Abstract

This article aims to analyze the national scientific production on protective measures aimed at institutional care for at-risk children and adolescents in Brazil. By carrying out an integrative review, we seek to reflect on the main trends, themes, institutional actors, methodologies, and objectives of studies on the aforementioned measure and to analyze how the conditions and the right to health are presented and articulated in these references. Six thematic units were identified in the collection: Perceptions and roles of different actors in institutional reception processes; Processes of autonomy, dismissal, and causes of institutional care; Legislative aspects, evaluation of services, and identification of profiles; Family and community coexistence; Education and professional training; and Physical and mental health of sheltered children and adolescents. In Brazil, specifically, few studies investigate the concepts of the children and adolescents placed in shelters concerning protective measure processes or access to education. The link between poverty and institutionalization appears prominently and the scarcity of activities aimed primarily at family reintegration is evident. A large number of surveys point to the difficulties in implementing legislation.

Key words:
Institutional care; Protective measures; Children; Adolescents

Introduction

The present study seeks to analyze the national scientific production about protective measures aimed at institutional care for at-risk children and adolescents in Brazil. Through an integrative review, this study reflects on the main trends, themes, institutional actors, methodologies and objectives of the studies regarding those measures, as well as analyzes how specific conditions and the right to health appear and interact in this scientific production.

According to the Statute of Children and Adolescents (Estatuto da Criança e do Adolescente - ECA)¹1 Brasil. Presidência da República. Lei nº 8.069, de 13 de julho de 1990. Diário Oficial da União 1990; 13 de jul., institutional care, as a protective measure, should be exceptional and provisory, working as a transition strategy for family reintegration or for placement within a foster family, and should not constitute deprivation of freedom²2 Acioli RML, Barreira AK, Lima MLC, Lima MLLT, Assis SG. Avaliação dos serviços de acolhimento institucional de crianças e adolescentes no Recife. Cien Saude Colet 2018; 23(2):529-542..

According to the ECA ordinance, institutional care services must structure the care they provide according to some principles: exceptionality and provisional character of the removal from the family environment; preservation and fortification of family and community connections; guaranteed access, respect to diversity, and non-discrimination; providing of personalized and individualized care; guaranteed freedom of religion and beliefs; and respect for the autonomy of the children, adolescents, and youths³3 Conselho Nacional dos Direitos da Criança e do Adolescente (CNDCA), Conselho Nacional de Assistência Social. Orientações técnicas: serviços de acolhimento para criança e adolescentes. Brasília: CNDCA; 2009..

Scholars from different areas have been discussing the ill effects resulting from maintaining children and adolescents in shelters, where collective measures prevail in detriment of individualities, and poor investment in education is rampant⁴4 Espindola SP, Viana MB, Oliveira MHB de. Crianças e adolescentes acolhidos no estado do Rio de Janeiro: a adoção é a solução? Saude Debate 2020; 43(4):34-47.^,55 Passeti E. Crianças carentes e políticas públicas. In: Del Priori M, organizadora. História das crianças no Brasil. São Paulo: Contexto; 2006. p. 347-375.^,66 Venâncio RP. Famílias abandonadas: assistência à criança de camadas populares no Rio de Janeiro e em Salvador - séculos XVIII e XIX. Campinas: Papirus; 1999.. According to Assis et al.⁷7 Assis SG, Pinto LW, Avanci JQ. Nationwide study on children and adolescents in foster care in Brazil. Cent Eur J Paediatr 2014; 10(2):135-146., there is a lack of studies concerning institutional care, in Brazil and worldwide, examining their structure and the quality of the services they provide.

The several questions mentioned so far were the impetus behind conducting this study, which recognizes that the implementation of protective measures is directly related to the production of knowledge on the theme. Examining the scientific production about institutional care, with the purpose of establishing the status of scientific research on the theme, can subsidize discussions regarding the system of protection of children and adolescents’ rights, and the practices involving this system. This also enables us to identify the knowledge gaps and themes that are absent and require more investigative effort.

The present study focused on two key-questions: (i) What is the status of scientific research concerning preventive measures aimed at institutional care for children and adolescents (reoccurring themes and those that are seldom present; manners of approaching; most prevalent disciplinary and theoretical references)? and (ii) How do the conditions and the right to healthcare appear and interact?

Methodology

This study is an integrative literature review about protective measures aimed at institutional care for children and adolescents. Integrative reviews help to conduct critical analyses in relation to knowledge production regardiong questions, objectives, and objects of study, shedding light on possible contradictions, erasure, and reasons for the prevalence of specific research themes and agendas⁸8 Vosgerau DSR, Romanowski JP. Estudos de revisão: implicações conceituais e metodológicas. Rev Dialogo Educ 2014; 14(41):165-189.^,99 Santos GC, Baptista TWF, Constantino P. "De quem é esse bebê?": desafios para o direito à maternidade de mulheres em situação de rua. Cad Saude Publica 2021; 37(5):e00269320.. Bibliographic research was conducted in July 2022, applying a search strategy with descriptors in the Portuguese and English languages in the following databanks: Virtual Health Library (Biblioteca Virtual em Saúde - BVS), Scopus, Web of Science and PubMed. In total, 541 articles were collected.

The Mendeley software (https://www.mendeley.com) was used to optimize the filtering of the database and the check for duplicates. The articles in Portuguese, English, and Spanish which appeared as available and accessible were read in full. Only articles that had Brazil as the country of reference, published between 2010 and 2022, were selected, while those without a full version available were excluded. After reading the abstracts, the articles that were directly related to the theme of protective measures aimed at institutional care for children and adolescents were maintained, considering that studies focusing only on children, but not considering adolescents, were excluded, as were those lacking a specific discussion on institutional care (Figure 1).

The 81 studies selected in this study originated a data matrix organized according to the following information: author, year, title, objective, methodology, participants, main result, and area of knowledge. Next, the abstracts were read, aiming at identifying themes and core statements present in those productions The articles were organized based on the definitions of thematic analysis, applying the codifications of unity, theme, and content¹⁰10 Souza LK. Pesquisa com análise qualitativa de dados: conhecendo a análise temática. Arq Bras Psicol 2019; 71(2):51-67.. Six nuclear thematic units were identified in the collection (Chart 1).

Results

Most of the studies analyzed were in the area of Psychology, 58 of 81 studies, and employed empirical methodology of a qualitative nature, in other words, they prioritized the act of listening to the subjects present in the many processes of the care services, although they bring some quantitative aspects as well.

Perceptions, roles, and profiles of different actors in the process of institutional care

Of the 44 articles in this axis, 17 are dedicated to understanding the perceptions and possible representations by the professionals and interns who work in shelter institutions, regarding different processes, actors, and functions related to protective measures for institutional care.

Some negative views stand out about the processes related to institutional care as well as references to contradictions between what is supposed to happen and what in fact happens¹¹11 Scopinho RA, Rossi A. Entre a caridade, a filantropia e os direitos sociais: representações sociais de trabalhadoras do care. Estud Psicol (Campinas) 2017; 34(1):75-85.^,1212 Costa CF, Santos TF, Santos VS, Lima LAG. Entre a instituição e o lar: uma odisseia com educadores. Pesqui Prat Psicossociais 2018; 13(1):e1208.^,1717 Carvalho CF, Razera J, Haack KR, Falcke D. Acolhimento institucional: considerações sobre a forma como o cuidado subjetivo se apresenta no cotidiano de trabalho dos educadores sociais. Aletheia 2015; 47/48:51-63., resulting in the occurrence of episodes of violence by the sheltered individuals⁶6 Venâncio RP. Famílias abandonadas: assistência à criança de camadas populares no Rio de Janeiro e em Salvador - séculos XVIII e XIX. Campinas: Papirus; 1999. indicating a future of the institutionalization of poverty¹⁸18 Furlan V, Souza TRP. Família, acolhimento institucional e políticas públicas: um estudo de caso. Rev Psicol Polit 2014; 14(31):499-516..

In terms of the perceptions and representations of the sheltered individuals, 12 studies were identified. It is evident that it is possible to have a healthy development of autonomy and the presence of positive expectations regarding the resolution of care contexts, as well as the perception of the institutions as places of protection⁹9 Santos GC, Baptista TWF, Constantino P. "De quem é esse bebê?": desafios para o direito à maternidade de mulheres em situação de rua. Cad Saude Publica 2021; 37(5):e00269320.^,3131 Miura PO, Tardivo LSLPC, Barrientos DMS. O desamparo vivenciado por mães adolescentes e adolescentes grávidas acolhidas institucionalmente. Cien Saude Colet 2018; 23(5):1601-1610., even though the studies did not further develop the definition of what those positive aspects are. Those results, however, were extremely punctual and diluted when considering that, in institutional shelters, authoritarian and vertical standpoints prevail³⁸38 Marzol RM, Bonafé L, Yunes MAM. As perspectivas de crianças e adolescentes em situação de acolhimento sobre os cuidadores protetores. Psico 2012; 43(3):317-324.^,3939 Somer DG, Junior CRO, Barros SAB M. Representações sociais da escola: um estudo com adolescentes em acolhimento institucional no município de Ponta Grossa/PR. Polem!ca 2018; 18(1):16-36., resulting in difficulties to preserve and develop identity, and representing an evident example of conservative morality in relation to sexuality⁸8 Vosgerau DSR, Romanowski JP. Estudos de revisão: implicações conceituais e metodológicas. Rev Dialogo Educ 2014; 14(41):165-189.^,1515 Brito CO, Rosa EM, Trindade ZA. O processo de reinserção familiar sob a ótica das equipes técnicas das instituições de acolhimento. Temas Psicol 2014; 22(2):401-413.^,3232 Franceschini E, Weschenfelder VI. Como vaga-lumes na escuridão: histórias de adolescentes em instituição de acolhimento. Fractal Rev Psicol 2021; 33(2):108-116.^,3434 Uziel AP, Berzins FAJ. Adolescence, autonomy and sexual rights: fragments of stories of girls living in shelters. Psicol Clin 2012; 24(1):105-115.^,3535 Rodrigues JLS, Santos LMM, Lima AF. Mudar, pensar em mudar, continuar mudando: narrativas das metamorfoses de uma adolescência em abrigamento. Psicol Soc 2021; 33:e217494-e217494.^,3939 Somer DG, Junior CRO, Barros SAB M. Representações sociais da escola: um estudo com adolescentes em acolhimento institucional no município de Ponta Grossa/PR. Polem!ca 2018; 18(1):16-36..

The perceptions of family/guardians also appear as a focus of the studies, which show evident suffering in the face of separation, with fragilization of family connections motivated by the protective measures, as well as difficulties in identifying with the care service.

The construction of negative social images occurs more often in families with institutionalized children and adolescents⁴⁶46 Zappe JG, Yunes MAM, Dell'Aglio DD. Imagens sociais de famílias com crianças e adolescentes: impacto do status socioeconômico e da institucionalização. Pensando Fam 2016; 20(1):83-98., as well as in those who are placed in shelters, who are perceived as the only ones to blame for social vulnerability, or seen as individuals of dubious character and related to criminality.

Regarding the profile of the individuals in shelters, studies demonstrate that they are mostly male⁴⁸48 Fukuda CC, Penso MA, Santos BR. Social and familiar setting of children who have gone through multiple shelter placements. Arq Bras Psicol 2013; 65(1):70-87.^,5050 Acioli RML, Barreira AK, Lima MLC, Assis SG, Lima MLLT. Tempo de acolhimento e características dos adolescentes acolhidos por tipo de serviços institucionais. Recife, Brasil, 2009-2013. Cien Saude Colet 2019; 24(2):553-562.^,5151 Couto RMB, Rizzini I. Acolhimento institucional para crianças e adolescentes em situação de rua: pesquisa e políticas públicas. Textos Contextos (Porto Alegre) 2022; 20(2):39173.; multiple episodes of institutional care are predominant⁴⁸48 Fukuda CC, Penso MA, Santos BR. Social and familiar setting of children who have gone through multiple shelter placements. Arq Bras Psicol 2013; 65(1):70-87.^,5050 Acioli RML, Barreira AK, Lima MLC, Assis SG, Lima MLLT. Tempo de acolhimento e características dos adolescentes acolhidos por tipo de serviços institucionais. Recife, Brasil, 2009-2013. Cien Saude Colet 2019; 24(2):553-562.; and that there are no significant patterns regarding age groups. Most of the studies identified delays in education⁴⁸48 Fukuda CC, Penso MA, Santos BR. Social and familiar setting of children who have gone through multiple shelter placements. Arq Bras Psicol 2013; 65(1):70-87.

49 Gontijo DT, Buiati PC, Santos RL, Ferreira ATD. Fatores relacionados à institucionalização de crianças e adolescentes acolhidos na comarca de Uberaba - MG. Rev Bras Promoç Saude 2012; 25(2):139-150.

50 Acioli RML, Barreira AK, Lima MLC, Assis SG, Lima MLLT. Tempo de acolhimento e características dos adolescentes acolhidos por tipo de serviços institucionais. Recife, Brasil, 2009-2013. Cien Saude Colet 2019; 24(2):553-562.^-5151 Couto RMB, Rizzini I. Acolhimento institucional para crianças e adolescentes em situação de rua: pesquisa e políticas públicas. Textos Contextos (Porto Alegre) 2022; 20(2):39173.^,5353 Heumann S, Cavalcante LIC. Rotinas de crianças e adolescentes em acolhimento institucional: estudo descritivo. Arq Bras Psicol 2018; 70(2):22-37.. The main causes of application of protective measures are negligence, homelessness, violence, poor care, abandonment, poor socioeconomic conditions of the family, and use of alcohol and drugs by the parents or guardians⁴⁸48 Fukuda CC, Penso MA, Santos BR. Social and familiar setting of children who have gone through multiple shelter placements. Arq Bras Psicol 2013; 65(1):70-87.

49 Gontijo DT, Buiati PC, Santos RL, Ferreira ATD. Fatores relacionados à institucionalização de crianças e adolescentes acolhidos na comarca de Uberaba - MG. Rev Bras Promoç Saude 2012; 25(2):139-150.

50 Acioli RML, Barreira AK, Lima MLC, Assis SG, Lima MLLT. Tempo de acolhimento e características dos adolescentes acolhidos por tipo de serviços institucionais. Recife, Brasil, 2009-2013. Cien Saude Colet 2019; 24(2):553-562.

51 Couto RMB, Rizzini I. Acolhimento institucional para crianças e adolescentes em situação de rua: pesquisa e políticas públicas. Textos Contextos (Porto Alegre) 2022; 20(2):39173.^-5252 Penso MA, Fukuda CC, Costa LF, Villela L. The migration and institutional sheltering of children and adolescents in the Federal District, Brazil. Int Journal Migration Health Soc Care 2017; 13(2):173-184..

Autonomy processes, reasons for admission into institutional shelters and for their release

Of the 18 studies in this unit, most refer to follow-ups and analyses of the contexts of the release of children and adolescents from shelter institutions. When approaching the theme of family reintegration, such processes are analyzed from the point of view of the new National Adoption Law and search for the implementation of public policies aimed at the guarantee of rights for children and adolescents¹⁴14 Silva ML, Arpini DM. A nova lei nacional de adoção: desafios para a reinserção familiar. Psicol Estud 2013; 18(1):125-135.^,5454 Iannelli AM, Assis SG, Pinto LW. Family reintegration of children and adolescents in foster care in Brazilian municipalities with different population sizes. Cien Saude Colet 2015; 20(1):39-48.. They also analyze the expectations of the sheltered individuals when faced with their return to the family⁵⁷57 Almeida SGC, Morais NA. Expectativas relacionadas à reinserção familiar: um estudo com adolescentes com histórico de situação de rua, familiares e educadores. Estud Pesqui Psicol 2016; 16(2):508-528. and the follow-up of former sheltered individuals that are in the process of reintegration⁵⁶56 Rosa EM, Nascimento CRR, Matos JR, Santos JR. O processo de desligamento de adolescentes em acolhimento institucional. Estud Psicol (Natal) 2012; 17(3):361-368..

Scientific production indicates precarity in terms of investments in reintegration. The actions of family support aimed at reintegration require the articulation of policies that consider specific regional and populational aspects⁵⁴54 Iannelli AM, Assis SG, Pinto LW. Family reintegration of children and adolescents in foster care in Brazilian municipalities with different population sizes. Cien Saude Colet 2015; 20(1):39-48.^,5555 Silva ML, Arpini DM. O acolhimento institucional na perspectiva da nova Lei de Adoção. Psicol Teoria Prat 2013; 15(3):95-106.. Although the former sheltered individuals report having good connections and positive feelings regarding family members,, and regardless of the efforts of the technical staff of the institutions, effective family reinsertion is compromised by material shortcomings, given that participation in programs that provide some kind of income to the child/adolescent, such as the “Young Apprentice” program, is indicated as an important factor in making reinsertion effective⁵⁶56 Rosa EM, Nascimento CRR, Matos JR, Santos JR. O processo de desligamento de adolescentes em acolhimento institucional. Estud Psicol (Natal) 2012; 17(3):361-368.^,5757 Almeida SGC, Morais NA. Expectativas relacionadas à reinserção familiar: um estudo com adolescentes com histórico de situação de rua, familiares e educadores. Estud Pesqui Psicol 2016; 16(2):508-528..

In terms of releases and processes related to reaching adult age, the study discusses the role of the shelters and of the entire care network in guaranteeing the rights and preparing the institutionalized individuals for the transition into adult life⁵⁸58 Figueiró MESS, Campos HR. Abandono e acolhimento institucional: estudo de caso sobre maioridade e desinstitucionalização. Psicol Argum 2013; 31(72):113-125.

59 Cassarino-Perez L, Córdova VE, Montserrat C, Sarriera JC. Transição entre o acolhimento e a vida adulta: uma revisão sistemática sobre intervenções. Trends Psychol 2018; 26(3):1665-1681.^-6060 Cassarino-Perez L, Montserrat C, Sarriera JC. fatores protetivos e de risco na transição entre o acolhimento institucional e a vida adulta. Estud Pesqui Psicol 2020; 20(1):142-167.. The authors point out the lack of preparation to deal with the issues of adult life due to the insufficient investment in developing the autonomy of the institutionalized individual and the lack of conformity between the plans and desires of those subjects and the limited options offered by the network. Processes of investing in autonomy appear as important strategies. Two studies approach the question through more specific investigation, conducting data collection on indicators of prosocial behavior among sheltered adolescents⁶⁴64 Fernandes AO, Monteiro NRO. Comportamentos pró-sociais de adolescentes em acolhimento institucional. Psicol Teoria Pesqui 2017; 33(1):e3331. and seeking to understand the process of bonding, demonstrating the importance of investing in empathy and sharing as part of the institutional routine. The preparation of children and adolescents for placement in a foster family is approached by the authors in one of the integrated reviews⁶³63 Hueb MFD. Acolhimento institucional e adoção: uma interlocução necessária. Rev SPAGESP 2016; 17(1):28-38., which also investigated the interest in adopting children that are considered to be too old⁶¹61 Borges CAP, Scorsolini-Comin F. As adoções necessárias no contexto brasileiro: características, desafios e visibilidade. Psico USF 2020; 25(2):307-320., as well as the effectiveness of the adoption process at the national level in this context⁴4 Espindola SP, Viana MB, Oliveira MHB de. Crianças e adolescentes acolhidos no estado do Rio de Janeiro: a adoção é a solução? Saude Debate 2020; 43(4):34-47..

The studies show that key questions have not been addressed, such as the need to delve into ethnic-racial issues in connection with the extensive institutionalization times of children and adolescents; likewise, there is a lack of studies regarding the placement of handicapped children and teenagers in foster families⁶¹61 Borges CAP, Scorsolini-Comin F. As adoções necessárias no contexto brasileiro: características, desafios e visibilidade. Psico USF 2020; 25(2):307-320.^,6363 Hueb MFD. Acolhimento institucional e adoção: uma interlocução necessária. Rev SPAGESP 2016; 17(1):28-38..

Regarding the causes for the institutionalization of children/adolescents, the scientific studies are emphatic in terms of relating those causes to family poverty, and definitions such as “at risk” and “vulnerable” are often used to justify government intervention in poor families⁶⁶66 Gross LL, Tamarozzi GA. (Des)proteção social e acolhimento institucional infanto-juvenil. Human Inov 2020; 7(2):167-181.

67 Ramos R, Euzébios Filho A. A problemática da pobreza nos acolhimentos realizados nos serviços de acolhimento institucional para crianças e adolescentes e os desafios para a atuação do psicólogo. Psicol Rev 2019; 25(2):759-773.

68 Crestani V, Rocha KB. Risco, vulnerabilidade e o confinamento da infância pobre. Psicol Soc 2018; 30:e177502.

69 Boesmans EF, Martins KPH. Acolhimento institucional: realidade, causalidade e singularidade na psicanálise e no direito. Gerais Rev Interinst Psicol 2016; 9(1):3-16.

70 Penso MA, Ferreira PJSM. Reintegração familiar e múltiplos acolhimentos institucionais. Rev Latinoam Cienc Soc Niñez Juv 2016; 14(2):1523-1535.^-7171 Mastroianni FC, Sturion FR, Batista FS, Amaro KC, Ruim TB. (Des)acolhimento institucional de crianças e adolescentes: aspectos familiares associados. Fractal Rev Psicol 2018; 30(2):223-233..

Those studies, only a few of which show more criticism, are evidence that institutional care can be a manner of biopolitical intervention⁶⁸68 Crestani V, Rocha KB. Risco, vulnerabilidade e o confinamento da infância pobre. Psicol Soc 2018; 30:e177502.. The services function through a double confinement system: confinement of bodies, locked up in institutions, and of subjectivity, which is sequestered, criminalized, punished, and kept from reaching its potential⁶⁶66 Gross LL, Tamarozzi GA. (Des)proteção social e acolhimento institucional infanto-juvenil. Human Inov 2020; 7(2):167-181.^,6868 Crestani V, Rocha KB. Risco, vulnerabilidade e o confinamento da infância pobre. Psicol Soc 2018; 30:e177502.. Moreover, the use of alcohol and/or drugs by the parents/guardians appear as an important event in terms of factors which result in the children being placed in shelters⁷¹71 Mastroianni FC, Sturion FR, Batista FS, Amaro KC, Ruim TB. (Des)acolhimento institucional de crianças e adolescentes: aspectos familiares associados. Fractal Rev Psicol 2018; 30(2):223-233..

In this area, scientific production based on empirical and qualitative methodology is the majority, amounting to eight studies; there were also six studies of theoretical nature and four studies based on secondary data.

Legal aspects and evaluation of the services

Among the studies that analyze the conformity of institutional are services to policies and legislation, one can see an interest in discussing the historical evolution, the configuration, and the current execution of the services and observance of norms⁷²72 Miranda GL. Serviço de Acolhimento Institucional para Crianças e Adolescentes: feedback effects, inflexões e desafios atuais. Rev Adm Publica 2017; 51(2):201-218.^,7373 Souza FHO, Brito LMT. Acolhimento institucional de crianças e adolescentes em Aracaju. Psicol Clin 2015; 27(1):41-57.. One an also see that some studies seek to establish relationships between the policies, and the institutional practices and daily routine of the many different professionals. These relationships are considered expeditious and successful⁷⁴74 Oliveira DS, Schwartz ERD. The new adoption law: legal and psychological aspects. Estud Psicol (Campinas) 2013; 30(3):445-453.^,7575 Guedes C, Scarcelli I. Acolhimento institucional na assistência à infância: o cotidiano em questão. Psicol Soc 2014; 26(Esp):58-67. in terms of meeting the standards predicted by policies⁷⁶76 Fonseca PN, Albuquerque AB, Lima BL, Santos JLF, Souza Filho JF. Acolhimento institucional de crianças: avaliação da estrutura física, do funcionamento e da equipe de profissionais. Psicol Conoc Soc 2020; 10(3):48-62.. The organization of a policy of care for the population is also an element that strengthens the protective function of the family⁷⁷77 Oliveira MLC, Lima AM, Silva RMF, Paiva IL, Moreira TAS. A reinstitucionalização de crianças e adolescentes na região oeste de natal/RN. Rev SPAGESP 2020; 21(1):66-76..

Some authors have mentioned that even public policies that are powerful and well-designed face difficulties in terms of implementation⁷²72 Miranda GL. Serviço de Acolhimento Institucional para Crianças e Adolescentes: feedback effects, inflexões e desafios atuais. Rev Adm Publica 2017; 51(2):201-218.. The current context in which services are provided has issues in relation to aspects considered as basic, such as separating siblings when placed in shelters, institutions that restrict their services to specific age groups, disconnection of the protection network, a significant number of children from the countryside being sheltered in capital cities, a lack of family support and difficulties to ensure the right to have a family and a community life⁷³73 Souza FHO, Brito LMT. Acolhimento institucional de crianças e adolescentes em Aracaju. Psicol Clin 2015; 27(1):41-57.^,7474 Oliveira DS, Schwartz ERD. The new adoption law: legal and psychological aspects. Estud Psicol (Campinas) 2013; 30(3):445-453..

It is also important to highlight issues such as the importance of questioning the attributions of roles and directives, the adequation of facilities, the training of personnel, and the need to have a greater presence of the government in the creation of effective policies⁷⁵75 Guedes C, Scarcelli I. Acolhimento institucional na assistência à infância: o cotidiano em questão. Psicol Soc 2014; 26(Esp):58-67.

76 Fonseca PN, Albuquerque AB, Lima BL, Santos JLF, Souza Filho JF. Acolhimento institucional de crianças: avaliação da estrutura física, do funcionamento e da equipe de profissionais. Psicol Conoc Soc 2020; 10(3):48-62.^-7777 Oliveira MLC, Lima AM, Silva RMF, Paiva IL, Moreira TAS. A reinstitucionalização de crianças e adolescentes na região oeste de natal/RN. Rev SPAGESP 2020; 21(1):66-76..

The review studies, about institutional care services and their legal aspects, consider the publication of the ECA as a starting point, and primarily investigate the effects of institutionalization on children and adolescents⁷⁸78 Malfitano APS, Silva TV. Abrigo como medida de proteção para crianças e adolescentes: um levantamento bibliográfico PÓS-ECA. Rev Ter Ocup 2014; 25(1):94-100.^-7979 Parra ACO, Oliveira JA, Maturana APM. O paradoxo da institucionalização infantil: proteção ou risco? Psicol Rev 2019; 25(1):155-175.. The main results indicate the impossibility of a reliable interpretation of the referred phenomenon due to the scarcity of scientific studies on the theme, thus demonstrating that institutional care requires significant support from public policies, taking into consideration that possible negative impacts of institutionalization can be extensive and potentially as damaging as the situations which resulted in the need for such a measure.

The studies aimed at evaluating services seek to analyze the structure and the processes of institutional care. One study conducted in the city of Recife indicated that only a small portion of the services were inadequate, while most of them were considered acceptable⁸⁰80 Acioli RML, Barreira AK, Lima MLC, Lima MLLT, Assis SG. Avaliação dos serviços de acolhimento institucional de crianças e adolescentes no Recife. Cien Saude Colet 2018; 23(2):529-542.. The study evaluated the structure and the process of institutional care for the protection of children/adolescents who suffered with abandonment and/or violence, by applying a questionnaire for the people who worked in those services. The study also included a qualitative analysis with members of the judiciary and executive branches.

Family and community life

Measures of institutional care can be effective in protecting children and adolescents in situations of personal and social risk; however, there are serious difficulties in the sense of restoring family connections, especially due to the shared belief in the ideal model of family⁸¹81 Moreira M. Os impasses entre acolhimento institucional e o direito à convivência familiar. Psicol Soc 2014; 26(Esp. 2):28-37.. According to Moreira⁸¹81 Moreira M. Os impasses entre acolhimento institucional e o direito à convivência familiar. Psicol Soc 2014; 26(Esp. 2):28-37., those families are seen as fragile from a symbolic point of view, in terms of material conditions: in most cases, families are female, single-parent, in a context marked by the imaginary ideal of nuclear, conjugal, and heterosexual families. Hence, other family configurations are seen as “unstructured”. The author emphasizes that shelter institutions provide services to the child or adolescent, but not to the family, and even though the network has many psychosocial services, they are, nonetheless, considerably disconnected.

Education and professional training

Three of the studies investigated the issue of education and professional training for institutionalized children and adolescents. One study indicates that behavior issues impact academic performance in the areas of reading and writing of institutionalized children and adolescents, who are further hampered by prejudicial and discriminatory attitudes towards them. Those attitudes favor exclusion practices, which compromise the rights of the subjects and reinforce the belief in the inability of building new and promising scenarios⁸²82 Silva JRLA, Pereira VA, Donatto ML. Habilidades sociais e acadêmicas de crianças e adolescentes em instituições de acolhimento. Psicol Cienc Prof 2021; 41(4):e203205..

Silva⁸²82 Silva JRLA, Pereira VA, Donatto ML. Habilidades sociais e acadêmicas de crianças e adolescentes em instituições de acolhimento. Psicol Cienc Prof 2021; 41(4):e203205. et al. discuss the importance of an inclusive attitude towards children and adolescents in the context of education by offering educational practices that respect differences and boost equity. The significant educational delay of institutionalized children/adolescents, and the lack of clarity by the educators regarding the actual meaning of professional education, result in children and adolescents who will enter the job market with inadequate qualifications, which is one of the main problems in this area⁸³83 Leal NSB, Alberto MFP. Jovens em acolhimento institucional: desafios entre a distorção série-idade e a formação profissional. Estud Psicol (Natal) 2020; 25(3):303-313.^,8484 Leal NSB, Alberto MFP. Política de acolhimento e juventude: a problemática da inserção na formação profissional. Psicol Cienc Prof 2021; 41:e220685..

Leal and Alberto⁸⁴84 Leal NSB, Alberto MFP. Política de acolhimento e juventude: a problemática da inserção na formação profissional. Psicol Cienc Prof 2021; 41:e220685. indicate the need to investigate the articulation between policies of professional training and of protective measures aimed at shelters for children and adolescents, enabling the construction of life projects and favoring the subsequent insertion of those individuals in the job market.

Mental and physical health of sheltered children and adolescents

The issue of physical and mental health of children and adolescents subjected to protective measures of institutional care was approached by 6 of the 81 studies. In relation to mental health, psychological problems were found by one of the studies through evaluations conducted with 61 adolescents in shelters, who showed indifference regarding the adversities and complexities of their life and their condition as an institutionalized individual, thereby indicating the presence of emotional problems and the discontinuity of psychological investment in the struggle against the situation of vulnerability that results from being away from people with whom they have affective ties. In one of the adolescents interviewed, suicide idealization was noticed⁸⁵85 Fernandes AO, Oliveira-Monteiro NR. Psychological indicators and perceptions of adolescents in residential care. Paideia 2016; 26(63):81-89..

One study sought to investigate the incidence of depressive symptoms in sheltered children and adolescents, and identified that 35% of the 23 participants reached a percentile considered to be clinically significant, while another 35% showed a similar percentile. The results suggest that being institutionalized for longer than two years, having a record of multiple periods of institutionalization, having no personal affective relationships during the process of institutional care, not having siblings in the institution, and being institutionalized after seven years of age, are issues directly connected to the development of such symptoms⁸⁶86 Álvares AM, Lobato GR. Um estudo exploratório da incidência de sintomas depressivos em crianças e adolescentes em acolhimento institucional. Temas Psicol 2013; 21(1):151-164..

Another study sought to understand the emotional experiences of intra-family violence suffered by adolescent mothers in institutional care, the main results of which showed multiple situations that cause significant psychological suffering: adolescent pregnancy, conflicts with family routine, running away from home, and situations in which adolescent mothers abandon their babies after birth. It is assumed that intra-family violence made the adolescent mothers incapable of symbolizing, elaborating, and re-signifying the psychological suffering related to these experiences⁸⁷87 Miura PO, Tardivo LSPC, Barrientos DMS. O sofrimento psíquico das mães adolescentes acolhidas institucionalmente. Rev Latinoam Psicopatol Fundamental 2017; 20(2):331-348..

One of the studies analyzed the medicalization of children and adolescents as a modus operandi of institutions. The study shows that, in detriment of care measures that value teamwork and the preservation of the rights of children and adolescents, services resort to measures that favor control and surveillance, and place those individuals in a situations of need, abnormality, and potential danger⁸⁸88 Oliveira A, Vicentin MCG, Massari MG. Entre medicalização e recusas: crianças e adolescentes nos circuitos socioassistenciais-sanitários. Rev Polis Psique 2018; 8(3):225-245..

Penna⁸⁹89 Penna LHG, Ribeiro LV, Ramos KAA, Félix FO, Guedes CR. Empoderamento de adolescentes femininas abrigadas: saúde sexual na perspectiva do Modelo Teórico de Nola Pender. Rev Enferm UERJ 2016; 24(5):27403. et al. describes the sexual attitudes and behaviors of adolescents in shelters, and analyzes the repercussions of such attitudes on their sexual health. As a general result, the study verified that, after institutional care, there was an increase in the use of condoms and a greater perception of sexual vulnerability by those adolescents, leading to the possible assumption that institutional care improved the sexual health of adolescents.

Finally, one study investigated the impacts of institutionalization on the physical and psychological health of children and adolescents, and found that removing a children from an institution and transferring them to a different place of care may lead to a reduction of psychopathological risks and promote better social, emotional, and cognitive development. It is crucial, therefore, to invest in care services that are prescribed by different policies on the issue in order to reduce possible deficits in the development of institutionalized children and adolescents⁹⁰90 Filho MSS, Neto JAL, Rodrigues IR, Neto MLR. Dignifying hidden lives: the institutionalization of any impact child development. Curr Pediatric Res 2016; 20(1-2):55-56..

Discussion

There are a high number of studies aimed at the perceptions and different actors of the process of institutional care - nearly half of the 81 studies - and even more impacting is the fact that among those, there is a prevalence of studies concerned with the work and the perceptions of those who work at the shelter services.

In Brazil, few studies delve into the concepts of children and adolescents, even though some studies indicate that, for the shelters to allow for a healthy development, there is a need for investment in the reformulation and evaluation of the institutions, since countless structural and processual flaws are noticeable in Brazilian institutions⁸⁰80 Acioli RML, Barreira AK, Lima MLC, Lima MLLT, Assis SG. Avaliação dos serviços de acolhimento institucional de crianças e adolescentes no Recife. Cien Saude Colet 2018; 23(2):529-542.. Silva and Montserrat⁹¹91 Silva LAM, Montserrat Boada C. Jóvenes que estuvieron en el sistema de protección social a la infancia: reflexiones a partir de una investigación realizada en Girona, España. 2014; 27(1):198-206. mentioned the evident lack of data about populations of children and teenagers undergoing protective measures, showing the invisibility to which those subjects are submitted.

A high number of studies show the difficulties regarding the implementation of legislations and norms aimed at the guarantee of the rights of children and adolescents, and reveal the lack of knowledge, by the professionals, about their roles and specific attributions, going against what was discussed by Masha and Botha⁹²92 Masha RR, Botha P. Is foster care the safe place we believe it to be? If not, why not? Social Work 2021; 57(4):499-515., who identified a system of institutional care which contributes to the perpetuation of the violation of rights, as well as negligence due to the gap between what is done and what is prescribed.

By ensuring family and community life, the ECA recognizes the importance of family in education and socialization during childhood and adolescence, highlighting the relevance of the preservation of such connections⁹³93 Lossaco S. O jovem e o contexto familiar. In: Acosta AR, Vitalle MAF, organizadores. Família: redes, laços e políticas públicas. São Paulo: IEE/PUCSP; 2004. p. 21-73., although there is still a lack of activities and proposals that specifically aim to improve connections and investments in family integration, as shown in this integrative review, although national legislation supports the priority character of such actions and reinforces the exceptionality and briefness of protective measures for institutional care¹1 Brasil. Presidência da República. Lei nº 8.069, de 13 de julho de 1990. Diário Oficial da União 1990; 13 de jul..

The relationship between poverty and the institutionalization of children and adolescents is a theme that stands out, especially in studies which make up the thematic axis of the causes of institutional care. Such data is also corroborated by the articles investigating the profile of those who are sheltered, revealing a contradictory protection logic, as mentioned by Rizzini⁹⁴94 Rizzini I, Rizzini I. A institucionalizaç¸ão de crianças no Brasil: percurso histórico e desafios do presente. Rio de Janeiro: Editora PUC-Rio; 2004., which puts children and adolescents within the scope of legal actions, assistance, and police measures due to their condition of poverty. The institutional micro-practices clearly influence and update the processes of discrimination against the poor at the level of policies of protection of children and adolescents⁹⁵95 Llobet V, Villalta C. Economías morales del cuidado infantil. Familias, género y desigualdades en los programas de acogimiento familiar en la Argentina. Horiz Antropol 2021; 27(61):227-256..

It is of utmost importance to establish a difference in relation to the studies on education and professional training. Access to education, which is a basic right, appears even less in the current review, given that, of the three studies concerning education, two refer to professional training. However, it is important to mention that both actions are strategic, considering the social reality of the families involved and the need to develop autonomy. Access to education provides the individual with a chance for self-construction and expands possibilities, thereby constituting an opportunity of growth as a citizen and of development of self-esteem⁹⁶96 Cury CRJ. Direito à educação: direito à igualdade, direito à diferença. Cad Pesq 2002; 116:245-262..

The use of alcohol and other drugs is indicated as the main factor generating violence in affective relationships, and is a key issue in episodes of the violation of the rights of children and adolescents, whether by them or by their guardians; the consequence of this issue is the removal from family life⁹⁷97 Arpini DM, Gonçalves CS. Drogas e álcool na relação com a violência: o olhar de adolescentes em situação de rua. Psico 2011; 42(4):442-449..

Although questions such as the use of alcohol and other drugs appear in many studies as a hurdle to the reduction of the need for shelters and for the promotion of family reintegration, none of the studies - and we are not considering here only those in the thematic axis of health - ventures into deeper reflection on health issues, causes of institutionalization, and the possible release of children and adolescents submitted to such measures.

Family and community life, access to education, and access to healthcare are fundamental rights of children and adolescents, and appear in nearly every study; however, it is important to note that it appears more commonly as a peripheral issue, as a consequence of investigations that have other specific objectives, rather than occupying a central place in discussions.

Final considerations

This integrative review shows that, given the large number of studies focused on the perception and actions of different actors who are part of the processes of institutional care, especially professionals, advances in legislation and regulations are not reflected in the execution of the aforementioned protective measures, and that, in view of this, efforts regarding the production of knowledge tend to focus on services and professionals, leaving aside the experiences of children and adolescents in shelters and the impacts that they suffer, directly, on their general development and, primarily, health conditions, even if it is admitted that there is a certain level of correlation between the two issues.

The protective measure continues with the tutelary nature of actions aimed at the supposed protection of poor children and adolescents in the face of risk situations that have their roots in political, economic, and social problems. It is necessary to consider the violations, when understanding the complexity of this context, which are being imposed in the name of protection, used as a mask. The analysis of access and health conditions, one of the main objectives of this text, proved to rarely be present and with limited investigations in the references collected in this integrative review. Likewise, there is also a lack of studies concerning the rights to family and community coexistence and education.

References

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