It was a typical day on the pediatric hospital medicine floor. Until my pager's shrill cry pierced the stillness of the physician workroom. 

"Need a doctor at bedside for restraint orders."

What began as a digital command to go to a patient’s bedside soon materialized into a harrowing reality before my eyes: A 16-year-old Black teenage boy, newly admitted for worsening mental health issues at home, was being held down by four security guards. A guard was stationed at each limb to keep him still. Was this our attempt as a medical team to de-escalate and calm him down?

"Please order soft cuffs."

"No, we need leather cuffs."

"We need medication immediately."

The hallway suddenly filled with nurses and other staff members, all issuing their commands.

His cries for help pierced the air; my fingers typed an order for haloperidol. 

And leather cuffs. 

The glimmer of innocence that so often characterizes pediatric care seemed to vanish as the restraints tightened around his ankles, and then his wrists. The stark contrast between his ebony skin and the whiteness of the hands that physically restrained him and his predominately white care team, lay plainly before me. In that moment, a sense of helplessness tightened its grip on my chest. The behavioral response team had not been called. Instead, the request for restraints had been shouted. Orders were entered, restraints tightened, and agitation medications administered; his humanity crushed under the weight of security guards, leather, and a health care system that so often mishandles pediatric mental health emergencies. 

As a pediatrician, I couldn't shake the troubling question: Was I complicit in a system where restraints would cause lasting physical, psychological, and emotional implications for this teen? Was I contributing to a system that would likely erode his sense of security, safety, trust, and willingness to engage with the health care system and its staff in the future?

Yes.

That answer left me disheartened. I couldn't help but see reflections of myself — my skin, my lived experiences as a person of color within and outside of the hospital — in this teenager. 

As a Black woman pediatrician, I keenly feel the weight of such moments. The American Academy of Pediatrics declared pediatric mental health a national emergency in 2021, and pediatricians are witnessing an increase in the number of children and adolescents requiring mental health care. However, among heightened mental health needs across all groups, disparities persist. Racial inequities in pediatric restraint use have been extensively documented. Studies indicate that Black children are disproportionately subjected to restraints in hospital settings — a disparity rooted in implicit bias, systemic inequity, and various individual, community, and society-level factors that ultimately impact the well-being of marginalized groups. 

The question arises: Who do we deem "dangerous" or "aggressive" and therefore requiring restraints, as opposed to someone who could benefit from dialogue and understanding and behavioral de-escalation strategies? Implicit biases can often cloud judgment in these situations. In a space intended for healing and resilience, the use of restraints in health care settings stands in stark contrast. It underscores the delicate balance between ensuring patient and staff safety, while also recognizing the humanity of all individuals involved.

What healing can there be in coercion?

Restraints should be the last resort, especially for children dealing with mental health conditions. It is time for clinicians and health care institutions to confront the very real disparities in pediatric restraint use. First, we must prioritize the recruitment of underrepresented populations into health care professions, with particular attention to mental health care. By diversifying our workforce, we can better address the unique needs of marginalized communities and bridge the gap in access to culturally competent care.

Furthermore, fostering spaces that are conducive to de-escalation and safety can minimize the need for coercive measures such as restraints. Collaboration is essential. By bringing together interdisciplinary teams like behavioral health specialists and child life professionals, we can ensure proactive steps are taken to de-escalate challenging situations. 

Next, education serves as a powerful tool in combating implicit biases that may influence patient care. By providing ongoing training and programming on crisis intervention and cultural sensitivity, we can navigate challenging patient encounters with grace, empathy, and understanding. Lastly, systematic data collection and analysis are essential in identifying and addressing racial disparities in restraint use. By implementing targeted interventions and monitoring progress, we can work toward achieving equity in pediatric care.

The journey from that initial pager alert to the sobering realization of my own complicity in a flawed system has left a mark on me. I am reminded of the profound impact of representation. I am reminded of the need to amplify the voices of underrepresented communities, to ensure that all children see themselves reflected in the fabric of health care. For in diversity lies our strength; and in unity, our path toward healing. There is no restraint that can hold down the power of our collective advocacy.

What experiences have you had with patient restraints? Share your observations below.

Dr. Tasia Isbell is a pediatrician at Boston Children's Hospital and Boston Medical Center. She enjoys cycling, traveling, and exploring the world through cuisine. She tweets at @DrTasiaIsbell. Dr. Isbell is a 2023–2024 Doximity Op-Med Fellow.

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