Keywords

Introduction

By analysing the diffusion and implementation of the Barnahus model through an institutional lens, this book has provided several examples of how different dimensions of this hybrid model can be affected by (and lead to) various legal, organisational, and professional-ethical tensions (see Chapter 1). These tensions may challenge the aims of the Barnahus model in terms of securing the needs and rights of child victims of violence and abuse in child-friendly premises and “under one roof” (Johansson et al., 2017). Our aim in the present chapter is to contribute to a greater awareness of the institutional conditions or prerequisites for the Barnahus model so that it may be implemented and work as a holistic service that balances justice and recovery for victimised children. Using the PROMISE network’s European Barnahus quality standards as our point of reference, we will draw on the lessons learned through the contributions in this book and will further discuss the institutional tensions that this book’s authors have identified.

The PROMISE standards have been developed to guide the diffusion and implementation of the Barnahus model across different jurisdictions (Haldorsson, 2019). These standards may be seen as necessary to maintain the integrity of what may be called a Barnahus, as well as to ensure more, rather than less, uniformity in the model in different contexts as the model gains traction and is established in increasing numbers across a diverse range of countries. As pointed out in the introductory chapter to this book, these standards may also be understood as an example of a general trend of increasing “transnational regulation” in social policy—that is, tendencies to create and implement policies that reach beyond nation-state borders, often developed in connection to the diffusion of popular “travelling” ideas (Djelic & Sahlin-Andersson, 2006).

The PROMISE quality standards may also be interpreted as serving a double aim. Whilst the standards function as implementation guidelines for countries that are considering the Barnahus model or are in the process of adapting it to their existing systems and policies, the PROMISE network also actively promotes the Barnahus model through its standard setting, presenting the model as a success story and subsequently as the solution for countries throughout Europe and beyond in their efforts to prevent and handle violence against children.

But, as Johansson and Stefansen (2020) have pointed out, the standards do not sufficiently address the complexity of the Barnahus model and its surrounding institutional landscape, nor do they address the tensions that may arise when the model is implemented in various contexts and as it develops over time. Put simply, reaching the aims of the Barnahus model is more complicated than what is presently recognised in the quality standards. PROMISE emphasises that the Barnahus model is flexible and adaptable to diverse legal systems, social structures, cultural traditions, and professional practices in many different countries. According to PROMISE, Barnahus is not a fixed model but “an evolving practice that can adapt to the complex needs of children exposed to violence and abuse” (Haldorsson, 2019, foreword). Common standards are underlined as necessary to set limits to the diversity of implementation in order to secure the model’s authenticity and core elements such as the “one-door” principle and the model’s holistic approach. The overarching aim of the PROMISE quality standards is therefore:

(…) to provide a common operational and organisational framework that promotes practice which prevents retraumatisation, while securing valid testimonies for Court and complies with children’s rights to protection, assistance and child friendly justice. (Haldorsson, 2019, p. 8)

The ten standards describe principles and activities, core functions, and institutional arrangements for the Barnahus model, as shown in Table 10.1.

Table 10.1 The PROMISE network’s standards/principles (Haldorsson, 2019, p. 22)
Full size table

Each standard is described and substantiated and, according to PROMISE, based on children’s rights “as set out in international and regional law, drawing on authoritative guidance provided by the UN Committee on the Rights of the Child and other bodies such as the Council of Europe” (Haldorsson, 2019, p. 28). As PROMISE states, the standards are also based on research within “relevant areas” and on positive experiences related to multidisciplinary work that has been proven to have a positive impact on a child’s and non-offending family’s well-being. The research PROMISE cites is primarily related to specific issues (e.g., treatment or interview methods), rather than being on the Barnahus model itself, although they also refer to early evaluation studies in the Nordic countries. Whilst PROMISE also includes proposals for monitoring the fulfilment of each standard, challenges in relation to each standard, or tensions between different standards, are addressed to a very limited degree. For this reason, one potential risk that we will address in this chapter is that the model might become implemented on a more surface level than what the standards aim for, thus hampering the Barnahus model’s potential to provide more substantial changes in the handling of child violence and abuse cases as well as the surrounding systems and service landscape.

In the following sections, we will discuss how the various institutional tensions (legal, organisational, and professional-ethical) discussed in the chapters in this book relate to the target areas and aims of some of the most central PROMISE standards; we will subsequently illuminate challenges and tensions that might exist within and between the standards and aims. Our discussion will especially focus on the standards and principles that most clearly reflect the tensions and dilemmas identified in this book: children’s rights (Chapter 1), multidisciplinary and interagency organisation (2), the inclusive target group (3), interagency case management (5), the forensic interview (6), and the medical examination (7).

Securing Children’s Rights

We will start by discussing dilemmas related to the securing of children’s rights. This theme is related to the first PROMISE standard, which includes three key principles that are meant to inform both the multidisciplinary practice and the decision-making that occurs in Barnahus. The first principle includes the child’s best interest (1.1), which is “a primary consideration in all actions and decisions concerning the child and the non-offending family/caregivers/support persons,” whilst the second principle includes the child’s right to be heard, including receiving information (1.2): “Children’s rights to express their views and to receive information are respected and fulfilled;” the third is about avoiding undue delay (1.3): “Measures are [to be] taken to avoid undue delay, ensuring that forensic interviews, child protection assessments and mental health and medical examinations take place within a stipulated time period and that children benefit from timely information” (Haldorsson, 2019, pp. 30, 34, & 38). PROMISE sees these three principles as fundamental to the Barnahus model and for carving out a direction towards more child-centred and child-friendly justice. The principles thus can be understood as core values for fulfilling the potential of the Barnahus model. The first question that arises, however, is if implementing Barnahus can be a catalyst that moves the existing system in this direction, and what the prerequisites are for that to happen.

The Barnahus Model as a Catalyst for Change

As some of the chapters in this book have shown, the Barnahus model is expected to be a catalyst for change in terms of moving the system in a more child-friendly direction. In Chapter 8, Magnusson and Ernberg describe challenges in investigating and adjudicating cases involving child sexual abuse in the Swedish Barnahus context. They point to aspects such as limited access to corroborative evidence, difficulty conducting child investigative interviews, and challenges in assessing preschoolers’ testimonies. They explore how Barnahus can help mitigate these problems, such as by securing more corroborative evidence through ensuring that children are medically examined in Barnahus and by improving the quality of child interviews through exchanges of information during the initial multidisciplinary consultation meetings. The authors also underline that adaptions are necessary in the Swedish system during the preliminary investigation (such as through access to specialised expertise) in order to accommodate the developmental abilities of preschool children and to ensure high-quality forensic interviews, thereby providing access to child-friendly justice. This situation illustrates how fulfilling the rights of the child according to the “child’s best interest” principle is closely connected to institutional prerequisites, as well as an understanding of the Barnahus model as being embedded in the wider institutional system.

In Chapter 9, Devaney et al. point to areas with a need for improvement in the UK system; they refer to “the adversarial nature of criminal proceedings where children are first and foremost witnesses for the prosecution, rather than victims of maltreatment,” and they discuss delays in case processing in child sexual abuse cases. A key challenge, as they see it, is to improve the interaction between the child welfare system and the criminal justice system. They stress the implementation of the Barnahus model as a catalyst for change, since the model provides an opportunity to recast the ways these systems interact in the UK to better cater to the needs of children in accordance with the UN Convention on the Rights of the Child (CRC). But Devaney et al. express a concern that this goal might not be fulfilled and that new practices instead will be co-opted into the existing system. They also fear that criticisms of the current system will not result in necessary action being taken by policymakers and that the implementation of Barnahus instead may function as a symbol of something being done without necessarily resulting in more substantial systemic changes. Such a scenario may be interpreted from an institutional perspective, where institutional ideas (such as Barnahus) rather function as “rationalised myths” (Meyer & Rowan, 1977) that organisations incorporate in order to gain legitimacy and survive, thereby creating gaps between formal structures of organisations and the actual activities and practices within.

Given that institutions have both symbolic and material sides (Scott, 2008), Finland’s Barnahus Project (2019–2025)Footnote 1 is also interesting to note, since the implementation process in that country was largely based on existing collaborative forms, which in this regard is open to different interpretations. Whilst the process represents an example of a less material and more symbolic implementation process that is not as focused on initiating new physical Barnahus localities (as is the case in several other Nordic countries), the project also includes reforms of the child and family services and efforts to strengthen the competence and collaboration in the broader institutional landscape (see Chapter 1). The Finnish Barnahus Project hence could potentially lead to more fundamental systemic changes compared to surface materialisations of the Barnahus model into physical Barnahus localities in other contexts. The state of the existing institutional landscape might therefore be important for the potential for the Barnahus model to function as a catalyst for change.

Defining the Child’s Best Interest: Potential Conflicting Interests

Another challenge relates to the determination of what is in the best interest of the child. In this assessment, a child’s own opinion is of course of the greatest essence. Inspired by Lavoie et al. (Chapter 3), our understanding is that the child’s position and view is both relational and contextual (see also Backe-Hansen, 2023). Such situations are especially challenging in cases of violence and abuse within the family, as children are often placed in positions of conflicting interests. In these cases, children often have close relations to both the suspected offender and the non-abusing parent. In this position, children might have difficulty identifying and expressing what is best for them, thus illustrating why the child’s view needs to be understood as relational and contextually dependent. These scenarios are also reminders of the importance of children’s right to information in order for them to make informed decisions (Kaldal et al., 2017).

The Barnahus model is based on a presumption that giving children the possibility of providing evidence in Barnahus in a child-friendly environment is in their best interest. The child does not have to provide evidence in court; instead the child’s recorded statement is presented in court. Experiences from the UK system, however, indicate that such might not always be the case, at least not in terms of securing the child’s access to justice. The chapters by Devaney et al. (Chapter 9) and Lavoie et al. (Chapter 3) both point to a risk of the evidential value of the child’s statement being reduced as a result of the child giving evidence outside the court, since cross-examination of the child by the defence is not possible. Tensions may thus occur between child-friendly justice (i.e., the child’s best interest) and the child’s access to justice.

This tension is avoided (or at least reduced) in Norway and Sweden, since the defence attorney can ask for a supplementary interview (Norwegian law on criminal procedure 1981 §239 c; Myklebust, 2017; Kaldal, 2023). This procedure has also been accepted as being in accordance with a defendant’s right to a fair trial, as noted in section 6 of the Convention for the Protection of Human Rights and Fundamental Freedoms, although the European Court of Human Rights (ECHR) has stated in a ruling that the evidence under these circumstances should be assessed with caution, which in practice implies a reduction in the evidential value of a child’s statement (see S. N. v. Sweden, no. 34209/96). Tensions may also arise between the child’s rights to participate according to the CRC and the child’s position as a victim, since the right to participate includes the right to be informed (cf. article 12, CRC). This situation might imply that a child’s right to information might conflict with the interests from the police/prosecution to secure the secrecy of the criminal investigation and to avoid evidential contamination in relation to the criminal case; the situation also illustrates how different interests within the criminal system may conflict. Securing children’s best interest is therefore challenging both in determining what their best interest might be and in balancing several potential conflicting interests.

Avoiding Undue Delay: Conflicting Mandates and Organisational Tensions

In Chapter 5, Ponnert illustrates how organisational specialisation within the child welfare system may challenge the fulfilling of the PROMISE principle of avoiding undue delay in case processing. She points to the current tendency in Sweden for increased specialisation within the child welfare system, which has resulted in organisational fragmentation. Challenges occur both in the collaboration within the child welfare services and in the collaboration between the child welfare services and Barnahus, thus causing delays in the case processing related to child welfare investigations. As such, striving for more specialisation within one system could end up having contradictory effects in a collaborative context, which reminds us that institutional changes must be assessed not only in relation to the individual agency, but in relation to the broader institutional context.

Multidisciplinary and Interagency Organisation

In this section, we examine PROMISE’s second standard, and more specifically the formal status of Barnahus (2.1), the organisation of multidisciplinary and interagency collaboration (2.2), and the process and practice of the multidisciplinary and interagency collaboration in Barnahus (2.3). We will start by addressing tensions related to the formal status of the model. According to standard 2.1:

The Barnahus is formally embedded in the national or local social or child protection services, law enforcement/judicial system or national health system. The Barnahus can operate as an independent service if it enjoys a statutory role, recognised by the national or local authorities including a formal mandate to collaborate with relevant public agencies. (Haldorsson, 2019, p. 44)

This standard relates to the form and level of formalisation and integration of the Barnahus within a wider national system.

Embeddedness and Sector Affiliation

The introduction to this book (Chapter 1) examines the significance of the state’s role and the wider system into which the Barnahus model is embedded. The implementation of Barnahus in the Nordic countries came as a result of a long process of systemic changes due to concerns over the handling of cases of violence and abuse against children. This prior development has likely been an important perquisite for the functioning of the Barnahus model in the Nordic countries, since the aims of the model were part of a common development that was pulling in the same direction. In Chapter 9, Devaney et al. highlight that what the implementation of Barnahus can accomplish depends on the situation of the broader surrounding system. If the broader system has general weaknesses in supporting children who have been exposed to violence and abuse, then the implementation of the Barnahus model might not necessarily result in child-friendly justice and recovery in accordance with Barnahus’s aims.

The authors of this book’s chapters have indicated that what part of the system the Barnahus model is affiliated with (such as the justice or child welfare systems) has various consequences; this affiliation also seems to affect the functioning of the Barnahus model. Across countries, the affiliation of the model seems especially important in relation to balancing the justice and welfare “tracks” of the model to ensure a holistic service. Several chapters have highlighted experience with (or concern for) an imbalance between the two tracks, in line with Johansson and Stefansen’s (2020) characterisation of the model as an “unstable hybrid.” For instance, Stefansen et al. discuss how the affiliation of the Norwegian model in the justice sector, together with other institutional factors such as routines, regulatory issues, and resources, have hindered the fulfilment of the medical mandate in this Barnahus model (Chapter 4). They show how the medical mandate is especially sidelined in the welfare track of the model—a development that probably would have been unlikely if the Barnahus model were instead affiliated within the health care system.

In Chapter 6, Andersen acknowledges how affiliation in a specific sector creates challenges for the governing authority, especially when the Barnahus operation involves the steering of functions that do not fall within its jurisdiction. In Norway, where Barnahus is affiliated with the justice sector and the police organisation, this situation is related to various follow-up and recovery services, which are areas that usually do not belong in the justice sector. To solve these challenges, inter-governmental steering mechanisms have been introduced in the Norwegian model. Different institutional logics are also reflected within the inter-governmental steering group, however, and the unbalance has yet to be resolved (Bakketeig et al., 2021).

Which sector the Barnahus model is affiliated with may also be a significant factor for multi-professional work in Barnahus. In Chapter 6, Andersen illustrates how the justice sector affiliation was initially beneficial during the adoption phase of the model, since this affiliation contributed to the model’s legitimacy and provided room for the development of “interstitial work,” a situational social work practice catered to each child’s specific needs (Andersen, 2019, 2022). But, if the Barnahus were instead affiliated with the health care sector, then such an affiliation could have provided another source of legitimacy by representing a stronger professional connection to the field of psychology, thus potentially strengthening the welfare-oriented follow-up mandate of the model. According to Andersen, however, affiliation with the health care sector could also risk resulting in a premature standardisation and “psychologisation” of the Barnahus work; such a direction could have negative consequences for the practice of interstitial work, which instead builds on ideas from social work. Barnahus’s affiliation, thus may affect the functioning of the model in different ways, related to its balance, steering, and legitimacy.

As illustrated by Devaney et al., who write from the UK context, Barnahus can also be organised as an independent service (see Chapter 9). In Scotland, for example, the initiative and funding for a Barnahus pilot came from a non-governmental organisation (NGO).Footnote 2 The question of how this solution has affected the legitimacy of the model, and the balancing of the justice and welfare tracks, is important to further investigate. This question brings us to the next point, which is related to the level of integration and formalisation.

Level of Integration and Formalisation

The PROMISE network’s quality standards address the question of implementing the Barnahus model as an independent agency and service organisation, or as part of a larger sector or agency. Implementing the Barnahus model as an independent service is generally recommended only as long as the Barnahus enjoys a statutory role, has sufficient recognition amongst the other agencies, and has a formal mandate for interagency collaboration with other services. PROMISE deems these factors to be necessary in order to ensure the sustainability of the model (Haldorsson, 2019, p. 44).

This issue is related to the level of formalisation of the Barnahus model. As described in the introduction to this book, the Nordic countries have differences in the regulation of the Barnahus model. The national laws of Denmark and Norway, for example, make the use of Barnahus statutory, albeit regulated in different legal areas and legislations. In Iceland, the use of Barnahus was not made statutory until 2022, within that country’s Child Protection Act. Prior to that time, various regulations provided the legal basis for the Barnahus operation, although they did not mention Barnahus specifically. The Child Protection Act then mandated the now-defunct Government Agency for Child Protection to run special service centres, with the objective of promoting interdisciplinary collaboration in the handling of child protection cases, whilst the Law on Criminal Procedure stipulated that investigative interviews of child victims up to 15 years of age were to be conducted under the auspices of a court judge in a specially designed facility, generally interpreted by court judges as Barnahus (Johansson et al., 2017). Sweden has no such regulation, even though such legislation has been debated and requested, although general guidelines for collaboration and quality criteria for Barnahus specifically have existed since 2009 (Swedish National Police Agency, 2009).

How the Barnahus activities are regulated, however, is significant for the functioning of the model. An evaluation of the Norwegian model, for example, showed that activities related to criminal cases were regulated in criminal procedure legislation, whilst Barnahus activities related to support and follow-up were primarily regulated within administrative guidelines, which might partly explain the tendency to give higher priority to activities related to the penal track than to the recovery track (Bakketeig et al., 2021).

Another side to regulations relates to the fact that many of the professionals involved in the Barnahus operation are employed primarily outside the Barnahus, which again might create tensions between their “regular” work and their Barnahus work. Stefansen et al. illustrate how medical personnel, whom are primarily employed outside the Barnahus, may experience conflicting expectations about their Barnahus work and their work in the hospital, even though formal agreements exist between the health care sector and Barnahus (Chapter 4). Although formal commitments are significant to avoid tensions, they alone might be insufficient to provide personnel with enough space to fulfil their functions within Barnahus.

Mutual agreements over procedures and routines are important for securing clarity of roles. In Chapter 6, Andersen has noted that the clarification of roles through procedures and routines could be important especially in relation to less-experienced Barnahus staff in order to make them more secure in their work performance. But the formalisation of interagency collaboration may influence the degree of autonomy related to the Barnahus work. As Andersen’s analysis shows, the significance of autonomy may vary in different phases of the Barnahus development. Whilst a higher level of autonomy seems to have been important in the initial phase of the Barnahus development, a stronger degree of formalisation in terms of joint regulations and standardisation appears to be more important once the model has matured, in order to secure the sustainability of the model over time. Hence, what is regulated or how the regulations are formulated is a significant factor.

Andersen notes that the regulations’ importance is related to the roles of the professionals involved, and not to the handling of specific cases, since doing so could reduce the level of discretion and the Barnahus staff’s ability to tailor their support to a child’s needs (Chapter 6). Securing mutual agreements over procedures and routines may also be challenging, since such factors often demand the involvement of representatives from the different sectors involved, which again involves a risk of imbalance between the different sectors and aims. In Norway, for example, such a scenario has resulted in internal contradictions within the national Barnahus guidelines, due to poor communication between sectors at the governmental level (Bakketeig et al., 2021). In short, the question of how sustainability may be secured through formalisation must be assessed carefully.

Organisation and Collaboration

The next part of the standard, related to multidisciplinary and interagency organisation, involves the structure and transparency of the collaborative work in Barnahus. Section 2.2 states that

[t]he collaboration [should be] structured and transparent, including clearly established roles, mandates, coordination mechanisms, budget, [and] measures for monitoring and evaluation, [all of] which contribute to efficient processes and ensure continuity and stability. (Haldorsson, 2019, p. 44)

Many of these aspects are generally recognised as success factors in the literature on interagency collaboration (Axelsson & Bihari Axelsson, 2013; Cooper et al., 2015). Several of the present book’s authors have identified different challenges related to these aspects (see Chapters 4–6, and 9). For instance, differences and tensions exist between the mandates of the agencies involved in the collaborative work, including the police and prosecutors, the child welfare services, and the health care services. These mandates represent different institutional logics underlying the hybridity of the model. The authors have shown that challenges exist across jurisdictions, related to the balancing of different professional perspectives and functions in the collaborative work, with a tendency for the penal perspective to dominate in the process known as “juridification.” Interestingly, this tendency seems to occur in models affiliated within different sectors (e.g., police or child welfare), which suggests a complex interplay between factors that reaches beyond the legal and organisational areas (see also Johansson, 2011, 2017; Bakketeig, 2017).

The chapters in the book illustrate the importance of documenting how the Barnahus model evolves over time, and of approaching the model from different perspectives. As mentioned in Chapter 1, state authorities have differed in their willingness to evaluate the model. Whilst full-scale national evaluations have been conducted in Norway and Sweden, to our knowledge, the same has yet to be done in the other Nordic countries. In order to monitor developments, national evaluations must be conducted on a regular basis. Comparative studies could also yield new insights and provide the basis for further development, but such studies are rare (see Johansson et al., 2017; Stefansen et al., 2017, Chapter 1; Council of Europe, 2023).

Process and Practice

The last point in this PROMISE standard about multidisciplinary and interagency organisation (2.3) relates to the starting point and duration of the multidisciplinary work: “The multidisciplinary/interagency intervention begins at the initial report and is guided by a process for collaborative interventions across the continuum of the case” (Haldorsson, 2019, p. 44). This book’s authors, however, as well as previous research referred to above, have illustrated various challenges in securing a close and balanced collaborative process throughout a given case. This situation relates both to securing the inclusion and participation of all the functions involved in the Barnahus operation and the duration of the collaborative process. Stefansen et al.’s analysis has illustrated how legal regulations represent a barrier for paediatricians to participate in the initial consultation meetings at Barnahus (Chapter 4). Regulations in the Norwegian Criminal Procedure Act prohibit participation, most likely due to concerns that medical personnel’s participation might risk a reduction of the evidential value of medical findings. Such regulations are an example of how the prioritisation of the criminal process at the expense of other considerations, such as support and treatment, may negatively influence the process of collaborative interventions. The marginalisation of paediatricians (and the medical perspective in general) in the follow-up phase has been linked to other factors, most importantly a lack of routines for including medical staff in consultation meetings and a lack of resources.

More generally, research has pointed to various challenges regarding the duration of collaborative processes. In the latest evaluation of the Norwegian Barnahus model, Bakketeig et al. (2021) showed that the degree of multidisciplinary collaboration was stronger in the first part of the process, connected to the forensic investigative interviewing of a child, whilst collaboration was more sporadic during the support/treatment phase. This situation might be due to greater variations in the follow-up phase, since the needs of the child and family will vary. But, closer multidisciplinary collaboration in the initial phase might also result from stronger statutory regulation regarding collaboration connected to the criminal case in the Norwegian model, which might indicate a need for stronger statutory regulation of the processes related to the recovery track in order to secure collaborative processes throughout the case. Importantly, such regulations would also need to secure sufficient flexibility to meet the various needs of the participating parties.

In other Nordic Barnahus models, such as the Swedish model, coordination between parallel investigations, such as criminal investigations and child welfare investigations, is more central to collaboration than in Norway, which serves to highlight this issue further. One important factor to note is that the regulations of criminal investigations generally comprise more coercive means than regulations for child welfare investigations, unless the case becomes a matter of compulsory care. Support and recovery services related to child welfare investigations are thus commonly based on voluntariness and depend on consent by the child’s legal guardian, which is widely known to be challenging to secure (Heimer & Pettersson, 2022). This situation likely explains why reaching a balance in Barnahus between justice and welfare and recovery can be difficult (Johansson 2011, 2017; Bakketeig, 2017; Stefansen et al., 2023; see also Chapters 3, 4, and 9 in this book). In other words, securing multidisciplinary collaboration throughout a case depends on a broad range of factors that must be taken into account.

The Target Group

Strengthening a child’s rights through the implementation of Barnahus depends on how the Barnahus target group is defined, since children who fall outside the target group will not have the opportunity to benefit from Barnahus’s services. The PROMISE network’s quality standard encourages a wide definition of the target group to ensure that child-friendly justice and support will benefit as many vulnerable and abused children as possible. According to principle 3.1, “The Barnahus target group includes all children who are victims and/or witnesses of crime involving all forms of violence. Non-offending family/care-givers are included as a secondary target group;” principle 3.2 also specifies that “[s]pecial effort is also to be made in order to reach all victims and witnesses regardless of violence” (Haldorsson, 2019, p. 54).

As shown in several contributions in this book, the definition of the target group has both changed over time and varied amongst the Nordic countries, as well as amongst the different nation states within the UK (Chapters 2, 3, 7, and 9). For example, discussions about Barnahus’s target group in Northern Ireland have focused on children who have been exposed to sexual abuse, whilst Scotland’s Barnahus model aims to target children who have been exposed to a wider range of abuse, including neglect (see Chapter 9). How wide or narrow the definition of the target group for Barnahus is in different contexts is thus related to various legal, social, cultural, financial, and practical aspects.

The definition of the target group in itself represents a dilemma, since such a definition implies that some children have access to the Barnahus’s services, whilst others do not. Besides being an ethical issue, such differentiation also represents a possible breach with international regulations (and obligations). Two chapters in this book probe the question of target-group constructions from different perspectives. In Chapter 2, Andersson and Kaldal illustrate this dilemma by focusing on legal tensions and by describing the tension between Barnahus’s aim of providing support and protection to all victims of domestic abuse in accordance with the CRC, versus the implications of the target group being linked to national criminal law. They argue that whilst Barnahus can be seen as an outflow of children’s rights to protection from all forms of violence according to the CRC, access to the services offered in Barnahus is limited by what is generally considered a crime in national law, based on examples from Sweden. The child’s rights thus are challenged.

In Chapter 7, Johansson and Stefansen illustrate various dilemmas of inclusion and exclusion related to different sub-groups of children in Swedish and Norwegian Barnahus contexts. They show how varied constructions—depending on different justice and welfare logics—result in different groups of children being positioned differently in various policy contexts as well as during different stages of case processing in Barnahus. The result is differences in access to various services amongst different groups of children. This situation highlights the importance of acknowledging gaps between aspired-to target-group definitions and the actual target group’s access to Barnahus in practice. A final aspect is that having a wide definition of the target group as a means to provide child-friendly justice and recovery to children exposed to violence and abuse might be difficult to fulfil due to capacity limitations. If the capacity of the model is challenged, then the quality of the service may suffer.

Interagency Planning and Case Management

This standard focuses closely on interagency planning and case management and encompasses four principles. The principles involve the case review and planning, which underlines the significance of formalising interagency work and the need for mutual agreements of procedures and routines (5.1); according to principle 5.2, this planning should take place on a regular basis. Principle 5.3 states the necessity of continuous documentation and access to relevant case information for the parties involved in the interagency operation throughout the case. The last principle suggests that a support person should be appointed from Barnahus to monitor the multidisciplinary response and follow-up of children and their families (5.4). In the following, we will focus primarily on principle 5.3.

Principle 5.3, which underlines the necessity of continuous documentation and access to relevant case information for the parties involved in the interagency operation, is an important but challenging principle. Principle 5.3 is probably one of the most complex principles within the PROMISE standards, since limitations to the sharing of information are a well-known barrier to interagency and multi-professional collaboration (Cooper et al., 2015). This principle is where we most clearly see the implications of different mandates, interests, and logics between the functions involved. Not surprisingly, in contrast to the previous PROMISE standards we have discussed, in this case, PROMISE refers to the potential institutional barriers (especially legal tensions) against fulfilment of this standard, with special reference to regulations related to the sharing of information: “Interagency planning, case review and case tracking can be shaped by restrictions from sharing information in national legislation, or lack of legislation that enables and mandates services to share case specific information” (Haldorsson, 2019, p. 66). Amongst various measures to meet this challenge, PROMISE suggests a step-by-step approach: “A high level of integration requires a clear and careful approach to confidentiality obligations and may require a step by step approach to ensure [that] the right exchange of information can take place” (Haldorsson, 2019, p. 66).

What a step-by-step approach implies and what the right exchange of information might be are not defined further. Do these factors i.e., relate to the level of information exchange, or to the types of information? The possible negative consequences of close collaboration, integrated work, and information exchange are similarly not discussed. The lack of attention to the possible downsides of interagency collaboration is also quite common when interagency collaboration is discussed beyond the Barnahus context as well (Breimo & Anvik, 2022; Bakketeig et al., 2019). In the Nordic countries, issues related to these questions are at least partly unresolved. In the Norwegian model, for example, questions remain unresolved about the exchange of information between health personnel and the police, as well as legal questions about case registration and documentation. Misunderstandings and a lack of knowledge about parts of the legislation are also problems amongst the Barnahus staff (see Chapter 4; Bakketeig et al., 2021). Legal barriers to the exchange of information and how this lack of information challenges interagency and multi-professional collaboration have also been a recurrent issue in evaluations and research on the Swedish Barnahus model (Åström & Rejmer, 2008; Johansson, 2011; Kaldal et al., 2010; Barnafrid, 2019; see also Chapter 8). In Denmark, however, the exchange of information is regulated in the legislation on that country’s Barnahus model, where information sharing is allowed between the professionals involved (who are specified in the regulation), if such sharing is necessary to ensure a child’s or young person’s health and development (Søbjerg, 2017; Danish Service Law, §50c, LBK no 1089 of 16/08/2023). As such, legal barriers (both in theory and practice) continue to be a challenge in relation to interagency planning and case management in Barnahus, and ways to solve this problem must be considered carefully.

The Forensic Interview

Standard 6 relates to the forensic interview and includes six principles, which recommend that interviews should follow evidence-based standards and protocols (6.1), be conducted by specialised staff (6.2.), be conducted in the Barnahus (6.3), and be carried out by a single professional, with the members of the multidisciplinary team having the possibility to observe the interview (6.4). The interviewers must also respect the defendant’s rights to a fair trial and “equality of arms” and adapt the interview to the child’s needs, per principles 6.5 and 6.6 (Haldorsson, 2019, p. 76). In this section, we will focus on principles 6.2 and 6.6.

These recommendations are important to ensure the security of rights for the defendant and the child as well as to ensure child-friendly justice. When acknowledging the significance of these principles, the potential of fulfilling them must also be understood in a wider institutional context. In Chapter 8, which examines the Swedish context, Magnusson and Ernberg point out the lack of formal demands related to forensic investigative interviewing of preschool children who have experienced sexual abuse; they also illustrate how the lack of specially trained interviewers has caused delays in case processing. The formal training of interviewers has been shortened to solve the problem with case delays; as the authors note, however, the consequences of this reduction have yet to be sufficiently studied empirically. Considering the challenges involved in investigating cases of child sexual abuse—especially involving preschool children—and the significance of securing high-quality forensic investigative interviews in order to secure their evidential value, a reduction in training of interviewers will likely have negative effects on interview quality as well as on assessments of their value as evidence. Such developments might also create difficulties in ensuring that interviews are properly catered to a child’s needs, which in turn can have negative effects on the security of the rights of the child (as well as of the suspect). This scenario illustrates how challenging and changing institutional conditions may affect the operation of Barnahus. Seemingly good intentions, in this case to overcome case delays, may result in new dilemmas for the Barnahus practice.

Medical Examination

This standard includes five principles, which provide recommendations for medical evaluations and/or forensic medical evaluations to be routinely carried out on the Barnahus premises by specialised staff (7.1); in addition, these examinations should be carried out on the Barnahus premises unless, due to urgency or because of various complications, they need to be carried out in a hospital setting, either as an inpatient or an outpatient; according to principle 7.2, the medical examination should be conducted by specialised staff who “are trained [in] recognizing indicators of physical, sexual, and emotional abuse as well as child neglect” (7.3) (Haldorsson, 2019, p. 88). Principle 7.4 also recommends that medical staff should be present in case review and planning meetings as appropriate; finally, principle 7.5 recommends “that children and family/care givers receive adequate information regarding available and necessary treatments and can influence the timing, location and set up of interventions” (Haldorsson, 2019, p. 88).

If a Barnahus is to provide a holistic approach and be able to secure a child’s legal rights, the Barnahus must ensure a medical assessment of the child and secure potential forensic medical evidence. This PROMISE standard, however, is quite general, and it does not specify the dilemmas and tensions that might create obstacles for the standard’s fulfilment. Some of the earlier chapters of this book have shown several tensions and dilemmas related to the medical examination and its dual aim. In Chapter 4, for example, Stefansen et al. analyse tensions related to medical examinations within the Norwegian Barnahus model. One question they discuss is who is to be offered a medical examination: in other words, the question of whether medical examinations should be a universal provision or should depend on discretion. They underline that a universal provision in Norway would challenge the current system in terms of resources and capacity. The authors also discuss what kind of medical examination is necessary: a full social-paediatric examination or a more limited examination. If medical examinations are to depend on discretion (which is the most common scenario), then the question again arises about the criteria for being offered a medical examination and whose discretion this decision should depend on.

A core challenge in relation to the medical examination is the difficulties in balancing the dual aims of the medical examination: the forensic and the clinical. As Stefansen et al. note, this imbalance is not limited to Norway but is visible in other Nordic countries as well. In general, the numbers of medical examinations (regardless of purpose) are low, and those examinations that are carried out primarily have a forensic purpose. Most children who come to Barnahus thus do not receive an assessment or follow-up of their health needs. This situation is problematic, especially since a trial project in Denmark found that almost half the children examined showed signs of abuse when a medical examination was offered as a universal provision. This Danish study concluded that both detecting and not detecting medical signs of violence and abuse during medical examinations contributed to the strengthening of the evidential value of children’s statements (Spitz et al., 2022).

In Chapter 4, Stefansen et al.’s analysis of the Norwegian model illustrates how the fact that the model is embedded in the penal track hampers the fulfilment of the medical mandate. Their analysis identifies several interlinked institutional barriers against fulfilling the dual mandate of the medical examination: for example, professionals’ views and regulations that exclude medical personnel from the initial consultation meetings, a lack of procedures for medical assessment in cases where a forensic medical examination is not requested, a lack of routines for passing on medical information, and a lack of knowledge (or the existence of misunderstanding) amongst the Barnahus staff about the relevant regulation.

A lack of resources regarding paediatric competence represents another problem. Police and prosecutors sometimes also note a lack of clarity regarding the extent to which a forensic medical examination should investigate or look for other marks of violence and abuse than is currently the case. Stefansen et al. argue that viewing the two aims of medical examinations as discrete could create a vulnerability to this lack of balance. Thus, one key message might be the importance of communicating that medical examinations in Barnahus should have two overlapping functions of equal value.

Concluding Remarks

This chapter has illuminated various tensions and challenges in many of the PROMISE network’s standards. We argue that the dual aim of these standards—which function both as a political instrument and a policy means for the promotion and diffusion of the model and as instruction for its implementation—risk creating a barrier for the model to reach its potential within different national contexts. By not bringing forward the complexity of the model in the presentation of the standards, governments may use the model mainly as a “symbol of action” instead of as a source for more fundamental system changes, thereby showing that they are doing something without actually changing the broader institutional landscape of surrounding justice and welfare systems in a child-friendly direction: a concern expressed from different UK contexts in two chapters of this book (Chapters 3 and 9). The political aim could also make illustrating various challenges in the model difficult, since acknowledging such challenges could also negatively affect such goals.

In this and earlier chapters, we have highlighted several legal, organisational, and professional-ethical dilemmas and tensions related to different standards. A key message has been that the Barnahus model must be understood in relation to the wider institutional system (political, legal, and organisational) it is embedded in. For the Barnahus model to reach its full potential, these challenges must be illustrated clearly in order to develop ways to solve them in relation to the various national systems where the model is implemented. More research is necessary to gain a closer understanding of the complex mechanisms in play, both in relation to the different dimensions of the Barnahus model and in various national contexts.

An especially relevant focus of research would be to further investigate the continuing diffusion and implementation of the Barnahus model in more European contexts, both in initial and later stages of adoption (Aksom, 2022). In Chapter 4, using a comparison of Norwegian data sets from 2012 and 2021, Stefansen et al. highlight the value of using a longer time perspective, since the institutionalisation of the Barnahus model and its consequences can only be identified over time. The contextually comparative analyses included in this book (see Chapters 1, 7, 9, and the present chapter) also illustrate the importance of identifying institutional variations in different contexts, both in terms of conditions for and consequences of implementing the Barnahus model. The authors of Chapter 1 have identified several variations in the ongoing diffusion of the Barnahus model—both between different European countries and compared to the Nordic region—in terms of steering and regulation, the role of the state, and affiliation. We hope that this book will stimulate further comparative research and institutional analyses of the Barnahus diffusion and implementation across Europe and beyond, both contextually in varied countries and over time.