In child and adolescent psychiatric units, mechanical coercive measures such as seclusions and/or restraints (S/R) are used as a last resort to prevent patients from harming themselves or others. Since the use of S/R is potentially harmful to both patients and staff, the overarching goal is to reduce them to a minimum. Risks to patients include injury [1, 2], re-experiencing from past traumatic events [3], and the risk of developing symptoms of post-traumatic stress disorder (PTSD) [2]. Chieze et al. (2019) found rates of PTSD after S/R ranging from 25 to 47% in adult populations [2]. The incidence of violence is a result of the complex interactions between patients and staff and is influenced by the culture of the unit [4]. Consequently, the use of S/R is expected to be closely related to this interplay. The use of S/R poses ethical and legal challenges for professionals, especially in the field of care for minors.
Studies report varying and sometimes high prevalence rates of coercive measure use in psychiatric facilities for children and adolescents [5, 6]. A review published in 2022 reported that the prevalence of S/R among inpatients in child and adolescent psychiatric units ranged from 6.5 to 29% [7].
Attempts to effectively reduce the use of S/R focus on structural levels, i.e., mental health service planning and evaluation [8], as well as on institutional levels with treatment concepts and staff training [9, 10]. A better understanding of affected underage patients is needed in order to minimize coercion on the patient level. Previous studies found a skewed distribution, with a small proportion of adolescents subjected to coercive measures repeatedly, while another proportion was affected only once or twice [11]. Data identifying clinical and sociodemographic risk factors for coercion are particularly relevant because they point to potential targets for prevention. Previous studies, including the development of machine-learning based algorithms [12], have yielded heterogeneous results, applied a wide range of methods and named a wide spectrum of risk factors [6, 11, 13–25].
Identifying as female has been associated with a higher risk of S/R in Finnish nationwide studies [6, 11]. This is further supported by a systematic review of European studies describing female adolescents as vulnerable [18]. Non-European studies tend to report younger age [16, 19, 20] and male gender as risk factors [18, 25]. A single study described an increase of risk with age in boys [21].
Several studies point to social perspective, with poorer family functioning associated with S/R [20], with foster care [14] and out of home placement [22] as further risk factors consolidating the link. Belonging to a minority group in predominantly White communities increased risk for S/R in some US studies [19, 21, 23, 25]. However, in sight of the sparsity of evidence, the complex interaction of children and adolescents at risk for S/R with their surroundings is least understood in social domains.
In contrast, more studies have focused on mental health characteristics of youth affected by S/R. Poorer psychosocial functioning associated with a mental disorder poses a risk for repeated S/R [11], and displaying more severe psychopathology is a risk factor for experiencing coercion [20]. Attention deficit hyperactivity disorder (ADHD) and conduct disorders (ICD-10 ‘F9’ category) [18], schizophrenia and mood disorders [6], and PTSD [17] are diagnostic categories linked to an increased risk of S/R. In respect of potentially traumatizing effects of S/R [2], it is further remarkable that children’s history of physical abuse is associated with the rate of S/R [17], and many adult psychiatric inpatients affected by coercive measures retrospectively report being abused in their childhood [26].
Lastly, aggression and/or violent behavior on the patient’s side are reported as important factors leading up to the use of S/R [20–22, 24], while higher counts of prior admissions and longer durations of admissions render the individual more prone to being affected by coercive measures [11, 13–16, 22, 25].
This paper presents data on the use of S/R in an acute psychiatric facility for children and adolescents in the city of Vienna, a metropolitan region in Austria.
The purpose of this study was to examine which of the adolescents’ sociodemographic or clinical characteristics influence the risk of S/R. In sight of heterogeneous previous research and conflicting arguments especially on the role of gender and age, this manuscript seeks to clarify and to confirm. A further aim was to identify individuals at risk, in order to shape necessary interventions and adapt clinical practice accordingly.