CHILD AND FAMILY SERVICES REVIEW BOARD
V.R.
v.
Youthdale Treatment Centres
REASONS FOR DECISION ON MERITS
Date: July 24, 2011
Citation: 2011 CFSRB 16
Indexed as: V.R. v. Youthdale Treatment Centres (CFSA s.124)
1This is an application to the Child and Family Services Review Board (the “Board”) by V.R., (the “Child”), born September […], 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 June 10, 2011 and the hearing was held on June 15, 2011.
2The Board must decide, on a balance of probabilities, whether each of the criteria set out in subsections 124(2) of the Act was met at the time of admission, having regard to the best interest of the Child. Youthdale’s position was that all five criteria had been met and that the application should therefore be denied. The Child’s position was that criteria (a), (b) and (e) were not met and consequently, she should be released.
3For the reasons that follow, the Board found that the Child did meet criteria (a) (b) (c) (d) and (e) at the time of her admission and therefore denied her application for release from the secure treatment program at Youthdale on June 15, 2011.
PROCEDURAL ISSUES
4The Child’s lawyer objected to the admission of the Form 14 and the Youthdale Admission Summary into evidence unless the admitting psychiatrist was available to give evidence and be subject to cross examination. He argued that the Child’s Charter rights would be subject to infringement since she is losing her liberty and that elevates the standard of procedural fairness to a very high degree. He argued that the absence of the admitting psychiatrist for cross examination was prejudicial to the Child as she would be unable to test the very evidence which had deprived her of her liberty and Charter rights through cross examination. He also argued that the documents were not business records and could not be entered as such. He relied on previous Board decisions; ES10-0010, ES10-0027 and ES10-0034.
5Counsel for Youthdale argued that previous Board decisions are not binding on the Board and that the diagnosis by the Youthdale admitting doctor has a high probative value and outweighs the prejudicial effect. She relied on Starson v. Swayze, 2003; SCC 32, paragraph 123 which she argued allows the admittance of hearsay evidence in Board hearings. She acknowledged that hearsay evidence cannot be tested; however, she argued that this evidence could be accepted by the Board and given the appropriate weight. Counsel for Youthdale also acknowledged that the Child’s liberty was at stake; however she also noted that this had to be balanced with the Child’s safety.
6The Board questioned the availability of the admitting psychiatrist to attend the hearing and Counsel for Youthdale responded that no psychiatrist was available as they were “busy treating other children”.
7The Board ruled that the Form 14 and the Youthdale Admission Summary would not be admitted into evidence without the admitting psychiatrist present for cross examination. The Board rejected the Youthdale position that they were too busy to participate fully with a high standard of procedural fairness by providing the admitting psychiatrist for cross questioning and explanation of the diagnosis.
8The Child’s Counsel conceded criteria (c) and (d) of the Act and stated that he would not be leading evidence against those criteria, however he challenged criteria (a) (b) and (e).
9The Board heard from the Child’s mother who presented the case for her admission and the Youthdale crisis worker who introduced the Crisis Assessment Form. He gave evidence that the crisis team had contacted the Child’s care givers to obtain the current and historical information required before admission could be recommended. Contacts included her school counsellor, the Children’s Aid Society of [ ], [Organization A], and [Organization B].
BACKGROUND
10[The Child] is a fourteen year old girl who lives with her mother and her stepfather. Her father is currently in jail; however, she enjoys a close relationship with him. The Child’s parents separated in 2006 under “volatile” and difficult circumstances. The Child and her mother moved in with her maternal grandparents with whom she was very close. The Child lived through the passing of both of her grandparents from cancer in 2007 and disclosed sexual abuse by her uncle in 2008. The abuse had started during the difficult time when she was eleven years old.
11The Child attends [School A] in [City] and she has been skipping school since grade seven although she is reported to be a brilliant student. She was recently granted leave for compassionate reasons. A Psychiatrist, Dr. M. diagnosed the Child with Post Traumatic Stress Disorder in 2009, and prescribed Prozac 10 mg which proved unhelpful. This medication was changed to Seroquel 25mg when the Child was admitted to the [Hospital A] in [City] during May, 2011 on a Form 1.
ANALYSIS
12Under section 124 (2) of the Act, the Board must decide whether each of the following legislative criteria were met at the time of admission:
(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.
Section 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).
13The Board is therefore required to release the Child unless all criteria are met. The Board concluded that in this case, criteria (a) to (e) were met at the time of admission, thus, denied the Child’s application to be released from Youthdale.
Criterion (a) the child has a mental disorder.
14The 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. The evidence demonstrated that, at the time of admission, the Child did have a substantial emotional processes disorder which grossly impaired her capacity to make reasoned judgements.
15The Child’s mother testified that her concerns for her daughter started in 2005 during the difficult separation from her husband who had issues with alcohol at that time. Her husband blamed her for their difficulties and her daughter blamed herself. Added to that was the loss of the Child’s beloved grandparents in the home and the sexual assault by her uncle.
16The mother stated that during the last month the Child’s behaviour has escalated to the point where she was hospitalized on a Form 1. The Child went missing on April […], 2011 and was found in a house described as a “crack house”. In another incident on April […], 2011 the Child got off the bus 5 km away from her intended destination at night and later reported to her mother’s friend that she had been kidnapped and sexually assaulted. The Child did not call police when she had the opportunity and refused treatment at the hospital.
17The Child’s mother testified that on May […], 2011 the child was found on the side of the road intoxicated and passed out. She was taken to hospital where it was deemed that she was one hour away from hypothermia. The Child’s risky behaviour endangered her life. When she woke up in the E.R., she spat at the nurses because they would not allow her to use her phone.
18The Child’s mother stated that the out of control behaviours continued on May […], 2011 when she jumped out of a moving car because she did not want to stay at the cottage. She did not return home on the night of May […], 2011 and she told her mother that she did not have the right to know where she was. On May […], 2011, when the Child came home at 10:30 pm, she demanded her phone. The mother tried to set limits and said no, resulting in the Child smashing empty bottles from the recycling bin against her mother’s bedroom door for twenty to twenty five minutes. The mother testified that the Child’s foot was cut by the broken glass and that she had been afraid for their safety as the Child had threatened to kill her mother and herself. This incident necessitated police involvement and resulted in the Child being admitted to [Hospital A] on a Form 1 for seventy-two hours. The Child stayed for an additional two days because she wanted to participate in an anger management workshop.
19The Child admitted to “cutting” because the pain calms her down, using marijuana two or three times per week and alcohol once or twice per week, to help her cope by keeping her calm and helping her to sleep. She further stated that she is “angry a lot” and that she is very angry maybe once or twice every two weeks. She testified that when she went to her mom’s room for the phone, she got angry and was knocking and yelling. She said that “once I reach that point of anger I don’t remember”. She further stated that she did it “just to get my way” and she did not remember much and did not know how she hurt herself.
20During testimony the Child minimized her risky dangerous behaviours and displays of poor judgement while in the community. She admits that she is frequently angry and after her rages, she does not remember what she has done.
21The Board found the Child’s mother to be a very credible witness who testified about the Child’s escalating behaviours, rages, impulsivity and opposition to authority that reflect a substantial disorder of emotional processes, thought or cognition which grossly impaired the Child’s capacity to make reasoned judgments. There were repeated examples of extreme behaviours exhibited by the Child while in the care of her mother. The impulsive, aggressive, destructive, dangerous behaviours toward the mother and herself, in the Board’s opinion, indicated a substantial disorder of the emotional process as required by the Act.
22Although the Board did not hear direct evidence regarding a current diagnosis, the weight of the behavioural evidence provided by the mother and the Child was sufficient to conclude that the Child suffers from a mental disorder.
23The Board finds that the Child did have a mental disorder, as defined by the Act, at the time of her admission to Youthdale. The Board was satisfied 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 another person.
24The Board must decide whether 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. After considering the evidence presented, the Board was satisfied that the Child has, as a result of the mental disorder, caused or made a substantial threat to cause serious bodily harm to herself or another person.
25The Board heard testimony from the Child’s mother regarding the Child’s self harming behaviours and threats to harm the mother as well as herself. The Child attempted suicide in grade eight, which resulted in hospitalization and her stomach being pumped. The mother testified that the child made “veiled” threats about harming herself by an Advil overdose again. The Child also physically threatened the mother by throwing bottles at her bedroom door for twenty to twenty five minutes. The mother testified that the Child said that she would kill herself and her mother on that occasion.
26The Child was hospitalized at the [Hospital A] in [City] for psychiatric care on May […], 2011 and discharged on June […], 2011. On returning home there was a dispute with her mother regarding a knife and a lighter that the mother had removed from the Child’s purse. The mother reported that the Child threatened to stab and kill her during the dispute. The Child reported that she did not intend to use the knife. However, the evidence before the Board is that the Child cannot control her anger and she admitted that she does not know what she does during her fits of rage. The mother also testified that her daughter said “I don’t care about myself”. The school’s social worker reported to the Youthdale Crisis Team on June […], 2011 (R2 Youthdale Psychiatric Crisis Service Fact Sheet) that she was working with the Child “daily around suicide” and that when the Child is triggered, she can’t control herself and she shuts off. The social worker also reported that the Child will say that if she drinks and dies “so what”.
27The Child behaved aggressively in a physical manner towards her mother. The Child was admitted to hospital where she required medical treatment for a cut on her foot. She did not remember how she received the cut because it happened when she was angry. The Child’s threats to hurt herself and her mother were substantial because they involved more than the Child making statements. She took actions (a prior suicide attempt, throwing bottles at her mother’s bedroom door), that increased the likelihood of the threat being carried out. Further, the Child seemed unable to manage her escalating out of control behaviours because she testified that she did not know what she did when she got angry.
28Based on the evidence presented and in the absence of a clinician from Youthdale or elsewhere to provide an interpretation of the behavioural evidence, the Board is satisfied that criterion (b) has been 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.
29The Child’s Counsel conceded criteria (c), however Youthdale argued that the secure treatment program would be effective to prevent the Child from causing or attempting to cause serious bodily harm to herself or 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. The high level of security, the safety measures, along with the high staff to child ratio will prevent the Child from harming herself or others.
30The 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.
31Counsel for the Child conceded this criterion, however Youthdale called evidence through a crisis worker. From the evidence presented, the Board was satisfied that treatment appropriate for the Child’s mental disorder was available at Youthdale.
32The Crisis Worker testified that Youthdale provides 24 hour nursing staff, a consulting physiatrist, as well as counselling and sleep therapy for the Child.
33Youthdale has appropriate clinicians and supports to closely monitor the impact of medication, as well as the Child’s behaviours which were identified at admission.
34The 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.
35The Board must decide whether no less restrictive method of providing appropriate treatment was appropriate in this case. Based on the evidence presented by the Child’s mother, the Board was satisfied that no less restrictive method of providing treatment appropriate for the Child’s mental disorder was appropriate.
36The Child was diagnosed with Post Traumatic Stress Disorder by Dr. M. in 2009 and placed on Prozac 10 mg. The Prozac proved to be unhelpful and was changed to Seroquel 25 mg in May, 2011.
37The mother reported that the Child had been seeing psychiatrist Dr. M., but the doctor was no longer practicing and the Child was currently waitlisted for a new psychiatrist.
38The mother has secured services from the [Organization B], an organization which coordinates access to services and provides support for adolescence with complex needs in [City]. She also contacted the Children’s Aid Society of [ ] which provided in home resources during May, 2011 for the Child.
39The Child has participated in art therapy, the [ ] Program for anxiety, and counselling through the [Centre]. She has seen social workers and she has been supported at home and at school, but none of these interventions proved to be successful. [Organization A] met with the Child twice in an effort to identify outpatient services and reported that none of their services would be effective as “the Child was too far gone and is in crisis”.
40The mother was open to having one- to- one intervention in the home through a youth worker. She has arranged for counsellors, school support, and attendance at a support group, as well as therapy for her daughter. However these options have not been helpful in addressing the Child’s escalating behaviours.
41From the evidence presented, the Board finds that no less intrusive interventions to treat the Child’s mental disorder are appropriate. The Child has had services with various degrees of intrusiveness with supports at home, in the community and at school, and despite these services her behaviours have escalated. The Board is satisfied that given the Child’s escalating extreme behaviours, a locked setting was required for stabilization and treatment at the time of admission.
42The Board finds that criterion (e) was met at the time of admission.
CONCLUSION
43Pursuant to section 124 (13) of the Act, the Board, having satisfied itself that the criteria in subsections 124 (2) (a) to (e) have been met, denied the application for the release of the Child, [ ] under section 124(9) of the Act, on June 15, 2011.
Mary Wong
Presiding Member
Lorna King
Panel Member
Celia Denov
Panel Member
Dated at Toronto, Ontario on this 24th day of June, 2011.