J.L. v. Youthdale Treatment Centres, 2011 CFSRB 39

CHILD AND FAMILY SERVICES REVIEW BOARD

J.L.

v.

Youthdale Treatment Centres

REASONS FOR DECISION ON MERITS

Date: November 9, 2011

Citation: 2011 CFSRB 39

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

INTRODUCTION

1This is an application by J.L. (the “Child”), born March […], 1996 for a review of her emergency admission to the Secure Treatment Program at the Youthdale Treatment Centre (“Youthdale”), pursuant to section 124(9) of the Child and Family Services Act (the “Act”). The application was dated October 4, 2011 and related to the Child’s admission to Youthdale on October […], 2011. The hearing was held on October 14, 2011.

2The Board must decide, on a balance of probabilities, whether each of the criteria set out in subsection 124(2) of the Act was met at the time of admission. The Respondent’s position was that all five criteria had been met and that the application should therefore be denied. The Child’s position was that all five criteria had not been met and that she should be released.

3Pursuant to section 124 (13) of the Act, upon review, 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 clauses 124 (2) (a) to (e).

4For the reasons that follow, the Board found that the Child meets all of the five criteria for admission and denied the Child’s application to be released.

BACKGROUND

5The Child is a 15-year-old girl who was admitted to Youthdale on October […] 2011, from her parents’ home. She was adopted at age 6; until some six months ago, there was no contact with her birth mother. The family includes an older brother, age 24, who was also adopted. Both came to the current family after adoption breakdowns elsewhere.

6The Child is registered in grade 10, at [School] in [City].

ANALYSIS

7The criteria that the Board must apply in secure treatment reviews are set out in the following legislative provision:

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.

8Each of the above criteria must be met at the time of admission to confirm the Child’s placement at Youthdale. In this case, each criterion was met, as described below.

Criterion (a) the child has a mental disorder.

9The Board is satisfied that at the time of this admission, the Child had a mental disorder within the meaning of the Act. A mental disorder is defined as a substantial disorder of emotional processes, thought or cognition, which grossly impairs a person’s capacity to make reasoned judgments.

10The Child’s father testified that the Child’s behaviour escalated late in the 2010-2011 school year, with an assortment of issues: skipping school, associating with peers much older than the Child and putting herself at risk in their activities such as roaming, illegal drugs, alcohol and sexual activities. The father described an incident where the Child left the school with another student and they went to a nearby park. The Child described what then happened as a rape, but police involvement did not result in any charges. In the past month or so, the Child’s behaviours escalated dramatically: clear and frequent expressions of hopelessness, statements of not wanting to live, and cuttings on both her forearms.

11Academic performance at school deteriorated significantly over the last few months of school. In the first semester of 2011, the Child was very successful at school, got very good grades, and received 4 out of 4 possible credits; in the second semester, she missed much school, and only got 2 out of 4 credits.

12At home, both parents became increasingly concerned about the Child’s escalation in behaviour. Much of the parents’ time and energy is spent trying to minimize the risks posed by the Child’s behaviour. The Child repeatedly says that her friends are the only ones who understand her. She will tell her parents repeatedly “You don’t understand me – I need help”. On at least one occasion, her friends did call 911, with police and ambulance responding; the friends were concerned for her safety. The father testified that he has not been employed for the last eighteen months, but that he has been “working full-time” for this period of time at keeping his daughter safe. He did express the strong opinion that he and his wife now feel that, with the escalating behaviours, they can no longer keep the Child safe at home. The parents strongly believe that Youthdale is required to break the cycle of the escalating risky behaviour. They have not been able to find any other service in the [City] area or in [County] that could meet the Child’s needs.

13Sleeping habits at home have also become distorted: for several months, the Child will sleep with the mother in the parents’ bed. The Child demands this arrangement, based on her being fearful of things at night – though she cannot articulate to the parents what her fears are about. Even on days when she is most angry with her mother, she will come to bed with her every night. The mother, in her testimony, indicated that this has been the practice every night for the last six or seven months. She explained the Child said she was afraid to sleep alone, that she was afraid that she might hurt herself.

14The father testified that at the beginning of October, he contacted Youthdale and had a two-hour intake interview. The father testified that the psychiatrist at Youthdale expressed to him his strong concerns that the Child was at strong risk and suggested she be taken to [Hospital] that evening to keep her safe.

15On October […], 2011, after a drug deal that went bad with an ex-boyfriend, the Child was taken by her father to the [Hospital] in [City], in line with the Youthdale psychiatrist’s suggestion.

16The father testified that he and his wife had found shards of broken glass and broken mirror in many locations throughout the house. They have also seen numerous Facebook entries, which raised serious concerns for them as to the level of risk in their Child’s behaviours. He also stated that there have been a number of incidents where the Child would run into busy traffic; so far, no serious harm resulted from this behaviour.

17With regards to the Child’s sexual activities, the father testified that he knows that the Child, at age 15, has had a total of five sexual partners.

18The mother’s testimony was very consistent with the testimony of the father. She related many of the same situations and incidents described above. The mother testified to a number of other situations that have occurred in the last number of months.

19The mother received the call from the school on September […], 2011 when the guidance counselor reported that the Child had been in her office and told her that she was afraid she was going to kill herself. The Child had a plan to kill herself. That incident led to a referral to [Treatment Centre], a large Children’s Mental Health Centre that offers both out-patient and residential treatment services.

20The mother has seen items that her daughter uses to cut herself, namely knives, scissors, and glass shards. The cutting incidents are becoming more frequent and the mother believes that the Child gets a physical “kick” out of cutting herself and that the pain actually makes her feel better. The mother described the Child’s fascination with fire; she always carries a lighter with her.

21The Board also heard testimony from S.L., Chair of the Special Education Department at [City] Secondary School. He has spent a considerable portion of his time working with and for the Child. In their sessions, she constantly uses phrases such as “questioning whether to continue being part of the world”, “why get up in the morning”, and “why keep on going”.

22S.L. expressed the strong view that the Child is at serious risk of being harmful to herself and has numerous suicidal thoughts. He sees her as one of the most at-risk youth he has worked with over his 17 year career in Special Education. He sees a significant and steady deterioration in her behaviour and the risk to herself in the last six months or so. He sees serious risk in her very impulsive behaviour and inability to work through the normal issues that teenagers face and eventually resolve.

23M.W., a social worker, has seen the Child in individual counseling on five occasions. She described the Child as unable to talk about issues that trouble her on an emotional level. She described how the cutting and the numerous piercings give the Child pain, but quoted the Child as saying “When I’m upset, I enjoy the pain”.

24The Child acknowledged many of the incidents that had been mentioned in previous testimony – notably the October […] texting to her mother that she “couldn’t take it anymore”, the May […] incident when she ran into traffic and acknowledged that she “was going to do it”, the December incident when a friend called 911 and her father drove her to the hospital – all these incidents were explained by the Child as “attention seeking”.

25In August 2011, while talking to someone on webcam at 2 a.m., the Child started cutting herself with scissors, because she said she was bored; she described this incident as “attention seeking”. She described how she cut herself with scissors, but denied using shards of glass and broken mirror that her parents found in her room – she stated that she was saving these pieces of glass in a box in her room to eventually use in an art project involving a collage of glass shards. The Child showed her forearms to the Board; the forearms did have scars visible, but these scars appeared not to have resulted from deep cuts.

26In her testimony, the Child described the loneliness she feels, living on a county road outside of [City], and where she has no friends. This is why she wants to spend so much time in [City], just to be with friends and away from home. She acknowledges problems at school and blames much of her absenteeism on boredom with school. She described her unusual sleeping arrangement as a way to get “more time together” with her mother with whom she acknowledges not having a good relationship.

27The Child described one of her biggest fears is that of not being wanted or loved. She referred to a time in her life when she knew she wasn’t wanted.

28The Child described in some details, voices she hears and visions that she sees. She described a creature in her room telling her that she wasn’t wanted or loved. The Child said that she also saw the grim reaper and two angels in her room, and in fact drew a schema of her room and indicated where these visions were. When queried by the Board whether these visions were in her imagination, or whether they were real persons similar to persons in the hearing room, she responded that they were “real, very real”.

29The Child gave her explanation for many other behaviours that were referred to in the testimony of others: she stopped taking her medications because she saw negative changes in her behaviour while on these medications; the cuttings she described more as scratches and a way to get the attention of her parents, to “get a rise out of them”. Initially she did cutting because of boredom, but this escalated to now getting a sense of rush from them. She mentioned that she doesn’t want to die, that she thinks about death intellectually, but also that she believes she could have “a great life”.

30A mental disorder is defined as a substantial disorder of emotional processes, thought or cognition, which grossly impairs a person’s capacity to make reasoned judgments. The Board heard from the Child’s parents about behaviours that reflect a substantial disorder of emotional processes, thought or cognition which grossly impairs the Child’s capacity to make reasoned judgments. There were multiple and repeated instances of behaviours exhibited by the Child while in the care of her parents. The Child’s dismissal of the incidents of cutting as mere attention-seeking is just not credible and demonstrates grossly impaired judgment, given the severity of her behaviours. Many of these behaviours are high-risk to the Child in that they are inappropriate and dangerous. The description of angels and the grim reaper as being real people in her room, rather than the result of a vivid imagination, are indicative of thought disorders.

31Although the Board did not hear direct evidence regarding a current diagnosis, the weight of the behavioural evidence provided by the witnesses was sufficient to conclude that the Child suffers from a mental disorder. Since there was no psychiatrist to present to the Board the psychiatric assessment resulting in her admission to Youthdale, the Board did not give any weight to the psychiatric reports that were made available to it.

32However, the Board believes that the pattern of behaviour exhibited by the Child in the months before her admission to Youthdale that are outlined in the preceding paragraphs, on a balance of probabilities, clearly demonstrates that she has a mental disorder as defined by the Act.

33The Board was satisfied that criterion (a) was met at the time of the time of admission.

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 another person.

34The Board was satisfied that the Child has, as a result of the mental disorder, attempted to cause or by words or conduct, made a substantial threat to cause serious bodily harm to herself or another person.

35Since there was no psychiatrist called by Youthdale to present to the Board the psychiatric assessment resulting in her admission to Youthdale, the Board did not give any weight to the psychiatric reports that were made available to it.

36The Board heard direct testimony from the parents, professionals who have worked with the Child, and from the Child herself that substantiated that the Child has on many occasions threatened to harm herself and engaged in serious self-harming behaviours. The Board heard of multiple instances of cutting, high-risk behaviours and hallucinations that placed the Child at risk of serious bodily harm.

37M.W. described how the Child’s impulsivity leads to a high level of risk that she will do harm to herself. Her opinion is that this is significantly beyond simple attention-seeking behaviour.

38The Board is of the strong opinion that, as a result of the mental disorder, the Child has made substantial threats through her actions and her verbalizations to cause serious bodily harm to herself. Of significant concern is the deterioration of the Child’s behaviour and the increase in intensity of the behaviours that can cause serious harm. Fortunately, through active intervention by parents, major injury has been avoided so far. However, the Board is of the opinion that inevitably, an episode of cutting will cause serious harm, or an episode of walking into traffic will cause serious injury. The hallucinations of having the grim reaper or angels in her room are very vivid and very real; it would only take a small escalation for her to hear voices from these hallucinations telling her to do things that would be harmful to herself or others. As referred to above under criterion (a), the verbalizations to her mother less than a week before admission to Youthdale that she “couldn’t take it any more”, or to her friends when she ran into traffic that she “was going to do it” are significant, substantial, and real. By her actions, the Child has followed through on many of her threats.

39The Board recognizes that there have not been any threats made against others; rather, the focus of the Child has been to harm herself.

40Not a single professional who has seen the Child has dismissed her comments and actions as attention-seeking. Instead, each has seen them as a significant threat to herself, requiring significant intervention.

41Based on this evidence, which also appears in more detail under criterion (a), the Board is satisfied that criterion (b) has been met in terms of the Child’s attempts to cause and substantial threats of causing serious bodily harm to herself.

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.

42The Board was 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.

43Both parents in their testimony described their understanding that at Youthdale, the Child would not have any access whatsoever to sharp objects such as glass shards, knives, scissors, as well as no access to lighters.

44B., a Youthdale staff, testified on behalf of the team with a description of what the secure unit would have available for the Child: a psychiatrist on site and on call, a nurse in the unit 24/7, psychology and social work staff, a structured program with clear routines, assessment and group and individual therapy. He described the staffing pattern as a minimum of three staff, with constant bed checks; as well, any objects which could be used by any resident to harm oneself or others are removed. As well, the Child is taken off medication to observe behaviour in the controlled environment when she is not on medication; if required, medication will be prescribed at an optimum level.

45The 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.

46The Board was satisfied that treatment appropriate for the Child’s mental disorder was available at Youthdale.

47The Youthdale staff testified that at Youthdale, they could keep the Child safe since she would be in a locked setting with continuous observation to ensure that she does not harm herself. Sharp objects and lighters are not available. The unit provides 24/7 nursing staff coverage and the opportunity for a medication review and stabilization of her ongoing medication needs. Professional staff are available to provide individual therapy for the Child as well as group therapy to assist her in finding ways to safely cope with her feelings and gain control from within over her conflicted behaviours. As well, an assessment at the sleep clinic could be arranged which is appropriate given her fears regarding sleeping alone.

48Youthdale is an appropriate placement for the Child while it is determined whether the Child can return home to her parents, with strong out-patient supports, or whether long term treatment residential services are being sought to address her needs and the ongoing assessments are being completed. The treatment results can be used for long term treatment planning, a medication review can take place while the Child is at Youthdale and a possible sleep disorder suffered by the Child can be assessed. Specifically, the current sleeping arrangements can be reviewed in detail, with suggestions made to revert back to a more age-appropriate sleeping arrangement for the Child.

49The 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.

50The father in his testimony stated that they have not been able to find any other service in the [City] area or in [County] that could meet the Child’s needs and provide the level of safety that her current behaviour requires.

51When the father went to get her at the school, the Child told him that she wanted to go to the hospital, that she was afraid that she was going to hurt herself. The Hospital has no child psychiatrist on staff, but she was kept overnight for observation. The Hospital did not complete a Form 1 because the Child had an appointment the next day with her psychiatrist, Dr. R.. The hospital discharged the Child on October […], and felt that with the father being at home full-time, he could keep the Child safe until her medical appointment the next day. The father related that in her meeting with Dr. R., the Child said that she wanted to go to Youthdale, and that the doctor’s response was “that’s exactly where you need to be”. The father testified that, in the next couple of days, Youthdale made numerous calls to the home, to ensure that he was able to ensure the Child’s safety.

52The father testified that in conversation with his daughter, she was starting to accept that a stay at Youthdale would be beneficial to her. At school the next day, the Child went to the guidance counsellor and indicated that she was going to kill herself. The father indicated that his daughter had been given a referral to the [Treatment Centre] program in [City]; she did make a contact with [the Treatment Centre], but that all that [the Treatment Centre] would offer her was group counselling sessions that would focus on building self-esteem. The father indicated that the Child’s reaction was that these groups were not sufficient for her needs and re-iterated to her father that she needed Youthdale.

53The admitting physician at [the Hospital], during the Child’s October […] hospitalization, indicated that placement at Youthdale was what the Child needed.

54The Chair of Special Education recommended a setting such as Youthdale, to contain the impulsive and high-risk behaviours in the Child.

55M.W. suggested Youthdale and knows of no less-restrictive setting that could meet this Child’s needs at this time. Her recommendation was that the Child receive a service that would provide containment, which leads to behaviour stabilization, which then leads to getting some insights into her thoughts and behaviours. She sees a great need for a full assessment and for stabilization of the Child’s medications. She knows of no setting other than Youthdale that would be able to provide what the Child needs at this time.

56The father testified that, even if an admission could be gained to the [Hospital B] in [City B] and to [Hospital C] in [City C], they would only keep the Child for a day or two. The Child needs intensive short term treatment, a comprehensive assessment, a treatment plan, medication stabilization and investigation of a possible sleep disorder. These interventions require a longer term and secure program like that offered at Youthdale. Reference was made above to the group sessions offered by [the Treatment Centre], however this was not sufficient at the time of admission. The parents would like the Child to return home after Youthdale, on the belief that Youthdale can set new directions for the Child and her parents to work on; without this, the parents do not feel they can properly care for and provide safety for the Child.

57The mother, in her testimony, outlined the various other attempts that have been made, unsuccessfully, to get intensive help for the Child. These steps include individual therapy with social worker M.W., a number of appointments at the hospital’s eating disorders clinic from spring to fall of 2010, appointments with Dr. H., pediatrician, who prescribed Concerta and Seroquel, with very little positive effect, due in part to the Child’s irregular use of the medication and eventual refusal to take any medication. [Treatment Centre B] was also consulted, but did not have anything to offer that would be geared to the Child’s intense level of clinical needs.

58The parents have become unable to manage the Child’s repeated high-risk behaviours at home. They explored many other options, but none are as structured and safe as is necessary in the circumstances.

59Each professional who testified saw Youthdale as a setting of choice for the Child at this time; this was also recommended by the physician at [Hospital] and by the Child’s s psychiatrist.

60The Child testified and described various steps she had taken to get help, notably the call to and meeting with a [Treatment Centre] staff and the five appointments she had with M.W..

61The Board is satisfied that no less restrictive method of providing treatment appropriate for the Child’s mental disorder is appropriate in the circumstances. The Board is satisfied that criterion (e) was met.

CONCLUSION

62Pursuant to section 124 (13) of the Act, the Board was satisfied that the criteria in subsections 124 (2) (a) through (e) have been met and therefore dismissed the application of the Child, under section 124(9) of the Act, on October 14, 2011.

Ruth Ann Schedlich

Presiding Member

John F. Spekkens

Panel Member

Mary Wong

Panel Member