Exploring Routine Practices of Coercion in Acute Child and Adolescent Psychiatry – Reflections for Practice

ABSTRACT

Topic

The article focusses on the use coercion in acute psychiatric wards for children and adolescents in Norway.

Purpose

The purpose of this article is to provide insight into how coercion within a continuum of formal and informal coercion is embedded in psychiatric treatment of children and adolescents. This integrated focus on multiple forms of coercion is critical for raising professional awareness regarding the effects of coercion on children's wellbeing, trust in professionals and future access to mental health services.

Sources Used

The study is based on ethnographic fieldwork in three acute wards in Norway conducted in 2023–2024. The research is part of a larger mixed‐methods study focusing on the complexities of coercion in Norwegian child and adolescent psychiatry, which in addition to fieldwork includes interviews and surveys with clinical staff and patients in 18 acute wards.

Conclusion

The study shows how formal and informal coercion is embedded in routine therapeutic practices in child and adolescent acute wards. Three forms of informal coercion are highlighted: misinformation or withholding information, the use of leverage to obtain treatment compliance, and the threat of formal coercion to secure treatment compliance. In clinical practice, the use of formal and informal coercion is interrelated. Children experience distress, frustration and exhibit forms of withdrawal when exposed to coercion. The study concludes that providing transparency in treatment activities and plans, listening to children's perspectives on treatment needs, and showing respect for their autonomy, also when they are admitted on parental consent, is vital for their wellbeing, recovery and future access to mental health care and other support systems.

1. Introduction

Coercion is a contested practice that can be viewed as necessary for safeguarding children and adolescents while also implicating significant risk of harm. Some forms of coercion are registered and regulated by national legislation and international conventions such as the UN Convention of the Rights of the Child and the UN Convention against torture and inhumane treatment. These include forced medication or nutrition, holding, mechanical restraints and seclusion, which can inflict pain, trauma, even death on patients (Furre et al. 2016; Jones et al. 2021; Mac Donald et al. 2023; Nielson et al. 2021). However, patients are also coerced in other ways to secure treatment compliance. These practices include inducement, motivation, the use of leverage, threats or misinformation often referred to as informal coercion (Hotzy and Jaeger 2016) or treatment pressures (Szmukler and Appelbaum 2008). This article provides novel insights into how coercion within a continuum of formal and informal coercion is embedded in routine psychiatric treatment of children and adolescents in an acute ward. This integrated focus on multiple forms of coercion is novel and critical for raising professional awareness regarding the effects of coercion on children's wellbeing, trust in professionals and future access to mental health services (see Furre et al. 2016; Pelto‐Piri et al. 2019).

The use of informal coercion in psychiatric treatment has warranted increasing academic attention in the past decade (Hotzy and Jaeger 2016; Valenti et al. 2015; Sjöström 2006). Studies show that professionals in mental health view many forms of informal coercion as justified, acceptable, and productive to secure treatment compliance and to avoid formal coercion. However, informal coercion can be experienced as unfair or coercive by patients, which can negatively impact the therapeutic alliance, treatment adherence and ultimately result in drop‐out or future reluctance to seek mental health services (Hotzy and Jaeger 2016). Studies on informal coercion conclude that mental health workers need to be better informed, educated, and sensitized to understand informal coercion and its potential for adverse effects in clinical practice (Hotzy and Jaeger 2016; Elmer et al. 2018). This study provides insights from child and adolescent psychiatry that are valuable for informing and sensitizing clinical staff to the adverse effects of using coercion in the treatment of children. A Norwegian study by Nyttingnes et al. (2018) found that a third of adolescents in inpatient psychiatric settings reported experiencing high levels of coercion, however insights on coercion from children and youth's perspective remain limited (Seed et al. 2016; Coutant 2016). Insights into the use and lived experience of coercion are vital for developing clinical practice aligned with a child‐centered approach to care and treatment provision.

This article contributes to the growing scholarship on coercion by analyzing clinical practices in acute psychiatric wards for children and adolescents in Norway. First, the article introduces key findings from studies on informal coercion, followed by a brief description of the Norwegian context of psychiatric care and a methods description. The analysis centers on three examples of coercive treatment practices; (a) treatment meetings, (b) physical constraint and medication, and (c) nutrition intake. Finally, the article discusses the analytical findings considering existing scholarship and proposes implications for further research and clinical practice.

1.1. Studying Informal Coercion

Informal coercion encompasses a wide range of practices characterized by subtle and non‐legalized pressures such as motivation, persuasion, the use of leverage, and ultimately threats (Sjöström 2006; Hotzy and Jaeger 2016). A cross‐national study finds that the use of informal coercion is routinized in everyday treatment practice and perceived, by mental health workers, as a prerequisite for securing treatment adherence (Valenti et al. 2015). Drawing on the concept of treatment pressures developed by Szmukler and Appelbaum (2008), the study by Valenti et al. finds that using soft pressures such as negotiation, motivation and the use of authority is largely accepted by clinical staff, while using stronger pressures such as telling patients what to do or using threats or leverage is less acceptable because it violates the patient's autonomy and jeopardizes the therapeutic relationship.

Coercion also takes place by withholding or activating information. A Swedish study finds that mental health workers apply informal coercion in subtle ways by invoking the “awareness context” or “coercion context” (Sjöström 2006). The awareness context refers to professional authority, legislation, medical insights etc., where the coercion context refers to the possibility of formal coercion, locked doors, ward regulations etc. Staff can create awareness of these contexts as a subtle form of undermining patient autonomy and shaping their decisions. For example, if a person in voluntary treatment wants to leave the ward, the staff can stall the patient by saying she can only leave if accompanied by staff; by asking the patient to wait for a specific therapist; by suggesting that if she leaves, she cannot be readmitted etc. These tactics may be successful in the short run, but harmful in the long run if they are experienced as unfair, manipulative, or disregarding the patient's autonomy.

Studies of adult patient experiences highlight that informal coercion can be viewed as helpful for recovery if professionals are transparent, if the coercive measure is experienced as fair, and plays out with respect for the patient's autonomy (Lorem et al. 2015). If professionals, such as nurses and therapists, disregard these process‐related factors and maintain a utilitarian attitude towards informal coercion, the short‐term effect may be positive, but with detrimental long‐term effects (Sjöström 2006). Without transparency and respect for autonomy there is a high risk of perceived coercion, which can be harmful for treatment adherence, the therapeutic alliance, and ultimately result in treatment drop out and future reluctance to seek mental health services (Lorem et al. 2015). One study finds that, particularly the use of stronger informal coercion is underreported and may be unrecognized by mental health professionals depending on their attitudes to coercion (Elmer et al. 2018).

Informal coercion is a dimension of coercion that remains less explored, especially in the context of child and adolescent psychiatry (Moell et al. 2025). The power dynamics that are the foundation of exercising informal coercion, such as between client/professional and system insider/outsider, are exacerbated by the power inequalities between children and adults. While children are not legally viewed as autonomous since they are subject to adult guardianship, they are widely viewed as subjects with rights to be included in decision‐making, rights to access complaints systems, and giving their consent depending on age and varying national legislation. Drawing on an epistemology aligned with Critical Childhood Studies, this study views children as autonomous from an ethical, if not legal, perspective. A Swedish study finds that staff (mainly nurses and nursing assistants) have few ethical considerations regarding the lack of patient‐involvement when it comes to adolescents (Pelto‐Piri et al. 2013). This suggests that some of the process‐related elements of ‘good coercion' (Lorem et al. 2015) such as providing transparency, fairness and respect for autonomy may not be equally acknowledged in routine psychiatric treatment for children and adolescents. While minors are protected from some forms of formal coercion, their exposure to informal coercion may be quite extensive.

1.2. Coercion in the Context of Norwegian Acute Child and Adolescent Psychiatric Care

In Norway, 18 adolescent psychiatric inpatient units are authorized by the Norwegian Directorate of Health to use coercion on patients if this is deemed necessary. The age of patients treated in these units range from 12 to 18 years, and the patients can be admitted voluntarily or involuntarily (Psykisk helsevernloven 1999). Children under the age of 16 are admitted with the consent of their parent(s) or legal guardian, regardless of whether s/he opposes admission. When the child turns 16, s/he acquires legal autonomy over his or her own health and body. This means that young people between the ages of 16 and 18 can either be admitted voluntarily with their own consent or they can be admitted involuntarily. Involuntary admission of patients over 16 is based on an assessment by an external and an internal doctor. The prerequisite for involuntary admission of a patient is that the person suffers from a serious mental illness and is unable to give consent or poses an urgent danger to their own life and health or an urgent danger to others. The units may use coercive measures (such as physical restraint, pharmacological restraint, mechanical restraint, and seclusion) and compulsory treatment (including medication and tube feeding) if this is deemed necessary. The law states that staff should always use the least invasive approach for each situation.

2. Methods

The article is based on a multi‐sited ethnographic fieldwork in three acute child and adolescent psychiatric wards in Norway. The units have a mix of functions dealing with emergency admissions, assessments, and treatment of eating disorders. Three researchers visited separate wards for 3–5 days at a time with 3–5 visits during 2023. The aim was to gain insight into coercive practices including both formal and informal coercion. During fieldwork, the number of patients ranged from 2 to 6 per unit. Generally, the patients had complex diagnoses, some were not diagnosed, had severe psychoses or were in different acute conditions. In two units, approximately half of the patients had restrictive eating disorder, while the third unit had three patients with this diagnosis during fieldwork. The personnel consisted of milieu therapists (primarily nurses and social educators, but some social workers), unit managers, psychologists, and psychiatrists/chief physicians. The milieu therapists worked and participated in the patients' daily lives at the unit. Psychologists and chief physicians were only present in staff meetings or in treatment meetings with patients and/or their parents, where decisions regarding patient intake and treatment were made. Fieldwork included observing and talking to staff, patients, and parents about clinical practices, everyday routines, and the use of coercive measures. Additionally, semi‐structured interviews were conducted with 9 patients ages 13–17, 5 parents and 10 staff. We participated in medical conferences, network meetings, in‐take meetings and spent time in the staff room, where treatment tasks were organized and discussed and in common areas such as the TV room. The researchers all identified as female, aged 40–50, with a background in anthropology and social work, and with extensive research experience with children in vulnerable positions.

An acute psychiatric ward is a difficult institutional space for conducting ethnographic fieldwork. Some spaces required permission by management, others required invitation by staff or the patients. The patients are vulnerable due to a combination of severe mental illness, young age, and a range of social adversities. Formal ethical approval was granted by the hospital administration, and posters were placed centrally in the ward to inform staff, children and parents about the research project. Informed consent was obtained by adolescents older than 15 and parental consent was obtained for those younger than 15. Formal ethical guidelines, such as securing voluntary participation and full confidentiality for all participants, were supplemented by situated ethical considerations to secure participant well‐being, comfort with research questions and researcher presence (Hastrup 2004). This required constant attention to body language, intonation, emotionality and unspoken boundaries expressed by participants in subtle ways particularly in situations with formal coercion. All names and places have been pseudonymized to secure participant anonymity.

There are some limitations to the study. Firstly, the limited time spent at the wards meant that we did not become fully acquainted with routines, nor establish a relation to participants that can be described as close or confidential. This will often be the case in an acute ward, since most patients are there for a short time and can be withdrawn due to severe illness. Secondly, two of the researchers were Danish, and while Danish is very similar to Norwegian, some communication was constrained for example when observing on‐line meetings or overhearing conversations at a distance.

The interview data has been transcribed, and has been read along with fieldnotes and tentatively coded manually to identify key themes following Lofland and Lofland's (2006) step‐by‐step description of coding processes. Secondly, the data has been coded using NVivo. The codes were thematic to gain oversight over a vast dataset and maintain an understanding of emic categories. The analysis presented in this article is mainly inductive to provide a detailed description of situations where informal coercion take place. Moving iteratively between data, descriptions, and interpretations, we thereby engaged in what Reed (2011) refers to as “maximal interpretation”. The purpose of this approach is to re‐signify empirical evidence through theory to develop a deeper understanding of the specific actions observed by the researchers and the accounts provided by staff and patients. Drawing on the theoretical framework of 'informal coercion', we identified three situations as illustrative examples of treatment activities involving coercion. These observed situations are considered a “most likely case” (Flyvbjerg 2006, p.231) encompassing key dynamics of coercion and treatment occurring in multiple observations. While not typical in a statistical sense, the observations illustrate a general pattern in the use of coercion across the three units.

2.1. Analysis of Coercion in Three Treatment Activities

The following sections illustrate how coercion is a routine practice embedded in safeguarding, stabilizing, and providing treatment for children in an acute psychiatric ward. We analyze three different treatment situations: (a) treatment meetings, (b) physical constraint and medication, and (c) nutrition intake. The situations provide detailed insights into how motivation, persuasion, withholding information, using leverage, and threats play out in these treatment contexts. The analysis illustrates how coercion is omnipresent in an acute ward, even though formal coercion is used only in distinct situations limited to a few minutes.

2.2. Treatment Meetings

Children admitted in an acute ward have regular meetings with the ward psychiatrist with the purpose of sharing information about treatment plans, scheduled examinations or plans regarding discharge. This specific meeting took place in the treatment ward adjacent to the acute ward with a boy who had been in and out of the two wards for more than a year. He was described by the staff as an 'interesting case considering your focus on coercion”.

Denis is 15 years old, admitted on parental consent as he is under 16. According to the staff, he had not given his consent to treatment. He consented to the researcher's presence at the meeting.

The researcher met the ward psychiatrist in the staff room where she briefly explained the purpose of the meeting. Her aim was to convince Denis to resume anti‐psychotic medicine to reduce his aggressive behavior. Alternatively, she wanted him to accept a smaller dosage to improve his sleep. She also explained that he wanted to be discharged to stay at home, while the medical team in collaboration with his parents were planning placement in out‐of‐home care. His discharge relied on stabilization and his motivation to collaborate on a treatment plan which included anti‐psychotic medication. His aggressive behavior was a challenge in the treatment ward and posed a threat to the staff and the other patients. As a precautionary measure, a (male) nurse attended the meeting since Denis was currently experienced to be aggressive in “demand situations”.

The meeting took place in a small room with Denis and the researcher sitting on one side of the table and the psychiatrist and the nurse on the other side. Denis appeared reluctant to engage in a conversation with the psychiatrist. He clearly stated that he would not take the suggested medicine. The psychiatrist explained that in a small dosage it worked as a sleeping medicine, which is not the same as he had tried previously. She reminded him that last time he took the medication he got better and was discharged. Denis rejected and said, “forget about convincing me”. She responded, “I am not trying to convince you. But I would like to advice you”. She explained that sleep is important just as regular healthy meals are important. Attending school is also important and having a normal daily structure. He said, “I am not sick and you know that”. Denis was getting increasingly impatient, rocking on the chair, looking absent minded when the psychiatrist spoke only to look at her very intensely repeating his position, “I am not taking the medicine, and I am not attending school”.

The psychiatrist then took a deep breath and paused before saying that he needed to cooperate to be discharged, “and that is what you want isn't it? You want to get out of here. In that case I am informing you that if you don't get better, don't sleep at night or lose weight, then we cannot discharge you”. The psychiatrist activates the possibility of discharge to make Denis collaborate on the treatment plan. The use of informal coercion in the conversation started with information sharing (“I would like to advice you”), motivation and attempts of persuasion and then moved on to stronger treatment pressures such as leverage and threats (“you want to get out of here”). The stronger pressures were implicated yet clearly understood by Denis. He shook his head suggesting maybe fatigue with the psychiatrist's explanations about a healthy diet, sleep and daily structure, maybe also suggesting resignation towards her attitude and decision, which he cannot challenge. After looking out the window for a while and shaking his head, he slammed his fist into the table. There was an instant change in the body posture of the clinical staff, and in a firm voice the psychiatrist ends the meeting. As we returned to the office, she explained that “he is getting darker and darker” and that his threatening behavior cannot be contained in the treatment ward. The next day, he was readmitted to the acute ward.

Denis had very few options in the treatment space which was observed. The space was defined by the authority of the psychiatrist and parental consent to treatment, and his modes of resistance had no legitimacy or impact; he repeated that he was not sick, he refused medicine, he withdrew into silence, and ultimately, he slammed his fist on the table. There were no records of formal coercion, while the informal coercion permeated his entire admission and treatment experience; being moved between wards without notice, being pressured to take anti‐psychotic medicine to be discharged, and eventually placement in out‐of‐home care. Based on conversations with staff and observation of the meeting, it appeared that he was largely informed about decisions but did not participate in the process of planning his treatment or discharge.

While the options for engaging Denis on the proposed treatment plan appear limited, the use of informal coercion such as persuasion and motivation seem to push him towards an oppositional stance. Furthermore, the use of coercion by withholding information may jeopardize Denis' trust in parents and professionals. A child‐centered approach highlights the processual elements of securing treatment compliance. This includes providing transparency in treatment planning, respecting his autonomy despite being admitted on parental consent, and considering his perspectives as vital for providing good care and treatment. These elements are vital in a treatment meeting as well as other daily routines throughout admission.

2.3. Physical Restraint and Medication

Avoiding formal coercion is a pivotal aim in an acute ward. Partly because of the time‐consuming registration of these situations, partly because the staff find it unethical and potentially harmful to children. This situation illustrates how informal coercion was used in multiple ways to prevent the use of physical constraint and forced medication, and how it entailed substantial emotional costs for both the patient and clinical staff.

Terance was 13 and admitted to the acute ward on parental consent. He had not previously been admitted to intensive care in child and adolescent psychiatry, but he had been diagnosed with ADHD, autism, and had an increasing drug use. Terance arrived at the ward in the morning accompanied by his mother and older sister. According to the staff, he did not consent to being admitted and objected to following the staff to the room he had been assigned. He got angry and aggressive, however the staff managed to escort him from the meeting room by walking on each side and behind him, leaving him no alternative but to move in their intended direction. Thus, as the staff explained, they managed to avoid using coercion.

After a few hours in the room Terance got increasingly agitated yelling and throwing items. At this point, the researcher arrived at the ward. After a quick briefing the researcher observed the situation standing in the hallway. Two staff members tried to calm Terance down but were forced to leave the room when he broke off the leg of a chair and threatened them. The staff withdrew to the hallway and notified the police to assist them in moving Terance to the secure section of the ward. They talked to him through the door, trying to calm him. When the police arrived, the ward psychiatrist entered his room escorted by two policemen trying to convince him to accept a tranquilizer. He denied, and the police escorted him to the secure section. The psychiatrist offered the tranquilizer again, insisting that he needed to calm down and he needed to sleep. She offered him pills, while she also had the tranquilizer in a syringe and eventually, he accepted the pills. This illustrates how formal coercion, in this case forced medication, can be presented as an alternative, or a threat, to make patients comply with treatment or measures for safeguarding.

Terance was clearly stressed and panicking in the presence of both the staff and police. While everyone was talking in low, calming voices Terance's voice shifted between aggressive yelling, talking and crying “stop, let me out of here, I don't want to”. At one point he asked to call his mother, and the staff responded by saying that his mother could not give him permission to leave. This is an example of withholding information or misinforming, since the staff cannot treat a minor without parental consent. He finally fell asleep, and the staff assembled in the office clearly affected by the events. The psychiatrist joined them saying, “Thank God, we managed to do that without coercion” referring to the tranquilizer. The staff asked which parts of the situation required registration as coercion, and they agreed that formal coercion took place twice: when they locked the door to his room and when they placed him in the secure section.

Throughout the episode, staff were calm and comforting, recognizing the vulnerability of a 13‐year‐old child. They expressed awareness that they were acting against his will, yet their relief regarding not using coercion also suggests limited acknowledgement of the impact of informal coercion. Formal coercion took place in two short incidents, while the use of informal coercion permeated the first 6 h of his admission causing panic and intense emotional distress. Beginning at intake, a child‐centered approach emphasizing the processual elements of securing treatment compliance may have reduced the level of coercion and emotional distress of Denis. In Denis' case the extensive use of informal coercion by means of misinformation, withholding information, and threats may result in the desired short‐term objectives, while jeopardizing long‐term treatment compliance, collaboration and trust in adults.

2.4. Nutrition Intake

In all three acute wards, we witnessed many children with eating disorders. These patients are often admitted for longer periods of time and readmitted multiple times. The staff strategize to make these patients commit to a specific treatment plan mainly focusing on intake of calories. These strategies can include using leverage such as a planned readmission if the patient complies with the planned intake of calories and does not lose weight. Other patients, typically in a more acute stage and admitted in intensive care have a “nutrition intake order”, which enables staff to subject the patient to tube feeding if the patient refuses voluntary intake of calories (see also Jørgensen et al. 2025). These patients are frequently subject to being weighed, drawing blood samples, and measuring blood pressure to check their health risk.

Anna was 15 and had been admitted on parental consent multiple times and had a nutrition order during her entire admission. Her treatment plan included three meals a day with detailed description of the calorie intake and what she should eat. She could use 30 min on the ‘meal', which could consist of two pieces of crackers, a slice of ham and two slices of cucumber with a 250 mL drink. She preferred to eat in a separate room with a staff member. However, on this day there were no rooms available, and she had her meal in the TV area with a milieu therapist. The researcher observed the situation from the dinner table, in plain view of Anna. During the first half hour they watched TV and talked, however the food remained untouched. The milieu therapist repeatedly encouraged her to eat. She sat close to Anna on the couch comforting her with an arm around her shoulder. After 30 min the milieu therapist told her they were running out of time, and she needed to start eating. An additional 5 min were spent trying to persuade her to start the meal. Anna had stopped talking or in any way responding to the staff's attempt to make her start the meal. She was sitting up straight in the sofa, and her gaze seemed to focus nowhere. The milieu therapist got up to remove the plate and prepare the calorie drink in the adjacent kitchen. She returned to the couch sitting close to Anna, who made no gesture to start drinking from the glass which had been put in front of her. After another 5 min the staff took the glass and placed it close to her face. There was a straw which almost touched Anna's lips. The milieu therapist held the glass while trying to motivate her to drink, her arm placed around Anna's shoulder, and sitting very close to comfort her.

There was a growing tension in the ward due to the progress of the eating situation. The staff were slowly preparing for a situation of tube feeding, discussing the options in the staff room. Eventually, the milieu therapist discarded the calorie drink and Anna returned to her room while the staff prepared for the tube feeding. This had been planned in the staff room, where the staff had shared reflections on who is most likely to be able to persuade her to let them perform the tube feeding with consent. This meant that staff did not need to hold Anna, which reduced the risk of physical injury.

After 20–30 min they were ready to conduct the tube feeding, and one staff went to Anna's room to escort her to the treatment room. She went quietly to the room looking down at her feet as she passed the staff room. The researcher waited here for the tube feeding to be completed, mainly for ethical reasons but also due to a shortage of space in the treatment room which already included a nurse and three staff members. The procedure took less than 5 min, and the staff returned to the staff room relieved that they managed to perform the tube feeding without physical coercion. Their relief is understandable, since tube feeding in combination with physical coercion is a painful and often terrifying experience for patients and emotionally stressful for staff. The situation highlights how multiple forms of coercion were employed ranging from motivation, persuasion, and the use of a nutrition order as leverage or implicit threat to secure compliance with the nutrition plan. With a nutrition intake order the scenario repeats itself daily, for some patients several times a day.

Multiple forms of formal and informal coercion are integrated in Anna's treatment. Reducing coercion requires attention to the processual elements of securing treatment compliance such as listening to her perspective and working towards consent, while formal consent has been obtained through parents. In an interview with Anna, following this episode, she expressed multiple relevant perspectives on her treatment such as wanting therapy, more activities in the ward, and home visits. She contemplated filing a complaint about the nutrition intake order. A recent study highlights the potential of non‐coercive treatment of even severe eating disorders (Stone et al. 2026), which is in line with the child‐centered approach proposed to reduce coercion.

3. Discussion

The study shows that coercion permeates everyday treatment in acute psychiatric wards. This is in line with findings by Nyttingnes et al. (2018) where 1/3 of the patients reported high levels of experienced coercion. We highlight particularly three forms of coercion that are pervasive in the treatment setting. Firstly, we observed multiple examples of misinformation and withholding information about admission/discharge plans, patient rights or access to a complaints system. Misinformation may result in treatment compliance in the short run, but in the long run it jeopardizes children's trust in adults and professionals. In support of this concern, the study by Nyttingnes et al. (2018) shows that children exposed to coercion express reluctance to confide in adults. Secondly, we find that the use of leverage to obtain treatment compliance is widely used. Patients' desire for discharge, home visits or returning to school were used as leverage to secure treatment compliance, or the promise of readmission if nutrition plans were followed. Finally, we find that formal coercion (forced medication or nutrition intake orders) is used as an (implicit) threat or leverage to safeguard a patient or obtain treatment compliance. In this way, formal coercion does not have to be used to have an effect. By activating the “coercion context” (Sjöström 2006) staff can obtain compliance, which suggests a blurred line between formal and informal coercion in psychiatric treatment. The study shows that the effect of using coercion is not only compliance but high levels of distress, withdrawal, and opposition to treatment. These findings resonate with multiple studies; adolescents exposed to coercion feel rejected, punished, disempowered or even terrified (Jones et al. 2021; Mac Donald et al. 2023; Nyttingnes et al. 2018; Henriksen and Øye 2023).

In the study, staff show concern about the use of formal coercion and express relief when they manage to avoid exposing patients to restraints, seclusion or tube feeding. Staff sentiments regarding informal coercion were ambiguous and to some extent legitimized and routinized by institutional logics. This is in line with previous studies finding treatment pressures, such as motivation and enticement acceptable in psychiatric treatment, while stronger pressures such as using leverage or threats were imbued with ethical concerns (Valenti et al. 2015). This study finds that stronger treatment pressures were regarded as acceptable when used either to safeguard a patient or secure treatment compliance. This suggests different thresholds for adults and children when professionals assess the legitimacy of treatment pressures in terms of both frequency and the use of stronger pressures.

The study has clear implications for practice. Coercion in clinical practice can be reduced by commitment to a child‐centered approach to treatment that centers on listening to children's perspectives, providing transparency in treatment planning, and being respectful of children's autonomy and consent regardless of age. These elements relate to the processual dimensions of coercion that have been well researched in adult psychiatry and found valuable for recovery and treatment compliance (Lorem et al. 2015). This approach should permeate routine activities from intake to discharge. According to UNCRC, art. 12, children have a right to be heard on matters regarding their everyday life and their views must be considered depending on age and maturity. Children's right to participate in treatment planning or discharge also apply in acute psychiatric care. Furthermore, studies from child protection services show that when children participate in decisions regarding placement in care or other forms of support, these interventions show better results. Children are subjected to adult/parent authority which, coupled with an understanding of children as immature and irrational, legitimizes practices of coercion. Our findings suggest that the power dynamics between children and adults exacerbate the power inequalities that underlie the use of informal coercion.

4. Conclusion

The study shows how informal coercion such as enticement, using leverage and threats is embedded in routine treatment practices in child and adolescent psychiatry. Staff express concern about the use of coercion – formal and informal ‐ but also display attitudes that disregard the harmful effects of informal coercion. Our findings suggest that coercion in any form can have negative effects on children's wellbeing and trust in staff. Transparency in treatment planning and purpose, increasing attention to children's participation in treatment planning and respect for children's rights and autonomy are vital to reduce children's experienced coercion in psychiatric care and secure their future access to treatment and support systems.

Author Contributions

Ann‐Karina Henriksen, Tone Jørgensen and Trine Brinkman made equal contributions to data collection and initial coding and interpretation of data. Ann‐Karina Henriksen and Esben Olesen contributed to conceptualization of the article. Ann‐Karina Henriksen wrote the first draft and analysis. Tone Jørgensen and Esben Olesen gave critical comments and revised for important intellectual content. Ann‐Karina Henriksen revised the article after review comments and Tone Jørgensen, Trine Brinkman, and Esben Olesen approved the final version before publication.

Disclosure

The authors, hereby declare that no AI tools or systems were used in the conception, design, analysis, writing, or revision of this manuscript. All content is the result of the authors' own intellectual work, supported only by conventional academic resources and methodologies.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The authors have nothing to report.