Crocker et al. (2010) identify how an increase in a child`s or teen`s risky behaviour (presentations related to aggression and disruptive behaviour disorder) is related to their increased physical control. Delaney and Fogg (2005) report the most common risky behaviours such as agitation, threats, and employee-directed attacks (most of which were extremely violent). Aggressive actions by a child or youth (defined as harmful behaviour, which may include intentional intent to hurt or harm another person (Bandura, 1973, as cited in Suris et al., (2004)) most often trigger the use of physical restraint (Crocker et al., 2010; Delaney and Fogg, 2005; dosReis et al., 2010; Duke et al., 2014; Furre et al., 2016; Muire-Cochrane et al., 2014; Pogge et al., 2013; Sourander et al., 2002; Stewart et al., 2010, 2013; Tompsett et al., 2011), where abuse between children and staff was identified as a common precursor (Sourander et al., 2002; Tompsett et al., 2011). Studies have also linked the use of physical restraint to «lower-level» behaviours (opposition, disinhibition, and flight) (Duke et al., 2014; Furre et al., 2016; Muir-Cochrane et al., 2014) and destruction of property (Furre et al., 2016; Muir-Cochrane et al., 2014). Self-injurious behaviour significantly increases the likelihood that a child or youth will be physically restrained (Furre et al., 2016; Muir-Cochrane et al., 2014; Stewart et al., 2010), while suicidal acts reduce this likelihood in favour of other management approaches (Sourander et al., 2002). There is a need to study children`s and youth`s perceptions of physical restraint and the effects of the frequency of physical restraint on health outcomes. Future research should continue to investigate the use of physical restraint in children and adolescents. Studies should focus specifically on understanding the effects of physical restraint on children and adolescents receiving mental health care.

Studies should also focus on determining the most appropriate use of physical restraint through collaboration with children, including the most appropriate approaches for the application of the intervention, where other strategies may be more beneficial to the well-being of children, adolescents and staff. dosReis et al. (2010) draw attention to the risk that children and youth may be exposed to physical (and psychological) harm due to an increased incidence of restraint. Two studies discuss a link between prolonged duration of physical restraint and increased risk of physical harm (Duke et al., 2014; Furre et al., 2016), Furre et al. (2016) stressing that the duration of the holdback should be as short as possible to reduce potentially harmful effects. Donovan et al. (2003) noted a reduction in the frequency and duration of physical restraint (by 26%) and duration (by 38%) over the two-year period of their retrospective naturalistic study. However, there has been a proportional increase in the number of physical injuries among children and youth (from 4% to 8%) over the same period, suggesting that a reduced risk of physical injury may not be directly proportional to the frequency or reduced duration of physical restraint. It is difficult to interpret the results further because physical limitations <15 min were excluded from the study. This review is subject to limitations in the available evidence base.

Services are representative of clinical and inpatient environments. While the context and culture of service delivery was examined, this was not reported consistently or effectively. However, among the articles (n = 11) that reported context, it was clear that some determinations were delivered more intensively (dosReis et al., 2003; Leidy et al., 2006; Stewart et al., 2010, 2013) than others (Crocker et al., 2010; Donovan et al., 2003; Furre et al., 2014, 2016, 2017; Sourander et al., 2002; Tompsett et al., 2011). Where resources were available, housing providers appeared to be able to provide more individualized and intensive treatment (Stewart et al., 2010). Some data from clinical providers were reported to be more nationally representative (Furre et al., 2017; Sourander et al., 2002), although it is recognized that there is room for improvement in the collection of clinical information in both settings (Furre et al., 2014, 2016, 2017; Leidy et al., 2006), which may influence the results of the review. In addition, there is still a need for indirect reporting on the outcomes of physical restraint of children and youth admitted to mental health services. The results of this review are based on a small number of empirical studies, most of which were based on retrospective data that may be missing or unreported. The study populations differed in terms of age, hiring characteristics, and length of landing periods, making some comparisons difficult. Restrictive interventions, which include restraint, have a long history in mental health services. Physical restraint in psychiatric care means «. the use of physical contact to prevent, restrict or suppress the natural movement of any part of the patient`s body» (Mental Health Units (Use of Force Act, 2018)).

Despite the potential risk of physical injury from physical restraint (Ministry of Health, 2014), its implementation in psychiatric practice is sometimes considered necessary to ensure safety (Wilson et al., 2015) and to protect children and youth and/or those around them from harm (National Institute for Health and Care Excellence, 2017). However, its implementation in all areas of health care involves ethical, moral and legal considerations (Hollins, 2017), including disproportionate use (Georgieva et al., 2012), unnecessary exposure to injury (Hollins & Stubbs, 2011), and death (Barnett et al., 2012; Scheuermann et al., 2016; United Nations Convention on the Rights of the Child, 1989). A focus on physical risks can lead to neglect of psychological harm (Bray et al., 2014; Ridley and Leitch, 2019). Leidy et al. (2006) found that children and adolescents who were required were twice as likely to experience multiple physical limitations. However, this is contradicted by three studies that indicate that forcibly admitted children and adolescents experience fewer physical limitations than their voluntarily admitted peers (Azeem et al., 2011; Donovan et al., 2003; Furre et al., 2016). Donovan et al. (2003) report that children and youth admitted to the emergency department (52%; n = 111) are 4.6 times more likely to experience physical limitations than their colleagues admitted to the emergency department. Similarly, Crocker et al. (2010) report that 82% of children and youth (n = 9) admitted to emergency situations experienced physical constraints. There was no section dealing with the status of the emergency room with a clear definition of what an emergency is. Although the Ministry of Health (2013) defines emergency departments as those that are unpredictable and unplanned, it is not possible to determine whether this definition is consistent with the terminology used in the individual studies in this review.

The incidence of restraint is positively associated with developmental disorders in children and adolescents (Azeem et al., 2011; Duke et al., 2014; Sourander et al., 2002), psychotic disorder (Delaney & Fogg, 2005; Furre et al., 2014; Sourander et al., 2002), externalization disorders (behavioural/opposition/disruptive disorders) (Azeem et al., 2011; Crocker et al., 2010; Furre et al., 2014; Leidy et al., 2006; Sourander et al., 2002) and internalizing disorders (mood, depression and anxiety) (Azeem et al., 2011; Delaney and Fogg, 2005; dosReis et al., 2010; Leidy et al., 2006). Crocker et al. (2010), Delaney and Fogg (2005) and Duke et al. (2014) report that multiple diagnoses (comorbidities) further increase the likelihood of using physical restraint (comorbidity, indicating conditions that co-exist in the context of the baseline condition (Yancik et al., 2007)). Three studies present results suggesting that psychosocial function rather than diagnostic status reliably predicts physical restraint experiences (Furre et al., 2014, 2016; Stewart et al., 2013). A younger age (<13 years) is associated with an increased likelihood of physical restraint in 10 studies (Azeem et al., 2011; dosReis et al., 2010; Duke et al., 2014; Furre et al., 2014; Leidy et al., 2006; Muir-Cochrane et al., 2014; Pogge et al., 2013; Sourander et al., 2002; Stewart et al., 2010, 2013). Young children are reported to be clearly more aggressive (Duke et al., 2014; Pogge et al., 2013; Sourander et al., 2002), where aggression is strongly associated with physical restraint. Four studies do not report an association between age and physical restraint (Crocker et al., 2010; Delaney and Fogg, 2005; Donovan et al., 2003; Tompsett et al., 2010), although methodological weaknesses were noted in each study (see Table 1). The first study (Donovan et al., 2003) excluded interventions of less than 15 minutes in duration, a period later identified as the most common for physical restraint of young children in this setting (Pogge et al., 2013). Eligibility criteria included empirical studies, availability in English, and reports on physical restraint among children and youth admitted to mental health services.