R.T. v. Youthdale Treatment Centres, 2014 CFSRB 34

CHILD AND FAMILY SERVICES REVIEW BOARD

R.T.

v.

Youthdale Treatment Centres

REASONS FOR DECISION

Date: July 2, 2014

Citation: 2014 CFSRB 34

Indexed as: R.T. v. Youthdale Treatment Centres (CFSA s.124)

INTRODUCTION

1R.T. (the "Child"), asked the Child and Family Services Review Board (the "Board") to review her June 16, 2014, emergency admission to the Secure Treatment Program at Youthdale Treatment Centre ("Youthdale"). The Child took the position that the statutory criteria (a),(b) and (e) for emergency admission contained in subsection 124(2) of the Child and Family Services Act, R.S.O. 1990, c.C.11, as amended (the "Act") were not met at the time of her admission. The Child's parents sought her admission to the secure Youthdale program because of the Child's severe anxiety attacks and her out of control behaviours.

2The Board was satisfied that at the time of the Child's admission she met all of the criteria for emergency admission and her request for release from Youthdale was therefore denied. The Board will only provide reasons for its findings on criteria (a), (b) and (e) in subsection 124 (2) of the Act because the Child conceded criteria (c) and (d).

BACKGROUND

3The Child is thirteen years old and her primarily residence is with her mother and her twelve year old sister. Her parents are divorced and have joint custody of both children. She sees her father four days per month but since August 2013, visitation has been inconsistent and their relationship has been unstable. The Child has a good relationship with her mother except when she is having an episode.

4The Child was diagnosed with ADHD and Anxiety and, at the time of admission, she was taking Clonazepam, Esatalopram and Risperidone. She has received individual psychotherapy since 2013. Since March 2014 she had three admissions at [the hospital] where her following psychiatrist noted that her anxiety met the criteria for generalized anxiety disorder. She was discharged to the care of her outpatient psychiatrist and counselling at [an agency] was recommended. The Child continued to experience significant difficulties and she was hospitalized at [another hospital] on May 27, 2014 for two nights in the emergency department for involuntary psychiatric assessment (Form 1), after which she was transferred to [the hospital] where she remained under a Certificate of Involuntary Admission (form 3) until her admission to Youthdale on June 16, 2014.

5The Child rarely attended school this year as a result of her frequent hospitalization and anxiety attacks. The outbursts often seemed to be triggered by the Child wanting more support from her mother or her wanting to be with her mother and the Child often held on to her mother by the legs or arms or she pulled the mother to the floor and would not let go of her for what seemed like hours to the mother. She expressed an intense fear of abandonment particularly by her mother.

6The Child's behaviour escalated this year and her difficulties have worsened since Christmas 2013. The parents testified that the Child has assaulted both parents as well as emergency medical and security personnel who tried to manage the Child's out of control behaviours.

7The mother testified that the Child was seeing two psychiatrists: one in the community and one at [the hospital], however, the Child continued to have significant difficulties and she threatened to kill herself as her complex needs were not being met. She had significant escalating out bursts at home and she was unable to utilize the suggested out patient counselling and related support services.

ANALYSIS

8Section 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).

9Section 124(2) sets out the criteria all of which must be met at the time of admission:

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 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.

10The Board must decide whether each of the relevant criteria was met at the time of admission. The Board's hearing is a new (de novo) hearing and, contrary to Youthdale's submissions, the Board does not look at whether the administrator had reasonable grounds at the time of admission. The Board's role is to make a determination on the facts before it, on the balance of probabilities.

Criterion (a): the child has a mental disorder;

11The Youthdale Psychiatrist on admittance of the Child made a provisional diagnosis of Parent-Child Relational Problem, Generalized Anxiety Disorder (by history), Attention Deficit Hyperactivity Disorder (by history), and she wanted to rule out Dysthymic Disorder or Major Depression. The Psychiatrist testified that the Child had frequent episodes of emotional and behavioural dysregulation lasting four to six hours during which she displayed aggression to both her parents and emergency personnel.

12The Admitting Psychiatrist believed that the Child was suffering from a mental disorder as defined in the Act because of the Child's emotional dysregulation, impulsive unsafe behaviours, and fear of abandonment, panic attacks and poor insight. She testified that the Child's intense demonstration of anxiety and distress around her fear of abandonment by her mother was not grounded in reality. The Psychiatrist also testified that the Child's denial about the episodes made her unable to accept the comfort and reassurance that she needs. The Psychiatrist stated that the Child made suicidal comments, behaved aggressively to family members and others because of her intense anxiety which increased her heart and respiration rates but the Child seem not to remember as she endorsed very few mental health issues.

13The Admitting Psychiatrist testified that the Child's judgment is grossly compromised because she cannot be soothed or comforted when she is in distress. The Admitting Psychiatrist believed that the Child's impaired emotions and thought process impelled her to act in ways which are harmful to herself and others because of her intense anxiety, fear and distress. She believed there was a serious risk of the Child harming herself and others because she could not make reasoned judgments due to the severity of her impaired thinking and loss of emotional control.

14The Child's mother testified that her daughter had increasingly frequent anxiety attacks during which she cried, twitched, breathed irregularly, yelled, ran up and down the stairs and around the house, jumped from one seat of the car to another, lay down on the street and held on to her mother at the waist, arm or leg for hours unable to let her go. Since Christmas 2013 there have been approximately 20 severe outbursts which resulted in multiple hospital visits to various hospitals for mental health treatment. Some of these visits entailed restraining the Child or involuntary admittance (Form 1 of the Mental Health Act) because of the Child's out of control behaviours. Both of the Child's parents alleged that the Child was so out of control at times that she had hurt them during her episodes. She allegedly choked her mother, punched her frequently and broke her ribs and she bit her father and hit him in the head when he tried to separate her from the mother.

15The mother testified that the Child called 911 and the Children's Help Line to ask for help and she frequently told people that her mother cannot help her. Despite the numerous visits to hospitals and a change in her medication regime the Child could not be stabilized.

16The Act states:

s.112 "mental disorder" means a substantial disorder of emotional processes, thought or cognition which grossly impairs a person's capacity to make reasoned judgments.

17The Admitting Psychiatrist gave evidence that the Child's emotional dysregulation, unstable mood and impulsive behaviours indicated that her emotional processes and thought were grossly impaired as was her capacity to make reasoned judgments. She noted that these impairments resulted in the Child acting in ways which were harmful to herself and others. She was impulsive and had been restrained, formed and hospitalized on multiple occasions at multiple hospitals but the concerning behaviours had not abated. The Admitting Psychiatrist believed that the Child needed a safe space to address her mental health concerns.

18The evidence of the mother and the father was that the Child's behaviour had been escalating and that she was unable to control her emotional state and out of control behaviours. They believed that, despite outpatient psychiatric interventions, the Child continued to escalate her concerning behaviours like trying to jump from a moving car and comments like: "I want to die".

19The Board finds that there was sufficient evidence presented to demonstrate that the Child had a substantial disorder of the emotional and thought processes at the time of her admission which grossly impaired her capacity to make reasoned judgments. The Board accepted the Admitting Psychiatrist's evidence that the Child's extreme emotional and behavioural dysregulation with aggression, her impulsive unsafe behaviour and significant anxiety attacks along with her ungrounded fears of abandonment indicated that the Child's emotional and thought processes were grossly impaired as was her capacity to make reasoned judgments.

20The Board finds 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 him, herself or others.

21The Board is satisfied that the Child, as a result of her mental disorder, has by her conduct made substantial threats to cause serious harm to herself and to her family, while in the car on two occasions. The Admitting Psychiatrist linked the behaviours to the actions described to her by the parents at the time of admission. The Board heard directly from the parents about several concerning incidents but finds that two clearly meet the test for criterion (b).

22The Mother testified that on May 11, 2014 she, the Child and the Child's sister were returning home from the sister's dance recital. Both children had signed up for the class but the Child had not been able to participate. Without warning the Child jumped from the back seat to the front seat of the car and tried to take the key out of the ignition of the moving car. From there she jumped into the trunk of the car. The mother stopped the car and the sister ran to the fire station while the Child lay on the ground smashing her head against the ground unable to calm down. Emergency services did not know how to help the Child and so the mother took her home with the help of family members.

23The father testified that on May 17, 2014 he picked up the Child from her home to go to his home. She became anxious, took off her seat belt and as they merged on to the highway she opened the car door, trying to exit the car, while the car was moving fast. He managed to reach over and pull the door shut and pull her back into the car and put on the brakes while still in the road. She tried to open the door again; he knew it was unsafe and he was able to go around and shut it. Cars were travelling past at over a 100 km per hour. He managed to get to the shoulder of the road and drove to the next exit. The Child was hysterical and she called 911 reporting that he was unsafe. He felt that she was escalating so much that she did not understand the seriousness of her surroundings or what she was doing. The Child wanted to go home and the father reports that she was anxious and screaming and he was yelling because he believes that she could have been hit by a car and she was unaware of the seriousness of the situation. The police attended the scene because an eye witness had reported the incident and later a crisis team also attended. The Admitting Psychiatrist testified that the Child was at serious risk of hurting herself because of her cognitive and emotional impairment and deep seated fear and panic which distorts her thinking and leads to impaired judgment and self-regulation.

24The Board finds that there was evidence that through this conduct, the Child made substantial threats and attempts to cause serious bodily harm to herself and others as a result of her mental disorder. The Child had on one occasion attempted to take the key out of the ignition while her mother was driving and she also attempted to open the car door when her father was driving fast on a highway. Both of these incidents could have resulted in serious injury and the latter could have caused the death of the Child and her father as well as injury to other motorists.

25The Board accepted the Admitting Psychiatrist's testimony that the Child's impaired judgement led to out of control conduct which put her and others at high risk of serious bodily harm. The Board finds that criterion (b) is met.

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

26The Child was diagnosed with anxiety and ADHT and had been followed by a psychiatrist who had prescribed Vyvanse and Intuniv. Vyvanse worsened her anxiety and Cipralex and Clonazepam were prescribed to address her anxiety. She saw two psychiatrists (one from August 2013 to January 2014 for individual psychotherapy), she has had multiple emergency admissions to hospitals including [ ], [ ], [ ], [another hospital], and [the hospital] and [a mental health facility]. Despite these interventions the Child was unable to complete an intake interview at a children's mental health centre ("Centre") on May 26, 2014 for outpatient services and the Centre's Child and Family Service Worker testified that the Child ran out of the room and was so out of control fighting, yelling and screaming that an ambulance and police escort had to be called to take her to the hospital. The Child was "formed" at [the hospital]. During 2014 the Child was involved with children's aid, a children's mental health service and the Centre but individual counselling was deemed to be unsuitable for her because she was in crisis. She also missed appointments in times of crisis.

27The parents testified that on May 27, 2014 the Child had another major attack because she did not want to go to soccer with her father. She held her mother on the couch for 45 minutes then held her ankles on the floor for another 30 minutes and when her father attempted to help her mother break free from the Child's grip the Child bit him hard and punched him repeatedly on the back of his head. The sister called 911 and the Child was taken to [another hospital] where she stayed for 2 nights on a Form 1 in the emergency department. The Child had to be handcuffed the first night because she was running from room to room calling her mother. During this episode she had difficulties settling, she kicked the phone off the wall, smashed a computer, fought with security, yelled and screamed and behaved so aggressively she had to be restrained by 6 security guards and medicated numerous times. She was transferred to [the hospital] on May 29, 2014 on a Certificate of Involuntary Admission (Form 3) and remained there until her admission to the Youthdale program.

28The Board finds that no less intrusive method of providing treatment would be appropriate for the Child based on the evidence presented. She had been referred to [an agency] for individual cognitive behavioural therapy commencing in March 2014 and she was also referred to the Centre to obtain in home behavioural intervention support for the family but that organization referred them to Youthdale because she was unable to complete the intake due to an episode and in light of their concern that the Child was in crisis. The Child had the services of two psychiatrists, she was taking prescribed medications, she had individual and family counselling services available to her and despite these interventions and services the Child's problematic behaviours continued to escalate. She was hospitalized and formed at multiple hospitals and she has spent a significant amount of time since the beginning of 2014 hospitalized for mental health issues.

29The Child has called 911 and the Children's Help Line asking for help. She has said she does not want to live on several occasions and this, combined with the nature, duration and intensity of the episodes and the Child's impulsivity and apparent lack of awareness during the episodes put the child at risk of serious bodily harm in the community. This was evidenced in the driving incidents set out above and by another incident in which the Child ran away from her father at the hospital to the top floor of the parking garage and had to be restrained and then formed to keep her safe. The Admitting Psychiatrist testified that she believed that the Child was at high risk of harming herself and that she needed a locked setting to keep her safe.

30The Board concluded that no less restrictive method of providing treatment for the Child was appropriate due to her escalating anxiety, emotional dysregulation, impulsive and unsafe behaviours and the necessity to keep her safe. The Board accepted the Admitting Psychiatrist's testimony that the Child's unstable behaviours compromised her safety and that she required the secure unit for stabilization and assessment. The Board accepts that a locked setting was needed at the time of admission in order to treat the Child's mental disorder.

31The Board finds that criterion (e) was met.

CONCLUSION

32Pursuant to section 124(13) of the Act, the Board, having satisfied itself that criteria in subsections 124(2) (a) (b) and (e) have been met, denied the application for release of the Child on June 23, 2014.

CONFIDENTIALITY ORDER

33Pursuant to Rules 30.1 and 30.2 of the Board's Rules of Procedure, parties and their representatives must not use, share, discuss or disclose any Board documents or decisions or any other documents or information provided or used in this application with anyone including through the media or on-line. The Board prohibits the use of any of this information for any purpose outside of the Board's proceedings.