Prevalence and correlates of seclusion and restraint use in children and adolescents: a systematic review

Abstract

Seclusion and restraint are frequent procedures to intervene in aggressive and potentially dangerous patients in psychiatric settings. However, little is known about their utilization and effectiveness in pediatric populations. We aimed to examine the prevalence and determinants of seclusion and restraint utilization in children and adolescents in psychiatric settings. Using PubMed, PsychInfo and Cinahl, we performed a systematic literature review of studies published in the last 10 years reporting on the prevalence of seclusion and restraint use in psychiatrically ill youth (<21 years old) treated in psychiatric settings. Only seven publications addressed the topic. Primary outcomes were prevalence rates, reported either as the proportion of patients restrained/secluded or as the number of restraints/seclusions per number of patient days. All studies found relatively high baseline rates of seclusion (26% of patients; 67/1,000 patient days), and restraints (29% of patients; 42.7/1,000 patient days). In four studies, an intervention, implemented to reduce seclusion and restraints, resulted in a dramatic weighted mean reduction in the more restrictive use of restraints by 93.2%, with a 54.2% shorter duration. There was a small, weighted mean reduction in the use of less restrictive seclusions (-0.6%), but results were heterogeneous (-97.2 to +71.0%), with the only increase in seclusions being reported in one study in which the intervention-based padded seclusion room was utilized more frequently instead of more restrictive measures. Otherwise, seclusion episodes reduced by 74.7%, including a 32.4% shorter duration. Few studies reported on risk-factors and predictors, consisting of past or current aggression and/or violence, suicidal behavior, more severe psychopathology, non-White ethnicity, emergency admissions, out-of-home placement, and poorer family functioning, while findings regarding age were inconsistent Except for duration, data about the effectiveness of seclusion and restraints were missing, although there is some indication that seclusion and restraints can lead to severe psychological and physical consequences. Future research should focus on indications, predictors, preventive and alternative strategies, as well as on clinical outcomes of seclusion and restraints in psychiatrically ill youth. In addition, there is a clear need for transparent policies and guidelines.