For the first time, researchers have systematically analysed social and clinical factors associated with psychiatric hospital admission of children and adolescents, finding nearly one-quarter (23.6%) were admitted involuntarily. The study was published in The Lancet Child & Adolescent Health journal.
Researchers also found that children and adolescents who were involuntarily hospitalised were nearly three times more likely to belong to a Black rather than a white ethnic group than those hospitalised voluntarily and more likely to have a diagnosis of psychosis, substance misuse, or intellectual disability.
Involuntary hospitalisation is a legal procedure used to compel an individual to receive inpatient treatment for a mental health disorder against his or her will. Mental health legislation varies nationally and regionally, with different legal criteria for involuntary hospitalisation. There is growing evidence from research into adult psychiatric hospitalisations that factors outside of those described in mental health legislation, including race and ethnicity, can influence whether someone is admitted voluntarily or not. Until now, little research has investigated social and clinical factors that may affect whether children and adolescents are admitted involuntarily to psychiatric hospitals.
Lead author, Dr Susan Walker from UCL, UK said: "This is the first research to systematically examine involuntary admission to psychiatric hospitals for children and adolescents and our results clearly warrant further discussion and analysis to understand what is behind the discrepancies in the use of involuntary over voluntary hospitalisation among different groups. Although involuntary hospitalisation is designed to offer protection to those who are temporarily unable to look after and make decisions for themselves due to the presence of a mental disorder, being admitted against one's will can be a traumatic experience at any age. The number of children and adolescents being admitted to hospital involuntarily is growing in some countries, including the UK, but research into the factors associated with involuntary hospitalisation among young people is surprisingly limited. Understanding why some people may be more likely to be admitted without their consent is key to understanding how we can reduce the numbers of involuntary admissions." 
The review identified 23 studies that included information on whether children and adolescents were admitted to hospital voluntarily or involuntarily. The studies were from 11 high-income countries , representing 41,271 young inpatients in total. Researchers amalgamated and analysed data from 19 studies (31,212 participants) to assess the association with 10 clinical and social factors .
For young people with psychosis, the odds of an involuntary rather than voluntary hospitalisation were more than three times higher than for those without psychosis. However, a diagnosis of anxiety was associated with voluntary rather than involuntary hospitalisation, as was a diagnosis of behavioural problems such as ADHD and conduct disorder. For young people with a primary diagnosis of substance misuse the odds of an involuntarily rather than voluntary hospitalisation were nearly twice as high.
For children and young people, the distinction between voluntary and involuntary hospitalisation is not always clear. For example, children and adolescents can be admitted to hospital under parental consent, and, even if the young person does not agree, this admission would legally be considered voluntary.
The analysis found that a diagnosis of intellectual disability increased the odds of an involuntary rather than voluntary admission by more than three times (233%). Intellectual disability was included in the analysis whether it was a comorbid or primary diagnosis . Psychiatric hospitalisation, whether involuntary or voluntary is rarely appropriate for young people with intellectual disability and this study highlights the need for further investigation into whether this group have been provided with appropriate and timely care in the community.
Young people perceived to be at risk to themselves or others were twice as likely to be involuntarily than voluntarily admitted. No association was found between gender and involuntary hospitalisation in children and adolescents. Older adolescents (16-17 years) were more likely to have been subject to involuntary hospitalisation than younger adolescents (aged 12-15), according to the study.
Three of the studies included ethnicity in their analysis . Analysis of these studies found that the odds of involuntary rather than voluntary hospitalisation among children and young people from Black ethnic groups were nearly twice as high (172%) than for those from white ethnic groups. No difference was found between young people from Asian and other groups compared to young people from white groups.
Dr Walker said, "By providing insight into the factors associated with involuntary hospitalisation our study represents an important step in reducing coercive psychiatric admissions and ensuring equity of care." 
She added: "Among adults, there are consistent findings that people from minority ethnic groups are more likely to be diagnosed with severe mental illness than people from white groups. However, recent research in England has shown that children and adolescents from Black and minority ethnic backgrounds are less likely than those from white ethnic backgrounds to have any mental disorder . It is essential that we understand more about the reasons behind the diagnostic discrepancies between different ethnicity and age groups, and how they relate to psychiatric hospitalisation. An assessment of the role of race in involuntary hospitalisation of young people should be a focus of urgent further investigation." 
The researchers acknowledge that limited research in this area is one of the main shortcomings of the study. The researchers also highlight that the review includes studies from different countries with different legal criteria for involuntary hospitalisation, alongside different mental health systems and processes. Another limitation is that the studies are all from high-income countries, highlighting the lack of data from low- and middle-income countries. In addition, the studies included in the analysis had little information on children under the care of social services, socio-economic status, and how patients came to be hospitalised (for example, if police were involved), which meant that these factors could not be investigated. The researchers suggest that it would be helpful to investigate the differences between subtypes of voluntary and involuntary admission i.e whether consent is from parents/caregivers or from the patients and how this affects experiences of care and mental health outcomes.
Writing in a linked Comment, Dr Schuyler W Henderson from Bellevue Hospital, USA, who was not involved in the study, said, "This study, in tandem with other studies identified by Walker and colleagues, shows evidence of a systematic bias against Black populations, honing in on a pervasive limitation to our practice. Antiracism initiatives and anti-racist education are required to address one kind of systematic bias that Walker and colleagues expose and discuss."
He added, "What we are seeing in this study is a vision of children and adolescents through the prism of adult systems and adult paradigms. Although clinicians will certainly want to dig into these findings to make sense of them, and Walker and colleagues provide interesting but cautious interpretations of their findings around diagnosis, age, risk of harm to self or others, and so forth, there is a real risk to this speculation, especially when it comes to adults thinking about children. We are too comfortable assuming we know the answers."
NOTES TO EDITORS
Peer-reviewed/ Systematic Review/ People
This research was funded by the National Institute of Health Research (NIHR) and the Wellcome Trust. It was conducted by researchers from UCL, UK.
 Quote direct from author and cannot be found in the text of the Article.
 The 11 countries were Finland, Germany, UK, Netherlands, Switzerland, Belgium, Sweden, USA, Canada, New Zealand and Israel.
 The ten factors were gender, primary diagnosis, intellectual disability, ethnicity, living arrangements, risk to self, risk to others, previous abuse, previous psychiatric hospitalisation and age.
 Intellectual disability was only clearly defined in one study as IQ<80. In UK mental health law intellectual disability is not classified as a mental disorder so someone cannot be admitted to hospital involuntarily with a diagnosis of intellectual disability alone.
 Ethnicity was generally defined in the studies non-specifically using aggregated ethnic groupings and it was unclear whether ethnicity had been self-reported.
 NHS Digital. Mental Health of Children and Young People in England 2017 https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017
The labels have been added to this press release as part of a project run by the Academy of Medical Sciences seeking to improve the communication of evidence. For more information, please see: http://www.sciencemediacentre.org/wp-content/uploads/2018/01/AMS-press-release-labelling-system-GUIDANCE.pdf if you have any questions or feedback, please contact The Lancet press office firstname.lastname@example.org
IF YOU WISH TO PROVIDE A LINK FOR YOUR READERS, PLEASE USE THE FOLLOWING, WHICH WILL GO LIVE AT THE TIME THE EMBARGO LIFTS: http://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(21)00089-4/fulltext
The Lancet Child & Adolescent Health