J.F. v. Youthdale Treatment Centres, 2016 CFSRB 23

CHILD AND FAMILY SERVICES REVIEW BOARD

J.F. v. Youthdale Treatment Centres

REASONS FOR DECISION

Date: July 8, 2016

Citation: 2016 CFSRB 23

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

1The applicant, (the “Child”), has made an Application to the Child and Family Services Review Board (the “Board”) to review his June 17, 2016 admission to the Secure Treatment Program at Youthdale Treatment Centre.

2The Child takes 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 his admission.

3The Child’s mother, [ ], with the assistance and guidance of a worker from the Catholic Children’s Aid Society of Toronto (“CCAST”), sought his admission to the secure program because of the Child’s threats of self-harm.

4During the course of the hearing, the Board heard from [ ], the Child’s mother, [ ], a child protection worker employed by CCAST, and the admitting psychiatrist, Dr. S., on behalf of the respondent. The applicant elected not to call any evidence.

5On June 28, 2016, following a hearing into the matter, and for the reasons that follow, the Board granted the application by the Child for his release as the Board was not satisfied that, at the time of the Child’s admission, the criteria under subsection 124(2), specifically criterion (e), had been met.

background

6The Child lives with his mother and step-father. He has two older siblings, both of whom live independently outside the family home.

7The Child’s mother testified that while her relationship with him is good, there have been some difficulties of late. She gave evidence that she has struggled with his behaviour in the last few months and she feels that they are not as close as they have been in the past. Although the Child’s mother did not allude to it, the social worker, [ ], disclosed that until very recently, the Child had believed his step-father was his biological parent and found out very recently that he is not. The CCAST worker attributes the deteriorating relationships in the family, in part, to this revelation.

8CCAST became involved with the Child’s family because of a report of conflict between the teen and his parents and the use of physical discipline on the Child. The case was assigned to the present worker approximately six months ago. He is tasked with preventing neglect and abuse of adolescent youth by assisting families with referrals and accessing services. The Child’s family receives this service from CCAST voluntarily.

9The evidence of the Child’s mother was that he is a good student but has been having difficulties attending school in the last few months. There have been arguments at home about his attendance problems. He goes to school but leaves before he should and either returns home or spends time with his girlfriend. He has had some minor conflicts and physical altercations with the new boyfriend of an ex-girlfriend.

10The Child’s mother has attempted to address his truancy issues by meeting with school staff and they have arranged for him to take credit recovery courses. An alternative flexible attendance program has been put in place for the Child.

11The Child’s mother indicated that on one occasion he cut his arm with a tab from a pop can. It bled but required no sutures or stitches, healed on its own and has not left a scar. She also reported that he once took an overdose of melatonin, a natural remedy that reproduces a substance the body produces naturally and that is an over the counter sleep aid, along with some adderall tablets, a medication prescribed for attention deficit and hyperactivity disorder. She was unable to specify when these two events occurred but the evidence suggests that the incident with the pop can took place more than two years prior to the admission.

12As a result of the cutting incident, the Child was initially seen by his pediatrician, Dr. Y., who referred him to an adolescent medicine program at a downtown Toronto hospital where he was seen by Dr. M., a psychiatrist. Dr. M. diagnosed him with depression, began treating him with melatonin and providing him with therapy two years ago. After one year, he stopped seeing Dr. M. because his mother had trouble transporting him to the treatment location.

13More recently, the applicant has been seen once a month for the last six months by Dr. R., a psychiatrist at [another] Hospital. Dr. R. made a diagnosis of Generalized Anxiety Disorder, some social anxiety and dysthymia, according to the record of his conversation with the staff of the respondent facility.

14Although there is also a reference to the Child having been diagnosed with “BTD”, later clarified at the hearing as “BPD” or “borderline personality disorder”, the only reference to that diagnosis is contained in a conversation between the respondent facility and the CCAST worker. It does not appear in any records of conversations with the Child’s treating psychiatrist.

15Dr. R. initially prescribed the Child with Prozac a treatment that was discontinued within a month by the physician as it made the Child feel worse. The psychiatrist also suggested that the Child be referred for additional counselling and therapy. He recommended that the CCAST worker try to obtain outpatient therapy for the Child at [facility] or [an institute].

16The evidence provided by the CCAST worker was that because there was no space available at those programs and the waiting lists are long, he did not pursue those referrals and instead arranged for the Child to speak to a psychology student at the [ ] Community Center once a week. It is not clear from the evidence whether the student was supervised by a qualified clinician. In any event, after a few months the Child discontinued the visits.

17The CCAST worker gave evidence that on May 26, 2016, the Child disclosed that he had thought of suicide and “had the tools”. He also disclosed that he had tried marijuana and cocaine. This alarmed the CCAST worker and he disclosed these conversations to the Child’s mother and eventually to the Child’s psychiatrist.

18The documentary record suggests that the CCAST worker and his supervisor discussed possible referrals for the Child and came to the conclusion that admission to the secure unit at the respondent facility should be explored. The CCAST worker gave evidence that he spoke to one of his colleagues who had once worked at the respondent facility and that person agreed with this course of action.

19The Child’s treating psychiatrist, Dr. R., was contacted by the CCAST worker, who provided additional information about the Child’s drug use. The CCAST worker testified that he understood that although the recommended course of action until then had been to obtain therapy and counselling on an outpatient basis for the Child, Dr. R. then agreed, upon receipt of the update from the CCAST worker, with the plan to seek admission for the Child at the secure program at the respondent facility.

20The documentary record produced by the respondent facility shows that when staff from Youthdale contacted Dr. R., he is reported to have said that he thought that an inpatient stay “might not be a bad idea”. There is no indication that he provided an opinion about whether the secure treatment option was appropriate in the circumstances.

21The documentary record also shows that the Child’s mother initially told the respondent facility staff that she was reluctant to proceed with the admission as she understood that the Child’s psychiatrist, Dr. R., was recommending outpatient counselling and the CCAST worker was insisting on inpatient treatment. She reported getting “mixed messages” from the Child’s psychiatrist and the CCAST worker.

22The CCAST worker was insistent that the admission process continue and, in fact, disclosed to the respondent facility staff that his agency would proceed to apprehend the Child if his mother did not complete an intake interview.

23Once the mother agreed to proceed with the intake process, the record shows she tried to delay the admission as she had concerns about the Child missing an orthodontist appointment.

24The evidence provided to the panel was that the CCAST worker completed the narrative portions of the Application form signed by the mother. He testified that the information was a direct translation of what she said to him. They both agree that all important information was included in the narrative section.

25The Child was brought to the facility and at the initial interview with Dr. S., the admitting psychiatrist, he disclosed that he had taken an overdose of melatonin the previous night.

26There was also evidence provided about a belt hanging in the Child’s closet that was described variously as a “noose”, “hanging apparatus” and a “belt tied to a rod in the closet” by participants in the hearing and some suggestion that numerous people believed it may have been a sign that he would use the belt to harm himself. The evidence of the mother and the CCAST worker was that he had not said it was a tool of self-harm and neither of them included any mention of this incident in the Application form. The admitting psychiatrist also gave evidence that he did not ask the Child any questions about the belt in question or its possible use as a tool of self-harm.

aNALYSIS

The Law

27Section 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).

28Section 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

29Section 112 of the Act defines “mental disorder” in the following way:

“mental disorder” means a substantial disorder of emotional processes, thought or cognition, which grossly impairs a person’s capacity to make reasoned judgements; (“trouble mental”).

30The Board must decide whether each of the relevant criteria was met at the time of admission on a balance of probabilities.

Criterion (a): the child has a mental disorder

31The admitting psychiatrist, who had been assisted by a resident whom he supervises, testified that the information they had received from the Crisis Team, their interviews with the Child, his mother, step-father, brother and the CCAST worker, as well as the observations from the Child’s doctors, led him to believe that the Child had a mental disorder as described under the Act. His first contact with the applicant was on the date of admission.

32The admitting psychiatrist gave evidence that the Child is a good and reliable historian who reported a general sense of unhappiness or sadness and anxiety. He also reported significant sleep disturbances and inconsistencies in eating. Most concerning was the applicant’s report of the attempted overdose the night before coming to the facility.

33His view was that while the Child had some insight into his behaviour and some awareness, his judgement was flawed and he did not have control over his behaviour. So, for example, he exhibited awareness when disclosing his overdose attempt to Dr. S. but not good judgement at the time he made the attempt.

34The Board accepts that, at the time of admission, the admitting psychiatrist concluded that the applicant exhibited sadness and anxiety leading to suicidal ideation and a substantial disorder of his emotional processes. There is no suggestion that he observed any disorder in the Child’s thought or cognition.

35The Board, therefore, finds that there is sufficient evidence before it to conclude that the Child had a mental disorder within the meaning of the Act and that paragraph (a) of s.124(2) has been satisfied.

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

36The evidence before the Board is that the Child has made some threats of self-harm and has attempted on at least two occasions to cause bodily harm to himself. There is no suggestion that he is at risk of causing harm to others.

37The evidence of the admitting psychiatrist is that he was concerned by the bland method of reporting the attempted overdose. Dr. S. indicated that the overdose itself was not a sustained or well-planned attempt but he did conclude that the Child ruminated about self-harm.

38In this regard, of greater concern to Dr. S. than the overdose, described by him as impulsive, was the fact that there was a belt tied to a rod in the closet of the Child’s room, which the doctor described as a “noose” and about which the Child reportedly refused to answer his mother. This led the doctor to conclude that there was an undercurrent of nihilistic thought present.

39There is no indication that the Child ever identified the belt tied to the rod in the closet of his room as a “noose” or “hanging apparatus” or an instrument of self-harm to anyone. Given that the Child’s mother did not consider the issue important enough to include the information in the Application form and the resident and admitting psychiatrist did not ask the Child any questions about it, the Board is not satisfied the belt and the speculations about its possible use as a tool of self-harm can form the basis of a conclusion that the applicant “by conduct made a substantial threat to cause serious bodily harm to himself”.

40However, there is uncontroverted evidence that the Child admitted to taking an overdose of medication, albeit relatively non-toxic medication, and communicated a threat to the CCAST worker that he wanted to kill himself and had the tools to do so. The Board is prepared to accept the conclusion of the admitting psychiatrist that the Child had made a substantial threat of self-harm to the CCAST worker in the weeks before his admission as a result of his sadness and anxiety. Accordingly, the Board concludes that criterion (b) was met at the time of admission.

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

41The evidence of the admitting psychiatrist and the conclusion of the Board is that the secure treatment program would be effective to prevent the child from causing or attempting to cause serious bodily harm to himself. As indicated previously, there is no risk of harm to another person in this case.

42The uncontradicted evidence of the admitting psychiatrist is that the respondent facility has a safe unit with an interdisciplinary team involved in patient care, where there is no access to anything of harm to the Child. It is a closed unit, skilled in keeping children safe. There are safeguards in place; people are checked for weapons and sharp objects. The level of observation and supervision is almost one to one and can be continuous, if necessary.

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

43The staff, representing various disciplines, is available all the time. There are peer therapy groups, school and physical activity. The unit was described as being as child-centered as possible.

44The Board accepts that the requirements of criterion (d) have been met and that the appropriate treatment for the Child’s mental disorder is available at the respondent facility.

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

45The evidence before the Board was that the Child’s treating psychiatrist had been recommending outpatient treatment, specifically therapy and counselling, for several months. Other than a brief statement from the CCAST worker that the waiting times for therapy and counselling at the facilities suggested by the treating psychiatrist were lengthy, there is no evidence that applications or referrals were made to those facilities or that the Child is or has been on a waiting list for treatment at those places.

46Once inquiries about admission for secure inpatient treatment had already been initiated by the CCAST worker at the respondent facility, and additional information provided about drug use to the psychiatrist by the CCAST, the opinion of the Child’s psychiatrist was that inpatient treatment “might not be a bad idea”. There was no evidence that he initiated the admission inquiries or that his recommended course of action was inpatient treatment in a secure setting.

47Section 124 is contained in Part VI of the Act in the section entitled Extraordinary Measures. Extraordinary circumstances must exist for a child to be placed on an emergency basis in a secure treatment unit. The right to review the placement before the Board is a significant safeguard and one 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.

48The 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.

49In the circumstances of this Application, the Board is not satisfied that less restrictive treatment methods have been considered and found to be inappropriate. Accordingly, the Board concludes that the requirements of criterion (e) were not met at the time of admission.

CONCLUSION

50Pursuant to section 124(13) of the Act, the Board, not having been persuaded that the criteria in subsections 124(2) were met at the time of the Child’s admission into the respondent facility, granted the application for the release of the Child on June 28, 2016.

CONFIDENTIALITY ORDER

51Pursuant 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.

Michelle O’Connor

Michelle O’Connor Presiding Board Member

Alina Lazor

Dr. Alina Lazor Board Member

Jay Sengupta

Jay Sengupta Board Member