Interrupting Cascades of Physical Restraint as a Path to Health Equity for Hospitalized Children

The decision to physically restrain a child is at least in part a clinician’s response to a child’s behavior and developmental expectations, which are in turn, informed by demographic factors like race and sex, clinician factors, such as interpersonal implicit or explicit racism, and hospital factors like patient volume and institutional racism. The loss of control and autonomy during physical restraint can be physically and emotionally traumatic and can mirror other episodes of restraint that are more likely to be experienced by Black children and children with mental health disorders, such as arrest and incarceration.⁸  With extensive research revealing the negative impact of trauma and loss of autonomy (eg, via arrest) on later mental and physical health, the short-term action of physical restraint may have negative long-term implications for mental and physical health recovery and equity. However, the converse is worth reflecting on as well; reducing physical restraint may have reverberating positive effects on child mental health beyond the hospital walls.

Reducing physical restraint disparities for hospitalized children mandates addressing multiple complex factors in child mental health that begin in the community before manifesting in the hospital.⁹  In this study, Black children had 1.9 times higher odds of restraint compared with White children.⁴  Black children have higher rates of mental health disorders, a racial disparity that is driven by multiple layers of racism, including structural racism, that leads to disproportionate experiences of neighborhood disinvestment, environmental and interpersonal trauma, and lower access to basic material needs.^10,11  Addressing disparate experiences of trauma and neighborhood disinvestment are necessary upstream steps in reducing physical restraint use among Black children. In addition to a disproportionate prevalence of mental health disorders, Black children also have lower access to mental health care.¹²  Limited access to mental health care in the outpatient setting makes it more likely that children will present to the hospital setting later in the course of illness, including in crisis, making it more likely that they will require higher levels of psychiatric care. With relative declines in inpatient psychiatric bed availability, this means many high-acuity children are admitted to inpatient general pediatric units, contributing to physical restraint disparities.

Interpersonal racism also contributes to physical restraint inequities. The decision to restrain a child is based on multiple factors, including perceived danger to the child or others. Because perceptions of danger are subjective, they are especially vulnerable to bias and racism. Specifically, adultification bias, in which Black children are seen as older, less innocent, and less deserving of comfort than White children, and anger bias, the perception of anger when it is not present, may contribute to higher perceptions of threat and higher rates of physical restraint use.^13–15  Adultification bias and anger bias may impact clinicians’ perceptions of a child’s behavior (eg, age-appropriate, dysregulated, or violent) leading to the observed racial disparities. Additionally, studies have revealed higher implicit bias scores at times of higher clinical strain.¹⁶  With higher rates of mental health boarding on general pediatric units, there is an important interplay between institutional and interpersonal factors that impact physical restraint disparities.

Clinicians and hospital systems must reduce physical restraint using multilayered interventions designed with equity and long-term wellbeing in mind.

Because the most significant predictor of future restraint is previous restraint, reducing restraint episodes at the individual level interrupts the cascade of restraint and its long-term effects. Staff training using tools like simulation can help staff recognize the impact of race on perceptions of pediatric patients, develop skills in behavioral de-escalation, and collaborate with behavioral response teams to reduce physical restraint disparities. Additionally, creating more trauma-informed and developmentally appropriate spaces for children that provide sensory and environmental modifications can reduce behavioral crises, and therefore, reduce physical restraint use.^4,17,18  Finally, other institutions have worked to develop behavioral plans in collaboration with patients, family members, nursing, child life specialists, developmental-behavioral pediatricians, and child and adolescent psychiatrists.¹⁷  Given the powerful cascade of physical restraint, such interventions, if implemented in conjunction with one another, could reduce physical restraint use and serve as a force multiplier to empower patients, families, and clinical teams to address behaviors in personalized and patient-centered ways.

Hospital-level interventions have the potential to reduce cascades of physical restraint by utilizing institutional interventions to intervene in and prevent restraint use. Episodes of physical restraint should be regularly reviewed by using quality improvement techniques, such as root cause analysis, to guide interventions and allocate investments in clinical teams (including behavioral response teams, child and adolescent psychiatry, and other behavioral health clinicians in both inpatient and outpatient settings) to improve health equity and reduce health care costs.⁴  Health technology can be a tool for reducing physical restraint by removing electronic medical record flags for children who have previously been restrained to reduce anchoring bias and stigma. Additionally, because physical restraint is a relatively rare, but severe, event, individual hospital systems may not have enough data to highlight all of the nuances and contextual factors that lead to physical restraint, or the interventions being used to reduce physical restraint use. Hospital systems should facilitate multisite collaborations to share data and interventions as a means of improving outcomes across multiple settings. In particular, institutions should engage in community-based participatory research to ensure that the perspectives of community members are central to the design and implementation of any research projects taking place in their communities.

Ultimately, the processes leading to disparities in physical restraint start long before hospitalization occurs, and therefore, solutions must address root causes in the community. Addressing root causes can take the form of advocacy for access to community- and school-based behavioral health services, which may reduce acute behavioral crises, lower the acuity of youth who require inpatient care, and subsequently reduce restraint use overall.^12,19,20  Additionally, nonprofit hospitals (which have a legal obligation to provide community benefits in return for their tax-exempt status) have the opportunity to address root causes by providing financial and operational support for affordable housing, mental and behavioral health resources, neighborhood reinvestment, and other community-level interventions to reduce physical restraint for those disproportionately impacted.

The evidence revealing disparities in restraint use in children is unequivocal and now extends from the emergency department to inpatient settings across geography and hospital types; now is the time to address and rapidly rectify these gaps. Most importantly, considering the cascade of restraint that children may enter, today’s solutions are essential to improving the broader health of children, particularly Black children, into the future. To eliminate these disparities, researchers, clinicians, and hospital leaders will have to work with community members and multidisciplinary teams, in and outside of the hospital setting, to ensure that children and families are receiving unbiased, patient-centered care that disrupts cascades of physical restraint before they start.