A 26-Year Study of Restraint Fatalities Among Children and Adolescents in the United States: A Failure of Organizational Structures and Processes

Abstract

Background Physical and mechanical restraints used in treatment, care, education, and corrections programs for children are high-risk interventions primarily due to their adverse physical, emotional, and fatal consequences. Objective This study explores the conditions and circumstances of restraint-related fatalities in the United States by asking (1) Who are the children that died due to physical restraint? and (2) How did they die? Method The study employs internet search systems to discover and compile information about restraint-related fatalities of children and youth up to 18 years of age from reputable journalism sources, advocacy groups, activists, and governmental and non-governmental agencies. The child cohort from a published study of restraint fatalities in the United States from 1993 to 2003 is combined with restraint fatalities from 2004 to 2018. This study’s scope has expanded to include restraint deaths in community schools, as well as undiscovered restraint deaths from 1993 to 2003 not in the 2006 study. Results Seventy-nine restraint-related fatalities occurred over the 26-year period from across a spectrum of children’s out-of-home child welfare, corrections, mental health and disability services. The research provides a data snapshot and examples of how fatalities unfold and their consequences for staff and agencies. Practice recommendations are offered to increase safety and transparency. Conclusions The study postulates that restraint fatalities result from a confluence of medical, psychological, and organizational causes; such as cultures prioritizing control, ignoring risk, using dangerous techniques, as well as agencies that lack structures, processes, procedures, and resources to promote learning and to ensure physical and psychological safety.

Healthcare staff's experiences of using manual physical restraint: A meta‐synthesis review

“…The need to minimize manual restraint practice has been reflected globally through the introduction of guidelines, policies, and programs advocating for its reduction and, where possible, elimination (e.g., Bowers et al, 2015;Department of Health, 2014;Duxbury, Baker, et al, 2019;Mental Health Commission, 2014;O'Hagan et al, 2008;Royal Australian and New Zealand College of Psychiatrists, 2021). This is not surprising considering that manual restraint has been linked to service user death (Duxbury et al, 2011;Nunno et al, 2022), service user and staff distress (Bigwood & Crowe, 2008;Cusack et al, 2018), staff misuse (Brophy et al, 2016;Lee et al, 2003), and staff and service user injury (Lee et al, 2003;Wilson et al, 2017). The development and implementation of multimodal restraint and restrictive intervention minimization programs such as "Safewards," "No Force First," and "REsTRAIN Yourself" have successfully led to reductions in manual restraint rates ranging from 19% to 26% within inpatient mental health, older adult, and learning disability settings (Bowers et al, 2015;Duxbury, Baker, et al, 2019;Haines-Delmont et al, 2022), highlighting that not all instances of manual restraint are necessary.…”

Mapping review of interventions to reduce the use of restrictive practices in children and young people's institutional settings: The CONTRAST study

“…The use of restrictive practices (RP) with children (i.e. children and young people) is a global concern associated with harm and violating human rights (Nowak, 2019 ; Nunno et al, 2022 ; United Kingdom Parliament, 2020 ). The United Nations (UN) Convention on the Rights of the Child states that depriving a child of liberty is acceptable only as a last resort, for the shortest appropriate time, as appropriate to their well‐being, and proportionate to the circumstances (Nowak, 2019 ).…”

“…This presents challenges, the management of which frequently involves the use of RP. In certain situations, restrictive measures can serve to protect a child from potentially life‐threatening behaviours to themselves or others (Blikshavn et al, 2020 ; Department for Education and Department of Health and Social Care, 2019 ); but there is broad consensus that it could often be less harmful and more appropriate to use non‐physical interventions (Department for Education and Department of Health and Social Care, 2019 ; Equality and Human Rights Commission, 2019 ; Lyons, 2015 ; Miguel, 2016 ; Nunno et al, 2022 ; Prince & Gothberg, 2019 ; van Loan et al, 2015 ; Wisdom et al, 2015 ; World Health Organization, 2019 ).…”

Restraint and Seclusion: A Review of Practices and Policy

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Misusing seclusion and restraint practices led to 79 child deaths between 1993and 2018(Nunno et al, 2022. The Office of Civil Rights (OCR) defines restraint as the "personal restriction that immobilizes or reduces the ability of a student to move his or her torso, arms, legs, or head freely" (U.S. Department of Education, 2012, p. 2), excluding physical escorts, but can include mechanical or medical restraints (U.S. Department of Education, 2012).

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“…nine students died from asphyxia, two from suffocation, and others died as a result of cardiac arrhythmia, cardiac arrest, asphyxiation, dehydration, and aspiration (Nunno et al, 2022). Long-term adverse psychological effects can occur, especially among students with previous trauma inflicted by adults (e.g., depression, posttraumatic stress disorder, anxiety; Freeman et al, 2021;Kern et al, 2022).…”