C.H. v. Youthdale Treatment Centres, 2013 CFSRB 36

CHILD AND FAMILY SERVICES REVIEW BOARD

C.H. v. Youthdale Treatment Centres

REASONS FOR DECISION

Date: July 25, 2013

Citation: 2013 CFSRB 36

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

INTRODUCTION

1C.H. (the “Child”), asked the Child and Family Services Review Board (the “Board”) to review her June 28, 2013 emergency admission to the Secure Treatment Program at Youthdale Treatment Centre (“Youthdale”). The Child took the position that the statutory criteria (a) through (e) 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 not met.

2The Board was satisfied that at the time of her admission, the Child met all five criteria for emergency admission for the following reasons, and therefore denied her request for release.

DECISION

3These are the Board’s reasons for its oral decision made on July 6th, namely finding that the five criteria for admission were satisfied and denying the Child’s application.

PRELIMINARY MATTERS

4Before the start of testimony, the Board dealt with a number of preliminary matters, as follows.

5Counsel for Youthdale requested to enter into evidence a binder of documents assembled by Youthdale, before the hearing of testimony. The Board directed that individual documents would be accepted entered as appropriate and related to the testimony of a witness.

6Counsel for Youthdale requested that the normal period during which documents or events are considered relevant to the consideration of a placement in an emergency secure treatment application be extended considerably; the Board re-iterated its practice of limiting evidence to a maximum of six months before the current admission, and that the Board would give the appropriate weight to such documents, depending on whether or not the author of the document was available to testify.

7Counsel for Youthdale requested that the Board accept into evidence a document which was written in early July, 2013. The Board reiterated for counsel that the Act is clear that evidence is limited to the period of time leading up to and including the actual admission of a child into Youthdale. The Board’s mandate is to review issues leading up to an admission, rather than to examine reports written after the admission.

8The Board inquired whether Youthdale would have a psychiatrist available for testimony and for entering into evidence any psychiatric reports which may assist the Board in reaching a decision in this case. Counsel for Youthdale indicated in a general way that no psychiatrist was available. Counsel furthermore indicated that a psychiatrist was “not necessary” to enter psychiatric evidence in written form, and requested that the hearing continue without a psychiatrist. The Board directed counsel to clarify and get instructions on whether a psychiatrist could be made available, at any time during the day of the hearing. After a brief recess, it was confirmed that the on-call psychiatrist would be available to testify, in person. The Board indicated that it would accept the testimony of the on-call psychiatrist, and the submission into evidence of the psychiatric report leading up to the Child’s admission, and that the psychiatrist could interpret and give her professional opinion on all psychiatric issues and on the risks faced by the Child at the time of admission.

BACKGROUND

9The Child is fourteen years old and resides with her parents and younger sister in a small community east of [ city A ]. An older sister has already left the home. Problems in the Child’s relationship with both of her parents have existed for a number of years, but there has been a marked increase in degree of difficulty, including significant and escalating physical aggression, over the last few months. The parents were separated for some ten years, during which period the father by his choice saw his children on only two occasions. The parents reconciled about two years ago.

10The [local] Children’s Aid Society (the “CAS”) has been involved for some time, mostly out of concern for the safety of the younger child.

11The Child has attended school regularly, and just finished grade 8 last month at the end of June 2013, although truancy became a significant issue in the last few months of the school year.

ANALYSIS

12Section 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).

13Section 124(2) sets out the criteria all of 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.

14Section 112 of Part VI Extraordinary Measures defines mental disorder:

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

Criterion (a): the child has a mental disorder.

15The Board heard evidence that indicated that the child suffers from a substantial disorder of her emotional processes, and that this grossly impairs her capacity to make reasoned judgments.

16The Child has great difficulty controlling her emotional drives and reactions, and this manifests itself in extreme mood swings, and in dangerous actions in line with those swings. At home, the Child is described as ranging from being the “sweetest daughter” to being capable of significant assaults on either parent. There is a clear deterioration in the Child’s ability to remain in control of her emotions of anger, and to refrain from actions that are causing harm to others.

17The Child’s mood swings have resulted in the police being called to the parents’ home on over 30 occasions during the two months before her admission to Youthdale. For the month of June, the cell phone of the Child’s father shows that 18 calls were made to the police on his cell phone alone. Attending officers have suggested to the parents that the Child needs a mental health facility.

18Since mid-February, 2013, the Child has been taking two psychotropic medications, one to control her anger, and the other to help her deal with her anxiety and her Attention Deficit and Hyperactivity Disorder (“ADHD”). These medications have had a very limited effect on her ability to control her moods and her actions, to a large extent because of her failure to take her medications as directed.

19On a number of occasions, the Child was taken to an emergency department of a community hospital. On one occasion, she was retained overnight at the hospital as an involuntary patient.

20[ ] a psychiatrist at Youthdale testified that the child suffers from a mental disorder, as she exhibits a substantial disorder of emotional processes which grossly impairs the Child’s ability to make reasoned judgments. She exhibits severe mood swings, has very aggressive angry outbursts, and shows signs of significant suicidal ideation. She presents as overwhelmed by her emotions to the extent that they impair her decision-making processes. The Child also has difficulties regulating her behaviours as evidenced by her escalating unpredictability. With regards to her thought and cognition processes, she does have a learning disorder, but she is not psychotic. She does not have cognitive delays, as she appears to be doing adequately in school when her emotions do not overwhelm her. There is no formal school assessment available.

21From the evidence presented, the Board finds on a balance of probabilities that there is sufficient evidence to demonstrate that the Child had a substantial disorder of the emotional processes at the time of admission which grossly impaired her capacity to make reasoned judgments. Evidence given by both parents shows that the Child was unable to control her anxiety and her anger, and this results in behaviour that presented a high risk both to the Child, to her younger sister, and to her parents. The Board is satisfied that the Child’s emotional processes were grossly impaired as was her capacity to make reasoned judgments.

22The Board finds that criterion (a) was met.

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 himself, herself or others.

23The Child’s behaviour included a number of instances where she assaulted her parents. They testified that on numerous occasions, they were struck or threatened by the Child. As well, the Child has done significant property damage.

24The Child’s assaults have resulted in injuries to the mother including a torn tendon, a torn rotator cuff, and significant bruising resulting from various episodes of kicking and punching. As a result of these assaults, the Child’s mother has been taking pain medication since early this calendar year. Most of the above assaults happened spontaneously, with no warning or obvious reason or cause. Others were incurred when the parent was trying to prevent the Child from harming herself or from going AWOL.

25The Child has also displayed aggressive and assaultive behaviour towards the father. These incidents include punching repeatedly in the face, beating him with punches and kicks, throwing a steak knife at his face, holding a butcher knife at his throat, threatening with a knife, and threatening with a hammer being swung at his head.

26At this time, it appears that most of the aggressive and assaultive behaviour has been directed at both her parents, and this aggressive behaviour towards her parents is escalating in seriousness. At night, the parents lock their bedroom door from the inside, because of the fear of an assault occurring while they sleep. The younger daughter lives in constant fear. When she goes into her bedroom, she blockades the door from the inside by pushing a dresser in front of the door. The parents are getting more and more fearful that harm will be done to their younger daughter. The police have informed them that they consider her to be at risk in the home. The parents realize that when things including knives are being thrown in the home, everyone is at risk.

27As referenced in the section above, the police were called with great frequency. The police were at the family home shortly before the Child’s admission to Youthdale.

28Other problems that have been developing since the beginning of the calendar year are frequent AWOLs, increasing incidents of truancy from school, staying out all night and using marijuana. More recently she has been starting to use drugs with her friends. She ransacked her sitter’s house when she became frustrated that she could not find a cord to charge her cell phone. Incidents of verbal aggression and threats are common.

29The Child has made a number of threats of suicide. Self-harming behaviour has been going on for a few years, yet it is recently escalating in intensity and level of risk. She has started cutting herself, she walked into a river with ice floes still prevalent in March saying she wanted to develop serious hypothermia so she would die. She has threatened to throw herself off a bridge, and she has snorted household chemical cleaning products.

30The evidence led by the psychiatrist suggests that much of the aggression is directed at the Child herself and her immediate family, namely her parents. She labelled the Child’s aggressive behaviours as medium to high risk. A very likely next step is that the behaviours would become directed at a broader circle of persons than the immediate family. The pattern of injurious behaviour is that it is precipitated when the Child is very angry and cannot deal with that anger in a more controlled or productive manner.

31The Board finds that the Child has made substantial threats and has caused serious bodily harm to herself and to others as a result of her mental disorder. The Child attempted to commit suicide by walking into a river, and has seriously threatened to jump off a bridge. Evidence of the Child’s past suicide attempts, and her escalating aggressive and assaultive behaviour, clearly demonstrate that she is at serious risk of harming herself.

32The Board finds that criterion (b) was 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.

33Both the Youthdale psychiatrist and the Crisis Support worker testified regarding the structure and the safeguards available at the secure treatment program. Residents are searched upon admission. The program is structured and predictable. It is a program that is secure, with locked doors. It would be very effective in preventing the Child from causing or attempting to cause serious bodily harm to herself or to another person. The secure program ensures that objects including belts, strings and knives are not available to be used by the residents to harm themselves or others. Rooms are searched daily for any items that may present a danger.

34Most of the residents in the unit present some level of risk, and therefore there is a very intensive system of monitoring very closely the activities of the residents. The high level of security and structure along with a high staff-to-child ratio which is maintained at all times will prevent the Child from harming herself or others. Placement at Youthdale will prevent the Child from engaging in the impulsive behaviours that have put the Child at risk of causing or attempting to cause harm to herself or others.

35The Board was satisfied that criterion (c) was met.

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

36The Board is satisfied that treatment appropriate for the Child’s mental disorder is available at Youthdale.

37The Youthdale psychiatrist testified that the secure treatment program would be of benefit to the Child because it offers a place of safety, and provides an opportunity to do a thorough, uninterrupted assessment. This would include a full psychiatric assessment, an assessment of the family, a neurological assessment, and an assessment at the sleep clinic.

38The Crisis Worker testified concerning Youthdale’s clinical, therapeutic and counselling services which would be available to the Child. The Board is satisfied that Youthdale has appropriate clinicians and supports to closely monitor the impact of medication, as well as the Child’s behaviours.

39The Board was satisfied that criterion (d) was met.

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

40The Board heard extensive testimony that a number of less restrictive settings were tried or considered, but that they were not appropriate in the circumstances of the Child.

41In February 2013, [a youth agency] was contacted. This setting offers various non-residential services and more intensive residential placements. They also offer a 21-day crisis intervention service, focussed on the complete family, with a number of contacts each week. The family went through the 21-day crisis intervention services twice. This was followed by the assignment of a counsellor for the Child, on a non-residential basis. The Child did not attend many of the scheduled sessions with her counsellor. The youth agency did not offer its residential service, because the Child’s behaviour was beyond their capacity. As well, for them to consider a residential placement, they needed a full assessment of the Child. The youth agency indicated that they would consider the Child on a residential basis if there was such an assessment done by Youthdale.

42The family went for family counselling through the local [counselling agency]. The counsellor would usually arrange to see the Child at her school. Most of these appointments were not kept, as truancy from school became an increasingly serious problem in May, 2013.

43Counselling was offered to the family through a community clinic. A program of family preservation was offered for some six months, with little impact on the family dynamics or the Child’s behaviour.

44A number of hospitals were involved with the Child. One of the Hospitals, [the hospital], did keep the Child overnight on a Form 1, after the incident with the butcher knife. The police were called, the Child became belligerent, and was handcuffed and taken to [the hospital]. While on her way there, she uttered threats that she was going to kill herself. After another assault episode in the home, the family took the Child to [ hospital 2]. The only service offered was an interview with a nurse in their crisis unit.

45Other hospitals were accessed, but they were unable to offer appropriate intervention. After a particularly difficult incident of an assault on her mother in early June, the Child was taken to [hospital 3], where she was seen by a crisis worker because no psychiatrist was on duty, and was not admitted. [Hospital 3] gave the family no long-term plan as to where the appropriate service could be found. This brief interaction with [hospital 3] had no impact on the Child’s behaviour.

46None of these community hospitals were able to provide much service, as they lacked the staff specializing in adolescent psychiatry. Despite a variety of programs to which the family turned, no tangible improvements were noted in the Child’s behaviours. In fact, her behaviours continued to escalate, especially during June 2013, right up to the time of her admission to Youthdale.

47When the family sought out [a service ], which has an extensive paediatric psychiatric service, they were told that the [service] did not want to see the Child, and gave as the reason that there were beds available at Youthdale, and that Youthdale was where the Child should be seen.

48Youthdale was recommended to the family by a number of settings: [ ] and Dr. [ ], the child’s paediatrician for a number of years. In fact, [the paediatrician] wrote a referral letter to Youthdale. In June, the parents were in touch with Youthdale.

49The secure crisis service of Youthdale is also offered on a parallel basis on a non-secure basis. Whether this non-secure basis would have been sufficient for the Child is moot, because this service is not offered to families who are not residents of the [City A]. Thus, the only service appropriate for the Child was the current placement at Youthdale’s secure unit.

50The Board finds that the only appropriate service for the Child was that offered at Youthdale’s secure unit, based on the Child’s high-risk behaviour and the absence of other appropriate and less restrictive settings.

51The Board finds that criterion (e) was met.

CONCLUSION

52Pursuant to section 124(13) of the Act, the Board having satisfied itself that all five criteria in subsection 124(2) were met, denied the application for release of the Child on July 6, 2013.

CONFIDENTIALITY ORDER

53Parties and their representatives must not use, share, discuss or disclose any Board documents or decisions or any other documents or information provided or used in this application with anyone including through the media or on-line. The Board prohibits the use of any of this information for any purpose outside of the Board’s proceedings.