A systematic mapping review identifying key features of restraint research in inpatient pediatric psychiatry: A human rights perspective

Introduction: Restraints, a highly regulated and contentious measure in pediatric psychiatry, have significant negative impacts on children. The application of international human rights standards, such as the Convention of the Rights of the Child (CRC) and the Convention of the Rights of Persons with Disabilities (CRPD), has spurred global efforts to reduce or eliminate the use of restraints. However, a lack of consensus on definitions and terminology, as well as quality indicators in this field, hinders the ability to compare studies and evaluate interventions consistently.

Aim: To systematically map existing literature on restraints imposed upon children in inpatient pediatric psychiatry against a human rights perspective. Specifically, to identify and clarify gaps in literature in terms of publication trends, research approaches, study contexts, study participants, definitions and concepts being used, and legal aspects. These aspects are central to assess whether published research is contributing to achieve the CRPD and the CRC in terms of interpersonal, contextual, operational, and legal requirements of restraints.

Methods: A systematic mapping review based on PRISMA guidelines was conducted, adopting a descriptive-configurative approach to map the distribution of available research and gaps in the literature about restraints in inpatient pediatric psychiatry. Six databases were searched for literature reviews and empirical studies of all study designs published between each database's inception and March 24, 2021, manually updated on November 25, 2022.

Results: The search yielded 114 English-language publications, with a majority (76%) comprising quantitative studies that relied primarily on institutional records. Contextual information about the research setting was provided in less than half of the studies, and there was an unequal representation of the three main stakeholder groups: patients, family, and professionals. The studies also exhibited inconsistencies in the terms, definitions, and measurements used to examine restraints, with a general lack of attention given to human rights considerations. Additionally, all studies were conducted in high-income countries and mainly focused on intrinsic factors such as age and psychiatric diagnosis of the children, while contextual factors and the impact of restraints were not adequately explored. Legal and ethical aspects were largely absent, with only one study (0.9%) explicitly referencing human rights values.

Conclusions: Research on restraints of children in psychiatric units is increasing; however, inconsistent reporting practices hinder the understanding of the meaning and frequency of restraints. The exclusion of crucial features, such as the physical and social environment, facility type, and family involvement, indicates inadequate incorporation of the CRPD. Additionally, the lack of references to parents suggests insufficient consideration of the CRC. The shortage of quantitative studies focusing on factors beyond patient-related aspects, and the general absence of qualitative studies exploring the perspectives of children and adolescents regarding restraints, suggest that the social model of disability proposed by the CRPD has not yet fully penetrated the scientific research on this topic.