“Chemical Restraint” for Children and Adolescents in Victoria

Children and adolescents with neurodevelopmental disorders such as autism spectrum disorder and intellectual disability commonly exhibit challenging behaviours, including agitation, irritability, aggression, and self-injurious behaviour [1]. Such behaviours are a major contributor to morbidity, functional impairments, and reduced quality of life in these individuals, and cause great distress for their families and carers. In severe cases carer burnout and relinquishment is a genuine risk.

Psychotropic medications including stimulants, antidepressants and anti-psychotics are prescribed for a high proportion of paediatric patients with neurodevelopmental disorders in Australia [2], for symptom management or the treatment of comorbid mental health conditions. These medications are often extremely helpful, enabling patients to function better, engage with allied health and behavioural interventions, and participate more fully in school and society. However they also carry a substantial risk of adverse effects, and patients with developmental disabilities may be at particularly high risk [3], as well as being less able to report their subjective experiences. Therefore medications need to be used judiciously and monitored closely.

The NDIS Quality and Safeguards Commission is responsible the National Quality and Safeguarding Framework, which is aimed at protecting and preventing harm to persons with disability. The intention is to ensure NDIS participants ‘live free from abuse, neglect, violence and exploitation’. The context for this policy framework is the historical practice of off-label use of medications for institutionalised people with disabilities, for the intentional purpose of sedation—often administered by support staff, with minimal oversight by the prescriber.

Restrictive practices include seclusion, mechanical restraint, physical restraint, environmental restraint, and “chemical restraint” (CR). According to the NDIS Rules 2018, CR is defined as ‘the use of medication for the primary purpose of influencing a person's behaviour, as opposed to treatment of a diagnosed mental disorder or physical condition’ [4]. The Disability Act [5] and NDIS Rules are based on the purpose for which the medication is used. The NDIS definition is different to that under the Victorian Mental Health and Wellbeing Act [6] which is much narrower: ‘the giving of a drug to a person for the primary purpose of controlling the person's behaviour by restricting their freedom of movement but does not include the giving of a drug to a person for the purpose of treatment or medical treatment’. In these definitions no distinction is made between which type of medical practitioner prescribes the medication.

Note that these definitions do not incorporate any evaluation of the clinical appropriateness of the medications, nor are the parent or guardian's wishes considered relevant to the assessment of whether a medication should be considered CR. An illustrative example is autism. Although no medication is indicated for the treatment of autism, some medications (e.g., risperidone) are indicated in the management of symptoms such as irritability, agitation and severe stereotypy in children and young people with autism [7]. These however they would still be considered by the NDIS as CR, as the purpose is to influence behaviour. This example demonstrates that prescribing which is classified as CR is not necessarily inappropriate prescribing. Furthermore, it is not the prescriber's responsibility to determine whether medications are considered CR under NDIS Rules/Disability Act. The intent of the regulatory framework is to provide oversight of the use of psychotropic medications in the disability sector, not to regulate doctors' prescribing behaviours.

Under the Disability Act, disability service providers are required to seek authorisation and approval for any use of restrictive practices. This has generated tension between service providers who are fulfilling their mandated requirements, and prescribers (mostly paediatricians) who are requested to complete forms describing the purpose of medications prescribed.

We analysed data on medications prescribed for individuals in Victoria aged under 18 years who have a Behavioural Support Plan, and have reported CR use on 6 August 2024. This data is routinely collected in the Restrictive Interventions Data System (RIDS). We also report trends over the past 10 years by medication group.

There were 270 individuals who were subject to any restrictive practice, of which 230 (85%) were subject to CR. Of these, 181 (79%) were male, and 190 (83%) were aged over 12 years. The commonest residential service types were supported accommodation (111 [48%]), respite (65 [28%]), and individualised support packages (in-home support workers) (41 [18%]).

The classes of medications prescribed were atypical antipsychotics (175 [75%]), benzodiazepines/sedatives (96 [41%]), alpha agonists (91 [40%]), and antidepressants (74 [32%]). 144 (63%) individuals had been subject to CR for over 1 year, and 51 (22%) for over 5 years.

The Figure 1 shows the trend in this data from July 2014 to June 2024, demonstrating an increase in antipsychotic medications as a proportion of CR medications.

This is the first data on reported CR for children and adolescents in Victoria. The findings are broadly consistent with previously documented patterns of prescribing of psychotropic medications by Australian paediatricians [2].

There are some limitations to these data. First, the dataset relies on reporting by NDIS-funded support service providers. Although this is legally mandated, anecdotally practice is inconsistent, and reporting may not be complete. Second, we do not have data on diagnoses or symptom profiles, and so are unable to comment on the clinical appropriateness of the medications prescribed. Finally, the RIDS dataset does not include individuals in out-of-home care or child protection systems. Children and adolescents with disabilities in these systems are particularly vulnerable to restrictive practices, and it would be informative to have data from this patient group including medication use, frequency of clinical review, and quality of information available to prescribers.

Paediatricians need to prescribe psychotropic medications thoughtfully, alongside non-pharmacological approaches such as behavioural interventions and family supports, for patients with developmental disabilities. Careful monitoring is important, incorporating salient information form families, carers, educators and therapists. Consideration should always be given to deprescribing where opportunities arise, particularly when there are significant adverse effects.

At a broader health services level, there appears to be insufficient specialist services available to support children and young people with neurodevelopmental disorders and associated challenging behaviour. There are limited public multidisciplinary services in either developmental paediatrics or mental health, and the private paediatric and child psychiatry sector is increasingly difficult to access. Furthermore, care coordination between health and disability services is often suboptimal. This results in fragmented, inconsistent and often low-quality care. Systemic reform, including innovative models of care with in-built evaluation and quality improvement, is required to improve the care we provide to these individuals. One outcome is likely to be more rational prescribing and a reduction in medication adverse effects.

The authors declare no conflicts of interest.