N. v. Youthdale Treatment Centres, 2013 CFSRB 18

CHILD AND FAMILY SERVICES REVIEW BOARD

N.

v.

Youthdale Treatment Centres

REASONS FOR DECISION

Date: April 9, 2013

Citation: 2013 CFSRB 18

Indexed as: N. v. Youthdale Treatment Centres (CFSA s.124)

INTRODUCTION

1N, the “Child”, asks the Child and Family Services Review Board (the “Board”) to review her March [ ], 2013 emergency admission to the Secure Treatment Program at the Youthdale Treatment Centre (“Youthdale”). Her position is that none of the statutory criteria for emergency admission contained in subsection 124(2) of the Child and Family Services Act, R.S.O. 1990, c.C.11, as amended (the “Act”) were met.

2For the following reasons the Board is satisfied that the Child met all the criteria for emergency admission at the time of admission. Her request for release from Youthdale is therefore dismissed.

BACKGROUND

3The Child is a fourteen year old girl who was adopted at the age of one from another country. In August of 2012, the Child ran away from home and was found by police in a man’s trailer. Police took her to a hospital for an examination and called the Society as they deemed her to be at risk. She came into the care of [ ] (the “Society”) under a Temporary Care Agreement. She was placed in a group home from August 2012 until February [ ], 2013 when she was discharged due to her unsafe and disruptive behaviour. The Child was initially considered by Youthdale for admission to the voluntary transitional psychiatric unit for stabilization, assessment and long term treatment planning, but during the tours of the unit, the Child displayed such disruptive and aggressive behaviour that she was referred for admission to the secure acute support unit.

ANALYSIS

4Section 124(13) of the Act provides that;

The Board shall make an order releasing the child from the secure treatment program unless the Board is satisfied that the child meets the criteria for emergency admission set out in clause 124(2) (a) to (e).

5Section 124(2) sets out the criteria which must be met at the time of admission.

124(2) The administrator may admit a child to the secure treatment program on an application under subsection (1) for a period not to exceed thirty days where the administrator believes on reasonable grounds that,

a. the child has a mental disorder;

b. the child has, as a result of the mental disorder, caused, attempted to cause or by words or conduct made a substantial threat to cause serious bodily harm to himself, herself or another person;

c. the secure treatment program would be effective to prevent the child from causing or attempting to cause serious bodily harm to himself, herself or another person;

d. treatment appropriate for the child’s mental disorder is available at the place of secure treatment to which the application relates; and

e. no less restrictive method of providing treatment appropriate for the child’s mental disorder is appropriate in the circumstances.

Criterion (a) the child has a mental disorder.

6[ ], (“Admitting Psychiatrist”) was the psychiatrist who completed the Admission Summary and is of the opinion that the Child has a mental disorder as defined by the Act. He diagnosed the Child with the following disorders: Oppositional Defiant Disorder, learning disabilities, Intermittent Explosive Disorder, Generalized Anxiety Disorder, possible Reactive Attachment Disorder, possible alcohol related Nero-developmental Disorder, rule out Pervasive Development Disorder. The Admitting Psychiatrist is of the opinion that the Child has met the Diagnostic and Statistical Manual (“DSM”) criteria for several of the above disorders but further assessment is needed to confirm the others. The test under the Act is not dependent on having a DSM disorder. However, the existence of or traits of a DSM disorder can be evidence of a mental disorder under the Act. The definition under the Act is:

s.112 “mental disorder” means a substantial disorder of emotional processes, thought or cognition which grossly impairs a person’s capacity to make reasoned judgments.

7The Admitting Psychiatrist is of the opinion that the Child had a substantial disorder of emotional process, thought and cognition at the time of admission.

8According to the Admitting Psychiatrist, there have been long standing, increasing concerns regarding the Child’s ability to understand and support positive relationships with peers, her difficulty in understanding reciprocity in relationships and her ability to accept and follow authority. Her early experiences of deprivation in an orphanage and possible intra-utero exposure to alcohol and drugs may have resulted in problems with her neurological development. In situations that are unpredictable, the Child has difficulties containing and regulating her feelings and maintaining her behaviours. Her thought processes are affected because she is overwhelmed or frustrated and she has difficulty problem-solving the concerns of the family or caregiver. The Admitting Psychiatrist testified that there is a circular relationship between the cognitive, thought and emotional aspects. The Child has learning difficulties which impact on her ability to differentiate her feelings and this leads to her feeling anxious and overwhelmed and interferes with her ability to problem solve. This difficulty with processing her emotions and her thoughts and her cognitive difficulties are substantial or significant. The outcome of the Child’s difficulties is that when stressed or overwhelmed, she becomes aggressive, runs away and puts herself at risk. Her capacity for reasoned judgment is, thus, grossly impaired.

9The Child’s worker testified to the Child’s pattern of behavior which led to her admission to Youthdale. The Child was placed in a group home with a behavior modification program using rewards. Due to the Child’s tendency to run away, she was placed in a group home outside the city, set back from the street and well away from the main street. While at the group home, the Child made persistent attempts to run away, threatened to harm herself and jumped on her parents’ car when they were leaving. The Child’s worker testified that the Child generally yells out “I want to die, let me kill myself”. She also engaged in “huffing”, an activity where she poured alcohol on a cloth and put it over her nose and inhaled to get high or pass out.

10The Child testified that she left the group home or ran away to get time to herself. However, within that time, she made very unsafe decisions like going out in the cold without shoes, wandering for long periods of time without knowing where she is going and threatening staff with a large stick.

11Staff from the group home testified as to several situations involving physical aggression to staff, false 911 calls, and use of restraints. For example, she punched staff in the face on at least two occasions in the group home and called 911 saying she had been kidnapped. On February [ ], 2013, the Child was disruptive and picked up a stick to hit two staff members who had followed her. She had to be placed in restraints and when in the car, she kicked the back window. She was rude and aggressive and made suicidal threats. She had to be escorted by police to the hospital where she was admitted involuntarily. When on the tour of Youthdale, on two separate occasions on March [ ] and [ ], 2013, the Child saw a girl that she felt uncomfortable with. Rather than asking for an alternative or a delay in placement, she acted out in an extreme manner and was assaultive towards the adults who were with her.

12The Board has considered all the evidence and is satisfied, on a balance of probabilities that, at the time of admission, the Child had a substantial disorder of emotional processes, thought and cognition, which grossly impaired her capacity to make reasoned judgments. The Child’s impulsivity, her reactivity, her inability to regulate her emotions, accept authority and process relationships demonstrated a substantial disorder of emotional processes, thought and cognition. This is supported by the evidence of the Admitting Psychiatrist. Her resulting behaviours at the time of admission were extreme and essentially out of control and demonstrated grossly impaired judgment as a result of her mental disorder.

Criterion (b) the Child has, as a result of the mental disorder, caused, attempted to cause or by words or conduct made a substantial threat to cause serious bodily harm to herself or others.

13The Admitting Psychiatrist is of the opinion that the Child‘s threats about killing herself at the time of admission were substantial or real threats and not just words. He noted that the Child has a well established history of impulsive behaviour and is not able to vouch for her own safety when very angry. At the time of admission, when agitated or upset, the Child’s behaviour was very unpredictable and not under her control.

14The Office Manager at the group home testified that the Child has thrown objects at her, kicked her and punched her in the face twice. She described a number of violent incidents involving the Child occurring between the end of January to the end of February 2013. There were eleven serious incidents reported during that time. In one incident, the Child was given the phone to call her mother but she called 911 and said that she had been kidnapped and was being kept in the middle of nowhere. Police came to investigate. The Child’s behaviour escalated and she kicked personnel. She punched the Office Manager twice in the face with her “full force” and had to be restrained. The Office Manager witnessed the Child being physically violent with other staff following this incident. The Child escalated to a level of crisis and physically attacked staff for no reason. She punched another staff member who suffered a swollen face. The Child made suicidal threats such as “I’m going to kill myself”. In another incident the Child grabbed a stick, threatened to hit staff and went out on the driveway to the road. Two staff members followed her in the car as she walked down the middle of the road without caring about her safety. She did testify that there was no traffic as it was a remote area. She walked through a field and hid for twenty minutes. When she finally got into the car, she said that she wanted to kill herself if she had to go back to the group home. On February [ ], 2013, the Child again threatened to kill herself and also threatened staff, while holding the broken drawers from a book shelf with the nails exposed.

15The mother testified to the Child’s behaviour during the tour of the transitional psychiatric unit at Youthdale. When the Child saw a girl from the group home in the unit and decided not to take the tour, the doctor tried to convince her but she threw a chair, and punched Youthdale staff. She was given another chance the following day to take the tour. However, when at Youthdale, the Child wanted to run away and the mother and the one-on-one worker restrained her. The Child became very aggressive and violent, threw things around and scratched the worker. The mother heard the Child threaten to kill herself on several occasions in the months leading up to admission. The Child said that she preferred to kill herself rather than live at the group home. At home, she said that she preferred to be dead rather than live in “this house”.

16The Child admits to being impulsive when she is “in the moment”. She testified that she speaks of self-harm when she is mad and just blurts things out without thinking about it.

17The Board is satisfied that there is ample evidence that the Child has made substantial threats to cause serious bodily harm to herself and that these are a result of the Child’s mental disorder. This is so because despite her evidence that she blurts out that she wants to kill herself when she is upset without really thinking about it, prior to admission, her words were accompanied by increasing aggression and out of control behaviours. While these behaviours were directed at others or at property, the unpredictability of her behaviours, the impulsivity and disregard for her surroundings are what made the threats of self harm a real possibility at the time leading up to admission. When “in the moment” the Child threatened to kill herself and was admitted to the hospital involuntarily. She realizes that she puts herself in danger but claims that she knows that group home staff or police will be there to prevent her from being harmed. The Child has demonstrated behavior that consistently puts her at serious risk of harm with the expectation that staff will be there to keep her safe. The escalation of these actions in the last month leading to admission increased the likelihood that the Child could have carried through with her attempts to harm herself. The Child’s extreme impulsivity and the escalation of the Child’s behaviour leads the Board to find that at the time of admission there was a substantial threat, that is, a very real chance that she could have caused serious bodily harm to herself when she threatened to do so.

18The Board is satisfied that criterion (b) has been met.

Criterion (c) the secure treatment program would be effective to prevent the child from causing or attempting to cause serious bodily harm to himself, herself or another person.

19The Board is satisfied that the secure treatment program would be effective to prevent the Child from causing or attempting to cause serious bodily harm to herself or others.

20The Psychiatric Crisis Worker testified to the resources available at Youthdale to prevent the Child from causing or attempting to cause serious bodily harm to herself or others. The Child would be constantly monitored so that she would have no opportunity to harm herself. Youthdale has a high staff ratio and staff are with any child at all times.

21Youthdale is a locked facility so that the Child would not be able to run away in an attempt to harm herself.

22The Board is satisfied that criterion (c) has been met.

Criterion (d) treatment appropriate for the Child’s mental disorder is available at the place of secure treatment to which the application relates.

23The Psychiatric Crisis Worker testified to the resources that Youthdale has in order to treat the Child. Generally, Youthdale can stabilize the Child, perform the required psychiatric assessments, including in a sleep lab, provide psychologists and psychiatrists and review medications in a safe environment. Specific to the Child, the Admitting Psychiatrist testified that the goal through treatment, in a safe environment is to have the Child “buy in” to a treatment plan for next steps, including work with the family. Youthdale would also conduct a sleep study and a medication review because her medication, to date, has not been effective, except to some extent, with sleep.

24The Board is satisfied that Youthdale has the appropriate treatment available to treat the Child’s mental disorder and that criterion (d) has been met.

Criterion (e) no less restrictive method of providing treatment appropriate for the child’s mental disorder is appropriate in the circumstances.

25Based on the evidence presented, the Board was satisfied that no less restrictive method of providing treatment appropriate for the Child’s mental disorder was appropriate.

26The group home provided a one-on-worker for the Child and when she attempted to run away sent two workers to follow her. When her behaviours escalated, the Office Manager (a child and youth worker) was called to assist. As well, additional security had to be called when the Child was in crisis situations. The group home, which is not a secure facility could not manage the Child’s behaviours and could not keep her safe. The Child was admitted to hospital for a week in early February, 2013 and was taken to hospital again on February [ ], 2013. The use of hospital admissions or visits at times of crisis did not appear to impact on the Child’s behaviour. The Child’s behaviours continued to escalate and on February [ ], 2013, the Child was dropped off at the hospital and the group home refused to take her back. The Child had outpatient access to mental health professionals. She has been seeing a psychiatrist, has had several assessments completed and has been put on medications. None of these interventions were effective. Two attempts at facilitating a voluntary placement at Youthdale were not successful and resulted in an escalation of aggression by the Child. Due to the Child’s escalating out-of-control behaviours, and consistent running from her placement, the Board concludes that no less restrictive method of providing treatment for the child is appropriate.

27The Board is satisfied that criterion (e) has been met.

CONCLUSION

28Pursuant to section 124(13) of the Act, the Board, having satisfied itself that each of the criteria in subsections 124(2) (a) through (e) have been met, dismissed the application for release of the Child on March 22, 2013.

CONFIDENTIALITY ORDER

29Parties and their representatives must not use, share or disclose any documents or information provided or used in this application with anyone including the media or on-line. Any documents or information shared by the parties must be used only for the purpose of the hearing of this application by the Board.