Rise in use of restraint in child psychiatric units

The commission said it had an oversight role to ensure that 'restrictive practices' are 'only used in rare and exceptional cases as an emergency measure'.

Use of physical restraint in the country’s adult inpatient psychiatric units has fallen, but cases have risen in facilities for children, according to the Mental Health Commission (MHC).

While the total number of restraint cases fell by 15% in 2022, they rose by almost 50% in Child and Adolescent Mental Health Service (Camhs) units.

In a new report, the State’s regulatory body said that the highest number of instances of physical restraint in 2022 was in Linn Dara Camhs unit, in west Dublin.

The MHC said use of restrictive practices can be “skewed” by frequent use in relation to a small number of residents arising from their clinical needs and the risk posed to themselves and others.

It said any comparisons between units — which can vary in their service and size — should be qualified and “undertaken cautiously”.

The commission said it had an oversight role to ensure that “restrictive practices”— including physical restraint and seclusion — are “only used in rare and exceptional cases as an emergency measure”.

It said recent research has shown that these practices “increase the risk of trauma and may trigger symptoms of previous experiences of trauma” and, of themselves, can and do “lead to physical and/or psychological harm”.

Following public consultation — including with those who have experienced restrictive practices and staff — the MHC introduced revised rules and a code of practice, which were brought into effect at the start of 2023.

The MHC said it “strongly advocates” for the use of de-escalation and behavioural supports over physical restraints, but that for this to happen it was “essential” that approved centres were appropriately resourced and that staff were appropriately trained in de-escalation and clinical risk management.

Following public consultation — including with those who have experienced restrictive practices and staff — the MHC introduced revised rules and a code of practice, which were brought into effect at the start of 2023.

Under the new measures staff who may be involved in restraint or seclusion have to undertake training on a range of areas, including trauma and human rights.

The inpatient units, known as approved centres, must from January 1 inform the MHC within three days all cases of restrictive practices. 

This now has to be done in electronic format and not manually.

In its code of practice, the MHC defines physical restraint as “the use of physical force (by one or more persons) for the purpose of preventing the free movement of a resident’s body when he or she poses an immediate threat of serious harm to self or others”.

The MHC report, Use of Restrictive Practices in Approved Centres, shows:

• There were 2,945 episodes of physical restraint across all 67 approved centres in 2022, compared to 3,460 in 2021 (down 15%);
• This includes an increase in physical restraint cases in three CAMHs units, from 248 in 2021 to 365 in 2022 (up 47%);
• In Camhs units, cases in Linn Dara increased from 190 to 247 (+30%), doubled, from 52 to 104, in the Adolescent inpatient unit in St Vincent’s Hospital, south Dublin, and also doubled, from seven to 14, in Eist Linn Child and Adolescent Inpatient Unit in Cork;
• The fourth and final CAMHS inpatient unit, in Merlin Park Hospital, Galway, had no cases in 2022, down from 12 in 2021.

The report shows that the 247 cases in Linn Dara in 2022 related to 21 children and the 190 cases in 2021 related to 25 children — meaning the rate of use in those years was 11.8% and 7.6% respectively.

In St Vincent’s Adolescent Unit, the 104 cases in 2022 related to just five children (rate of 20.8%), while the 52 cases the previous year related to 20 children (rate of 2.6%).

The report said both the number of episodes and the rate of them can vary both within units over successive years and between other units.

“Large numerical differences may be due to a small number of residents requiring a high level of care and attention in a particular year,” it said.

It said that international evidence suggested variations can be due to a range of factors, including:

• Differing practices and cultures in the centres;
• De-escalation techniques used in the centres;
• Variations in the prevalence and severity of mental illness, including the number of emergency and involuntary admissions;
• Staff numbers (including lower nurse-patient ratios), skills, experience and training.

The report said that use of physical restraint increased year on year between 2008 and 2018, from 2,123 to 5,665, but have been falling since then, which it said was “a positive trend”.

In Camhs  units, usage has also dropped, most noticeably in Linn Dara, which had 1,054 episodes of restraint in 2019 and 601 in 2020.

Separately, the report said mechanical restraints — such as soft cuffs — were only used in two centres in 2022 — the Central Mental Hospital and one, unnamed, Camhs unit.

These restraints are legally allowed for “immediate threat of serious harm to self or others”, the report said.

It was used less than five times in the Camhs unit in 2022, was not used in 2021, but was used 150 times in 2020.