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Comments Regarding
Child and Youth Mental Health Services Policy Framework

Although the paper purports to discuss mental health services for all children, there is very little mention of children with developmental disabilities. Page 5 lists a range of services, but does not mention children with dual diagnosis. Service to this population is hinted at on page 8, bullet # 3, but that is the only mention.

• Many children’s mental health agencies do not feel that it is their mandate is to serve children with delays and, if they do, they do not know how to serve them. They also believe, mistakenly, that developmental service agencies provide counseling and therapy for children with developmental delays.
• Some feel that the modality they use is not suitable for children with developmental delays (e.g. psycho therapy vs. a more behavioural or interactive approach), and are not sure how to adapt their approach to meet the needs of less verbal children and youth.
• The other concern is fear that children/youth with developmental delays who need residential treatment may be at greater risk or more vulnerable if they are included with the regular population of youth. Can they be adequately protected from more intelligent youth who are involved in risky behaviours (sexual, legal, behavioural, etc.)? Are both groups of kids being “set up” for more problems if they are mixed together? The risks are definitely there, but there are also solutions that can protect everyone involved.

Do we, then, do more cross-sectoral training of staff, so that children’s mental health staff can expand their skills to include youth with disabilities, or do we develop specialized services for children with dual diagnosis? Both are probably necessary.

• Most children with developmental delays can benefit from regular children’s mental health services, and the issue is improving the comfort level and training of staff. A few may need specialized services, but hopefully, these services can be provided within the existing system.
• One solution might be for the developmental services system to enhance children’s mental health system staffing when a child needs residential treatment.
• Another might be to have a certain number of dedicated beds that are staffed by a combination of children’s mental health and children’s developmental services staff.
• The risk with developing a parallel specialized system is that the numbers are small. This means that residential services, especially, would end up being at a distance from the child’s home, which would make it difficult to involve the family. Research indicates that therapy for children is most successful when the family is fully included in the process. Any system that removes the child from the home community is already less likely to be successful, and is more likely to result in long term residential placement.
• For children and families who need child and family therapy, but not residential treatment, it is often helpful to send a worker with the family to at least some of the counseling sessions, so that the worker can mediate between the therapist and the child/family. This may be ensuring that the child/family understands what the therapist is saying (simplifying concepts, instructions, etc.). It may involve reinterpreting the activity, exercise, etc. at a level the child can work at. Or it may involve providing follow up support in between sessions. This has been especially helpful when the parents also have a delay.
• The other issue is that services tend to be crisis oriented rather than prevention oriented. There are long wait lists for service and no supports while the child is on the wait list. As a result, by the time the child/family finally gets service, they are burnt out, the family is seeking residential placement, and the child becomes a part of the system forever.
• The obvious solution is to provide service sooner, in order to prevent burnout. Provide a quick response before the problem escalates or becomes entrenched, and hopefully, you keep the family together.
• The other solution would be to provide respite (both enhanced and specialized) for children on the wait list for counseling services. While in-home respite (a provider who can go into the family home for a few hours) can usually be found for families, it is more difficult to find out-of-home respite, primarily because of the behaviours involved. What is really needed is some form of residential respite, similar to what is offered to families of children who are medically fragile. – a place where the family can take the child for a weekend or a few days, while they take a break from parenting, but that will also be able to deal with the child’s behaviours, support the child in daily activities, and administer medications as necessary.
• The other current gap is the need for service to children/youth who are considered borderline. Their IQ is often in the 70-85 range, they may have fetal alcohol spectrum disorder (FASD) or Asperger’s syndrome, severe ADHD, communication disorders, or physical disability etc., all of which affects their ability to function. Because their IQ is over 70, they don’t qualify for most developmental services, but because their IQ is lower, the traditional children’s mental health system often feels that they cannot serve them well, either. As a result, they get bounced back and forth between the two systems without getting adequate treatment. We need to find a way to get beyond our “mandates” and address the needs of the children involved. The solutions are the same as those listed above.
• Another concern is the number of Ministries involved in serving these children: MCSS, MCYS, Health, Education, and Justice. They each have their own service areas, that don’t match (e.g. the region for MCSS is different from the corresponding Ministry of Health region), which means that services are harder to coordinate, especially in the border areas. Each Ministry also its own funding mandates and boundaries which create artificial barriers. For instance, MCSS & MCYS funded service providers often cannot send a 1-1 worker into the school with a child both because of liability issues, and because then MCSS would be funding a service that should be funded by the Ministry of Education. As a result, a child who is coming out of a treatment program, and who could be slowly integrated back into the school system, with a worker, may have to wait until an EA is available. It may take some time for the school to find an appropriate EA, and, even if an EA can be found, it might be better for the child if a Child and Youth worker from the treatment program, who knows the child’s treatment needs, fill the position. Also the school’s zero tolerance policy may work in contradiction to the child’s mental health treatment plan which might want to use a time out approach in the school. There are similar issues across all the sectors. We need to find ways to break down these inter-ministerial barriers to meet the needs of the child.

Discussion Questions:

Do we need to state a vision for a child and youth mental health policy framework beyond the Ministry’s mission statement? If so, what are the critical elements of a mental health policy vision?

The vision statement needs to be more proactive and address the need to break down the barriers that prevent people from accessing service, not just “make it easier to access service”. It needs to recognize that some of the barriers are artificial, and created by the very system designed to provide service. Alberta’s vision statement is much stronger, as is the United Kingdom’s.

Do the key principles outlined in this document provide the right balance and detail to guide a policy framework for child and youth mental health in Ontario?

The principles are fine but, again, need to address the whole issue of cross sectoral, cross ministerial needs of children and families.

Which services are core to a provincial policy framework of child and youth mental health?

The current situation focuses on crisis intervention rather than providing a broad range of service, including prevention. Prevention is much cheaper in the long run than treatment; early intervention much cheaper than residential treatment and long term placement

Should the core services envision a system that provides a broad range of services that focus on the health and well-being of child youth and their families or does it focus on the most in need of mental health services?

We need a broad range of services rather than focusing on providing service only to those with higher needs. While we will always have people who need intensive support, we could reduce that need by intervening earlier. The current situation provides funding for the more expensive (treatment) services, but not for the cheaper (prevention, early intervention) services. Families have to pay for parenting courses, but not for treatment. OHIP covers doctors and psychiatrist fees, but not psychologists or social workers, who are cheaper. And psychologists are more likely to be covered by private insurance than social workers. This means that the families who can least afford it, are left waiting for the more expensive services when they could probably have used the less expensive services earlier. We should be able to find a way to provide parenting classes, behaviour management classes, individual and family counseling in a manner that is affordable to all.

How do we build in accountability and an outcomes focus into the policy framework?

There are models already available that are outcomes based, and measurable, e.g. Triple P program from Australia, being tested in parts of Simcoe County now. It has prevention, early intervention, treatment and residential components, including specialized approaches for children and youth with disabilities. There are probably other models as well.

October 31, 2005