Foster care time and characteristics of adolescents under foster care by type of institutional services

This study aimed to analyze foster care time and characteristics of adolescents in the institutional foster care services in the city of Recife. This is a descriptive study with a quantitative approach. The study population consisted of all adolescents under foster care in the city of Recife-PE, in the period 2009-2013. The information was retrieved by consulting the Individual Assistance Plans (IAP), with 1,300 analyzed plans. Variables were categorized and described from absolute and relative frequency. Pearson’s chi-square test was used to verify the association between variables, with a significance level of 0.05. Three types of services were observed: for adolescents who are victims of violence and neglect; at-risk with/without drug use; and with special needs. A predominance of older male adolescents, with lower school attendance, greater use of psychotropic substances, involved with socio-educational measures, suffering death threats and with a higher number of service entries-exits was observed. We can conclude that the different profiles of foster care services should be addressed and investigated in a particular way because they show different difficulties related to the establishment of efficient public policies.


Introduction
Adolescent institutional foster care has attracted the attention of several researchers from different areas [1][2][3] .Studies seek to understand this practice from its origin in Brazil to the effects that a period of institutionalization can cause on cognitive, emotional and social development in young people under foster care [3][4][5] .
The reception of children and adolescents -for being orphans, due to abandonment, temporary incapacitation of family care, or due to the violation of rights -is a protective measure of an exceptional and provisional nature until it is possible to return to the community with the family of origin or referral to a surrogate family, or preparation for independence with the majority [6][7][8] .
In Brazil, 7.9 million adolescents aged 12-17 years live in extremely poor households 9 .This fact contributes to fostering children and adolescents and their difficult reinsertion in their families of origin, since poverty is a relevant determinant to foster care 1,2,10,11 .Other foster care-inducive factors are domestic violence, alcoholism and drug use, mental illness of parents, lack of caregivers at home, among others, which influence increased levels of social vulnerability 1,[12][13][14] .
It is now widely recognized that the preferred form of alternative care is within a household environment, such as those offered by relatives or social care, and that large-scale institutional care should be avoided whenever possible 8 .
The most frequent actions on the part of the institutions are welfare-oriented, with a weak commitment to the issues of childhood and adolescence evolution 15 .Discussions about the quality of care and the damage provided by institutional shelters to development are far from being fully known, highlighting the need to elaborate studies that address the processes found in this context 3,5,16,17 .
Some authors argue that the institutional environment would be the best alternative to provide children and adolescents with better upbringing when they do not have a healthy home environment 3,5,16,17 .On the other hand, some scholars believe that foster care harms development 3,[17][18][19] , and one can observe that the prolonged period of institutionalization negatively influences the fostered, associating it with early drug experimentation, low school performance and high repetition rate, living with stigma related to the condition of being under foster care, as well as being frequently victimized at school 4,17 .
From the ecological viewpoint, shelter can and should be recognized as a comprehensive context of development for children and adolescents under foster care, because it materializes the real conditions they live in and develop skills that are decisive for shaping their own personality and sociability.Thus, the discussion about shelter as a comprehensive development context is of paramount importance, given the magnitude of the phenomenon of institutionalization in society 20 .
This study is strongly justified by the lack of national literature on the subject, when compared to the international context.It may stir discussions about the elaboration of appropriate actions and policies in the setting of institutional foster care in the country.Thus, this work aimed to study the length of foster care and characteristics of adolescents under foster care in the city of Recife, Brazil, by type of service.Only adolescents were chosen for analysis, since they have a different profile than children in foster care and are under greater social vulnerability, compromising the success of the foster care outcome, besides being a group that is less investigated in the studies on institutional foster care.

Methodology
This is a descriptive epidemiological study with a quantitative approach.The study population consisted of all the adolescents under foster care following judicial process, in the institutional foster care establishments of the city of Recife-PE in the period 2009-2013.The information of study subjects was retrieved from the consultation to the Individual Assistance Plans (IAPs) filed in the foster care services and in some cases complemented with data obtained at the Entities' Guidance and Inspection Center (NOFE).
Consultation was performed following judicial authorization, and 1,415 adolescents' IAPs were analyzed.We excluded 115 IAPs due to incomplete, modified and duplicated data, resulting in 1,300 records for analysis.
Twelve services provided foster care to adolescents in the period investigated, of which five were municipal, six state and one philanthropic establishment.Of the twelve units, only eight were operating during the collection period, three units were closed and one was under renovation.However, information on adolescents attended in closed and renovated services was also obtained from NOFE or other units to which these adolescents had been transferred.
The studied variables include sociodemographic data of adolescents and their families, as well as factors related to the foster care process.Data on gender and age were analyzed among the sociodemographic characteristics.Concerning families, we observed whether the adolescent was deprived of family power.Other variables considered were possible return to family, regardless of whether or not visits are received and regardless of family attachment and affection, as this information was not well completed in the IAP.Regarding foster care process and experience, investigated variables were agencies responsible for the referral; school attendance; psychotropic substance use; having undergone socio-educational measures and receiving death threats; number of admission to foster care; and foster care time.
Due to the large number of agencies responsible for referring and due to the lack of uniform information, a categorization was created for this variable with the support of NOFE's manager.The various bodies were grouped by type of referral, in: ( Foster care services were grouped in this paper according to the characteristics of the population they host, in three types aimed at: victims of violence and neglect; adolescents with special needs; and in other risk situations than those mentioned previously, with and without drug use.
The information collected were entered twice and set a single database in the Microsoft Excel 2010 program.Data were analyzed in SPSS version 18.0.Variables were categorized and described from absolute and relative frequency.
Pearson chi-square test was performed to verify data distribution by shelter type, with a significance level of 0.05.This work is part of a research supported by CNPq (Universal Project 14/2013) and was approved by the Research Ethics Committee of the Aggeu Magalhães / Fiocruz / PE Research Center.

Results
Three foster care profiles were observed during visits to institutional shelters in the city of Recife, in which those who attended victims of violence and neglect generally had more children and adolescents victims of domestic and sexual violence; services for at-risk adolescents included more adolescent drug users with street life history; while the third type of special needs fostered mostly neglected adolescents with chronic health conditions.
However, it is important to emphasize that this distribution is unofficial and not rigid; for example, other types of shelters, other than those for special needs, also host adolescents with chronic health conditions because of the recommendation not to separate siblings.Another observed situation was the attempted preservation of adolescents without drug use and street life experience, avoiding fostering them in the services with an at-risk adolescent profile.
Regarding gender of adolescents, it can be observed that males prevailed in all types of services, with special emphasis on foster care for special needs, in which 80.8% were male (p = 0.004) (Table 1).
As for age, 57.1% were aged 15-18 years and 42.9% were aged 12-14 years.A higher prevalence (51.9%) of younger adolescents in services for victims of violence and neglect was observed, while the older age group predominated in other types of services, especially for at-risk services (p = 0.000) (Table 1).
In the topic related to family power removal, it can be seen that 90% of the adolescents fostered were not deprived of family power; at risk-type services accounted for 95.4% of adolescents with no family power removal, followed by services for adolescents who are victims of violence and neglect, while almost half of adolescents fostered with special needs had been deprived of family power (p = 0.000) (Table 1).
Bodies that referred to the shelter system were more frequently Guardianship Councils (63.7%) or court orders (26.8%).This pattern was repeat-ed in the analysis by type of services.We observed that 32.7% attended school, of which 18.1% with a risk profile attended school, and more than half of those fostered due to violence and neglect (57.2%) attended school (p = 0.000) (Table 2).
The use of psychotropic substances was found in 72% of adolescents and was more frequent in the units fostering at-risk users (92.4%).There were no users in the special needs units (p = 0.000) (Table 2).
Half of adolescents under foster care have undergone socio-educational measures; adolescents of services for at-risk people had the highest rate (73%), unlike services that foster adolescents with special needs, with no cases (p = 0.000) (Table 2).Some 62.8% of adolescents had already received death threats, with a higher percentage (87.4%) of adolescents with death threats in services more geared to at-risk people (p = 0.000) (Table 2) .
The single admission was the most prevalent among adolescents (70.9%), with the highest rates in services focused on violence and neglect (82.9%) and special needs (76.9%).In the case of foster care of at-risk people, only slightly more than half entered only once and there were more adolescents who were admitted to the services 2-5 times (28.1%) and more than 5 times (17.4%)(p = 0.000) (Table 3).
Predominant analyzed adolescent foster care stay time was 0-30 days (56.4%), often decreasing progressively to shorter periods.In the analysis by service profile, adolescents victims of violence and neglect and at risk spend mostly up to 30 days in foster care with a frequency of 53.8% and 61.2%, respectively (p = 0.001).Services for adolescents with special needs had a higher number of children who stayed for more than two years (p = 0.000) (Table 3).

Discussion
This study aimed to evaluate personal and adolescent characteristics in Recife.A very distinct pattern was observed among the three types of service available in Recife to accommodate adolescents separated from family life by court order.As mentioned above, this separation is not official, but is an attempt to organize the service in order to better serve adolescents in their needs, avoiding other harms to their development, and contributing to the success of the foster care outcome, such as return to family, adoption and adulthood with autonomy.
Males were predominant in the three types of foster care, with emphasis on services focused on the population with special needs.A study by Slayter and Springer 21 in 46 U.S. states in a population of children and adolescents with special needs evidenced a greater number of males over females under foster care, which corroborates with this study, which showed a large proportion of adolescent males in services more geared towards people with special needs (80%).Regarding age groups, the youngest adolescents (12-14 years) were more under foster care in services aimed at people in situations of violence and neglect, and adolescents aged 15-18 years were more under foster care in services for at-risk people.This is explained by the fact that the older age group is more vulnerable to involvement with alcohol and drugs, crime and evasion from services 22 .
Older adolescents prevailed in shelters of facilities directed to people with special needs, compared to the other shelter types.Similar data were observed for children and adolescents with special needs 23 in the National Foster Care Sur-  vey.For this population, neglect due to lack of family conditions, deprivation of family power and family conflicts are more common.Furthermore, they are adopted less frequently and, therefore, many tend to grow old in foster care services 24 .
In this study, the variable that indicates that children or adolescents were not deprived of the family of origin and still have the possibility to return to was confirmed in more than 80% of adolescents under foster care.This result corroborates with the first Canadian longitudinal study, which found that about 68.9% of children aged 0-9 years were reintegrated with their families.However, in those aged 10-17 years, the rate of family reunion was 86.3%, indicating that the younger the child the lower the probability of return to family 25 .In Brazil, in 2004, approximately 86.7% of the children and adolescents under foster care had a family and 58.2% were not deprived of family power 26 ; in 2010, 61% did not lose their family power 23 .
The Guardianship Council referred 63.7% of adolescents, 26.8% were referred by court orders and 6.2% were transfers, and court orders had a higher rate in services for people in situations of violence and neglect, and transfers and referrals through other support programs were more related to foster care for at-risk adolescents.Again, in the national survey, 52.3% of referrals to foster care were from the Guardianship Council, 32.9% from the Judiciary Branch of Childhood and Youth and 6.5% from other foster care services 23 , which is close to the results of this study.
Only 32.7% of adolescents in shelters in Recife attend school, a result observed in other studies, highlighting the difficulty of this population in maintaining a regular school attendance during foster care.A study by Smithgall et al. 27 showed that, after entering foster care, more than half of the children and adolescents enrolled in school had excessive absenteeism, most of whom were adolescents.According to Lemos et al. 28 , the low school attendance occurs because many adolescents are unable to conform to hegemonic pedagogical standards, especially since the school structure itself is not prepared to accept them.In addition to experimenting alcohol and drugs, constant evasions, difficulties at school or problems with inadequate friendships contribute to school failure 29,30 .
When analyzed by type of shelters, the one targeting people in situations of violence and neglect had a percentage of 57.2% and only 18.1% in shelters for those who are not at risk, which can be explained by a high involvement with drugs, socio-educational measures, death threats, and, in general, spend little time on services, which reflects the lack of school attendance, although foster care services enroll almost all adolescents in the school system.Other studies also demonstrate the difficulty of keeping these adolescents in school [28][29][30][31] .
The National Foster Care Survey 23 revealed that, in Brazil, 83% of children and adolescents under foster care had school discrepancy, with a grade-age gap of up to two years.Authors also observed that 22.8% of adolescents aged 16-17 years did not study, a result that surpassed all age groups, except those younger than 5 years.
Several studies highlight the fact that the shelter itself causes developmental harm, associated with poor school performance and high repetition rate, living with stigma related to the condition of being fostered and being often victimized at schooll 4,17 , and that adolescents can show some difficulties at school associated with problems such as friendships involved in risk activities 13 .
In foster care units geared to at-risk adolescents, 92.4% were psychotropic substances users, while this prevalence was 47.2% in services more targeted to victims of violence and neglect.The survey carried out in Brazil found that 45.2% of those in foster care used drugs 23 .It is worth noting that results of the national survey include both children and adolescents of all types of foster care facilities and those in this study only include adolescents, which, according to a systematic review by Braciszewski and Stout 32 , characterizes larger chances of involvement with illicit substances.According to Smith et al. 33 , adolescents with deviant behavior and involved with socio-educational measures, most (about 90%) have used at least one illicit substance in the last six months.
Involvement with socio-educational measures (SEM) was observed in approximately 73% and 25.5% of adolescents in foster care according to the at-risk and violence and neglect profiles, respectively.Shelters' high rate of at-risk adolescents is justifiable, since most of them have street life and drug trafficking history.
The survey carried out in Brazil in 2010 found that slightly more than half of adolescents aged 12-15 years were received in foster care due to death threats, which corroborates with results of this study, where 62.8% of adolescents had suffered or were under foster care due to death threats, largely related to drug trafficking involve-ment.Observing this result by type of shelter service revealed that only 27.4% were intended for people in situations of violence and neglect and 87.4% in other risk situations, including many adolescents with street life history and who are drug users.This relationship was also observed by Rosa et al. 34 .
This study showed that, in all shelter types, most adolescents were admitted only once in the service, resulting in a readmission rate of 29.1%.Several studies have evidenced that the number of entries and exits is related to unsuccessful family reunification 35,36 and evasions, especially among adolescents 14,21 .Results are similar to the study by Festinger 36 with 19.5% readmission and the study by Wulczyn et al. 35 with readmission rates ranging from 21 to 38%.
The readmission rate was much higher in services for at-risk adolescents, and almost all those who entered the service more than 5 times are in this group.This is justified because most are drug users and traffickers under death threat, in addition to displaying frequent behavior of deviation from social norms and having vulnerable families, which favors leaving foster care facilities for not being able to follow rules and for being attracted to street life.
Regarding foster care time by service profile, it was observed that the most targeted care for people at risk and for those in situations of violence and neglect showed about 79.7% and 91.7%, respectively, of those who stayed in the shelter for up to 6 months.Other studies, both in Brazil and in several parts of the world, had a higher percentage of stay in foster care for a period of up to six months [37][38][39] .
The highest percentage of exits during the first six months pointed out by the study in Georgia (USA) is identified by the fact that the younger the person under foster care, the greater the likelihood of staying in the service longer than older adolescents, such as those aged 13-18 years 40 , similar to this study.
The National Survey of children and adolescents in shelter services found that more than half (67.6%) of children and adolescents in Brazil spent less than a year in the service and about 30.9% stayed for more than two years 23 .In Brazil, the reduced length of stay in foster care is evident when referring to the first national survey of IPEA/CONANDA (2004) 26 , which indicated that 52.6% of children and adolescents of the institutions then evaluated throughout the country stayed 2-5 years under foster care and that 19.7% did so for more than six years.This result reflects a breakthrough and is in line with the new wording given to the Statute of Children and Adolescents (ECA): according to Law 12.010/2009, "the maximum stay of children and adolescents in an institutional shelter program will not be more than two (2) years, except proven necessity that meets their higher interest, duly substantiated by the judicial authority." In this study, the reduced length of stay in foster care services, especially for those at risk, may also have been influenced by the high number of evasions common among adolescents.In several studies, this behavior is explained by several reasons, such as difficulties of adaptation, involvement with drugs, prostitution, physical violence by colleagues and employees, leisure and search for their family of origin 13,14 .
A study carried out in the USA in 17 states (945 municipalities) found a greater number of family reunions in the first six months of foster care, a fact that is influenced by factors such as race, families headed by women, poverty and the need for social welfare 39 .Delfabbro et al. 41 also noted that about 50% of children and adolescents under foster care in Tasmania, Australia had gone home within 2 years, but that 79% of returns occurred in the first 6 months.Despite the persistent highly reduced stay in shelters, according to a study carried out in Brazil, the excessive valuation of the institution by the parents who consider it as an ideal place for their children hampers family reunion 42 .
According to Connell et al. 43 , the less time children and adolescents remain in service, the greater the likelihood of successful family reunification.In addition, some characteristics of children and adolescents were associated with the probability of leaving the shelter.Others, such as having suffered sexual abuse and emotional / behavioral disorders increase their permanence.
With regard to adolescents under foster care services for people with special needs, it can be observed that almost half (42.3%) remained in the units for more than 2 years.This result is similar to the Brazilian National Foster Care Survey, in which the average time of children and adolescents with special needs was 40 months in the service 23 .
In a review of literature, involving countries such as the United States, the United Kingdom, Canada, Australia, China and the Netherlands, Welch et al. 24 observed that children and adolescents with disabilities and behavioral problems are less likely to achieve family reunification and stay longer in services, with a reduced probabil-ity of family reunification and adoption.Other studies from different parts of the world show similar results 12,44,45 .This study had limitations related mainly to the poor information records, which hindered data collection, such as lack of registration in the IAPs, poor completion with lack of standardized terms used, incomplete and lost files, one adolescent with two IAPs, but with a different date of birth.In addition, at the time of collection, due to turnover, most employees had been working in the service for less than a year and did not have enough knowledge to supplement the information they needed.The lack of technical staff to complete the IAP at the weekend also compromises results, as it leads to an underestimation of adolescents' admissions.
Both national and international literature lacks separation of studies on children and adolescents under foster care by type of service, which is extremely important, since they are distinct populations and need reintegration requiring planning in a particular way.

Conclusion
In summary, when analyzing the types of foster care institutions, we can see that they had distinct populations.In the case of foster care for adolescents in other risk situations, we observed a greater number of young, older males who were not deprived of family power, drug users, involved with socio-educational measures, and greater number of shelters care entries-exits, low school attendance and lower shelter stay time that may be related to the greater number of evasions portrayed in the shelter's entries-exits.
Services that provide foster care to more adolescent victims of violence and neglect evidenced adolescents who do not leave the shelter frequently, but many drug users have low school attendance and require special attention, since they are a population with serious emotional problems, stigmas and are vulnerable to different risks.
The main issue of services that mostly provide foster care to people with disabilities is total neglect of their families and living a long time in the service.
As we can see, it is necessary to invest in research that itemizes well the population under foster care, looking for ways to reduce the neglect of these adolescents, besides being necessary to elaborate and comply with public policies in an efficient, responsive and effective way for this population, which represents a significant and relevant part of the future and development of the country.

Table 1 .
Characteristics of the adolescents receiving foster care by service type, according to sociodemographic and family variables, Recife, 2009-2013.
Note: * All the reasons for the entry-exit of adolescents who entered and left more than once were accounted for.**Fisher'sExact Test.Source: Individual Assistance Plan (IAP).

Table 2 .
Characteristics of adolescents receiving foster care by type of service, according to personal and foster care-related variables, Recife, 2009-2013.

Table 3 .
Characteristics of adolescents receiving foster care by type of service, according to the variables number of entries and foster time, Recife, 2009-2013.