Today our review (#BCTContrast) of interventions to reduce restrictive practices in children’s institutions has been published in the National Institute for Health and Social Care Health and Social Care Delivery Research library.
Our group looked for interventions that help children’s institutions to cut back their use of practices known as ‘restrictive’. Restrictive practices include restraining children, seclusion, injecting sedating drugs and constant observation and are legally sanctioned in many contexts in the UK and beyond. We already know that they carry a significant risk of physical and psychological harm, not only to children but also to staff; yet incidents involving distress, aggression and violence are a frequent occurrence in children and young people’s institutional settings and restrictive practices are often used to manage them across health, social care, education and criminal justice. These children are already vulnerable because of previous experiences, and preventing further trauma is crucial.
This is a recognised problem and so there are numerous interventions to cut down the use of restrictive practices, but we do not know which are the most effective, or why. We used Susan Michie and colleagues’ taxonomy (list) of techniques for changing behaviour to define and categorise the techniques that are used within the interventions. We wanted to work out exactly which techniques make a difference- and how convincing the evidence was.
Across health, social care, education and criminal justice settings we found 82 different interventions, mostly from mental health care. Many were complicated and involved several techniques which were difficult to look at separately. The evidence seemed to support four key techniques: teaching new skills to staff, improving the social atmosphere or physical environment, talking with children about their behaviour, and structured problem solving with children. However, the results should be viewed with caution as although many of the reports about interventions tended to imply that they are effective, we noticed that in many cases, the evidence did not support the implications. Often, we could not tell from the records whether an intervention had been rigorously tested, or whether it had been carried out correctly in day to day practice. Of note, young people with lived experience had been involved in developing only six of the interventions, and costs were reported in only twelve interventions.
It seems that institutions are routinely using interventions without knowing whether they help reduce restrictive practices, or what it is about them that makes things better (or worse) for the children and young people who are on the receiving end. We believe that children, young people and staff deserve better and we call for simpler interventions and better reporting of evaluations, rather than continuing with unproven assumptions about how best to reduce restrictive practices in children and young people’s institutional settings.
Children and young people who are spending time in institutions urgently need protection from further harm, but at present it seems that organisations are using interventions to reduce restrictive practices, without knowing for sure whether they work or not. By describing these interventions in a standard way, this project helps researchers, policy makers and clinicians describe and understand interventions so that they can make better choices in the future.
The full report can be found here:
Mental Health Research in Leeds 