Interventions to prevent and reduce coercive measures in psychiatric care and residential care for children and young people

A systematic review including ethical aspects

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SBU Assessment

Presents a comprehensive, systematic assessment of available scientific evidence for effects on health, social welfare or disability. Full assessments include economic, social and ethical impact analyses. Assessment teams include professional practitioners and academics. Before publication the report is reviewed by external experts, and scientific conclusions approved by the SBU Board of Directors.

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Published: Report no: 400 Registration no: SBU 2023/1016 ISBN: 978-91-989734-8-8 https://www.sbu.se/400e

Main message

Interventions targeting organisational culture and staff practice may reduce coercive measures (restraint and seclusion) in child and adolescent psychiatric care as well as in residential care.

Conclusions

  • Interventions focusing on organisational culture and staff practice may have an effect on moderate to large reductions in coercive measures, whereas child-focused behavioural interventions appear to have more limited or uncertain effects.
  • Reports from children (including adolescents) and staff highlight the importance of relational care, collaboration, staff reflexivity, and organisational support, in prevention of coercive measures.

Aim

The main purpose of this systematic review was to (1) evaluate the scientific evidence regarding effective interventions aiming to reduce the use of coercive measures in child and adolescent psychiatric care and residential care and (2) investigate experiences of such interventions among children/adolescents and staff. The systematic review includes an ethical discussion.

Background

The use of coercive measures is particularly complex in relation to children and young people, whose emotional, mental, and intellectual immaturity increases their vulnerability and limits their ability to assert autonomy.

Coercive measures continue to be widely used in youth services, despite efforts to reduce their use. Such services include residential and juvenile justice settings, as well as child and adolescent psychiatric care.

Across youth psychiatric inpatient and residential settings, previous reviews report that multi-component or trauma-informed programmes often coincide with reductions in restraint/seclusion, but the evidence base is small, heterogeneous, and subject to risk of bias.

Method

We conducted a systematic review and reported it in accordance with the PRISMA statement. The protocol is registered in Prospero (CRD42024537890). Quantitative findings were synthesized using Synthesis Without Meta-analysis (SWiM), while qualitative findings were thematically synthesized into analytical themes. The certainty of evidence was assessed with GRADE and Grade CERQual.

Inclusion criteria

PICOs:

Population: Children and young people (aged <25 years)
Intervention: Interventions to reduce the use of coercive measures
Control: Treatment as usual or other intervention
Outcome: Restraint, seclusion, forced medication
Study design: Controlled studies, with or without randomization

Language: English, Swedish, Norwegian, Danish

Databases searched: Academic Search Premier (EBSCO), Campbell Library, Cochrane Library, Criminal Justice Abstracts (EBSCO), Embase (Elsevier), ERIC (EBSCO), Medline (Ovid), PsycInfo (EBSCO), Scopus (Elsevier), SocIndex (EBSCO)

Patient involvement: Yes

SPICE:
Setting: Child and adolescent psychiatric care and residential care
Perspective: Children and young people (aged <25 years) and staff
Intervention: Interventions to reduce the use of coercive measures
Comparison: None
Evaluation: Children and young people’s experiences and staff attitudes and experiences regarding the implementation of preventive interventions

Result

We included 26 studies concerning intervention effects and reported experiences (Flow chart).

Quantitative findings showed that interventions targeting organisational culture and staff practice were associated with moderate to large reductions in coercive measures, whereas child-focused behavioural interventions showed more limited or uncertain effects (Table 1 and 2).

Qualitative synthesis highlighted the importance of relational care, collaboration, staff reflexivity, and organisational support. Integration through joint display indicated that organisational and staff-focused interventions were most closely aligned with the qualitative themes.

Table 1 Summary of findings (main results) for the effect of interventions organisational culture and staff practice on coercive measures (seclusion or restraint).
Abbreviations: CPS = Collaborative Problem Solving, TI-PRT = Trauma-Informed Psychiatric Residential Treatment, TARGET, Sanctuary model, DtG = ’Do-the-Good, Neurosequential Model of Therapeutics
Outcome
(Interventions. Type of institution)		 Number of participants
(Number of studies, Study design)		 Effect
(95% KI)
(Synthesis without meta-analysis)		 Grade Interpretation
Seclusion
(CPS, TI-PRT, TARGET, Sanctuary model, DtG. Psychiatric and residential care)		 1 777
(7, NRSI)		 Cohen’s d: md (IQR) = −0,55 (−0,96 to −0,51) ⊕⊕◯◯ Seclusion decreased
Restraint
(CPS, NMT, TI-PRT, TARGET, Sanctuary model, DtG. Psychiatric and residential care)		 1 463
(7, NRSI)		 Cohen’s d: md (IQR) = −1,07 (−2,01 to −0,26) ⊕⊕◯◯ Restraint decreased

 

Table 2 Summary of findings (main results) for the effect of interventions primarily aimed at youth behavior on coercive measures (seclusion or restraint).
Abbreviations: DBT = Dialectical behavior therapy, BMP= Behavior Modification Program, M-PBIS = Modified Positive Behavioral Interventions and Supports, ASD-CP = Autism Spectrum Disorder Care Pathway
Outcome
(Interventions. Type of institution)		 Number of participants
(Number of studies, Study design)		 Effect
(95% KI)
Synthesis without meta-analysis)		 Grade Interpretation
Seclusion

(DBT, Sensory room. Psychiatric care)		 881
(2, NRSI)		 Cohen’s d: md (IQR) = −0,23 (−0,42 to 0,04) ⊕⊕◯◯ Seclusion decreased 
Restraint or seclusion

(BMP, M-PBIS. Psychiatric care)		 1 995
(2, NRSI)		 Cohen’s d: md (IQR) = −0,60
(−0,93 to −0,27)		 ⊕⊕◯◯ Restraint or seclusion decreased 
Restraint

(DBT, ASD-CP. Psychiatric care)		 891
(2, NRSI)		 Cohen’s d: md (IQR) = −0,57
(−0,65 to −0,48)		 ⊕⊕◯◯ Restraint decreased 

Ethics

The use of coercive measures in psychiatric and institutional care involves a conflict between, on one hand, the individual's right to privacy and autonomy, and on the other hand, society's responsibility to protect and care for those deemed unable to take care of themselves. Reduced use of coercive measures does not automatically mean better care. Instead it depends on the overall quality of care and on children having equal access to effective and non-coercive interventions.

Discussion

The interventions that are most successful in reducing the use of coercive measures (those focusing on organisational culture and staff practice) are also those that to a greater extent meet the expressed needs of children, young people, and staff. The working methods are based on a set of values that acknowledge the participation of children and young people, promote supportive relationships and a safe care environment, while also providing staff with tools and support to act consciously and preventively.

The content of the interventions can be described at both the individual level (treatment components, such as training the child to manage difficult emotions) and the structural level (organisational components, such as management support for change initiatives, including the reduced use of coercive measures).

Conflict of Interest

In accordance with SBU’s requirements, the experts and scientific reviewers participating in this project have submitted statements about conflicts of interest. These documents are available at SBU’s secretariat. SBU has determined that the conditions described in the submissions are compatible with SBU’s requirements for objectivity and impartiality.

The full report in Swedish

Interventioner för att förebygga och minska tvångsåtgärder inom psykiatrisk vård och institutionsvård av barn och unga

Project group

Experts

  • Astrid Moell, MD, Department of Clinical Neuroscience, Karolinska Institute, Stockholm
  • Sofia Enell PhD, Department of Social Work, Linnaeus University, Växjö
  • Maria A. Vogel, PhD, Department of Criminology, Stockholm University
  • Sebastian Gabrielsson, PhD, Department of Health, Education and Technology, Luleå University of Technology
  • Antoinette Lundahl, MD, PhD, Department of Learning, Informatics, Management and Ethics, Karolinska institute

SBU

  • Uliana Hellberg, Project manager
  • Elizabeth Åhsberg, Assistant project manager
  • Elin Malmer, Project administrator
  • Maria Hoppe, Project administrator
  • Hanna Olofsson, Information specialist
  • Johanna Wiss, Health economist
  • Jonas Bergström, Head of department
  • Johan Wallin, Analyst
  • Maral Jolstedt, Analyst

 

Flow chart

.41 eligible full-text articles. 0 quantitative and 3 qualitative had low risk, 13 quantitative and 10 qualitativ had moderate, and 7 quantative and 8 qualitative had hig risk of bias.

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