Being admitted to inpatient child and adolescent mental health care (CAMHS) as a child or young person (CYP) is incredibly difficult. This usually happens as a last resort when all other community options have failed.
CAMHS services treat children and young people with a range of difficulties that have a serious impact on their mental health and emotional well-being. These may include serious suicidal risk, avoidance with a significant threat to safety, aggression or sensitivity due to anxiety or sexual inhibition, or severe eating disorders. We recently reported that long waits for support mean more children and young people present at the point of mental health crisis. and stressed the importance of offering support to young people before they reach crisis point.
Many children and young people are subject to coercive interventions or measures, which may include, but are not limited to, mechanical, physical or chemical restraint (forced administration of drugs) and seclusion, depending on the circumstances. These often occur in response to extreme distress, self-harm or violence by staff, or when best efforts to support oral feeding have failed. Forced tube feeding may be used if the child's physical health deteriorates to dangerous levels. We have previously described findings indicating that the very early stages of hospitalization are particularly associated with the use of coercion..
Coercive practices can result in psychological and physical harm to patients, and the resulting trauma can lead to further deterioration of mental health. Based on the concept that coercion is a form of torture and a violation of fundamental human rights, policymakers at the international level have expressed the ambition to reduce or eliminate the use of restrictive practices in all inpatient settings, with children and young people being considered a priority. In order to reduce or eliminate enforcement, services and countries need to better understand current rates and the associated factors that may contribute.
A study by Moell et al., (2024) set a goal 'systematically review both rates and risk factors for mechanical restraint, physical restraint, seclusion, pharmacological restraint and forced tube feeding in inpatient CAMHS.'
Internationally, policy makers have set an ambition to reduce or eliminate the use of restrictive practices in inpatient settings for children and youth.
Methods
The authors conducted a systematic review with additional narrative analysis focusing on the frequency, prevalence and risk factors of coercive interventions in CAMHS inpatient care. Definitions of studied coercive measures were pre-recorded. Their main outcome was exposure to any of these coercive measures.
They searched MEDLINE, Embase, Web of Science Core Collection, PsycINFO, Cinahl, and the Dissertations & Theses Global: Science and Engineering Collection from January 1, 2010, to January 10, 2024, using a strategy developed with information specialist librarians.
They included quantitative studies, including gray literature, reporting on the incidence, prevalence or risk factors of coercive measures in 24-hour inpatient CAMHS care for patients up to 17 years of age. They excluded investigations of forensic and living conditions.
Results
- 30 studies (of 34 articles) were reviewed, 20 of which also reported risk factors or variables associated with the use of coercive measures.
- Sample sizes ranged from 16 to 9,865, for a total of 39,027 patients
- Rates varied considerably, but the median prevalence for any restraint was 17.5% (IQR 13·4 to 20·8) and for any restraint (physical/mechanical ratio combined) 27.7% (IQR 21·3 to 29 ·4), and 6.0% for isolation (IQR 2·6 to 11·0).
- In nine reports, a small group of young people were subjected to the majority of coercive measures, and no detailed information was provided about them. Two studies of patients with eating disorders found the most extreme values.
- Sociodemographic factors are the most commonly reported patient characteristics. Units treating eating disorders had the highest coercive measures.
- In addition to being White (especially Black or African American), young age, male gender, ethnicity or race, and aggression were also predictors of coercive use.
- Regarding care-related factors, length of stay and readmissions were generally associated with exposure to involuntary measures.
- This systematic review shows that the use and risk factors of coercive measures in inpatient CAMHS vary significantly across settings.
This systematic review shows that the use and risk factors of coercive measures in inpatient CAMHS vary significantly across settings.
Results
The authors conclude that:
The rates of mandatory measures identified indicate a continued reliance on these interventions in some settings, despite ongoing, vigorous ethical debate and concerns about their impact on human rights and patient prognosis. Continued efforts are needed to understand and minimize the use of coercive measures in child and adolescent psychiatric inpatient treatment…
And this:
Variable rates and conflicting risk factors suggest that patient characteristics alone are unlikely to determine mandatory measure use. More research is needed, especially in the form of nationwide studies, to clarify the influence of care and worker factors. Finally, we propose reporting rules to improve comparisons across time and parameters.
Strengths and limitations
Not surprisingly, wide variation remains in the use of mandatory applications, which is clearly due to more than patient variables. However, it remains to be seen that some CYPs are exposed to higher levels than others. Being young increases the risk of coercion – is it related to children's perceptions and their behavior, or is it easier to coerce a younger child or respond to older children?
Although being male is clearly associated with perceived aggression, repeated concerns that young women who self-injure face disturbing levels of coercion do not, surprisingly, appear to be a feature of the included literature (Nawaz et al., 2021). There is also little new insight into the CYP most commonly induced by forced tube feeding. Similarly, given that medication was the most commonly used coercive practice overall, it was noted that a small number of included studies involved pharmacological restraint.
The range of studies identified presented highly heterogeneous data, thereby limiting the author's ability to perform a meta-analysis. Studies have been conducted mainly from the global north, mainly the United States, which makes generalization to other settings problematic.
There remains a need for standardized approaches to definitions, measurements, and outcomes related to enforcement.
Recurring concerns that young women who self-harm experience disturbing levels of compulsion do not, surprisingly, appear to feature in the included literature.
Implications for practice
Ideally, coercive experiences should be avoided in children. These may be extreme times that cannot be avoided, but clinical staff must be aware of the physical and psychological harm this can cause to children. This study suggested that some groups may experience more coercion, but the reasons for this need further investigation. Certainly, employees make the final 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 may reduce the use of restrictive practices in children and youth institutional settings, including mental health. It concluded that interventions are complex, reports are inconsistent, and reliable evaluation data are limited. However, some behavior change techniques appear promising. The most common setting in which behavior change techniques were found was “mental health,” and the most common procedure focused on employee training. Prospective behavior change techniques include instructions on how to perform the behavior, restructuring the social environment, feedback on the consequences of the behavior, and problem solving.
Child coercion should be prevented, and we are building a better understanding of behavior change interventions that can help reduce it.
Connections
Primary paper
Astrid Moell, Maria Smitmanis Lyle, Alexander Rozental, Niklas Långström, 2024 Rates of coercive use and risk factors in inpatient child and adolescent mental health services: 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. A Review Mapping Interventions to Reduce Use of Restraint Practices in Children and Youth in Institutional Settings: The CONTRAST Study. . Children and Society: 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 wards: a systematic review. BJPsych Open. 2021 Apr 16;7(3):e80. doi: 10.1192/bjo.2021.41. PMID: 33858560; PMCID: PMC8086389.