Psychiatry · Medical Literature
[Review] Interventions to prevent and reduce coercive measures in psychiatric and residential care for youth: a mixed-methods systematic review
Abstract
Coercive measures (eg, restraint and seclusion) remain common in child and adolescent psychiatric and residential care despite efforts to reduce their use. We conducted a mixed-methods systematic review of interventions to reduce coercive measure use. Eligible studies were published between Jan 1, 2005, and Feb 19, 2025; examined interventions in psychiatric, residential, or juvenile justice settings for people younger than 25 years; and reported quantitative outcomes, qualitative experiences, or both.
Clinical relevance
What interventions are effective in preventing or reducing coercive measures (such as restraint and seclusion) in psychiatric, residential, and juvenile justice settings for children and young people under the age of 25? __SNAPSHOT__ {"studyDesign":"Mixed-methods systematic review (quantitative synthesis and qualitative thematic synthesis with integrated convergent design)","setting":"International; psychiatric inpatient, residential care, and juvenile justice settings for youth; specific countries not reported in abstract","sampleSize":"26 studies included (13 quantitative, 13 qualitative); total participant counts across studies not reported in abstract","population":"Children and young people younger than 25 years receiving care in psychiatric, residential, or juvenile justice settings where coercive measures (restraint, seclusion) were documented","intervention":"Any structured intervention aimed at reducing or preventing coercive measures, including organisational culture change programs, staff practice interventions, and child-focused behavioural interventions","comparator":"Pre-intervention baseline periods or comparator conditions as reported within individual included studies; design varied across studies","primaryOutcome":"Frequency or rate of coercive measure use (restraint and/or seclusion) as reported quantitatively; qualitative experiences of patients, staff, and organisations regarding coercive practices","followUp":"Not reported (varied across included studies)","fundingSource":"Not reported in abstract; review conducted with involvement of Karolinska Institutet, the Swedish Agency for Health Technology Assessment (SBU), and affiliated Swedish academic institutions"}
Key findings
26 studies rated as having low-to-moderate risk of bias were included, comprising 13 quantitative and 13 qualitative studies. Quantitative synthesis associated interventions targeting organisational culture and staff practice with moderate-to-large reductions in coercive measures, whereas child-focused behavioural interventions showed smaller or more uncertain effects. Specific pooled effect sizes, confidence intervals, and p-values were not reported in the abstract; formal meta-analysis was not conducted due to heterogeneity across interventions, settings, and outcome measures (not reported). Qualitative thematic synthesis generated four analytical themes emphasising relational care, collaboration, staff reflexivity, and organisational support. Integration of quantitative and qualitative streams indicated that organisational and staff-focused interventions aligned most closely with qualitative themes and were associated with the largest effect sizes. No adverse events or harms data were reported in the abstract.
Practice implications
This mixed-methods systematic review establishes that interventions oriented toward transforming organisational culture and staff practice are more strongly associated with reductions in coercive measures in youth care settings than approaches targeting only individual child behaviour. The qualitative findings add explanatory depth: reductions in coercive practices appear contingent on sustaining relational care, enabling staff reflexivity, fostering collaboration, and securing organisational support. The review did not establish causality, and the inability to conduct formal meta-analysis due to heterogeneity in interventions, settings, and outcome measures limits precision of effect estimates. The findings apply most directly to psychiatric and residential care settings for those under 25; juvenile justice settings were included but may be underrepresented. Populations with specific diagnostic profiles (e.g., eating disorders, intellectual disability, autism spectrum disorder) and from non-Western healthcare systems may not be adequately represented. Evidence supports a systems-level change agenda rather than individual patient management changes, and aligns with children's rights frameworks. Practice change toward prioritising organisational and staff-focused interventions is supported, but the absence of randomised controlled trial evidence means confirmation through higher-quality study designs remains necessary. NOTE: This summary is based on the published abstract only; the full paper may contain additional data, effect sizes, and subgroup analyses not available here. __LIMITATIONS__ Formal meta-analysis was precluded by heterogeneity in interventions, settings, and outcome measures across included studies. All 26 included studies were observational, quasi-experimental, or qualitative in design — no randomised controlled trials are referenced in the abstract, limiting causal inference. Risk of bias was rated as low-to-moderate (not low across all studies), introducing potential for confounding and selection effects. The literature search window (January 2005 to February 2025) may not capture earlier foundational programmes. Inclusion of juvenile justice alongside psychiatric and residential settings increases scope but also increases heterogeneity. Effect sizes for quantitative studies are described categorically (moderate-to-large vs. smaller/uncertain) without pooled numerical estimates, reducing clinical precision. Youth-reported outcomes and long-term sustainability of reductions in coercive measures are not addressed in the abstract. Generalisability beyond the settings and countries represented in included studies is uncertain. Funding source and potential conflicts of interest are not disclosed in the abstract. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ Interventions targeting organisational culture and staff practice — rather than child-focused behavioural programmes alone — are most consistently associated with moderate-to-large reductions in restraint and seclusion in youth psychiatric and residential settings. Qualitative evidence reinforces that sustained reductions depend on relational care, staff reflexivity, collaboration, and institutional commitment. While the evidence base lacks randomised controlled trials and formal meta-analysis, the convergence of quantitative and qualitative findings supports prioritising systemic, staff- and organisation-level change strategies in settings caring for children and young people under 25.