CHILD AND FAMILY SERVICES REVIEW BOARD
P.R.
v.
Youthdale Treatment Centres
REASONS FOR DECISION
Indexed as: P.R. v. Youthdale Treatment Centres (CFSA s.124)
REASONS FOR DECISION
1This is an application by P.R., born November [ ], 1995 (the “Child”) for a review of his emergency admission to the Secure Treatment Program at the Syl Apps Youth Treatment Centre (“Syl Apps”), pursuant to section 124(9) of the Child and Family Services Act (the “Act” or “CFSA”). The application was dated January 20, 2012 and related to the Child’s admission to Syl Apps on January [ ], 2012. The hearing was held on January 25, 2012.
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. 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 criteria (a), (b), (d) and (e) had not been met and that he should be released.
3For the reasons that follow, the Board found that the Child meets all of the five criteria for admission and denied the Child’s application.
BACKGROUND
4[The child] is a 16 year old youth who is in the care of the Peel Children’s Aid Society (the “Society”).
5On January [ ], 2011, the Child was hospitalized under a Form 1 and Form 3 at [the hospital] for assessment and behavioural stabilization. Upon release from [the hospital] on March [ ], 2011, he was placed by the Society at [a residence], an intensive structured residential treatment home operated by [an agency].
6When he first arrived at [residence], the Child had difficulty speaking, communicated by writing on paper, wouldn’t change his clothes or shoes, and wouldn’t remove his winter coat in the summer. From December 2011 to January 2012, the Child appeared to deteriorate. He refused to take his medication regularly, even though its purpose was explained to him, and would leave the building without permission to go unsupervised into the community.
7On Friday, January [ ], 2012, an incident occurred at [residence] during which the Child pushed a staff person and was restrained by staff. Police were called and the Child subsequently went voluntarily by ambulance to [the Hospital].
8The Child was seen in Emergency by a psychiatrist. He was ultimately not held in the hospital, although the [residence] staff had been led to believe he would be held under a Form 1.
9At the hospital, the Child was combative with police who handcuffed him. He made a verbal threat to harm a [residence] staff person, and it was decided that he should not return to [residence].
10The Child was sent by the Society to its [Assessment home], where he remained for the weekend. On Monday, January [ ], 2012 he was admitted to Syl Apps.
REASONS FOR DECISION ON THE MERITS
ANALYSIS
11Pursuant 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).
12The legal tests in this case are reflected in the criteria as set out in the following legislative provisions:
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.
Criterion (a) the child has a mental disorder.
13The 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.
14Counsel for the Child submitted that the Child takes the position that he does not have a mental disorder.
15Counsel for the Respondent submitted a psychological report completed by [the agency] in September 2011. The report provided a working diagnosis for the Child of Schizophrenia-Disorganized Subtype. Additionally, a provisional diagnosis of Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) (mild variation of autism) was suggested.
16The Board heard [the doctor], Child and Adolescent Psychiatrist, Director of Clinical Services [at agency], and Acting Clinical Director, Syl Apps, testify that although there is not complete clarity regarding the Child’s diagnosis, there is compelling evidence that there is a complex mental disorder which includes a psychotic disorder, autistic spectrum disorder, and developmental disorder. The Child exhibits and has shown aggressive conduct, severe withdrawal close to catatonia, inability to control bodily functions including urination and defecation, difficulty with interpersonal interactions, large degree of suspiciousness, anxiety, and possibly, serious hallucinations.
17[The doctor] testified that the Child suffers from severe mental illness, onset in adolescence. He indicated that PDD-NOS may lead to a gradual change in personality; it is characterized by a lack of dramatic features, but is accompanied by a general decay of competency, impairment of thinking, judgement and decision making, and withdrawal from society.
18[ ] [residence] Social Worker, testified that in January 2012, the Child showed signs of deterioration, including an increase in speaking to himself, pacing, urinating in his clothes, freezing when speaking, becoming physically aggressive, and leaving the residence without permission.
19Based on the evidence of [the doctor], [the social worker] and the [agency] Psychological Report, September 2011, the Board finds that the Child did have a mental disorder as defined by the Act at the time of his admission to Syl Apps. The Board is 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.
20The Board was satisfied that the Child, as a result of his mental disorder, made a substantial threat to cause serious bodily harm to himself.
21Counsel for the Child submitted that the Child had not caused a substantial threat to himself or another person. She submitted that the Child was not seen to be in a state of emergency by the Consulting Psychiatrist, [the psychiatrist], in the week prior to the Child’s admission to Syl Apps. At that time, the Child had refused to speak with [the psychiatrist], who had been asked to assess him, and had locked himself in the bathroom. [The psychiatrist] had subsequently indicated that his appointment with the Child should be rescheduled. Additionally, the Child was not admitted by the psychiatrist to [a hospital] under a Form 1. Also, the Child had been managed over the weekend, from January [ ] to January [ ], at [city], without extra support.
22The Board heard [the social worker] testify that on January [ ], 2012, the Child pushed a staff person and later threatened that he would harm a staff person.
23The Board also heard that the Child would periodically go AWOL, that is, leave the [residence] property without permission, go to his mother’s home, and be escorted back by police who, it was reported, represented a known trigger for the Child’s anxiety.
24Both [the social worker] and [the doctor] testified that the Child had difficulty adhering to his medication, an anti-psychotic medication indicated in the treatment of schizophrenia, and an anti-depression medication. [The doctor] testified that the Child’s failure to take his medication would lead to deterioration in his condition, producing a negative effect on the Child’s thought processes. He was of the view that this failure to take medication provided further risk for the Child.
25[The doctor] was of the view that although the Child had been managed in a Society receiving home over the weekend, it would take more than a weekend to address the mental health issues facing him. He pointed out that in light of the Child’s years of history and mounting problems, his inconsistent taking of medication and his inability to consent to treatment, he was very concerned for the Child’s safety. He was also concerned about the Child’s being in the community unsupervised. He was of the view that the Child was “rudderless in the system” and that his needs were not being met. He pointed out that an emergency can be a continuing event and that a temporary hiatus does not alleviate the underlying issues causing the crisis.
26The Board finds, with regard to the submission regarding the Child’s aggressive behaviour and threats to staff, that these were likely not substantial threats to harm another person. The Board however, is of the view that the Child’s leaving the [residence] premises without permission, did expose him to danger in light of his apparent lack of judgement and awareness, poor communication, and fear of police. Given the Child’s inability to speak, his anxiety and his aggressiveness, he poses a threat to himself by being alone and unsupervised in a highly urbanized environment. The Board is of the view that serious harm could come to him in this vulnerable state. As well, the Board finds that although the Child was maintained over the weekend in a group home, after being medicated in the hospital on Friday, January [ ], 2012, this does not alter the fact that the Child continued to be in a state of emergency.
27The Board is of the view that on January [ ], 2012 the Child was in urgent need of stabilization and that his impaired judgement, exacerbated by his unwillingness to take his medication and his going into the community alone, constituted a substantial threat to cause serious bodily harm to himself. The Board finds that this urgent state continued to exist on Monday, January [ ], 2012.
28Based on the above evidence, the Board is satisfied that criterion (b) was met in terms of the Child’s threat of substantial 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.
29[The doctor] testified that Syl Apps is a secure unit which is locked. As well, the perimeter of the building is locked. There is staffing available based on a child’s individual needs; this includes expertise with young people with complex needs. The Child would be provided with appropriate psychiatric care and medication.
30The 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 himself or another person. The Child conceded that this criterion was met.
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.
32Counsel for the Child argued that criteria (d) had not been met. She submitted that it is unclear whether the treatment the Child requires is available at Syl Apps. Further, there is no reason to lock-up the Child. She reiterated that neither [the psychiatrist] nor the psychiatrist at [the hospital] had indicated that the Child was in an emergency state.
33Counsel for the Respondent submitted that Syl Apps provides a secure environment collectively suited to the Child’s behaviours. There is a highly trained staff, specifically trained in dialectical behaviour therapy, a therapy of choice in this case. There is the presence of a multi-disciplinary team and an individualized approach for each patient. In this case, this would include the Child’s need for quiet containment in a secure place. She submitted that the treatment appropriate for the Child’s mental disorder is available at Syl Apps. Psychiatrists are available at all times, and the opportunities to assess the Child are available over an extended period, a capacity unavailable in a group home setting. A process to undertake a capacity assessment for the Child is needed, as is the means to ensure compliance with medication. The security of the physical environment and the available staffing structure provide the opportunity for the treatment required and appropriate to stabilize the Child’s mental disorder.
34The Board finds that given the complexity of the Child’s mental illness, the treatment offered by Syl Apps is appropriate. Its capacity to provide a full psychiatric assessment over a sustained period of time and to ensure that the Child takes his medication, given that the Child’s treatment is dependent on the stabilization of his medication, is critical.
35The 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.
36Counsel for the Child submitted that criterion (e) had not been met; that there was a less restrictive option available to the Child. She submitted that the Child had demonstrated that he could be managed over the weekend at the [group home]. Additionally, [the doctor] had testified that the Child’s bed at [residence] was still available and that the Child might transition back to [residence] following his stay at Syl Apps. Counsel submitted that the Child had been placed at Syl Apps because of constraints within the service system, rather than because there was no less restrictive method of providing treatment available.
37Counsel for the Respondent submitted that the issue is not whether there are less restrictive options available to house the Child but rather whether there are less restrictive options to provide treatment appropriate to his mental disorder. She submitted that both the treatment group home and the hospital had failed to provide the Child with the necessary treatment. Further, the weekend placement at [group home] was a stop-gap measure only, based on the practicalities of the situation, and not an alleviation of the emergency. She referred to [the doctor’s] testimony that an emergency can be a continuing event and that a respite does not alleviate the underlying issues causing the crisis. She submitted that Syl Apps offered the least restrictive method of providing treatment to the Child appropriate to the Child’s mental disorder in the circumstances.
38The Board is of the view that at the time of the Child’s admission to Syl Apps, there was no less restrictive method of providing treatment that was appropriate. The question is one of appropriateness and not availability. The [treatment group home] was unsuccessful in ensuring that the Child took his medication or underwent a full psychiatric assessment. There was no evidence that the hospital could offer appropriate day to day treatment. The Child’s placement at [group home] for the weekend, although not a problematic experience, did not negate the Child’s need for immediate treatment with a focus on continuation of his medication.
39Given the Child’s lack of insight into his own condition and his unwillingness to take his medication, upon which his stabilization depends, the Board finds that under the circumstances, there is no less restrictive method of providing treatment appropriate to the Child’s mental disorder. The Child requires a locked setting with constant monitoring of medication in order to keep him safe. In a less restrictive setting, the prospect of medication refusal and AWOLS would have posed an ongoing, serious risk.
40The Board is satisfied that no less restrictive method of providing treatment appropriate for the Child’s mental disorder is appropriate in the circumstances.
41The Board is satisfied that criterion (e) was met.
CONCLUSION
42Pursuant to section 124 (13) of the Act, the Board, having satisfied itself that the criteria in subsections 124 (2) (a) through (e) have been met, dismissed the application of the Child, under section 124(9) of the Act, on January 25, 2012.
Michele O’Connor
Michele O’Connor
Presiding Member
Celia Denov
Celia Denov
Panel Member
Alina Lazor
Alina Lazor
Panel Member
Dated at Toronto, Ontario on this 6th day of February.