subsequently those individuals who have experienced abuse in institutions.

6.13 The extremity of the impacts of ICA on the health and wellbeing of many survivors is clearly demonstrated in this literature review (Wolfe et al, 2006; Colton et al, 2002; Wolters, 2008). In particular mental health can be severely compromised, and this can negatively affect many aspects of personal and public life, including the ability to maintain employment, for example. This might be further complicated by coping responses to abuse experiences, which may include drugs misuse and criminal behaviour (O'Leary, 2009; Wolfe et al, 2006), and consequently the chances of living in poverty in later life are increased (Jackson and Martin, 1998; Rutter, 2000). Long term mental health problems and potentially damaging and dangerous coping strategies such as these might limit the ability to participate and fully engage in social and work activities, impeding the development and maintenance of self esteem and a sense of purpose - and therefore meaningfulness - in life.

6.14 Issues of gender already discussed in Chapter Five might be equally pertinent to survivors of ICA. There is some evidence in the literature reviewed that coping strategies following child abuse, including ICA, are differentiated by gender - for example, men are more likely to use drugs than women (Wolfe et al, 2006; O'Leary 2009). Although there were no direct comparisons of gender in the literature reviewed, some studies focussed specifically on men because of an acknowledged lack of research relating to male survivors of many types of abuse (Colton et al, 2002; Wolfe et al, 2006; O'Leary, 2009). Colton et al (2002) interviewed 24 survivors of abuse in residential care, 22 of whom were male, and reported that participants felt that institutional responses varied between male and female survivorss based on assumptions that abuse of boys by men was worse than that of girls by men, or boys by women, attitudes which were seen as reflected in the varying amounts of compensation paid. Moreover, the authors found that those who were in charge of the investigation - mostly men - were believed to "regard[ed] female perpetrators as less dangerous and less of a problem than male abusers" (p546), an assumption which might have significant impacts on the likelihood of a survivor being believed, or the longer term effects of their abuse being seen as equally damaging and distressing.

6.15 Perceptions of the severity of abuse based on gendered assumptions were also apparent in attitudes towards perpetrators: Perry et al (2005) interviewed 81 adults who grew up in institutions in Canada from birth, most of whom reported experiencing a variety of forms of abuse while in care, and found that men reported more sexual abuse compared to women, who were much more likely to experience emotional abuse and neglect. The authors attribute this discrepancy to the higher number of male care workers working with boys, and who are much more likely to sexually abuse children than female care workers. There is some indication, therefore, that children in different care contexts might be more likely to be subjected to different forms of maltreatment, may respond in diverse ways, and may face different value judgements from those to whom they disclose, depending on gendered perceptions of childhood abuse. A reluctance to disclose and seek help might be driven by perceptions such as these, further compounding the stigmatisation of male survivors of abuse or survivors of female abusers, and might increase a tendency to internalise blame, driven by feelings of shame and guilt, underpinned by public discourses of 'normal' masculinity and femininity.

6.16 In common with other forms of abuse, there is little evidence available relating to the frequency and severity of ICA (Rutter, 2000; Wolters, 2008; Gallagher, 2000) and scant literature directly addressing resilience and adults survivors of abuse in institutional care. This may be because the locus of abuse is not seen as a distinctive feature in other types of abuse. However, this section has highlighted some of the unique aspects of residential care which may well have significant impacts on the recovery processes of survivors of this type of childhood maltreatment.

6.17 Many papers reviewed address resilience and looked after children, but on the assumption that any abuse experienced happened prior to admission. Care and protective practices have been reformed in recent years, in light of what has emerged in the aftermath of public investigations into historical abuse in residential facilities, and modern frameworks of care can provide opportunities to increase the resilience of children who are currently looked-after. However, what we know of abuse in general - the enforced secrecy, the manipulation and corruption of adult/child power dynamics, and the delayed realisation of harm - means abuse in any setting, including residential care, is likely to continue to occur, and that survivors will continue to emerge in years ahead. Although it is difficult to unravel abuse experiences of children who may have been abused prior to admission and further victimised once in care (Rutter, 2000), this review has highlighted aspects peculiar to this particular type of child abuse which may have longer term implications for survivors who strive to live well in its aftermath. Ungar asserts that:

we do not yet know what constellation of interventions and protective processes positively influence children's development, while under the care and/or supervision of formal and/or informal service providers (2005, p441).

6.18 There is a corresponding gap in our knowledge about what might contribute to the healthy and robust recoveries of those children exposed to abuse in these environments as they grow into adulthood. However, based on a synthesis of the available evidence, some reasonable conclusions about the impact of ICA on the resilience of adult survivors might be drawn.