Coercive measures are used recurrently in inpatient child and adolescent psychiatric care but vary greatly between services and countries, according to a new doctoral thesis from Karolinska Institutet. The results also suggest that coercion has not decreased after Sweden introduced more restrictive legislation.
The use of coercion is influenced not only by laws and patients' needs, but also by the care environment and time constraints."
Astrid Moell, PhD student at the Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and senior consultant at Region Stockholm's inpatient child and adolescent psychiatric care
In psychiatric inpatient care, it may sometimes be necessary to provide care against a person's will under the Compulsory Psychiatric Care Act. This may involve specific formal coercive measures, such as mechanical restraint or involuntary medication. In addition, informal coercion, which is not regulated by law and includes persuasion or pressure to encourage patient cooperation, may also occur.
A recurring feature of care
In her thesis, Astrid Moell has investigated how coercion is used in child and adolescent psychiatric inpatient care, how common it is, and what influences its use. The studies include interviews and register data from Swedish child and adolescent psychiatry, as well as a review of international research and comparisons with care in Finland.
"Coercion is often presented as a last resort, but our results suggest that it is a recurring feature of care, even though levels vary greatly between different settings and countries," she says.
Stricter legislation had no effect
Two studies in the thesis analysed a Swedish legislative change from 2020, which aimed to strengthen children's rights and reduce coercion. However, analyses of register data found no clear reduction in coercive measures following the reform. Instead, involuntary medication increased immediately after the legislative change, while other measures remained unchanged.
"This suggests that stricter legislation in itself does not necessarily lead to less coercion," says Astrid Moell. "My hope is that the thesis's findings will contribute to care that is characterised to a greater extent by safety and participation, and where coercion is used as little as possible."
Informal coercion is common
Interviews with healthcare staff revealed that factors such as ward culture, staffing levels, time constraints and previous experiences influence the use of coercion in practice. Informal coercion appeared to be quite common in day-to-day work.
"Unlike formal coercive measures, informal coercion is often less visible and can be difficult to identify, both for staff and for patients," says Astrid Moell. "At the same time, it can be very tangible for those subjected to it, particularly children and young people who depend extensively on adults."
The thesis also shows that younger age, male gender, longer periods of care and repeated admissions are more frequently associated with the use of coercive measures. Some studies also identified differences between ethnic groups, with children and youth from minority groups being subjected to coercion more often. However, the results were not consistent enough to identify clear risk profiles.
The thesis work was supervised by Niklas Långström, adjunct professor at the same department at Karolinska Institutet, among others. The public defence, which can also be viewed online, will take place on 5 June 2026.
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