J.M. v. Youthdale Treatment Centres, 2012 CFSRB 56

CHILD AND FAMILY SERVICES REVIEW BOARD

J.M.

v.

Youthdale Treatment Centres

REASONS FOR DECISION

Date: December 17, 2012

Citation: 2012 CFSRB 56

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

INTRODUCTION

1The Child J.M., born [ ] [ ], 1999, asked the Board to review his 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 , R.S.O. 1990, c.C.11, as amended (the “Act”).

2The Child was admitted to Youthdale on November [ ], 2012. His application is dated November 22, 2012. The hearing was held on November 26, 2012.

DECISION

3These are the Board’s reasons for its oral decision made November 26, 2012 finding that the five criteria for admission are satisfied and denying the Child’s application.

PRELIMINARY ISSUES

4In correspondence faxed to all parties, counsel for the Child advised that she would object to the admission of the Form 14 and/or the Admission Summary unless the admitting psychiatrist or another psychiatrist was available to be cross-examined on those documents.

5Youthdale did not ask to introduce or rely on either document at the hearing.

6The Child did not attend the hearing, but was represented by counsel throughout the hearing.

BACKGROUND

7The Child was admitted to Youthdale upon application of his mother. Prior to his admission, the Child lived at home with his parents and younger siblings. The Child experienced difficulties at home and at school leading up to his admission.

ANALYSIS

8The criteria that the Board must apply in secure treatment reviews are set out in s. 124 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.

9Section 112 of the Act defines mental disorder as follows:

“a substantial disorder of emotional processes, thought or cognition, which grossly impairs a person’s capacity to make reasoned judgments”.

10Each of the above criteria must be met at the time of admission to confirm the Child’s placement at Youthdale. 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 all five criteria had not been met and that he should be released.

Criterion (a) the child has a mental disorder

11The Child attended a day treatment program at a children’s mental health centre dedicated to working with youth with educational, emotional, and behavioural challenges [“day program”] from September [ ] to November [ ], 2012 when he was expelled because staff concluded they did not have the ability to keep the Child safe given his escalating and dangerous behaviour. The Board heard testimony from the Child and Youth Worker at the day program about both the intensive nature of the program as well as the Child’s behaviour. The Worker testified by teleconference.

12The Worker explained that the Child was often non-communicative, frequently went into “shut-down” mode, and would very often spend 90% of the day in the quiet room in the fetal position and not respond to staff despite various strategies used to engage with him.

13The Worker described the following safety concerns: the Child talked to staff about feeling depressed and searching for sharp objects at the day program for cutting himself; the Child often ran away rather than enter the building and would not return for at least an hour; the Child frequently climbed one of the trees behind the property, approximately 30 to 50 feet above ground, and stayed there for extended periods of time. The Child admitted to the Worker that he often left his house in the middle of the night, without his parents knowing, and climbs trees.

14The suggestion of an intensive assessment-placement at Youthdale was made to the parents by the day treatment program.

15Both the Child’s parents testified. While worried about the Child’s behaviour for a number of years the situation escalated dramatically since September 2012. The Child now frequently leaves the house, during the night without appropriate clothing, often climbs trees in the dark, fences, onto roofs, and into areas where there are high voltage hydro wires. The Child has acknowledged to his parents that he actively seeks out danger[ous] situations. Climbing is one consistent theme in all of the Child’s dangerous behaviours.

16The Child has frequently told his parents “danger soothes me”, and that he goes out and seeks out danger. They indicated that the Child has been fascinated by and involved in climbing for his whole life, but that the dangerous climbing only started quite recently. They summed up the Child’s current view of climbing in a very concise way: “Heights = Danger = Soothing”.

17The parents testified that the Child has told them that he has been hearing unfamiliar voices since September or early October, 2012. The voices call him by name, tell him what to do, and more recently, have been saying “cut!”. The Child also has reported that at times he feels that his head is going to explode.

18The parents also told the Board that, whenever they try to talk to the Child about feelings, either together or separately, the Child will shut them down, and often this is the cause of a run. He will leave by the bedroom window, often without shoes or other appropriate clothing.

19Around November [ ], 2012 the Child was taken to hospital as the result of a major cut he made to his arm. He required 7 stitches and plastic surgery to repair the wound. The Child has multiple superficial cuts on his right arm, and a number of healing lacerations on his left arm.

20After this incident the parents realized they could no longer provide the safety needed by the Child, and made the decision to apply for admission to the secure unit at Youthdale.

21The Board heard from the Child’s paediatrician by teleconference. She has been the Child’s paediatrician since a week after his birth, and has been most actively involved with the Child and his parents in the last couple of years when difficulties started to arise with his behaviour and his emotional state. She last saw the Child on November [ ], 2012. The paediatrician’s current diagnosis on the Child includes A.D.H.D., a learning disability, a sensitive and anxious temperament, depression, and an anxiety disorder.

22She testified that during the last few months the Child has been rapidly decompensating, as evidenced in his behaviours of aggression towards himself, running, and putting himself in situations of significant risk, namely the cutting and the tree and roof climbing. He has sleeping difficulties. He also is unable to deal with any discussion of feelings or tolerate close proximity to other persons.

23Although the Board did not hear direct evidence regarding a specific and definitive current diagnosis, the weight of the behavioural evidence provided by the physician who has known the Child for his entire life and has been very involved over the last number of months, supplemented by the compelling evidence given by the Worker and by the parents, support finding that, at the time of admission, 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 himself, herself or another person.

24The Child’s behaviours have included numerous cutting incidents, one of which required 7 stitches and plastic surgery.

25There is significant danger in the child climbing trees to dangerous heights, and climbing onto roofs where there is exposure to electric wiring. Many of these activities have occurred at night, increasing the risk of serious bodily harm to the Child.

26The Worker described that the child’s dangerous and destructive behaviour was always turned inwards towards himself. He advised that there were no incidents where the Child has been aggressive or has hurt others; his behaviour was described by the worker as “he implodes, not explodes”.

27The recent significant deterioration of the Child’s behaviour and the increase in intensity of his risky behaviours is of serious concern. This escalation is significant in increasing, at the time of admission, the substantiality of the threat that more serious bodily harm to himself would occur.

28Based on this evidence, the Board was satisfied that the Child has, as a result of the mental disorder, caused serious bodily harm to himself and attempted to cause by his words or conduct, a substantial threat to cause serious bodily harm to himself.

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 heard evidence that Youthdale’s Secure Treatment Unit is locked, there are no areas of the building where the youth could climb up on or into, and the program is such that youth do not have any access whatsoever to sharp and dangerous objects such as glass shards, knives, scissors, and lighters. This will likely result in the cessation of the child’s cutting behaviour. At all times, the staffing ratio in the unit is one staff for every three residents or better. Youthdale Staff testified that the Child will be safe since he will be in a locked setting with continuous observation to ensure that he does not harm himself.

30Placement at Youthdale will prevent the Child from the behaviours that have put him at great risk of causing or attempting to cause serious harm to himself. The Board was satisfied that the secure treatment program would be effective to prevent the Child from causing or attempting to cause further serious bodily harm to himself or others.

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

31The Youthdale Staff described the services that are available on the Secure Treatment Unit: a psychiatrist on site and on call, a neurologist available if required, a nurse on duty on the unit, psychology and social work staff, a structured program with clear routines, as well as assessment and group and individual therapy. A thorough assessment will be done, with emphasis on the medication that the Child is currently taking, and which increases suicidal ideation as a side effect.

32Professional staff are available to provide individual therapy for the Child as well as group therapy to assist him in finding ways to safely cope with his feelings and gain control from within over his self-harming behaviours. As well, an assessment at the sleep clinic could be arranged to assess any issues with regards to the Child’s sleep difficulties.

33The program is also geared to setting up supports for after discharge. Current outside resources and professions, such as his paediatrician, are usually to be involved in case conferencing.

34The Board was satisfied that treatment appropriate for the Child’s mental disorder is available at Youthdale.

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

35The Board heard detailed evidence concerning the Child’s medications which is not necessary to repeat in these reasons; suffice to say a number of medications have been tried and discontinued and a comprehensive and controlled review of his medications will be beneficial. The Child’s paediatrician confirmed that what is needed now is a well-founded diagnostic and ensuing comprehensive treatment plan. Out-patient appointments cannot offer this. The Child needs evaluation over a longer timeframe from which he cannot withdraw and which permits observation of his interactions with peers.

36The Board heard evidence about the large number of different voluntary placements and referrals, both residential and non-residential, which were considered or were referred to, without success, prior to the referral to Youthdale. Again, it is not necessary to record the details of the history of referrals in these reasons. The Board was satisfied that this evidence demonstrates that there was no other setting at the time of admission that was appropriate for the Child’s mental disorder.

37Other options were considered but the Board agrees they would not be adequate under the circumstances given the needs of the Child. The parents of the Child have made clear that they no longer feel they can contain the Child at home, and keep him safe from himself. The Child refused a voluntary admission to Youthdale’s Transitional Unit, which offers many of the services offered in the secure unit but is not locked, because it requires a commitment of between 8 and 12 weeks. There would also have been a delay of a number of weeks before admission to the Transitional Unit could occur which both the parents and the Child’s physician felt would be inappropriate given the escalation of the Child’s dangerous behaviours and likelihood that the Child would react to the one on one staffing by running away.

38The Board was satisfied that no less restrictive method of providing treatment appropriate for the Child’s mental disorder is appropriate in the circumstances. This is so because the Child’s behaviour prior to admission was escalating, specifically the rapidly escalating self-harm actions and danger as described under criterion (a) and criterion (b). As well, the Child was not able to engage himself in the day treatment program, and in fact had mentioned to his parents that Youthdale may be a good setting for him. Without a locked setting, the current pattern of escalation would not be broken. A less restrictive environment is not appropriate at this time to provide treatment given the level of risk and dangers in both the actions and the ideation of the Child. The Board is satisfied that criterion (e) was met.

CONCLUSION

39Pursuant 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 November 26, 2012.

CONFIDENTIALITY ORDER

40Parties and their representatives must not use, share or disclose any documents or information provided or used in this application with anyone including the media or on-line. Any documents or information shared by the parties must be used only for the purpose of the hearing of this application by the Board.

RUTH ANN SCHEDLICH

_____________________

Ruth Ann Schedlich

Presiding Member

ALINA LAZOR

_____________________

Alina Lazor

Panel Member

JOHN F. SPEKKENS

_____________________

John F. Spekkens

Panel Member