Physical and Pharmacologic Restraint in Hospitalized Children With Autism Spectrum Disorder



Children with autism spectrum disorder (ASD) often have difficulties with communication, social interaction, and sensory processing. These challenges can make hospitalization a stressful and overwhelming experience for them and their families. As a result, some children with ASD may exhibit violent or self-injurious behaviors that require the use of physical or pharmacologic restraint to prevent harm to themselves or others.


However, restraint use is not only traumatic and dehumanizing for the child, but also ineffective and potentially harmful in the long term. Restraint can worsen the child’s anxiety, distrust, and agitation, and increase the risk of injury, infection, and adverse drug reactions. Moreover, restraint use can reflect the lack of appropriate training, resources, and support for the health care staff who care for these children. Therefore, it is imperative to find ways to reduce or eliminate restraint use in hospitalized children with ASD.


The Study


The researchers conducted a retrospective cohort study using electronic health records of all children aged 5 to 21 years who were admitted to a pediatric medical unit at a large urban hospital between October 2016 and October 2021. They identified children with ASD and other co-occurring mental health, developmental, and behavioral disorders based on their billing diagnoses. They also identified children who experienced physical or pharmacologic restraint because of violent or self-injurious behavior based on their clinical orders.


The researchers used propensity score matching to ensure that the ASD and non-ASD groups were equivalent on demographic factors such as age, sex, race, ethnicity, insurance type, and primary language. They then used logistic regression to determine the odds of restraint use in children with ASD compared to children without ASD, controlling for hospitalization factors such as reason for admission and length of stay, and co-occurring diagnoses.


The Findings


The study included 21\u2009275 hospitalized children, of whom 1187 (5.6%) had ASD and 367 (1.7%) experienced restraint. The researchers found that after adjusting for the covariates, children with ASD were significantly more likely to be restrained than children without ASD (odds ratio 2.3, 95% confidence interval 1.6–3.4; P < .001).


The researchers also found that among the co-occurring diagnoses, having a developmental disorder (other than ASD), a behavior disorder, or a psychiatric disorder increased the odds of restraint use in both ASD and non-ASD groups. However, the effect of these diagnoses was stronger in the ASD group, suggesting that children with ASD and co-occurring conditions are particularly vulnerable to restraint use.


The Implications


The study provides further evidence that hospitalized children with ASD are suffering inequitable rates of physical and pharmacologic restraint, which can have negative consequences for their physical and mental health, as well as their quality of care. The study also highlights the need for more research and interventions to address the underlying causes and modifiable factors of restraint use in this population.


Some possible strategies to reduce restraint use in hospitalized children with ASD include:

  • Modifying the hospital environment to make it more sensory-friendly, predictable, and comfortable for children with ASD and their families.
  • Providing adequate training and support for the health care staff to enhance their knowledge, skills, and confidence in caring for children with ASD and managing their challenging behaviors.
  • Implementing evidence-based behavioral interventions and coping strategies to help children with ASD regulate their emotions, communicate their needs, and cooperate with medical procedures.
  • Involving the family and other caregivers in the care planning and decision-making process, and respecting their preferences and concerns.
  • Developing and evaluating specialized care pathways and units for children with ASD that can provide individualized and comprehensive care.


By adopting these strategies, we can envision a future where restraint use is eliminated or minimized in children’s hospitals, and where children with ASD and their families can have a safe, positive, and respectful hospitalization experience.



What is the definition of restraint in this study?


Restraint is defined as the use of physical or pharmacologic methods to restrict the movement or behavior of a child who is exhibiting violent or self-injurious behavior.


What is the difference between physical and pharmacologic restraint?


Physical restraint involves the use of straps, belts, or other devices to secure the child to a bed or chair. Pharmacologic restraint involves the use of sedatives, antipsychotics, or other medications to calm the child or induce sleep.


What are the ethical and legal issues of restraint use in children?


Restraint use in children raises ethical and legal concerns about the violation of human rights, dignity, and autonomy, as well as the potential for abuse, neglect, and harm. Restraint use is regulated by various laws and policies at the federal, state, and institutional levels, which aim to protect the safety and well-being of children and ensure the use of restraint is justified, monitored, and documented.


What are the alternatives to restraint use in children?


Alternatives to restraint use in children include preventive and de-escalation strategies, such as creating a supportive and therapeutic environment, providing individualized and family-centered care, using positive reinforcement and distraction techniques, teaching coping and communication skills, and involving the child and family in the decision-making process.


How did the researchers measure the outcomes of restraint use in children?


The researchers did not measure the outcomes of restraint use in children, such as the physical and psychological effects, the satisfaction of the child and family, and the quality of care. They only measured the rates and factors of restraint use, which are descriptive and not evaluative.


What are the limitations of the study?


The study has several limitations, such as the use of billing diagnoses, which may not capture the full spectrum of the child’s condition, the reliance on clinical orders, which may not reflect the actual practice of restraint use, the lack of generalizability to other settings and populations, and the inability to establish causal relationships between the variables.


What are the implications for future research?


The study suggests several directions for future research, such as exploring the perspectives and experiences of the children, families, and staff involved in restraint use, developing and testing interventions to prevent and reduce restraint use in children with ASD, and examining the long-term outcomes and costs of restraint use in children with ASD.


What are the implications for practice and policy of the study?


The study suggests that restraint use in children with ASD is a prevalent and complex problem that requires multidisciplinary and multi-level interventions. The study calls for the development and implementation of evidence-based guidelines and protocols for the prevention and reduction of restraint use in children with ASD, as well as the provision of adequate training and support for the health care staff who care for these children. The study also advocates for the involvement and empowerment of the children and their families in the care process, and the respect for their rights and dignity.


How does the study compare to previous research on restraint use in children with ASD?


The study is one of the few that specifically focused on restraint use in children with ASD in a pediatric medical setting. Previous research on this topic was mostly conducted in psychiatric or educational settings, or included children with various developmental disorders. The study also used a large and diverse sample of hospitalized children, and applied rigorous statistical methods to control for confounding factors.



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