Characteristics of adolescents frequently restrained in acute psychiatric units in Norway: a nationwide study

Rates and risk factors of coercive measure use in inpatient child and adolescent mental health services: a systematic review and narrative synthesis

Reducing the use of coercive measures in inpatient child and adolescent mental health services (CAMHS) requires an understanding of current rates and associated factors. We conducted a systematic review of research published between Jan 1, 2010, and Jan 10, 2024, addressing rates and risk factors for mechanical, physical, or pharmacological restraint, seclusion, or forced tube feeding in inpatient CAMHS. We identified 30 studies (including 39 027 patients or admissions) with low risk of bias. Median prevalence was 17·5% for any coercive measure, 27·7% for any restraint, and 6·0% for seclusion. Younger age, male sex, ethnicity or race other than White, longer stay, and repeated admissions were frequently linked to coercive measure use. 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.

Children and adolescents at risk for seclusion and restraint in inpatient psychiatric treatment: a case control study

To reduce coercion in acute inpatient child and adolescent psychiatric units, a better understanding of individuals at risk for seclusion and/or restraint (S/R) is needed. We report data on the proportion of patients secluded/restrained and factors associated with higher risk of S/R. Identifying preventative mechanisms through risk stratification upon inpatient admission can aid the training of mental health professionals, and support shaping specific workflows for at-risk populations for example by joint crisis plans or post-coercion review sessions.

METHODS

A case-control study included all admissions (n = 782) to a department of child and adolescent psychiatry within 36 months between 2019 and 2022. Data on age, sex, out of home care, primary and comorbid ICD-10 diagnoses, length of stay, prior/multiple admissions were compared between admissions with and without S/R using chi square tests for categorical and t-tests for continuous variables. Uni- and multivariate binary logistic regression models were computed.

RESULTS

The overall proportion of S/R was 12.8% (n = 100). Females (p = 0.001), patients in out of home care (p < 0.001), with prior admission (p < 0.001), Post-traumatic stress disorder (PTSD; p < 0.001) and Borderline personality disorder (BPD; p < 0.001) were at a significantly higher risk of S/R. Length of stay in days (OR 1.01), out of home care (OR 3.85), PTSD (OR 6.20), BPD (OR 15.17), Attention deficit hyperactivity disorder (ADHD)/conduct disorder (OR 4.29), and manic episode/bipolar disorder (OR 36.41) were significantly associated with S/R in multivariate regression.

CONCLUSIONS

Child and adolescent psychiatric staff should consider risk factors when using coercive measures. Patients with PTSD and/or BPD are the most vulnerable subgroups. Training of professionals and clinical practice need to be adapted in order to prevent the use of S/R and its potential hazards.

Prevalence and correlates of restrictive interventions in an Irish child and adolescent psychiatric unit: a 4-year retrospective study

BACKGROUND

There has been a global effort to reduce the use of restrictive interventions (RIs) in healthcare settings. In order to reduce unnecessary RIs, it is essential to understand their use in mental health settings. To date, there have been few studies examining the use of RIs in child and adolescent mental health settings, with no such studies in Ireland.

AIMS

The purpose of this study is to examine the prevalence and frequency of physical restraints and seclusion and to identify any associated demographic and clinical characteristics.

METHODS

This is a 4-year retrospective study of the use of seclusion and physical restraint in an Irish child and adolescent psychiatric inpatient unit from 2018 to 2021. Computer-based data collection sheets and patient records were retrospectively reviewed. Eating disorder and non-eating disorder samples were analysed.

RESULTS

Of 499 hospital admissions from 2018 to 2021, 6% (n = 29) had at least one episode of seclusion and 18% (n = 88) had at least one episode of physical restraint. Age, gender and ethnicity were not significantly associated with rates of RI. Unemployment, prior hospitalization, involuntary legal status and longer length of stay were significantly associated with higher rates of RIs in the non-eating disorder group. Involuntary legal status was associated with higher rates of physical restraint in the eating disorder group. Patients with a diagnosis of eating disorder and psychosis had the highest prevalence of physical restraints and seclusions respectively.

CONCLUSIONS

Identifying youth who are at greater risk of requiring RIs may allow early and targeted intervention and prevention.

A systematic mapping review identifying key features of restraint research in inpatient pediatric psychiatry: A human rights perspective

INTRODUCTION

Restraints, a highly regulated and contentious measure in pediatric psychiatry, have significant negative impacts on children. The application of international human rights standards, such as the Convention of the Rights of the Child (CRC) and the Convention of the Rights of Persons with Disabilities (CRPD), has spurred global efforts to reduce or eliminate the use of restraints. However, a lack of consensus on definitions and terminology, as well as quality indicators in this field, hinders the ability to compare studies and evaluate interventions consistently.

AIM

To systematically map existing literature on restraints imposed upon children in inpatient pediatric psychiatry against a human rights perspective. Specifically, to identify and clarify gaps in literature in terms of publication trends, research approaches, study contexts, study participants, definitions and concepts being used, and legal aspects. These aspects are central to assess whether published research is contributing to achieve the CRPD and the CRC in terms of interpersonal, contextual, operational, and legal requirements of restraints.

METHODS

A systematic mapping review based on PRISMA guidelines was conducted, adopting a descriptive-configurative approach to map the distribution of available research and gaps in the literature about restraints in inpatient pediatric psychiatry. Six databases were searched for literature reviews and empirical studies of all study designs published between each database's inception and March 24, 2021, manually updated on November 25, 2022.

RESULTS

The search yielded 114 English-language publications, with a majority (76%) comprising quantitative studies that relied primarily on institutional records. Contextual information about the research setting was provided in less than half of the studies, and there was an unequal representation of the three main stakeholder groups: patients, family, and professionals. The studies also exhibited inconsistencies in the terms, definitions, and measurements used to examine restraints, with a general lack of attention given to human rights considerations. Additionally, all studies were conducted in high-income countries and mainly focused on intrinsic factors such as age and psychiatric diagnosis of the children, while contextual factors and the impact of restraints were not adequately explored. Legal and ethical aspects were largely absent, with only one study (0.9%) explicitly referencing human rights values.

CONCLUSIONS

Research on restraints of children in psychiatric units is increasing; however, inconsistent reporting practices hinder the understanding of the meaning and frequency of restraints. The exclusion of crucial features, such as the physical and social environment, facility type, and family involvement, indicates inadequate incorporation of the CRPD. Additionally, the lack of references to parents suggests insufficient consideration of the CRC. The shortage of quantitative studies focusing on factors beyond patient-related aspects, and the general absence of qualitative studies exploring the perspectives of children and adolescents regarding restraints, suggest that the social model of disability proposed by the CRPD has not yet fully penetrated the scientific research on this topic.

Algorithmic Prediction of Restraint and Seclusion in an Inpatient Child and Adolescent Psychiatric Population

BACKGROUND

Restraint and seclusion in an inpatient child and adolescent psychiatric population adversely affects the overall value and safety of care. Due to adverse events, negative outcomes, and associated costs, inpatient psychiatric hospitals must strive to reduce and ultimately eliminate restraint and seclusion with innovative, data-driven approaches.

AIM

To identify patterns of client characteristics that are associated with restraint and seclusion in an inpatient child and adolescent psychiatric population.

METHOD

A machine learning application of fast-and-frugal tree modeling was used to analyze the sample.

RESULTS

The need for restraint and seclusion were correctly predicted for 73% of clients at risk (sensitivity), and 76% of clients were correctly predicted as negative or low risk (specificity), for needing restraint and seclusion based on the following characteristics: having a disruptive mood dysregulation disorder and/or attention-deficit hyperactivity disorder diagnosis, being 12 years old or younger, and not having a depressive and/or bipolar disorder diagnosis.

CONCLUSIONS

The client characteristics identified in the predictive algorithm should be reviewed on admission to recognize clients at risk for restraint and seclusion. For those at risk, interventions should be developed into an individualized client treatment plan to facilitate a proactive approach in preventing behavioral emergencies requiring restraint and seclusion.

Adolescent inpatient mental health services in the UK

Inpatient mental health services are an indispensable part of the mental healthcare for adolescents. They provide comprehensive assessment and treatment for young people severely affected by mental health difficulties whose presentation is associated with high level of risk or where diagnostic clarity and effective intervention cannot be achieved with less intensive community input. In the UK, a range of different mental health units have been developed with the aim to meet the needs of young people requiring admission with the appropriate expertise and in the least restrictive way possible. Although an inpatient admission is necessary and helpful for a number of adolescents, it may also be linked to some adverse effects that need to be carefully assessed and managed when such an option is considered or pursued. Collaborative working between inpatient units, community teams and young people and their families is paramount in ensuring that inpatient interventions form part of a wider treatment plan, are as efficient and effective as possible and are used in a way that fosters engagement, independence and optimal outcomes.

Methods and Strategies for Reducing Seclusion and Restraint in Child and Adolescent Psychiatric Inpatient Care

Restraints and seclusions are restrictive interventions used in psychiatric inpatient units when there is an imminent risk of harm to the patient or others. Coercive measures are controversial and can lead to negative consequences, including negative emotions, re-traumatization, injuries, or death. The article summarizes the last 10 years of literature regarding methods and strategies used for reducing seclusions and restraints in child and adolescent psychiatric inpatient units, and reports on their outcomes. The literature was reviewed by searching PubMed and PsycInfo for English-language articles published between May 2010 and May 2020. Eighteen articles were found that described methods or strategies aimed at reducing restraint or seclusion utilization in child and adolescent psychiatric inpatient units. The following interventions were evaluated: Trauma-Informed Care (TIC), Six Core Strategies, Child and Family Centered Care (CFCC), Collaborative & Proactive Solutions (CPS), Strength-Based Care, Modified Positive Behavioral Interventions and Supports (M-PBIS), Behavioral Modification Program (BMP), Autism Spectrum Disorder Care Pathway (ASD-CP), Dialectical Behavior Therapy (DBT), sensory rooms, Mindfulness-Based Stress Reduction Training (MBSR) of staff, and Milieu Nurse-Client Shift Assignments. Most of the interventions reduced the use of seclusions and/or restraints. Two child-centered and trauma-informed initiatives eliminated the use of mechanical restraints. This review shows that the use of coercive measures can be reduced and should be prioritized. Successful implementation requires ongoing commitment on all levels of an organization and a willingness to learn. To facilitate comparisons, future models should evaluate different standardized parameters.

Non-restrictive interventions to reduce self-harm amongst children in mental health inpatient settings: Systematic review and narrative synthesis

Rates of self-harm amongst children appear to be increasing. This presents challenges for practitioners responsible for maintaining the safety of children admitted to mental health inpatient settings. Policy guidelines recommend that practitioners should aim to avoid the use of restrictive practices for children. It is currently unclear, however, what evidence-based alternatives to restrictive practices are available. We aimed to identify what non-restrictive interventions have been proposed to reduce self-harm amongst children in mental health inpatient settings and to evaluate the evidence supporting their use in clinical practice. A systematic search of five databases (CINAHL, Embase, Ovid MEDLINE, APA Psycinfo, and Cochrane) was conducted to identify articles reporting on non-restrictive interventions aimed at reducing self-harm amongst children in mental health inpatient settings. Articles were quality assessed and relevant data were extracted and synthesized using narrative synthesis. Searches identified relatively few relevant articles (n = 7) and these were generally of low methodological quality. The underlying theoretical assumptions and putative mechanisms of change for the interventions described were often unclear. Despite concerns about the rates of self-harm amongst children in mental health inpatient settings, there is a lack of high-quality research to inform clinical practice. There is an urgent need to develop effective non-restrictive interventions aimed at reducing self-harm for children using inpatient mental health services. Intervention development should be theoretically informed and be conducted in collaboration with people who have lived experience of this issue.

Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis

Physical restraint is regularly used in children and adolescent mental health care, often as a reactive behaviour management strategy. Physical restraint has been associated with physical injury, but psychological consequences are poorly understood. The aim of this systematic review was to examine physical restraint of children and adolescents in inpatient mental healthcare services. Healthcare databases were searched to identify English language publications discussing anyone aged ≤18 years who had experienced physical restraint as a mental health inpatient. No date restrictions were applied. Sixteen quantitative studies are included within this review. Most studies are retrospective in nature. Publications were appraised using the Critical Appraisal Skills Programme quality assessment tool. Common characteristics associated with children and adolescents who experience physical restraint include age, gender, diagnosis, and history. Most studies associate physical restraint with the management of aggression. Findings suggest that it may be a combination of patient (intrinsic) and environmental (extrinsic) factors which ultimately lead to children and adolescents experiencing restraint. This review confirms that little is known about children and adolescents' first-hand experiences of physical restraint. Future research should address children and adolescents' perceptions and first-hand experiences of physical restraint.

Debate: Feeling understood in a fake world - the place of inpatient mental health units in the care of children and adolescents

Inpatient units are a significant element of mental healthcare for children and adolescents with the most severe and challenging clinical presentations. Inpatient input has been associated with substantive and sustained health gains across a range of diagnoses and cannot be fully replaced by intensive community treatment options. The potential benefits and risks associated with an admission should be carefully weighed in all referred individuals and may differ depending on several parameters including the type of unit and aims of admission. Although every effort should be made for admissions to be as efficient and short as possible, access to inpatient care and its extent should continue to be determined by clinical need.

Physical restraint during inpatient treatment of adolescent anorexia nervosa: frequency, clinical correlates, and associations with outcome at five-year follow-up

BACKGROUND

Studies of the use and effects of physical restraint in anorexia nervosa (AN) treatment are lacking. The purpose of this study was to describe the frequency of physical restraint in a specialized program for adolescents with AN, and to examine if meal-related physical restraint (forced nasogastric tube-feeding) was related to 5-year outcome.

METHOD

Thirty-eight (66% of 58) patients with AN (mean age 15.9, SD = 1.9) admitted to a regional, specialized adolescent eating disorders (ED) inpatient unit. Patient data, including restraint episodes, were obtained from hospital records, and outcome was assessed at a 5-year follow-up.

RESULTS

A total of 201 restraint episodes occurred over 5513 days of inpatient treatment, including 109 meal-related episodes and 56 episodes to avoid self-harm. Twelve (32%) patients experienced at least one restraint episode during the admission, of which eight (21%) experienced meal-related restraint. Four patients represented 91% of all restraint episodes, experiencing 10 or more episodes during admission. Meal-related restraint was significantly associated with a higher rate of persisting ED diagnosis, but not with weight gain during admission, EDE-Q global score or BMI at follow-up.

CONCLUSIONS

Restraint episodes occurred rather infrequently. A small number of patients (n = 4) accounted for a high proportion of episodes (91%). More knowledge is important to reduce the need for restraint in treatment for AN.

The Impact of Milieu Nurse-Client Shift Assignments on Monthly Restraint Rates on an Inpatient Child/Adolescent Psychiatric Unit

INTRODUCTION: Restraints in the inpatient child/adolescent psychiatric population pose a threat to client safety and quality of care. Nurses are key in reducing restraints through implementation of evidenced-based interventions to improve quality and safety. AIM: To identify the impact of milieu nurse-client shift assignments on monthly restraint rates when compared with individual nurse-client shift assignments on an inpatient child/adolescent psychiatric unit. METHODS: A quantitative, retrospective, comparative project design was used. The sample included all inpatient child/adolescent clients admitted to the child/adolescent psychiatric unit between the months of January-May 2016 and 2017 who were physically or mechanically restrained. Retrospective chart audits were conducted, and information transcribed onto an adapted chart audit tool by Edwards et al. (2006). Monthly restraint rates were compared using the Mann-Whitney U test. A p value of <.05 was used to determine statistical significance. RESULTS: The Mann-Whitney U test revealed statistical significance between the impact that the individual nurse-client shift assignments (Mdn = 61.2, n = 6) and the milieu nurse-client shift assignments (Mdn = 6.8, n = 6) had on monthly restraint rates, U = .000, z = -2.88, p = .004, r = .83. CONCLUSION: Use of milieu nurse-client shift assignments are associated with lower monthly restraint rates when compared to individual nurse-client shift assignments. Milieu nurses provide structure, safety, consistency, and security, leading to early intervention and de-escalation of clients who display aggressive behaviors. Nurse staffing structures also need to be optimized to meet the needs of this population.