Being admitted to an inpatient 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 that are seriously impacting on their mental health and emotional wellbeing. These may include serious risk of either suicide, absconding with a significant threat to safety, aggression or vulnerability due to agitation or sexual disinhibition, or severe eating disorders. We have reported recently that lengthy waits for support mean that 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 crisis point.
Many children and young people are subjected to coercive interventions or measures, which depending on the setting could include but not be limited to mechanical, physical or chemical restraint (involuntary administration of medication) 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, forced tube feeding might be used. We have previously described findings showing that very early stages of hospital admission are particularly associated with the use of coercion.
Coercive practices can result in psychological and physical harms for patients and the resulting trauma may contribute to further worsening mental health. Led by the concept that coercion is a a form of torture and counter to fundamental human rights, policymakers internationally have set out an ambition to reduce or eliminate the use of restrictive practices for all inpatient settings, with children and young people seen as a priority. In order to achieve reduction of coercion or its elimination, services and countries need a better understanding of current rates and associated factors which may contribute.
A study by Moell el al., (2024) aimed to ‘systematically review both rates and risk factors for mechanical restraint, physical restraint, seclusion, pharmacological restraint, and forced tube feeding in inpatient CAMHS.’
Policy makers internationally have set out an ambition to reduce or eliminate the use of restrictive practices across inpatient settings with children and young people a priority.
Methods
The authors conducted a systematic review with an adjunct narrative analysis focused on the incidence, prevalence, and risk factors of coercive measures in CAMHS inpatient care. Definitions of the studied coercive measures were preregistered. 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 specialist librarians from Jan 1, 2010, to Jan 10, 2024.
They included quantitative studies, including grey literature, which reported on the incidence, prevalence, or risk factors for coercive measure use in CAMHS inpatient care that provided 24-hour care for patients aged up to 17 years. They excluded studies of forensic and residential treatment settings.
Results
- 30 studies (from 34 papers) 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 (physical/mechanical rate 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 of the coercive measures with no more detail provided about them. The most extreme outlier 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, ethnicity or race other than White (especially Black or African American) and aggression were also predictive of coercive measures being used.
- Regarding care-related factors, extended length of stay and repeated admissions were, overall, associated with coercive measure exposure.
- This systematic review suggests that coercive measure use and risk factors in inpatient CAMHS vary substantially across settings.
This systematic review suggests that coercive measure use and risk factors in inpatient CAMHS vary substantially across 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 regarding their impact on the human rights and prognosis of patients. Ongoing efforts are needed to understand and minimise the use of coercive measures in child and adolescent psychiatric inpatient care…
And that:
Variable rates and conflicting risk factors suggest that patient traits alone are unlikely to determine coercive measure use. More research, especially in the form of nationwide studies, is needed to elucidate the impact of care and staff factors. Finally, we propose reporting guidelines to improve comparisons over time and settings.
Strengths and limitations
That there remains a wide variance in the use of coercive practices is not surprising, it is clearly related to more than just patient variables. But it remains concerning that some CYP are subjected to higher levels than others. Being young increases the risk of coercion – is this related to perceptions of children and their behaviour, or just easier to coerce a younger child, or do older kids hit back!
Whilst being male obviously links with perceived aggression, repeated concerns that young women who self-harm experience disturbing levels of coercion surprisingly doesn’t seem to be a feature in the literature that was included (Nawaz et al., 2021). There is also little new insight into those CYP who are coerced the most through forced tube feeding. Similarly, given medication is the most used coercive practice overall, it was notable that a small number of included studies addressed pharmacological restraint.
The range of studies identified provided highly heterogeneous data thereby limiting the author’s ability to undertake a meta-analysis. Studies were largely from the global north, mainly from the US, which makes generalisability to other settings problematic.
There remains a need for standardised approaches to definitions, measurement and outcomes related to coercive practices.
Repeated concerns that young women who self-harm experience disturbing levels of coercion surprisingly doesn’t seem to be a feature in the included literature.
Implications for practice
Ideally the use of coercive practices in children should be avoided. There may be extreme times when they cannot be avoided, but clinical staff need to be aware of the physical and psychological harm this can cause children. This review has suggested some groups may experience more coercion but the reasons why need further exploration. Arguably staff make the ultimate decision to use coercion and there are promising interventions that could reduce this.
One of my blogs (Baker et al., 2022) sought to understand interventions which may reduce the use of restrictive practices in children and young peoples’ institutional settings, including mental health. It concluded that interventions tend to be complex, reporting is inconsistent and robust evaluation data are limited. However, some behaviour change techniques seem promising. The most common setting in which behaviour change techniques were found was ‘mental health,’ with the most common procedure focused on staff training. Promising behaviour change techniques included instruction on how to perform the behaviour, restructuring the social environment, feedback on outcomes of behaviour and problem-solving.
The use of coercive practices in children should be avoided and we are building a better understanding of the type behaviour change interventions that can aid its reduction.
Links
Primary paper
Astrid Moell, Maria Smitmanis Lyle, Alexander Rozental, Niklas Långström, 2024 Rates and risk factors of coercive measure use 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. Mapping Review of Interventions to Reduce the Use of Restrictive Practices in Children and Young People’s 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 in-patient wards: systematic review. BJPsych Open. 2021 Apr 16;7(3):e80. doi: 10.1192/bjo.2021.41. PMID: 33858560; PMCID: PMC8086389.
