L.H. v. Youthdale Treatment Centres, 2015 ONCFSRB 17

CHILD AND FAMILY SERVICES REVIEW BOARD

L.H.

v.

Youthdale Treatment Centres

REASON FOR DECISION

Date: April 7, 2015

Citation: 2015 CFSRB 17

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

INTRODUCTION

1L.H. (the “Child”), made an application to the Child and Family Services Review Board (the “Board”) to review her March 24, 2015, emergency admission to the Secure Treatment Program at Youthdale Treatment Centre. The Child took the position that the statutory criteria (a) (b) and (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 at the time of her admission. The Child’s father sought her admission to the secure program because of her persistent and prolonged absences from her home, her drug use and her high risk behaviours during her absences.

2The Board was not satisfied that, at the time of the Child’s admission criterion (b) and criterion (e) were met as required in subsection 124(2). For that reason the Board granted the application for her release on March 30, 2015. The Board’s reasons address criterion 124 (2) (a) (b) and (e) because the Child conceded criterion (c) and (d) of the Act.

BACKGROUND

3The Child is fifteen years old and she resides with her father, two brothers (ages four and two), her grandmother and her grandfather. Her thirteen year old brother lives in foster care and he visits on weekends. The Child has a strained relationship with her mother with whom she lived in [Province 1], [Province 2] and [Province 3] until she was twelve years old. The father gained custody of the Child in 2012, after which she returned to live with him in [City 1]. The father reported that the family has an extensive history of involvement with Children’s Aid Societies, beginning in 2002.

4The Child has experienced substantial trauma continuously during her life.

5Most recently the Child ran away from home on January 22, and returned January 30, 2015, after which the father sought medical treatment for her at [Hospital 1] where she was admitted involuntarily, (Form 1), from January 31 to February 1, 2015. The Child left home a few days later on February 2 or 3, until February 8, 2015. On February 14, 2015 she left her home again until March 14, 2015. The father testified that when the Child returned after a month away from home she seemed to have lost weight, she was extremely pale and her behaviour was irrational.

6She was admitted to [Hospital 2] on March 16, 2015 where she was held involuntarily (Form 1). Subsequently her admission was extended on a Form 3 for risk of serious physical impairment as she was deemed a flight risk. The Child was transferred to the secure treatment program on March 24, 2015 directly from the [Hospital 2].

7The father stated that the Child was argumentative, she fought with her thirteen year old brother and her behaviour was escalating. He was particularly concerned that she was abusing drugs and running away from home for extended periods during which she put herself at serious risk in the community. The Child had difficulties sleeping and she also engaged in superficially cutting her arms. He testified that she had made statements to him about not wanting to live.

8The Child initially agreed to be placed in the secure treatment facility however, after her arrival she requested a review of her admission.

ANALYSIS

9Section 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).

10Section 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 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

11The Board must decide whether each of the relevant criteria was met at the time of admission on the balance of probabilities.

Criterion (a): the child has a mental disorder

12The Admitting Psychiatrist did not make a provisional diagnosis. She testified that the information she had received from the Crisis Team and her interviews with the Child and the father led her to believe that the Child had a prior diagnosis of post-traumatic stress disorder and anxiety disorder NOS with other suspected but unconfirmed disorders including major depressive disorder as noted in the Admission Summary dated March 24, 2015.

13This information was incorrect as the Child had not been diagnosed with a mental disorder by any of her previous doctors. The Psychiatrist testified that even without a prior diagnosis, she believed that the Child had displayed concerning behaviours and her recent instability could be “re-traumatizing”. She stated that the Child’s impulsivity and her poor social judgement could be associated with her “chronically traumatized childhood” during which she had experienced multiple traumatic events. The Psychiatrist noted the Child’s two very recent involuntary admissions for mental health issues.

14The psychiatrist believed that the trauma of the Child’s early years could have affected the Child’s mental and emotional process. She testified that, in her professional experience, the Child showed impaired judgment as evidenced by her running away from home for lengthy periods of time during which she made poor choices in the community. The Child had minimized her issues on admission but the Psychiatrist believed that the Child’s behaviour showed her emotional disturbance and fragility and pointed to her need for stability.

15The Child admitted to smoking Marijuana and she tested positive for drug use at [Hospital 2]. The Child also admitted to superficially cutting herself. The Psychiatrist testified that in her opinion the Child’s substance abuse, her aggressive behaviour with her family, her poor social judgement, her suicidal ideation, her significant emotional upheaval and dyssregulation along with her at risk behaviour in the community were indicators that the Child was suffering from a mental disorder as defined in the Act.

16The father testified that family has received supports through the CAS beginning in 2002 when a complaint of neglect was made by the Child’s day care against the mother. The mother had moved to several provinces with the Child and in 2012 he gained custody of her and she returned to [City 1] to live with him. The Child and her thirteen year old brother fought frequently and he sought the assistance of his employment services. The family currently participates in the ALERT program which provided pick up and drop off services, small classes, and therapy for the Child who needs educational supports as she had missed many grade 9 credits. The family is also involved with K, a children’s mental health organization that provides help to children, youth and their families. It assisted the father in providing structure and rules within the home using the Multi Systemic Therapy (MST) approach. The family received ten hours of service weekly and a safety plan was instituted along with regular drug testing of the Child administered by the father. The Child also saw a counsellor for cognitive behavioural therapy.

17The father testified that his daughter was highly stressed and argumentative and she wanted to cut herself. She wanted to get away from the family home and she had difficulties sleeping. He also testified that she returned “high” on January 30, 2015 after running away for eight days and she slept for almost twenty four hours only getting up for meals. He stated that that the Child told him that she had used Ketamine, Cocaine, Meth and MDMA.

18The father’s evidence was that he completed regular drug testing on the Child as a part of the home’s safety program but the Child had changed the drugs she used so that they could not be detected when he administered the test. After the Child’s absence in January, she had cut herself with her earrings because all of the sharp objects in the home were locked away. He admitted her to [Hospital 2] because she had lost weight, her colour was pale and she behaved in an aggressive manner, screaming and yelling and angry while refusing to show him her cuts. The Child had committed to working with K on the PALS program on February 2, 2015 however she ran away during the next couple of days and removed the sim card from her phone so she could not be tracked. On her return the Child was restless and would not clean up after herself. The father stated than when he spoke to her about this she “flipped out” and told him that he would drive her to kill herself.

19The father testified that his daughter perceives things differently and the reason she gave him for taking drugs was that she did not want to “feel”. The Child would not acknowledge what transpired during her lengthy absences from the home or his safety concerns. He testified that the Psychiatrist at [Hospital 2] had informed him that his daughter had no attachments or boundaries and the father believed that this contributed to her concerning behaviours.

20The CAS’s Family Service Worker testified that the family received services from the MST and PALS programs through the K organization. The K Clinical Case Manager (“Case Manager”) testified that K provided an intensive in house behavioural management program for the father from April 2014 to October 2014. They also assigned a counsellor for the Child and her brother. The PALS program commenced in September 2014, for the Child and included day treatment along with academic assistance. The Child has not participated since January 2015, except for a few days in February 2015. The Case Manager testified that the Child disclosed to others that she was unhappy at home and in January she wanted to live away from the family. Alternative living arrangements were explored but a psychological assessment was not completed because the team sought to locate a treatment home suitable for the Child’s complex trauma needs. The Case Manager testified that [Hospital 2] had recommended a trauma informed placement for the Child and she believed that the Child was a flight risk who put herself in dangerous situations without feeling that the situations were unsafe.

21The Act states:

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.

22A provisional diagnosis of mental illness was not placed before the Board to explain the Child’s emergency admittance to the facility, however, the Admitting Psychiatrist testified that in her opinion the Childs’s escalating pattern of concerning behaviours and mood instability resulted in the Child’s risky behaviours in the community, her poor social choices, impulsivity, emotional and behavioural dysregulation which indicated that her emotional processes, thought or cognition were grossly impaired as was her capacity to make reasoned judgments.

23The Psychiatrist testified that in her professional experience the Child’s behaviour was consistent with that of a mental disorder which impaired her judgement although it may not have been diagnosed prior to admittance to the secure unit. She noted that the Child’s impaired judgment and her poor decision making has resulted in two mental health hospitalizations since January of 2015. She believed that re-traumatizing of the Child was of concern given the past multiple traumatic events and abuse in the Child’s life. She also stated that the Child’s impaired judgment resulted in her repeated pattern of returning to danger in the community.

24The evidence of the father was that his daughter was highly stressed and argumentative and she would “flip out” when he tried to talk to her. She ran away from home three times for increasingly lengthy periods since January 2015 and on each occasion she took the sim card out of her phone so that he could not contact her. The last absence was for a month and she would not acknowledge the dangers of her lifestyle or his concerns for her safety. Despite in home supports, counselling and academic support the Child continued to abuse drugs, cut herself and make statements about killing herself.

25The Board accepted the testimony of the admitting psychiatrist and finds that the actions of the Child demonstrated a substantial disorder of emotional processes, thought or cognition which grossly impaired her capacity to make reasoned judgements. The Board heard evidence that the Child’s emotional processes were so impaired that she ran away repeatedly from her home and made poor social decisions. The behavioural evidence presented demonstrated that the Child had a substantial disorder of her thoughts and emotional processes at the time of her admission to Youthdale which grossly impaired her capacity to make reasoned judgments.

26The Board finds that there was sufficient evidence before it to conclude that the Child had a mental disorder within the meaning of the Act.

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.

27The Admitting Psychiatrist was of the opinion that the Child posed a substantial threat to cause serious harm to herself and others. She testified that the Child’s capacity to make choices in her best interest was impaired and she has placed herself at risk for extended periods of time in the community under dangerous circumstances. The Psychiatrist cited the Child’s fighting with her brother, and her aggression with her family as potential harm along with suicide ideation. The Child had used drugs including amphetamines, which was identified during the [Hospital 2] drug testing.

28The Child was taken to hospital on two occasions and admitted involuntarily in 2015. During the second admissions her Form 1 admittance was extended on a Form 3 because she was deemed to be a flight risk. The father testified that his daughter made suicidal statements like “what is the point of living?” during their verbal arguments and she wanted him to allow her to smoke Marijuana daily He also testified that the Child has never attempted to harm herself except by cutting her arms superficially and that none of the instances of cutting required medical attention. He stated she had never voiced or acted on a plan to hurt herself or others.

29The Board was not satisfied that by her actions, the Child has made substantial threats to cause serious bodily harm to herself or to others as a result of her mental disorder. The Child led a risky life in the community, she was sometimes aggressive with her family, especially her brother, she superficially cut her arms and she made questioning comments about why was she living, but she did not make any concrete plans to harm herself or others nor did she take any actions to do so. No evidence was presented to establish that the Child caused serious bodily harm to herself or others.

30The Board was satisfied that criterion (b) was not met.

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

31The Admitting Psychiatrist testified that admission to the secure program was appropriate because of the Child’s high risk behaviors which made her a flight risk. She believed that a stable environment free of drugs would facilitate a better understanding of the Child’s disorder.

32The father testified that the Child has been involuntarily hospitalized twice this year and they had had services from K which provided day treatment, counselling, academic and in home supports for the Child. Despite these interventions, the Child’s behaviours did not stabilize.

33The Case Manager testified that as early as January, the Child reported that she did not like living at home and she wanted to live elsewhere. She has a history of chronic trauma and during her hospitalization at [Hospital 2] the recommendation had been made that her caregivers should secure a “trauma informed placement” for her. The Child has been involved with a counsellor but she was not referred to a psychiatrist despite her history of chronic trauma. No psychiatric evaluation or medication trials were conducted except for a brief unsuccessful trial of Quetiapine for insomnia during her last hospitalization.

34Section 124 is under Part VI, Extraordinary Measures, of the Act. There must be extraordinary circumstances before a child is placed on an emergency basis in a secure treatment unit. The right to review the placement before the Board is a significant safeguard, which is in place to protect the child’s right to liberty. The admitting program has a duty to present sufficient evidence to support a finding on the balance of probabilities that on admission, a child has met the criteria set out in section 124(2) of the Act.

35The Board heard testimony that since the end of January and while the Child was hospitalized, a number of placement options were considered, including the secure treatment option. Once the Child agreed to be placed in the secure treatment facility, the Board heard from the Child’s Case Manager that the exploration of all of the other options was abandoned and that there was no other treatment placement that was available at the time of her admission.

36The test to be met under section 124(2)(e) of the Act is not whether another placement is available but rather whether another less restrictive method of providing treatment is appropriate. This is an important distinction. The extraordinary measure of admitting a child to a locked secure treatment facility is not to be viewed as a placement option, but rather, it is to be considered and used only in cases where, having looked at all other less restrictive treatment methods, it is determined that none of them have been or would be appropriate to treat the child’s mental disorder in the circumstances.

37The Board was not satisfied that no less restrictive method of providing treatment for the Child’s mental disorder was appropriate. A psychiatric evaluation of the Child was not completed and appropriate medication was not explored prior to the secure unit admittance. Although both [Hospital 2] and the Admitting Psychiatrist identified the Child’s chronic trauma as an area of difficulty, no interventions to address this issue in an open setting were attempted. Moreover, while placement options were identified, they were abandoned once the child indicated that she would consent to be placed at the secure treatment facility. Finally, despite the fact that the Child indicated in January of 2015 that she no longer wanted to reside with her father and she engaged in running behaviour an alternate placement was not offered to her during that period.

CONCLUSION

38Pursuant to section 124(13) of the Act, the Board, having satisfied itself that criteria (b) and (e) in subsections 124(2) have not been met, released the Child on March 30, 2015.

CONFIDENTIALITY ORDER

39Pursuant to Rules 30.1 and 30.2 of the Board’s Rules of Procedure parties 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, except with an order of the Court or the Board, as appropriate.