First Do No Harm: Racial Disproportionality of Restraint Use in Pediatric Hospital Settings

Introduction: Physical and chemical restraints are widely used interventions in response to behavioral dysregulation in pediatric emergency departments and inpatient settings. This case 1) discusses use of restraints for behavioral dysregulation, 2) demonstrates how hospital environments contribute to behavioral dysregulation, and 3) introduces the concept of racial disproportionality in restraint use.

Case Description: A Black adolescent with ADHD and newly diagnosed type 2 diabetes was admitted to the hospital for insulin initiation. He had no history of psychiatric hospitalizations. Insulin titration was prolonged due to difficulty achieving glycemic control and due to challenges with family diabetes education secondary to language and health literacy barriers as well as parental availability. After six days, he began pushing behavioral boundaries, leaving his hospital room, walking down the hallway, and repeatedly asking for his father to complete diabetes teaching so that he could be discharged. In response, hospital security was called multiple times. These episodes progressed to include yelling and attempting to hit staff, resulting in use of both chemical and physical restraints. The inpatient team’s difficulty managing his behavioral dysregulation presented challenges in establishing a safe discharge plan.

Discussion: This case exemplifies several issues with current healthcare responses to behavioral dysregulation. First, stressors of hospitalization can trigger behavioral dysregulation. Lengthy stays, restrictive activities, unreasonable expectations, and other factors contribute to this. Second, hospitals may be unprepared to respond to behavioral dysregulation. Staff are often not trained in behavioral de-escalation which may lead to overuse of physical and chemical restraints. While there is a paucity of data in pediatrics, studies in adults indicate that restraints are applied disproportionately to Black patients. Examining the history of American psychiatry through an equity lens demonstrates that the use of chemical and physical restraints has been racialized, often utilized to control behavior that was deemed socially unacceptable, disproportionately ascribed to people of color. This is likely to also be the case in pediatrics, particularly due to “adultification bias,” a form of racial prejudice where children of color are assumed to be less innocent and more deserving of punishment compared to their white counterparts. The patient described in this case was likely subjected to this bias. His behaviors were not seen as testing boundaries or as expected in the setting of ADHD. Instead, he was considered aggressive, leading to restraint use and exacerbating barriers to appropriate medical care.

Conclusion: Pediatricians must recognize how the stressors of hospitalization may impact children’s behavior and understand that use of chemical and physical restraints for behavioral dysregulation may be ineffective, dangerous, and inequitably implemented. As pediatricians committed to anti-racist practice, we should examine our responses to behavioral dysregulation for racial disproportionality and implement non-restraint-based, developmentally appropriate interventions for behavioral dysregulation in hospital settings.