M.E. v. Roberts/Smart Centre, 2024 CFSRB 10

CHILD AND FAMILY SERVICES REVIEW BOARD

BETWEEN:

M.E. Applicant

-and-

Roberts/Smart Centre Respondent

DECISION

Adjudicators: Catherine Bickley, Sara Mintz, Tracy Foster Date: February 2, 2024 Citation: 2024 CFSRB 10 Indexed As: ME v Roberts/Smart Centre (CYFSA s.171)

APPEARANCES

M.E., Applicant Renatta Austin, Counsel

Roberts/Smart Centre, Respondent Aaron Rubinoff, Counsel

INTRODUCTION

1On January 19, 2024, the Applicant (the "Child"), made an application to the Child and Family Services Review Board ("CFSRB") to review her January 18, 2024 emergency admission to the Secure Treatment Program at Roberts/Smart Centre ("Roberts/Smart" or the "facility"). A hearing was held by videoconference on January 24, 2024.

2At the hearing, the Child took the position that statutory criteria (c), (d) and (e) in subsection 171(2) of the Child, Youth and Family Services Act, 2017, S.O. 2017, c.14, Sched. 1 (the "Act") were not met at the time of her admission.

3Roberts/Smart called as witnesses Dr. Megan Simpson, clinical supervisor for Roberts/Smart, Mr. Phil Hiltz-Laforge, child protection worker with the Children's Aid Society (the "Agency"), and Dr. Dhiraj Aggarwal, psychiatrist at Children's Hospital of Eastern Ontario ("CHEO"). The Child did not testify or call any witnesses.

4Following the January 24, 2024 hearing, and for the reasons that follow, we denied the application by the Child for release as we were satisfied all criteria under subsection 171(2) had been met at the time of the Child's admission.

OBSERVERS

5With the consent of both parties and the CFSRB, Jean-Michel Dako, an articling student with counsel for the Respondent, and Judith Mendez, case processing officer with the CFSRB, observed the hearing.

BACKGROUND

6The Child is 15 years old. She was placed at Mary Homes Inc. ("Mary Homes"), a group home, in early January 2024. Prior to Mary Homes, the Child lived at home with her mother and stepfather. The Child's maternal grandparents live close to the Child's home and are also very involved with her.

7Mr. Hiltz-Laforge testified that the Child is suspected of having a neuro-developmental disorder and has been on a waiting list for an assessment for approximately 12 months. The results of the assessment may allow the Child to access a broader range of services. Dr. Aggarwal testified that the Child's psycho-educational report, completed in 2023, places her in the second percentile for IQ and she has poor adaptive functioning. The Child has been diagnosed with attention deficit hyperactivity disorder (ADHD), Oppositional Defiant Disorder (ODD), generalized anxiety and separation anxiety disorder. Fetal alcohol spectrum disorders are also suspected but not confirmed. She is prescribed medication for her mental disorders.

8The Child has been seeing a psychiatrist at CHEO on an outpatient basis for approximately one year. She changed to a different psychiatrist at CHEO, but has only seen her once to date. The Child was also recently referred to a 12-week, 5-day per week program for youth with developmental needs, but there is no indication of when that program will begin.

9Approximately one year ago, the Agency became involved with the Child after the Child's mother contacted them with concerns about the Child's behaviours and truancy. This was triggered by an incident with the Child involving human trafficking concerns.

10The Child was also experiencing significant difficulties at school, including conflict with peers, leaving the school without permission, and demanding her mother pick her up on an almost daily basis. Assessments were completed through the school psychologist and meetings were held with Coordinated Access, a collective of community resources that can provide recommendations and referrals for children with complex needs. It was determined the Child required greater support than the school could provide.

11In the fall of 2023, the Child was accepted to M.F. McHugh Education Centre ("McHugh"), a school/day-treatment program with a high ratio of teacher support and counselling. The Child continued to struggle with self-regulation and aggressive and violent behaviours, often to the point of requiring physical restraint of the Child. This led to a one-month suspension requiring a detailed safety plan for her return. Additional resources were allocated and her behaviours at school improved, but at home there was constant conflict. The Child's aggressive behaviours led to many violent incidents at home injuring her mother, her grandparents and herself, as well as extensive property damage.

12In early January 2024, the Child became dysregulated at home and started breaking items and punching holes in walls. When her parents attempted to stop her, the Child threatened to harm herself and to kill her parents. Police were called and the Child was dysregulated to the point of requiring chemical restraint. She was taken to the hospital by police and ambulance and unable to return home due to safety concerns. The Child and her mother signed a Temporary Care Agreement ("TCA") with the Agency, placing the Child in the Agency's temporary care for two months. The Child was placed in Mary Homes and continued school at McHugh.

13The Child's stay at Mary Homes lasted only 12 days. During this time, the Child became dysregulated on many occasions, exhibiting verbally and physically aggressive behaviours, causing significant injuries to herself and staff, and most times requiring restraint by multiple staff. Over the final two days of her stay at Mary Homes, the Child was transported to CHEO by the police twice for separate incidents. During these instances the Child was violent with Mary Homes staff, police and EMS workers. These incidents led to her immediate discharge from Mary Homes because her behaviours were escalating in nature and frequency, putting herself and others at risk of harm.

14The hospital would not admit the Child and her mother took her home. Once home, the Child again became dysregulated and violent. She threw her grandmother to the floor and also threatened self-harm and suicide. She was again taken to CHEO by police and paramedics after having been chemically restrained.

15The Child was admitted to CHEO on January 17, 2024, and continued with periods of dysregulation. The Child was admitted to Roberts/Smart the next day.

THE LAW

16Section 171(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 171(2)(a) to (e).

17Section 171(2) sets out the criteria:

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.

ANALYSIS

18In deciding this application, we must determine whether each of the relevant criteria in subsection 171(2) of the Act was met at the time of admission. This determination is made on a balance of probabilities. If any one of the criteria was not met at the time of admission, we must order the Child released.

19The Child concedes that criteria (a) and (b) were met at the time of admission but argues that criteria (c), (d) and (e) were not.

20We conclude that all five criteria were met at the time of admission.

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

21The Respondent argued that there are significant modalities available at the facility to keep the Child safe and prevent her from causing harm to herself and others. Consideration of the Child's individual needs have been taken into account in the placement.

22Dr. Simpson testified that the facility is equipped to deal with self-harming behaviours such as headbanging; walls are padded, and occupational therapists are onsite to rapidly ensure head protection. The facility has clear sight lines, and access to materials that could potentially be used for self-harm or harm to others is contained. Importantly, staff are well-trained to de-escalate dysregulated behaviours especially with children with cognition issues.

23The Child argued that because there has not been a comprehensive assessment completed, it is challenging to assess the effectiveness of the program for the Child at the facility. The Child further submitted that some behaviours such as hair pulling and headbanging can occur anywhere, regardless of being in a secure environment. The Child also submitted that her separation anxiety disorder would be exacerbated by her placement at the facility and that treatment allowing her to stay in the care of her family would be more appropriate at this time.

24The facility is a secure setting, designed to minimize the risk of harm, with staff well-trained in de-escalating and assisting with coping strategies. Consideration for things such as cognitive deficiencies or separation anxiety disorder are taken into account during de-escalation strategies.

25For these reasons we conclude that criterion (c) has been met.

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

26Dr. Simpson testified that the goal of the Child's treatment is stabilization and further assessment, as well as helping her to re-integrate into the community with supports and an understanding of her triggers. Dr. Simpson indicated that cognitive behavioural therapy (CBT) or adaptive CBT would be most appropriate for the Child and is a modality used at the facility. To date, community-based interventions have not been successful. The facility will work with the family to help them understand the Child's triggers and provide aftercare follow up with the Child and family.

27Dr. Simpson explained that when children have cognitive or expression disabilities, their inability to express themselves can create frustration, triggering stress and dysregulation. Staff at Roberts/Smart are trained to communicate with children with cognitive deficits through methods such as using shorter sentences, and the use of PECS, a picture exchange system which helps those with cognitive delay express themselves. Tools such as PECS help identify triggers that lead to dysregulation. By identifying the triggers and equipping the Child with tools to cope when faced with triggers, she will be more able to remain at a stable baseline.

28A treating psychiatrist attends the facility weekly to meet with patients and manage medications. In addition, the facility integrates and consult with existing outpatient psychiatrists and supports that the Child already has in place. Roberts/Smart will also work with the Child's family and the treatment will extend beyond the 30-day emergency admission for a further three months, helping to ensure the Child's future regulation and appropriate treatment.

29The Child submitted that there is not a clear treatment plan given that a comprehensive assessment has not been completed.

30Given the severity and frequency of the Child's dysregulation prior to admission. the Child requires stabilization in a location where she cannot harm herself or others in order to be effectively treated and assessed. A focus on specific interventions and tools for those with cognitive disabilities will be beneficial to the Child. These interventions and tools are available at the facility.

31For these reasons we conclude 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

32The Respondent submits that treatment and resources in the community have not been effective in treating the Child and less restrictive methods would not be appropriate for her at this time due to the Child becoming increasingly dysregulated, posing a risk to herself and others.

33Dr. Simpson testified that the Child's family has accessed many community supports including Crossroads, school assessments and a psycho-educational analysis were completed, Coordinated Access, a live-in facility, outpatient psychiatric treatment, a counselling service for youth at risk, and respite workers. Additionally, at the time the application was made for secure treatment, Cramer, the open facility aligned with Roberts/Smart was also considered and it was determined it would not be appropriate to meet the Child's needs.

34Mr. Hiltz-Laforge explained that while he did not want to see the Child placed outside of her community, resources available for treatment were exhausted locally. Treatment options in the community did not prove effective to treat the Child's escalating behaviours. At one point, Mr. Hiltz-Laforge looked at an emergency option of housing the Child in a shelter, but it was deemed inappropriate for the Child given the level of care she requires.

35We find there are no less restrictive methods of providing treatment appropriate for the Child's mental disorder. The Child's aggressive behaviours were escalating in the community despite accessing various services and treatments. While we note that the Agency did not extend its search for treatment outside of the local area, we are satisfied that secure treatment is required in order to stabilize the Child while she is being further treated and assessed. Treatment at a different secure facility would also likely be appropriate, but it is beneficial that Roberts/Smart, being a local facility, can not only provide the Child with treatment appropriate to her mental disorder, it will also integrate with the Child's existing community supports and provide follow up care.

36For these reasons we conclude that criterion (e) has been met.

CONCLUSION

37We find that all five criteria in subsection 171(2) of the Act were met at the time of the Child's admission to Roberts/Smart. Accordingly, on January 24, 2024, we denied the Child's application for release pursuant to section 171(13) of the Act.

CONFIDENTIALITY ORDER

38Pursuant to Rules 9.3 and 9.4 of the CFSRB's Rules of Procedure parties and their representatives must not use, share, discuss or disclose any CFSRB 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 CFSRB prohibits the use of any of this information for any purpose outside of the CFSRB's proceedings, except with an order of the Court or the CFSRB, as appropriate.