One important factor to note in analysing this tension is that the individual who has made the allegation of wrongdoing equally desires a fair trial in which their perspective will be heard. To disclose abuse, regardless of age, requires a great amount of courage.  This power imbalance, in combination with the impartiality of the court proceedings, can lead to a sense that the child's (victim's) perspective is of less importance than the defendant's perspective. Barnahus, in some respects, aims to provide the child with all the necessary "tools" (e.g. support services and flexibility) to level the power imbalance between the child (victim) and adult (defendant) so that the justice process feels, and becomes, fairer.

As minors affected by abuse and maltreatment according to the UNCRC (1989), and to the Council of Europe Convention on the Protection of Children Against Sexual Exploitation and Sexual Abuse, known as the Lanzarote Convention (Council of Europe, 2014), children have rights to protection, participation, and provision and can expect their welfare to be the paramount concern. As child witnesses, children's primary role in the various legal processes is to provide evidence to establish the guilt or otherwise of the person alleged to have caused them harm. At the same time, many cases of abuse concern an allegation against a family member or someone close to the child. Subsequently, children may be particularly reticent to disclose any information because of the anticipated consequences, such as those threatened by the perpetrator as a means of maintaining the child's silence, and separation from or creating a rift within the family (Goodman-Brown et al., 2003). Children have often reported that as witnesses, the court process may be even more traumatising than the initial injustice they have experienced (Warrington et al., 2017; Streich & Spreadbury, 2017).

Regarding children's rights as victims, victims' rights codes in the United Kingdom and the European Union largely overlap with child rights as outlined in the UNCRC (1989): for example, the right to be heard, the right to access information about the case and their involvement (both aligned to participation rights), the right to protection (EU, UNCRC), and the right to access victim recovery services. Given that Barnahus is predicated on children's rights, victims' rights codes are largely upheld through the model, and in fact, the Council of Europe recommends the Barnahus model as an appropriate recourse to justice and recovery for children who have experienced violence and abuse (2018). But for Barnahus models that are less aligned to court proceedings (for example, the child may still need to appear in court or via a live link), external justice processes should work to uphold children's and victims' rights to the same degree as the Barnahus model, in particular by recognising and responding to the particular needs of the children involved and ensuring that processes are responsive and the trauma informed. Victims' rights should be upheld throughout the justice process and proceedings.

Barnahus also aims to extend beyond victims' codes in simplifying and shortening the criminal justice proceedings for children, so that children can avoid being "stuck" in justice proceedings that will require them to live and re-live their experiences by actively bringing them to mind for recall purposes to officers of the court. Under Barnahus, children should ideally be able to speak about their experiences with trained forensic interviewers and to have such conversations video recorded, and for such material to serve as "evidence-in-chief " for any court proceedings (Haldorsson, 2019), as is the case in the Nordic model (Myklebust, 2017). This situation means that the child's video-recorded forensic interview will be used as evidence in court, and the child is not generally required to appear in court to testify in person.

One challenge that has arisen in stakeholder discussions (as outlined in Lavoie et al., 2021a) is the question of how new disclosures or evidence that come to light after the child's testimony has been recorded should be treated within the criminal justice system if the court proceedings have not closed. At the root of this question is the concern for a fair trial for the defendant, but the nature of the question highlights the tensions that are continually being navigated between the defendant's rights and a victim's rights in procedural discussions. In Norway, legal regulations in the criminal procedure outline that if a child discloses new evidence, the police will conduct a supplementary child forensic interview, which is a possible solution for other jurisdictions as well.

#### **Systems Level: Tensions Between Justice and Welfare**

Another system-level tension is that between justice and welfare. "Justice" in this case refers to the services and procedures related to the criminal investigation (e.g. the forensic interview, any court proceedings, and forensic medical examinations), whereas "welfare" refers to the recovery support and services (e.g. victim support services, medical examination when not for forensic purposes, child protection assessment, mental health assessment and services, and therapeutic services). The two systems have competing mandates—a fair trial for justice, and therapeutic support, safety, and well-being for welfare—which influence the tensions between these two systems (Johansson, 2017). Within Barnahus, both systems are important for the child and for the family, and the aim is a co-located structure where both can operate collaboratively to support the child.

At the same time, each system has its own internal structure, which includes procedural structures and a particular way of thinking. Such structures might include case management, data gathering, and information sharing. In addition, each of the multiple disciplines involved has a particular way of thinking—that is, they have accepted viewpoints and values, or "external regimes of governance" (Emerson & Nabatchi, 2015). For example, in the case of Barnahus, the best interests of the child can represent safety and recovery or can represent formal acknowledgement of wrongdoing from the defendant through the court system.

These different viewpoints require effort on behalf of all staff to navigate meaning and power dynamics, both seen and unseen (Johansson, 2017), all of which can affect the child's experience within Barnahus. As Johansson (2017) explains, there can be a tendency for all systems within Barnahus to be skewed towards the justice system in a process called "juridification", given the nature of collaboration and co-location within Barnahus. Further, the formality of the justice proceedings and the rigidity of the internal systemic structure convey a high level of decisionmaking power, which can influence the decision-making of professionals in child protection and recovery (Johansson, 2017). In discussions with professional stakeholders in Northern Ireland about the challenges and opportunities of a Barnahus model, one key theme that arose was to keep in mind the needs of children and families and to involve them in the process of developing the specifics of a Barnahus model (Lavoie et al., 2021a). Such an approach could help to reduce some of the systemic challenges involved by bringing the focal point to children's and families' needs.

Navigating power dynamics is also possible through open communication and learning about the functioning (e.g. the professional practices as well as regulated mandates that incorporate structural and regulatory issues) of each of the disciplinary teams to support a greater understanding and empathy of the background processes and ways of thinking (Herbert & Bromfield, 2019). Other methods for effective team working include establishing clear goals and having a shared team identity, as well as having clear roles and responsibilities (Reeves et al., 2010). Of particular importance for inter-professional working is inter-professional education, reflection of daily practices, and evaluation to ensure that joint goals are being met (Broukhim et al., 2019).

### **Child Level: Tensions Between Child Protection and Participation**

Children are the primary service users of Barnahus and are those who have experienced the greatest injustice in the form of abuse and violence. We have some knowledge about what children's needs are through the justice and recovery process. For example, children seek to be heard (Hayes & Bunting, 2013), to be included and participate in the process (Hill et al., 2022), and to have their experiences acknowledged in some way (Lavoie et al., 2021a).

Among the tensions that can arise with children's involvement in Barnahus is the tension that exists between children's protection and their participation rights. Although seemingly peripheral to justice tensions, children's experiences with the justice and recovery process can contribute to whether they feel that they have experienced justice, however that looks to them. Their experiences also contribute to whether they will continue with any criminal justice proceedings or withdraw entirely (Lavoie et al., 2021a). Their participation is key to this feeling. Thus, navigating a balance between the two is important.

With Barnahus being premised on children's rights through the UNCRC and the Lanzarote Convention, participation is a key element that is built into the Barnahus model. That is, Barnahus creates space for children to express their views (and be heard) through the justice and recovery processes, to the extent that they would like to be involved. Participation rights also include the child having access to meaningful information and being aware of what they can expect throughout the process, including the timing. At the same time, participation in any one process should never be construed as obligatory; children are invited to participate in the Barnahus processes as much as they are interested and able, given their age and maturity. At the same time, some jurisdictions will have legal regulations regarding participation in the penal track (including any potential court proceedings) that will work against this normative principle. With these elements of participation in mind, a tension can sometimes arise between children's participation and child protection.

The child protection element of Barnahus is concerned with ensuring that children are in a safe environment, free from abuse and violence, and that any abuse or violence that has occurred will not recur in the future. This element can, at times, mean that decisions are made without giving due weight to children's views, which is one of the practical challenges involved in upholding participation and protection rights simultaneously. This situation highlights, in a sense, a perceived tension between participation and protection that often influences practice and results in professionals prioritising protection. It is possible for the two to exist harmoniously together, however, such that children have space to speak their views, are heard by the professionals supporting them, and that they are provided with up-to-date information through the child protection process.

Recognising the tension is helpful for being aware of the inherent power dynamics in participation and protection, and professionals in Barnahus are consequently able to be cognizant of how these dynamics play out in practice. Recognition of the inter-dependencies between children's rights to protection and participation should also support the recognition that children's involvement in the process, according to their increasing capacity, is also likely to strengthen protection because it will help to enable informed decisions and children's engagement with the process (Mitchell et al., 2023).

# **Discussion: Advancing Child-friendly Justice**

We have now outlined our analysis of the theoretical frameworks for situating three justice-related tensions. Together, these frameworks can help to situate different perspectives of justice: victim needs versus defendant needs, justice versus welfare, and participation versus protection. With these in mind, a helpful way to move forward is to consider perspectives from the broader body of knowledge of multi-disciplinary working and child participation that can help us to situate how a Barnahus model could support moving towards a conceptualisation of justice that supports the multiple perspectives we have outlined in this chapter.

The first learning point that emerged from our analysis was what is intended by child-friendly justice, and what does it look like in the Barnahus system? This was a key theme to emerge in our research with professional stakeholders in the UK—to determine whose needs for justice were being met in the current system and to be mindful of the different perspectives of justice moving forward (Lavoie et al., 2021a). That is, the intention of the Barnahus is that justice procedures and recovery services should be easily accessible and navigable for children and their families, but part of the adaptations to the justice procedures in making them more purportedly child-friendly can also put children's statements at a disadvantage relative to other pieces of evidence that may be presented in courts. For example, in many European Barnahus, an accepted practice is for the courts to see the child, and hear the child's testimony, at Barnahus, and not at a formal court building. When this occurs, however, the child's statement is given lower evidentiary value. Although not subjecting the child to formal court processes, either by necessity or design, does seem more child-friendly, the fact that the child's statement has lower evidential value enhances the power imbalance between the victim and the defendant. As a result, a relevant future direction that has arisen is to explore how proposed or real (depending on the jurisdiction and accompanying legislation) changes to the justice procedures within Barnahus may contribute to child-friendly justice or perhaps, in some ways, detract from them. If the latter, we must also consider ways to mitigate any detraction from child-friendly justice through the Barnahus model.

Related to this point, in moving forward, it will be important to have a clearer sense of what justice looks like within the family after abuse has occurred. Previous interventions have explored the possibility of restorative justice approaches (Julich, 2006; McGlynn et al., 2012), but perhaps one area of learning to be highlighted first before establishing interventions should be to understand, from a child's and family's perspective, what justice looks like to them, in terms of an outcome or a process toward an outcome. Professional stakeholders in Northern Ireland have indirectly highlighted this element, through ensuring the involvement and co-production of children and families in the development of the specifics of a Barnahus model (Lavoie et al., 2021a). By coming alongside children and their families to assist them through the justice and recovery process through Barnahus, we may be more likely to disrupt a cycle of violence and victimisation so that children and their families can truly thrive post-abuse. This understanding would also contribute to refining the support provided to children and their families throughout the justice and recovery process via Barnahus. Given the implications for recovery, this should be a priority area moving forward.

Another element highlighted in our analyses is the power dynamics and power imbalance inherent within the justice tensions in Barnahus (Johansson, 2017), and the need to be aware of whose needs for justice are being met through the current systems (Lavoie et al., 2021a). The power imbalance stems from the hierarchy of power within each of the tensions; we have noticed that the more formalised the structure, the higher the perceived power. The tendency towards a hierarchy of power within each of the tensions is not inherently problematic, but it is important that these elements be acknowledged and addressed explicitly as much as possible so that power dynamics can be discussed to achieve a greater balance across systems and perspectives. The multidisciplinary team members of the Barnahus must also come to a shared understanding of their goals and values, as well as each other's different but inter-dependent roles and responsibilities in achieving those goals (Reeves et al., 2010). Undertaking joint training, reflection, and evaluation of the services would also support such inter-professional working (Broukhim et al., 2019). In this way, the Barnahus model could provide a space (both physical and in terms of human resources) where the different needs and perspectives for justice may be navigated through careful attention to inherent power dynamics and through open communication of the needs of each of the parties involved, whether they are the child and family or professionals working in child justice and recovery.

Finally, we must also highlight that there are ways to navigate justice tensions. Formal mediation is one approach that can help to balance out imbalances in power dynamics and can give each side the chance to contribute to discussions and to be heard (Ashford & Faith, 2004; Hart, 2009). In Barnahus, this balance is possible to achieve through the central coordination system, when that system is not directly housed by one of the four systems involved. Mediation also helps to ensure that each side has recourse when difficulties arise so that power imbalances can be negotiated through discussion.

Even though we have discussed the benefits of mediation in navigating power imbalances, we should note that Barnahus has no formal element of mediation, and we highlight mediation rather because it can provide learning points for moving forward in addressing tensions within children's justice experiences within Barnahus. In other words, the Barnahus model may support the implementation of formal, or informal, ways to navigate justice tensions so that each perspective is held in balance throughout the procedural elements of the criminal justice process. Assessing the benefits of mediation, as well as other approaches to navigating justice tensions, is one key area for future research and knowledge production.

# **Conclusion**

In sum, the goal of children's experiences in Barnahus is that they will feel that a sense of justice has been achieved and that they will be well established on a recovery journey with their families. Throughout this journey are a child's perspective of justice, a multi-disciplinary perspective, and a system perspective. Tensions can arise between these differing viewpoints, including those between a victim's needs and a defendant's needs, the justice versus welfare approach, and child participation versus child protection. Awareness of these tensions and how they play out in a practical way can help to inform discussions moving forward about how to navigate such tensions as they arise, while always keeping the child at the centre.

# **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/ licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# **Part II**

**Organisational Tensions**

# **4**

# **Institutional Barriers to Medical Examinations in Barnahus**

**Kari Stefansen, Elisiv Bakketeig, and Susanna Johansson**

# **Introduction**

The present chapter scrutinises the role of medical examinations in the Barnahus model: a topic that has received limited attention from researchers to date. According to the quality standards for Barnahus issued by the PROMISE network,1 medical examinations are a key component in setting up a holistic service for victimised children. The standards specify that medical examinations and treatment should be offered routinely at Barnahus and that the medical staff should be present

K. Stefansen (B) · E. Bakketeig

e-mail<EMAIL_ADDRESS>
<sup>1</sup> The PROMISE Barnahus Network is a member-led stakeholder organisation that aims to harmonise and consolidate good Barnahus practice across Europe. The organisation's quality standards were issued in 2017 and are available online, in different languages: https://www.bar nahus.eu/en/the-barnahus-quality-standards/.

Norwegian Social Research (NOVA), Oslo Metropolitan University, Oslo, Norway

E. Bakketeig e-mail<EMAIL_ADDRESS>
in consultation meetings and case reviews when appropriate. In line with PROMISE's core idea of the model as a flexible and adaptable structure for the provision of child-friendly justice and recovery (Johansson & Stefansen, 2020), the standards do not describe *how* its medical mandate can be achieved.

Our empirical setting is Norway, where the Barnahus model was implemented starting in 2007; today, Barnahus is a national service that is mandatory to use in police-reported cases of violence and abuse of children (as well as adults with intellectual impairments). As with many national Barnahus models, the Norwegian model is a hybrid institution that combines two "tracks," whose boundaries may shift over time and be blurred in practice: the penal track that refers to the processing of criminal cases, where the child forensic interview is the primary task to be coordinated, and the welfare track which refers to psycho-social work such as needs assessment, support, and recovery services for children and their families (Johansson, 2011; Johansson et al., 2017; Stefansen et al., 2023).

Medical examinations have been part of the Norwegian Barnahus model from the outset (Bakketeig et al., 2012; Stefansen et al., 2012), but they are primarily conducted in the small percentage of cases where the prosecutor sees them as relevant for the gathering of evidence for a criminal case; this situation primarily links medical examinations to the penal track and mandate of the model. But because medical examinations also when ordered by the prosecutor are performed according to an extensive social paediatric protocol, they can also identify healthcare needs and thus serve a purpose in the welfare track of the model.

Still, the potential of medical examinations in Barnahus to contribute to securing the welfare of victimised children more generally is presently unfulfilled in the Norwegian context. The large majority of children who are referred to Barnahus in Norway are not offered a medical examination, although scaling up the offer of medical examinations is a goal, as

S. Johansson

School of Social Work, Lund University, Lund, Sweden e-mail<EMAIL_ADDRESS>
explicated in the formal guidelines for Barnahus from 2016 (Directorates of Police, Family and Health, 2016). The offer of medical examinations in cases where they are not ordered for forensic purposes has generally been understood as important primarily for two reasons: an examination can alleviate the worries of children and their families about irreparable harms, particularly in cases of sexual abuse, and an examination can identify any needs for the treatment of illnesses and conditions both related and unrelated to the violence or abuse the child has suffered (Bakketeig et al., 2012).

National authorities have recognised the limited role of medical examinations in Barnahus since the early-adoption phase of the model, but measures to increase the usage, such as the establishment of funding programmes and guidelines, have had limited effect to date. The aim of the present chapter is to examine why this situation of *institutional inertia* (Aksom, 2022; see also Firsova et al., 2022), or standstill, has materialised in an otherwise innovative and evolving organisation (Johansson & Stefansen, 2020, 2024) that has contributed to a more holistic approach to victimised children and their families (Stefansen et al., 2023), for instance through the practice of interstitial work (Andersen, 2019, 2022, 2024).

Our analysis is grounded in an institutional perspective that is sensitive to how organisations are embedded in wider institutional fields. We draw on data from two national evaluation studies; the first was conducted in the adoption phase of the model (Bakketeig et al., 2012; Stefansen et al., 2012), while the second was conducted in the post-adoption phase (Bakketeig et al., 2021). We identify three types of institutional barriers that together hamper the realisation of the potential of medical examinations, especially in the welfare track of the model: *established routines*, *regulatory issues*, and *lack of resources*. Having improved knowledge about these barriers is relevant not only to the Norwegian authorities (who have struggled to find solutions to the ongoing neglect of victimised children's healthcare needs in Barnahus), but also for countries that are in the process of adapting the Barnahus model to their specific institutional context.

As a background to the analysis, we first describe how medical examinations are organised and regulated in the Norwegian Barnahus model.

## **Medical Examinations in Norwegian Barnahus**

In Norway, the use of Barnahus for forensic interviews is regulated by law (Criminal Procedure Act 22, May 1981, no. 25). The target group is children up to 16 years of age who may have experienced sexual or physical abuse, genital mutilation, violence in close relations, or homicide, or they may have witnessed such incidents (Directorates of Police, Family and Health, 2016). All Barnahus (11 in total in 2023) have a room for medical examinations that is equipped for the purpose and designed to be as child-friendly as possible, with pictures on the walls and other decorative elements. The examinations are conducted by doctors specialised in paediatric medicine who do their daily work at children's wards in local hospitals and are summoned to Barnahus (which are located elsewhere) when their services are needed. Medical treatment and follow-up are not offered at the Barnahus and must be done in hospitals or within the primary healthcare sector.

All medical examinations in Barnahus follow an extensive social paediatric protocol, which means they include a thorough clinical examination as well as a comprehensive mapping of the child's medical history, general development, family situation, daily activities, and psycho-social well-being. When the prosecutor orders a medical examination, the examination also includes the securing of evidence that can be used in a possible penal case. For this part of the examination, the doctor receives a mandate from the prosecutor and writes a forensic report on the issues specified in the mandate. (In the following, we refer to medical examinations that are ordered by the prosecutor for forensic purposes as "forensic medical examinations" and those that do not include such a purpose as "non-forensic medical examinations.") Forensic medical examinations are funded by the police on a case-by-case basis. Funding for nonforensic examinations was unresolved until 2017—ten years after the first Barnahus opened—when a corresponding funding programme was established. These examinations were then placed under a section in the Health Personnel Act (2 July 1999, no. 64), and the responsibility for the funding of all non-forensic medical examinations was placed with the regional health authorities.<sup>2</sup>

The provision of medical examinations in Barnahus is regulated in two formal documents: the general Barnahus guidelines (Directorates of Police, Family, and Health, 2016) and the specific guidelines for medical examinations in Barnahus (Directorate of Health, 2019). Both documents describe the target group for medical examinations, while the latter also details competence requirements for the professionals involved, as well as procedures. Each Barnahus also has a formal agreement with its health region that specifies the responsibilities of the parties: while the Barnahus is responsible for providing equipment and facilities for medical examinations (which include functioning IT systems) and for summoning medical staff to scheduled examinations, the health sector is responsible for recruiting and qualifying doctors and nurses to conduct medical examinations in Barnahus, establishing supervision and mentoring systems, and ensuring the existence of necessary resources for conducting medical examinations and writing forensic reports.

The share of Barnahus cases that include a medical examination has been consistently low among Norwegian Barnahus, although the number has gradually increased. In 2012, 13% of all Barnahus cases included a medical examination (Stefansen et al., 2012); in 2019, after the guidelines from the Directorate of Health had been implemented, the corresponding share was 24%. The share dropped to 21% in 2020, and then to 19% in 2021—most likely because of the COVID-19 pandemic (Directorate of Health, 2022; Police Directorate, 2021).

During the whole period from 2012 to 2021, most of the medical examinations conducted in Barnahus were forensic medical examinations ordered by a prosecutor. Non-forensic medical examinations are rare and are primarily carried out in one Barnahus. In 2021, less than 1% of children referred to a Barnahus received a non-forensic medical examination. The present situation in Norway is thus that, although a

<sup>2 &</sup>quot;Health personnel must ensure that the health care does not cause unnecessary loss of time or expense to the patient, health institution, social security system, or others" (section 6, our translation).

system of provision and funding is in place on paper for both forensic and non-forensic medical examinations, approximately eight out of ten children referred to Barnahus are not offered a medical examination at the Barnahus following the forensic interview.

The issue of limited use of medical examinations and the dominance of forensic medical examinations in Barnahus is not exclusive to Norway. Researchers have described a similar situation in Sweden (Åström & Rejmer, 2008; Barnafrid, 2019), and Iceland is currently revising its system of provision. In Denmark, as well, very few children are offered medical examinations in Barnahus when standard procedures are followed (Spitz et al., 2022).

# **Theoretical Grounding**

The Barnahus model has been described as a social innovation (Johansson & Stefansen, 2020), i.e. a new way of approaching an existing social problem that has the potential to drive change in its surrounding field of services as well. But from an institutional perspective, which we apply here, while organisations are malleable and can adapt to new challenges, they are also resistant to change when practices are and become routinised. Standstill in professional development is thus something that will become visible over time as an organisation becomes more settled—which the Norwegian Barnahus model is. To understand how institutional resistance to change is produced in Barnahus we draw specifically on the concept of *institutional inertia*, as it directs attention to "when and why organizations ignore, adopt, modify, maintain and abandon practices and the way intra-organizational institutional pressures shape, direct and constrain these processes" (Aksom, 2022, p. 464). The concept of institutional inertia is particularly relevant for our empirical case as it emphasises how resistance evolves over time, and not only during the adoption stage of new ideas and practices but also, more importantly, during the post-adoption stage (Aksom, 2022). According to Aksom (2022), initial change can occur, but it may lead to organisations reverting back to previous and familial routines, practices, and structures, illustrating how intra-organisational resistance can be understood as having long-lasting impacts on existing institutional routines (Aksom, 2022; Firsova et al., 2022). Following Aksom, our analysis spans the adoption and post-adoption phase of Barnahus in Norway and is based on empirical data gathered in 2012 and 2021.

In understanding resistance to change in the Barnahus model, it is important to recognise the model's hybridity (Johansson & Stefansen, 2020; Stefansen et al., 2023). The Barnahus model brings together professionals who are simultaneously committed to the joint task of providing justice and support to victimised children and to their own professions' standards, core values, and ideals. These factors again serve different public value goals—which are embedded in different external "governance regimes" (Emerson et al., 2012). And since Barnahus is a hybrid organisation, the analysis of institutional resistance needs to encompass how different mandates (and their respective organisations and practices) become institutionalised—or non-institutionalised—to a varying extent, as well as over time (Aksom, 2022).

Mair et al. (2015) underline how hybridity simultaneously represents a possibility for innovation and new practices and is easily challenged. Drawing on Battilana and Dorado (2010), Johansson and Stefansen (2020, p. 6) have suggested that the Barnahus model "can be seen as a somewhat unstable hybrid organization," since the balance between the penal and welfare tracks of the model may shift over time. Researchers have proposed that the Barnahus model in both Sweden (Johansson, 2011, 2017) and Norway (Bakketeig, 2017; Stefansen et al., 2023) is skewed towards the penal track, since activities within this track tend to become prioritised over activities in the welfare track, especially when the case load increases; this scenario is often conceptualised as a process of *juridification*. In Norway, the potential of medical examinations to contribute more within the welfare track is currently hampered because of such examinations' strong link to the penal track (Stefansen et al., 2023). The institutional dynamics that have produced this situation have yet to be further explored.

# **Methods and Data**

The analysis presented below draws on data from two evaluation studies led by the first and second authors of this chapter (Bakketeig et al., 2012, 2021; Stefansen et al., 2012). Both studies were commissioned by the Police Directorate and were designed as mixed-methods studies. In 2012, six of the then seven existing Barnahus were included in the study, while all 11 Barnahus (with sub-units) across Norway were included in 2021. For both studies, we made field visits to the Barnahus as well as conducting individual interviews with Barnahus leaders and focus group interviews with the social workers and psychologists who were employed as permanent staff. The interviews were broad, and they covered all aspects of the Barnahus model, including the organisation and purpose of medical examinations in Barnahus. We also gathered data from collaborating partners both through interviews and surveys. For the analysis in this chapter, we draw particularly on the interviews with the Barnahus leaders.

Our analysis also builds on key policy documents issued starting from the early-implementation phase through today, as well as a survey study among doctors affiliated with Barnahus in Norway. The set of documents consists of policy proposals, working group reports, and formal guidelines and legal provisions. The survey data was collected for the 2021 evaluation study. Of the 40 doctors who were affiliated with a Barnahus at the time, 36 answered the electronic questionnaire. The majority of the participating doctors were specialists in paediatric medicine and had substantial experience with conducting forensic medical examinations in Barnahus. The survey covered the doctors' professional background and competence and their work at the Barnahus, as well as systems for supervision and peer support, collaboration with other Barnahus professionals, and viewpoints on different aspects of conducting medical work in a Barnahus setting. Many questions allowed for the possibility of providing written comments, and these comments have also informed our analysis.3

<sup>3</sup> The quotes in this chapter have been lightly edited for clarity in English.

We have approached the interviews, documents, and written comments with a primary focus: What can explain the continuous marginalisation of the role of medical examinations in the welfare track of the Norwegian Barnahus model?

# **Institutional Barriers**

Our analysis points to three interlinked institutional barriers towards fulfilling the dual mandate of medical examinations: longstanding *routines* catered to criminal cases, *regulatory issues*, and a lack of *resources*  for upscaling.

## **Routines: From Holistic Idea to Practices Catered to the Penal Track**

When the idea of establishing a Barnahus model in Norway was first launched, medical examinations were understood as vital both for securing forensic evidence for criminal cases and for ensuring children's welfare by identifying their healthcare needs. The idea of a medical examination with this dual mandate is evident in (1) the initial private member motion to Parliament in 2004 that Norway should implement the Barnahus model (Document 8:86, 2003–2004), (2) the report issued by Save the Children Norway suggesting that a Barnahus model similar to that in Iceland should be piloted (Skybak, 2004), and (3) the report from a working group appointed by the Ministry of Justice and the Police and tasked with outlining a model that could be piloted (Ministry of Justice and the Police, 2006). The working group report resulted in the establishment of a pilot project with five Barnahus in different cities. Local working group reports described how the model was to be organised, where it was to be located, and what the procedures would be for case processing. In the first of these reports, from the local working group based in Bergen (Barnehuset Region West, 2007), it was suggested that children should be medically examined if relevant to secure evidence, provide treatment, or take other follow-up measures, thus reflecting a

holistic understanding of the role of medical examinations in Barnahus. The group also underlined that the medical examination needed to be of good quality in order to secure not only the forensic value of the examination but also the well-being of the child.

When the first six Barnahus were evaluated in 2012, all were equipped with a medical examination room and had established routines for summoning doctors from local hospitals to conduct the examinations when ordered by the prosecutor. But some observers expressed concern about the rare usage of medical examinations. The Barnahus leaders voiced that prosecutors were too restrictive when considering the possibility that the examination could yield forensic evidence and therefore requested too few examinations, thus suggesting that the leaders did not see requesting medical examinations to be part of their mandate which at the time was not formally regulated. More recent research from Norway has also pointed to physical health issues as being more or less overlooked in the welfare track, since the clinical Barnahus staff rarely ask children about physical symptoms (Myhre et al., 2019). This situation is not surprising, since the staff's follow-up mandate (according to the Barnahus guidelines) revolves around identifying and relieving psychosocial problems, which is reflected in both their understanding of their role and the practices that have developed over time (Andersen, 2019, 2022, 2024; Bakketeig et al., 2021).

In practice, the routines established during the adoption phase of the model continued through the latest evaluation in 2021. In the whole period, medical examinations have primarily been ordered by the prosecutor and conducted on a case-by-case basis. Only one Barnahus has taken a different approach by offering non-forensic medical examinations on a regular basis. As yet, no system is in place to assess whether a non-forensic medical examination should be conducted in cases where the prosecutor has not ordered a forensic medical examination, aptly illustrated in the following doctor's comment from our survey study:

Today it's primarily the prosecutor who requests medical examinations. So it's mainly forensic medical examinations that are requested, and many children are not offered a medical examination where their health is the main purpose. I suggest the following [solution]: Health personnel should be included in the consultation meeting and provide recommendations on [children's] health care needs.

The survey also documented how the doctors became involved late in the case processing at the Barnahus, and that they only followed the case for a short period of time. The doctors were either present at the Barnahus one day a week to do scheduled examinations or were summoned to the Barnahus on a case-by-case basis. Rather than being involved in discussions about the need for medical examinations, either for forensic or welfare purposes, they were on standby. At the Barnahus, their time was primarily dedicated to the actual examination, and they most often returned to the hospital to write the forensic statement.

A recent report from the Directorate of Health (2022) points to the problems that can arise from the current routines: "The health personnel in our material feel that they are not very involved and are not very integrated in the Barnahus services, and medical examinations are presently a downgraded part of the services" (p.12, our translation). Routines for passing on medical information to professionals involved in the case from the welfare track side are also generally lacking in many Barnahus which hampers the possibility to follow up on a child's healthcare needs, as illustrated in this doctor's description:

There's also a missing or unclear connection to the responsibility to follow up on possible findings, because it's not always the case that what you find gives the child a right to follow-up [treatment] in the secondary health care service. To discover health care needs in otherwise healthy children is normally the responsibility for the primary health care service, and it feels unfortunate and incorrect to jump over this element for most children [who are referred to Barnahus]. The link to the child's legal guardian (in cases where a legal guardian is there for the examination) is also unclear and difficult to follow up after the examination.

But different practices may have been in place among the various Barnahus in this respect; some doctors described well-functioning routines for receiving and passing on medical information, which suggests that room for improvement does exist within the current system: We have good routines at the Barnahus for what's included in the case file [which the doctor receives prior to the medical examination]: the notification of concern [to the child welfare service], the mandate for the forensic medical examination, and a short summary of the forensic interview. We also provide a short briefing to the Barnahus staff and the child welfare services if they accompany the child, and to the prosecution if the examination reveals findings [relevant to the criminal case].

The weak link between the medical examination and the welfare track was however evident in the lack of routines in most Barnahus for passing on medical findings to the Barnahus staff and other professionals. Doctors generally did not participate in follow-up meetings between the professionals involved in the criminal case after the forensic interview has been conducted (the second consultation meeting) even though medical personnel who have performed the medical examination are mentioned among those who should participate in these meetings in the general Barnahus guidelines (section <IP_ADDRESS>).

## **Regulatory Issues: Inconsistencies in the Scope and Integration of the Dual Medical Mandate**

Our analysis also points to several regulatory issues that hamper the possibilities of offering medical examinations in Barnahus on a broader scale. One issue relates to inconsistencies about the target group for medical examinations, or the form of universality that is to be applied. The general Barnahus guidelines issued in 2016 by the Directorates of the Police, Family, and Health are unclear about whether medical examinations *should be* offered to all children who are interviewed as aggrieved parties4 (as stated in section 2.2), or if an examination *can be* offered, as stated in section 4.2.2. The guidelines also state that the implementation of this new obligation—to offer medical examinations on a standard basis—must await a plan of action from the Ministry of Health and Care

<sup>4</sup> Children who witness violence against a family member are also considered victims in the Norwegian penal act (Directorates of the Police, Family, and Health, 2016) and thus are included among the aggrieved parties mentioned in the general Barnahus guidelines.

Services to increase capacity, which suggests that the intention is to scale up to a more universal offer, albeit one that is restricted to children who are referred to Barnahus as aggrieved parties.

The 2019 national guidelines for medical examinations in Barnahus issued by the Ministry of Health and Care Services are also inconsistent in terms of the target group. The guidelines first state that "all children" (p. 4) referred to Barnahus for a forensic interview should be offered a medical examination, hence indicating that children who have a prosecutorial status as witnesses, and who are not suspected of being victims of violence and abuse themselves, should also be included in the target group. But the guidelines also describe that Norway's health regions have been instructed that medical examinations in Barnahus should be offered to children who have "experienced abuse" (p. 4), thus indicating a narrower target group more in line with the general Barnahus guidelines. Similar inconsistencies also exist in the report on medical examinations in Barnahus issued by the Directorate of Health in 2022, which may be linked to different views on the scope of the medical mandate in Barnahus among the health and justice authorities. For Barnahus, the different expectations produce regulatory vagueness about the target group for medical examinations, as well as which types of procedures and routines should be developed for a more universal provision of medical examinations that caters to the dual medical mandate.

Another regulatory issue concerns the possibility for doctors (and other medical personnel) to participate in the formal multi-professional consultation meetings at Barnahus, where participants plan the forensic interview and discuss further case processing. Earlier, we described doctors' frustration that their current role was restricted to simply conducting the medical examination. In their view, their earlier involvement could ensure that the medical health perspective would be given more weight in the processing of cases, which could possibly lead to an increase in both forensic and non-forensic medical examinations.

The general guidelines for Barnahus from 2016 do not include medical personnel among those who can attend the initial consultation meeting, and our survey showed that the current practice was in accordance with this regulation. But both the recent report from the Directorate of Health (2022) and the national medical guidelines from 2019 recommend that medical personnel should participate in the formal consultation meetings. According to the medical guidelines, full integration in the Barnahus collaboration, including consultation meetings, is necessary to assess whether a medical examination is needed. The medical personnel also need to receive necessary medical information about children and their cases in order to adapt the medical examinations to specific children and their psycho-social situations, as well as to secure forensic evidence and medical documentation. Allowing doctors to participate in the initial consultation meeting, however, would require a change in the statutory provisions on facilitated interviews (FOR-2015- 09-24-1098, §7), since medical personnel are not mentioned among those who can be present. Medical personnel are also not among those explicitly mentioned in the Criminal Procedure Act (see §239d) among those who are allowed to observe the investigative interview, which also excludes them from this part of the case processing. Hence the Barnahus cannot change their routines before these regulations allow for the participation of medical personnel.

The Barnahus model is also regulated by a complex set of other legal provisions, which can pave the way for misunderstandings. The report from the Directorate of Health (2022) shows that some Barnahus employees feel that the Norwegian legislation is vague about who has the authority to refer a child to non-forensic medical examinations. According to the same report, however, this question is partly resolved through the National Insurance Act (28. February 1997 no 19) and the statutory provision about out-patient health services in the specialist health service (FOR-2007-12-19-1761), which regulates who has the authority to claim reimbursement and claim equity of patients within specialist health services. Beyond this provision, however, no legal regulations stipulate who can refer people to medical help—which, according to the Directorate of Health, implies that anyone employed at a Barnahus can refer a child to a medical examination. The lack of knowledge in Barnahus about who holds the legal authority to refer a child to a non-forensic medical examination has likely contributed to the rarity of such examinations, which is an understanding also shared by the health authorities. The report from the Directorate of Health (2022, p. 19) thus underlines the necessity for developing routines within the Barnahus to ensure that children are offered a medical examination based on a thorough assessment. But for Barnahus to take on this responsibility, it would need to be included in the general Barnahus guidelines, which is currently not the case.

Another area where the regulations are insufficiently clear among Barnahus employees relates to who has the legal authority to consent to non-forensic medical examinations on behalf of children in cases where one or both parents are suspects in the criminal case. Starting at age 16, children can consent on their own behalf; for younger children, their parents hold the right to consent on their behalf due to their parental rights. In this situation, however, the parents and the child may have conflicting interests. When this is the case, a legal guardian may be appointed according to the Guardianship Act (26. March 2010 no 9, section 16) and issued the authority to consent on behalf of the child. A widespread understanding in Barnahus is that the legal guardian lacks the authority to consent to a non-forensic medical examination on behalf of a child. The Directorate of Health report (2022), however, points out that this interpretation is incorrect, at least in terms of medical examinations conducted on the same day as the forensic interview at the Barnahus, since both the Guardianship Act and its preparatory work indicate that this authority lies within the mandate of the legal guardian. The non-forensic medical examination is also explicitly mentioned in the standard text on mandates for legal guardians, appointed by the county governor in Oslo and Viken Counties, thus mirroring the same view. If the medical examination is to be done sometime after the forensic interview has been performed, then the situation might be different, since the reasons prohibiting the parents from consenting on behalf of the child might no longer be present. Under these circumstances, the parents' consent would be required if they are holders of parental rights and if the child is younger than 16. Even though the question of consent according to the health authorities is at least partly resolved in the present regulations, the current practice in Barnahus reflects a need for more information on how the regulations should be interpreted, as well as guidance on the routines that must be in place for obtaining a valid consent to non-forensic medical examinations. This situation again would require clarification of the target group for such examinations: whether they should be offered to all children interviewed in Barnahus or only to those interviewed as aggrieved parties.

## **Resources: Little Capacity for Upscaling**

The rarity of cases that include a medical examination has been a continuous source of concern ever since the Barnahus model was implemented, and an explicit goal from national authorities is to upscale this part of the Barnahus operation. But what, exactly, medical examinations in Barnahus should entail is not part of the discussion. As mentioned earlier, medical examinations today are performed according to an extensive social paediatric protocol, regardless of the purpose of the examination (forensic or not). Most Barnahus observers take for granted that upscaling means a more universal offer of social paediatric medical examinations, which require specialist training and is time consuming. This view is explicated in the national medical guidelines from 2019 and is supported by Barnahus leaders and doctors alike.

For doctors, setting the protocol aside would mean going against agreed-upon medical standards for the assessment of vulnerable children's healthcare needs, as illustrated in this quote from our survey study: "It's important to sustain the quality of what we deliver and not increase the number of cases at the expense of quality." To date, no one has fully acknowledged the resource requirements for upscaling to a universal offer of medical examinations, based on the social paediatric protocol. Upscaling would require investments on the Barnahus side, and thus for the justice sector where Barnahus is affiliated. Investments would include additional examination rooms and medical equipment, which are minor costs compared to the costs involved for the health sector. Even though not all children summoned to Barnahus will need a medical examination, the goal of having a more universal provision of medical assessment in Barnahus is hardly within reach in any foreseeable future: Only one in five cases presently include a medical examination, and qualified doctors are already a scarce resource in Norway's health regions (Bakketeig et al., 2021; Directorate of Health, 2022). Such is the situation, despite the fact that Norway's health regions in 2016–2017 were instructed to develop sufficient competence and capacity in order to be able to offer children interviewed at Barnahus medical examinations (Directorate of Health, 2022, p. 13).

In our survey, we asked the Barnahus doctors about how realistic they thought the plan to upscale to more universal provision in their respective health regions was. Close to half the doctors indicated the capacity to do more forensic medical examinations in their health region. Their answers most probably reflect their experience that prosecutors are generally restrictive when considering the need for forensic medical examinations, and that upscaling would not mean a considerable increase in such examinations—at least not in the short term. The possibility of upscaling to offer medical examinations in *all* Barnahus cases was another matter. Six out of ten doctors answered with a definitive "no" to this question, while only a quarter answered with a definitive "yes." The positive answers should be interpreted with caution, however, given the rarity of cases that include a medical examination today.

We should note that the doctors differed somewhat in their view about the universal provision of full medical examinations in Barnahus. Some doctors were open to alternatives, for instance, the use of a screening model, or the idea that medical professionals should be more involved in deciding which children should be examined:

Medical examinations should be mandatory to offer to all children who come to Barnahus. Alternatively, health personnel should play a larger role in decisions on who should be given the offer of a medical assessment.

Some doctors also stated that medical examinations were unnecessary in certain types of cases and that, given the limited resources, more serious cases should be prioritised. The Directorate of Health report (2022) also brought up the issue of differentiation, or finding the right level of universality. According to the report, medical examinations in Barnahus could be unwarranted in cases where the health of the child has been assessed elsewhere, the child does not belong to the target group, or the incident happened a long time ago.

The doctors' survey answers also indicated the existence of unresolved resource issues in the present situation, which provides important context to their answers about upscaling: 22% indicated that they sometimes had too little time for a medical examination, and only 19% stated that they always had enough time to write the forensic report. For most (61%), whether they had enough time varied, while 17% usually experienced problems finding the time. The following quote from one doctor is illustrative of these findings:

We have the capacity to do more forensic medical examinations, but it's a challenge to write the reports from them. [If we were to upscale], the hospital would need to allocate enough time for report writing, court appearances, consultation meetings, and so on.

In addition, the doctors' answers indicated major differences between hospitals in terms of their quality control and psycho-social support systems, which also points to a lack of priority for medical work in Barnahus in Norway's health regions. Only four out of ten doctors answered that their hospital units regularly conducted case reviews which is a well-established method for quality assessment and knowledge transfer. Some doctors described how quality control routines were lacking altogether in their hospitals:

We don't have any systematic quality control of forensic medical examinations. No time is allocated to training, reviewing reports, or supervising [inexperienced doctors'] writing or preparation before [they] must give testimony in court. We really need to establish a system for these things. Managers who don't have experience with this field of expertise don't understand this need, and as long as there aren't any official recommendations, they won't follow through.

As illustrated, the issue of funding of non-forensic medical examinations is much more complex than simply funding doctors' time so they can conduct medical examinations and write reports. The issue also involves recruiting and qualifying doctors and resources for supervision and quality control as well as ensuring their participation in collaborative work throughout case processing.

## **Concluding Remarks**

Drawing on the concept of *institutional inertia* (Aksom, 2022), in the present chapter, we have examined how resistance or standstill can occur within a system designed to work innovatively and to provide momentum to broader societal changes in response to child victimisation (Devaney et al., 2024, chapter 9). Despite clear aims and efforts to the contrary, in the Norwegian Barnahus model, medical examinations have become closely intertwined with the penal track, while their role in the welfare track has been sidelined. The reasons for this development are complex. While the professionals and agencies involved generally understand that medical examinations in Barnahus have a dual mandate and serve important roles in both the penal and welfare tracks of the model, the established system of institutional routines, regulations, and funding programmes seems to have facilitated more of a bifurcation in how the system "thinks" about medical examinations in Barnahus.

Our analysis shows some of the challenges involved when a hybrid practice is to be implemented in an "unstable" hybrid organisational model (Johansson & Stefansen, 2020) that (in the case of Barnahus) has become increasingly skewed towards the penal mandate (Stefansen et al., 2023). When the Barnahus model was first implemented in Norway in 2007, these challenges were only partly understood, and many of the routines for case processing through the Barnahus were established according to the logic of criminal cases, with the forensic interview as the primary task to be coordinated. The room for integrating the medical staff—and making use of their expert competence in the whole process of the case—has been hampered from the outset. Progress has been held up by legal and administrative regulations that exclude medical staff from key collaborative arenas in the preparatory stage of case processing (such as the formal consultation meeting) and by weak or absent routines for information sharing and collaboration with the professionals responsible for children's recovery and welfare during the follow-up phase. Their possibility of offering medical assessments to a broader group of children is also restricted due to the perceived lack of clarity in which circumstances Barnahus staff must refer children to non-forensic medical examinations and their perception of their role in terms of follow-up. Non-forensic medical examinations are thus a largely non-institutionalised practice, even though they are clearly included in the idea behind the Barnahus model as a holistic service.

All in all, the present guidelines do not sufficiently explicate the Barnahus mandate to coordinate and facilitate medical examinations within the welfare track. The Barnahus staff also see their role as primarily linked to ensuring the psycho-social welfare of children and their families. In addition to securing the necessary legal basis for medical examinations, including having sufficient legal clarity, the incorporation of the medical mandate across the penal and welfare tracks thus entails changes both in organisational routines and professional "gaze" and practices, both of which are more difficult to achieve when a practice has become more set. In the Norwegian context, the medical examinations have become more institutionalised within the penal track than the welfare track. The barriers can be understood as a clash between external governance regimes (Emerson et al., 2012) and existing institutionalised intra-organisational norms (Aksom, 2022) related to the respective collaborating agencies and professionals. Medical staff often struggle with long-lasting intra-organisational routines, established within their ordinary healthcare organisations, while non-institutionalised routines for practices that fulfil the dual medical mandate within the hybrid Barnahus organisation present their own challenges. As Aksom (2022) acknowledges, this scenario tends to push organisations back towards previously routinised practices and structures, thus making successful changes difficult to achieve.

Another contributor to institutional inertia is the resource situation in the healthcare sector and the fact that qualified doctors are a scarce resource. Even if Barnahus do succeed in establishing new routines for needs assessments and referrals to non-forensic medical examinations, the goal of upscaling to the universal provision of full-scale social paediatric medical examinations at the Barnahus is not within reach in any foreseeable future. To date, policy documents have not sufficiently addressed this issue. Such documents include the Barnahus guidelines and the latest report from the Directorate of Health (2022), which assumes that medical examinations in Barnahus should be done according to the social paediatric protocol and do not discuss alternative systems of provision.

Universal provision can be achieved through other organisational setups, however. In a trial project in Denmark, all children suspected of having experienced violence and abuse in close relationships, and who were referred to the Barnahus via the Copenhagen police for an investigative interview, were offered a forensic medical screening (Spitz et al., 2022). One of the aims of that project was to strengthen the child's rights by documenting traces of physical harm to the child caused by being exposed to violence, and, on a qualified basis, optimising further followup of the child within the legal, medical, and social systems. Based on parental consent, the examination consisted of a comprehensive forensic examination combined with an examination of the child's general health and well-being, consistent with what we have referred to as Barnahus's "dual medical mandate." Within three days, the forensic examinator issued a preliminary conclusion that was shared with the prosecutor; based on this conclusion, the prosecutors decided if they would ask for a full forensic medical statement, which could be used as a legal document. Among the children who were examined for the trial project, almost half showed traces of abuse and/or illness. The report concluded that the project had contributed to a stronger evidential basis in criminal cases, as well as securing more children's medical follow-up after the investigative interview. The strength in this trial project seems to lie in its universalism, since all children who are interviewed at Barnahus are offered an examination and are examined if their legal guardian consents. This routine removes the assessment of whether an examination is necessary and gives the prosecutor a better foundation for deciding if any medical evidence is relevant to the penal case.

One question that could be raised from our analysis is whether children who are referred to Barnahus for a forensic interview should have a legal right to a medical examination. Making medical examinations a legal right would strengthen Barnahus's obligation to offer such examinations, and to establish necessary routines for the follow-up of any healthcare needs that are identified in collaboration with medical personnel. How such a right could be regulated within the Norwegian legislation would first need to be assessed. Another necessary precondition for such a system to function is that sufficient resources must exist in the healthcare sector to educate and allocate medical personnel to conduct medical examinations in Barnahus on a much larger scale than is the case today.

Legal changes take a long time. In the short term, progress is possible by implementing new guidelines that explicate the responsibilities of the Barnahus staff for referrals to medical examinations, and the possibilities of acquiring consent from a child's legal guardian in cases where the parents and the child have conflicting interests. More can be done within the present regulatory system to involve doctors in multi-professional consultation meetings at Barnahus and to develop routines that ensure that any medical health needs that are identified are attended to after the forensic interview has been completed.

For countries that are piloting or implementing the Barnahus model, some general advice from our analysis is that the role of Barnahus staff in medical matters must be explicated in Barnahus guidelines as part of the coordinating responsibility. The quality standards from PROMISE can be a starting point for how to carve out the medical mandate of national Barnahus models. Such standards are general in nature, however, and must be complemented by context-specific analyses of both the formal and practical obstacles to fulfilling the dual aim of medical examinations.

# **References**

Kaldal (Eds.), *Justice and recovery for victimised children: Institutional tensions in Nordic and European Barnahus models*. Palgrave Macmillan.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/ licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# **5**

# **Accumulated Silence When "Passing the Buck": Organisational Tensions in Child Welfare Investigations**

**Lina Ponnert**

# **Introduction**

Child welfare caseworkers operate in a professional field characterised by juridification and hard-law initiatives as well as increased standardised procedures (Ponnert & Johansson, 2018). Although the use of Barnahus is not mandatory by law in Sweden, the model has rapidly become a standard normative procedure.1 Specialisation and professionalisation tend to result in increased functional and structural differentiation of organisations (Axelsson & Bihari Axelsson, 2006), examples of which include both Barnahus and increased organisational specialisation into different

L. Ponnert (B)

School of Social Work, Lund University, Lund, Sweden e-mail<EMAIL_ADDRESS>
<sup>1</sup> In 2018, approximately 77.6% of the 290 municipalities in Sweden were connected to a Barnahus (Barnafrid, 2019).

units within the child welfare services. This chapter examines these developments by using the perspective of child welfare caseworkers,2 with a focus on child welfare investigations (henceforth "child investigations" or "investigations") in cases of suspected violence.

For almost a decade, Sweden's child welfare services have been required by law to initiate an investigation when they receive knowledge that a child might have been exposed to, or witnessed, violence, or other abuses by or directed to a close relative (SOSFS, 2014:4, 6:1). We might look at this legal regulation as an attempt to strengthen the protection of children from violence and to reduce the risk that children who are referred to the child welfare services will not be thoroughly investigated. But an obligation to initiate a child welfare investigation might also create legal, professional, and ethical tensions (Ponnert, 2023). As of November 2022, initiating an investigation is no longer mandatory, partly due to interpretation problems in practice discovered in a follow-up and analysis by Sweden's National Board of Health and Welfare (2021, 2022).

Violence in close relationships, however, is an area where the law is still complemented by binding regulations and general advice from the National Board of Health and Welfare (HSLF-LF 2022: 39), including a reminder to initiate investigations of children when appropriate, and an obligation to provide support to children who have been exposed to or witnessed violence in close relationships. The child welfare service's responsibility in the event of violence has accordingly come to be emphasised and regulated in more detail in legislation in recent years. Since August 2021, such legislation also includes a legal responsibility to ensure that those who have subjected relatives to violence or abuse will change their behaviour (Prop. 2020/21:163; 5:11a Social Services Act [SSA]3 ). Subjecting a child to witnessing violent acts between people close to the child is also now a crime, as of July 2021 (Prop. 2020/21/21:170; 4:3 Criminal Code), which may result in an increased number of children

<sup>2</sup> I use the phrases "social worker" and "child welfare caseworker" synonymously in this chapter, both of which refer to social workers who have the legal authority to conduct preassessments and/or child welfare investigations within the child welfare services. In Sweden, this work requires a 3.5-year education which results in the professional title *socionom,* or a corresponding relevant degree (3:3a Social Services Act [SSA] 2002: 453). 3 SSA 2001: 453.

being subject to parallel investigations and hence referred to Barnahus in Sweden.

Although one aim of Barnahus is to provide an integrated and child-centred model for investigating suspected child abuse by using a "one-door principle" to avoid secondary victimisation, the opposite development may occur in how the child welfare services are organised. Today the services are characterised by an intra-organisational specialisation (Blom et al., 2009; Grell et al., 2022). In Sweden, municipalities have specific intake units (sometimes called reception units4 ), which specialise in making the immediate risk assessment of referrals/reports concerning children at risk, to make a pre-assessment, and (within 14 days) to decide whether an investigation should be initiated (National Board of Health and Welfare, 2019, pp. 8–9 and 53). If an investigation is initiated, the case is then transferred to a specific investigation unit, where another child welfare worker (henceforth "social worker") conducts the actual investigation. Social workers at separate support/ intervention units also provide support to children and their families and follow-up children in care. When they have reason to believe that a child has been subjected to violence, social workers thus need to collaborate within the child welfare services and to do so in accordance with their own legal obligations and organisational procedures; they must also collaborate with the police and Barnahus. The challenges found in child investigations from a social worker's perspective are thus important to highlight.

While research on Barnahus from the perspective of social workers is scarce, Mosegaard Søbjerg (2017) has shown that, from a broader holistic approach, social workers in Denmark may experience challenges while working with children and their families when Barnahus is involved, and police reports may also challenge collaborations with families (Mosegaard Søbjerg 2017; Johansson, 2011). Johansson (2011, 2017) has found that the inter-professional collaboration in Barnahus in Sweden is generally characterised by juridification, in the sense that a logic oriented on

<sup>4</sup> Based on a survey answered by 251 municipalities and neighbourhoods (of 312 in total), a total of 82% had a special intake unit concerning children and youth. In 61%, the intake unit only concerned children and youth, but 21% of the municipalities had intake units directed towards children as well as adults (p. 53).

criminal law tends to guide work and override an approach oriented on social work. In my own thesis (Ponnert, 2007), which was carried out before Barnahus and specific intake units became standard in child welfare services, I also found several aspects of juridification influencing the compulsory care process within the child welfare services. For instance, as decisions were handed over to the administrative court, social workers expressed a need to await enough "legal evidence" before intervening, although they were morally and professionally convinced that compulsory care was required.

One question that then arises is the question of what happens with social workers' risk assessments today, when they are both filtered internally at different levels within the child welfare services organisation and in relation to Barnahus, and a logic that is oriented towards criminal law (Johansson, 2011, 2017). In this chapter, I will explore a few organisational tensions within the child welfare services (intra-organisational tensions) and in the collaboration with Barnahus and other agencies (inter-organisational tensions), and how these tensions might affect child welfare investigations and practice concerning suspected violence. I ask which dilemmas can be discerned when it comes to violence from a social worker's perspective and in relation to Barnahus, and what are the possible consequences from a child's perspective?

This chapter's discussion and results are based on a Swedish research project on social workers' interpretations of violence in child investigations.5 The Swedish system has been described as being oriented towards family service (Gilbert, 2012), with low legal thresholds for mandatory reports and for child welfare investigations. A child investigation proceeds most interventions from the child welfare services in Sweden, and interventions are rarely possible as a "service" without previous investigation. Hence not only are the most serious cases or referrals investigated, but so are cases where the family applies for, or only needs, minor support, such as counselling. Voluntary support, however, is preferred

<sup>5</sup> The research project is titled "Child welfare investigations when violence is suspected: Social workers' interpretations of violence, assessments of the best interests of the child, and consequences for practice" (Barnavårdsutredningar vid misstanke om våld: Socialsekreterares tolkningar av våld, bedömningar av barnets bästa och konsekvenser för praktiken). The project is financed by the Swedish Crime Victim Authority (Brottsoffermyndigheten).

and is often used in cases of maltreatment as well, if the child's custodians give their consent. As an example, babies are primarily removed to foster care as a result of voluntary or emergency measures (Hestbaek et al., 2020), and the division between support/welfare and protection vis-à-vis interventions can accordingly be blurred in practice. Pösö et al. (2014) have problematised the family-service orientation in Nordic countries due to its principle of providing the "least intrusive" form of intervention, since this approach may result in an overly high threshold for providing out-of-home care, even when children experience adverse home conditions. The large number of teenagers with behavioural problems in out-of-home placements in the Nordic countries may be an unintended consequence of a lack of sufficient protective interventions at an early age (Pösö et al., 2014).

## **Theoretical Framework**

The analysis presented below is grounded in two theoretical frameworks: institutional theory and perspectives on professional discretion. I argue that both approaches are necessary to understand the challenges and consequences of different collaboration practices regarding child welfare investigations.

#### **Institutional Theory and Organisational Perspectives**

Institutional theory focuses on how organisations adapt to the institutional context (Di Maggio & Powell, 1983; Meyer & Rowan, 1977). Researchers have elaborated on the concepts of integration and specialisation from different perspectives to understand such adaptions. Lawrence and Lorsch (1967), for instance, claimed that organisations tend to become differentiated into parts in order to correspond to changes in the institutional environment, but they also found that these parts need to be integrated and provide a unified perspective for the organisation to thrive. Today, the child welfare services in most Swedish municipalities are also characterised by an intra-organisational specialisation that can be described as both problem-based and function-based specialisations (Blom et al., 2009). In a problem-based specialisation, separate units manage different social issues or target groups (such as children), whereas a function-based specialisation usually refers to the separation between authoritative work and decisions (such as conducting investigations and making decisions) and the provision of social support and treatment (Blom et al., 2009).

Axelsson and Bihari Axelsson (2006) relate the increased specialisation and professionalisation in public health to increased differentiation on different levels, both within organisations and at the inter-organisational level. They claim that functional differentiation results in structural differentiation, which may cause a fragmentation of responsibility, which in turn may result in a need for horizontal and vertical integration between organisations or units through coordination, co-operation, contracting, and/or collaboration. Integration, however, is a broadly used concept (Fisher & Elnitsky, 2012) that has also been used to describe organisational structures and specialisation (Grell et al., 2022; Smith et al., 2018). In this chapter, "organisational integration" refers to an organisational structure that avoids the differentiation of work into different specialised units, while "integration practices" are defined as collaborative forms of integration work.

Drawing on previous studies on collaboration in Barnahus, one starting point for the analysis is also that the collaboration in Barnahus has often been characterised by juridification, in the sense that the power dynamics result in a logic oriented on criminal law primarily setting the agenda, whereas the treatment-oriented logic (represented by social workers) tends to take a back seat (Johansson, 2011, 2017). In Johansson's study (2011) and in interviews with staff at six local Swedish Barnahus, she showed that social workers may be excluded from cohearings due to the secrecy of the criminal investigation; she also found that Barnahus coordinators might propose that social workers not inform a child's custodians about police reports before the investigative interview at Barnahus has been conducted (Johansson, 2011, 2017). King and Piper (1995, pp. 132–138) have described such a juridification phenomenon whereby the legal system becomes the dominant discourse once the law or justice perspective "enslaves" child welfare knowledge. But juridification is a broad concept that may relate to many different dimensions, including increased legal regulations and judicial power or a tendency for people to think of themselves and others as legal subjects (Blichner & Molander, 2008). In this chapter, I refer to juridification as a regulatory process that tends to result in increased "instrumental orientation" (Teubner, 1987), which occurs as a result of both legal and organisational rules and norms for practice.

#### **Social Workers' Discretion**

Discretion has been described as a doughnut hole, surrounded by a belt of restrictions (Dworkin, 1977). Social workers belong to a professional group that is usually associated with considerable discretion or room for manoeuvring to make assessments and decisions based on their specific knowledge and judgement. But researchers often distinguish between the actual room for manoeuvre, or "discretion as granted", and the "discretion as used" (Hupe, 2013), as well as between professionals' "discretionary reasoning" within their "discretionary space" (Molander, 2016). Molander (2016) claims that when discretion is split up among several actors, the power of each person is reduced. Such "divisive mechanisms" thus narrow the discretionary space and may also (either by intention or otherwise) function as a delaying mechanism. Hood (2020) has elaborated on how sharing discretion can be seen as a way of spreading responsibility. He uses the concept of "pooled discretion" or "hanging together" to describe situations where the responsibility for decisions is shared but not avoided. The functional specialisation of social services into several units may be seen as an example. Another way to spread responsibility is by "semi-delegated discretion", where the discretion is fully or to some extent, passed on and delegated to another actor, also referred to as "passing the buck" (Hood 2020). In this chapter, this situation may be related to how the main authority to talk to children who have disclosed exposure to violence is passed on or transferred between agencies: either vertically (from mandatory reporters to child welfare services, and from child welfare services to Barnahus) or horizontally, between different units.

# **Method and Empirical Material**

The analysis in this chapter is based on qualitative interviews conducted with 16 social workers in seven municipalities of different sizes in Sweden. One interview was conducted in each municipality. Six of the interviews were minor group interviews with two or three social workers, and one was an individual interview. In all municipalities, the child welfare services were organisationally specialised, and reports/referrals were first handled by an intake unit and transferred to an investigation unit (if an investigation was seen as necessary). All municipalities were also connected to a Barnahus (three different local Barnahus). The participants in the interviews all worked with, or had previous experience of, conducting child investigations. At the time of the interviews, 11 social workers worked at intake units, four at investigation units (of which one had previous experience of intake units), and one with following up children in care. The interviews lasted approximately 60–80 minutes and took place during 2020 and January 2021. Six interviews were conducted at the caseworkers' workplaces, while one was a digital interview. A semi-structured interview guide was used guided by different themes; the organisation of the investigative work, the interpretation of legal regulations for child investigations in cases of violence, the various risks and opportunities involved in child investigations, and any legal tensions. Specific questions were also related to if and how Barnahus and police reports were used, as well as possibilities and challenges related to that aspect. All interviews were recorded and transcribed verbatim. The author translated the quotes used in this article into English; the quotes were then lightly edited for clarity.

The focus in the analysis is on illuminating intra- and interorganisational tensions in social investigative work in cases of suspected violence, including the pre-assessment that occurs prior to a child investigation being formally opened. The interviews were analysed according to the principles of thematic analysis (Braun & Clarke, 2006), guided by the specific questions and theoretical approaches described in this chapter. I searched for quotes that displayed organisational and legal tensions in relation to Barnahus and the work within the child welfare services, noting initial codes. I then reread the transcriptions and searched for any overarching themes before finally reviewing, defining, and naming the themes. The study has been approved by the ethics review authority in Sweden. In the presentation, each social worker is represented by a randomly chosen letter (A-P).

# **Analysis**

I will start by discussing how the organisational specialisation within the child welfare services affects the work with investigations, as well as showing examples of the integration practices that social workers use to avoid performing fragmented work. I then show how the immediate protection assessment conducted at intake units may be affected (and delayed) by new intra-organisational interpretations of the legal framework, the division of work between different units, and the Barnahus procedure itself. This organisational process involves the risk of what I call "administrative thresholds" for taking the child into care. Instead, social workers use different integration practices to try to keep the child secure before and after the experience with Barnahus. Finally, I discuss child investigations and professionals who respond to children's disclosure of violence from an inter-collaborative perspective, also taking mandatory reporting into account, and the risk of what I refer to as "accumulated silence".

# **The Administration and Integration of Work**

The tasks at intake units in most municipalities include receiving reports, making immediate protection assessments, deciding on investigations and police reports in the event of violence, and, if necessary, making immediate arrangements (National Board of Health and Welfare, 2019), which was also the case in this study. In one municipality, however, the social workers stated that whether or not a police report was to be made was decided at the investigation unit. The work involved at intake units also in general (not only in cases of suspected violence) allows limited time for contact with children and parents, since the pre-assessment is restricted by law to 14 days. Also, within a pre-assessment, the social workers are only allowed to talk to the children and their custodians and the person who made the referral; further contacts are only allowed if a child welfare investigation has been initiated (11:2 SSA). As one social worker said, "We usually only have the chance to meet with them *once* during a pre-assessment". Since initiating a child investigation in the event of suspicion of violence was also mandatory at the time of the study, the function of the intake units primarily seemed to be to urgently assess and then administer the violence by passing the case on to the investigation unit and, where appropriate, reporting to the police and contacting Barnahus.

At the same time, some emphasised that immediate protection assessments required more professional expertise and experience, and that those working at intake units often had long experience as investigators. Not talking to the family or the child before transferring the case may also be seen as a form of integration practice, to avoid the involvement of too many social workers. But some social workers could view the limited time for pre-assessments at intake units (14 days, according to 11:1a of the SSA) and the organisational specialisation as problematic and as causing unnecessary delays, since each unit has its own routines for case distribution.

B: I think [things are] going *too* fast, because we have a case for 14 days. As well as having an investigation for four months, we'd need to have [the case] a little bit longer than a few days, because that's a process as well. I'd have to meet the woman or the child who's experienced threats and violence one more time. But as you say [case worker], it should be farmed out [from our unit] as soon as possible.

The social workers above also noted that the process was set in motion once they had met a child and parent, and that this process then ended abruptly after a meeting; they also expressed how the division of work could result in what Molander (2016) calls a "delaying mechanism". Hjärpe (2022) has analysed how social workers can relate in various ways to the time limit of four months for child investigations, including task-oriented, relational, or clock-oriented approaches. The discussion above indicates a task-oriented organisational specialisation, where the case should preferably proceed quickly when the task of the respective unit has been conducted. The social workers themselves, however, could perceive a need for a relational perspective that typically requires time. In general, the strictness of the formal boundaries between the intake unit and the investigation unit may differ slightly between municipalities. In some municipalities, the case could remain in the intake unit somewhat longer, which may also provide discretionary space for integration practices. Social workers at intake units and investigation units could also collaborate when a need existed for immediate protection of a child and urgent compulsory care.

E: We [case workers at the intake unit] do it [the out-of-home placement] together with the investigating social worker. / …/ [The case may involve] a child at school who doesn't dare go home. Sometimes it's us, the people from the intake unit, running [the case]. But a child welfare investigation will happen, since we take action. If you assess that the child needs urgent protection, then usually one of us [social workers at the intake unit] leave, and you connect a social worker from the investigation unit.

—Interview 2, intake unit

The organisational specialisation into separate units, as well as the limited legal authorities within a pre-assessment, seemed to result in an administrative focus for the work that went on at intake units, especially when cases concerned violence, since such cases are quickly passed on for further investigation at the investigation unit. In cases of urgent protection, however, social workers may also cross their intraorganisational boundaries and collaborate across units, which may be seen as an example integration practice.

## **Administrative and Normative Thresholds for Urgent Protection**

One question is what consequences the internal specialisation may have for the first urgent protection assessment (the assessment if something needs to be done right away, based on the information in a referral) and for the pre-assessment that follows, given the limited legal authority and time available within a pre-assessment. In practice, social workers at intake units must decide relatively quickly whether immediate compulsory care needs to be provided, or whether the process at a Barnahus could wait. Several social workers mentioned the example of a child who talks about violence at school, and the dilemma of deciding whether the child will go home again the same day. When asked how they reached conclusions about this type of dilemma, several social workers emphasised that if the child expresses some form of fear, or regarding matters of serious or repeated violence, they could not let the child go home or await the child investigative interview at Barnahus.

But the interviews also showed, as illustrated below, how collaborating with Barnahus, as well as the internal organisational interpretations of the legal framework, might affect the immediate protection assessment in a way that would make social workers take a more passive approach in the immediate protection assessment.

say to the police that he or she is beaten at home. Because

then the child's been ordered not to speak by Mum and Dad.

Legally, as stated above, always informing parents before talking to a child within a pre-assessment or child welfare investigation is not a formal requirement. Later in the same interview, the social workers described how they felt that the requirement to inform guardians early had become stricter over time in their own organisation, which also created difficulties in talking to children before they went to Barnahus.

The interviewees described what once was a normal internal procedure—going out and talking to children at school whenever they disclosed violence—as having become more complicated due to Barnahus, but also based on the internal rules about when the guardians needed to be informed. This situation means that the organisation of the work in the event of suspected violence may result in bureaucratic/ administrative obstacles where emergency protective measures become increasingly practical and ethically complicated. The protection of the child "here and now" is pitted against the protection of the child in the long term via the legal process and Barnahus. This scenario may be interpreted as a result of a combination of pooled (internally) and semi-delegated discretion (Hood, 2020) on an inter-organisational level, resulting in delay mechanisms regarding assessments of urgent protection (Molander, 2016).

Previous studies have shown that child welfare services with less specialised work organisation often increase the tendency to investigate children (Östberg, 2010, 2014). Research also indicates that protective measures as compulsory care are rare interventions, since a focus on parental consent tends to guide the assessment (Heimer et al., 2018; Leviner, 2011; Linell, 2017a; Ponnert, 2007, 2019). In a study based on 291 reports processed within 208 investigations of suspected physical violence in a Barnahus region in Sweden, the researchers found that only 4.5% of the reports were assessed to have resulted in a need for immediate protection (of which less than half resulted in placement), and none of the 208 investigations resulted in compulsory care for the child (Quarles van Ufford et al., 2022). In addition, research on Barnahus has shown that children usually go home to their parents after a visit to a Barnahus, even if the parents are suspected of violence, and that usually children are only placed outside their own homes in the more severe cases (Landberg & Svedin, 2013; Kaldal et al., 2010). One possible risk with suspected violence being administered and filtered through several actors and different organisational units could be that stronger administrative and normative thresholds will arise for social workers where immediate protective measures (such as temporary foster care) are regarded as something that can generally wait and be decided upon at a later stage, after the intake unit has passed the case on, or after the forensic interview at Barnahus has taken place.

### **Protection Through Potentially Risky Integration Practices**

In accordance with the findings from previous studies (Kaldal et al., 2010; Landberg & Svedin, 2013), several social workers in the present study also reflected on the fact that children are often allowed to go home to their parents after a visit to a Barnahus. Deciding whether a child should go home or not after the disclosure of violence raises a form of moral uncertainty (Ponnert, 2015), since both taking immediate actions and letting the child go home will raise ethical concerns.

N: I'm thinking [about] these cases of violence where we go to school. Mostly, the child still goes *home.* But we *also*  contact the parents*.* You might get in touch later that day and decide on a time, so the parents can come and talk to us over the next day or so. You try to safeguard [the child]. And what will happen now, when you go home together this evening? How will you talk to each other? I think that's important for the child, to feel safe and know he or she will return [to the child welfare services] the next day.

Interviewer: Yes, right.

/—/

—Interview 6, intake unit

In this interview excerpt, the participants expressed that handling the matter in any other way was sometimes impossible, even if the child was scared and feeling unwell, and they perceived the discretionary space they

had been granted as being quite limited. Fear of violence can be an incitement for compulsory care, so the organisational context and collegial norms appear to be the factors that restrict the perceived discretionary space. Instead, the social workers described their use of discretion as focusing on more informal ways to safeguard the child by different integrating practices, such as preparing the after-hours social welfare office or by telling the child to contact the social services if something happens. The interviewees described using similar informal safeguarding practices to compensate for the lack of direct contact with children while waiting at a Barnahus.

Interviewer: But sometimes you have to make an immediate protection placement; you can't wait— P and O: —Mm. P: —to safeguard the child's protection. But you might also make a police report and then have a contact with the school, since the investigation's been [formally] initiated.

Sometimes you might check with the principal at the school who knows the child. Perhaps [the contact is] the person who reported about violence. This person might keep an extra eye on the child until the police have conducted the child investigative interview and can be a little vigilant to ensure that nothing happens. So, there are some ways to make sure the child isn't hurt as we wait [for Barnahus].

—Interview 4, intake unit

This discussion may be thought of as including examples of integration practices, in order to fill the gap for children between the report and the child investigative interview at the Barnahus and until a child investigation can move forward. But such practices can also be risky, since the protection of the child is at least temporarily semi-delegated (Hood, 2020) to external actors who lack the legal powers that social workers have to actually be able to control or ensure that the child will not get hurt.

## **The Accumulated Silence When Passing the Buck**

Similarly to previous studies (Johansson, 2011, 2017), the social workers in the present study expressed an adaptation to the criminal justice process and said that they avoided further social investigative measures prior to the child investigative interview at Barnahus, even if a child investigation had been formally initiated. If the time for the child investigative interview at Barnahus dragged on,6 the initial process in the child investigation would be delayed and, in reality, compressed in time, since the child welfare services normally have only four months to conduct an investigation (11:2 SSA).

In a similar way that the social workers in this study could perceive the internal organisational specialisation into units as a delay mechanism (Molander, 2016), so could co-operation with Barnahus. A document study of 69 children referred to Barnahus has also shown that several of the children had to wait a long time for the interview at the Barnahus, some more than three months (Landberg et al., 2020), indicating that such delay processes are not unusual. Following the fact that the criminal justice logic has priority also means that professionals avoid talking to children before the child investigative interview at Barnahus has taken place, which previous researchers have discussed as well (Johansson,

<sup>6</sup> While there are no explicit time limits for when the police will conduct the child investigative interview, the law states that a preliminary investigation must always be completed as quickly as possible (23:4 Trial code 1942: 740). When the victim is a child, and the crime might result in more than six months in prison for the offender, the preliminary investigation must be completed in an especially urgent manner, and within three months from when a person is suspected on reasonable grounds, but that time period may be exceeded due to specific circumstances (2a § Preliminary investigation announcement 1947: 948).

2011; Kläfverud, 2021). Children are given limited information before the investigative interview when they are taken to Barnahus by a companion (Kläfverud, 2021), and the information about Barnahus they do receive is most often provided by their custodians and not professionals (Kaldal et al., 2010, 2017). Landberg and Svedin (2013) found that approximately eight of 23 local Barnahus in Sweden followed a clear structure and routines for who should inform and follow up with children after a visit at Barnahus, and some lacked procedures altogether. This situation may result in a lack of information and support for children or their families after professionals have conducted the investigative interview at Barnahus (Kaldal et al., 2017).

The social workers in the present study also noted that professionals who had a legal obligation to report suspected violence to child welfare services did not talk sufficiently with children who expressed something related to violence.

—Interview 1, intake unit

Such scenarios can result in social workers feeling that they receive overly vague reports of violence that are difficult to assess. At the same time, a similar process occurs within the child welfare services when social workers at both the intake unit and the investigation unit avoid talking to children or parents before the interview at Barnahus. As previously mentioned, social workers at intake units often expressed that they in fact talked less to children when violence was suspected, since it was then obvious that the case would be passed on to the investigation unit. Some also expressed concerns about the limited number of times in which social workers talked to children and the tendency to avoid talking about violence specifically in child investigations.

B: There will be a hearing at the police, and before that, we've only done a *fictitious* immediate protection assessment based on the information from the reporter—where we'll find some protection factors that will result in us not taking the child into care right away. That becomes the leading words here, "compulsory care."

/…/

B: And then [the case is] left to the investigators. And that's where I think the problem is *gigantic*, because a child welfare investigation then consists of a period of four months where, in the *worst* case, you've only spoken to the child *once*, and in the best case, *three* times. But then these cases are closed without further action in most cases if the parent refuses support interventions. And in my world, if a child's told a person that someone beats them, they've eased their heart, picked out that person usually, and then nothing more happens. So we sometimes get these cases back at the intake unit. And then we can see that in *exceptional* cases, you [social workers] talk about the violence, but it's not part of the *rule* to do so. Instead, [they discuss] everything else around the child—family, what they do, their free time, etc.—which should also be included. But *not* the specific violence.

A: Many times, the role at intake units, we don't talk to the child about the violence. Since a child welfare investigation is initiated immediately, a social worker [at the investigation unit] will be able to create a relationship and talk about what is difficult during those four months. But I think it's easier to talk about school and other things.

—Interview 1, intake unit

Previous research has shown how child welfare investigations into violence may be guided by a focus on investigating the violence, or by a more holistic perspective where violence is discussed with less clarity (Landberg et al., 2020; Mattsson, 2017). The tendency to talk about easier subjects than violence, as expressed by the social worker above, could be seen as an example of a more holistic approach. The child assessment framework in Sweden7 also provides a holistic framework for child welfare interventions in which violence is not highlighted by a specific predetermined heading in the written investigation (Ponnert, 2017). Several social workers in the present study also expressed the ethical dilemma of encouraging children to talk about violence when their parents could refuse support measures, hence highlighting some of the challenges involved in having a family-service orientation (Gilbert, 2012; Pösö et al., 2014).

The intra- and inter-organisational tensions discussed in this chapter also create the risk for what I call "accumulated silence" from several professionals when children disclose experiences of violence. Due to organisational specialisation and professional collaboration, and the overall adjustment to the criminal logic when violence is concerned, the common outlook is that talking to a child about the violence is best done by somebody else, at some other time and place. We may think of this scenario as a result of what Hood (2020) refers to as "semidelegated discretion", better known as "passing the buck". This approach is problematic from a child's perspective, since disclosure of violence or sexual abuse is a process (Foster & Hagedorn, 2014; Jensen et al., 2005;

<sup>7</sup> The assessment framework is called "BBIC", an abbreviation for "Barns Behov I Centrum", which in English translates to Children's Need in Focus.

Linell, 2017b; Thulin et al., 2020). Research from the perspective of children has also shown that they feel that they lose control after a disclosure of violence and that they experience a lack of information from child welfare caseworkers and Barnahus on what will happen, resulting in fear or anxiety (Thulin et al., 2020). If they do not feel listened to because of various delay mechanisms in professionals' responses, then the accumulated silence from professionals might also silence the voices of children. The family-service orientation (Gilbert, 2012) and the legal focus on parental consent for interventions in Sweden can also add to this silencing of children.

# **Conclusion**

Since violence is a clear incitement for starting child welfare investigations, either legally and/or normatively, meeting children and their families at the intake unit is sometimes regarded as unnecessary from an integrative perspective, to avoid fragmentation (Axelsson & Bihari Axelsson, 2006). The limited time frame and limited legal authorities within a pre-assessment may also result in a focus on "administrating violence" at intake units, since the case is quickly transferred to the investigation unit. But the analysis has also shown how the organisational specialisation into different units within child welfare—where the immediate protection assessment and pre-assessment is separate from the actual child welfare investigation—in itself can act as what Molander (2016) refers to as division or delay mechanisms in cases of suspected violence, since cases may be distributed during specific weekdays at investigation units.

The inter-organisational collaboration at Barnahus also adds a further layer of division/delay mechanisms, resulting in additional administrative and organisational thresholds for providing immediate protection to children who disclose violence. Together, these mechanisms produce an "accumulated silence" among professionals, where a professional's response to a child's disclosure can be delayed or even absent. Social workers' integration practices to try to safeguard children under these circumstances can also be described as risky, since they might involve

people without a mandate to protect the children in practice, or even the children themselves. We may view this situation as a result of a multi-layered juridification process that, in the long run, also creates a serious risk for silencing the voices and further disclosure of children. This risk is probably even more apparent in what Gilbert (2012) refers to as family-service systems, such as in Sweden and the other Nordic countries, where the "least intrusive" principle and the focus on parental consent to interventions also narrows the scope for interventions and social workers' discretionary space.

The analysis presented in this chapter is based on a limited number of qualitative interviews with social workers in a particular country, Sweden, with a focus on legal tensions in child welfare investigations. How the mechanisms I have identified in this chapter translate to other contexts is a topic for further research; the way in which the collaboration between Barnahus and the child welfare services is affected by the use of different units at child welfare services in most municipalities is also a question that needs to be explored. This chapter however does contribute to an understanding of the complex and intertwined layers of pooled and semi-delegated discretion associated with intra- and inter-organisational collaboration in a highly juridified practice such as violence and child protection, as well as some of its challenges.

## **References**

Axelsson, R., & Bihari Axelsson, S. (2006). Integration and collaboration in public health: A conceptual framework. *International Journal of Health Planning and Management*, *21*(1), 75–88.

Barnafrid. (2019). Slutrapport. Utvärdering av Barnahus.

Prop. 2020/21:163: Förebyggande av våld i nära relationer.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/ licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# **6**

# **Enabling and Preserving Situational Social Work in Barnahus: A Vulnerable Jurisdiction Caught in the Crossfire Between Juridification and Psychologisation**

**Lotte C. Andersen**

# **Introduction**

The starting point of this chapter is a particular context-sensitive or situational social work practice within the Norwegian Barnahus model that can provide a safety net for children in police-reported child abuse cases (Andersen, 2019). This practice may be conceptualised as "interstitial work" (Andersen, 2019, 2022) and involves Barnahus staff—mainly social workers—identifying and compensating for gaps and shortcomings in the systems and relations surrounding each child following investigative interviews, resulting in help that is customised to each child's and family's particular situations and needs. Core elements of the practice can be particularly valuable for children and families who have experience with Barnahus (Bakketeig et al., 2021). The three main objectives of this chapter are to discuss (i) the structural conditions that

L. C. Andersen (B)

Norwegian Social Research (NOVA), Oslo Metropolitan University, Oslo, Norway

e-mail<EMAIL_ADDRESS>
have enabled this practice to emerge within the Norwegian Barnahus model, (ii) various potential exogenous and endogenous threats that could threaten this practice, and (iii) how the practice may be sustained over time.

These questions are used to address scholarly discussions related to the balance between standardisation and professional autonomy in social work (Healy, 2009; Munro, 2005; Ponnert & Svensson, 2016; Sletten & Ellingsen, 2020). The chapter examines exogenous threats, especially those that are relevant within Barnahus models (particularly juridification and psychologisation); the discussion also reflects on how situational practices, such as interstitial work, can be stimulated and preserved when implementing the Barnahus model in new countries.

A central backdrop for the study is the ongoing concern among social work scholars for a general reduction of situational social work practices. Researchers have related this development to the dominance of exogenous trends, such as new public management (NPM) and evidencebased practice (EBP) (Hanssen et al., 2015; Petersén & Olsson, 2015). A key argument is that the increased use of top-down standardised procedures and regulations embedded in these trends reduces clients' problems into predefined, measurable variables and force out the professional autonomy and discretion necessary to tailor interventions to the situational particularities of each case (Petersén & Olsson, 2015; Ponnert & Johansson, 2018). An alternative (or, rather, supplementing) explanation is found in Andrew Abbott's (1988, 1995) notion of "professional regression," which refers to a partly endogenous process whereby professionals tend to "rule out the confusions and difficulties that clients often present to professional knowledge schemes" (Abbott, 1995, p. 550) in order to pursue "purer" jurisdictions associated with higher status. Following this line of thinking, social workers involved in situational social work will eventually be drawn towards more definable practices, such as direct interventions (in the case of psychologisation). Accordingly, previous research and theories suggest that both top-down steering and professional regression may represent potential threats to situational practices such as interstitial work. These arguments are elaborated on and nuanced in this chapter, where the focus is on the experiences of professionals (Barnahus staff) who perform situational social work within institutional frames that can be described as forming a loose regulatory context for social work practice—in this case, in the Norwegian Barnahus model.

# **The Norwegian Barnahus Model and the Practice of Interstitial Work**

The empirical case used in this chapter is the Nordic Barnahus model, more specifically the Norwegian version of the model and the work undertaken by social workers and psychologists who are employed at Barnahus as regular staff. The Barnahus model was introduced in the Nordic countries as a response to a growing recognition of the need for more integrated and child-centred services for children who had been exposed to violence and sexual abuse (Johansson et al., 2017). It represents an inter-agency and co-located model that addresses police-reported cases of suspected child abuse. The model includes the investigative interview, a forensic medical examination, and a coordinative responsibility for follow-up work on victims—for example, referring to or guiding relevant services or providing treatment at the Barnahus. Accordingly, the model encompasses two institutional logics: one related to the penal process and the other to child welfare and health (Johansson & Stefansen, 2020; Johansson et al., 2017). In this sense, it represents a hybrid model (Johansson & Stefansen, 2020; Stefansen et al., 2023).

In Norway, the Barnahus model was first implemented as a trial project in 2007 and became a permanent national-level solution a few years later. It represents a collaboration project among the Ministry of Justice and Public Security, the Ministry of Health, and the Ministry of Children and Families. The organisation falls within the justice sector, and Barnahus is monitored by the National Police Directorate on behalf of the Ministry of Justice and Public Security. Each Barnahus (eleven in total, three with sub-units) represents a separate unit within the police district where it is located.

In practice, the coordinative responsibility related to the double mandate of Barnahus is carried out by the Barnahus staff, which consists of social workers and some psychologists. Most of the staff are clinical social workers with extensive experience from adjacent services, such as the child welfare service, the young people's psychiatric outpatient unit (BUP), or both. Typically, staff members have also taken continued education courses in various therapeutic treatment methods and must be considered experienced social workers.

When the Barnahus model was implemented in Norway in 2007, it had a loose mandate, and few regulations existed to guide or monitor the practices of the social workers. Initial reports (Skybak, 2004; Norwegian Ministry of Justice and the Police, 2006) provided some key guiding principles for practice; for example, the Barnahus staff should not take over tasks or responsibilities from previously existing agencies involved in working with child victims of violence or abuse. The purpose of the strategy was to avoid conflict and tension around the model; Barnahus was not intended to involve changes in the mandate of other services (Bakketeig et al., 2012; Stefansen et al., 2012). Accordingly, the police were still to be responsible for criminal investigations, the child welfare services for placement of children in need, and the BUP system for providing therapy to children with severe trauma symptoms.

Apart from this principle and the designated coordinative responsibility, the model was introduced without specific Barnahus regulations or national legislative changes connected to the implementation. Some regulations and legislation, however, were introduced later on. In 2015, the Criminal Procedure Act was amended, and the use of Barnahus became mandatory in child abuse cases (Johansson et al., 2017). The Criminal Procedure Act of 2015 also provides regulations for the responsibilities of social workers related to the investigative interviews; for example, they must attend collaborative meetings before and after investigative interviews and advise the investigative interviewers on how to approach children. Tasks related to the penal process thus have become more strongly regulated in recent years.

Moreover, National Barnahus Guidelines (National Police Directorate et al., 2016) were issued in 2016. Here, the social workers' key roles related to both the investigative interview and the follow-up work are described. These national guidelines are currently under revision (as of 2023), meaning that new and possibly more detailed and/or stronger regulations related to follow-up work may be expected in the near future. In many ways, social work practice evolved at Barnahus before regulations were introduced in Norway.

Within these institutional frames, experienced Barnahus staff have been observed to engage in a particular context-sensitive or situational social work practice conceptualised as "interstitial work" (Andersen, 2019, 2022). The conceptualisation is meant to grasp a pattern in practice in which contextual features of the case (the response of other services and the child's significant others) play a more significant role than the type of case (e.g. type and severity of the suspected abuse, the child's age, or the child's relation to the abuser) when these staff members decide on how to proceed in their casework. In practice, this situation means that the way in which the experienced staff members evaluate the content and quality of other agencies' responses to the child's situation and needs (as well as the responses of the child's significant others) represents the determinant factors when they decide *if* and *how* to intervene. Accordingly, if the local system lacks important knowledge or has no adequate measures to provide for the child, or when the child must wait a long time for such treatment to start, the staff provide the child with direct interventions (e.g. follow-up conversations or therapy) at the Barnahus.

Staff members also engage in indirect interventions when they identify that someone (such as a professional or significant other in the child's life) is not currently a resource for the child, although they could be if provided with guidance and/or support. In practice, such support could mean having follow-up conversations with (non-abusive) parents, guiding professionals over the phone, inviting to or attending collaborative meetings, or pursuing community work and presentations in schools or kindergartens. Much of the work conducted by the staff falls within the category of indirect work. When "interstices" at the relational and/or system level are identified and compensated for, the practice ensures that someone is continuously there to look after the child in a potentially critical phase and that these people are sensitive towards the struggles the child faces (Andersen, 2022). In this way, the response of the staff is customised to the situational and particular needs of each child in every case.

This chapter's subsequent analysis includes a discussion of which factors within the structural terms of the Norwegian Barnahus model have enabled the situational practice of interstitial work to emerge, as well as future challenges the practice could face.

# **Theoretical Framework**

This chapter draws on literature focused on both exogenous and endogenous threats to situational social work practices. As noted above, a number of scholars have related the ongoing reduction of the situational focus in social work to exogenous processes, more specifically to NPM and EBP (Ferguson, 2008; Hanssen et al., 2015; James, 2004; Lorenz, 2005; Munro, 2014; Petersén & Olsson, 2015; Rogowski, 2010), which have gradually come to dominate the public sector and social work in most European and Anglo-Saxon countries since the 1980s and the 1990s.

NPM may be described as a "structure of organisations as well as a way to obtain efficiency" (Marthinsen, 2018, p. 355). In short, it refers to a cluster of ideas whose aim is to restructure the public sector, with the main goals being increased efficiency and higher service quality through control and monitoring based on goal attainment (Marthinsen, 2018; Petersén & Olsson, 2015). EBP is commonly defined as the "conscientious, explicit and judicious use of current evidence in making decisions about the care of individuals" (Sackett et al., 1996, p. 71). The central idea in EBP is that interventions should be "systematically based on proven effectiveness derived from sound empirical research" (Otto et al., 2009, p. 472). Typically, and similarly to NPM's logic, this approach involves a structured use of standardised manuals to ensure the execution of standardised practice. Scholars have argued that NPM and EBP must be considered interrelated trends and perceived as an integral part of the development of a managerialised social work practice (Petersén & Olsson, 2015; Ponnert & Svensson, 2016). Petersén and Olsson (2015, p. 1585) describe both NPM and EBP as involving a "top-down rationalistic view, incorporating the belief that policy goals, rules and evidence have general relevance independently of context." Consequently, scholars have argued that a tension exists between organising social services in the welfare state and the opportunity for social workers to practise their profession according to their code of ethics (Hanssen et al., 2015). Other scholars have challenged the "degree of autonomy such professionals possess and the discretionary expertise they are allowed to exhibit" (Maillard & Savage, 2021, p. 2). Links may hence be drawn between a high degree of professional autonomy and the ability to perform situational social work in practice.