Wide variance in the use of coercion in children and young people’s inpatient services

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

CAMHS services treat children and young people with a range of difficulties which have a serious impact on their mental health and emotional wellbeing. These may include a serious risk of suicide, running away with a significant threat to safety, aggression or vulnerability due to sexual agitation or disinhibition, or serious eating disorders. We recently reported that long waits for support mean more children and young people are presenting at the point of mental health crisis and highlighted the importance of offering support before young people reach the point of crisis.

Many children and youth are subject to coercive interventions or measures that, depending on the setting, could include, but are not limited to, mechanical, physical, or chemical restraint (involuntary administration of medications) and seclusion. These are often triggered by staff in response to extreme distress, self-harm or violence or when best efforts to support oral nutrition have failed. If a child’s physical health is deteriorating to dangerous levels, force-feeding by tube may be used. We have previously described findings showing that the very early stages of hospital admission are particularly associated with the use of coercion.

Coercive practices can cause psychological and physical harm to patients, and the resulting trauma can contribute to further worsening mental health. Guided by the concept that coercion is a form of torture and contrary to fundamental human rights, international policy makers have set the ambition to reduce or eliminate the use of restrictive practices in all hospital settings, taking into account the children and young people as a priority. To achieve reduction or elimination of coercion, services and countries need a better understanding of current rates and associated factors that may contribute.

a study of Moell et al., (2024) intended for ‘to systematically review both the rates and risk factors of mechanical restraint, physical restraint, seclusion, pharmacological restraint and forced tube feeding in CAMHS inpatients.’

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

Methods

The authors conducted a systematic review with a complementary narrative analysis focusing on the incidence, prevalence and risk factors of coercive measures in CAMHS inpatient care. The definitions of the coercive measures studied were previously recorded. Their primary outcome was exposure to any 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 with information librarians from January 1, 2010 to January 10, 2024. .

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

Results

• Thirty studies (out of 34 articles) were included in the review, 20 also reported risk factors or variables associated with the use of coercive measures.
• Sample sizes ranged from 16 to 9,865, with a total of 39,027 patients.
• Rates varied markedly, however, the median prevalence for any coercive measure was 17.5% (IQR 13.4 to 20.8), for any restraint (combined physical/mechanical rate) 27.7% (IQR 21.3 to 29.4), and for confinement 6.0% (IQR 2.6 to 11.0).
• In nine reports, a small subgroup of youth was exposed to most coercive measures without providing further details about them. The most extreme atypical rates were found in two studies of patients with eating disorders.
• Sociodemographic factors were the most frequently reported patient-related characteristics. Units treating eating disorders had the highest rates of coercive measures.
• Younger age, male sex, nonwhite ethnicity/race (especially black or African American), and aggression also predicted the use of coercive measures.
• Regarding care-related factors, prolonged length of hospital stay and repeat admissions were generally associated with exposure to coercive measures.
• This systematic review suggests that the use of coercive measures and risk factors in inpatient CAMHS vary substantially between settings.

This systematic review suggests that the use of coercive measures and risk factors in inpatient CAMHS vary substantially between settings.

Conclusions

The authors conclude:

The rates of coercive measures identified suggest a persistent reliance on these interventions in some settings, despite ongoing vigorous ethical debates 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 care…

And so:

Variable rates and conflicting risk factors suggest that patient traits alone are unlikely to determine the use of coercive measures. More research is needed, especially in the form of nationwide studies, to elucidate the impact of care and staffing factors. Finally, we propose reporting guidelines to improve comparisons across time and settings.

Strengths and limitations

Not surprisingly, there continues to be wide variation in the use of coercive practices; is clearly related to more than just patient variables. But it remains a concern that some CYPs are subject to higher levels than others. Being young increases the risk of coercion: is this related to children’s perceptions and their behavior, or is it simply easier to coerce a younger child, or do older children hit back?

While being male is obviously related to perceived aggression, repeated concerns that young women who self-harm experience alarming levels of coercion surprisingly do not appear to be a feature in the literature that was included (Nawaz et al., 2021). There is also little new information about those CYP that are most coerced by force-tube feeding. Similarly, given that medication is the most commonly used coercive practice overall, it was notable that a small number of included studies addressed pharmacological restraint.

The variety of studies identified provided very heterogeneous data, which limited the author’s ability to conduct a meta-analysis. The studies largely came from the global north, primarily the United States, making generalization to other settings problematic.

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

Surprisingly, repeated concerns that young women who self-harm experience alarming levels of coercion do not appear to be a feature of the included literature.

Implications for practice

The ideal would be to avoid the use of coercive practices on children. 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 to children. This review has suggested that some groups may experience more coercion, but the reasons why need to be explored further. Arguably, staff make the final decision to use coercion and there are promising interventions that could reduce this.

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

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

Golf course

primary job

Astrid Moell, Maria Smitmanis Lyle, Alexander Rozental, Niklas Långström, 2024 Rates and risk factors for the use of coercive measures in mental health services for hospitalized 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. Mapping review of interventions to reduce the use of restrictive practices in children and youth Settings institutional: the CONTRAST study. Children and society: International journal on children 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. Open BJPsych. April 16, 2021; 7 (3): e80. doi: 10.1192/bjo.2021.41. PMID: 33858560; PMCID: PMC8086389.

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