Child and Youth Mental Health: the Realities Dr. Simon Davidson Chair, Child

1
Child and Youth Mental Healththe Realities
Dr. Simon DavidsonChair, Child Youth
Advisory Committee,Mental Health Commission of
Canada Chief Strategic Planning
Executive, Centre of Excellence for Child
Youth Mental Health at CHEOToronto, Ontario
November 6, 2009
2
The Facts About CYMH

• High prevalence of psychiatric disorder (13-22).
• High demand for service, limited access, long
  wait lists (only 1 in 6 of those needing help
  (16) had accessed services in the previous 6
  months).
• More than 70 of adults with mental illnesses
  onset in childhood/adolescence.
• Est 51B lost per year workplace absenteeism due
  to mental illness
• It all begins with children and youth!

3
Mental Health Commission of Canada

• The History
• The Structure
• The Priorities
• www.mentalhealthcommission.ca

4
Key Initiatives

• National Mental Health Strategy
• Anti-stigma Campaign
• Knowledge Exchange Centre
• Homelessness/Mental Health Research Projects
• Partners for Mental Health Campaign and
  Foundation

5
Child and Youth Advisory Committee (CYAC) of MHCC

• The orphan of the orphan

.NO LONGER!

• 16 member Committee
• Across the age spectrum to age 25
• family youth centredness
• maternal family health

6
MHCC CYAC Funded Initiatives

• National Mental Health Strategy
• Evergreen Document
• School-based mental health programs
• -evidence
• -demonstration projects
• Youth Reference Group
• Anti-stigma, Anti-discrimination Campaign
• Youth Focus
• Youth Reference Group
• Family Self Stigma
• Knowledge Exchange Centre
• cymh component
• collaboration and engagement across Canada
  encouraged whenever possible
• (exploring national prevalence surveillance
  study)

7
The Many Faces of Child Abuse Neglect

• Prevention
• -the name of the game
• If not, then early identification and early
  intervention

8
The Many Faces of Child Abuse and Neglect

1. Iatrogenic abuse neglect?
2. Does system inadequacy or failure constitute
   abuse or neglect?
3. What about the Rights of the Child and Youth?

9

• Our children are a living message to a time we
  will not see
• Sir Al Aynsley Green
• Childrens Commissioner for England

10
Conclusion

• Great Program
• Stimulating day ahead
• Thank you for your attention!

11
Understanding the Developmental Determinants
Changing the Life Scripts of Abused Neglected
ChildrenDeborah Goodman, MSW, RSW, PhD.
Manager of Research Program Evaluation,Child
Welfare Institute, Childrens Aid Society of
Toronto

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

12
Canadian Child Welfare Context

13
Child and Welfare vs. Child Protection Systems

• Child Protection Systems (CPS)
• Canada, United States, United Kingdom,
  Australia
• Emphasis individual rights responsibilities
  Mandate stand-a-lone authority
• Family Service Systems (FSS)
• France, Germany, Sweden, Netherlands
• Emphasis consensual agreement Mandate child
  family welfare systems
• Focus support parent-child relationships
  care of children
• Community Caring Systems (CCS)
• Canadas Aboriginal Peoples, New Zealand
  Maori
• Emphasis consultations with parents, extended
  family, local community
• Focus keeping children within their
  family/community respect traditional values

14
Canadian Child Protection System Characteristics

• Provincial authority model
• Residual system
• Focus is on risk safety
• Focus is on protecting children from harm in
  their own home
• Mandatory reporting
• 1-point entry system
• Reliance on court to convey authority
• Viewed as stigmatizing
• Division between services for family support
  child protection
• Service is to vulnerable / at risk youth via a
  patchwork of services delivered by different
  ministries (e.g. child welfare, youth justice,
  childrens mental health)

15
The social construction of child maltreatment
a moving target

• 1900-2000
• 1900s Physical Neglect / Abandonment
• 1960s Physical harm / Medical Neglect
• 1980s Sexual harm
  
• 1990s Neglect / Inadequate Supervision/
• Inappropriate Child Care
• 1990s Emotional harm /Exposure to adult conflict

• 2000- 2100
• Deleterious effects of 2nd-hand smoke is well
  established in literature and law
• Parental right vs. child abuse?
• Unintentional injury (UI) is the leading cause of
  death for children age 1-11 half UIs are
  transportation accidents
• Poor parenting decision vs. neglect?
• Parental alienation
• Family dysfunction vs. emotional harm?

16
Child maltreatment by contextdiffers
USA 2007 vs. Britain 2005 vs.
Canada 2003 vs. Toronto 2003 Population
302M 61M 32M 2.5M Neglect
60 44 30 46 Phys. Abuse
11 15 24 28 Sexual Abuse
8 9 3 5 Emotional Abuse
4 20 15 1 Exposure to DV
28 20 Mixed
13 12 Other
4 TOTAL 100 100 100
100 Britain includes DV
Over
1.8million Over 214,000 Over
12,000 investigations investigations
investigations

17
Canadian Incidence Study (CIS 2003) 5 categories
20 maltreatment forms

• Categories
• Physical abuse
• Sexual abuse
• Neglect
• Emotional maltreatment
• Exposure to domestic violence

18
Substantiated by child age CIS 2003

• CIS 2003

• Age Incidence/
• Group per 1000 Substantiated
• lt1 28.22 7
• 1-3 19.93 15
• 4-7 21.35 24
• 8-11 23.21 29
• 12-15 20.40 25
• Total 21.71 100

19
Reason for service at an Ontario CAS

• Ontario Eligibility Spectrum 
• PROTECTION SECTIONS 1-5
• Section 1 Physical/Sexual Harm by Commission
• Section 2 Harm by Omission / Neglect
• Section 3 Emotional Harm/ Exposure to Partner
  Conflict
• Section 4 Abandonment/ Separation
• Section 5 Parental Capacity

20
Top 3 Ontario Eligibility Codes Children 0-5
for 2008 _at_ 1 CAS in GTA

• Children 5 under
• No Court Involvement
• N2,245
• Section 1-Physical Harm 29
• Section 3-Emot Harm/DV 28.5
• Section 5- Parental Capacity 27
• Total 84-85

• Children 5 under
• Court Involvement
• N50
• 22
• 12
• 48
• 82

21
Eligibility Code Top Section Top
ScaleChildren 0-5 2006-2008
22
About a Canadian public health issue children
at risk

23
About the areas of concern for thePublic Health
Agency of Canada

• AREAS
• 1- Poverty / low SES
• 2- Child abuse and neglect
• 3- Prenatal
• 4- Childrens mental health
• 5- Obesity
• 6- Unintentional injuries

• APPROACH
• 1- Prevention
• 2- Promotion
• 3- Protection
• 4 -Treatment

24
About the development of brain growth newborn to
6 months
Wotherspoon
newborn 1 month 3 months
6 months

25
Outcome Former youth in care (Results from US and Canadian research studies) Canadian youth (ages 15-25)
Not complete high school 27 to 75 15
Unemployed 46 14
Receive public assistance 38 6 a
Experienced homelessness 45 to 90 -
Pregnant at an early age 30 b 6
Involved in justice system 60 2
Emotional/mental health problems 50 18
These statistics are not direct comparisons as
they are not based on controlled sampling within
single research projects. a Total Canadian
population b Of the 30 of former Crown wards
who became pregnant at an early age, 60 became
re-involved in the child welfare system as
parents.
MCYS
26
Early developmental determinants of risk and
resilience

27
Risk and protective factors

• Risk
• Personal/Internal factors
• Exist within the individual e.g. genetic,
  disabilities
• Environmental factors
• Exist within a social context e.g. family,
  school, community, country
• NOTE The of risk factors is more important than
  the type of risks

• Protective
• Personal/ Internal factors
• Exist within the individual e.g. personality,
  autonomy
• External factors
• Exist within a social context e.g. family,
  school, community, country
• NOTE Protective factors reduce risk of harm,
  improve resistance to risk, contribute to
  positive outcomes

28
About the effects of physical discipline/harm on
child development

• About the effects of line on child development
• 10/11 meta analyses found parental corporal
  punishment is associated with the following
  behaviours outcomes
• Decrease in Increase in
• - Childs moral internalization - Child
  delinquency
• - Quality of relationship parent to child -
  Child anti-social behaviour
• - Child mental health - Likelihood of being a
  victim phys. abuse
• - Adult mental health
  - Adult aggression
• - Adult criminal/anti-social behaviour
• - Likelihood of abusing own child/spouse
• Short-term effect
• Immediate child compliance

29

?2 5.9, plt.04
30
About the effects of domestic violence on child
development

• The effects of domestic violence on infants and
  toddlers place these children at increased risk
  of abuse by their mothers and/or the abusive
  adult in the home.
• Child abuse occurs in 30-60 of spousal violence
  cases.
• 21 Canadian women are abused by their partners
  during pregnancy.
• 40 of those women who were abused during
  pregnancy reported that the abuse began when they
  were pregnant.
• 11 of the women stated the violence occurred
  before their current pregnancy
• 64 of the women indicated the abuse escalated
  during the pregnancy

31
Still Face Experiment
http//www.youtube.com/watch?v7AGJFg6twjgfeature
related
32
About the effects of neglect on childs
developing brain
no neglect
neglect

33
About the effects of sexual abuse on the
developing brain

34
About the effects of alcohol on the developing
fetus

• Direct Effects of Alcohol on Fetus
• Neuronal cell damage/cell death
• Inhibited protein and DNA synthesis in the
  placenta, fetal liver and brain fewer cells,
  decreased growth and differentiation smaller
  organs
• Effected the hippocampus, amygdala, cerebellum
  -all appear particularly sensitive to effects of
  alcohol
• Smaller skeleton, greater cartilage and less
  skeletal bone creation (e.g. craniofacial
  anomalies due to effects of cell death reduced
  neural crest cell numbers)
• Indirect Effects of Alcohol on Fetus
• Nutritional deprivation/malnutrition
• Calcium abnormalities
• Structure and function of the placenta was
  altered
• Circulatory changes decreased fetal blood flow
• Interference with growth factors and other cell
  signaling mechanisms
• Fetal overexposure to stress hormones (brain
  areas involved in a) the stress response, b)
  depression, and c) addiction overlap

35
Prenatal alcohol exposure delays skeletal
development in fetal rats
Alcohol
Pair-fed control
Ad-lib fed control

Weinberg
36
About the impact of emotional trauma on the
developing brain

• /frequency/duration/chronicity of stress
  episodes is important
• e.g. infant feels unsafe with caregiver (physical
  harm),
• /or is in an unsafe situation (DV),
• /or has unpredictable/no response from caregiver
  with infants distress cues (parent capacity re
  substance use/mental health, neglect)
• STRESS SITUATION
• Activates infants stress response system
  
• Large amounts of cortisol flood the infants
  developing brain
• Cortisol floods can be toxic to the brain/ may
  change brain structure

37
About the effects of poverty on a childs
development

• Low-income families are over-represented in child
  welfare involved families (both in care and out
  of care)
• USA National Incidence Studies (NIS1,23) found a
  strong inverse correlation with income and child
  maltreatment cases
• Child maltreatment report rates are greatest in
  communities with high poverty rates and high
  unemployment rates
• Strong correlation between welfare assistance and
  child protection caseloads

38
Changing life scripts

39
Reducing maltreatment is about protective factors
prevention strategies

• Five Protective Factors to Reduce Child
  Maltreatment
• Nurturing attachment between family members
• Knowledge of parenting/ child development
• Parental emotional resilience
• Social connections for parents
• Concrete supports adequate food, clothing,
  housing
• Prevention Strategies
• Universal/Primary before the fact
• Targeted /Secondary before the fact
• Indicated / Tertiary after the fact

40
Preventing child maltreatment Evidence-based
to promising practices

• Evidence-based interventions
• Primary prevention programs e.g. Back to Sleep
  - reduced SIDS
• A caring, committed caregiver stable placement
• Healthy Babies/Healthy Children Head Start
• Emerging evidence-based interventions
• Triple P Parenting
• Trauma treatment e.g. CBT
• FASD training for professionals and respite
  services for children with FASD
• Family Group Conferencing
• Early diagnosis / meconium testing
• Promising practices
• Home visiting/targeted parenting programs
• Quality preschool/family support
• Improve and repair brain function e.g. exercise,
  pharmacology
• Targeted education to children e.g. prevent
  sexual abuse, dating violence

41
Key practice learning areas

42
Future Research Areas

• Gene and brain research
• Impact of substance use on fetus child
• Infant mental health
• Stronger links -poverty to child maltreatment
• Link affordable, high quality early learning
  child care programs to maltreatment prevention
• Impact of greater collaboration across sectors

43
Combating child maltreatment -professionals

• Common focus, consistent message
• Comprehensive approach by all levels of
  government
• Consolidate knowledge, especially Canadian
• Consistent collaboration practice policy
  research
• across-sectors
  across-disciplines
• Coordinate on evidence based practices
• Capabilities to identify expanded
• Collect data, analyze outcomes

44
Combating child maltreatment- Canadian society

• Stronger prevention focus
• Much earlier intervention with infants/young
  children
• Improve understanding of infant developmental
  needs
• Better education on risks of maternal alcohol use
• Provision of quality child care
• Eliminate corporal punishment of children

45

THANK YOU!
Child Welfare Institute, CAS-Toronto Developin
g evidence-based knowledge today...so we can be
more effective tomorrow Deborah Goodman,
PhD Manager of Research Program Evaluation,
dgoodman_at_torontocas.ca 416 -924-4640 x 2792
46
Working Towards WinningThe Collaboration of
Childrens Aid Societies, Parents and the Courts
47
Howard Hurwitz, M.S.W., R.S.W.Director of
Childrens ServicesJewish Familyand Child
Service of Greater Toronto MODERATOR

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

48
Paramount Concern is Early Permanency Planning
for Children

• Although a large percentage of cases are settled
  out of court, there are still too many legal
  battles
• Issues related to Family Courts are laden with
  emotion rather than complex legal theory
• We need to work more effectively with other
  professional groups, understand one anothers
  roles, and forge multidisciplinary approaches
• The goal is early resolution of litigation and
  early decisions to give children permanent homes.

49
Kristina ReitmeierChildrens Aid Society (CAS)

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

50
CAS Mandate

• Child and Family Services Act
• investigate allegations and information that a
  child is in need of protection
• provide assistance to parents to prevent need for
  protection and to protect where required
• when no less restrictive alternatives available,
  must intervene through court
• Dual role of CAS worker

51
Nature of Child Protection Proceedings

• Civil, not criminal
• Remedial in nature
• CAS is a party (usually the Applicant), but
  subject to different expectations as an
  institutional litigant
• CAS has Crown like disclosure obligations in
  litigation

52
Role of CAS Counsel

• give legal advice
• act on instructions
• represent CAS in court proceedings
• in contrast to the Crown in criminal proceedings,
  CAS counsel does not decide to initiate or
  discontinue a case

53
Gary Gottlieb, B.A., LL.B.Family Lawyer and
Mediator

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

54
Child Welfare Clients

• Usually very needy individuals
• Many struggle financially
• Many grapple with emotional challenges
• Some struggle to read and write
• Many are from foreign countries and cultures with
  parenting roles that conflict with Canadian norms

55
Role of Child Welfare Lawyer

• Educate the client about the legal process and
  current legal difficulties
• Calm highly emotional clients in order to focus
  on the legal issues
• Gather evidence to present to the CAS and court
• Attempt to clarify and resolve issues with CAS
  counsel
• Work with other professionals to provide support,
  prove misapprehension on the part of the CAS, and
  /or rehabilitate the client.

56
Role with Respect to the Child

• Parents believe they are best suited to raise
  their children and, until proven otherwise, the
  lawyers role is to do whatever is possible to
  keep parents and children in frequent contact
• Where it is unlikely that parents will be
  reunited with their children, the lawyers role
  is to educate his/her client about the realities
  and move the case forward expeditiously in the
  interests of the childs need for permanency
  planning.

57
Elizabeth McCarty, B.A., LL.B.In-House
CounselOffice of the Childrens Lawyer

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

58
Role of the Office of the Childrens Lawyer

• OCL is a law office in the Ministry of the
  Attorney General
• OCL represents children, those under the age of
  18, when the court believes a lawyer for the
  child is necessary to represent his or her
  interests
• In addition to child protection matters, the OCL
  represents children in other custody and access
  disputes, litigation cases of personal injury and
  estate matters.
• OCL must have a court order to get involved
  unless a parent is a minor, in which case
  involvement is automatic

59
Role with Respect to the Child

• We are not neutral we take a position on behalf
  of the child client
• We have a solicitor client relationship we are
  obligated to keep our clients up to date on court
  processes
• We do not take instructions children at law
  cannot instruct.

60
Position Taken by a Childrens Lawyer

• We do not take a best interest position that
  is, we do not determine what in our view is
  best for the child.
• We take a position which is based on views and
  preferences of the child which are independent,
  consistent and strong
• Children do not necessarily decide where they
  will reside but their feelings and views need to
  be put before the court

61
Robert Spence, B.A., LL.B., LL.M.Ontario Court
of Justice

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

62
Important Roles for Many in Family Court

• Family Lawyer advocates for family
• Childs Lawyer presents childs perspective
• CAS Lawyer presents Societys perspective
• Judge role changes significantly from pretrial
  to trial

63
Judges Role is Dramatically DifferentPre-Trial
vs. at Trial

• Pre-Trial Role
• Active and proactive
• Probing, prodding, asking questions
• Creating a roadmap for the work to be done
• Offering opinions about each lawyers case
• Setting timetables

64
At Trial Role for Judge

• First of all its a different judge!
• Judge assumes a passive role
• Listens to the evidence
• Asks the odd question
• Renders a decision at conclusion of trial

65
Early Intervention for Abuse and NeglectThe
Best Get Out of Jail Free Card!
66
Child Abuse A Noxious Precursor to Subsequent
Psychiatric and Forensic SequelaeHy Bloom,
LL.B., M.D. F.R.C.P.(C.)MODERATOR

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

67
Facts About Child Abuse

• Child abuse is pervasive in the general
  population, regardless of race, culture, gender,
  SES or geographical location.
• Higher rates of abuse are seen in special
  populations (e.g. psychiatric patients and
  offenders especially sexual and violent
  offenders).
• Abuse does not invariably lead to psychopathology
  or loss of enjoyment of life.

68
Poor Psychosocial Adjustment for Many Abused
Individuals

• Psychosexual disorders and adjustment problems
• Delinquency, crime, deviancy and violence
• Educational and vocational underachievement
• Problems with intimacy, trust, authority, and
  control
• Attachment problems with own children

69
Early Abuse Can Lead to Enduring Difficulties in
Later Life

• Psychiatric conditions and Psychopathology
• depression
• anxiety disorders including PTSD
• dissociative disorders
• substance abuse
• psychosomatic conditions
• maladaptive personality traits (e.g. antisocial,
  borderline)
• self injurious behaviour

70
Best Interventions

• Primary prevention of abuse and neglect
• Thorough assessment
• Case coordination
• Early multimodal, multidisciplinary intervention
• Education and training
• Systemic flexibility and understanding
• Creative approaches which target the individual

71
Police and PreventionINSPECTOR MARK
ALLENCrime Prevention Section Ontario
Provincial PoliceOntario Association of Chiefs
of PoliceYouth Committee
72
Role of Policing

• Police Services Act Section 4(2)
• Core police services
• Adequate and effective police services must
  include, at a minimum, all of the following
  police services
• Crime prevention.
• Assistance to victims of crime.
• Public order maintenance.
• Emergency response. 1997, c.8, S.3

73
Directing Prevention Resources

• Research indicates best value for investing in
  crime reduction occurs during the early years,
  when police have little access/involvement/mandate
  
• Dr Mathews insight into the balance of
  investment. Investing in the Moderate Risk Youth
  and maintaining an investment in the Low/No Risk
  Youth

74
Progress

• National Youth Officer Program
• Ontario School Resource Officer Program
• Committee of Youth Officers of Ontario
• Developmental Asset Approach Understanding
  Youth
• Ontario Association of Chiefs of Police Youth
  Committee

75
Best Practice

• Ottawa Police Service
• Community Youth Diversion Program
• Youth Mental Health Court
• Youth Services Bureau Mental Health Worker
• Mental Health Unit work with Mental Health
  professionals on the road
• On Staff Youth Intervention and Diversion
  Coordinator

76
Challenges

• Focus on Prevention
• Access to Resources
• Consistency of Police Service Delivery
• Training

77
Youth Criminal Justice Act and Mental Health
DiversionTANYA KRANJC, B.A., LLBAssistant
Crown Attorney
78
Classification of Extrajudicial Sanctions

• Criminal Code offences are divided into 3
  categories
• Class III offences are never appropriate for
  extrajudicial sanctions
• Class I offences are the least serious and are
  presumptively appropriate for extrajudicial
  sanctions
• Class II offences are all other offences and
  eligible for consideration at the discretion of
  the Crown

79
Other Factors for the Crown to Consider

• Reasonable prospect of conviction and public
  interest
• Prior extrajudicial sanctions or alternative
  measures
• Prior youth court record
• Views of the victim and victim impact

80
Eligibility for Mental Health Diversion

• A behavioural disorder
• A developmental disorder
• A concurrent disorder (mental illness and another
  presenting issue)
• A dual diagnosis (mental illness and
  developmental disability)

81
Youth Mental Health Court Workers Assist Youth
with Issues such as

• Conduct Disorder (CD)
• Attention-Deficit Disorder (ADD)
• Attention-Deficit Hyperactivity Disorder (ADHD)
• Oppositional Defiant Disorder (ODD)
• Fetal Alcohol Spectrum Disorders
• Depression
• Anxiety including PTSD
• Dual diagnoses and mental illness plus a
  concurrent disorder such as addiction

82
Referrals to a Youth Mental Health Worker may
come from

• Duty counsel
• Defence counsel
• Parents or guardians
• CAS
• Community agencies
• Toronto Bail programme

83
Documentation to Develop a Treatment Plan

• Psychiatric/psychological assessments
• Information from the family doctor
• Reports from a counselor or therapist
• Reports from community organizations
• Contact with family or caregivers
• School reports
• Information about start dates for programs in
  which the youth is enrolled/waitlisted

84
Youth Criminal Justice Act Rehabilitative
HighlightsMIRIAM BLOOMENFELD, B.A., LLBOntario
Court of Justice
85
Youth Criminal Justice Act General
Background

• YCJA replaced Young Offenders Act in April 2003 -
  governs all young persons aged 12 through 17 who
  are investigated, charged, prosecuted and/or
  sentenced in relation to criminal offences.
• Federal governments goals included reducing the
  incarceration rate for young persons, (especially
  for property offences), restricting and
  clarifying judicial discretion in sentencing and
  emphasizing accountability, rehabilitation and
  reintegration rather than deterrence and
  punishment.

86
YCJA Preamble

• Members of society share a responsibility to
  address the developmental challenges and the
  needs of young persons and to guide them into
  adulthood.
• Communities, families, parents and others
  concerned with the development of young persons
  should, through multi-disciplinary approaches,
  take reasonable steps to prevent youth crime by
  addressing its underlying causes, to respond to
  the needs of young persons, and to provide
  guidance and support to those at risk of
  committing crimes.

87
Principles of the YCJA

• Promote the long term protection of the public
  by
• Preventing crime by addressing the circumstances
  underlying a young persons offending behaviour
• Rehabilitating young persons who commit offences
  and reintegrating them into society
• Ensuring that a young person is subject to
  meaningful consequences for his or her offence
• Youth criminal justice system separate from
  adults
• Use least restrictive degree of intervention,
  e.g. diversion, alternatives to custody, no
  custody for mental health or social welfare
  issues

88
Purpose of Sentencing S.38(1)

• Hold young person accountable through imposition
  of just sanctions that have
• Meaningful consequences for the young person AND
• Promote rehabilitation and reintegration into
  society
• Thereby contributing to the long-term protection
  of the public.

89
Conferences YCJA s.19, 41

• A youth justice court judge, the provincial
  director, a police officer, a justice of the
  peace, a prosecutor or a youth worker may convene
  a conference for the purpose of making a decision
  required to be made under the YCJA.
• The mandate of a conference may be, among other
  things, to give advice on appropriate
  extrajudicial measures, conditions for bail,
  sentences, review of sentences and reintegration
  plans.

90
Sentence Options Rehabilitation, Treatment,
Custodial Alternatives

• All custody sentences include a mandatory
  component of community supervision to facilitate
  reintegration
• Attendance program
• Intensive Support and Supervision Program
• Intensive Rehabilitative Custody and Supervision
  Program

91
Child Welfare Assessment

• YCJA s.35
• In addition to any order that it is authorized to
  make, a youth justice court may, at any stage of
  proceedings against a young person, refer the
  young person to a child welfare agency for
  assessment to determine whether the young person
  is in need of child welfare services.

92
Native Children in CareROBERT NEILL, B.A.,
M.S.W.Director of Child Welfare ServicesNative
Child and Family Services of Toronto

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

93
Children in Care Fact Sheet as of March 31st,
2008Aboriginal Children (With or Entitled to a
Status Number) in Care, by Age Group
OACAS Report

• Of the 51 Childrens Aid Societies that responded
  to the survey, 40 (78) report aboriginal
  children with or entitled to a status number in
  their care. The total number of children is
  1,960, or 11 of all reported children in care.

CIC by Age Group
Age Group Age Group No. of Children Percentage change to March 31st, 2007
0 5 559 28.5 3.3
6 12 719 36.7 0.3
13 15 376 19.2 -2.1
16 106 5.4 15.2
17 82 4.2 -5.7
18 61 3.1 35.6
19 28 1.4 -6.7
20 29 1.5 61.1
Total Total 1,960 100 2.4
6.0
9.6
28.5
19.2
36.7
94

95
RESEARCHERS(2005/2006)

• John Anderson, NCW (played an instrumental role,
  especially in organizing the interviews for this
  report.)
• Lucie Cossette, NCW
• Matthew Sanger, NCW
• Trica McDiarmid, Research Contractor (Port
  Coquitlam, British Columbia)

96
Aboriginal Children in Care by Province and
Territory

97
Putting Children and Youth FirstA
Multidisciplinary and Rights-Based Approach to
Service Delivery Marvin M. Bernstein, B.A.,
J.D., LL.M. (ADR)Saskatchewan Childrens Advocate

• The Many Faces of Child Abuse and Neglect
• Ontarios First Multidisciplinary Conference on
  Child Abuse and Neglect
• Friday, November 6, 2009 Design Exchange,
  Toronto, Ontario

98
Fundamental Assumptions

• Better outcomes for children and youth will be
  achieved where there is
• A commitment to respect and implement rights
  under the United Nations Convention on the Rights
  of the Child.
• The implementation of a Children and Youth First
  Vision where children and youth are treated as
  the primary clients.
• An integrated, multidisciplinary delivery model
  with services delivered across systems without
  narrow service mandates, privacy barriers or
  funding silos.

99
Child Maltreatment is a Multidimensional Social
Problem

• Children and families do not live in isolation
  from the broader socio-political systems -
  schools, community, and the law.
• Not something that one Ministry, or one
  discipline, or the child welfare system, can fix
  by itself.
• Addressing child maltreatment requires
  coordination between child welfare, other
  child-serving ministries and agencies, and the
  community at large.

100
Saskatchewans Childrens Advocate

• Is an independent officer of the Provincial
  Legislature.
• Can take referrals from any source.
• Has authority to work towards resolving disputes
  through informal processes such as negotiation
  and mediation.
• Has authority to conduct formal investigations
  with respect to child death, critical injury, and
  fairness within systems.

101
Saskatchewans Childrens Advocate (contd)

• Has authority to conduct both case-specific and
  broader systemic advocacy and investigations into
  the provision of services to children/youth by
  ministries and agencies of the provincial
  government.
• Engages in public education and is informed by
  youth voice.
• Can compel the production of documents and has
  subpoena powers.

102
Majority (68) of Our Work Intersects with Child
Welfare

• Off-reserve child welfare serves are delivered by
  the Ministry of Social Services.
• On-reserve child welfare services are delivered
  by 18 First Nations Child and Family Services.
• Significant over-representation of Aboriginal
  children in welfare care in Saskatchewan 15 of
  the total Saskatchewan population is Aboriginal.
• Approximately, 80 of children coming into care
  are of Aboriginal background.

103
United Nations Convention on the Rights of the
Child

• A landmark human rights document serving as a new
  global standard on the treatment of children.
• Most widely endorsed international treaty in
  history by 193 states. Only the United States
  and Somalia have not ratified.
• Childrens rights are human rights and include
  the whole range of civil, political, social,
  economic and cultural rights.
• Children have the moral and legal right to have
  their provision, protection, and participation
  needs met.

104
Federal and Provincial Governments must Ensure
that all Children

• Benefit from special protection measures.
• Have full access to education and health care.
• Can develop their personalities and abilities to
  their utmost potential.
• Can grow up in an environment of love,
  understanding and non-violence.
• Are informed about their rights according to
  their age and maturity.
• Can actively participate in exercising their
  rights.

105
Specifically, Governments are obligated to

• Ascertain that professionals remain respectful of
  the childs/youths views, while not abdicating
  their responsibility as best interests
  decision-makers.
• In child welfare, the childs or young persons
  best interests must be the priority when working
  with families child is the primary client.
• States and child welfare agencies are obligated
  to protect children and youth from all forms of
  physical or mental injury or abuse, or
  exploitation, including sexual abuse.

106
Rights-Based Child Welfare Services

• Children and youth are entitled to be with their
  parents unless they would otherwise be in need of
  protection and such placement would be contrary
  to their best interests.
• Resources should be accessed to assist families
  to provide a safe and nourishing environment.
• In Ontario, once a child/youth is admitted to
  care, there are codified rights that are
  stipulated in child welfare legislation.
• Alternative care must be monitored by regular
  private visits and the investigation of
  complaints. Moving is traumatic children and
  youth are entitled to resources to make the
  alternative placement successful.

107
Rights-Based Child Welfare Services (contd)

• Children are negatively affected by multiple
  changes in placement, caregivers and service
  providers stability, security and continuity
  are important for all children being served in
  the child welfare system.
• Child welfare system must provide appropriate
  services for children to heal from the abuse and
  neglect they have experienced.
• Services must be provided with cultural
  competence, recognizing the distinctive cultures
  of minorities, especially the unique
  circumstances of Indigenous children.

108
We have Identified Cases Where

• Jurisdictional, political, and/or financial
  considerations have been given priority over the
  needs and best interests of children and youth.
• Family and blood ties have taken precedence over
  the safety, protection and well-being of children
  and youth.
• Sometimes, family reunification and cultural
  considerations are valued over the needs and
  protection of the child. When the child remains
  in an unchanged environment, the cycle continues
  and becomes inter-generational.

109
Permanency Planning

• Purpose of permanency planning is to minimize the
  length of time that a child will live in a
  setting that lacks the promise of being
  permanent. Placement choices may include
  maintaining the child with the biological parents
  or placing her/him with relatives, permanent
  foster parents, adoptive parents, or
  foster/adoptive parents.

110
Permanency Planning (contd)

• To achieve permanency planning, it is necessary
  to avoid litigation limbo occurs when the
  court machinery fails to be sensitive to the
  childs time frame, either by allowing too much
  time to elapse before a decision is reached
  and/or by allowing legal proceedings to be so
  prolonged that the child is kept in limbo during
  that critical period in which a child must either
  develop a secure emotional attachment or be left
  with lifelong emotional and social deficits.
• Planning must be on an individualized basis and
  child must be considered the primary client in
  any planning process.

111
Permanency Planning (contd)

• Children/youth should have a direct say in the
  development of their case plans should not be
  left out of the process or simply treated with
  tokenism.
• Government ministries and child welfare agencies
  have the right to intervene in the lives of
  families without fear of being sued by family
  members to protect vulnerable, at risk children.
  It is the child and not the family to whom
  the duty of care is owed, and whose best
  interests are to be served at all times (Supreme
  Court of Canada Syl Apps Secure Treatment
  Centre v. B.D.)

112
Children and Youth First VisionAnchored by
Children and Youth First Principles

• The Children and Youth First Principles are
• Based upon the provisions of the United Nations
  Convention on the Rights of the Child.
• Intended to simplify and highlight the most
  critical and relevant provisions in the
  Convention, based upon our observations and
  experience.
• Intended for use by our Office and the provincial
  government as a filter in the development and
  implementation of future child-serving policies,
  programs and legislation.

113
All Children and Youth are Entitled to

• Those rights defined by the United Nations
  Convention on the Rights of the Child.
• Participate and be heard before any decision
  affecting them is made.
• Have their best interests given paramount
  consideration in any action or decision involving
  them.
• An equal standard of care, protection and
  services.
• The highest standard of health and education
  possible in order to reach their fullest
  potential.
• Safety and protection from all forms of physical,
  emotional and sexual harm, while in the care of
  parents, governments, legal guardians or any
  person.

114
All Children and Youth are Entitled to (contd)

• Be treated as the primary client, and at the
  centre, of all child serving systems.
• Have consideration given to the importance of
  their unique life history and spiritual
  traditions and practices, in accordance with
  their stated views and preferences.
• Children and Youth First Principles were adopted
  by the Saskatchewan Government in February 2009,
  with the commitment to use them as a guide in
  examining policy and legislation and in
  developing and implementing both policy and
  legislative changes.

115
Professionals involved in Multidisciplinary Teams

• Physicians, including pathologists and coroners,
  and nurses
• Mental health and social work professionals
• Child protection workers
• Police, crown prosecutors and judges
• Experiential youth
• Aboriginal representatives
• Participants from both urban and rural centres

116
Roles and Responsibilities

• Largely mandated by provincial, territorial and
  federal legislation, policies, procedures and
  protocols.
• Important to carefully define in writing various
  roles and responsibilities in order to avoid
  confusion, duplication and vacuum in service
  delivery.
• Collaboration between child protection and police
  is essential for the purpose of conducting a well
  co-ordinated joint child abuse investigation.
• Priorities of members of the multi-disciplinary
  team may occasionally be in conflict with one
  another.

117
Roles and Responsibilities (contd)

• Resolution of conflicts between service providers
  must be guided by open and respectful
  communication and the best interests of the
  child.
• Team members statements and actions can affect
  the outcome of an investigation - avoid
  contaminating the evidence and interfering with
  the investigation by the police and/or child
  welfare authorities.
• Specialized and ongoing training is necessary.

118
Principles for Information Sharing

• Knowledge of applicable legislation, policy,
  protocols and professional codes of ethics this
  foundational knowledge is essential.
• Policy and protocols do not create independent
  authority and must be consistent with relevant
  legislation.
• Consultation with legal counsel in case of
  uncertainty the law of access to and
  confidentiality of records has become more
  complex with the development of both provincial
  and federal freedom of information and protection
  of privacy legislation.

119
Principles for Information Sharing (contd)

• Sharing of information on a need-to-know basis
  to ensure that all service providers are
  functioning with the same baseline knowledge and
  that there are service plans, which meet the best
  interests of the child and the needs of the
  family.
• Fully-Informed Client consent wherever
  possible, written consents should be informed and
  voluntarily obtained from parents and children
  with authorization to have their personal
  information shared.

120
Principles for Information Sharing (contd)

• Confidentiality and personal privacy rights
  should be safeguarded where possible however, in
  the absence of a comprehensive legislative scheme
  and the updating and proclamation of Part VIII
  (Confidentiality of and Access to Records) of
  Ontarios child welfare legislation, child
  protection agencies should consider the paramount
  purpose of The Child and Family Services Act, as
  stipulated in the Declaration of Principles,
  which is to promote the best interests,
  protection and well being of children.
• There have been many documented child deaths and
  critical injuries suffered by children where
  privacy barriers have impeded child protection
  workers from accessing key information.
• A liberal interpretation of privacy legislation
  should be applied, whenever it is reasonably
  arguable to do so, in order to ensure the safety,
  protection and wellbeing of children.

121
Multidisciplinary Advisory Teams Assist in Child
Death and Critical Injury Investigations

• Identify and describe systemic and
  cross-jurisdictional issues.
• Propose strategies for prevention.
• Propose new/amended findings or recommendations.
• Provide guidance with respect to best practice in
  child service issues
• Inform the investigative process through
  discussion, reflecting several multi-disciplinary
  perspectives (e.g. medical, legal, law
  enforcement, educational, mental health, child
  welfare, Chief Coroner, Chief Forensic
  Pathologist, experiential youth, Aboriginal
  representative).
• Provide external quality control and additional
  accountability to the community.
• Support investigators during distressing
  investigations of child death and critical
  injuries.

122
Current Selected Themes

• Lack of integrated and co-ordinated case
  management, role clarification, and communication
  among service providers.
• Different systems do not speak to one another and
  operate in silos.
• The child welfare sector is perceived as having
  the singular responsibility for ensuring the
  protection and safety of children - rather than
  this being seen as a collective responsibility.

123
Tenants of Cooperative Multidisciplinary Model

• Shared responsibility and mutual respect
  services should reflect a shared leadership,
  planning, decision-making, resources, evaluation
  and mutual respect for the unique expertise and
  contribution of each participant.
• Holistic, Child-Centred Focus services should
  be child-centred and customized, with the
  interdependent nature of all systems and programs
  being recognized.

124
Tenants of Cooperative Multidisciplinary Model
(contd)

• Community empowerment communities should be seen
  as diverse and unique, each with its own
  strengths, history, needs and vision, and capable
  of designing its own solutions.
• Cultural affirmation and sensitivity a
  respectful, barrier-free environment should be
  fostered where individuals have their cultural
  and spiritual values acknowledged and have
  opportunities for equal access and equal benefit.

125
Tenants of Cooperative Multidisciplinary Model
(contd)

• Preventive Services the goal is a comprehensive
  range of services including a proper balance of
  prevention, early intervention and support
  services which contributes to quality of life,
  enhances well-being and provides care for the
  most vulnerable.
• Integrated Services services should be
  integrated to reduce service fragmentation and
  improve effectiveness, with fewer children
  falling between the cracks.

126
Tenants of Cooperative Multidisciplinary Model
(contd)

• Concurrent case-specific and systemic services
  while a co-operative approach should be taken in
  addressing the immediate risks to individual
  children and families, a larger systemic focus
  should be applied in identifying the chronic
  underlying problems that contribute to ongoing
  family dysfunction and child protection
  intervention (e.g. child poverty lack of
  adequate housing, childcare and employment lack
  of early childhood education and adequate parent
  support inadequate facilities to address alcohol
  and drug addictions, mental health concerns, and
  family violence and disparity of services in
  remote rural communities).

127
Conclusions

• It is important to make the effort to respect the
  rights of children and youth and to break down
  rigid silos and artificial bureaucratic barriers
  that impede effective multi-disciplinary and
  integrated service delivery to children, youth
  and families.
• On November 20, 2009, we have the celebration of
  the 20th anniversary of the adoption of the
  United Nations Convention on the Rights of the
  Child while Canada and our Provinces have made
  some measurable progress, these entitlements have
  not been sufficiently implemented and have been
  largely relegated to mere paper rights.
• On this special anniversary, we all need to
• Transform these paper rights into lived
  rights.
• Continue to speak with and speak up for children
  and youth.

128
Conclusions (contd)

• Develop the attributes of an effective advocate
  be assertive, collaborative, courageous,
  creative, persistent, principled, proactive,
  resilient and strategic.
• There can be no keener revelation of a societys
  soul than the way it treats its children.
  (Nelson Mandela)

For More Information Contact our website at
www.saskacao.ca or email me at mbernstein_at_saskcao.
ca.
129
WRAP-UPJanet Morrison, M.A., C. Psych.
Assoc.PresidentChild Psychotherapy Foundation
of Canada
The Many Faces of Child Abuse and
Neglect Ontarios First Multidisciplinary
Conference on Child Abuse and Neglect Friday,
November 6, 2009 Design Exchange, Toronto,
Ontario
130
What Do We Know?

• We know that the costs of child maltreatment are
  staggering for the child and the larger
  community.
• 60 of children in care will come into contact
  with the criminal justice system
• 50 will experience a mental health problem
• According to the last Child Welfare Review
  (2007), 82 of Crown wards have special needs
  including psychiatric diagnoses, developmental
  disability and learning disability.

131
What Do We Know? (contd)

• Child maltreatment report rates and poverty are
  closely linked
• There is a very significant over-representation
  of aboriginal children in welfare care and of
  those who are, few are being raised by aboriginal
  families
• There is catastrophic impact of substance abuse
  on brain development
• Children need early permanency planning and a
  permanent home to develop a secure emotional
  attachment or are left with lifelong emotional
  and social deficits.
• Children need appropriate often multimodal
  services to heal from abuse and neglect

132
What are We Doing which Reflects What We Know?

• The law upholds that the child or young persons
  best interests must be the priority when working
  with families the child is the primary client.
• The law recognizes the importance of early
  permanency planning and requires decisions be
  made about children in care expeditiously one
  year for children 0-6 and two years for older
  children.
• The YCJA recognizes the need to
• address the circumstances underlying a young
  persons offending behaviour and have mental
  health diversion

133
What are We Doing? (contd)

• Best Police Practice now includes
• Community Youth Diversion Program
• Youth Mental Health Court
• Mental Health Worker for assessment and
  assistance on the road
• Youth Intervention and Diversion Coordinator

134
Despite this

• Children continue to be in limbo for long periods
  of time and move back and forth between home and
  foster care and between foster homes.
• Children and youth frequently do not get a proper
  assessment to determine whether they qualify for
  Mental Health Diversion. Often a child or youth
  can only get services if they have been charged
  with a criminal offence.
• Many communities are not yet able to provide
  best practice services.
• Children and youth receive inadequate and
  piecemeal treatment and support services.

135
Recommendations

• A Holistic, Child-Centred Focus which includes
• Thorough assessment including assessment of the
  family as well as the child at the outset of
  child welfare involvement - therapeutic access
• Assessment of child or youth when first coming
  into contact with the criminal justice system
• Case coordination specific to the individuals
  diagnosis and treatment needs
• Integrated services to reduce service
  fragmentation and expand treatment options

136
Recommendations (contd)

• Education and training for professionals to work
  in a multidisciplinary way
• Services provided with cultural competence,
  especially with an understanding of the unique
  circumstances of indigenous children.
• A liberal interpretation of privacy legislation
  to ensure the safety, protection and wellbeing of
  children.
• More research and greater practice attention to
  linking poverty and child maltreatment
• Increased and earlier FASD diagnosis and
  intervention

137
Power Point Presentation onlineGo to the Child
Psychotherapy Foundation website tomorrow to view
todays slideskidfix.org
The Many Faces of Child Abuse and
Neglect Ontarios First Multidisciplinary
Conference on Child Abuse and Neglect Friday,
November 6, 2009 Design Exchange, Toronto,
Ontario