When Angelica, an Afro-Latina teenager, tried to leave the hospital, two white guards grabbed her and pulled her back to her room, kicking and screaming the whole way. She was ultimately put into physical restraints and injected with an antipsychotic to “calm her down.”

Angelica’s history was marked by sexual abuse and for using self harm as a coping mechanism. She also had waited weeks in the emergency room to receive care and was still awaiting transfer to a psychiatric facility. 

The incident, recounted in a 2022 essay in Pediatrics by Jeffery Edwards, caused the author, a Black physician, to burst into tears because he felt the use of restraints on Angelica represented a failure of the system. Use of restraints appears to be growing, with restraints used more often on people of color. Meanwhile, more children and adolescents with psychological challenges are showing up at the hospital, due to the surging mental health crisis among youth since the start of the pandemic. 

Those factors led LDI Fellows Polina Krass, Chris Feudtner, Judy A. Shea, Stephanie K. Doupnik, and former LDI Fellow Evan Dalton to study how clinicians and others use restraints on hospitalized children in severe mental distress. 

Their study, published recently in the Journal of Hospital Medicine, identifies factors that influence agitation, de-escalation, and the use of physical restraints—as well as chemical restraints, in the form of sedatives—at a children’s hospital. 

To learn more, we spoke with Doupnik, an Assistant Professor of Pediatrics at the Perelman School of Medicine, and Dalton, now an Assistant Professor at Baylor College of Medicine.

What is the landscape of mental health care for children? Is there enough access and care? 

Stephanie Doupnik: In an ideal world, children would have easy access to care in their communities while maintaining their school and family routines. However, there is an extreme shortage of mental health professionals across the country, which makes accessing timely appointments difficult in some places and nearly impossible in under-resourced places such as rural areas. There is also a shortage of beds for children requiring inpatient psychiatric treatment, and therefore, a delay in treatment, especially those with complex needs. Often, children have to wait in the medical hospital until a space becomes available at an inpatient psychiatric facility. 

Prevention is a key piece of the puzzle, and schools and early childhood education centers also need more resources to identify young people with mental health concerns and support them to establish healthy habits and thrive.

More children are coming to hospitals with mental health conditions. Can you explain the use of physical restraints in these cases and discuss national trends in their use?

Evan Dalton: In our study, we use the term “physical restraint” to refer to restraints that are used when behaviors jeopardize the immediate physical safety of the patient, staff, or others. These restraints—often called “violent restraints” or “behavioral restraints”—are mechanical devices made of rubber-like neoprene, leather, nylon, or vinyl, attaching to patients’ ankles and wrists and manually fixing their extremities to their bed frame. Children are typically placed in restraints for periods that may last minutes or hours and often receive medications while in them.

We do not have robust national data on trends in physical restraint use. There is variability in physical restraint reporting and coding practices between hospitals nationally. Physical restraints are not tracked in national utilization databases like the Public Health Information System database since they are not considered a billed transaction or procedure. Also physical restraints are a relatively new topic of research in children’s hospitals, since most children in mental health crises were previously cared for at psychiatric hospitals. Destiny Tolliver and Katie Nash showed racial and ethnic disparities in physical restraint use exist among pediatric emergency departments in New England as Black children were more likely to be physically restrained than white children. We also know that chemical restraint use, which is a restraint using medications, is increasing (nearly 370% over the past decade per ER doctor Ashley Foster) nationally, and patterns in the use of chemical restraints exhibit similar disparities to physical restraints, again per Ashley Foster.

What has prior research shown on the effects and effectiveness of restraints on patients and providers?

Dalton: Studies in adult patients can give us insight into children’s experiences. Ambrose Wong studied the psychological harm of restraint use by interviewing adult patients about their experience being restrained in an ED. Patients described a loss of freedom and personal dignity, akin to being in prison. They felt dehumanized and mistreated, expressing emotions such as confusion, frustration, and worry, and experienced lasting negative consequences relating to distrust and avoidance of the health care system.

From a physical injury standpoint, studies from children’s out-of-home care settings have shown physical restraints’ can result in serious physical injury or even death, with 79 restraint-related fatalities reported between 1993 and 2018.

There also are undoubtedly psychological effects of restraint use on providers. The essay in Pediatrics by Jeffery Edwards, describes the psychological weight of watching the restraint of a Black child. Research by Maria Brenner describes physical restraint as extraordinarily stressful for nurses.

Why are restraints sometimes necessary? What is the risk of not restraining agitated children?

Dalton: Using physical restraints, especially in pediatrics, is a complex ethical and moral dilemma. Despite their negative physical and psychological effects, clinicians may feel that they have no other option to protect themselves and the agitated patient. The most significant risk of not restraining would be serious physical harm to the child, staff, or property. However, as detailed earlier, use of physical restraints risks similar physical consequences.

Clinicians interviewed in our study described their personal beliefs, which ranged from “unacceptable” to “often necessary for safety.” Clinicians felt that they must weigh their perception of the patient’s safety with their own security.

What are some top de-escalation tools and how practical are they for clinicians to use? What could make them effective?

Doupnik: When we, as clinicians, can process our own emotions in response to patient situations, we are better positioned to respond calmly in the early stages of agitation and avoid unsafe situations. Clinicians have shared with me a wide range of supports they rely on to help process these patient situations outside of work—from spending time with friends and family to exercise to spending time with animals. Other supports our clinical teams use include debriefings after agitation events or other difficult situations, regular team meetings about long-term and challenging patient cases, and group social activities to help us unwind at work like a team celebration.

What recommendations do you have for policymakers, what guidance for clinicians? 

Dalton: Disparities in funding and reimbursement are at the root of many limitations clinicians face when treating children with mental illness in hospitals. Stephanie and I collaborated on a study led by Alison Herndon that found financial margins for children’s hospitals were over four times higher on average for medical hospitalizations compared to mental health hospitalizations. Without adequate funding, hospitals may be unable to afford the interventions we recommend.

This disparity occurs because acute care units at medical hospitals that care for children with mental health conditions often are not licensed for psychiatric treatment. A national study of pediatric mental health boarding by JoAnna Leyenaar showed only 36% of surveyed hospitals had licensed pediatric psychiatric beds.

In addition, mental health is a “carve-out benefit” for Pennsylvania Medicaid, making pediatric mental health care funding available at the county level through separate managed care organizations. This serves as an additional barrier to reimbursement for children with mental illness who are hospitalized at children’s hospitals due to a lack of psychiatric resources in the community. Policymakers should advocate for bills like Senate Bill 119 that support the integration of physical and mental health services.

Finally, at the clinician level, there is a significant opportunity to understand best practices in de-escalation training better. As we discussed in our study, it is a ripe area for research and should be a future priority in this space.

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The study, “Factors Influencing Agitation, De-escalation, and Physical Restraint at a Children’s Hospital,” was published July 3, 2023, in the Journal of Hospital Medicine. Authors are Evan M. Dalton, Diana Worsley, Polina Krass, Brian Kovacs, Kathleen Raymond, Chris Feudtner, Judy A. Shea, and Stephanie K. Doupnik.

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