Disparities in involuntary psychiatric hospitalizations among racial and ethnic minorities and individuals with psychiatric diagnoses like psychosis are well documented in adults. However, there is a lack of research investigating inequalities in involuntary hospitalizations in children and adolescents.
A new review, published in Lancet Child Adolescent Health, is the first to explore current international research of the clinical and social factors influencing involuntary hospitalizations in children and adolescents. The authors also offer suggestions about further avenues for future research.
The authors, led by Dr. Susan Walker of University College London, write:
“. . . understanding more about the clinical and sociodemographic factors that are associated with legally defined involuntary and voluntary admissions of young people is important in order to design early interventions to reduce coercion; to ensure equity of care; and to potentially prevent negative service trajectories being established.”
Although there are legal criteria that designate when involuntary hospitalization is warranted, research evidence indicates that systemic biases play a role in who is involuntarily hospitalized versus who is not. For example, Black and ethnic minority adults are more likely to be involuntarily hospitalized than White adults.
Other groups that tend to be hospitalized against their will more often than others include men, unemployed individuals, individuals receiving welfare benefits, those diagnosed with psychosis, persons with legal involvement, and individuals who have been previously involuntarily hospitalized.
Yet, the existing literature targets adults, raising questions about whether the same disparities in treatment are experienced in children and adolescents. Exploration into the inequalities present in the involuntary hospitalization of children and adolescents is crucial, considering that previously being hospitalized against one’s will places an individual at risk for future involuntary hospitalization.
Therefore, children and adolescents who are coerced into treatment are likely at risk for future forced treatment. Also, unsurprisingly, the effects of being hospitalized against one’s will have been shown to deter youth from seeking mental health treatment.
Investigating involuntary psychiatric hospitalizations in children and adolescents is challenging due to legalities surrounding how children and adolescents are forcefully hospitalized. In the United Kingdom, children 15 years old and younger who are hospitalized under their parents’ consent are considered to be voluntarily hospitalized, even if the youth themselves did not want to be hospitalized.
Children who do not receive parental consent to be hospitalized can still be involuntarily hospitalized under the Mental Health Act. Although the blurred legal distinctions between voluntary and involuntary commitment can make distinguishing between the two difficult, examining what factors might lead to unfair treatment is critical to ensure more equitable mental health care to children and adolescents of all backgrounds.
In the current review, Walker and her colleagues examined 23 studies from 17 high-income countries, including European countries, the United States, Canada, and Israel. Overall, 41,271 children and adolescents were represented in this study, with 9,753 or 23.6% of those children being hospitalized against their will.
In their exploration of clinical factors that contributed to involuntary hospitalization, the researchers found that substance misuse, perceived risk of harm to self or others, and a diagnosis of an intellectual disability and/or psychosis all led to an increased risk of forced hospitalization. Additionally, psychiatric symptoms that were perceived as more severe and poorer levels of overall functioning also appeared to contribute to involuntary hospitalization.
Looking at sociodemographic factors, the researchers found that older adolescents and Black as opposed to White ethnic groups were more likely to be involuntarily hospitalized, which is consistent with research in adult populations that highlights structural racism in the mental health industry and racial disparities in coerced treatment.
Research has consistently found that individuals from ethnic minority groups are more likely than White persons to be diagnosed with severe mental health disorders. For example, psychosis, which was identified as a contributing factor to involuntary hospitalization in children, tends to be overdiagnosed in Black persons compared to other racial groups.
Additionally, young Black and ethnic minority persons tend to receive more mental health referrals from the criminal justice system or social services when compared to young white people, who are more likely to be referred in less coercive ways, such as through a family doctor. Further, racism and discrimination have been shown to contribute to poor health outcomes.
Given the significant impact of systemic racism, discrimination, and racial bias in the mental health system, further investigation must be conducted into how race factors into the forced hospitalization of children and adolescents so that steps can be taken to begin to address racial and ethnic disparities in the treatment of youth.
Based on the findings, the researchers make other recommendations for future research, such as learning more about the impact of involuntary commitment for youth substance misuse and working towards improving community interventions, which are more effective than coercive treatment.
Moreover, as a perceived risk to self and others was identified as a contributing factor to forced hospitalization, further research regarding exactly how risk is assessed and how this influences admission is key. Along similar lines, looking into the role of family functioning and parental ability and capacity to support young persons is important, particularly when considering how these factors might impact hospitalization.
Other potential areas for future exploration include how gender and socioeconomic status might influence involuntary psychiatric hospitalization, how mental health legislation for forced hospitalization varies internationally for children and adolescents, how youth under the care of social services are at higher risk for mental health issues and poorer outcomes, and the influence of different paths to involuntary hospitalization, like police involvement or previous coerced treatment.
Limitations of the review include the small number of studies examined, the variation in mental health systems and laws across the countries included, and the inclusion of only high-income countries.
The authors conclude:
“We hope that a greater understanding of the factors associated with involuntary psychiatric hospitalization of children and adolescents will contribute to the creation of more equitable pathways to psychiatric treatment for patients of all ages and, ultimately, a reduction in long-standing health-care inequalities.”
Walker, S., Barnett, P., Srinivasan, R., Abrol, E., Johnson, S. (2021). Clinical and social factors associated with involuntary psychiatric hospitalization in children and adolescents: a systematic review, meta-analysis, and narrative synthesis. Lancet Child Adolescent Health. (Link)