Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 14 - Evidence
OTTAWA, Friday, May 6, 2005
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 9 a.m. to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the chair.
[English]
The Chairman: First, let me thank all of you for coming. My colleagues and I really appreciate it.
We have people from coast to coast. I appreciate the effort that everyone has made to get here, all the way from Vancouver at one end of the country to Halifax at the other, and a number of places in between.
Let me give you a little background as to what we would like to accomplish today. All of the invitees have received a letter from me and the letter has been distributed to everyone again today.
First, let me tell you where we are in our process. The committee is in the midst of coast-to-coast hearings. If Parliament is not dissolved for an election, by mid-June we will have completed hearings in every province and virtually every territory. We have to finish two of the territories this summer. Our intent then is to write a report that will be finished very late this year or very early next year, so that we will be tabling a report in Parliament no later than the beginning of next year, subject, of course, to there being a Parliament in which we can do so.
The exact timetable for putting out our final report will depend on the timing of an election. Even if Parliament is dissolved, we will continue with our writing process over the summer. We would simply have to finish our public hearings in the fall when Parliament came back, and that would mean the report probably would not be out until February. However, within that timeframe, that is where we are going and we are still reasonably on schedule.
We have decided to hold three special one-day sessions. This being one of them, and it is on children's mental health. There were three issues, the problems with mental health related to children, to seniors and to the workplace. We felt it would be useful to get a group of experts from around the country to give us their views. All of you are here because you come highly recommended by an eclectic cross-section of people, which is why, if you look around, you will see that this is a very eclectic group. I will have people introduce themselves in a minute.
As many of you know, this committee does not have the kinds of resources that royal commissions and other bodies have. All our previous work on health care and the three reports on mental health last year were done by a committee of eleven senators and a staff of two. Our great strength is our ability to get people like yourselves, who are willing to contribute your time and your thoughts, to help us do our work. The level of cooperation we had on our first report was unbelievable, and we are getting an incredible amount on the mental health report, from consumers, families, service deliverers and experts like you. We thank everybody for that.
Today we would like to focus as much as we can on what specific recommendations we ought to make by way of changing policy. Do not worry about whether it is federal government or provincial government. Our last report clearly had a number of recommendations that were directly in areas of provincial jurisdiction. None of the provinces complained. We have had better support from the provinces than from the federal government in many ways. Therefore, do not worry about the jurisdictional question. We will worry about that.
If we want to improve the mental health system with respect to children, we need to know what we should do. It is not enough to wring our hands and lament. What is needed is to be able to say to people and to governments — federal and provincial, service providers and others — here is a list of specific, concrete recommendations on which we need your help. If we can keep that in mind, I will go around the table and have everyone give us their opening thoughts concisely. Then we will turn to a discussion of the themes that emerge from that. There are also two or three specific issues that I would like to raise with you, which are mentioned in my letter and are covered again in the agenda before you.
Let us begin this way. Can we just go around the table and have you identify yourself in a sentence and why you think you are here.
Ms. Judy Hills, Executive Director, The Canadian Psychiatric Research Foundation: I am from The Canadian Psychiatric Research Foundation. I am here today to talk about our school program and the involvement of educators in the early identification of children with mental illness.
Mr. Andy Cox, Consumer and Mental Health Advocate, IWK Health Centre: My name is Andy Cox. I am from the IWK Health Centre children's program in Halifax. I work with the mental health programs as mental health advocate and I am here to represent the youth.
Dr. Ian Manion, Psychologist, Children's Hospital of Eastern Ontario: I am from the Provincial Centre of Excellence for Child and Youth Mental Health at the Children's Hospital of Eastern Ontario. I am a psychologist and a researcher and I wear many different hats, so I will bring many different perspectives. I work quite extensively with youth in community-based mental health promotion. Hopefully, that will be of some value to you.
Senator Keon: I am a member of the committee. I am never really sure where I am or why I am here.
Ms. Judy Finlay, Chief Advocate, Office of Child & Family Services Advocacy of Ontario: I am the Child Advocate for the Province of Ontario. Advocates across the country are mandated through legislation to look after the rights and entitlements of children in their respective provinces. There are eight provinces with child advocates, and I am presently the President of the Canadian Council of Provincial Child and Youth Advocates. I am also here representing a reference group of parents and young people who are consumers of mental health services.
I do that on behalf of the Centre of Excellence for Children's Mental Health at CHEO.
Ms. Michelle Forge, Superintendent of Student Services, Bluewater District School Board: Honourable senators, our board has a number of partnerships with our local children's mental health agency to provide integrated services for children, integrated from their perspective and from the school board's perspective. I am pleased to be here.
Ms. Barbara Whitenect, Acting Director of Child & Youth Services, Department of Health and Wellness of New Brunswick: Honourable senators, I am here trying to represent children's services, some of the struggles we have in New Brunswick, and maybe we can come up with some of the solutions.
Mr. Bill Mussell, Manager & Principal Educator, Sal'i'shan Institute; Chair of the Native Mental Health Association of Canada: Honourable senators, our organization is a private post-secondary organization that focuses on health education and social development issues in the lives of mostly First Nations people. I do a lot of work on suicide. I have done a number of studies dealing with Aboriginal child mental illness and mental health. I believe I am here to hopefully shed some light on the challenges that are facing all of us relative to Canada's Aboriginal populations.
Mr. Richard C. Mitchell, Department of Child and Youth Studies, Brock University: Honourable senators, in addition to my duties at Brock University, I am also the Vice-President of the Canadian Coalition for the Rights of Children. I come from a background as a practitioner for about 10 years in an inpatient mental health facility for children and young people in Victoria before I went off to do my Ph.D. in children's rights in the United Kingdom.
I am here to make the case that we adopt part of the action plan A Canada Fit for Children, much of which is concerned with the mental and emotional wellbeing of children and young people in Canada.
Senator Cook: Good morning. I am from the province of Newfoundland and Labrador. I am here because the chair has designated that I should be here today and because I firmly believe that together we will make a difference in the lives of children.
Dr. Richard Goldbloom, Professor of Pediatrics, Dalhousie University; Member of the Consulting Staff at the Nova Scotia Rehabilitation Centre: Honourable senators, I am an aging pediatrician who specializes mostly in reminiscences. Though I am ready for carbon dating, I have some background in regional health care for children. We developed a regional health program in Nova Scotia and I chaired the provincial task force on regionalization of health care. I am only here because I do whatever Senator Kirby tells me to do.
Dr. Mimi Israël, Psychiatrist-in-Chief; Co-director, Clinical Activities Directorate, Douglas Hospital; Associate Professor, Department of Psychiatry, McGill University: As honourable senators may know, the Douglas Hospital is a psychiatric hospital that serves at least a third of Montreal for tertiary care, but also offer second-line services to children and adults in a population of about 300,000.
I am not sure why I am here. You will see that my comments were aimed at my other role in life, which is as a clinician who works with eating disorders. Even though I am an adult psychiatrist, I work in an area where I think early intervention is crucial.
I do not know why I was chosen, so I hope that whatever I say will make sense. I believe that I can contribute in terms of my interest in the organization of services in general, as well as my concern about more children developing eating disorders in our country.
Dr. Ellen Lipman, Child Psychiatrist; Associate Professor, Division of Child Psychiatry, Department of Psychiatry and Behavioural Neurosciences, McMaster University; Core Member of Offord Centre for Child Studies: Honourable senators, in addition to my duties at McMaster, I am a member of the Offord Centre for Child Studies, which is a research centre looking at children's mental health and developmental issues.
Part of the time I wear a clinical hat as a child psychiatrist, so I see children and families. The other part of my time I do research. Much of the research I have done has been looking at interventions in the community, in the real world. I hope that I will bring both a clinical and a research background to some of the ideas for the action plan today.
Senator Cochrane: Good morning. I have been a senator here for 18 years. I must tell you I was appointed by my whip last year to be on this committee. As well, my background is teaching. I am anxious to hear from you because I see the majority of you have dealt with children.
Dr. Cheryl Van Daalen, School of Nursing, York University: Good morning. I think I am here because of my paralyzing good looks. That would be a joke.
I am pleased to be here. I am a child and youth pediatric nurse and a professor at York nursing school, and I am proud to say it is the only nursing program that teaches children's rights.
My appointment as Special Advisor to the Canadian Coalition for the Rights of Children is an honour that I am still shocked that I hold.
My research into youth mental health has clearly demonstrated that rights violations create mental health concerns for children. Richard Mitchell and I are hoping to launch a pilot study looking into the interface between the rights of children and Canada's health care system.
I am here to talk about policy and practice that is informed not by a for-children-and-youth framework, but more by a with-children-and-youth framework and, hopefully, a by-children-and-youth framework through organizations such as YouthNet.
I am hoping that YouthNet and other youth-driven organizations will be invited to these kinds of meetings in the future.
Dr. Nasreen Roberts, Director, Adolescent Inpatient & Emergency Service, Division of Child & Adolescent Psychiatry, Queen's University: Honourable senators, I am primarily an adolescent psychiatrist and my area of interest is adolescent suicide and its prevention.
Dr. Simon Davidson, Chief of Psychiatry, Children's Hospital of Eastern Ontario: Honourable senators, I am a child and adolescent psychiatrist. I am chair of the division of child and adolescent psychiatry at the University of Ottawa. I am co-head of the centre of excellence with Ian Manion. I am also the chief of psychiatry at the Children's Hospital. I am a co-founder of YouthNet.
I like to see myself as a strong ally in terms of advocating for the rights of children and youth and, more particularly, children and youth with mental health problems. I am very interested in systems, and I would love to, at some point before I die, be able to proudly say that we do have a mental health system for children and youth.
Mr. Howard Chodos, Library of Parliament: Good morning, I am the lead researcher for this Senate committee.
The Chairman: I wish to thank everybody for coming.
We will start with Ms. Hills. I will ask you to give us your thoughts on the specific things that we ought to do.
Ms. Hills: I appreciate the opportunity to speak to you today. It is a wonderful learning experience to find out what else is happening across the country. The Canadian Psychiatric Research Foundation was founded about 25 years ago to raise funds for research into mostly mental illnesses. We have since added addictions. Ours is a small organization but remains the only charity in Canada that continues to raise funds for psychiatric illness and addictions.
Several years ago, the board of directors realized that there were very few applications for children's mental health and went to one of our corporate partners, which is sponsoring an award called the CIBC Children's Miracle Award. Dr. Lipman is on our professional advisory board.
Even though we are a small charity, we have the most remarkable group of dedicated people, 100 active volunteers who are raising funds. We also have a professional advisory board of senior researchers from across Canada who review and rank our applications every year.
We were shocked when in the first year that we announced the award, very few people applied for a children's mental health research award. I see heads nodding around the table.
The community in Canada is very small. Dr. Richard Swinson from McMaster recently told me that the first study on obsessive compulsive disorder, or OCD, in children was released in the fall. OCD is now being diagnosed in children as young as three. There was no research available until the fall. There are very few people applying for research grants in children's mental health. I was pleased to see that CHEO, as the centre of excellence, was offering one.
Our board of directors realized that some of the research we had been funding in the knowledge transfer area was sitting on shelves and people were not accessing it. At the same time, things were changing in our school system. One of the grants was for research into children in high schools. That research was showing that about 20 per cent of high school students were at risk of serious mental illness. I am not talking simply about behavioural problems or people not getting along with their families, but serious mental illness.
The teachers were having problems coping with things changing so quickly. They asked if we would put together a guide to help them until they could get help for the children they were working with. They were facing waiting lists for referrals of up to a year and a half for children in their classrooms.
The foundation gathered together a group of experts in the field of education. We had principals, teachers, special education people and youth themselves involved in putting together a handbook entitled "When Something's Wrong." I hope I have brought enough copies for everyone. Dr. Stan Kutcher, whom many of you know, was the lead psychiatrist helping us put it together. Many others, including people from CHEO, reviewed parts of it.
We did a lot of focus testing, not only in the Toronto District School Board where it was initiated, but across the country. We want to find out what assistance teachers need. We know that teachers cannot be diagnosticians, and we do not want them to be that, but we do want them to have some skills in early identification and to understand some of the mood and behaviour disorders that might be caused by mental disorders. With that, they have a basis on which to go forward.
The research shows that the first person youth go to for help is the teacher. They go to their friends second and their parents third. The family doctor is at the bottom of the list, which makes sense when we think of how little time family doctors have to spend on each patient, let alone those who might have a mental disorder and be a little reluctant to talk about it.
Again, the teacher is an important person in children's lives to whom they often will go first, or who might identify something first. We wanted to create a simple-to-use tool to help teachers in the interim. The handbook is packed with references to particular disorders, such as Tourette's syndrome and eating disorders.
We found that teachers were dealing with parents who either did not understand or were afraid to ask questions, and parents asked if we would compile another tool for them. Therefore, we have expanded on the first book, adding many more resources and more disorders.
When the foundation creates these tools, we ensure that the information is scientifically sound. Every time it is reprinted — which has happened three times in two years — we update the scientific information. As more research becomes available, we try to add it to the resources in here. From there, we started doing training sessions. The first one was four years ago. Three hundred teachers come to each training session. It was amazing to see the need that exists, and the teachers do want to be helpful.
In an effort to combat the stigma, which is so great and is an underlying cause of why a lot of things do not happen in mental health, we started a cross-Canada tour involving the media, the corporate sector and other community leaders. We went to Vancouver, Calgary and Winnipeg in the first year of the tour. In each city, school boards sent personnel to the workshops. It was wonderful that local doctors donated their time to speak to the groups. They enjoyed having an audience of up to 300 people to whom they could speak about the disorders, again to raise awareness.
We hope that our East Coast tour will happen in the fall. Unfortunately, we cannot do more of these tours because we have to raise the money, market the program and develop relationships in each city that we go to.
I have found that in the mental health sector, people seem to be willing to work together. It is wonderful to find a champion in a city where we do not have a chapter who will send out the emails and brochures and bring the community together if we can bring the speakers, because they often do not have access to speakers of the calibre of those sitting at this table.
Senator Keon: Mr. Chairman, I believe it would be worthwhile to allow a little time after each speaker. For example, this speaker raised an issue that should be well considered throughout the day by everyone in the room. She quite rightly pointed out how enormously important the education system is to children. However, as you and I heard at the international summit in Calgary this week, the emphasis is now shifting to the first three years of life with regard to the mental development of a child.
If we look at the bigger issue of mental health, we are addressing about 30 per cent of people with mental disabilities. We have to try to get to the other 70 per cent through recommendations that will come out in another six or eight months.
It is my impression, having heard what I have so far, that we will need community mental health resources, that is, community resources that provide primary health care and services such as food, housing and so on, coupled with public health, emergency services, home care and a number of other services.
It is wonderful to have these resources in pediatrics or children's mental health here today because we have to consider how we will get at these children from the time of birth to age three. Will that be done through pediatricians? Will it happen in the primary care facilities, where it may be through a psychologist, a social worker, a nurse or a primary care physician? I think the evolution will be to primary health teams in these community facilities.
I simply want to leave that thought with you as we go around the table.
The Chairman: Thank you. If people have thoughts like that when a presentation is finished, let us put those on the table and other people may choose to comment on them.
Senator Keon is right. At the event we were just at in Calgary, there was a substantial focus on what I would call the preschool years, the very early ages of zero to three, in the sense that a lot of problems are established long before people get to schools.
Mr. Cox: I am Andy Cox, and my position at the IWK Health Centre in Halifax is mental health advocate. There are three components to that, which will lead to my suggestions.
First, I educate and intervene on rights of youth. Second, I help hook the youth up with community resources; and the third point will lead into something I feel needs to expand across the country. I myself am a mental health consumer with bipolar disorder, and when I am meeting with the youth and, when appropriate, disclose this, there is a special relationship built or they feel relief. They feel, wow, someone has gone through something similar, and there is potential for me to get better and be able to live a half-decent life. The families find hope as well.
The most important thing for me is peer-support mechanisms. I know when I was not well at 17 or 18 years old I got pretty good treatment. However, the one component that I wanted was to talk with other youth of roughly the same age about the illness.
We can use programs like YouthNet, which I am sure you will hear more about today. There is also in Halifax Lang House, a support centre. It is not a clubhouse model. It is more a youth-friendly place for peer support, help with schooling, getting back into school, university, help finding housing, which is a huge issue, justice, employment, socialization, re-socialization. We need more organizations like that, and funding must come from the government.
The next one is prevention, promotion and anti-stigma education. First, we must educate the students and teachers early. One way I have experienced this is as a consumer, educating from my perspective, but we also need it in the curriculum, and clinicians must be able to educate. The other prevention, promotion and anti-stigma work is educating teachers, professors, residence dons, peace officers, ambulance personnel, MDs, ER staff, persons working with the homeless, immigrants, visible minorities and other medical staff, other disciplines of child and adolescent health care.
Next, we have to practice true family-centered care. The youth and the family have to be an equal part of the team, on the same level as the clinicians, with perhaps patients being included on rounds here and there.
My next point, acute or not so acute, is what I call "resorts." When I was younger, my dream was to not enter a hospital but to go to a facility like our youth detention centre. We have certain cabins at the centre, and each has different needs. There are people with similar disorders in each cabin to allow them to come together for holistic activities like recreation.
Wait lists will be another issue. I am not sure what the situation is across Canada, but my top solution is more groups have to be organized. We have youth sitting on a wait list when we can bring them together and start talking earlier about mental illness and, therefore, we will know in what direction to refer these youth.
I feel mental health needs its own emergency system. Some people say this adds a stigma. I do not believe this; but there is a stigma. The waiting time is just inappropriate. I also believe in mobile crisis units. There is the transition from the youth to the adult mental health system. I was very young in transferring into the adult system and felt very alone — more programs, holistic day treatment, residential facilities.
The next point is departmental partnerships. We need seamless partnerships between education, health and justice departments. Community services need to be more efficient. With partnerships it will be more efficient, better financially, and everybody will be learning about mental health.
The next point is early education. We teach sex education pretty early, but we are not teaching mental health early enough. We have a lot of homeless youth who just cannot afford medication. They get out of the hospital and they run out of medication. We need easier access to medications. I am hoping, this being a federal Senate, we will be able to communicate with and help these provincial departments I am talking about.
As a consumer with bipolar disorder and a professional mental health advocate, and as a huge baseball fan, I see this as the World Series for mental health, our chance to briefly cash in, just like the Red Sox. I am quite proud of Nova Scotia. We are in the process of creating mental health standards, and a lot of the effort is on child and adolescent mental health. I do see hope, especially with things like today's meeting.
The Chairman: Thank you, Mr. Cox. I will now introduce two of my colleagues who have joined us. Senator Landon Pearson some of you in the room already know. She has been involved in children's issues for a long time. Senator Trenholme Counsell is a former Lieutenant-Governor of New Brunswick but was also a family practitioner in New Brunswick for many years and has much familiarity with these issues.
I ask people to comment on this as the day goes on. When we put out our previous reports last November, we put on our website a short questionnaire, seven questions seeking input from consumers and family members, thinking we might get 75 or 100 replies. We took the questionnaire off the website when it got up to 550 because we just could not process any more data.
However, one of the things that struck all of us on the committee was that a number of the consumers said what Mr. Cox said, that the most important thing for them had been peer support. I make the observation that to the best of our knowledge, there is no government funding at any level for peer-support groups around the country. We believe that is the case. If anyone has a counter-example, we would like to know that.
Second, what specific recommendations can we make that will in fact help get the peer-support movement off the ground? Mr. Cox made the observation that we saw in responses to the questionnaire. Clearly there is a gap there. Any thoughts people have would be helpful.
Mr. Manion: I believe we will hear a lot of good ideas today from people who have done something worthwhile. The problem is that these ideas do not necessarily always come together. Perhaps it is the first time we have heard about a lot of these ideas, and perhaps that speaks to a lack of a cohesive system, a lack of a road map and the ability to benefit from what has already been done as opposed to reinventing the wheel.
One of the first points I wish to talk about is fragmentation. We can argue about whether we have a child and youth mental health system in Canada, let alone in each of the provinces, to guide some of our activities and make decisions about where funds should be directed. You see a lot of silos. There is now, as a colleague of mine would say, almost a garrison mentality. When funds are short, people tend to put their walls up, and it precludes conversation, it precludes partnership. There are notable exceptions where many of us have been able to partner successfully in innovative ways, but sometimes the garrison mentality prevents that great partnership from being replicated in another community with different partners.
Some of the places where we see the splits that we have to work hard to overcome are the different sectors of the academic community. Mr. Cox was referring to the need to look at child and youth mental health in the child welfare system, in the justice system, especially in the education system, and in the health system, where it is a predominant concern.
You talked about peer support, which is wonderful, but then you have a split between peer support and specialized care. There should not be a split there. The YouthNet model has been mentioned a couple times. One of the strengths of that model is that it is a youth-for-youth, by-youth program with a safety net of professionals, where you have the capability to cross some of those boundaries, those lines. You have a hand-off and a hand-back approach, as opposed to someone taking over and there being no communication down the line.
That speaks to my second point, which is the need for a continuum of care as we are trying to build this system. When we think about a mental health system for children and youth, we have to think all the way from mental health promotion, prevention, early identification, to treatment, rehabilitation and chronic care. I would actually argue with Senator Keon, if you would allow me to, about whether we need to focus on a specific, narrow window for prevention at the ages of zero to three or zero to six. Or do we have to recognize that along the developmental continuum there are key critical periods? A lot of new brain development occurs in early adolescence. We know that things are being re-organized in the brain, we know that behaviour changes are a function of that, and the challenges are different.
If you focus solely on one area you create another garrison. You are saying that that is where the funds should be directed, and that means that a generation of middle-years children and youth lose out, or a generation of adolescents lose out. Of course, if you lose a generation of adolescents you are actually losing the next generation of parents, who will parent those zero-to-three-year-old children down the road. Therefore, you need to have a full appreciation of the continuum of care along a developmental continuum. That should be a key factor.
Another point is, and Mr. Cox has mentioned this, where are the opportunities for cross-training and continuing training of all those who may need to have information about child and youth mental health? It is not just mental health professionals whom we are solely lacking nationally. We are not training enough people across many disciplines to meet the need. We do not have an idea of what the need is. How many psychiatrists do we need? How many social workers do we need? How many psychologists do we need? How many child and youth workers with specialized training in child and youth mental health do we need? We do not have a clue, and the way we are organizing our training sectors does not reflect the needs down the road.
We can learn from some of the experiences of other countries who have faced this dilemma and realized where they have fallen short in terms of their needs. We also talk about training as not just continuing training. It is not just training teachers to understand child and youth mental health. That is essential. It is also training those who will become teachers at a fundamental stage of their education. How do they incorporate this into their curriculum? How do we incorporate it into the curriculum for family doctors and pediatricians? How do we incorporate it into training for police officers, lawyers, judges? They all will have an impact on what will be happening in child and youth mental health.
The next issue I want to speak to, and has been mentioned by Ms. Finlay, is research and integrating research in practice. It has been mentioned that there are great ideas but a lack of capacity when it comes to child and youth research. Some of that is a lack of one place where people feel they should be addressing their proposals. There are places that fund mental health research, and children and youth are a piece of that. There are places that fund health research, and mental health is a piece of that and child and youth mental health is a smaller piece.
Do we know where we want to encourage our researchers to send their research? Do we have enough researchers? Are we attracting researchers to this very important area of investigation? How do we create that fire in their bellies so they want to ask the important questions?
Most of the important questions are coming from those who are on the front line: the clinicians, the teachers, the parents. Where is their ability to have input on directing the research questions and directing funding to answering those questions? Where is our opportunity to, in the tidal wave of service demand, allow some of those who have research questions to take the time to do the research, to partner with other researchers and increase uptake down the road? No one wants research to sit on a shelf. Sometimes, to increase uptake you have to find innovative ways or new models of doing research. Our systems and score sheets in academia do not always recognize those innovations, so do we have to change the way that we evaluate success in the academic sector to recognize the need for innovation?
The last point I want to make is on the issue of stigma. Stigma will affect the uptake of information, it will affect someone's ability to seek out care, and it will affect how we can convince people that there is a need to direct more funds to this area. The more people are talking about mental health, whether it is child and youth mental health or adult mental health, the better chance we have of changing people's perceptions and convincing them that one can live and function well, even when suffering from a mental illness or facing significant mental health concerns.
We have had some interesting strategies over the years, whether for physical health and well-being or prevention of smoking. Do we have a national strategy on de-stigmatization of mental illness? If so, who needs to direct that and from whom do we need guidance? I would venture to say that people like Mr. Cox, young people who have faced some of these problems, people who have children who have experienced these problems, people in the business sector who are willing to stand up and be champions for this, are all players who can have a significant impact on how we view mental health and illness nationally.
Senator LeBreton: On the question of stigma, is there any attention paid to not only the stigma the individual feels but the denial of family members? That is a huge problem. It seems to divide families. I was interested in the comments of Mr. Cox, too, about having the youth and the family involved.
When we are dealing with stigma, we tend to think of the individual and we are not dealing with the broader issue of denial in the extended family.
Mr. Manion: I absolutely agree with you. We have seen situations where the youth are quite enlightened. They realize they have a problem or have been picked up through a mental health promotion program screen and want to seek help, but the parents refuse to let them seek that help due to the possible aftermath. They fear the family will be labelled as having a member with a mental illness. It gets quite heated.
Therefore, when we talk about de-stigmatization, there are different strategies for different groups. There is also a huge cultural component. Different cultures view mental health and mental illness very differently. Some are quite open, and some are incredibly closed. For new Canadians struggling to fit into a new society, a mental health concern that could make them look like a greater burden on that society may be another reason to close the doors and not allow family members to seek help. Even though the help could dramatically turn their lives around and make it easier for them to adjust to a new society.
Senator Keon: Dr. Manion raised an issue that we have heard over and over, the huge problem of fragmentation and the lack of cohesion. There are some very good isolated services, but there is no overall plan. We are the only G8 country without a mental health strategy. It is still a long way off in Canada, but hopefully our report will precipitate the development of one.
Where, in the development of an overall mental health strategy for Canada, should the strategy for children fit? Should it be a separate strategy? Of course, the question of stigmatization is raised over and over again. Should this be part of the overall strategy? Should there be a targeted program of anti-stigmatization?
Ms. Finlay: As child advocates across the country, we deal with all children and all services. In Ontario we get 4,000 new cases every year, and 40 per cent of them have to do with children's mental health. The system has been failing kids. Our job as advocates is largely to steer these kids through a system that is complex and fragmented.
The other hat I am wearing, as I said earlier, is with the reference group for the Centre of Excellence for Child and Youth Mental Health. The reference group is made up of parents or young people who have experienced the system, and they have gone one step further. These are parents whose children had difficulty navigating the system. Their children are now grown, so they have dedicated their time, their passion and their wisdom to developing services at the grassroots level for other families who might be facing the same kinds of situations.
The kinds of recommendations I am talking about today take into consideration both contexts: the national context of child advocates and the context of that particular reference group.
There must be a dramatic paradigm shift, both in how we understand mental health and configure services and in how we engage children, youth and families in providing these services. We presently view children's mental health on a continuum of care, from prevention to tertiary care, from the least intrusive to the most intrusive. Ministries line themselves up along that continuum. It is a systems model of defining need and service delivery that is largely self-serving. It is configured to serve agencies and institutions and become self-perpetuating.
We require a model that allows for the clustering of services. If we begin to view parents and children as collaborators in assessment, planning, delivery and evaluation of mental health services, it will force a family-based intervention, with the child and the family at the centre. As long as we have a provider-driven system, we will always have the families on the periphery. We need to move to a family-driven model that enables the child and the family to do well in their community. This would be a strength-based model, which means we will have to redefine how we look at mental health. Redefining our understanding of mental health is a paramount part of this. It must be defined by looking at the entire life of the child, and not just in terms of chronological life. Every part of a child's life represents their mental health.
We are looking at family-focused approaches like multi-systemic services or wraparound services, and quite frankly, in the evaluative research, it is not very promising. It does not go far enough. We need family-driven models where families can take leadership, responsibility and ownership in the treatment planning. There must be a transparent exchange of information and knowledge between the professionals and the families in order to fit the family's strengths and needs with the level and quality of care with which they are being provided. We have to match the mental health services to the consumer.
I have distributed a diagram that essentially shows the kind of system that families and children have to navigate to access services. The second diagram, where the child is at the centre and services configure around them, is a more appropriate model.
As Dr. Manion was saying, the services we have now are non-integrated, and for the most part we cannot penetrate those systems because of economic restrictions. A lot of our resources go to just navigating service systems. Every children's aid society in Ontario has an entire branch of people whose sole function is to navigate kids through the system. That should speak strongly to the system.
Even when we do navigate kids through the system, the service we finally get does not always fit the needs of the child. The service provider is often the entity that identifies the needs of the child, and they make every effort to approximate a service on that particular continuum, but it is often us trying to fit the kid into the service rather than the service wrapping around the young person.
On our inter-ministry provincial advisory committee, we have clinicians from across the province and four senior ministry officials from four different ministries to force the issue of integration. The hardest-to-serve cases in Ontario come forward to that committee. When they do, we ask that they identify to us where they have been for service previous to looking for resolution at the IMPAC table. What we find is they have been to, minimally, 20 children's mental health service providers, and they have been turned away. The intake goes to an agency, and the agency will determine if it is appropriate or not for that client to be served by them, instead of the agency welcoming the child into service.
We very much take a needs-based approach to service around children's mental health, but parents take a best-interest approach, which is quite different. We need to move to a best-interest approach so we can target key points in the child's life where service is required, and not just when the family is worn out and handing their child over for service.
The second piece is the need for children's mental health to be mandated through legislation. Youth justice, child protection and health are all mandated. As long as they are not mandated, legislated services, it allows service providers to essentially determine the kind of service they will or will not provide, as in the example of families shopping from place to place, as opposed to services wrapping around children and meeting their needs.
We know as well that children's mental health is at the centre of all other services. It is at the centre of youth justice, child protection, special-needs kids in the schools, kids on and off reserves and street kids. We need to value it to the point where we legislate it and mandate it as a necessary service.
We need to mandate that there be non-traditional and non-medical approaches in those services. We honour kinship relationships as a very valuable part of service delivery to families. As Mr. Cox stated, natural support networks like mentorships or peer groups are important.
Finally, I want to talk about special populations, and I will start with systems kids. Those are the kids who come into the care of the state and where we as a community and a society are the parents; and we are very poor parents. In Canada, we know that there are over 100,000 kids in the care of the state. Those kids, for whom there is a trajectory from child welfare into the youth justice system, receive catchments of children's mental health services along the way when we know at the beginning they need an intrusive intervention to help them through their lives.
My recommendation on these systems kids is for a comprehensive assessment at the front end, with decisive intervention at the point of their entry into the system and a constellation of services available to them.
As Mr. Cox said, transitional-age youth are a special population who fall through the cracks because they are making the transition from children's to adult services; and that is where the gap is. Dual-diagnosed kids fall through the cracks because they are between developmental services and mental health.
Aboriginal children and youth, and I will defer to my colleague, have the highest needs and are in the most remote areas. We too have reserves in the farthest parts of Northern Ontario. When we go to the schools, we see that over one-third of the kids in each class have high special needs that are not being assessed, let alone addressed. If that situation that we see in the remote communities were visible in Hamilton, Toronto, Vancouver or Halifax, we would not tolerate it.
Finally, I want to speak about community mobilization, how we need to move forward at a community and grassroots level to embrace systems reform and de-stigmatize the issue. It has to start at the community level and grow from there. It must be consumer driven, grassroots and recovery oriented, and it has to engage these young people in the dialogue in a meaningful way.
Schools can monitor and fortify the multiple determinants of mental health across the community as a community player. We need to create community mobilization templates that can be transferred from community to community across issues.
The Chairman: You have raised two issues that we can come back to, one of which goes back to the question that Senator LeBreton asked Dr. Manion. A family-centred model works fine if the family is prepared to be supportive and sympathetic. How do you deal with cases where they are not?
When we get to Mr. Mitchell and Dr. Van Daalen — and this is just an impression I have — the question is to what extent do the privacy laws create a problem in terms of bringing the family into the solution? To what extent do privacy laws constrain the service provider in being able to bring the family in? Does that mean some changes may be needed for this unique, special category of people? We will come back to those questions.
Ms. Forge: I would like to say I am pleased to be here as a non-expert. I am an educator and not an expert in mental health. However, I believe that is part of a partnership that I will describe to you today. I have become expert in the needs around children's mental health and how school boards and providers can work together to provide service that is community based and child centred. Ms. Finlay, I appreciate your comments. I will address some of the issues that you have mentioned.
I am a superintendent responsible for special education, grades JK to 12, in a rural area slightly larger than Prince Edward Island. We have 43 elementary schools ranging in size from 60 students to 750, and 11 secondary schools ranging in size from 120 students to 1,200. We have one children's mental health agency, which has allowed us to do some things that might not have been done otherwise, and two children's aid societies. The closest specialized treatment centre is three hours away by car, when it is not snowing.
The only public transportation system is in one urban area, and it serves about 10 per cent of our population. The only other transportation system in the entire jurisdiction is run by the two school boards. Transportation for us is a major issue in the rural area. We cannot ask families to come for service. We have to take service to families, and we do so through the schools.
The partnership that we have with the local children's mental health agency has allowed us to provide a service that is community based, and while it does not wrap around the traditional or research-based context, it does wrap around the children and the families at the school.
I will not talk much about funding, but I will say that we are probably lucky that we have an underfunded agency in a rural area. I say "lucky" because it has forced us to do things differently. It has forced us to think about how we can combine minimal resources, whereas if we all had lots of money, we would probably have spent a lot of time putting up barriers rather than pulling them down. That is the last time I will say that we are lucky we are underfunded.
The program itself involves both the public and the Catholic district school boards. We have seven teams that are geographically based. Each team has a resource teacher and a behaviour lead teacher, or BLTs, as they are affectionately known. Those teachers are supplied and paid for by the local boards of education. That is a critical piece.
We also have social workers on each of the teams. They are funded by the local children's mental health agency. Each team has a child and youth worker. The funding is cobbled together from municipalities, pilot-project money and some children and youth services money, but that is the one area we are continually hoping that we can fund on a year-to-year basis.
Each team works with a series of schools. Each team works through the identification of students. They work with anywhere from 10 to 12 families at a time. They work in conjunction with the school, the community and anyone else who needs to come to the table. That could be recreation facilities, if such exist, or any other community-based agency.
The teams provide the service at school, at home, and in the community and are interchangeable. Team members and teachers will go into homes; social workers will come into schools; child and youth workers will go everywhere. They work as a team. That has been our success. We work with families and the children 24 hour a day, not in a piecemeal fashion, not just for five hours of school.
There has been some research, but the results are that the program works. It works for the children and youth; it works for the parents; it works for the team members, and it works for the communities and the schools.
One of our successes is that we have built significant capacity in our own systems, in each other's systems and at the community level. Although we scramble every year for funding to make it work, there would be a hue and cry if we were to lose it.
I have to say that there was a hue and cry when we set it up. People did not like this idea. They were not sure about it. They really did not see us working across boundaries. We had to persevere and make it work.
We do not have children leaving their communities, and it works. Before this, children had to go three hours away from home. Parents had to travel three hours to see them maybe once a week, if they had a car and if they could get through the snow. They came back to our communities and to our schools, and while they may have experienced significant change in that tertiary setting, it did not translate back into the community or the school.
I would like to move directly to the recommendations. What makes this work is that education is a partner at the front end. We are not brought in at the end for a consultation. We are a partner at the front end in not only planning the service, but in funding it. It happens from time to time, when nothing else is going on, schools see a need and the boards step in and try to do it all. They cannot and should not.
Schools must be recognized as a front door to service. We are the ones; kids will go to teachers. Teachers will recognize situations that families are maybe unwilling to. Teachers can help families to recognize those situations, because in fact, we have children from ages three to 18 in our system. We are the only place where they all come.
We have to connect with preschool children's mental health, and we do that. Now we have a preschool team in place, with a social worker and a child youth worker. If I can find a way to fund it, we will add a teacher to that team. One of the significant issues about preschool children is that they will hit that school door. When they do, they will be better for having had a teacher who has been able to help them understand what school looks like and how to make those transitions. It also helps the preschool team to navigate the system. We are a system, and we are very different from anybody else. We know it, and we need to provide the navigation tools and people to do that.
We must, as a nation and province, say that the service must be integrated. We do not have to say that it must look the same in every community. That is key. We need to talk about integration, not coordination. We need to recognize it will look different in each of our communities.
To that end, we have to provide the resources necessary to do the planning, to make it look different and to make it look appropriate. We have found that integrating services takes hard work and a lot of time to talk through the issues that invariably come up when you have two or more very different systems trying to work together. You cannot take for granted that people will understand your realities or that, over time, there will not be issues that will have to be dealt with. That is an expense that needs to be recognized if we are to integrate services.
We have found that incentives need to be provided. When services are integrated well, it allows reinvestment in the community of the funds that are saved. We can prove that we do save money through the way we provide our services. When we save money, there is no opportunity for us to reinvest it in our community. That is a significant issue for us. We invest anyway, but if we had even a part of the money that we save to reinvest, we could be growing our services. We grow them anyway. One partnership has led to several others. The bottom line is, if we had a way to reinvest those savings, it would be helpful.
I should have mentioned at the beginning that we do have access to telepsychiatry. That has allowed us to be much more community based. We do not have a children's psychiatrist in our jurisdiction. Quite frankly, the wonderful access that we have had through telepsychiatry to, I believe it is over 200 psychiatric consultations, has allowed us to do things at the community level that we would not have been able to do otherwise. We need that access. We do not necessarily need it all the time, but we need the access and we need a pediatric community that is willing to support it.
I would like to underline something that Ms. Finlay said. Until I started researching this, I did not realize that children's mental health was not a mandated, legislated requirement. Education is; health is. It was unbelievable to me that as a society we have not legislated that. I believe we must do that, and I believe we have to mandate it as a separate provision, as part of mental health in our provinces. The question about connecting child and adult mental health is another issue for us. Invariably, our children's mental health issues will have some impact on adult mental health, on their families, or vice versa. Our connections there are not as good as they should be. We need to be making those connections between children's and adult mental health. They need to be separate but connected.
In looking at community-based support, we have to encourage innovation. We cannot expect that it will look the same in every community. However, it must be comprehensive and integrated. There must be a national children's mental health system.
Senator Pearson: Thank you to everyone who has spoken. Ms. Forge, I wish you could be cloned.
I had 22 years of experience in the Ottawa Board of Education on primary prevention in children's mental health, kindergarten to grade 6, a program called Children Learning for Living. The program worked extremely well when the model was in place, but we could never get out of that bind of being funded by the board of education. We tried to break into the health system to get the program mandated. Children's health should be mandated in every school system in all provinces and territories. I know that this is not a federal jurisdiction, but we can recommend it.
The Chairman: That has not stopped us in the past.
Senator Pearson: The partnership is important. The system has to buy into it, but it cannot do it alone. If it is alone, in the end, it is pushed off. You understand exactly what I am saying. I appreciate your comments.
Stigmatization is something we always dealt with. We called our personnel "mental health workers," and everybody disagreed and said they could not be called that because that is a stigma. We persisted because we wanted to break the stigma. I suspect one of the worst places for stigmatization is in the political system. Nobody in the political system dares admit that they have any kind of mental health problem. We should start among ourselves, to be honest.
The Chairman: On that note, when our committee began its work, we finished our other study and decided we would look at mental health. It took us literally less than 15 minutes to decide at an in camera meeting to study mental health because it turns out that a majority of members of the committee, including myself, had a member of their immediate family who has had significant mental illness. That was a surprise, but the bigger surprise was that in the two and a half years we had been doing our original study on the acute care system, we all knew about the physical health problems that our families had gone through. We knew that my wife had gone through chemotherapy. We knew that Senator LeBreton's husband had had a heart attack. We knew a lot about everybody, but we found it interesting that none of us ever, in the course of the two and a half years, mentioned that we also had family members who in fact had a mental illness. We had just assumed automatically that stigma did not apply to us, and we suddenly discovered that there was an interesting subliminal message that it does.
Dr. Davidson: That reminds me of the joke about the definition of "minor surgery." Minor surgery is surgery that happens in other people's families. That is applicable to mental health.
I enjoyed both visiting with and hearing from Ms. Forge today about their wonderful approach. Obviously the school is the cog. I would mention, however, that not every kid goes to school. Every child has access to the school system, but I do not want us to lose sight of the fact that the kids who are experiencing the most difficulty are probably not making it to school, both for reasons of truancy and for reasons of school suspension. Both entities cover the waterfront of psychiatric disorder.
Senator Trenholme Counsell: Ms. Forge, what you said about your district was immensely exciting. I am anxious to learn whether this is at all typical across the nation. In New Brunswick, where I worked with families when I was in government and then in other capacities, it seemed to me there was a real breakdown between our early intervention, from zero to three or five, and when they got to school. I can say, with shame, that we had taken our public health nurses and most of our social workers out of the schools. It is a real struggle to get them back, and it is largely a human resource factor, which boils down to a budget factor. The wish is there, the desire is there, but the funding is not. It has been a low priority, like school libraries. There is a long list of low priorities, including art and music.
We are in a very exciting time in terms of the early childhood years. I sat with your minister last night, the Minister of Children and Youth Services for Ontario. She is extremely excited that these wraparound programs in pre-kindergarten will include early intervention, diagnostic and therapeutic services, opening the door to these problems very early. It is all wonderful news. However, the big challenge is to continue that on through the school years.
I feel confident we will do a better job than we have in the past through the quality learning and child care agenda and with what the provinces are now doing. This certainly is not new, and provinces are working very hard. I still think there is a break in reality in too many cases, although I cannot generalize, between all this early intervention and then the school years. I have absolute sympathy and praise for our teachers, because they need to have the support of other professionals, government and the greater community. That is a real challenge.
In terms of what Dr. Keon said, the early years are important. We know that some of this is development of self-esteem and all the things that can happen in the early years. Of course some of it is genetic, but it can all be picked up, and it has to continue through the school years.
I would like to hear from other provinces whether Ms. Forge's testimony is common.
The Chairman: On the basis of the evidence we have had from across the country in the past, if it is not unique in Canada, there are certainly less than three or four or five places that are using a combined program.
Senator Cochrane: Ms. Forge, I am interested in what you had to say. As an educator, I have not seen this system before. Would you describe your teams for me? Where are they working? Do you have one centre as a foundation for all of these teams? Do they come there to talk to each other when problems arise? Do they refer students to different personnel? How many children are you dealing with as superintendent in your entire jurisdiction?
Ms. Forge: In my particular board we have 21,000 children spread out across that geographical area. There would be another 4,000 in the Catholic district school board, so we have 25,000 children in total. That would be JK to 12.
The behaviour lead teachers, who are provided and paid for by the education sector, are part of a team, and they meet in teams. Because of our geography, it is critically important that they be available, so they work out of a particular school and a particular part of the area. They do come together as groups to study, learn, look at research and share strategies, but for the most part, it is the team of three — the teacher, the social worker and the youth worker — who work together on any given case and situation. They will do everything, including the child and youth worker going into the home — and that, oftentimes, is the first step, getting into the home — including the behaviour teacher going into the school to provide support for the classroom teacher and whatever needs to be done there, and including raising community involvement.
The teams each have about $1,200 in discretionary funds. The teams say that the most important thing is that $1,200, because it allows them to do things like buy recreation centre memberships, to do any number of things. They have paid for cosmetic surgery. They have done the whole nine yards.
Senator Cochrane: What is the name of your community?
Ms. Forge: We are Grey and Bruce County. The city is Owen Sound. These services are provided in places like Flesherton, Markdale, little towns of 1,000 people, right out into the country.
I have said something about growing this service. It is also important to mention that we have been able to take on other services as a result of providing these teams who work together. We have had significant success with using the same kind of model in other areas, particularly in our program for expelled pupils.
Ms. Whitenect: I am from New Brunswick, so I will speak about our experience and echo some points. There are many issues that I would love to raise, but I focused on four key ones that I thought would be recommendations to address some of what you want to include in a report.
In mental health services we talk about children and adolescent teams. We should call them "children and family teams" because we have to emphasize the need for family involvement and the importance of that.
I will give you a couple of examples in terms of the first recommendation, which is the need for coordinated children services. People have talked about that, but we need to emphasize it, because many services exist for children, but often they are scattered, with different mandates; people have different waiting lists and different ways to prioritize their service. I am not sure that needs to fall under one responsible centre. That makes it difficult and maybe creates barriers.
One approach we have used in New Brunswick is comprehensive case conferencing. We talk about case conferencing a lot in terms of children and adolescents in the schools, in mental health, in the child welfare system. Often, because of demands for service, wait lists or mandates, people do not make the time. We have to look at mandating that and linking it to funding. People have to come together and bring their resources for children, their issues, to the table. That is important because all the service providers do bring their resources, and sometimes we do not always know the limitations of our partners. It is important that we know and understand the dynamics. We will if we are sitting at the same table.
By using a case conference model, having people at the table, you can get past some of the consent issues and legislative barriers because the family and the child are present. They are giving their consent. You get past some of those blockages around privacy and privacy acts. Plus, you also have buy-in. They are part of the process, they are at the centre. That is a key responsibility. It also identifies the gaps. When an issue comes forward that no one is able to deal with, then sometimes people are able to pool their resources and say, "It is not exactly our mandate, but if we push there and you push there, we will be able to do that."
In New Brunswick, we have tried to link that to funding. We have two comprehensive ways in which we do case conferencing. One is our youth treatment program. I know B.C has a similar wraparound program. It is difficult, and we have to justify it every year in terms of the funding. It involves four departments, education, child welfare, justice and mental health services. Mental health happens to be the lead, but all those service providers bring not only their resources but their dollars to the table. They all bring something unique to that table.
We have 13 community youth treatment teams and a centre of excellence where youth go if they need a particular diagnosis, because this relates to conduct disorder. The result is that most of our work is done in the communities and most of our young people do not need to go for the elaborate assessment. People in the 13 communities, all those four agencies, come together and bring what they have to the table, but they also bring their struggles with what they have not been able to accomplish for the young person. Again, it is always keeping that in place, because it is no one's particular mandate to come to the table. It is an important example of how it works.
With the changeover from the Young Offenders Act to the new Criminal Youth Justice Act, case conferencing is now mandatory. When a young person commits an offence, the judge orders the community partners to have a case conference before sentencing. It is too bad that the young person has to commit an offence before we can legislate case conferencing.
We have seen the importance of people coming together because it is mandated. People say, "I have waiting lists," and this and that. If a judge says "You will do it," you do it. We have seen some positive results. It has not overtaxed our people because it is only in those very difficult cases, those high-need situations that we all encounter that we throw our resources onto the table. I will not overemphasize that, but if we start acting strategically and say our funding dollars are linked to doing these case conferences, thus reshaping the way people do their work, then we can achieve that.
The second point was on a national or provincial strategy. My dilemma is should we have an overall mental health strategy or do we need one specifically for children. We are lost in the overall picture of mental health, and we approach it so differently. A lot of times, with adults, there are all those privacy issues. With children, we need to come to the table with our information and to get past that. I struggle with it being an add-on to another way to do that. I am open to realizing that creates more difficulties. Getting child and adolescent services on the radar screen is tough.
A lot is happening in the early childhood initiatives. A lot of federal funding has come to the provinces for those initiatives, but I want to echo some of the concerns that people have raised. Once they start school, we have already done a lot; we have put in a lot of effort. We are really moving forward on a great plan and everyone is on the same page. All of a sudden, they start kindergarten, and guess what? That is the end of that. We need to continue with those whom we are targeting, because adolescence is so difficult. If we drop the service at that level, we are missing the boat. I will not overemphasize that because have talked about it.
Early detection, intervention and targeting youth are very important issues. We have early psychosis programs and mobile crisis services. I know other provinces do also, but many times they start at age 19. Children are not a part of that. If they are, it is an adaptation of what exists. We have to look at strategies for early identification and following these children. We need changes to the child welfare legislation, because its jurisdiction ends at age 16. In New Brunswick, for 16- to 19-year-olds, there is a huge void.
I did a position paper on this at university, and it has not changed in 20 years. We are struggling with the issue of 16- to 19-year-olds. That is one of the most difficult phases of life, and we lose our child welfare supports, the housing, et cetera.
I was talking to Mr. Mitchell about advocacy. There are two provinces in this country that do not have youth advocates and New Brunswick is one of them. That speaks volumes about how we are able too move services forward.
I come to my last point, and this one is controversial. We talk about accountability frameworks a lot because we have to justify funding dollars. It is difficult because there are a lot of priorities out there. When we look at funding for child and adolescent services, we need to look at two-to-one dollar funding for community services versus health care institutions. If we want to do a good job of service provision, we have to allot our funding to the community, because that is where the children are. Often, we are the ones trying to fight for every dollar. Thank you for your time.
The Chairman: We were at a conference in Calgary where we were talking about exactly that.
Mr. Mussell: Thank you. I did not mention when I introduced myself earlier that I am a First Nations person. I was born and raised and live in a First Nation, and have provided leadership for many years in our communities. One of the biggest challenges that I have dealt with is trying to understand why we live as we do.
It is relevant to our discussion today.
I attended university and did an arts and science degree. I worked as a probation officer then moved to parole services after getting my credentials in social work. I became a high school teacher, did graduate work in adult education and have now been working in mental health for many years.
Eight weeks ago, I was in New Zealand at an international conference of leaders in mental health attended by seven nations. They are hoping that Canada will become an eighth nation. I was the sixth speaker on a panel in the final afternoon. We were asked to speculate on our vision for the future of mental health in our nation. The five other speakers mentioned fixing up existing systems, most of which have many faults.
I was not able to talk about fixing up an existing system because we simply do not have one. I recently read proceedings of consultations dealing with collaborative care, and people in the Yukon are saying, for instance, "The closest I get to any kind of mental health service in this country is to go through the courts and end up in jail." Many isolated communities have no access to resources. The first point is that there is no system. There is a need for a seamless system. I will give reasons for that later.
Turning to the subject of current programs, a few of us in First Nations, off and on reserve, have some familiarity with the spotty nature of the service and how strongly Western those services are, and therefore, not necessarily relevant to the realities of the lives of people with the difficulties.
What is being attempted today across the country is what I would best describe as a cookie-cutter approach. What is being done with other people in the country, the practitioners are attempting to do to us. We have significant evidence to demonstrate that that will not work.
Research that has been done repeatedly describes the effects of our colonization. There is no sense repeating what history tells us because we know what the problems and issues are. However, there is no documentation of the good ways of life prior to contact.
Elders today will say that the answers are in our history; the answers are in our past. I believe that. No one has taken the time to begin to research and document those good ways.
The notion of culture skews perception of what that reality is. The notion of best practices skews the perception of what that life was about. There are many parts of the language that we deal with that we have been required to learn as Canadians, but as people of a different cultural background, that has not been helpful to us in beginning to establish a foundation for what we require for health and wellness.
The focus has been on our deficiencies, not on our strengths. I fully support the idea of a strength-based approach. Conditions for health and mental health were based on understanding the good ways of our indigenous cultures of North America.
Why do people urge the involvement of elders as advisers in regard to meetings, conferences and the strategic planning we are doing? Non-Aboriginals say that as well. Elders are closer to the historical circumstance, they know more about it, but it has not been taught very well. The existing educational systems have not taught it to us. We are not expecting that system to teach it to us.
I was at a conference last week organized by Health Canada because they are interested in knowing how we can use the $100 million of the $700 million dedicated to Aboriginal para-professionals and professional health technicians, how we can train them. The CEO of the AFN said that government looks at the 5 per cent of the Aboriginal population that has been successful, mostly the people sitting in that room. That money is not for that 5 per cent; it is for the 95 per cent who are not there. He makes an extremely good point. The 5 per cent will be successful regardless of circumstances. The 5 per cent are those who have a strong connection with the cultural foundation, but that has not been researched and identified very well.
In regard to that cultural foundation, it is important to know the significance of place, to know the place of our ancestors, where the spirits of our predecessors exist. The boundaries of our territory help us to establish who and what we are, to whom we belong, how we are similar to other indigenous peoples and how we are different.
The significance of language and literacy is powerful. In most places across this land, our traditional languages were taken away from us. This is another colonized concept of traditional language. Language is language; if it works, it works.
My understanding in studying language is that most of us rely upon an institutional language, because our forefathers were forced to learn a foreign language that was not taught at all. After three and four generations of that use of an enforced language, you lose the vernacular of your traditional language and you do not gain the vernacular of your new language. In terms of making sense of life, you really need that vernacular understanding.
I was fortunate to learn the vernacular of the English language because my great-grandmother, grandmother and mother spoke English and believed that we had to learn English in order to fight white men; we have to use the same kind of bullets and ammunition.
Kinship is really important, but it includes the spirit life. There is not an elder that I have met who has not stressed the importance of kinship. The point I make is this: Spiritual energy brings and bonds people together; their families, other social systems and additional entities of their cultural world describe kinship. There are more and more people of other cultures who are subscribing to and promoting that. I believe there is substance in that.
Wholeness is integral to kinship. What we do not have in our communities is a strong kinship, again because of the impositions on our lifestyles over the last 150 to 200 years in Western Canada, and longer in Eastern Canada.
Relationships are essential for finding meaning in one's life, a source of life and a foundation of connection with the Great Spirit and the Creator. We live with a significant amount of distrust in our communities. That is embedded in the institutional foundation identified with Indian residential schools, with a system much like a jail. The relationships being mediated and promoted in the jail system are really no different from those of the residential school system.
On the subject of family and community history, my experience tells me this is when you know what you are, who you are and what you belong to in terms of the roots of your ancestors. You can walk with confidence. You can handle yourself in a social situation because you have that knowledge, awareness and understanding.
When you have tools like language, you will be able to look after yourself well. The tragedy is that these tools are represented more by the 5 per cent than by the 95 per cent.
I believe the good way of traditional life was characterized by order. That applies to all living societies, human, animal, bird, et cetera. The ways in which our forefathers had to learn and were treated, that order and the condition necessary to create order was sometimes destroyed, and certainly damaged. That is what we are attempting to deal with today. Some of your recommendations and discussions reflect that.
The final point I wish to make is that access to cultural institutions and access to and understanding of the wider world of planet earth are closely connected, but are very much anchored in who we are, what we are, to whom we belong.
When we are introduced to and understand the basic institutions and practices of our respective cultures, we have some understanding of healthy ways.
What do we, as the indigenous cultures and nations of this country, know about our places of healing? What do we know about our places of worship? We know about the church, but the church was not an institution of our forefathers; it was brought to us by immigrants. What about places of safety, places for teaching and learning core life skills such as hunting, fishing, processing food, finding and processing medicines, teaching and learning personal safety, self-care and care of others?
There is an assumption that those things do take place. However, when you look at the history of the last 50 to 200 years, you can begin to understand why they do not. Much of the research says that we understand the issues and problems and no longer need to go there. That assumption hides the fact that we really do not understand what is at the foundation of today's First Nations and other Aboriginal societies, and it is critical that we have that understanding. Applying what is available will certainly not work. We need a seamless approach that encompasses the entire family, which is a core institution of our cultures. The community, in particular, must be the primary context for the work and we need a system that addresses the needs of all stages of life within our societies.
When a flock of geese travels in formation, they can travel 70 per cent farther than one goose would be able to alone. If a goose is injured in flight, it leaves the flock and goes to the ground, always accompanied by two other geese.
Think about that model in terms of attending to the needs of the children and families that fall out of life and the educational system and about the importance of having resources that focus specifically on when that takes place.
We must understand the importance of collaboration, integration and teamwork and how much more we can accomplish when we work in that way.
Senator Keon: Your presentation was truly profound.
There is a trite old saying that it takes a village to properly raise a child. We have lost all our villages, but perhaps we can build communities.
In my advancing years, I have become more convinced that our social structure and medical system, including as it applies to mental health, must be built in the communities.
Mr. Mussell: I fully support that. In the achievement of that, it is important to consider family and other people in a person's life as critical resources to facilitate positive change. It is absolutely necessary to work through the strengths of family and other social systems. Tragically, most practitioners in this country are married to the one-to-one approach, and that does not recognize the importance of the people who have a much stronger influence on the life of the person we are treating, although our intelligence and common sense tell us that it works. Why are not we doing it more?
Senator Trenholme Counsell: The most wonderful storyteller I ever met was an elder in the Yukon. I hope that we can have your permission to use your story. I have heard it before, but never told it as well as you told it, sir.
Do you see some hope in the Aboriginal Head Start program, which is growing community by community?
Mr. Mussell: I am familiar with some centres that have that program. It has promise, but it is very dependent upon the resourcefulness of the people delivering services on the front line. My daughter is a specialist in dealing with special needs children at the preschool stage. She is going on to do graduate work. She does a lot of work in this area and I am familiar with that work. My wife is a director of education, and she is responsible for those kinds of projects.
Therefore, I am constantly exposed to these very important questions. I am a member of a very healthy family. We do not have mental illness in our family, and I thank the Creator for that. However, others in our community have those kinds of difficulties. My mother and my grandmother were healers, and therefore specialists in health issues. As the eldest survivor, at this stage, that falls on my shoulders. I accept the responsibility and do what I can to ensure that people get proper care. That is extremely important.
The Chairman: Our next witness is Richard Mitchell, from the Department of Child and Youth Studies at Brock University in St. Catharines.
Mr. Mitchell: I am always humbled and a little frightened when I hear myself referred to as any kind of expert. I have been engaged in studying for a Ph.D. over in the U.K. for almost four years, and I am still lumbering along with its final stages. What I have come to know is how little I really know, and that is what a Ph.D. will do for me. I hope to contribute just a couple of things here today to our understanding about childhood, children and young people themselves that come out of those studies, but also out of my 23 years of work in British Columbia in education, mental health, foster care and youth justice, all four of the service delivery systems that grapple with the mental health of children and young people each day.
As the title of my remarks here today I chose "A Canada Fit for Children One Year Later — A Rights-based Action Plan for Promoting the Mental and Emotional Well-Being of Canada's Young Citizens."
I will ask for a show of hands on how many have seen this document or heard of it. That is a smaller number than I might have anticipated, so I am grateful for that as well, that at least I can bring this to your attention. There is an online copy and it is available through a link that I sent with my submission.
The Chairman: We will eventually put together a package that we will send out to everyone who has participated today.
Mr. Mitchell: I would like to bring forward a couple of key findings from my work in the U.K. and from my research over there that will be useful for us to incorporate into our recommendations here.
In the U.K., I ran into a way of being with children and young people that is not prevalent in Canada. It is a theoretical approach and a framework for understanding how it is that children exist in U.K. society known as the "sociology of childhood." A number of us have looked at paradigm thinking about children and this was one for me. The sociological approach to children, childhood and young people starts out with the assumption that kids are actually competent social actors and powerful contributors to society right where they are. It also starts out with the notion that they are citizens, and that they can impact not only their own development and the development of their peers, but also, shockingly, the development of their caregivers and parents. The sociology of childhood does not see kids on a linear trajectory towards independent development that stops at some stage of adulthood.
I will tell you, I am more dependent than ever on my paycheque, on my wife, on my social support system, and any notion that I have reached an independent state in life is just false. I would like us to think about how we see and construct children and young people from that perspective, particularly the notion that they are impacting not only their own development, but the development of their peers and their adult caregivers. That was a profound shift for me.
I noticed that the UN Convention on the Rights of the Child was being widely researched at graduate and post-graduate levels throughout U.K. universities, and that is not happening here. My post at Brock University showed me that. They particularly looked for someone who had a background in children's rights at a post-graduate level. I would like to suggest that that might be one of our recommendations: to look at more research that is adopting the Convention on the Rights of the Child, both theoretically and in an applied way.
The core principles of the convention are embedded in U.K. legislation. They provide for active participation of children and young people as competent social actors in their own community. As I discussed earlier, kids are being increasingly viewed by decision makers and constructed within policy documents as competent and as citizens, while here in Canada we are still viewing kids as future citizens and investments. The assumption there is that kids are actually of economic value alone, and within the convention we have the opportunity to engage kids and young people as citizens — as subjects, not objects of concern. This was really the heart of what I found in my research in the U.K., which is ongoing.
I will not suggest that there is a direct causal relationship between this way of knowing about children and young people and the differences in legislation that I see happening. That is not my area of expertise or research. What I do see happening is that kids are participating with politicians, with policy-makers, with teachers, with advocates, with practitioners across disciplines.
I was at a children's services planning session just about this size, with police and recreation officers, mental health practitioners, the whole range, as well as people engaged in the environmental community and so forth, actually discussing with kids firsthand what their views were and bringing those on board. That is profoundly different from the way it is here in Canada right now, and it has a particular resonance with and relevance to children's mental health.
I would like to move to my experience as a practitioner for 10 years in a children's inpatient facility in B.C. I found that about a third of the kids actually got better over the years. I did not do any statistical analysis to come up with this figure. This is pretty anecdotal but is supported by all of my colleagues. About a third of the young people who came to us actually gained something by our intervention and a third stayed the same. I am really sad to admit that a third was profoundly damaged by our intervention. Some of them actually may have killed themselves due to our intervention.
In the summer of 2003, when Health Canada put out a GlaxoSmithKline warning about the inappropriate prescribing of Paxil for those under 18, I was able to understand some of the links. We do not know how many children or young people may have harmed themselves because of those interventions in the 1990s because we do not keep track of those records in mental health right now. We do not evaluate our outcomes. We do not do follow-up in the communities. My colleague suggested that not seeing kids more holistically, as part of a community, is part of why this is the case. We send kids after they have been our patients — victims often, I have to say — back into the community as though our work is done, and that needs to shift as well.
It would be wrong to suggest that the research I have been engaged in and coming from the U.K. points towards easy policy solutions. That is not the case at all. Trying to engage kids in a rights-based approach will cut across disciplines and across service delivery systems. What we will see, and what is coming out of the discourse in the U.K., is that this notion of rights-based "spaces" for children and young people changes the conceived relationship between professionals and service users, adult responsibilities and children's rights. A rights-based approach allows professionals to become facilitators rather than technicians, and children and adults then become co-constructors of knowledge and expertise. We engage children and young people in a profoundly different way than we have up to this point, culturally, socially and politically and within our service delivery systems.
I am here to make an argument that a lot of our work has been accomplished in the document A Canada Fit for Children. When I reviewed the action plan within A Canada Fit for Children and thought of my 10 years' worth of practice, the concerns that I had about children and children's mental health service delivery, I found the action plan fit congruently. Therefore I would argue that we bring forward some of the most relevant pieces within this action plan that was adopted across Canada in a comprehensive way with children and young people themselves.
If at all possible, I would also like to urge you — and I am not sure whether you have, but I looked at the documents of the interim reports and I could not find evidence of this — to talk to children and young people who have actually experienced our mental health interventions and see what kind of knowledge we can co-create with them.
As Mr. Mussell pointed out here, year in and out, the young men and women who came to us from First Nations and Aboriginal communities were sent back as though our work had been completed.
I was always deeply disturbed about that. Thank you for bringing forward a holistic way of seeing things and an approach that comes from a different kind of world view than evidence as something that is absolutely measurable. Sometimes the evidence is more profound than that. It comes from the stories, the oral traditions, the way that children and young people are in relationship with each other and their families.
Based on a growing consensus, there is a case to be made for a relationship between the promotion of children's rights and the promotion of mental and emotional well-being. There is early literature on this in the U.K. We are not quite there yet. In 2000 I did a piece of action research in the Victoria Capital Health Region of British Columbia using the Convention on the Rights of the Child and a population health framework to actually talk about these issues with children themselves. It was through that work and research that I was awarded a fellowship in the U.K. I could not find anyone here to do doctoral work based on that research. Using children's rights in a population health framework would not fly here, but it did over in the U.K.
Perhaps the best-known support for this contention is the McCain-Mustard study, which I am sure most of us are familiar with.
I have made some recommendations in my presentation and in my submission online, but I would like to highlight what I feel might move this agenda forward and help us to see kids not as objects but as subjects and citizens. We need increased research to apply the Convention on the Rights of the Child across disciplines and in a trans-disciplinary way. Our DSM-IV ways of knowing children and young people are inappropriate. The GlaxoSmithKline and Health Canada announcement last summer supports that.
I would recommend that a national children's commissioner oversee some of this interconnectedness throughout disciplines and throughout service delivery systems. These are arguments that have been made elsewhere and are taking place throughout the U.K. nations. Children's commissioners have been appointed there under the terms of the convention and the reporting system with the Geneva Committee on the Rights of the Child.
I would like to reinforce adopting the national plan of action and its relevant recommendations where the participation of children and young people in mental health is concerned. I would also like to make an argument, based on my own practice out in B.C., for school-based mental health teams that work across disciplines and have a variety of counselling modalities that are not located solely within the DSM-IV approach to these issues.
The Chairman: What is DSM, for those of us who are not technicians?
Mr. Mitchell: The Diagnostic and Statistical Manual of Mental Disorders.
The Chairman: It is the psychiatric bible?
Mr. Mitchell: Yes. That would be another vernacular. I believe the fifth version is coming out shortly.
Dr. Roberts: I am a child psychiatrist who came fully trained from England. I lived in England, went to school in England, and as recently as 1993-94 went back and worked in England. If I wanted to use an example of a functional system for children, I would use Scandinavia rather than England, as they have a humane system that continues across the lifespan. It is important to remember that the DSM, unlike the Bible, is not a finished product. It is a work in progress. It goes a long way toward actually providing commonly used language to describe disorders.
13,000 children and adolescents under the age of 17 kill themselves each year. I am not certain what that number would be without the interventions we have now compared to the interventions we had when I started practice in the 1970s, but it is important to remember that the rate of suicide in children and adults has stabilized since 1996.
Dr. Goldbloom: During World War II, at a time when the Allies were losing a tremendous number of ships in the Atlantic, a gentleman came before the Joint Chiefs of Staff and said he had a solution to the German submarine program. The Joint Chiefs of Staff were very interested and asked him to describe his solution. He said, "Bring the Atlantic Ocean to a boil. All the submarines will come to the surface and then it will be very easy to pick them off." They said, "That is very interesting. How do you propose to do that?" He said, "Look, I gave you the idea. You work out the details."
On that note, I would like to try to be as practical and action-oriented as possible in the few suggestions I have to make. In my view, and I do not know to what extent it would be shared, if you had to pick the number one problem across the country in children's mental health, wait lists would spring to mind. The wait lists are totally unacceptable right across the country. I have had occasion to deal with this both through reading and through personal experience.
As a neutral observer, I was asked to chair a group that has been focusing on eye care in Nova Scotia. We have significant wait lists in that particular area of health care. In Nova Scotia, there was a wait list of people for cataract surgery of 2,000 to 2,500 patients, none of whom could find out exactly when they could have their surgery because booking was being done by individual surgeons making their own arrangements.
Solving the wait list problem is not rocket science. In this instance, we quantified the wait list. We quantified the extent to which it was increasing over each year, and we decided what was necessary in practical terms to bring it down to a reasonable standard. By adding an additional operating room and staffing it, it has been possible in a year to bring the wait period down to 90 days.
It does take money, but it is a lot more than money. It is a matter of specific planning. One of the first things that need to be done in terms of mental health is to quantify the size of the wait lists in different communities and different regions and to calculate specifically what it will take to bring those wait lists down to a satisfactory size.
There is no need to reinvent the wheel here. This is a paper that was presented last month in Armagh at the British Paediatric Association. This had to do specifically with children with ADHD, which, as you know, is of epidemic proportions here and around the world. The waiting list of children referred for assessment of possible attention deficit disorder had tripled over a one-year period. To deal with this, they held patient information sessions targeted at parents who had been on the clinic wait list for nine months or more.
They reduced the wait list. Many of these children were put in treatment through group sessions. They reduced the wait list from 20 months to zero over a period of only seven months. It can be done.
One of the first ways of dealing with a significant wait list for mental health, or for any other situation, is to bring patients and families together and deal with them as groups. It is quite amazing the extent to which you can reduce the wait list in an extraordinarily short time. I was delighted to hear Michelle Forge mention telehealth. Given the long distances in Canada, it is a vastly underused technology in dealing with children's mental health problems. I know we have used it to a limited extent in our area; I cannot give you numbers. However, talking to a family over a video connection is 99 per cent as good as having them right in the room with you. You can deal with a huge number of patients who have real problems of access by doing that.
Coming back to the wait lists, in one of the suburban regions in Halifax, in Sackville, where we have a community mental health team, through parent groups, they reduced the wait list from 21 months to eight or nine months.
In cataract surgery, we got it down to 90 days within about a year. These are not insoluble problems, but they all start from the same point, and that is the demography, namely, the size of the list, the waiting time, the rate of change in the wait list, and what it will take to resolve that problem. That is where an innovative approach can do a lot of good.
The second suggestion is that we need a major move of mental health services from their present locations in most communities into the schools. The school is children's natural habitat. For six or eight hours a day, it is where they are, it is where their parents often come and it is where you can deal with the problems in collaboration with the teachers.
I happen in my senile days to deal with a lot of children with mental health problems and I am in constant communication with teachers, something that in the first 50 years, I did not do very often. I have found it one of the most useful things that I do.
The next practical suggestion, which I have made previously at the annual meeting of the Canadian association of child psychiatrists, is that departments of child psychiatry and departments of pediatrics across the country should become single departments of child health. The dissociation of body and mind lives on, even though all the scientific evidence makes it clear that there is no distinction. We have far more in common with each other than, in my view, child psychiatrists have with adult psychiatrists. Therefore, as a British physician once said, the romance between pediatrics and child psychiatry has been going on for decades, and it is time they got married, if only for the sake of the children.
Pressure needs to be exerted through the heads of Canadian departments of child psychiatry and of pediatrics, through the Royal College of Physicians and Surgeons of Canada, who certify these people. The evidence is well documented that pediatricians who see huge and increasing numbers of children with mental health problems are inadequately prepared for the job. Here is a paper that is being presented on May 15 at the Pediatric Academic Societies. This is from the University of California. They sent a questionnaire to all the heads of pediatric residency training programs, post-graduate training programs. Eighty-four per cent of program directors indicated they felt the amount of training in children's mental health issues was minimal or suboptimal. They went into the various conditions, namely, ADHD, eating disorders, mood disorders and so forth. Less than 15 per cent of the programs had inpatient-based child psychiatry training, and only 25 per cent described ambulatory training by psychiatrists or mental health professionals.
It is clear, not just to psychiatrists but also to pediatricians, and it would certainly be duplicated in Canada, that the training that people who look after children are getting is grossly inadequate, and I did not mention family physicians. That brings me to my next practical suggestion.
Children do not exist just as children. That may not come as great news to you. They exist as members of a committee that we call the family, which is a committee of people who live in a kind of dynamic equilibrium. One of the things I learned early in my career from the people at McMaster, where family therapy was born in Canada and, to some extent, in the world, was that when you change any member of that dynamic equilibrium, whether for the better or for the worse, you change everyone. That is one of the factors at the root of treatment failures. We treat the child, but not in the family context.
Here is my next practical suggestion. I am a confirmed family therapist. I deal with families as families. I refuse to see children unless both parents are present.
I believe that we need a rebirth of family therapy training in Canada, and this is not only for psychiatrists or physicians, but also for social workers, nurses and clergy. We have a pastoral care director who is a trained family therapist, and most of the people on our medical staff are unaware of that fact. Therefore, we need a form of mental health hamburger extender. You can make a certain amount of hamburger go twice as far by adding that powder you buy at the grocery store. This is a form of mental health hamburger extender.
Health care is too important to leave to the doctors or the psychiatrists or the nurses. It has to involve everybody, and it is possible to train first-quality family therapists. I believe that Canada should have a minimum of one or two centres that are specifically devoted to that, where all provinces and territories are required to send a certain number of people every year so that we can use that multiplier effect to scatter effective family therapists across the country. It can be done.
When we talk about the issue of mental health, people say that we need more psychiatrists and we need more psychologists. How long does it take to train one? How long can we wait for those wonderful people to be trained? You cannot. You can train family therapists in a relatively short time. They may not perform absolutely as well as a highly trained child psychologist, but three quarters of a loaf is better than no loaf at all.
I mentioned moving mental health into the schools. One has to pay attention to people's lives and when they can get access. I do not think we take nearly enough advantage of evenings. This is the time to get parents together. We live in a society that works nine to five, but where children's mental health is concerned, particularly where group intervention is important, you have to get people together.
The same applies to pregnant women, which is the time that mental health care should begin, when they, their partners and their other children often should be involved.
I mentioned telehealth. That should be developed more extensively across the country. It may be that, with the help of organizations like CDC, this can be done. It needs to be a planned development so that people have access to mental health care without having to leave their homes in remote areas and travel to other places, which can create enormous hardship for them.
The Chairman: Further to your comment on locating services in the schools, the trend is clearly toward multidisciplinary primary care, as opposed to primary health care centres with psychologists. Do you see those as playing a significant role or do you see the service more in the school?
Dr. Goldbloom: I see the service more in the school. In some high schools we have teen health centres, which are usually staffed by one nurse who is responsible for the mental and physical health care of the entire school.
We send our residents occasionally into the schools. Other centres do as well. It is not nearly enough. A one-day exposure does not do it. We need exposure and responsibility over time to deal with children where they are and where their families are willing to come. I see the school as the most underdeveloped site for effective health care of any in the country.
The Chairman: That is not just mental health care.
Dr. Goldbloom: That is for all kinds of health care, but mental health care in particular.
Ms. Whitenect: I would like to reinforce that point. With regard to primary care facilities, we are doing the same thing in New Brunswick. When you talk about adult services, it will work for adults. However, when it comes to child and adolescent services, we need to talk about the school system.
Our addictions people do not have an office other than in the school system. They do all their work within the schools. You are right that it reduces the stigma. Parents are willing to come there. It is a natural environment. Many young people use the school system, so it is accessible. For those young people who cannot be in the school system, we have alternate sites. They are still school based. I reinforce the point that that is the key area.
Ms. Hills: It is also a way that schools can address some of the cultural issues in an individual community. Some recent creative examples include an instance where Jewish family services provided a psychiatrist to a school, but the psychiatrist was not called a psychiatrist. The psychiatrist was called a guidance counsellor. The students would not go to a psychiatrist's office, but they would go to see a guidance counsellor. It was known that Mr. Goldbloom was coming on Wednesday afternoon as a visiting guidance counsellor. Ultimately, the kids all knew he was a psychiatrist, but he was not labelled as such. The families were more comfortable with that.
Because of the cultural differences in the GTA and in many communities in Canada, parents often do not like to address mental health issues. The school was the hub. The schools became very creative in the way they were able to work with these multicultural communities.
Mr. Mussell: I do not like to throw a wrench into a good idea, but I am concerned that schools do not necessarily have a good reputation for dealing with the stigma experienced by culturally different children, especially Aboriginals. There is a great deal of bullying. In British Columbia, fourteen-year-olds have lost their lives because of bullying. My sense is that teachers are not well prepared and equipped to intervene in instances of stigma and bullying. In Canada, based on what I have read, the major victims of bullying are people of the Aboriginal communities.
That is a caution that I raise. I like the idea, but I am aware of another reality.
Ms. Forge: I would like to make three points. The first is to respond to Mr. Mussell's point about bullying. It is an issue that needs to be addressed. This year in our district we will have full implementation of anti-bullying policy and procedure, and all of what that means in terms of staff development. We surveyed half of our students about bullying to find out where the issues are and what we need to do to address them.
It is a crucial caution, but it needs to be taken in the context of what we can do to ensure it does not continue or does not get in the way of using schools as a partner in delivering service.
That leads me to my other two points. One of the advantages for us in this partnership is that we can run a 10-month school year in 10-month blocks. In working with community agencies, we have been able to extend our opportunity to support young people to 12 months. In those two months in the summer, we often find there is slippage with issues related to the mental health of children and youth. We find that the good work that was done gets undone because there is not that ongoing support over the summer period. That is a key to the partnership idea. It becomes more important to do exactly as you say, to talk about schools as the hub.
The other point is a caution. Schools are different beasts. We are a different organization. We have a fairly narrow mandate, in some ways, and yet it is all-encompassing in other ways. When we try to partner, we do it more or less effectively, based usually on the personalities and the relationships that are built.
If we are to say that schools are the hub, we need to identify how to do that effectively, what it looks like when it is done effectively, what are the skills necessary and who needs to be involved. It can go off the rails fairly quickly if people are not committed to it.
Mr. Mussell: In efforts to enrich the quality of teaching of Aboriginal learners in British Columbia, parents and community people have been limited by the system because of the union's rulings and their requirements. I would be concerned about that in terms of making the schools the hub of mental health services.
Dr. Davidson: I would like to support what Mr. Mussell has been saying. I will remind you of my previous comment on the notion that schools have access to all children and youth. Not all children and youth get to schools, some because of bullying, and many because they have a severe psychiatric disorder of the internalizing type. Those would be school-refusers. Of the externalizing variety, that is more school truancy. The late Dan Offord spoke and wrote very elegantly about the concept of civic communities. When we talk about the school as the hub, we have to enlarge that thinking. It is not just a place of services for children and youth, in my view. It is a community place. Schools are there to serve, and they should be serving people across the age span. I would see a hub as a place where people of all ages go.
When one of my colleagues, Yvon Lapierre, retired, I asked him if he would be a consultant in the program I run at the Children's Hospital. He said to me, "You do not want me. I am on the back nine holes of my life." I said, "That is exactly why we do want you."
Our elders and seniors have a tremendous amount to offer. Their presence in our school system would be invaluable for us. It would give them a strong sense of self and an appreciation of what they have done in the rest of their lives.
My pitch is that the school is there to serve. As was mentioned, evenings are important. Schools should be open almost 24/7, and we should have in-school services, but across the age span, including programs such as literacy programs, learning how to cook programs, learning how to grow fruits and vegetables. There are opportunities within school systems if we broaden our vision of the hub model to incorporate people of all ages.
Dr. Israël: I will subject you to some selective redundancy, which means I agree with a lot that has been said, but I have also already learned a lot today, which I feel like running back and sharing with my child psychiatry students.
The inspiration for my talk is where do the good ideas go? There are many good ideas that go nowhere, that are never tested and not implemented. I want to talk about just that.
What strikes me most about mental health service delivery, whether to children or to adults, is how heterogeneous it is and how within our own country there exists such a disparity in how services are organized, how resources are rationalized, and how orientations and priorities are established. Without sacrificing the principle of adapting programs to local needs and resources, there is a lot to be gained from centralization of key tasks and from channelling expertise into the development of a multifaceted, national strategy focused on the mental health needs of Canadian children.
You have already convinced me today that children have to be dealt with separately from adults. I am an adult psychiatrist, and I mostly focus on the adult world. However, I know just from my own experience in my hospital that the partners and the issues are entirely different. You dilute things by merging the two together. On the other hand, in keeping with what Dr. Goldbloom said, there are perhaps ways of integrating with other sectors that do not apply to adult mental health.
In the mental health field, we deal with complex disorders that are the product of intricate interactions between genetics and environment. I come from the specialized treatment sector, but I feel that specialized treatment is costly, not accessible to many, does not focus on prevention or promotion, and only addresses the tip of the iceberg when it comes to children's mental health.
How can we integrate a rapidly increasing global body of knowledge on promotion, prevention, early intervention and treatment into public health policy, public and professional educational strategies, and service organization and planning? Of course, I do not know the answer, but there are many ways of going about this.
I would propose that, no matter what, we need a centralized structure that would be focused on mental health for children, but working with other sectors as well. A centralized structure would serve six different dimensions.
First, it would pool data from epidemiological and population studies in order to measure and monitor population health needs that are changing as our environment changes. For instance, trends have to be detected in the increase or decrease of certain problems in order to anticipate needs and to adequately allocate resources, as well as to be able to promote early identification of potential risk factors once they are known.
What I am thinking of in my own field is obesity in children. In the States, the numbers are grossly out of proportion. In Canada, it is starting. It will have both physical and mental health impacts. As you know, obesity and lack of self-esteem go hand in hand, not to mention the bullying and teasing that obese children go through. The sooner we learn about what is happening within a particular community and which communities are at risk, the faster we will be able to intervene in order to design comprehensive interventions promoting healthy eating and increased activity. We are not talking here about treating children who are obese and have developmental health problems, or treating children who are obese and then develop eating disorders because they go on strict diets.
The second way in which a centralized structure would work is that it would orient research agendas and research fund allocations. It should not be haphazard who gets the money. We have to decide where our research efforts should be directed. We need more evaluative research to assess the efficacy of existing programs and the impact of early interventions on future health. We do not know enough about this. We need to focus on gene/environment interactions and look for factors that not only mediate risk, but also focus on resilience. Who is spared and why? We need to study the impact of advertising on children and evaluate how media and communication tools can be harnessed to decrease stigma instead of reinforcing it.
I heard a lecture last week by Kelly Brownell from the States, from Yale, and he effectively demonstrated how the media trains children to overeat and to eat fast food. He talked about portion size and how vulnerable our children are to that, and about new strategies involving text messaging children on cell phones. Apparently, most children have cell phones now. Our children are being influenced by people whom we do not control at all, and it does not just apply to my area, eating disorders, with all those thin ideals that the children are being bombarded with daily. It also applies to other issues like violence and role models that are presented to children through the media. I think this is a big issue that most of us do not even broach.
We do not have answers to many of the questions we are talking about today because data are lacking. We can rely on expert opinion by default, and that is pretty good sometimes, but ideally, some of our questions would be answered through appropriately directed research efforts. That is why we need to control what kind of research gets done. We need to have the experts inform the research strategy.
The other thing that a centralized structure could do is translate research findings once they are collected from international health policies aimed at promoting health or preventing illness.
Going back to eating disorders for a moment, researchers around the world met in Montreal last week, where I organized an international conference, and we discussed prevention of childhood obesity, but also the potentially harmful effects of promoting diets with respect to heightened risks of developing eating disorders. This is a double-edged sword that we work with. There was an NIMH-sponsored meeting where people got together to talk about screening and assessment tools for the preadolescent population, which has now definitely been targeted as highly at risk. These tools would be aimed at family practitioners and pediatricians, not at psychiatrists. By the time they come to us, it is way too late.
Similarly, I learned at this conference that web-based tools are being developed in Halifax that are targeted to teachers and that will help teachers promote healthy eating practices and self-esteem enhancement strategies. Had I not met this woman in the hallway or seen her poster, I might not know about this. Why cannot we all benefit from these things that are happening, not just in Canada but around the world?
Fourth, such a structure would centralize the preparation and dissemination of information such as public education and awareness campaigns, but also invest in the teaching and training of non-mental health professionals. We should produce a mental health curriculum that would be integrated into the educational programs of teachers, daycare workers and other health professionals. As many people have said, at medical school there is hardly any teaching on mental health. Many of the specialties that come in daily contact with mental health problems do not know anything about it. The objective would be first to reduce stigma by educating people, but also to familiarize them with common disorders.
What Judy Hills brought out is exactly what I had in mind, but I did not know it existed. It is great idea, and it would also teach people how to access services or tell them where to go if they identify a problem, which is something many people do not know.
As always, when you implement any program, you need to predetermine indicators to be tracked in order to know whether it works or not.
Number five, it would translate research findings into the development of evidence-based models of care and ensure that research findings and major impacts, new strategies and initiatives that have been successful, are implemented quickly and across the board, instead of locally for the benefit of a few.
Finally, it would monitor quality assurance and help organize service delivery so that optimal services are delivered to the greatest number of children. There is a pressing need to define levels of care and implement the hierarchical system with clear referral lines and dissemination of appropriate tools so that non-specialized health workers can effectively intervene with a majority of children. The idea here is that things are organized centrally by lots of specialists and experts, but care is mostly delivered by people who are not necessarily specialists but who have the greatest contact with children. Benchmarks are sorely needed as to reasonable ratios for staffing and services. We have no idea. We have all kinds of numbers that people debate, but we need to know the minimum that a community requires to ensure the mental health of their children.
Creating a centralized structure would not necessarily imply hiring more scientists or professionals, but rather coordinating the efforts that are already being deployed, eliminating redundancy and offering an infrastructure that facilitates the pooling of expertise and the dissemination of knowledge and know how. The driving principle is the optimal use of scientists and mental health specialists and the redistribution of tasks amongst all those who impact on the mental health of children. Projects could be delegated to a group with a particular expertise, but then all would benefit from the results.
Currently, we have a small group of mental health specialists struggling to keep up with an increased demand for their services while a multitude of primary care workers, non-health care professionals, teachers and daycare workers, who could intervene meaningfully, are not organized to do so. I would therefore advocate that specialists' time be channelled into either the delivery of specialized care and/or the design and implementation of comprehensive mental health plans with clear definition and guidelines for personalized services.
Senator Keon: You come from a very interesting constituency as an adult psychiatrist talking about children. You were very clear about how you think children could be handled. At least, you were very clear that it needs a special focus — do not lump it in with adult services.
Somewhere along the road of life, as we all know, this child becomes an adult. There are a couple of difficult transitions in there. There is adolescence. Nobody knows what an adolescent is. It depends on whether you are defining it for a driver's licence or whatever. With my limited knowledge, I see two big holes in the system. One is birth to age three. The other is the transition of child to adult. How would you handle that?
Dr. Israël: I will start with birth to three. I mentioned other health care workers. Take nurses who do well-baby visits or child care workers, how much are they educated on identifying children who have problems or knowing where to go for help? They do not have to treat them or intervene. My ideas do not start at age five. They could start at zero, with pediatricians or GPs who come in contact with children.
In Israel, the nurses follow children from the local community clinics up to 18, with a weight chart so you can identify which kid started to go off into eating disorders and lose significant weight. There must be ways of tracking, screening, identifying, but also aiming interventions at these people because they are the first line.
The transition age is an area to be studied. It is open-ended when adolescence ends. I have heard 25 lately. In Quebec we are just putting out a mental health plan. I do not know if you have seen it.
The Chairman: We heard about it. We had a long talk about it.
Ms. Israël: It is coming out in its final form in the next few weeks. It is an example of centralization and getting directives on resource allocation, on hierarchy of services. It is far from perfect, but it is taking a stance and having us all react to it. There is talk about the possibility of seeing up to age 25 as adolescence, especially when kids stay home longer and so on. They are still more in the adolescent mode of being. We need transitional services. We need to aim services at certain kids and not have cut-offs, but rather be able to assess where the person is at instead of using an arbitrary 18 years and 11 months, or whatever it is in your province.
That is part of the issues we need to study. The first step is the programs should not start at 18, they should start at 14. That is what we have done in our hospital, because the early psychosis can start at that age, and if you want to intervene quickly you should do it then. There must be communication between and integration of the two sectors, especially for adolescents.
Mr. Manion: I agree with much of what you said. To comment on your last statement, not all 14-or 15-year-olds are the same. We do put artificial boundaries around things, more for financial and fiduciary reasons than for realistic developmental reasons and better serving people. The lens must be changed dramatically, based on what the individual's needs are.
I want to comment on the research. I am a strong believer in the need to enhance our knowledge about what works. Evidence-based practice is very important, but there is a limitation to it. We have to realize that what is developed in one locale or one laboratory or in a well-controlled setting does not necessarily work in an isolated community that does not have the same kinds of resources or control over the situation. At times, we have to look at a promising practice in another community and perhaps validate it through some science to demonstrate that it does work and might be replicable across situations. We have to go from the top down and the bottom up at the same time in terms of increasing our knowledge.
Dr. Israël: That is why I made a distinction between evidence-based practice and quality assurance. In quality assurance, you are not using scientific methods to prove something, but you can track what is going on and see what the impacts are. Sometimes, we feel things are working, but then when we measure it, it is not working as well as we thought. It may also be able to identify the people who most benefited. In that way, you may not want to export it across the board, but you might say there is a similar community elsewhere with some of the same realities that could benefit from such a strategy, where this would not work in an urban centre.
Mr. Manion: Program evaluation and quality improvement are essential. It is strange how little research is funded in that area because it is not always considered to be real science. The value of that is also important in how we look at science, and is it really valuable to communities.
Dr. Israël: We agree.
Mr. Manion: Yes, we agree.
Dr. Goldbloom: On the evidence-based practice versus consensus issue, which Dr. Israel referred to, I confess my bias has been strongly oriented towards evidence based. Where you do not have the evidence, there is an obligation to collect it, because consensus has a very bad track record. Dr. Alvin Feinstein of the Harvard School of Public Health said most of the greatest errors in medical history are traceable to the opinions of experts, and when you think about it, that is very true. There are a thousand examples of that.
The other issue that was raised was providing mental health care within primary care. It is important that we take a large dose of reality-based medicine here. I happen to function currently as a consultant. Most of the children I see are referrals from primary care physicians.
It did not take me long to learn that the number one reason for referral is that the primary care physician realizes this will take more than 10 minutes.
Sir William Osler once said that when doctors speak of matters of principle, they invariably mean money. There is a practical problem in mental health. That is, that people are paid by the number of patients they see. As long as that is the case, you will not see much mental health care in primary care.
Senator LeBreton: Dr. Goldbloom reminded me of the question I was thinking of when Dr. Israël was speaking. We have heard from witnesses before about people who went into psychiatry or psychology, the amount of training required, the time they have to spend per patient, and even the stigma that they deal with when people say, "My goodness, you're going into psychiatry?" Has anything happened on that front to address those issues?
Turning to your point, Dr. Israël, about teaching and training of non-mental health professionals, is there some way that that group can be brought into the picture to make the lives of people who do go to medical school and into these specialized areas easier, so they do not have to deal with the stigma even within their own community?
Dr. Goldbloom: I tried to suggest one way that that could happen, and that is through training in family therapy, which crosses as many disciplines as you like. You can train intelligent lay people to be excellent family therapists. It is an issue of training and certification, but it does not require eight years in university. We need to take the quick and dirty approach to doing that on a national scale. This would be one of the fastest ways of resolving the mental health issue, quite frankly.
Dr. Israël: I have a comment about GPs and family physicians not having enough time. The concept of a team and using the shared care model, not with psychiatrists but with other mental health care professionals, having quick access to a counsellor, a psychologist or a social worker as part of their practice, would make it easier. All they have to do is pick up the problem. Why should the child wait six months to see a psychiatrist when maybe the problem requires an intervention at the level of the family?
The instinct to say "This is strange, I cannot handle it, I do not have time to deal with it, I will send him to a psychiatrist" is because there is nothing on hand to help them out.
I was not talking about content because I could talk for an entire day on all the different ways in which we could have people access care earlier. When we talk about early intervention or prevention, we are talking about before kids even get to the point that they need a psychiatrist. There are many strategies. The question is how do we pick the best ones and ensure we all benefit from them.
Senator Trenholme Counsell: I have to speak in defence of family doctors. I do think that family doctors need more training, particularly in children's mental health issues. We get a fair amount of training in mental health generally, which is mainly adult mental health. That definitely needs to be increased in the curriculum.
I do not know what the percentage of cases is. Often, the family doctor sees the problem right from the earliest months. One of the crucial roles that a family doctor plays in this is taking the family by the hand — literally, physically and emotionally — and getting them to realize that there is a problem, guiding along the path of beginning the diagnosis of the problem and helping the family to accept that they have to go on and get help. That is very difficult. It is time consuming, but it is often the family doctor who does this, especially in the earliest years. Family doctors need more training, but I do not think it is quite as bad as a 10-minute visit. You can look at an ear in one minute, but you sometimes spend an hour with a kid.
Dr. Davidson: Six or so years ago, we did a quick and dirty study. We called the 16 family practice training programs across the country. We asked three questions — I said it was quick and dirty. The first question was: In your family practice program, do you have a mandatory rotation in child and youth mental health? None of the 16 programs had a mandatory rotation.
The second question: Do you have elective opportunities in child and youth mental health? Of the 16 programs, eight offered elective opportunities.
The third question was: In the previous two years, how many of your family practice residents have utilized the elective opportunity in child and youth mental health? In the entire country in the previous two years, one resident in family practice had done an elective rotation in child and youth mental health.
Dr. Lipman: I have the opportunity to follow many articulate speakers. Many of the things that I wanted to say have already been said. I will try to be brief.
A conclusion and overlying message from the issues that I will talk about is about evidence. We need to start looking at the evidence for what we do in dealing with children, youth and families with emotional, behavioural and mental health problems.
There are some intervention treatments and therapies. Sometimes the evaluations have been done in specialized settings so they are not applicable to the real world. We need to evaluate those interventions in the real world to see how they work. Where interventions are used that have not been evaluated, we need to start, because there are many in children's mental health that have not been evaluated. That is my bottom line.
Some of things I will say as background most of you know already, but I am just building my case. First, there are many kids with emotional/behavioural problems in the general population. We know it is about one in five children, so 20 per cent. Second, these children do not generally have one disorder or problem but, commonly, things co-occur. You cannot focus on one problem as the way to approach things. Third, many of these children do not actually get to a child welfare centre or to a children's mental health centre. That does not mean that all of them need to, but we know that only about one in six gets that specialized help. There are long waiting lists. Not that everyone needs to see a child psychiatrist, but we know the number of child psychiatrists compared to the population of children across Canada. Some work has been done by the Canadian Academy of Child and Adolescent Psychiatry. The numbers are dismal in terms of the availability of that kind of service to kids.
Many kids, co-morbidity, so multiple problems; they do not get clinical service, or if they actually get service, not necessarily in a clinic but in other places, we do not know whether the interventions work. That is the key point. They may help; they may do nothing. They may actually make things worse. We do not know that about many of the things we do.
I try to be practical in my action plan. What do I think we need? What is the approach that we should take?
First, it needs to be a broad approach. We should not focus on one disorder or difficulty because of this issue of multiple problems occurring in one child, one youth and one family. Second, we need to consider moving services into the community. People have been very articulate about that, whether that is a school or some other community setting. It does not mean there is not a need for some clinical services, but maybe the bulk of services should move out into the community.
That would allow you to use multiple types of personnel to deliver services and allow those services perhaps to be more seamless than they can be in these medical silos or education versus medicine silos.
In deciding what you want to work on, it makes sense to use a participatory approach, where you ask children, youth, families, teachers, medical doctors, front-line workers and others what they think is important. In that way, you arrive at agreed-upon needs. Some may be with regard to prevention and some may be with regard to treatment.
When you have decided on your needs, you must look at what we know about what helps. If there is evidence, you try to use it or adapt it. If you do not know whether what you are proposing to do helps, you have to add an evaluation to show whether it does.
Next is the need for education. That is very broad. I am not talking only about family doctors or teachers. I am talking about children and parents. It has to do with de-stigmatization and with understanding risk factors and prognoses of various problems. It has to do with why you choose or are evaluating a particular approach. There is a multi-faceted need for education.
The next point is with regard to research. We need a real push toward training evaluators or making research part of the culture of service delivery agencies. It is usually an add-on for an already stressed group of people. It is important that we have a shift in the culture toward evaluation in order to know what we are doing is right, in order to justify funding or whatever.
The last point is the same one that Dr. Israël made with regard to population health, that is, informing our practice through use of the data that are being collected across Canada on how children are doing and what risk factors are important in how they do in the long run.
Dr. Van Daalen: I believe that how we view things determines how we do things. I want to talk about a tree. Trees are not seen for their intrinsic value. They are often seen for the fruit they bear or their ability to provide shade. Children are also not viewed for their intrinsic value. They are seen as property or incomplete beings — although not at this table. They are seen as our future, and that is often linked to finances. I believe that they just are, and that they have intrinsic value.
I want to tell you about a boy named Mark whom I know through my practice in a pediatric mental health institution. Mark was 11 when he came into an institution that I thought was rooted in providing safety. Mark had stopped eating, walking, talking, toileting himself, and was wearing sunglasses. In my estimation as a public health nurse for over a decade, he had gone "in," and that was his safe place.
Within a day, he was sent to an adult facility for electric shock treatment. That was a year and a half ago. I was reprimanded for speaking about this, for questioning this practice, for wondering what was going on.
I also know that you all agree that there could be children and youth at this table who have interfaced with the system. In preparation for this, I met with 25 adults who had been child users of the psychiatric system. Some of what I say may be quite controversial, but I promised them that I would bring their voices here today.
My comments also come from my 12 years of bearing witness to the lives and spirits of children and youth as a school community-based public health nurse. It worked well. Our community was the school. The school allowed us to come in. We worked with addiction workers who were youth centred. We worked with HIV teams that were child and youth centred. Parents came in. The elders of the families came in. The police came in. It was beautiful.
The only reason I left public health to go to York University is, as was said, public health nurses and other practitioners were yanked from high schools. They were pulled completely away from schools, away from living rooms, away from the curbsides where the children were.
We cannot talk about children's mental health without some core considerations, some of which I have already heard embraced. The first is that we are almost at the 20-year mark of the Ottawa Charter for Health Promotion. I think that health is about peace, finances, social justice, hope, purpose, agency, and the ability to authentically self-define. When those are impinged upon, we sometimes have children's mental health concerns.
It is a breach of rights. I believe that everyone's rights are interrelated with the rights of others. I do not suggest that children's rights are separate, but in my experience and practice the breach of rights has been at the core of many spirit injuries, what some people are calling obsessive-compulsive disorders, which I consider pathological language, but I invite us to consider thinking about these as spirit injuries.
Children and youth have rights. We have ratified this convention and it behoves us all to ensure its enactment. I was excited to be coming here because I think this is the way we can ensure that we enact that convention.
Children's rights must be protected at any interface with services that are designed to support them. The focus of any care must, first and foremost, be rooted in the embracing of these rights. Children have voice and children have choice, and that is not linked to their age.
Children and youth are the experts. They are the ones living the life. In some institutions that I have partnered with, consulted for or learned from, the child is shrouded in family-centred care. The Canadian Paediatric Society, for example, wants to move children more to the centre of family-centred care so that the adults around the children do not make the decisions for them.
We cannot talk about children's mental health without talking about sexual abuse. We know the statistics. My schooling did not prepare me for what I concluded as a public health nurse. I spent most of my time with a dustpan cleaning up after sexually abused kids. Not a month went by that I was not disclosed to. Any of us will be trusted when we are in a partnership model with kids. We cannot talk about children's mental health without addressing how children are sexualized.
Although this is controversial, the pharmaceutical industry's mentality of "a pill for every ill" is a problem. Parents are often so stretched that they want the quick fix and pressure family doctors into that. Nurses are often the ones who distribute the meds and, as a nurse, I refuse to be complicit in that mentality.
We cannot talk about children's mental health without talking about poverty, racism, homophobia, able-ism, size-ism, particularly marginalized children, and also the effects of environmental toxins on children's health. Why is there so much autism and so much ADHD? What are we putting in food?
As a children's mental health nurse and now a so-called special advisor, I am more of a sponge on the Coalition for the Rights of Children, but I am very concerned about the drugging of Canada's young people.
Senator Kirby, I probably lost about two years' worth of sleep of worry over that. In fact, that fuelled me into my Ph.D. You may remember the time of the huge measles outbreak in Ontario. All the public health nurses got pulled off our work with children and youth and new moms to do these measles inoculations. I decided to make it useful. I spoke to approximately 700 kids and added an additional question about medicines. The race and class was irrelevant, and about 80 per cent of the girls and young women I spoke with were either on an anti-depressant or had been offered it. The ones deemed troubled boys had almost all been medicated in some way. We know as practitioners you cannot bear witness on people's lives without them taking action on that.
Some of the recommendations I am suggesting might be controversial, considering I am sitting with some folks that may not ascribe to this.
When I spoke to the 25 adults that had interfaced with the system when they were children, they asked me to put forth a recommendation for policy that restraints not be used when children are institutionalized and that electric shock treatment should be unthinkable. They said to me that the last thing we should do is institutionalize children, that we should be working in the communities. They said that compulsory medicating or meds as the default should be questioned or have parentheses and that strict public policy on meds should be put in place. There are so many drugs for children and youth that have never been tested properly, and we do not know the effect. Sometimes, they have been very helpful in pulling kids out of very deep slumps, but we have to question that. The adults I spoke to also said that isolation therapy — that is what it is called — is violent and that they felt they got worse in that. They felt that when they were the hardest to love was when they needed to be loved the most.
It was extremely passionate last Sunday. I was in tears with these people, thinking how I could possibly bring their voices to you today.
Upon interface with the system, if that ends up having to be the case, they ask for an automatic investigation that is child-friendly and non-confrontational for sexual abuse. They felt that all their peers and all their work with other psychiatric consumers, that one of the poor connectors was they had experienced some form of sexual abuse.
We need more children's advocates embedded in the CCRC, the Convention on the Rights of the Child, with a strong code of ethics. I am not talking about advocates like Judy's. I am talking about ones in institutions, and that they are able and not constrained by the institution through which they are coming to visit kids, so that they are more constrained perhaps by their own code of ethics.
When a mental health program is mandated here in Canada, there must be a rights-based framework. We have said that. I think all practitioners who are going to work with children and youth must be trained in child rights. There are very few nursing programs where child health is a core course. Mine is a fringe course, and it is even more fringe because it is child-rights based and looks at issues of social hierarchy.
The next thing I wish to mention respects a broad social marketing campaign about children's rights. I think about the Netherlands, being a Dutch woman and just having returned from meeting with them, that the people involved in children's rights there said that every child born in Holland knew that they had rights and that their rights did not infringe on someone else's rights. It is a right of being, and they understand that in Holland.
In terms of schools, when we are going to put people around schools, it is middle schools. If we have to choose, it is middle school time where the pressure to fit in to an impossible mode erodes children's mental health. We must ensure that violent exclusion done by children to other children is being addressed well by empathy and bullying programs. They are just so vulnerable and have so much capacity at that age.
I was trained in a medical model in nursing and emerged into a more body-mind-spirit model. So many of us spend so much time at the end of a fast-flowing stream where there is a ton of people drowning at the bottom. We spend time trying to pull them out and figuring out how to keep them from drowning as opposed to moving upstream to figure out what is pushing them in to start with.
Mental health is about social inclusion. The degree that inclusion is afforded must never be rooted in age.
The Chairman: Thank you for going through the trouble of talking to 25 people. Dr. Van Daalen raised an issue that we have heard other witnesses over the last years comment on. The anecdotal evidence is overwhelming on the overmedication of children, particularly children that are disruptive. We have had teachers come before us with the following observation: "If I have a class of 35 and one child is reasonably disruptive, in order to be able to deal with the other 34, I have to get that child on some form of medication." It does not solve the child's problem. It solves the teacher's problem.
Is there any research on this? Is there any statistical evidence on this? We will use the anecdotal evidence, if that is all we have, but I would love to know if there is more than that.
Dr. Goldbloom: We can probably get some statistical evidence right here. Would it be fair to ask for a show of hands as to how many people in this room are taking a medication of any kind? It is the overwhelming majority. I have tried that in various audiences.
I agree on the basis of impressionism that probably too many people, including young people, are getting medication. On the other hand, I also have to remind myself that a British physician once said that a normal person is an individual who has not been adequately investigated. There is a lot of truth in that. The statement was originally made facetiously, but it turns out to be biologically correct because each one of us sitting in this room has approximately eight genetic abnormalities, some of which are quite deleterious. They may cause us to die young or develop diabetes, or anything you care to name.
We are very selective about where we accept medication. A diabetic needs insulin; that is fine. Nobody will argue that. It is not a sign of weakness or of society going to rot or anything of that sort. There is a lot of talk about children with ADHD being overmedicated. People who feel there is too much really need to document that. There are a lot of children being medicated, but you cannot bring back the past.
When I went to school, to a very British-type school, I had the bejesus beaten out of me if I stepped that much out of line. I was caned repeatedly. I have to tell you I was caned very often, and I had black and blue marks to show it. That does not exist anymore. We also had 10 or 12 kids in the class; now there are 30. The circumstances have changed.
If you take a child who is unable to succeed educationally or socially and you can turn him around 180 degrees, you will not be able to stop the parents from insisting on having that child medicated. I feel guilty every time I prescribe Ritalin for a child. On the other hand, I have seen the literal miracles it can do for some children. It is important, before we push the panic button, that we really document how many children are being, in fact, excessively medicated.
I tell every parent I see that a child will learn nothing from a pill. However, on the other hand, the education system is just factually not set up in a way to deal with these children behaviourally as some of them probably could be dealt with — a proportion, not all by any means. Some of them would certainly just be out of school if it were not for their medication. We need evidence and we do not have the evidence.
Dr. Lipman: I do not know of any evidence, either. I do not think the question is whether medication is bad or good. The question really is medication where you have done a thorough assessment of whether a child can do what you expect them to do at their age and stage of development in school with friends and the family, understood in the context in which they live, their family, their community. If you have done that properly and it looks like medication makes sense, then it should be monitored carefully and started slowly. Inappropriate medication versus appropriate medication is really the question.
Senator Cook: When you visit my province, you will find some statistics on OxyContin and Ritalin. There are a couple of studies being done. This issue has been in the news a lot lately.
The Chairman: Yes, it has, and there has been a CBC program on that issue.
Dr. Davidson: I endorse what Dr. Lipman was saying. That was the same comment I wanted to make. We have to ask the right question.
One of the things that is absolutely fundamental to me is that medication when used is always adjunctive to other interventions. It is not the sole treatment.
Senator Trenholme Counsell: I just want to say that I would hope that in nearly all cases, after reasonable study and counselling and looking into the whole situation of the child, it is a trial of medication, whether it is one month or three months or six months. That is very valuable in certain cases. Most medications have great benefits for certain people in the population. They would not be out there if they did not. These medications do, too. It is not always possible to change the home environment, and it is not possible to change the genetics or what food is being eaten necessarily, but a trial of medication may be valid.
Dr. Israël: A recent study in Quebec looked at group homes. I could probably get the data. I believe 99 percent of the kids were on medications, and more than one. Perhaps I can forward that to you.
We opened an ADHD clinic recently, which is there for quick evaluation. Sometimes the GPs just do not know and will medicate before even making an appropriate diagnosis. It is a research-based clinic. In one strategy, the parents agree to a placebo trial. It is randomized. For the first two weeks, a child can be on a placebo and the next two weeks on Ritalin. The parents can decide — if there is no change, it is a way of testing whether it is subjective or there is really something happening. We are combining that with some research on pharmacogenomics, which means looking at the genes, because the dopamine receptor is implicated and that is where Ritalin works. Are there people with certain forms of the gene that respond to the hyperactivity or the inattention? Eventually, this research could help us identify children who could benefit from Ritalin.
I am not making a pitch for my clinic; I am trying to give an idea of how research can benefit and how you can use strategy.
Dr. Roberts: Having heard all of you, most of what I was going to say has been said. I am a clinician primarily, but I also do research and work at the university. However, I am primarily a clinician. I look after an in-patient unit for adolescents, 13 to 18. I have done that in Ottawa, in Toronto and now in Kingston.
The in-patient units are much maligned. I, in 25 years of child and adolescent psychiatry, have never given ECT to anyone or heard of it being given to anyone. I needed to make that point — it is very important. As well, I think restraints went out a long time ago. People are not physically restrained. You are not allowed to tie people down.
There is a lot of research. Ritalin has got to be the most maligned medication. If you search the Internet for "Ritalin," you will find web pages that have been set up by parents, users, abusers, grandparents et cetera.
I am going to tell you the story of Doug. Doug is 14 year old boy who was brought in by the police because he had stolen a paddle boat on a lake because he had a first girlfriend and wanted to show off. He took the paddle boat and they drove around. He had a record, however, so he was hauled in by the police, taken to 30-day detention for having stolen and having had a record. He was then mandated to go the in-patient unit for a full assessment. When you ask for a full psychiatric assessment, the community cannot do it. Therefore, the only place where all the required professionals are present is in the hospital, on the in-patient unit, where you have a psychologist, an occupational therapist, a recreational therapist, et cetera. It costs $3,000 a night.
Doug came in. We assessed him within the first week, and it was quite apparent even from clinical assessment and from the history provided by his mother that he had a fairly severe attention deficit disorder. As well, most of these kids also have learning disabilities, which makes school an all-round negative experience from the day they enter to the day they drop out.
He and I had a chat. I told him that he did not have any attention, that he needed attention to learn social skills, that to manipulate words he needed social skills. To learn those social skills, he needed to be paying attention. He needed to be watching, he needed to be listening, and he needed to be able to remember what he learned. I told him that he could do the following: Have a trial of one week on, one week off Ritalin, and then he could tell me if it worked for him.
Of course, he said it worked for him at the end of three weeks and that he was not going to come off of it and that was not doing drugs at the time. That boy is back in school. His reading abilities and all that is being looked after. It is a very convenient and easy treatment, but it also has to be done judiciously. That is in defence of attention deficit disorder.
I also want to point out that externalizing disorders, which is attention deficit disorder and conduct disorder, constitute the bulk of mental health problems that go on to develop into anti-social personality and inhuman burden of suffering. In the cost to the state, it is the singularly most important group of disorders that need to be picked up fairly early and treated.
The school has a zero tolerance policy. Who do you think comes under that zero tolerance policy? It is these kids that we look after in mental health. The conduct-disordered ADHD kids are frequently on suspension or expelled until they have seen a psychiatrist or other health care professional. They do not have a parent at home. If you throw my kid out of school, I will come running down there, pick up my kid, take him home and he is going to get it. There are not parents available to do that for the conduct-disordered ADHD kid. Therefore, not only is the kid in a class of 32 to 35 kids, he or she is also suspended. What does a kid do when he is suspended? He gets into more trouble outside, because there is no one to look after the kid when he or she comes home. There is no one to give the kid a detention in-house or out. It is a very important issue to consider.
In some ways, I believe zero tolerance is understandable. I am going through with what Dr. Goldbloom had to say. Zero tolerance is fine and dandy; however, it is not developmentally appropriate. Children fight. There is a difference between fighting and beating somebody to a pulp. It is important to maintain those differences in our heads because we cannot throw out the baby with the bathwater. That is my political speech.
The rest of my list includes early diagnosis and intervention. It is very important if we take a public health and public policy perspective, and it has to do with educating — not educating just the health care workers, just the teachers and educators, but the educating of our country.
Stigma comes from lack of knowledge. Lack of knowledge translates into an inability to pick up when things are going wrong for your children. Children are our future. They are the only future we have. We may not be able to prevent everything because these are disorders that are based in genetics, but we can ameliorate the effects of our genetics by providing for these kids at a very early age.
Attention deficit disordered boys and girls growing up in privileged homes have a totally different trajectory to their lives compared to attention deficit disordered children growing up in low-rental housing. The late Dan Offord, who was a champion for the cause of these kids and did one of the most phenomenal epidemiological studies in Canada, talked about these social ails that lead to and actually make worse the mental health problems that our children have. It is important that they are addressed. We need to provide something that is universal, and that has to be universal education.
You raised the issue of Holland. The Dutch take a very socialist perspective on child rearing, as do the Scandinavians. Everybody knows their rights.
This was my fantasy for a solution. In my fantasy solution, I was writing of the ability to target high-risk families and their progeny before the birth to be able to provide appropriate respite for the parent and appropriate care for the child from childhood on.
These countries tag these children. If Canada mandated that, there would be the most outrageous hue and cry about it. There would be a lot of parents who will say do not put my child's name in a database because that becomes public domain and can be used for other reasons. That is something that is important to consider. A lot of the other countries, like Scandinavia especially, have a public database from where all our nominal psychiatric research has come, because they had data that they had accumulated over years and years.
It is very important that we look at how and when, what is to be provided universally, what is to be provided that is good parenting. We just have nuclear families now — not even nuclear families, we have all forms of blended families. It is important to provide for that. Knowing what we know from all the research we have done, we need to implement what our research has told us. We do the research and produce the results, but I do not know where it goes. The implementation falls down because it takes money; it is a fiscal issue.
As an adolescent psychiatrist, I think it is very important that we do not lose children to death that is self-inflicted. What I have done for the bulk of my career is look after kids in emergencies and crises. I would like them not to come as an emergency or crisis. To that end, we have done a particular kind of intervention in school, which is to screen all kids in high school. That is an imperative time, which is the point of most crises coming to a head. That is also a time of the beginning of a number of major psychiatric disorders. They become apparent, more so because of the added burden of adolescence.
Providing very quick care, providing an urgent consult service, is important. I have just done a waiting list from across the country for all the 16 medical schools. The waiting list for triage is two weeks to four weeks. The waiting list to see somebody varies between eight weeks to 18 months. There are less than 500 child and adolescent psychiatrists in the country. If you look at only 14 percent of the severely disordered kids in the general population, that translates to 800,000 kids across Canada. That is taking just the severe disorders; I am not including the 22 percent that I should be. Those are very important numbers.
You have got 3,500 kids in your 25,000 that need specialist attention. It needs to be accessible in a timely way. Having it available in six months may not be useful.
We need to redeploy our resources in a way that makes sense. I am a very pragmatic third-world woman, so I do not expect finances to get better with any passing year. Within that, given what we have, I think there are some things we can do that work, and I know from my clinical and research experience that they work.
One of the most useful things I have done with my 57 years of life is provide urgent service, where you can call me and tell me that you have a kid in your school who is suicidal and ask me what you should do. I may send you to the emergency room; I may not. I may say that the individual can come to my clinic within the next so many hours or days if he has a parent to look after him. This is something we provide, and it would be useful to provide that. You would also have to train the people in school to use those services judiciously. You ask the school kids to write an essay on something personal to them, and then you take that essay and call me and say he is suicidal. It does not work. I know you are mandated to cover yourself if someone has said something, but sublimation is a very good way of looking after one's head. Writing or making a story is good. That has to do with what I would like to have provided.
Improving access: Dr. Goldbloom talked about waiting lists. They are going to be there. How do we look after the ones on our waiting lists; how are we going to prioritize them is what is important. All the health caregivers, including the family doctors, the schools, need to be able to prioritize, which comes back to education.
Having done ongoing educational workshops with schools, with public health, with whomever the community agency is and CAS on an ongoing basis means that we can share, that we know from each other what our limits and our resources are. Also, it allows us to say, this is a psychiatric emergency or this is a psychosocial crisis or this is a parent-child conflict.
People come to the hospital because their child is having a paddy because they are grounded. That is not acceptable. There is something wrong when we are not able to look after in-home quarrels about grounding and it deteriorates into turning up in the emergency room. It is very expensive as well. The waiting lists are constituted because we are busy looking after referrals. There will be 800 to 900 referrals, and Kingston is a small town. We have a very small population, and 800 new referrals to the hospital-based service clogs it. There will be a waiting list.
Teaching people and the whole community to triage better would be helpful, and that comes from education. I think it is very important that we pay attention to basic levels of education, an awareness in all of us to be able to recognize the signs and symptoms of major psychiatric disorders that are required to be addressed now as compared to psychosocial crises.
Senator Cook: You have spoken about stigma and we have heard a lot about it. In your discipline, at what age is the individual aware that there is a stigma attached to his or her being? When do they become aware of it? Is it something they become aware of, or is it something that is inflicted upon them from outside?
Dr. Roberts: I am not an expert in stigma. I do know that the stigma studies I have looked at show physicians in university hospitals and their stigmatization of psychiatry when they are teaching medical students. There is written evidence of that. There is written research on other people making negative comments such as, a bright guy like you, why would you want to do psychiatry? Stigma is something that exists across the board and it exists across societies and culture.
In Pakistan and India, people might have long family histories, but will you ever get them? No. However, as people become more educated that this is not a weakness or a moral flaw but rather biochemical or genetic in nature, something that has to do with the brain, people are more willing to go and get help.
The Chairman: We have run into a number of doctors who do not think that psychiatrists are real doctors. If that sort of attitude is present in the profession, imagine what it is like in the public.
Dr. Goldbloom: Stigma, of course, has always been with us. We change what it is that we stigmatize as time goes by. I remember having uncles and aunts who died of cancer. They never knew what they had, and nobody in the family was allowed to use the "C" word. That has been more or less destigmatized. Teen pregnancy has been relatively destigmatized. We do not put the girl on the next train out of town to go and stay with her aunt in Vancouver anymore. Alcoholism and homosexuality are becoming less stigmatized.
There is no question that mental health and its problems are being progressively destigmatized. One of the best measures of that is the dollars that people are contributing to mental health. We have an annual event in Halifax that has grown to such proportions that there is no place to accommodate them anymore, and they raise hundreds of thousands of dollars.
I had a lady in my office whose son was somewhat depressed. She was from Cape Breton. I asked her, "Has anyone else in the family ever had serious depression?" "Well," she said, "I have a cousin who has committed suicide several times."
Dr. Davidson: Earlier this year, in the Children's Hospital of Eastern Ontario, there was a code blue, which means a respiratory or cardiac arrest. The code was on the in-patient psychiatry unit. In the elevator, there was a nurse. I do not know if she was going to the code or not, but she said, "What is going on in the in-patient psychiatry unit? Is there a kid holding her breath?" That is a good example of stigma within the profession.
YouthNet project is a population mental health program by youth, for youth, supported by clinicians. During the course of this project, we have learned that it is relatively simple to destigmatize mental health with youth. I do not think the same is true of adults.
Ms. Van Daalen: Children that are disabled have told us that they knew that they were being seen as different from a very early age. They can feel that very early on. Some of you may know the Rainbow Health Coalition. It is a coalition of gay, lesbian, transgender, transsexual, bisexual individuals — the whole gamut. They have begun studies suggesting that people know when they are being stigmatized. Young children know when they are being seen as different and can articulate that in their own age-appropriate way.
Dr. Roberts: Because of the bureaucratic hassle of providing information, we are misusing some of our really expensive resources because we are not getting information from someone who has looked after the child before. The child comes in to do a psychology test, which costs about $1,500, and says at the end of the test, "I already did that last year." "Where did you do it?" "My mother took me and had it done."
The sharing of information is something that will have to be looked at in a meaningful way.
Dr. Davidson: I should like to challenge the system a little. The Social Affairs, Science and Technology Committee is embarking on a fundamental and extremely important endeavour. The problem is that probably every single one of the witnesses around this table has been around similar tables many times doing the same thing. Unfortunately, it is just an exercise in frustration management at the end of the day, because it is very difficult to make change.
My sincere hope is that this time it will be different. Wherever we talk about children, including a Canada fit for children, we need to be talking about children and youth. Youth do not appreciate being referred to as children, and we do not mean to offend them, but inadvertently we are offending them when we do not acknowledge them appropriately.
Politicians often talk about the fact that our children and youth are our future. This has become rhetoric and nothing more. If we mean it, we had better do something significant about it, like the many wonderful suggestions that we have heard around the table.
We all think we are pretty bright but, fundamentally, humans are stupid. Good evidence of that is — Ms. Forge's catchment area was able to get together and pool their resources together in an effective way. Why is it that we cannot do that without stress or fiscal pressure? Why can we not do it just because it is a smart thing to do?
We must be bold. We need a significant paradigm shift. We have heard much about the prevalence of psychiatric illness. I like the work of David Shaffer. He did not simply go out and find out how many children and youth in a community sample were suffering from at least one psychiatric disorder; he took it further on each end of that spectrum. When his study showed 19.2 per cent, he asked, "How many of the 19.2 per cent actually suffer from severe mental illness (SMI)?" They found that 5.4 per cent of the total population had SMI.
This is why, when we put a system in place, the system needs to be balanced. The more intensive, more expensive end of the spectrum has been talked about, but you cannot shift everything to the other end and give up on a generation of children and youth who have SMI either. We have to figure out, like smart human beings, how to do this.
I will remind you that, in order to make a diagnosis of psychiatric disorder, you must have the symptoms of whatever the disorder is and impairment of functioning. At the other end of the spectrum, Shaffer said, "If 19.2 per cent have a psychiatric disorder, how many just have symptoms?" They found that 50.6 per cent of a community sample had symptoms. How then do you set up a system that will address kids that are at risk, kids that have psychiatric disorders and kids that have SMI?
Based on the late Dan Offord's work, one out of six Ontario children and youth 4 to 16 years of age received some kind of service in the previous six months for their mental health problems.
Ten per cent of the whole population in their lifetime will suffer from osteoarthritis, which is the single biggest cause of hip and knee replacements. Tell me what you think would happen in this country if one out of six people who needed a hip or knee replacement actually got a hip or knee replacement? Romanow was correct when he said that mental health services are the orphan of health care services. I would say that since that is correct, child and youth mental health services are orphan of the orphan.
I will not talk about all of the details of a system, but one of the last things I want to say has to do with funding. The system is dramatically under-resourced, but we cannot pour more money into an already broken fragmentation of services that we cannot really call a system. We have to put a system together, but that new system, which will do things differently, needs additional funding in my view.
As has already been said, in this new system, or a community of practice, it needs to be flexible and to have innovation, and we need to have a facility for it to be different, community by community, but with fundamental similarities.
In terms of structure, we do have this provincial-national kind of dichotomy going. We have to somehow figure out how we can set up a system for child and youth mental health in this country that is protected, mandated and legislated and not encumbered by the politics of nationalism and provincialism.
Senator Cook: I should like to make a comment for Dr. Davidson. My philosophy is that it does not matter how many studies are done or how often we fall down. What is important that we get up. I believe, and I am challenged by this committee and its mandate, that we have to get up.
Something else is happening across this country, however, and that is that members of the public are becoming engaged in what we are doing. If the public becomes engaged, the politicians will, of course, need to become engaged, and then we will find a way.
Dr. Davidson: That is excellent. I am reminded of about 12 years ago in Sweden when there was a motion on the floor in their government that suggested that there should be a change in how people vote. That change was this: If in your family, there are four people, two of whom are under 18, you should get four votes, and if in my family there are two people, both over 18, we should have two votes. That is what I am thinking when I am talking about meaning or rhetoric that our children and youth are our future.
Dr. Lipman: I agree with all the things Dr. Davidson has said. We can have more funding and a better system, but if we do not know that what we are doing works, it is money poorly spent.
Dr. Davidson: I totally agree, and that is part of that whole big system, namely, what does the system look like and what are the components in it.
The Chairman: Let me be clear. Unlike a lot of public debate, our committee has always taken the position that money is the means to an end. The reason money always appears in our last chapter is that we first decide what the end is, and then we figure out how much money is required, as opposed to the typical health care debate, which is to just throw money at the problem.
Senator Keon: I wanted to mention a word of optimism. In our 2002 report, virtually every recommendation is in the process of being implemented. People are starting to listen. It is important for you people, who have had a terrible time, really, much worse than anybody else in the health system, not to get discouraged now. People are beginning to listen.
I want to comment on the situation of one sixth of the hips being replaced. There would be a lot of people on the limp.
Ms. Forge: I should like to talk about the stigma piece — and we have talked about it a lot. Something that comes from all of the discussion today, and in thinking about this, is that it is not really about removing the stigma; it is about creating the societal responsibility. That speaks to what you were saying earlier, Senator Cook.
We have to help people understand that we all have a responsibility for our children and especially for our children and their mental health as it relates to what we have been talking about today. We all talk about our responsibility for children and their education. We do not talk about something even more fundamental in terms of their rights as children, and that is their mental health. We need to have that conversation at that level, creating the responsibility rather than removing the stigma.
The Chairman: What I would like to do in the next hour is to put some issues on the table and move to questions.
To the people who have been kind enough to give us a day of their time, there are three things that I do not want to discuss today but that I would like to have your reaction to. What are the highest priority areas for research? We all agree that if we are going to run an evidence-based program, it needs to be evidence-based. If you do not have evidence, you cannot go out and do research in the entire field. The question would become one of what are the priority items.
Related to that, we are hoping to begin to develop through CIHI a mental health information base that will go along with an information base being developed for other parts of the health care system. It would be helpful to get a sense from you as to what are the handful of things that need to be measured. It is an interesting observation that the health care system has all kinds of measures but that not a lot of thought is being put into — for example, Statistics Canada was going to do another Canada health survey like it did two years ago. What are the things that it ought to be measuring with respect to mental health? If you can think about that, that would be helpful.
I will give you the topics that are of interest to me. I agree on the need to reduce waiting times. That has been a focus of this committee. What are the concrete things that need to be done to do it? Related to that question, because you cannot do one without the other, is how do you get the kind of inter-agency cooperation that Ms. Forge talked about? We all agree that this is a very silo-driven system. What are the incentives that will get people to cooperate? Is the cooperation achieved because you have a particularly strong leader? Do you have to clone Ms. Forge in order to get it done everywhere, or is there some other incentive system that would work?
Two issues that a number of you have raised I find intriguing. You have all talked about the issue of rights, the issue of legislation vis-à-vis children and youth mental health. Is that what is needed? If so, do you have any thoughts on what the essence of such a bill would be?
The second thing is that I want to make sure I understand the point some of you raised. At our hearings in Toronto a while ago, we heard that under the age of 16 children are regarded as children and that 19 and over they are regarded as adults. We had someone point out to us that, in fact, individuals between 16 and 19 are not eligible for a lot of the programs they would be eligible for if they were a child or an adult. That struck me as so absurd that I did not believe it. However, a number of you have repeated it. It is so stupid that I cannot get my mind around how one could design that system. The question then becomes: If you close the gap, which way do you close the gap? Step one is to eliminate the gap. Do you raise the children and youth age to 19, or do you lower the adult age? Some of you may have comments on that.
I have one comment on anti-stigma. Two different concepts have been put forward to us. One is that it would be better to run a national anti-stigma campaign across the board on mental health issues. The second is that it would be better to focus your communication resources on a couple of things, such as depression or suicide. The real question becomes: Do you run a targeted campaign on a limited number of mental health issues, or do you run a more generic campaign, which, by its very nature, would be less specific on broader mental health questions?
If anybody wishes to pick up on those points as we go around, that is fine.
Senator Cook: I just want to thank you all again for being here today to contribute to what I consider to be one of the greater challenges since I came to this place. I applaud the wisdom of the table. I will challenge you now with my simplicity.
We are here talking about children. Really, what we are talking about is change and how do we manage it. How do we manage it in the lives of our children in this more and more complex society that we are living in — which begs me to say that I am glad I grew up when I did.
I need you to help me on the definition of today's family. I grew up in a family with a brother and a mother and a father and a granny. I did not appreciate the granny until I became one myself. In order to look at the total picture — because all the things that are relevant around this table today result from the evolution of where we are as a people. It has changed. How do we manage it?
Going back to the family, one of my first committee challenges was to sit on the Senate Special Joint Committee on Child Custody and Access with Senator Pearson. Everyone should read the report from that committee because where we saw children in that picture gave us more than food for thought.
I should like someone to address the issue of security, where professionals such as yourselves cannot share information across jurisdictional lines. The school nurse cannot talk to the teacher, and vice versa. There are some areas around privacy that need to be addressed in our report.
More and more, I see us drifting away from being a family — some would say that it is not a family, that it is a committee. Canada has a need, because of this complexity, to take responsibility for the well being of us someday.
You talk about all the structures and resources that you have. I come from Newfoundland, where there is no resident child psychiatrist, although one visits once per month from a neighbouring province. In order to put together a seamless delivery of services, we will have to look at alternatives.
A couple of weeks ago, I was asked to speak to the national Girl Guide movement. The challenge for me was to speak to the impact of my Guiding years on my life as a senator. It forced me to reflect on the Guiding program that I know and that led me to realize that there are numerous programs by NGOs that contribute to the mental health and wellness of children. What affect are those programs having? Looking back, I recall that simpler time of outdoor activities. It was wonderful. Today, to be a leader a Guide leader, one has to undergo a rigorous security check, which was unheard of in my day. Society is becoming ever more complex.
What preoccupies me is the child under three years of age. I am watching to see what the national child care program will provide for children. Children are born into a family where parents have to work. Sometimes, there might be only one parent and sometimes no parent. Often, at the age of six months, children are bundled up and taken to another place to be cared for. That is today's reality for some children. My three year old grandchild is going off to daycare in September, and he will spend the greater part of his waking hours there. What are the building blocks for daycare? What are the principles? What is there for that child? Much can happen in the two years a child might spend at daycare. Often, when the primary caregivers come home, they are too tired to do anything except feed the children and put them to bed. The learning of skills and social development for many children takes place in the daycares. Have you looked at that part of the child?
Ms. Forge: The community I live in has a population of 4,000. We have two elementary schools and one secondary school, and both are experiencing declining enrolment and, therefore, all have extra space available. We have in place an Early Years Centre in the elementary school and a Parent Mutual Aid program in the secondary school. That allows us to work with our Early Years partners to focus on how to support all of the child's development, and not only in terms of the life from zero to two. We have three and a half year olds in our junior kindergartens. With those support systems built into the schools, we are trying to build a system of care from the beginning of a child's life through support for the parents and support for the daycare service.
The zero-to-six and the seven-to-eighteen thinking has been a problem for us. We have to stop thinking that way and think about a continuum. The school cannot be everything, but it can host those who can be everything to children.
Senator Cook: The daycares are licensed by the provinces, but I am not aware of the standards, if any. If we are to look at a national strategy, we will have to look at that as well. I know daycares fall under provincial jurisdiction, but it is the place where children spend their early years, by and large, in this country.
The Chairman: Does anyone know whether there has been research on daycare in respect of these issues?
Dr. Lipman: I do not know about the daycare data.
Senator Pearson: Yes, there has been such research.
Dr. Lipman: This is about a different issue — it is about the effects of the Girl Guide Movement. Studies have been done by Dr. Dan Offord and others that have looked at risk and protective factors for kids. A couple of the protective factors are involvement with another adult who is not a family member, such as a teacher, a Guide leader or a sports coach.
I just came back from a meeting with Big Brothers Big Sisters of Canada and they are looking at putting out a national research agenda because they want to know what happens to kids who are part of their organization. There are many stories about how important a big brother or a big sister was in the life of a little brother. For any service-providing agency to have some data showing what happens is important. It is the whole idea of the cultural shift that we need to collect these numbers to survive.
There is substantial pull within their agency and others because that is not their primary mandate — they do not collect data; they provide a service. When you talk to children, you talk in different ways to a six year old than you might to a 12 year old and to a 15 year old. You might need to communicate the story to some people and the data to other people and both to a third group of people. In terms of survival of agencies, that is important. Something like Girl Guides can be extremely important in someone's life.
Senator Pearson: I will comment about the research on daycares. The Canadian Child Care Federation has put together large amounts of data from various studies. You could likely find what you need from their resources.
What we are trying to set out in the agreements with the provinces through the early childhood care and development is quality, in which is supposed to be incorporated the kinds of standards that will concern our grandchildren.
Much research is available, including pertaining to the engagement of children with special needs and children with disabilities. There is a very large body of research. Good things are being done, in many areas, for example, working with children diagnosed with fetal alcohol syndrome — the kind of work they have been doing in Manitoba and other places — as well as issues around autistic children.
The issue always emerges about education and more parents knowing about what is available and reaching out, and the places where you reach them are to some extent around the birth period, as someone has already mentioned, where somebody knows about a baby being born — a time that you can then begin to do some interventions and give information, a time when parents are prepared to receive it. There is then a kind of vacuum, for two or three years, where there is no natural place for them to get information, unless it is somehow a really attentive parent.
I spoke to a public health nurse the other day who had been working at CHEO. She had worked with babies who fail to thrive. One of the mothers had said to her, "I understood that you only fed a dog once a day, so I thought perhaps you only fed a baby once a day." What a missed opportunity, I thought. Somebody knows about dogs but does not know about babies.
Dr. Goldbloom: I thought Senator Cook hit on a topic of vital importance but one that could be an entire day's discussion — that is, what has happened to the family. The family of 2005 is very different even from the family of 1995.
One of the things that has happened is that families no longer take meals together. I ask families on a regular basis: "How many times a week do you sit down for a meal together?" Sometimes, it is once, sometimes it is not at all, because of television or different work schedules. Sometimes, contracting with a family to start having two or three meals together a week can be one of the most important remedial interventions.
If you look at the architecture of what has happened to the kitchen, it has shrunk progressively. You can now run an entire kitchen with one microwave. It used to be the biggest room in the house — certainly in Newfoundland — where all the kids gathered, did their homework, the meal took mother two or three hours to prepare and that was the conference centre of the family. That no longer exists. We must take this into account.
The other thing I often ask kids in my office is this: "Tell me what you do as a family for fun." I am staggered at how often the instant answer will be "nothing." This is from seven and eight year olds. This emphasizes how much the family is changing.
Finally, Newfoundland only has one child psychiatrist because it is the only province where everyone is normal.
The Chairman: Dr. Goldbloom, let me press you on that. Given what you have just said about the family, is that not completely inconsistent with your comment that you need people trained as family therapists, because in a sense there is not a family?
Dr. Goldbloom: I feel I am doing family therapy when I get them to eat together or get them to have recreational time together. This is family therapy. Unfortunately, we are sitting around here talking about national solutions. I am sure everyone here must know the starfish story. There was a man standing on a seashore that was littered with starfish. Most of the starfish were dead, but the man would pick up the occasional living one and put it back in the ocean. Somebody said to him: "What are you doing? That's crazy. There are millions of starfish. How will you help by putting a few back in the ocean?" As he put another one back, he said, "Well, I helped that one."
As individual physicians, we help one family at a time. Helping one family is something in which one can take a personal triumph. There are two different perspectives.
The Chairman: As they say, all politics is local, but so is all the real care. It must be community-based, as Senator Keon was talking about.
Senator Trenholme Counsell: First, I wish to praise what we have in New Brunswick and what I think what we have across the country — that is, Family Resource Programs that are reaching many of our most vulnerable families. This is a program that is funded by the federal government; it is a national program. All of the money that goes into the family resource centres is federal money. We have some opportunity to have influence there and certainly to support what they are doing. Their national conference will be held here in Ottawa in two weeks.
I have visited quite a few of these centres. They are really quite marvellous. They are for parents and pre-school children, and they offer many programs. One of the most remarkable things they offer is outreach programs. If you are in a big city, they go to the high-rise apartments, to the inner city housing developments. If you are in a rural area, they go along the rural roads and to the isolated homes. That is a growing organization and a growing system. It will continue to be valuable. They need information, support and guidance, and they are looking for that.
I am optimistic about our young people. Our young people are returning to some of these values that perhaps have been neglected. Young people want to have good families and good family life and to bring up children well. There is hope.
Dr. Israël: We are talking about values. Right now, we are talking now about protective factors, things that decrease the likelihood of developing mental health problems. I would say that these should be targets of public education as well as professional education. That is easy enough to do on a national scale without investing millions. If we realize that that is one of the causes of problems and for kids going the wrong way, then we can have a campaign about it. It does not necessarily deal with the stigma of mental illness, but it certainly reinforces the value that protects children.
Similarly, to reinforce how families are, right now the best evidence-based treatment for kids with eating disorders is family-based. It involves getting the families to feed the children.
I reinforce your idea that families are essential, but it must be integrated into our curricula when we teach mental health professionals and when we teach the public.
Senator Keon: Dr. Israël stole my thunder. In America, the private schools for kids with learning disabilities have educational programs where the child goes to school for half a day, but for at least a couple of hours a day the parents have to come in and be educated with the child. At the present time, this is reserved for the rich.
Since, we are talking about the family theme and about how important the education system is in the development of children, let me ask the question: Does anyone know where this exists either publicly or privately in Canada, and what is the potential for the introduction of something like that?
Mr. Mussell: In 1970, Indian Affairs began to provide some funds to First Nations to begin to hire their own persons to look after the administration in some programs. What has happened in the 35 years since then, in my experience, working as community development worker — I do various kinds of consulting and teaching and training — is that people in our communities do far less for one another than was the case in 1970.
What that reminds me of is John McKnight's book called The Careless Society: Community and Its Counterfeits. As I read that book, I thought he was describing life in our First Nations. His basic point is that the more systematic, organized and professional your programs and services become, because of the way in which they are delivered by paid people, the more it displaces what people naturally do with each other because they are family and they care about each other and love each other.
I see that as a reality in our communities because of the extensiveness of programs and services and how the education of those practitioners is being delivered. Too much of what is being delivered, as I see it, is practitioners telling us how to live our lives. They are doing our thinking for us; telling us what to do, when to go to treatment and so on. That does nothing to help people learn how to learn and to take charge of their own capacity building and their own self-determination. That really concerns me.
We need to look critically at how post-secondary education is done and what is being produced as a result of that process.
Ms. Hills: You asked about the most successful relationships and partnerships. Many years ago, before the legislation around tobacco, I worked as a volunteer with an agency that decided we needed to do something about smoking prevention. We pulled together a group of NGOs and worked on smoking prevention and cessation. We involved kids and schools. Many of us had been or were teachers. The coalition was successful because there was no money involved. A group came together that really wanted to make a difference. We put the issue in the middle of the table, and everyone brought their own expertise and resources to the table to make something happen. That may not be sustainable, especially today.
The coalition began to fall apart as soon as there was funding, because, as Dr. Manion mentioned earlier, the silos came up and everyone was worried about getting their share and so on. It came back together again when people started to trust each other again, but that took 15 years.
That also leads to the role of the NGO, which Senator Cook mentioned. NGOs and the various charities that are involved are an interesting lot. Rémi Quirion, at the Institute of Neurosciences, Mental Health and Addiction, brought together 400 NGOs that are involved in the mental health sector. I was astonished that there were 400 of us that are involved in the mental health sector. Some are much more visible than others, like the Alzheimer's Society, the Parkinsons Society and so on, but there are many very small ones working in the community.
There are a few things that they can do that government organizations and big systems cannot. One is bridging the divide between some of those things. NGOs are often made up of the consumers, people who want resources but do not know how to access them and so on. However, they are also made up of experts in the field. Most NGOs also have doctors, nurses and psychologists working with them. They have the expertise in the community to do things and to bring partners together. We might look at the roles of NGOs and charities in the community, because they can play a very key role. They can also bridge between health, education, social services and so on, and create partnerships that can make things happen locally.
Dr. Manion: I want to speak to the idea of community capacity building. So many natural resources exist in a community and, in the absence of a family — because a family is different than it was — those natural resources within a community become that much more important.
An amazing natural resource in a community is the individuals themselves. They are natural leaders. We keep hearing that one in five youths have mental health problems. That means that four out of five do not. They are on the front line; they are creative, energetic and wanting to engage. We know through the work of the Centre of Excellence for Youth Engagement and the research they have reviewed by many other researchers that engagement is a huge protective factor for physical health as well as mental health.
As we look into the communities again, we have to look at what the natural resources are, and they are not necessarily in our systems. Sometimes it is the coach; sometimes it is the church group; sometimes it is the informal youth group. We have to look at whether there are barriers to engagement that we have to eliminate.
Similarly, we have to look at opportunities for engagement in more formal systems by those who would not be the typical players. I am looking around the room. I do not see a lot of youth, and I know why. It is hard to find the right people at times. How do we look for creative opportunities to allow people to engage who would not otherwise engage? If they are not engaged, there is even more fragmentation. Even if you build a system, they will not engage in it.
Dr. Roberts: One thing that I hear very frequently from grandparents, when they are available, is that we have deskilled our populace. It is a very humbling experience to be told that what I do may in some ways have eroded the skills of the people I am trying to help — the parents. Mr. Mussell talks about resources within, and there is a general sense that the more we have thrown at things the less people have developed the skills to do things. The kids who do well are those who not catered to hand and foot. They do better because they acquire the skills they need to negotiate the curveballs.
Dr. Davidson: With regard to age groups, it creates siloism and competition between age groups when you divide them into groups of zero to six, 7 to 12, and 13 to 18.
I worry that if we were to ask 20 people on the street what they think prevention means, they would say that it means doing something with people who are about zero to three years old, when in fact prevention can happen right across the lifespan. We need to get that point through.
Senator Cochrane: I want to ask you about the rights of the child. Recently, in my home community, a child accused a teacher of pinning him up against a wall. When the child told his father, the father went right to the RCMP. This teacher was dismissed from her position for six months. The matter went to court, although it was thrown out.
How do we deal with this? The child has rights, but professionals have rights as well. It is difficult to draw a line. In some ways, rights of the child has gone a little too far. The child believes that the parent will take their side and go to the police. When I was a child, if I told my parents about a concern at school, my parents would be down my back and take the side of the school system.
Senator Pearson: Long before children's rights were recognized, I had to deal with parents complaining in the school. Rather than having to do with rights, I think it has more to do with the dynamics and the systems we set up to deal with an issue. In the case you cited, there presumably was an inadequate system for screening the complaint. A lot of children have felt entitled forever.
Senator Cochrane: There are situations with social services people, who are not always conducive to ironing out a problem. They take the side of the child. I have seen that happen, and just recently. I realize that in some parts of Europe the child has rights from the time they are born and know what their rights are. I should like to do some research on that, to find out whether the European children have had problems of this sort in their whole lifestyle.
It would have been nice to have had a dietician here today. Many parents do not know the right foods. Often, children will not need medication if they are served the right foods. For instance, often children cannot sleep if they are served chocolate at night. There are parents who do not care about that. How can children think in school during the day if they cannot sleep at night?
I know we have the Canada's Food Guide. We have had that for years in our health system. Canada's Food Guide has gone by the wayside. The food guide was prominent in years past. The teachers were teaching us first class, but lately — over the last five years — it is something that is not prominent any longer.
I know curriculum is a provincial jurisdiction. We have to change curriculum. We can change our biology and health classes to include mental health in many ways. It has come to the point now where we have to look at the curriculum. Even though it is a provincial jurisdiction, perhaps all of us can do something here in regards to the curriculum.
Has anybody heard of the program in Toronto called Roots of Empathy? Is it in New Brunswick as well? I want to get some idea as to your assessment of it.
Ms. Whitenect: Yes. When I gave some points, Roots of Empathy was one of my examples, but I did not elaborate on it. We do have programs like that going into schools, but often they are an add-on and need to be advocated. Yes, there will be superintendents and districts and principals that will welcome the program into the school. In New Brunswick, we have the program in region 2, which happens to be open to that; we have tried in other regions, but with no success. It is about people understanding the importance of that. Everyone has talked about the importance of mental health being everyone's concern, and not just the mental health clinic or health department's concern. Everybody has a role to play.
We talk about self-esteem. I do not know if anyone wants more information, but Roots of Empathy is a program where they bring young children into grade 2 classes and the children see the mother and/or father, often it is mother, and child interact. The students are exposed to the baby being very vulnerable and how you have to pay attention to that child. Young children get to have a different understanding of that kind of attachment and connection. Much of the early childhood stuff is looking at attachment. We have to caution again to make this a continuum, so it does not happen at a certain phase and period, so we are able to keep recognizing those things. Again, across the board, it cannot just become those that are willing to engage in this process. Somehow we say we have to engage because of the relevance.
The Chairman: In Halifax, we will here from Roots of Empathy.
Mr. Mitchell: Mary Gordon will be in the Niagara Falls region next Saturday at a parenting conference being hosted by Brock University talking about Roots of Empathy connecting parenting and the school and kids in an empathic way. Part of what she is up to has a rights component in it. I have talked to her about this and looked at that piece of it. She does not find it incongruent with working with kids in the context of the school.
I do want to come back to the point you made earlier about the sense that professionals working with kids feel threatened by kids knowing about rights. I liked Dr. Van Daalen's point from Holland that when kids are educated about rights they see that everyone has rights and it is not excluding anyone. That is important for professionals working with kids. Adults know about rights and we know about the law, but I have found that kids do not know they have rights and the adults working with kids do not know what those rights really mean or what they indicate. Certainly, grabbing a kid and putting them against the wall, that is a fundamental violation of rights and it is illegal. If indeed those allegations had substance, then it deserved to be in front of the Mounties.
Senator Cochrane: It did not happen.
Mr. Mitchell: That would be something that would be sorted out in a legal way, I would argue, and could be mediated by an understanding of rights and how they work.
I want to bring forward a young man that was in some research I did in Victoria using the convention and a public awareness campaign. This young man was in my home as a foster son for a couple of years and then became a co-participant in my research program and is now in his mid-twenties. He is my friend. We have passed through the stages of being a service provider and power relationship into this collegial place. Bo was part of a symposium we had on children's rights out there. As all foster kids that came to my home, I gave them a little blue book. In the first two weeks, Bo peeled through this thing and learned every aspect of it. He went into the school and said that article 15 says that I have the right to privacy. I do not want you to ever tell my foster parent whether I have been to school or not.
The principal phoned me up and said that according to the rights of the child he could not tell me whether Bo has been to school or not. I learned something about how rights work in your own home. I felt like a little knowledge would have gone a long way because there are a lot of other rights in there than the right to privacy.
I will close this with a statement that Bo made years later. He was 15 when that event occurred, and when he did the research with me he was 19. He said: "When Richard talked to me about the Convention on the Rights of the Child, I understood it as a weapon and I used it as a weapon, but now I understand it is a tool." That is one of the most profound things I have heard anyone say about this document.
Dr. Israël: I wanted to speak to the nutrition issue. The Public Health Department in Montreal put out their 2004-05 report on the health, including mental health, of children in Montreal, including their habits and perception of their life. Because I specialize in eating disorders, I went right to the sections on eating, activity and body dissatisfaction, and I learned that only 30 per cent of adolescents in Montreal eat fruits and vegetables at least once a day, that four out of 10 have at least one soft drink and three quarters of kids go out for fast food at least once a week. Again, four out of 10 have chips every day.
In terms of body dissatisfaction, I learned that by fourth grade 43 per cent are dissatisfied. By secondary five, 60 per cent are dissatisfied, and 40 per cent of those are on diets or trying to do something about it.
What I know about eating is that the media is much more powerful than parents or teachers in telling kids what to eat and addicting them to substances like soft drinks and chips and foods with high sugar content like Cocoa Puffs and things like that. What Canada's Food Guide tells you is not very exciting compared to all those palatable, easy to eat, easy to access foods. We need to control access to that or the power these companies have to reach our children when they are only two years old sitting in front of their TVs watching Sesame Street. If we want to change the eating habits of Canadians, we will have to get involved to fight organizations that have a lot more money than parents.
Senator Cochrane: Those companies.
Dr. Israël: Yes.
We also have to be concerned about where money goes. The talk I heard last week was that farmers who farm corn are getting more funds and the corn is being turned into corn syrup, which goes into most soft drinks and fast foods.
The other point is that we saw that body image dissatisfaction doubled between fourth grade and secondary five, which means there is a chance to intervene in between. These are very vulnerable years. As kids get older, they are vulnerable to different things; therefore, we must keep intervening right up to the granny years.
Dr. Van Daalen: I will go back to the children's mental health question about zero to three. If we are talking about infant mental health, or children that are zero to three, we are really talking about women's mental health and women's health, and hopefully men as well. Hopefully, they are involved and that we can create a society that embraces that more.
We need to name that, because the other practice that has gone unnamed today is the pervasive practice of mother blaming in children's mental health. What is wrong with mother? How is mother contributing to this? What is missing? Sometimes, it invites dialogue with the father or the partner, or it does not.
We need to remember the story about the dumpster babies in the U.S. and the states that enacted policy that made it safe for women or men to bring their babies to a hospital and drop them off as opposed to in a dumpster. I realize this is quite a violent example. However, they had from 200 or 300 down to almost zero babies dead or babies left in dumpsters. We need to make it safe for mothers or fathers to come forward when they are struggling and be able to say that they are struggling, that they cannot do this, that they are depressed or addicted, that there is violence in the home. There needs to be a non-punitive way for them to come forward and ask for help. We cannot talk about zero to three without talking about what happens when men and women come forward.
Senator Cook: The complexity of change is going to be forever thrust upon us and we have to manage it. If you put that aside, my question is this: For this particular continuum of care, be it education, management of mental health or wellness, do you think that one of the ways is through a community health service, with a staff of whoever needs to be there, be it a nurse practitioner, a visiting psychiatrist, a psychologist or a nutritionist? For me, where I live, which I consider to be a rural part of Canada, we have to be realistic with the level of professionals that are available; we have to use whatever services we have available, such as the local Girl Guide leader who takes someone out for a walk.
I will close on this: When we decided that mental health institutions no longer needed to keep people, that they should be part of the community, we put them out without adequate supports. I became part of a group — we are 25 years old this year — who said we cannot stand to see those people on the street with no supports. They have a bed in a boarding house and life is pretty dim. We have been underfunded. Through that process, we now have a program that invites nursing students, social workers, and parks and recreation people — whoever we can find. Born out of necessity has come a need. There are even kids who come in. It is consumer-driven. We have about 95 or 100 a day. I live in a small city compared to Toronto, and it works. The answer in most cases is going to be within ourselves, notwithstanding the critical concerns of mental illness.
I know that first-hand. I have a daughter who suffered anorexia for three and a half years after the death of her father. She cured herself with the aid of a dietician and a psychologist, and with her mother keeping her mouth shut, if you can believe it, Mr. Chairman. That is a success story. She is the mother of two today and thank God for her.
I knew that I could only contribute by being still. I did not have the skills. Your professions did it for her. We have to know where our strengths are. I am still convinced that, at least in my corner of the world, the community health center will be the conduit where we can help the most.
Senator Keon: Dr. Van Daalen, I want to explore with you the concept of parenting. Since Senator Cook is able to talk about her kids, I think I should be able to talk about mine. I have one daughter. Her career is just as taxing as mine was at her age, and she is in the same profession. The only difference is that my three children were looked after by my wife. My daughter has had three children, and it has interfered somewhat with her career, but she has done a pretty good job. Her husband is very understanding and is in the same profession.
When I talk to her about this, she tells me that my thoughts are archaic on this. The important thing is parenting. Motherhood is long gone. The important thing is parenting. Whether our grandchildren get that from her or her husband, or whether they get it from granny and grandpa, she says it does not matter at all. A whole generation in England has grown up in this way, she says, and she is not the least bit concerned about this.
How do you handle that?
Dr. Van Daalen: Well, she has not called me yet.
We are talking about what a traditional family is and who is working and who is not. My point was that we need to make it safe for families — however they are constructed — to be able to come to forward and say that they are overextended, or that their default is to hit, or that they find themselves putting them down the way they were put down. What parents are telling me is that when they do come forward it is actually the exception, that they are looked at for their strengths, that they are affirmed, that they are treated with dignity, and that shrouding forces people back into silence and secrecy.
I know I am not addressing your issue about who should be at home and who is working and all those struggles that today's modern women face. I think that has an impact on women's mental health by the way — all the expectations that are wrapped around doing it all and being it all. However, my point is that we need to create more spaces like those that you provide here, where people can come forward in a shame-free zone.
Senator Keon: You are avoiding my question, and the next time I have an argument with her I want to win.
What about the concept of parenting as opposed to the concept of motherhood that we grew up with?
Dr. Manion: You do not have to be a parent to parent. In talking about community development and that it takes a community or village to raise a child we need to have a common view of what appropriate child-rearing means. There is a collective in that. If you are looking at mothers versus fathers, there is data now that suggests that the impact of fathers is tremendous, particularly during the adolescent years.
To put all the parenting responsibility on one individual is inappropriate. Maybe we are more progressive now. That means that there are different targets for our parenting efforts in terms of teaching parenting. You do not just teach parenting to mothers; you need to teach parenting to fathers and to entire communities, and to teachers and to nursery school providers.
If you have children that have mental health concerns, very often you are dealing with parents who have mental health concerns. The parenting advice or the recommendations, in that sense, also have to be delivered or supported in a different way, and that leads us to understand a more holistic view of what parenting means.
Parenting is also affected by culture. If you have a way of teaching parenting, you better understand the cultural values in a given community or you might actually turn people off from wanting to receive the advice that could make their situation better.
Ms. Whitenect: I just want to expand on that point. When you said families ask for help, sharing the concept of parenting is key. It is not just about the parents, it is about other community partners.
The other piece is that, when we talk about children, it goes hand in hand with child protection. We have to look at proactive child welfare. We have to look at legislation around child protection because it is not just the family. It is about how we project that as a community piece.
This relates to the 16-to-19 group we talked about. I hate to harp on that, but it has been such a huge issue. There is child protection legislation for those 16 and under; for those 19 and over, there is adult protection legislation. However, for the 16-to-19 group, they have no protection.
The Chairman: What is the solution to that? Do you want the 16 moved up or the 19 moved down?
Ms. Whitenect: Either way you do it is fine, as long as we have some protective factors, some ability to intervene.
The Chairman: Just close the gap?
Ms. Whitenect: Exactly, recognizing that this is a crucial time. We need to constitute a family for them, provide a family for them, but there is no way we can do that legislatively. Mental health is not legislated, so we are stuck between a rock and hard place.
Senator Pearson: I have two or three things I want to put on the table. With respect to your immediate question, the Youth Criminal Justice Act is under 18. The Convention on the Rights of the Child is under 18. That should be the universal, and we should do that right across the country. It would address the gap; it has a logic of its own.
One of the issues I wanted to raise was to help the researcher with some ideas. With respect to violence in health, we have been bringing this up to some extent already in terms of the mental health of women and so on as the parent.
The WHO World Report on Violence and Health is excellent. I am coordinating a meeting in early June on children as victims of violence. The violence issue is a powerful component of children's mental health now. Unless we address that, we will have difficulties. When you come across stories of people killing their babies out of revenge against the other partner — stores that have come out in the last two or three weeks — we have some real issues to deal with.
The latest copy of the Vanier Institute's Transitions shows the change in 40 years in family structures. What they do is define it by function; so it should not be a battle for you and your daughter.
Senator Keon: It is not.
Senator Pearson: I know it is not, but it is a useful document and I highly recommend it. It is the latest issue.
Part of our challenge is to find the things that the federal government can do, the recommendations to make it happen. For example, I was in Washington last week, and we have not been taking part in the longitudinal study that was launched on the impact of the environment on children. David Anderson wanted us to get into that study. It was X thousands of dollars to get Canadian children into the cohort. They have a big cohort. They are going to be following a longitudinal study with things like environmental health, and I feel badly that we did not take advantage of that. We should be saying at the federal level, keep your eyes open for every opportunity to build the research base and do not confine it to our country.
There are things going on in the United States — for example, the Surgeon General's work on prevention of violence, the Centers for Disease Control, they are all moving in the same direction as we are, trying to do more coordination, integration and so on. I would recommend building stronger links with them.
Mr. Mussell: With respect to Senator Keon's question about parenting, it strikes me that the most important question has to do with the kind of formative influences we expose our children to so that they grow up with a relatively secure personal and cultural identity. I think that is the key.
My sense is that parenting is a big thing in it, in terms of our culture, because very often people believe that the soul lives on and we are just like great grandfather. There are older people around who will say that, and it has a great influence — usually a very positive one — on your perception of self and what your potential is and so on. It is important to have quality relationships with mother, with father, with grandmother and so on, because that contributes to that relatively secure personal and cultural identity.
Senator Trenholme Counsell: I have to comment on Senator Keon's question, but then I want to address what I would call some really hardcore mental illnesses and ask a question.
I think I would be on your daughter's side, Senator Keon. I raised my kids as a single parent after my husband died from cancer. I think it does go back to those early years and the bonding, the attachment. A lot of people can help you with this parenting. I needed the help of many people, because I practised medicine many hours every day.
The thing is that kids have to have be bonded and have that attachment. They have to believe that they are first in the parents' hearts and lives, that their parents will be there for them in all the serious times to come, and that this will go on for the rest of their lives. They may get married, they may get divorced, but the parent is always there — then I think they will be okay. Also, you have to build in a lot of good supports if you are going to do what your daughter did and what I did. It is okay to do what she is doing, but you need a lot of support and that bonding, that attachment, has to be there from day one.
We have entered into a huge society debate here, all about society in so many aspects. I am trying to think about whether this kind of debate would take place around any other illnesses. You could have some of it about heart disease and cancer, but there are a lot of diseases where you would not have it — like ALS and so on — except for the support that people need.
We say that there are 20 percent of children with mental illness, one out of five. Increasingly, we are realizing that you are born with it. I would like to know, in terms of the most serious illnesses — there are all the societal problems, family breakdown, bullying, body image — for example, the people that were let out of our mental hospitals that need the support of the community, are we realizing that a higher percentage of that 20 percent are serious genetic, or chemical, or environmental or stress factors in the womb?
What percentage of the 20 per cent are born with it? We have some distinguished psychiatrists and doctors here who perhaps can answer this question. We spend much of our time talking about society, but we should get back to serious mental illness.
Dr. Israël: Even if you are born with it, the environment will determine whether you express the disorder. The current thinking is not around those issues, because for all genetic disorders — especially for mental illness, which is complex — there are often many genes that are involved. Often, whether the child is exposed to a certain environment or to certain protective factors can make all the difference between those who develop the disorder and those who do not.
Senator Trenholme Counsell: Are you talking about bipolar disorder or schizophrenia?
Dr. Israël: Yes.
Senator Trenholme Counsell: In what percentage could the environment make a significant difference?
Dr. Israël: The percentage of people who suffer from schizophrenia and bipolar disorder has been relatively constant. There may be other disorders whose incidence is increasing, but those are relatively constant. The ones that vary more include depression and anxiety disorder, which are probably more vulnerable to environmental factors, where there are many mediators that occur during development that can influence whether it goes one way or the other.
When one gets to schizophrenia and bipolar disorder, the current thinking is that to intervene extremely early can dramatically change the course and prevent chronicity.
Senator Trenholme Counsell: I know that the earlier the detection, the earlier the intervention. However, what percentage is innate?
Dr. Lipman: The answer is that we do not know. It is a newly developing field. If we look at this over the next 10 or 20 years, we will find that how we understand genes and their effect on mental illness will go up like mad, but it is because the technology and the investigation is happening, not because it has not always been there. So right now, we do not know. I think we will find that we will understand more about what genes might be influencing things.
Senator Trenholme Counsell: Are ADHD and conduct disorder, Dr. Goldbloom, something one is born with?
Dr. Goldbloom: In many cases, yes, one is born with it, but it is very much modified by environment.
Senator Trenholme Counsell: It is modified by detection, by intervention and by all the things one does.
Dr. Goldbloom: Unfortunately, we are still under the influence of this body-mind separation. All the science shows that this is a totally artificial division. Body and mind are indistinguishable. Each one interacts with the other, and in many incredibly different ways. It comes back to the fact that every individual is one of a kind. We tend to individuals together, but each person around this table is unique. That is why we can recognize you by your DNA.
Senator Trenholme Counsell: The course of a disease will depend a great deal on the environment into which one is born and what happens to an individual. We need to put in our report the most up-to-date information about where this is, because it is easy to blame society and families. I hope we can obtain the latest information.
The Chairman: We will, but we do not intend to blame anybody.
Senator Trenholme Counsell: I am not saying "blame."
The Chairman: Our outlook has always been, as in the previous study, to redesign the system to make it work. We are always looking forward rather than backward.
Dr. Manion: You have to be very careful about the language around this. It is inaccurate to suggest that if there is a clear biological or genetic genesis to this, it will be a more severe and important mental illness. You can have incredible trauma, and your resulting mental illness can be as or more severe than if you have a genetically determined illness from birth. You do not want to classify mental illnesses by their genesis. They are classified by the degree of dysfunction. Our goal is to try to decrease dysfunction.
You can have a mental illness that we can test eventually by a blood sample and have good functioning and not express that mental illness in day-to-day life. You have to be careful about the biology of this.
Mr. Cox: Is it right that some of the environmental factors are not always negative and that there are positive factors? I would not like to say that I have had a negative life and that that has contributed totally to my illness. There are positives. Going to university was a positive thing for me, but it helped bring out my illness.
Ms. Forge: I will return to Dr. Van Daalen's comment about making it safe for families and for parents to say they need help. We not only need to make it safe, we need to make it normal. As a parent, I needed help from time to time. Somehow, we have to normalize that and make it not only okay but actually expected that from time to time over one's life as a parent one will need some support. It will ebb and flow, depending on the age of the child or youth, but there will be times when one needs that support. We must make it normal.
The second thing relates to the family piece, in terms of integration. We talk in education about deprivatization of our practice, of our work as teachers. For the most part, we are trained to think about ourselves in front of one class for the entire day. We are beginning to understand that that is not an effective way to improve our practice as teachers.
We have run into the same issue with our social work colleagues when we tried to put our project of integration together. They were trained to sit with one client in an office, for usually one hour, and at the end of that hour the client would go away and the next client would come in.
Although our staff struggled with this at the beginning, one of the most positive parts of the process was that teachers, social workers and child and youth workers had to deprivatize what they did, how they did it and why they did it. It has been a learning experience for us in terms of thinking of treatment or intervention or support in the long run. We have to see it not as a counselling one-on-one session but as being a team. Part of the team, Senator Cook, is the family. It becomes that ongoing support.
We must make it okay for the family to say, "Two years ago we went through a really rough patch. With your support and our hard work we got through it, but it is two years later and we need to re-enter the system for some support, although we are older and wiser." That give and take will have to be built in to whatever we end up recommending.
Dr. Goldbloom: We have talked about how things have changed. It is important that we remind ourselves of what the things are that have not changed, that have stayed exactly the same.
Medicine is a good analogy. We are diagnosing and curing diseases in ways that were unheard of previously. However, as one of my revered teachers once said, the doctor's mission has not changed. When I say "doctor," it could be a psychiatrist or a psychologist. He said that the doctor's mission is to relieve anxiety. Everything we do in the way of diagnosis, treatment and even research is only a means to that end. It is a very fundamental concept.
By the same token, because we are talking about families here, and my particular interest, of course, is children, we have talked about how life has changed and how society has changed, but there are certain things that have not changed. That is what the family needs.
That was defined about 50 years ago in a study at McGill by William Westley and Nathan Epstein on 100 families. It was written up as a book called The Silent Majority: Families of Emotionally Healthy College Students. They studied 100 ostensibly normal families in enormous detail to try to identify the characteristics in the children that gave them resilience against mental or emotional illness. It boiled down to three very simple things: one, warm open communication between the family members; two, leadership — every committee needs a chair, and a family is a committee in that sense; and, three, and most important of all from the therapeutic point of view, shared labour, something that has disappeared from a lot of families. It does not matter what aspect of this problem we are dealing with. Those are the objectives that we have to aim for. Just dealing at the level of individual families, this is the thing that makes the difference in plain hard everyday terms: sharing the labour, whether the labour has to do with treating a sick child or establishing a better family relationship, because very often one parent has opted out, sometimes using work as an excuse.
These are factors that can be easily manipulated. We do not need to overcomplicate them. I just wanted to emphasize that those are some of the issues about families and mental health that have not changed over the last 1,000 years.
The Chairman: Let me say thank you to everybody for attending here. I know we prevailed upon you, not only for your six hours today, but also for the time many of you spent getting here and will spend getting home. We appreciate it.
The downside of this for everyone is that each time we get a group that comes in and helps us like this, we feel absolutely no compunction about calling on you again to help us to edit things and look at documents, although not necessarily to come to meetings.
Our committee is somewhat unusual, and I say this because there are a number of academics around this table. Because Senator Keon and I are both academics by training, we believe in a peer-reviewed process. One of the reasons our previous report got the reception it did was that individual chapters had been peer reviewed by key people before it ever got published. Therefore, we easily reserve the right to bug you again to read some material and give us some comments.
It has been a great day from our point of view.
The committee adjourned.