CHILD AND FAMILY SERVICES REVIEW BOARD
E.T.
v.
Youthdale Treatment Centres
REASON FOR DECISION
Date: July 10, 2015
Citation: 2015 CFSRB 30
Indexed as: E.T. v. Youthdale Treatment Centres (CFSA s.124)
INTRODUCTION
1The Applicant, (the “Child”), made an application to the Child and Family Services Review Board (the “Board”) to review her June 22, 2015 emergency admission to the Secure Treatment Program at Youthdale Treatment Centre. 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 CAS (Guardian) sought her admission to the secure program because of the Child’s frequent absences from her group home, her drug use and high risk behaviours in the community.
2The Board was not satisfied that, at the time of the Child’s admission criterion (b) and criterion (e) were met as required in subsection 124(2). For that reason the Board granted the application for her release on July 3, 2015. The Board’s reasons address criteria 124 (2)(a) (b) and (e) because the Child conceded criteria (c) and (d) of the Act.
BACKGROUND
3The Child has been in the care of the Society since 2008 and she became a Crown Ward in 2011. Several of her [ ] siblings are also in care or have been in care. She has telephone contact with her parents but the Child had not seen her family in several months. Their relationship is unpredictable and strained and her Guardian believes that the Child has trust issues because of her early negative interactions with her biological family. The Society had concerns regarding abuse, domestic violence, drug use, physical abuse, neglect as well as general concerns about the home environment which led to the apprehension of the Child.
4The Child’s stable long term foster home broke down in 2014, after five years, resulting in the Child being placed unsuccessfully at three or four emergency treatment foster homes. They all proved inappropriate to meet her needs and subsequently the Child was placed in a [small], staffed, group home on December 10, 2014.
5The Guardian testified that the group home placement was initially successful until the Child began putting herself at risk in the community by leaving the residence and hanging out with older men one of whom is a known sex offender. She became disengaged from the program and was unable to regulate herself. There were over thirty contacts with the [authorities] during the last six months pertaining to the Child and on approximately sixty occasions she left the home without permission. The Guardian stated that the Child was not taking care of herself and she was using drugs and alcohol. She also believed that the Child was suspicious and paranoid of others and she appeared sometimes to have been responding to unseen stimuli.
6The Child was admitted to Hospital A for twenty four hours after which she was transferred to Hospital B and held involuntarily (Form 1) in April 2015 for seventy two hours. In May 2015 she was also hospitalized for mental health concerns at her request. On many occasions she would call the police and report to them that she wanted to go to the hospital. Sometimes the police did take her to the hospital and sometimes they did not. At her request the staff would also take her to the hospital where she would be seen and discharged without being admitted. The Child engaged in superficially cutting and scratching her arms but she did not require medical treatment for any of these incidents.
7The Child’s pediatrician prescribed [medication], which she discontinued a few weeks prior to admission because it made her feel sick; she had also stopped taking [other medication] in November 2014 because of other issues. She took [further medication] to help with sleep on an irregular basis.
8The Child’s conduct led to two lock downs at her school this year because of her poor behavior. She was transferred to an alternative school but she did not like her partner and since May 2015 she has attended infrequently. In March/April the Child began to engage in an escalating pattern of high risk behaviours causing significant concern to her caregivers. She was in the community almost on a daily basis without permission, associating with older men, one of whom was alleged to be a sex offender. She allegedly engaged in sexualized behaviours for cigarettes and drugs.
ANALYSIS
9Section 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).
10Section 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
11The Board must decide whether each of the relevant criteria was met at the time of admission on the balance of probabilities.
Criterion (a): the child has a mental disorder
12The Admitting Psychiatrist testified that the information she had received from the Crisis Team, her interviews with the Child, the Guardian as well as the observations from the Child’s doctors led her to believe that the Child had a mental disease as described under the Act. The Psychiatrist listed the following diagnoses to be assessed;
Developmental trauma disorder (this is not a DSM-5 diagnosis) versus post-traumatic stress disorder
Attachment Disorder
Conduct Disorder
Learning disability
Parent-child relational problem
Sibling relational problem
Attention deficit hyperactivity disorder
13The psychiatrist stated that the Child was angry when they met but she believed that she suffered from development traumas as well as attachment and conduct disorder. She believes that the Child is reenacting early trauma by turning to inappropriate persons. The Psychiatrist was concerned that the Child had lost her long term placement at the foster home and this was leading to an adjustment issue. She described the Child as unable to keep herself safe and she testified that the Child displayed a “profound” lack of care in her associations.
14The Psychiatrist further testified that, in her professional experience, the Child showed impaired judgment as evidenced by her constant out of control behaviours, her mood swings, dysregulation and aggressiveness with peers, poor insight, and disregard for her safety. She also testified that the Child broke things and escalated others because of her dysregulation, resulting from the severe past trauma and neglect in her life. The Child ran away from home almost on a daily basis during which she made poor social choices in the community. The Psychiatrist noted that although the Child had been angry and she had not been communicative on admission to the secure facility, the behavioural evidence indicated that the Child had a mental disorder of the emotional process which impaired her cognitive function.
15The Child had smoked marijuana and cigarettes, experimented with alcohol and superficially cut herself. She was impulsive and aggressive with her peers. The Psychiatrist testified that in her opinion the Child’s substance abuse, her aggressive behaviour, her poor social judgement, her involuntary hospitalization, her suicidal ideation, her significant disregard for her safety, her emotional upheaval and dysregulation along with her at risk behaviour in the community were indicators that the Child was suffering from a mental disorder as defined in the Act.
16The Guardian testified that Child had lived with her foster family for five years, after which the placement broke down. Subsequently the Child was placed in three or four emergency placements but they were unable to meet the Child’s needs. The decision was made to place the Child in a group treatment home because it was felt that she needed staff support. The Guardian stated that the Child began to disengage from the program and she refused to attend medical appointments or school. She also began to run away from the home and left without permission on approximately sixty occasions.
17The Guardian received reports from the group home that the Child had started to carve and scratch words on her arm but the Child refused to show her the cuts in March 2015. None of the cuttings required medical care. The Guardian stated that the Child did not want to talk to her and she had made four attempts to convene meetings with no success as the Child was not available. She testified that the Child had stolen cough medication in order to get high and she was associating with older men and allegedly prostituting for drugs and alcohol.
18The Child’s pediatrician managed her medications and she had access to a consulting doctor who runs workshops at the group home as well as a counsellor whom she saw five to ten times. The [ ] offered the Child the services of a mentor but she declined the offer. Her school also provided resources but the Child did not avail herself of those services. A one-to-one worker was assigned to keep the Child from running away and to keep her engaged. The program worked for one week after which the Child reverted to her old pattern of behaviour and she continued to leave the home without permission and she continued her association with inappropriate men.
19The Guardian’s evidence was that the Child seems to respond to “unseen stimuli” and she would laugh at something “unseen”. She also described the Child’s affect as “strange”. She noted that the Child seemed to hear voices which were loud and bothering her. The Child had reported being hit by a car in April; however, x-rays did not show any injury.
20The group home Owner testified that she did not have hands on experience with the Child as she was only on call every other weekend and for emergencies. During her visits to the home she saw the Child by “happenstance”. She testified that the Child’s behaviours met expectations until March or April when she started to absent herself from the home. Most nights the Child returned home except on two occasions when she stayed out all night.
21The Child would generally call home and “check in” but the staff was increasingly concerned about her associations and her safety as she had been seen on multiple occasions with inappropriate older men. The Owner testified that the Child’s drug use had gradually increased and her cutting became less evident but there was more evidence of suicidal ideation. She was taken to the hospital after threatening to hurt herself with a boxcutter in June, 2015. The hospital released her and gave her [medication]. The Child engaged in daily verbal threats with her peers after which she would escalate and leave the home. On one occasion while she was with her one-to-one worker, she ran across a train line in front of a train having verbalized that she did not want to live. The Child reportedly found the one-to-one worker intrusive and was running away. The Owner concluded that the home was not able to meet the safety needs of the Child because, even with additional supports from a one-to-one worker, the Child continued her running behaviour.
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.
23The Admitting Psychiatrist testified that in her opinion the Child’s escalating pattern of behaviours in the community, her mood instability, her poor social choices, impulsivity, emotional and behavioural dysregulation indicated that her emotional processes, thought or cognition were grossly impaired as was her capacity to make reasoned judgments.
24The Psychiatrist also testified that in her professional experience the Child’s behaviour was consistent with that of a mental disorder which impaired her judgement. She stated that the Child’s impaired judgment and her poor decision making resulted in two mental health hospitalizations. She believed that the past multiple traumatic events and abuse in the Child’s life is leading her to reenact the trauma which includes seeking out inappropriate men. The Psychiatrist also believes that the Child’s self-injurious behaviour is as a result of her impaired judgment which leads her to repeat the pattern of returning to danger.
25Despite in-home supports, access to counselling, mental health intervention at Hospitals A and B, and academic supports the Child continued to abuse drugs, cut herself, make statements about killing herself and run away from home on a regular basis, placing herself at serious risk in the community with inappropriate older men.
26The Board accepted the testimony of the admitting Psychiatrist and finds that the actions of the Child demonstrated a substantial disorder of emotional processes, thought or cognition which grossly impaired her capacity to make reasoned judgements. The Board heard evidence that the Child’s emotional processes were so impaired that she ran away from her home almost daily and made poor social decisions. The Child exhibited mood swings, displayed poor insight and is highly impulsive. The escalating dysregulation and volatile emotional behavioural evidence presented, demonstrated that the Child had a substantial disorder of her cognitive and emotional processes at the time of her admission to the facility which grossly impaired her capacity to make reasoned judgments.
27The Board finds that there was sufficient evidence before it to conclude that 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 herself or others.
28The Admitting Psychiatrist was of the opinion that the Child posed a substantial threat to cause serious harm to herself and others. She cited the Child’s constant running away from home, spending time with older men and possibly having sexual contact, her jumping out of a moving vehicle as well as crossing the railway line unsafely, coupled with suicide ideation as evidence that the Child’s capacity to make choices in her best interest was impaired and that she has placed herself at risk in the community under dangerous circumstances. The Psychiatrist also noted the Child’s aggression towards her peers as potential harm as well as her cutting and her refusal of medical services. The Child’s drug and alcohol use and her discontinuance of her medications were also noted.
29The Child was taken to hospital three times in 2015 and admitted involuntarily on one occasion for seventy two hours. She was referred to an outpatient facility for a psychological assessment where she was placed on a priority waitlist while her Guardian sought an alternative rural placement which the Society hoped would provide a more stable environment for the Child who was becoming anxious. The Child had verbally threatened to harm herself but she did not communicate a plan of action to her caregivers. She did not attempt to harm herself except by cutting her arms superficially and none of these cuttings required medical attention. The Child was in the habit of asking both the police and the staff to take her to the hospital for mental health related reasons and they had done so on many occasions. It was noted that she was not hospitalized on the majority of these occasions.
30The Board was not satisfied that by her actions, the Child has made substantial threats to cause serious bodily harm to herself or to others as a result of her mental disorder. The Child led a risky life in the community, she was sometimes aggressive with her peers, she talked about killing herself, she superficially cut her arms and she allegedly made unsafe choices by running across a train track and jumping out of a moving car. However, no evidence was presented that she made any concrete plans to harm herself or others or that she took any actions to do so.
31The Board was satisfied that criterion (b) was not met.
Criterion (e) no less restrictive method of providing treatment appropriate for the child’s mental disorder is appropriate in the circumstances
32The Admitting Psychiatrist testified that admission to the secure program was appropriate because the Child had not engaged with prior treatments in a less restrictive setting. She believed that medical care for the Child had been provided by the Child’s pediatrician as well as the outpatient facility and Hospital A and B and that none of these interventions proved beneficial for the Child. She noted that the Child had multiple medication trials which she discontinued and that even with a one-to-one worker to keep her from running away, the Child continued her pattern of absences from her home and risky social behaviours in the community.
33The Guardian testified that in the group home the Child has been provided with counselling, academic and in home supports but the Child’s behaviours did not stabilize. The Child has been involved with a counsellor whom she saw sporadically at the beginning of the placement but she was not seeing a psychiatrist despite her history of chronic trauma and abuse except when she was hospitalized. A psychiatric evaluation had been recommended and the Child had been placed on a priority waitlist at the outpatient facility.
34Section 124 is under Part VI, Extraordinary Measures, of the Act. There must be extraordinary circumstances before a child is placed on an emergency basis in a secure treatment unit. The right to review the placement before the Board is a significant safeguard, which is in place to protect the child’s right to liberty. The admitting program has a duty to present sufficient evidence to support a finding on the balance of probabilities that on admission, a child has met the criteria set out in section 124(2) of the Act.
35The test to be met under section 124(2)(e) of the Act is not whether another placement is available but rather whether another less restrictive method of providing treatment is appropriate. This is an important distinction. The extraordinary measure of admitting a child to a locked secure treatment facility is not to be viewed as a placement option, but rather, it is to be considered and used only in cases where, having looked at all other less restrictive treatment methods, it is determined that none of them have been or would be appropriate to treat the child’s mental disorder in the circumstances.
36The Board was not satisfied that no less restrictive method of providing treatment for the Child’s mental disorder was appropriate. A psychiatric evaluation of the Child was not completed prior to her admission to the secure unit; she has not seen her pediatrician during the last six months nor was evidence presented of a medication review after the Child discontinued usage because of their side effects. Both the Admitting Psychiatrist and the Guardian identified the Child’s early trauma and abuse as areas of difficulty yet no psychiatric interventions to address these issues in an open setting were attempted. Moreover, other placement options were being investigated but they were abandoned once a bed became available at the locked facility.
CONCLUSION
37Pursuant to section 124(13) of the Act, the Board, having satisfied itself that criteria (b) and (e) in subsections 124(2) have not been met, released the Child on July 3, 2015.
CONFIDENTIALITY ORDER
38Pursuant 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, except with an order of the Court or the Board, as appropriate.
JOHN F. SPEKKENS
_____________________
John F. Spekkens
Presiding Member
LORNA KING
_____________________
Lorna King
Board Member
MICHELE O’CONNOR
_____________________
Michele O’Connor
Board Member
Dated in Toronto, Ontario on this 10^th^ day of July, 2015.