U.N. v. Youthdale Treatment Centres, 2011 CFSRB 52

CHILD AND FAMILY SERVICES REVIEW BOARD

U.N.

v.

Youthdale Treatment Centres

REASONS FOR DECISION

Date: December 23, 2011

Citation: 2011 CFSRB 52

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

INTRODUCTION

1This is an application by U.N., (the “Child”), 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 November 30, 2011 and related to the Child’s admission to Youthdale on November […], 2011. The hearing was held on December 5, 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, born […], 1996, was admitted to Youthdale on November […], 2011, from her father’s home. This admission was the result of a significant increase in the Child’s ideation about committing suicide. The Child told both of her parents about the increasing frequency of these thoughts, and indicated that she had the means to carry them out. She was seen a couple of times in emergency departments at two hospitals during the week preceding the admission to Youthdale. The recommendation for Youthdale was made by the Child’s counsellor, with the full agreement of the Child and of her parents.

6At the time of admission, the Child had been living with her father in [city]. The Child moved to her father’s home on October […], 2011. The Child’s parents separated in September 2008; their divorce granted them joint custody. Until October […], 2011 the Child had been living with her mother; on that date, the Child went to her father’s home. After a few days, it became obvious that this would become a more permanent living arrangement, and the Child has effectively lived with her father since then. Because the parents live in different cities, the move to the father’s home also required a change in school for the Child.

ANALYSIS

7The Board had to decide if the criteria for admission in the Act were met. The criteria that the Board must apply in secure treatment reviews are set out in the following legislative provision of the Act:

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.

8In this case, each criterion was met, as described below.

Criterion (a) the child has a mental disorder.

9The Board was satisfied that at the time of her 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 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 such behaviours exhibited by the Child while in the care of each of her parents. For example, the parents reported a hospitalization in April 2011 following an overdose of Tylenol. There was another hospitalization in September following an increase in threats about committing suicide. The Child made clear to her parents that she had the means to put her thoughts into action: jumping off a balcony or the roof, overdosing, or deep cutting. The frequency of cutting on the arms increased, and the thoughts about suicide increased in frequency near the end of October. Just prior to the admission to Youthdale the Child was saying to her mother “not an hour goes by that I don’t think about killing myself”.

11The Board heard testimony from G.G., a counsellor at [centre], a Toronto-based Centre focused on child abuse prevention and intervention. Services include assessment and counselling, and a program specifically geared to internet child exploitation. The referral to [centre] had been made on October […], 2011 by the [ ] police, after charges were laid against a person for sex abuse involving the internet. This referral was made after the Child had been living with her father for just a week. On November […], 2011, the family was seen at [centre] for the normal intake meeting.

12The Child met with the counsellor from [centre] on November […], 2011. The Child’s mother was present at this meeting. The counsellor testified that at their first meeting, the Child told her that she was actively suicidal, that she was planning to do harm to herself, and that she had the means to do so. The Child told the counsellor that she has been cutting herself for about two or two-and-a-half years, and that this has increased in thought and in activity since moving to her father’s house and to a new school. She related that she had a very difficult time with the move to her father’s home.

13At this meeting, the Child elaborated on the means that she considers committing suicide: jumping off the apartment balcony or roof, cutting herself with razor blades, and taking pills. The Child related that she has taken pills in the past. In April 2011, she was hospitalized on an emergency basis after taking an overdose of Tylenol. In September 2011, she was again hospitalized on an emergency basis, because of active thoughts about committing suicide. The mother and the Child requested [centre] to provide counselling three times per week, because they realized help was needed. [Centre] was not able to provide this level of service, but a number of sessions were held with the Child. The counsellor also came to the conclusion that the Child’s needs were much greater than [centre] could deal with, and that the risk factors in this case were very high. In late November, there had been cutting incidents, and the Child related that she was actively thinking “every hour” about harming herself by cutting. Consequently, [centre] made the suggestion of a referral to the Youthdale crisis unit. The single most important factor in making this referral was [centre’s] desire to ensure the safety of the Child. After making this referral, [centre] stayed involved to ensure that all necessary steps would be taken to secure the appropriate placement for the Child.

14On November […], 2011 the Child was taken by the father to [the Hospital]; she was discharged that same evening.

15On November […], the Child was again taken to [the Hospital]. She was frequently and actively thinking about suicide, 4 or 5 times per day. An inpatient admission was discussed as a possibility, but it would have been for a maximum stay of 3 days. [The Hospital] decided not to admit, with the rationale spelled out in their “Emergency Visit Discharge Information Sheet”, given to the Child and the parent. This Discharge Information Sheet (Exhibit R1) refers to the fact that the Child was going to Youthdale early the next week. The Discharge Information Sheet also noted “Depression – no suicidal ideation tonight”.

16Even though the Child moved to her father’s home in late October, the Child had been at the mother’s home on the weekend of November […], just preceding the November […] visit to [the Hospital].

17The Board heard evidence from both parents, describing similar incidents and conversations. The parents’ testimony was that the Child, during the weekend of November […], 2011, was acutely exhibiting high risk thoughts. They quoted the Child as saying “there’s not an hour that goes by that I don’t think about killing myself”. Other conversations that weekend covered the topics of more cuts being made on her arms, and that the Child has bulimia and throws up regularly after meals. They also testified that on Sunday afternoon, the mother did access the Child’s Facebook and found what she described as “porno pictures” of her daughter that had been sent to boys who were friends of the daughter. The mother also commented that it was easy for her daughter to be victimized “after the incident with the guitar teacher”.

18The father’s testimony related very similar conversations with his daughter. He related that during a conversation on November […], the Child told her father about the very frequent suicidal thoughts that she has, about her frequent cutting, and about her bulimic vomiting. The Child relayed that she felt very stressed and very unsafe.

19The mother’s testimony included parts of the conversation she had on the November […] weekend, where the Child indicated that she knew she was experiencing crises, and that she wanted to be taken to a hospital. The mother twice more repeated the quote from above, namely “there’s not an hour that goes by that I don’t think about killing myself”. She believed that, if left alone, the Child might act on her suicidal thoughts. She testified that the cuts on her arms were deep, that they had left scars, that she has seen blood on her bed sheets, and that she, as a trained nurse, had applied dressings to them on occasion. On one occasion, the mother had to call 911; the attendant medics acknowledged the cuts were deep, and the Child was taken to hospital where she was kept for 2 hours.

20The mother testified that, this past summer, the Child on separate occasions had ingested heavy doses of Gravol, the anxiety medication Affexol and Benadryl. Cutting incidents used scissors, and when these were removed, the Child started collecting and stashing the blades removed from razors.

21Although 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. The Board believes that the pattern of suicidal ideation, at times on an hourly basis, and the behaviour of cuttings as exhibited by the Child in the months before her admission to Youthdale, clearly demonstrates, on a balance of probabilities, that she has a mental disorder as defined by the Act.

22The Board finds that these behaviours show a substantial emotional and cognitive disorder because the Child cannot regulate her suicidal thoughts or actions. These grossly impaired the Child’s judgment because she continues to make unsafe choices on a repeated basis, and has spoken about having the means to give effect to these choices.

23The Board was satisfied that criterion (a) was met at 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.

24The 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.

25The Board heard testimony from the parents, from the counsellor at [centre], and from the written Discharge Information Sheet from [the Hospital] 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, and frequent suicidal ideation.

26While the Child lived with her mother in [city 2], the mother became increasingly concerned about the Child’s escalation in behaviour, specifically the thoughts of suicide and the incidents of cutting. This deterioration gradually happened over the last two years, with a significant escalation since the summer. The behaviours continued their escalation when the Child moved to her father’s home in [city].

27The Board finds that, as a result of the mental disorder, the Child has made substantial threats through her actions and attempted suicides, as well as her verbalizations to cause serious bodily harm to herself. The Board recognizes that there have not been any threats made against others; rather, the focus of the Child has been to do harm to herself.

28Of significant concern is the deterioration in the last 2 months in the Child’s behaviour and the increase in intensity of the behaviours that can cause serious harm. Because of this escalation, the Board has determined that inevitably, an episode of cutting will cause serious harm to the Child. The Board’s finding is based on the Child’s past experience of a hospitalization for a drug overdose, the history of cutting with its increased frequency and severity, the need for a call to 911 after one episode of cutting, the increasing frequency of suicidal ideation expressed to the parents, the Child’s repeated statements of the means available to her to commit suicide. It therefore finds that the Child’s words and conduct constitute a substantial threat to cause 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.

29The 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.

30A Youthdale staff and member of the psychiatric crisis team, testified on behalf of the team with a description of what the secure unit would have available for the Child: a structured in patient program; stabilization in a secure setting, and a comprehensive psychiatric assessment. He explained that a youth could receive 1-to-1 staffing if required to ensure their safety, that any sharp and potentially harmful items are not available, that any objects such as pencils and cutlery are used under strict supervision and are always counted when their use is finished.

31The 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.

32The Board was satisfied that treatment appropriate for the Child’s mental disorder was available at Youthdale.

33The Youthdale staff explained that each Child is connected with a psychiatrist, and that there is constant staff supervision throughout the day. As well, there is constant counselling available from staff trained in various disciplines. A thorough assessment is done, and any current medications are reviewed. Any new medications are prescribed as needed.

34The Youthdale program will provide safety and security to the Child. In addition, the unit provides a full staff complement to provide nursing, counselling, and treatment planning as required. As well, there is the opportunity for a medication review and stabilization of any 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.

35The treatment program at Youthdale is intense in nature: it is medical, with psychiatric intervention available and provided to each resident. It is insight oriented, with the goal to lessen or eliminate the behaviours that presented a high risk at the time of admission. Psychotherapy and counselling are available. Youth, such as the Child, will start withdrawing from their habit of cutting by means of removing of any materials used in cutting, and by therapy aimed at changing the root causes of such behaviour. Medication can be prescribed as required, and the child will be stabilized on any such medication prior to discharge.

36The 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.

37The question for the Board is whether a less restrictive method of providing appropriate treatment is appropriate in this case. The answer to that question is: no.

38The conversations with the Child wherein she repeatedly relates her thoughts about dying, her description of the means at her disposal to bring about a suicide, and the repeated visits to hospital emergency wards which did not bring about lasting changes in the Child’s thoughts and behaviours made the parents realize they did not have the ability to cope with these escalating behaviours, and led them to conclude that they could no longer keep the Child safe at their respective homes.

39Both parents, in their testimony, gave a listing of the various settings that had seen the Child, including the following:

• [centre 2], after the overdose;
• counselling services from [program] (an employee assistance program);
• the first hospitalization in April 2011, consisting of 7 days of inpatient (after a substantial overdose of medication), followed by outpatient services which the parents said was not effective;
• contact with a counselling service in [city 2], which suggested that the Child move to her father’s home because at that time, there was an excellent bond and trust between daughter and father;
• hospitalization at [hospital 2] in September, where the parents report that there was no psychiatrist available other than one very brief face-to-face contact;
• counselling at the Child’s former school in [city 2];
• an attempt at counselling services at […] Services in [city];
• [centre] (referred by [… Services]) when the Child moved to [city];
• the various contacts with [the Hospital], which did not address any of the root causes of the Child’s self-destructive behaviour.

40[The Centre] recognized, based on many years of service delivery, that it was not capable of delivering the intensity of services required in the Child’s circumstances. In [centre’s] opinion, this Child would not be able to obtain the necessary intensity and safety of assessment and treatment services in the community to meet her needs. This is so especially in view of the fact that the thoughts about suicide were increasing in intensity and in frequency, and that the Child articulated very plausible means of achieving those ends. In fact, her hospital visits were all in response to her frequently articulated thoughts; however those hospitals were not able to provide the service over a period of time, as is required to get at the root causes of the Child’s emotional distress.

41On a number of occasions, when the Child was hospitalized, she was discharged when the acute stage of suicidal ideation had diminished. However, the thoughts of suicide often returned soon after a visit to the hospital. The community-based hospital settings are not geared to keeping a Child on a longer term basis, to deal with the root issues that are causing the self-destructive ideation and actions such as those experienced by the Child.

42The counsellor indicated that the referral to Youthdale also involved a referral to the Mobile Crisis Unit of Youthdale; she stated that this Unit told her that placement in the secure unit was preferable, based on the input from the counsellor and from the father. A structured program is what [centre] felt was needed, and [centre] also relied on Youthdale’s assessment of the situation in determining if the secure unit would become the placement of choice.

43The Child was again taken to [the Hospital] on November […], 2011. An inpatient admission was discussed as a possibility, and in fact seen as the best option, yet she was discharged a couple of hours later. The hospital’s discharge notes (Exhibit R1) provides the rationale for this discharge, referring to the fact that the Child was going to Youthdale early the next week. This rationale in the discharge note is in effect a confirmation from [the Hospital] that Youthdale is a suitable place, necessitated by the Child’s risky behaviour and past suicide attempts, and that [the Hospital] was not in a position to offer the required level of safety.

44None of the contacts with and admissions to hospitals resulted in any referrals to any setting, other than Youthdale’s secure unit, that would be appropriate to respond to this Child’s risk levels and strong need for assessment and intervention to identify and change the root causes of her distress.

45The professional staff at [centre] saw Youthdale as the only appropriate setting for a child with this level of suicidal ideation and high-risk cutting behaviour, and therefore made the referral to Youthdale.

46The Youthdale staff testified that anyone with suicidal tendencies, such as exhibited by the Child, would not be a suitable placement in the open and voluntary unit, and that the admission would not be suitable for this Child, even if a bed were available, because the open program could not ensure her safety and security. This child with her current level and frequency of suicidal ideation, and various attempts at suicide, could not be kept safe in any open program.

47Both parents in their testimony stated that, in all of their contacts with various professionals, no one was able to suggest a more appropriate or less restrictive setting than Youthdale. The mother stated that on several occasions, she asked for a referral to a psychiatric service, as she knew that more intensive and longer term help was needed for her daughter. None of the facilities made such a referral, until [centre] became involved and made the referral to Youthdale crisis unit. The mother stated she was looking for intensive mental health services, where a professional multi-disciplinary team could develop a specific plan and implement intensive therapeutic work. Without such planning, she sees that the Child would be at high risk of self-harm in an open setting. The mother did not see any effective results or longer-term change in behaviour from the various out-patient counselling services that the Child had so far received, or from the hospital emergency rooms where the Child has been seen on a number of occasions.

48The father specifically stated in his testimony that a unit in a general hospital, such as [Hospital 2], would not be sufficient: it would provide only an emergency response, and would be a placement of one week or less. At [the Hospital], the maximum stay would have been 3 days.

49The father’s testimony was that the Child did not feel safe, and that she expressed the need for safety and the need to feel secure. He testified that, in seeking admission to Youthdale, both he and the Child knew that the unit at Youthdale was a locked unit. The father quoted his daughter as saying that she doesn’t feel safe from herself, and if she can walk out of a setting, she doesn’t feel safe.

50The father testified that, in his view, the various visits to hospitals did not change the behaviour of the Child. They may have removed an immediate threat of harm, but did not contribute to changing the pattern of suicidal thoughts and high-risk behaviour.

51Both parents have testified to their inability to manage the Child’s repeated high-risk behaviours in their respective homes. They explored many other options, but none are as structured and safe as is necessary in the circumstances.

52The Board finds that no less restrictive method of providing treatment appropriate for the Child’s mental disorder is appropriate in the circumstances. The Board was satisfied that criterion (e) was met.

CONCLUSION

53Pursuant 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 December 5, 2011.

Lorna King

Presiding Member

John F. Spekkens

Panel Member

Mary Wong

Panel Member