There are major differences in the use of coercion in intramural care for children and young people

Being admitted as a child or young person (CYP) to an inpatient child and adolescent mental health service (CAMHS) is incredibly painful. It is usually done as a last resort when all other community options have failed.

CAMHS services treat children and young people with a range of problems that have a serious impact on their mental health and emotional well-being. These may include a serious risk of suicide, absconding with a significant threat to safety, aggression or vulnerability due to arousal or sexual disinhibition, or serious eating disorders. We recently reported that the long wait for support means more children and young people are on the brink of a mental health crisis. We have emphasized the importance of providing support before young people reach crisis point.

Many children and young people are subjected to coercive interventions or measures, which depending on the setting may include, but are not limited to, mechanical, physical or chemical restraint (involuntary administration of drugs) and seclusion. These are often caused by staff in response to extreme distress, self-harm or violence or when best efforts to support oral feeding have failed. If a child’s physical health deteriorates to a dangerous level, forced tube feeding may be used. We have previously described findings showing that very early stages of hospitalization are particularly associated with the use of restraint.

Coercive practices can result in psychological and physical harm to patients and the resulting trauma can contribute to further deterioration of mental health. Guided by the concept that coercion is a form of torture and violates basic human rights, policy makers internationally have set the ambition to reduce or eliminate the use of restrictive practices in all residential settings, with children and young people being seen as a priority . To reduce or eliminate coercion, agencies and countries need a better understanding of current rates and the associated factors that may contribute to them.

A study of Moell el al., (2024) focused on ‘systematically assess both rates and risk factors for mechanical restraint, physical restraint, seclusion, pharmacological restraint, and forceful tube feeding in inpatient CAMHS.’

Policymakers internationally have set the ambition to reduce or eliminate the use of restrictive practices in residential settings where children and young people are a priority.

Methods

The authors conducted a systematic review with additional narrative analysis focusing on the incidence, prevalence and risk factors of coercive measures in CAMHS inpatient care. Definitions of the coercive measures examined were registered in advance. Their main outcome was exposure to one of these coercive measures.

They searched MEDLINE, Embase, Web of Science Core Collection, PsycINFO, Cinahl and Dissertations & Theses Global: The Sciences and Engineering Collection using a strategy developed together with information specialists between January 1, 2010 and January 10, 2024.

They included quantitative studies, including gray literature, that reported on the incidence, prevalence or risk factors for the use of restraints in CAMHS inpatient care providing 24-hour care to patients aged up to 17 years. They excluded studies of forensic and residential treatment settings.

Results

• Thirty studies (from 34 articles) were included in the review, 20 of which also reported risk factors or variables associated with the use of restraints.
• The sample size ranged from 16 to 9,865, with a total of 39,027 patients
• The figures varied considerably, but the median prevalence for each coercive measure was 17.5% (IQR 13.4 to 20.8), for each form of coercion (physical/mechanical combined) 27.7% (IQR 21.3 to 29 .4), and for seclusion 6.0% (IQR 2.6 to 11.0).
• In nine reports, a small subgroup of young people were exposed to most coercive measures, without further details being given. The most extreme outliers were found in two studies among patients with eating disorders.
• Sociodemographic factors were the most commonly reported patient-related characteristics. Units treating eating disorders had the highest rates of restraint.
• Younger age, male gender, ethnicity or race other than white (especially black or African American), and aggression were also predictive of restraint use.
• Regarding care-related factors, longer length of stay and repeat admissions were generally associated with exposure to coercive measures.
• This systematic review suggests that the use of restraints and risk factors in inpatient CAMHS vary considerably between settings.

This systematic review suggests that the use of restraints and risk factors in inpatient CAMHS vary considerably between settings.

Conclusions

The authors conclude:

The number of coercive measures identified indicates continued reliance on these interventions in some situations, despite ongoing, vigorous ethical debates and concerns about their impact on patients’ human rights and prognosis. Continued efforts are needed to understand and minimize the use of restraints in psychiatric inpatient care for children and adolescents.

And that:

Variable rates and conflicting risk factors suggest that patient characteristics alone are unlikely to determine the use of restraints. More research, especially in the form of national studies, is needed to gain insight into the impact of healthcare and personnel factors. Finally, we propose reporting guidelines to improve comparisons across time and settings.

Strengths and limitations

That there is still great variation in the use of coercive practices is not surprising; it is clearly related to more than just patient variables. But it remains a concern that some CYPs are subjected to higher levels than others. Being young increases the risk of coercion – does this have to do with the perception of children and their behavior, or is it simply easier to coerce a younger child, or older children hit back!

Although being male is clearly linked to perceived aggression, repeated concerns that young women who self-harm experience disturbing levels of coercion surprisingly do not appear to be a feature of the literature included.Nawaz et al., 2021). There is also little new insight into which CYP patients are most exposed to forced tube feeding. Because medication in general is the most commonly used restraint practice, it was notable that a small number of included studies focused on pharmacological restraint.

The set of studies identified provided very heterogeneous data, limiting the author’s ability to conduct a meta-analysis. The studies were largely from the Global North, especially the US, which makes generalizability to other contexts problematic.

There remains a need for standardized approaches to definitions, measurements, and outcomes related to coercive practices.

Repeated concerns that young women who self-harm experience disturbing levels of coercion seem surprisingly not to be addressed in the included literature.

Implications for practice

Ideally, the use of coercive practices on children should be avoided. There may be extreme times when they cannot be avoided, but clinical staff must be aware of the physical and psychological damage this can cause in children. This review has suggested that some groups may experience greater coercion, but the reasons for this require further investigation. It is likely that staff ultimately make the decision to use coercion and there are promising interventions that can reduce this.

One of my blogs (Baker et al., 2022) sought to understand interventions that can reduce the use of restrictive practices in children and youth institutional settings, including mental health settings. It concluded that interventions tend to be complex, reporting is inconsistent and robust evaluation data is limited. However, some behavior change techniques appear promising. The most common setting in which behavior change techniques were found was ‘mental health’, with the most common procedure focusing on staff training. Promising behavior change techniques include instruction on how to perform the behavior, restructuring the social environment, feedback on the outcomes of behavior, and problem solving.

The use of coercive practices in children should be avoided and we are building a better understanding of the types of behavior change interventions that can help reduce them.

Links

Primary paper

Astrid Moell, Maria Smitmanis Lyle, Alexander Rozental, Niklas Långström, 2024 Rates and risk factors of the use of coercive measures in inpatient mental health care for children and adolescents: a systematic review and narrative synthesis, The Lancet Psychiatry, https://doi.org/10.1016/S2215-0366(24)00204-9.

Other references

Baker J, Kendal S, Berzins K, Canvin K, Branthonne-Foster S, McDougall T, Goldson B, Kellar I, Wright J, Duxbury J. 2022. Overview of interventions to reduce the use of restrictive practices in children and youth Institutional Settings: The CONTRAST Study. Children and Society: The International Journal of Childhood and Children’s Services. 1351-1401, 36, 6.

Nawaz RF, Reen G, Bloodworth N, Maughan D, Vincent C. Interventions to reduce self-harm on inpatient units: systematic review. BJPsych Open. 2021 Apr 16;7(3):e80. doi: 10.1192/bjo.2021.41. PMID: 33858560; PMCID: PMC8086389.

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