Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 15 - Evidence - May 10, 2005 - Afternoon Meeting


HALIFAX, Tuesday, May 10, 2005

The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 1:25 p.m. to examine issues concerning mental health and mental illness.

Senator Michael Kirby (Chairman) in the chair.

[English]

The Chairman: Senators, before we begin this afternoon, Menna MacIssac will actually represent both the Alzheimer society and the family caregivers association because Sharon Reashore, who is the Executive Director of the Family Caregivers Association of Nova Scotia, has just gone into the hospital for emergency surgery on a detached retina. They have had a conversation and she will do both. Then we will have a number of questions we would like to raise with you.

Ms. Menna MacIssac, Director, Program and Operations, Alzheimer Society, Nova Scotia: Thank you very much for having me here today. I have given you all a copy of the presentation with our annual report.

I have stated our mission up front, which is alleviating the personal and social consequences of Alzheimer disease and other dementias and promoting the search for causes and cures. We have been in existence for 20 years, and the amount of research that has gone on and the contribution to alleviating Alzheimer disease within that period is very exciting.

Alzheimer disease is a progressive, degenerative disease and the most common form of dementia, affecting memory, judgment, reasoning, behaviour, mood and physical functioning. It is not normal memory loss that accompanies aging. It is, for instance, if you get in the car and you forget how to drive; it is not forgetting to pick up your children on the way home from work, it is forgetting you have children. It affects your ability to perform simply tasks, to recognize family members, and impacts upon the dignity of your cognitive abilities.

Today 420,000 Canadians over 65 years of age have Alzheimer disease, and with the aging of our population it is expected that by 2031 that number will be 750,000. Twenty-five per cent of Canadians will have someone in their family with this disease.

The Chairman: Menna, you do not necessarily need to read all of the pages. If you just want to hit the highlights and then we can talk to you about it.

Ms. MacIssac: Sure.

The costs of care, both the human cost and the cost to the health system, are remarkable. It is $5.5 billion in Canadian health care costs at this point. However, the real cost that we see on a daily basis at the society is the cost to the caregiver.Ninety-three per cent of seniors are living at home. Many of them are being cared for by their spouses, and it is a 24-hour,seven-day-a-week job. Many are living in isolated rural communities. My own experience with my father andfather-in-law is that a person with dementia, as the disease progresses, does not even like the caregiver to leave the room, let alone go out for groceries. It is almost like child dependency. It is very confining and isolating.

The impact is such that caregivers for a person with dementia are twice as likely to experience depression, and often depression co-exists with dementia. The need for mental health is not well known because people are living in the community with the disease, being cared for by caregivers who are at risk of also having depression themselves.

I have come to you today with some suggestions that we feel are significant health system policy changes that could be incorporated into your recommendations.

The first is that caregivers themselves and persons with the disease say that the most important thing is respite. That is their number one priority. There are many documents and surveys that the federal government has been involved in that indicate that. By "respite'' I do not mean just respite for the caregiver. There are creative approaches to respite that also include programming for the person with the disease, and it is most important to break down the barriers attached to taking the person outside the home and actually bring respite to the home, allowing caregivers to go to their own appointments and to attend support groups and other activities that are available to them.

The Chairman: What does ADRD mean?

Ms. MacIssac: Alzheimer disease and related dementias.

The second point is the significant impact that community capacity initiatives can make. Alzheimer societies across Canada are moving in a direction where they want dementia networks to exist at the community level. The dementia networks bring together groups of at least three health profession organizations at a local level — and this can be replicated across Canada if so desired — to do an inventory of what health services exist at the district or community level and which ones do not. Then, using the local providers who are around the table, they look at the means within their own community to address those deficits and to better integrate services for dementia within their community. In addition, those providers become engaged in a variety of subcommittees that address services, education, promotion of research, and service integration. That would be one of our recommendations.

The other is that in order for integration to truly occur, we would like to see a referral system called "InfoLine First Link,'' which would begin at the time of diagnosis and follow the person through a referral to the Alzheimer society, and then to the networks that would be newly created. That is the second point about community capacity.

The third is around the need for an enhanced curriculum in mental health within the medical schools and other professions.

The fourth is to expedite approval of and access to medications.

The fifth is to establish and fund a national Alzheimer strategy.

There are a couple of points I would like to make around the community capacity initiative, which has the two components of networks and the third-party physician referral. This has been tried in Ontario. The Ontario model may be a little rich for some of the other provinces, but it has been evaluated and is based on best practice and evidence. The findings are that with these informal networks of caregivers coming together, 93 per cent of families and persons with dementia were able to handle a crisis situation more readily. Often as a society we only hear from people when they are in crisis because they cannot cope with the isolation; they cannot cope with watching the one they love lose their cognitive ability.

With this link from the physician's diagnosis right through to a network, people are provided with proactive supports as opposed to waiting until they are in crisis. It is a referral system.

Also, once the networks were developed and the health providers came together to address gaps, 63 per cent of people with the disease and their families indicated that they stayed at home considerably longer or were able to retain their loved one at home, as opposed to an early admission to long-term care, because the networks were providing broader services.

Given the aging population, we cannot fix the demands on the health care system by putting more acute care and long-term care beds in place. We have to partner with the community. If Sharon Reashore were here she would say that so much of the care goes on in the community and more could be done with the right supports, including the networks and a better referral system.

Other provinces are going in this direction as well. Tomorrow I have a conference call with the other societies across Canada. They are all moving in this direction. The Ontario provincial government is providing $100 million towards this initiative through their Trillium Foundation, which I believe is funding from their gambling casinos or something of that nature. The Alberta society is also receiving some funding from government. However, the rest of us are struggling to do what we see needs to be done to give better care to people in dementia services through fundraising.

The Chairman: Describe to me in a bit more detail what exactly is included in a local network. You say you have to have three professionals.

Ms. MacIssac: Yes, three organizations, not just three professionals. They are there to represent their organization.

The Chairman: What kinds of organizations?

Ms. MacIssac: It could be VON. It could be home care under the district health authorities. It could be mental health providers, GPs. We are looking to get primary medical care people involved.

We have the first pilot on the go right now in Cape Breton. Ten provider organizations have become part of this. In the year and a half since they have been in place they have done an inventory of existing services, but they have also looked to develop certain things on their own. In the last year they have developed education modules that the providers can put on in the community for people who have dementia and their caregivers. They have put on six education forums. They have developed a home care toolkit for people who work in home care, and I would like to take it to the Department of Health to see if we can give it to home care workers throughout the province. It is recognizing and supporting people with dementia in home care situations.

They have developed two support groups for caregivers. Once the networks are developed, they assess the gaps and begin to figure out local ways to address them, and they work with the society. For instance, we have volunteers on the ground in Cape Breton who are connecting now to the network and providing public education. All of our materials are now moving to the network and being used in their work. We would like to create an info-line there, but we currently do not have the money for the third party referral.

We want to work with the medical staff in Nova Scotia to create what is called "referral pads,'' which is what they are using in Ontario. When people in Ontario are diagnosed with dementia they get a referral to the society. From the society they get a variety of education materials and support groups, and then they are also linked to the local networks. That is the model we would like to see.

The Chairman: I am surprised at your $100-million price tag; that strikes me as extremely high. Where does the money go? A lot of what you are talking about is done by volunteers. Correct? So what is the money being spent on?

Ms. MacIssac: Well, in Ontario they have 33 chapters and they hire staff to put on the education programs that are delivered in the community. We would not hire staff; we would use the providers who are around the network table. We have submitted a proposal to the provincial government that is based on that model but uses more volunteers and network members; we have not been able to determine yet if we have been approved in the budget process.

The Chairman: If you do not mind my asking, what is the cost, roughly?

Ms. MacIssac: We put in for $120,000 in year one to hire three coordinators in Nova Scotia who would work with the communities on identifying who the members of the networks would be. Help with the paperwork and running the networks once they are in place, the administration costs, the travel costs and the staff fees of the three coordinators are included in that $120,000. In the first year we said we would develop an evaluation framework, and that by year three we would do a comprehensive evaluation. In Ontario they hope that these networks will become self-sustaining. We stated that we feel they can be self-sustaining within a three-year period because one of the main parties at the table would be the district health authorities. The only real costs are the administration costs and the coordinator's salary.

The Chairman: Essentially, you asked for $120,000 a year for three years.

Ms. MacIssac: It is $120,000 for each year.

The Chairman: The group that was here before lunch had a budget in the same range, right? It has to be saving the health system an unbelievable amount. It just seems so obviously cost effective, what am I missing here? Or am I not missing anything? It really is that cost effective?

Ms. MacIssac: Well, just from what has been accomplished through the dementia network in Cape Breton, I think the only thing we are missing is an opportunity. We have a part-time coordinator down there and what they have been able to produce in the brief time that they have been in existence is amazing.

The Chairman: Now, you are only dealing with dementia and Alzheimer's, is that correct?

Ms. MacIssac: Yes.

The Chairman: However, logic says to me — and tell me if I am wrong in this — that the same process ought to work with respect to home care for individuals suffering from other types of mental illness. In other words, is there something unique about your structure that makes it work only for dementia?

Ms. MacIssac: No. In fact, I would say that the idea of having an overall mental health network would be a definite step in the right direction. I think that what could be brought to that is amazing, especially the involvement of the consumers in a mental health network. The work of the Capital District Health Authority, and I do not know if Steve Ayr was here —

The Chairman: Yes, he was.

Ms. MacIssac: Yes. That work is phenomenal. A larger mental health network could work.

The Chairman: It would be a little more expensive because you would have a few more bodies, but we are not talking about a huge expense, unless I am missing something. Are you likely to try that in the Cape Breton health district?

Ms. MacIssac: A mental health network? If the mental health networks roll out across the province we would definitely be a part of it. The seniors' population would certainly benefit from that.

Some of the mental health needs that you would find in adolescents, youth and even young adults are different from those of dementia. I worked in mental health for five years and with the Department of Health for 20 years.

Youth being cared for do not often see their caregiver as someone that they want to spend time with or that they want to depend on for care. The opposite is true for people being cared for by their spouse in their home and who are fearful of leaving their home, which is not the case for young adults and adolescents who are receiving mental health services. I would say that the needs for caregiver education and special home-based support are also very different. The respite aspect is different.

The Chairman: To that extent, the seniors, the young adults and the children's services are quite different. The seniors' aspect would not be dependent on it being Alzheimer's? It is more a function of the patient's age?

Ms. MacIssac: Yes. When I left the Department of Health I said what was most lacking — and I worked in acute care mental health and drug dependency policy and planning shops — was adolescent mental health, in particular, day programs for adolescents where they can convalesce with each other. They have a program here in Capital put on by Nancy Beck, and I do not know if you have heard about that or not, but that is a model where the youth themselves talk about how part of their recovery and healing is a result of that because they get life skills; they get counselling; a whole variety of services that are directed toward adolescents.

The Chairman: Who runs it? I know Nancy does, but under what authority?

Ms. MacIssac: It is under Capital District Health Authority. Nancy is the head of that. It is an outreach day program.

The Chairman: She was here, right? Yes.

Ms. MacIssac: The young people really talk it up themselves.

Coming back to your point, Senator Kirby, about would we be part of a broader mental health network? Yes. Would we still need better integration of dementia services themselves? Yes. Geriatrics is not an attractive area, in the same way mental health overall is not. It is just not sexy in the health care system.

Senator Pépin: It is not attractive to be surrounded by elderly persons.

Ms. MacIssac: Yes. I think people become engaged in acute care right from the time they are in medical school, whether it is surgery, orthopedics, oncology or whatever. Looking after the elderly or people with mental illness just has not been the Canadian health care system's priority.

The Chairman: Tell me about what one really needs to do for the family caregiver. I understand you said respite is not just time off to go shopping et cetera, but time off also to go to support groups and take a break. Are there other supports that family caregivers need? They take on an awful burden.

Ms. MacIssac: I know. I think being part of a support group makes a huge difference for many of them. We have 33 support groups in the province, so that support makes a big difference on the ground.

The Chairman: Are the members of support groups all people who are in the same situation?

Ms. MacIssac: Yes, they are sharing their experiences. The support groups are not really for people who have the disease. They are for the caregivers. They talk about the burden that they are experiencing and how they do not want to make the person with the disease feel bad.

The Chairman: Do professionals attend these support groups?

Ms. MacIssac: We run ours with volunteers, but it just happens that some of them are people who worked in health care or who have lost a loved one to the disease.

Senator Cordy: How do you make sure that people actually use these services? Human nature being what it is, particularly in women — and I do not want to stereotype but it is true — people tend to say, "I can do it, I can do it.'' However, a 75-year-old caring for another 75-year-old cannot do it day after day. You talked about a referral; would that be to the VON? Who would know that this family needed a referral?

Ms. MacIssac: The referral is for everyone who is diagnosed with dementia. It is becoming part of the formal health care system to have a referral to those supports, just as, if you needed a referral for drug treatment, it would automatically happen. This is a referral for the person with the disease and the caregiver at the time of diagnosis.

Senator Cordy: Does the caregiver often have to be persuaded to leave the home? You are absolutely right; the person who needs the care becomes more and more clingy and does not want the caregiver to leave, and the person who is leaving tends to feel guilty about it.

Ms. MacIssac: Yes. I think that home care is further ahead in some of the Western provinces than it is in Nova Scotia. Right now I would say persons with dementia are falling through the gaps, because once you have met the criteria for chronic home care, there are 78 respite beds for the entire province that you have to access through a single entry point. Therefore, first, there is no assessment tool. One has been researched at Mount Saint Vincent by Janice Keefe that assesses caregivers' needs at the same time that the needs of the person with the dementia are assessed. That would make a huge difference in the care and treatment of people, if you looked not only at the person with the disease but at the family as a unit, and then the referral would be automatic.

The most important issue right now is it is a burden to try to take people with dementia out of their home in order to get that respite, and often, caregivers will not do that. An unfamiliar environment often makes dementia worse. By using a health care professional, not a volunteer, for this component, and expanding home care, public health, nurse practitioner or mental health practitioner services to go into the home to provide respite, you can provide a service to a person with dementia. Those practitioners are trained to know what to do, and meanwhile, the caregivers are caring for themselves and going outside the home for respite.

The Chairman: When people talk about Alzheimer's in ordinary, run-of-the-mill conversations, you do not detect the same stigma as is attached to mental illness. Why is that? If you tell someone you have a mentally ill parent as opposed to saying you have someone with Alzheimer's or dementia, the reaction is quite different.

Ms. MacIssac: I think actually there is a high degree of stigma, because when people have a spouse with dementia, often they will be reluctant to go out socially and take their partner with them because they might do things that would embarrass them. They kind of hide away in the community and become less visible.A big part of the reason they do that is the stigma.

The Chairman: It is more than I would have thought.

Ms. MacIssac: Yes.

Senator Pépin: If you say that your spouse is suffering from Alzheimer's, people will say, "Oh, my God'' and they will be much more supportive. I think that people will say, "Well, it is a mental disease.'' They will say, "Oh yes, it is a terrible disease,'' and things like that.

Ms. MacIssac: Yes. I think the fact that there are physical elements to dementia, more so than with other mental illnesses, is a factor too in comparison with the increased stigma of mental illness in the younger population. It is less physical. However, with dementia there is a real physical element to the disease whereby the brain cells are being broken down and deteriorating.

Senator Cordy: Is it easier to become invisible when you get older?

Ms. MacIssac: Yes.

Senator Cordy: It is easier to say, "I am tired'' or "We are too tired'' than it is in your 20s or 30s.

Ms. MacIssac: Yes. The fifth point on our list is about medications. If I have cancer I will get chemotherapy because the health care system does not want the disease to get progressively worse. If I have dementia, medication will help me in terms of preventing the disease from progressing. When a drug is not on the formulary — for instance, right now there is a mid-stage drug in front of the drug review board — you do not get back that time as you get worse. If you go on the drug, you do not go revert and get better; your symptoms do not get better. You do not get that time back. If I had schizophrenia or bi-polar disorder or something of that nature and went on medications, it does not matter whether I go on them today or six months from now, we can be optimistic that the drugs will have an impact. If over six months I have progressively deteriorated from early-stage tomid-stage dementia, I do not get that time back and the impact of the drugs will be diminished. Early diagnosis, early intervention and early support are important so that caregivers are not lost in the system. To do that, we really need that third-party referral system whereby right upon diagnosis, you are linked to the society. Right upon diagnosis your community is working on issues of education, research and coordination of services at the community level.

The Chairman: Are drugs covered?

Ms. MacIssac: Only some drugs. In some provinces, you have to be tested to prove which stage you are at in order to access them.

The Chairman: What about Nova Scotia?

Ms. MacIssac: Some drugs are covered, but others are still under review.

Senator Cook: You are back to the formulary. The same thing applied to the drug of choice for schizophrenia. In my province there has been a hue and cry about getting the drug of choice for Alzheimer's.

I personally do not see the stigma with Alzheimer's, because it is a part of the aging process that, if we live long enough, we will all experience; it is a kind of end of life phenomenon. How often will someone say of an older person, "Oh, he or she is such an age and as smart as a tack''? There is a qualifier there. I think Alzheimer's is a fancy name for losing your memory and we know a lot now that we did not before. My grandfather had Alzheimer's, but we did not know it. We just thought he was difficult and we cared for him.

The Chairman: Or words like "senile'' were used.

Senator Cook: Yes. In Newfoundland we would say "low minded.''

We noticed with Grandfather Cook that it changed his personality and he swore like a trooper. He never swore in his life. This amazed us. He was cute. For a long time he hid it. He was a farmer of the old school. We only noticed it when one day he asked about my oldest girl, who the little boy was, because she had overalls on. However, that is part of growing old and I do not see the same stigma around Alzheimer's that I do around mental health issues.

Ms. MacIssac: I would agree with you to a certain extent that the stigma is more around adolescent and young adult mental health problems. However, in terms of whether it is a normal part of aging, we point out in all of our literature that that is a prevalent myth in society. Alzheimer disease is not a normal part of aging. It is a disease. It is like diabetes, you either have the disease or you do not. Most will not suffer from the disease as they age, but 25 per cent of families will experience someone in their family with dementia. We are currently working diligently on the cause and the cure and many advances are being made. The drugs that are being produced now are having an impact on slowing the progression of the disease. There is new cell research that may even lead to a cure.

Also, the other point is that, perhaps because we have become more aware of the disease, it is occurring more and more in younger people — early onset. We do have to be very aware that it is not just older seniors who are faced with this as a daily part of life, but it is affecting a large segment of the population at younger ages.

Senator Pépin: When you say "younger age,'' starting at?

Ms. MacIssac: There can be early onset at age 30, 40, 50.

The Chairman: Some of the staff may remember way back when someone talked to us, in Ontario somewhere I think, about a 30-year-old individual in a mental institution who had Alzheimer's, although admittedly it is rare.

It is obvious that the kind of support you people provide is much better for the patients and more economical than putting them in an institution somewhere, which is the other realistic alternative. Has anybody done a study of the cost effectiveness? The reason I ask is that people are always talking about how to make the health care system more efficient.

Ms. MacIssac: Sustainable.

The Chairman: Have there been any data collected or has a study been done? Does anybody know if there have been studies on that?

Ms. MacIssac: I do not, other than an analysis of the cost of treating persons with dementia in acute care and long- term care settings, and that was $5.5 billion. The Canadian Medical Association did that study and published it in one of their journals.

The Chairman: However, that is the cost to society. I was trying to understand the cost if the Alzheimer society, the family caregiver and so on looked after someone versus an institution. We should try to find that out. Somebody must have done that work somewhere along the way. When I look at $120,000 a year and $1,500 a day per hospital bed, just intuitively it has to be hugely cost effective.

Ms. MacIssac: Well, 63 per cent of people say that it allows them to keep their loved one at home, which is their preferred option. I can understand that palliative care research would indicate that some do not want the responsibility of a palliative care scenario at home. Although we are also advocating that there are not enough palliative care home- based options either. The end of life is a very difficult time for a family. However, if 63 per cent of those assessed in the survey are saying it will allow them to retain someone in their home longer, it just seems to make sense.

The Chairman: Knowing how everything in the health care system now is driven by money, it would be nice if we could establish that it is not only the right thing to do for the patient, but in fact there is no excuse for governments not to do it because it actually saves them money. That is why I would like to see if we could find hard evidence. We will check with your national association. I cannot believe somewhere along the line somebody has not —

Ms. MacIssac: — done a cost/benefit assessment. Yes.

The Chairman: Exactly. On the medication side, as you say, it depends on whether or not it is on the provincial formulary. That is the issue, right?

Ms. MacIssac: Yes.

The Chairman: It is slow getting onto the provincial formulary because the government does not want to pay the cost. Is that basically it?

Ms. MacIssac: Yes. For instance, just to give you an example, one of our board members with dementia, Fred West, is doing promotions with the national society. Before he went on theearly-stage drug he was unable to read, to drive, and was forgetting everything. It is a bit uncommon, because usually you do not gain that ground back, but now he is an active board member. He is reading. He is driving. His entire quality of life and, therefore, the quality of life of his wife have been affected by access to this drug.

The Chairman: Who pays for his drugs? Who pays for his medications?

Ms. MacIssac: He would have a medical plan, if it is on the formulary. If not he would have to pay for it himself.

The Chairman: When you say a "medical plan,'' the government is not paying for it?

Senator Cook: If it is on the formulary the government pays.

Ms. MacIssac: Yes.

Senator Pépin: It is insurance if you have a private plan.

Ms. MacIssac: Right.

The Chairman: The government pays even though you are not taking it in a hospital; you are taking it at home?

Ms. MacIssac: Yes.

Senator Cochrane: I would like to know how much research is done on drugs for Alzheimer's. Do you have any idea?

Ms. MacIssac: I am probably not the most qualified person to answer that, but we have an extensive research group right here in Nova Scotia working on new drugs in this area. The research community is quite strong.

Senator Cochrane: I have heard concerns from a lot of family members of people who leave their homes to go into an institution that the nurses and staff will give these people a drug just to keep them low key.

Ms. MacIssac: A sedative.

Senator Cochrane: Yes, so they are not wandering or shouting out. You have heard some if it.

Ms. MacIssac: Yes.

Senator Cochrane: I wonder, is that the right way to do it? I do not know.

Ms. MacIssac: I think that there are important considerations in creating an environment for people with dementia. One of your colleagues mentioned earlier that she visited a site in Montreal recently where they had an external garden, with fences that people could see through and where they allow wandering.

There are best practices for facility construction in long-term care for people with dementia that are progressive. Our province is currently becoming aware of many of them and is actually looking at them as models. However, we have a long way to go. I would say there is still some warehousing and overmedication occurring within the long-term care sector. I think there is an opportunity to change the physical and pharmacological environment in which people with dementia are currently living.

Senator Cook: In Newfoundland, the Glenbrook Lodge has a garden for the Alzheimer's unit.

The Chairman: It is fenced, it is enclosed?

Senator Cook: Yes. It is locked inside. However, the patients on the unit can wander there and they can wander out through the open door. We had an architect design it about seven years ago. We have an Alzheimer's walk, because the patients tend to walk in circles, and that has been an incredible place; and the calming effect on —

Ms. MacIssac: It would be really helpful if provincial governments would develop policy around creating friendly environments for those with dementia when they are building long-term care facilities.

Senator Cook: Ours cost $45,000, and we raised the money ourselves. The next time you go up Torbay Road, if you look to the north side of Glenbrook Lodge, you will see a beautiful garden.

The Chairman: I was in one of those actually in Calgary, visiting with the mother of a friend. It was a long-term care home and the lady I was visiting was in the nursing home section, not the dementia section. However, I went through the dementia part, and you are right, it is quite amazing, the effect of the garden, and patients can go outside. There is a bench where you can sit down.

Senator Cochrane: I was wondering earlier if that was privately funded. I have a feeling it is.

Ms. MacIssac: That is the kind of facility that everyone should have a right to.

Senator Cochrane: That is right. Yes.

Do you have many cases where the wife and the husband go into the institution together? We have had that in our area, where both partners go to the institution and one has Alzheimer's and the other does not. They go as husband and wife.

Ms. MacIssac: Yes. I think that kind of consideration probably needs to be looked at as well.

There are facilities now, and we have one here in Capital called Northwood, which have an array of services and housing options under the same facility so that as people's needs change — and I am not talking about necessarily dementia, but about a person who has care needs — they can progress through different options. That should be looked to as well.

Senator Cochrane: Yes, the options are wonderful.

The Chairman: Certainly, if you look at the homes being built in the private sector, typically, they accommodate stages.

Ms. MacIssac: Yes.

The Chairman: You start off in what I would call a classic retirement home, and then it just depends on the amount of care you need, because that way you are not changing your environment. There is a degree of familiarity.

Ms. MacIssac: We would like all provincial governments to have policies that support dementia-friendly environments.

The Chairman: However, that has not happened anywhere at this stage?

Ms. MacIssac: Not yet. I do not think so.

The Chairman: Any other advice you have for us?

Ms. MacIssac: One of the other important points is the fifth one, about a dementia strategy, and that has been put forward. There are fundamental items within that framework — we did not bring copies but we can send you one — that speak to the federal and provincial governments working with community-based organizations on a strategy in which both levels of government can support a variety of the needs of people with dementia. Right now it is a private member's motion. There is a lot of detail within that to support a direction for a national strategy.

The Chairman: Yes. We probably have that, but if we do not we will get it from you.

Ms. MacIssac: It is on the NACA website.

The Chairman: NACA is your national association?

Ms. MacIssac: Yes.

Senator Cook: On your third point here, "Enhance mental health and dementia education,'' how do you see implementing that in a rural area?

Ms. MacIssac: I think you made a point earlier about nurse practitioners, and that is important. At one time, mental health was a bigger part of public health. There were nurses who specialized in mental health, and that has been lost. The community mental health nurse has been lost. Having community mental health nurses available, whether engaged in the schools for younger people or going out to people's homes as age becomes a factor, is one of the components. Enrolment within medical schools in gerontology is another. More awareness of dementia among mental health professionals, psychiatrists or psychologists, is another area.

Senator Cook: The health care professional working in a rural area could benefit from telehealth. Could that could be another way that person could access education?

Ms. MacIssac: Yes.

Senator Cook: In Newfoundland they are using that for continuing education in, I think, four disciplines now. The other action you advocate is to establish and fund a national Alzheimer's strategy. We are looking at developing a mental health strategy. Do you see yours as a stand alone strategy or part of the national strategy?

Ms. MacIssac: You have a section within your report directed towards seniors, and I think a lot of what is being brought to you today in terms of the five points can be incorporated into your recommendations. Your strategy is for mental health, but it would encompass dementia.

The Chairman: Whatever our strategy is vis-à-vis seniors — and we will be holding a day-long session on seniors — obviously dementia will be included.

Senator Cook: I just wonder if your wish was to have it stand alone or to be integrated?

Ms. MacIssac: I think it is an important part of mental health. Whether it involves caregivers and families or seniors or mental health, I think we will try any number of avenues to make people aware of the very simple approaches that can make a difference in the quality of life of the people we are concerned about.

Senator Cook: I am just looking ahead to what this might look like, because there will be a component in it, no doubt, for autism, say.

The Chairman: Just as an aside, we should tell you that interestingly, we have had, at least I had, several complaints in my office about the fact that we referred to autism as a mental illness.

Ms. MacIssac: Many people say that.

The Chairman: I did not know that. I was completely surprised. I am told roughly half of parents of autistic children do not like it referred to as a mental illness — we may do so anyway — I guess because of the attached stigma.

Ms. MacIssac: I think that comes back to the chemical and biological differences too.

The Chairman: Yes.

Ms. MacIssac: For instance, many people say that dementia, particularly Alzheimer disease, is also a physical rather than a mental illness.

The Chairman: However, by that token, you could say the same of most depression, which has to do with the serotonin level in the brain being out of balance, and at that point you have systematically eliminated all mental illnesses, if you follow me.

Ms. MacIssac: Again, it probably comes back to labelling.

The Chairman: Right.

Ms. MacIssac: Alzheimer disease impacts the cells within the brain and that is considered a physical condition.

The Chairman: However, we are taking the position that a brain disorder of some kind is a mental illness.

Ms. MacIssac: It impairs cognitive abilities.

The Chairman: Right.

Ms. MacIssac: The impairment of the cognitive abilities in autism is probably similar to dementia in terms of people not wanting it to be referred to as a mental illness.

The Chairman: Because of the baggage that come with the mental illness label.

Thank you for coming.

Ms. MacIssac: Thank you for having me.

Mr. Chairman: Please tell Sharon you carried her material well and we hope she gets well quickly.

Senators, our last session before we head for the floods in Fredericton, where I understand the river overflowed last night, is with a group of people from a combination of Dalhousie and the IWK Health Centre, the children's health centre.

Mr. Patrick J. McGrath, Canada Research Chair in Pediatric Pain, Dalhousie University: Senators, I am a professor at Dalhousie in psychology, pediatrics and psychiatry, but I do most of my work at the IWK Health Centre, and much of it is on children with mental health problems.

As you know, the prevalence of mental health problems in children is about 18 per cent. There are a lot of good studies: the Ontario Child Health Study; the Quebec mental health study. There is no doubt that is a significant problem.

What we have to always keep in mind is that treatments work. We know that there are treatments. They may not work for every child, but there are dozens and dozens of well-designed, randomized trials, millions of experiences, that show that treatments work. These are both psychological treatments and drug treatments. They make a difference to kids. Early intervention is better than waiting until the problems get more significant.

Access is a significant problem. Again, referring to the Ontario Child Health Study, studies found that only 16 per cent of children with diagnosable disorders, not minor worries but diagnosable disorders, had seen a mental health practitioner in the previous six months. Children with mild and moderate cases experience a long time on waiting lists, and this is true throughout the country.

The waiting lists are actually an underestimation, because when you have a long waiting list, people stop referring patients to the list. Also, families say, "Well, no, I am not interested in going on a waiting list for six months for a four- year-old child who is having severe temper tantrums.''

There are lots of other barriers to treatment. Stigma is an important barrier. Although things have grown much better over the last 20 years, there still is a serious problem with stigma.

In Canada we have a public health system that supposedly provides free treatment. However, oftentimes it is not free.If you are, for example, a mother of a six-year-old child with severe anxiety that is interfering with everyone's lives and you need to go to a psychologist, if you are working, you have to take maybe 10 half-days off work. You have to find child care for your other children. You have to find transportation. You may have to pay for meals away for home. If you live in a remote area of Canada, it may take several days travel just to get a couple of hours of treatment.

The question is why do some parents attend? Why does anybody attend for treatment when you think of the sacrifices they have to make for that?

You have targeted the research issues in your reports and I am very interested in those also. The CIHR, the Canadian Institutes of Health Research, actually does a very good job. Rémi Quirion, Scientific Director of the Institute for Neuroscience, Mental Health and Addiction, is a great leader, as is Michael Kramer of the Institute for Human Development, Child and Youth Health. They are all interested in child mental health.

The problem is that there are no targeted funds for that. I would encourage targeted funds for major national problems such as child mental health.

The CIHR has had a number of different initiatives to bring together clinicians, communities and academic researchers. One of them is the Community Alliance for Health Research, and I want to tell you a little, in the last minute or so, about the program that we have developed under that.

We have developed distance treatment programs, called Family Help. I can leave some of the manuals, but I do not know how much material you want. We target high-prevalence problems and treat them at a distance. We use manuals such as these, videotapes, audiotapes, and a coach, a non-professional, who talks to the family on the phone.

We are currently doing randomized trials using funding from CIHR to test whether these are effective, both in rural areas and in the city. These trials are done in collaboration with our colleagues in the mental health system. Cathy Thurston, for instance, the Director of Cumberland Mental Health Services in Amherst, has been actively involved. We have advisory committees and so on to advise us on how to make the trials responsive to the needs of the mental health system. Our colleagues are now putting forward proposals that these treatments be made part of the mental health system. We hope that that will happen.

However, you should note that we recently had a very large increase in the health budget in this province: $212 million,$220 million, and less than 1 per cent of that went to mental health. That is just not acceptable, given the prevalence. Thank you.

Ms. Susan Mercer, Acting Vice-President, Child and Adolescent Mental Health Program, IWK Health Centre: Senators, thank you for asking me here today. My name is Susan Mercer and I am the Acting Vice-President of Child and Adolescent Mental Health Services at the IWK Health Centre. I have been here seven years, and I came from Ottawa, where I worked for 11 years. I spent my 11 years in Ottawa thinking there were not enough resources for people with mental illness. I worked primarily with street youth. Then I moved to Halifax and —

The Chairman: You realized how much you had in Ottawa?

Ms. Mercer: Honestly, I did. When I moved here there was no shelter for street youth, and I spent the first year as a kind of volunteer, trying to lobby with others for a shelter. I could not believe that there was not even somewhere for kids to sleep.

At the IWK we offer a lot of mental health services. We have 13 different teams and are spread out over the province. We have a Maritime mandate. We support the Friends Exist. We have a clinical team at the youth corrections centre. We do forensic rehabilitation. We do a lot with kids who are seriously mentally ill, and we have a relatively small budget, probably $12 million or $13 million.

However, we have a problem with wait-lists, as people do across the country. I believe that we are not meeting the needs of the children and adolescents who are sitting on our wait-list. They wait because they have a mild to moderate mental health difficulty — anxiety, or not wanting to go to school, or parents have just separated and they are not dealing well with it. That is not to say that that is not important, but when you look at the other children on that list, who tried to kill themselves or are hearing voices, we attempt to meet the needs of those children.

We have done a lot of work in the last year to try to figure out how we can do things differently with what we get, but we also realize that we do need more to be able to attack that wait-list. We have 380 people on our wait-list, and that is just the capital area, because outpatient services are only in the Halifax-Dartmouth area. That is a huge number, and children are waiting in excess of a year. I get calls from the parents to tell me what is happening: "I need my child to be seen.'' We have office-based appointments, and that is not what that child needs. Often, they wait, and then they come once and do not come back.

Therefore, we are trying to, one, redesign our system. We are looking at a new triage system. We are planning to use some of Chuck Cunningham's work from Ontario. We will specialize within outpatient services, so that when people are referred we know exactly where they need to go. We are applying for funding from the government for programs such as Dr. McGrath's.

The Department of Health in the province has worked quite hard in the last couple of years to develop standards for mental health services, the only province in Canada to do so. We have been heavily involved with that, as has the rest of the province. Their standards provide the outline of what services should exist, and then each year we say how much money we need to meet them.

Within those standards there is a continuum of service, including outpatient, mild to moderate mental health problems, prevention education — all the things that we have not been doing. Therefore, when we apply for funding, we are able to use those standards to justify our requests, and that is a good thing.

The difficultly we face is that we have a very fragmented system here. Children can often sit in our inpatient unit or in our residential programs for months because there is nowhere for them to go when they are discharged. That is very frustrating for children, for families, for all government departments. I think we have to all figure out how to work together, not just governments, but everyone, because it is not your kid and my kid, it is this one child going through the system. I know you have discussed that in your report and have made those same recommendations.

We have a lot of work to do. I think that we do not reach out to the multicultural population, the homeless youth, the African Nova Scotian. There are big gaps in the populations we serve, for a lot of reasons, and if we have more resources we can spend the time trying to figure that out.

I do not think it is just throwing money at a system, because you can do that forever. However, it is looking at how to get the best bang for the buck.

Our priority this year is to look at our wait-list and figure out what we can do differently with what we have, because there is not a lot more forthcoming.

I will leave it at that.

Dr. Herbert Orlik, Clinical Director, Chief of Psychiatry, IWK Health Centre: Honourable senators, I am the Chief of Psychiatry for the Child and Adolescent Mental Health Program at the IWK. I am also Head of the Division of Child and Adolescent Psychiatry at Dalhousie University, so I have administrative, clinical and academic responsibilities.

I have reviewed the committee's three reports, which meantlots of reading. I am impressed with the amount of work the committee has done; the research you have done; the people from whom you have sought and received advice; and a not-astounding consensus emerging on mental health issues in general terms, and, to a smaller extent, for children. If I could level one minor critique, which we are here to correct, I thought that the report so far was somewhat thin on the children's side and would like to contribute to enlarging that part.

The report also refers to the children under special population groups, and I have mixed feelings about that. On the one hand, to be special means you might get special attention. On the other hand, it puts you into a category different from anyone else. I am reminded that people looked at adolescence that way. Adolescence did not really exist, because they were only in transition between childhood and adulthood. I have concerns that to be special in that way could have downsides.

I think children are as special as young and middle-aged adults, as older people, and as adolescents. Within the child and adolescent age group there are special population groups that require attention, but beyond that children need as much attention as adults, and equal footing, equal funding, equal research and equal therapeutic opportunities. In that sense, I would not like them to be special. I would like them to be equal to other age populations.

Comparisons with adults have sometimes been helpful and have sometimes been a hindrance in the history of child and adolescent mental health. We have wasted time on arguments over whether the children could have a disorder because psychoanalytic theory said that you could not have a depression until you were of a certain age; or that you could not have a disorder, or problems, or suffer as a child if you did not meet the criteria for adult disorders. The study and treatment of children has been in the shadow of adult disorders, properly so for the sake of protection and because they were like-minded professionals, but improperly so sometimes, because you always had to justify it against the adult standards. I think the time has passed when that needs to happen. Children need to be seen in their own right.

I echo what has been said about research, that we do not have enough, that it needs to be better funded. We are still in the relative infancy of research in child and adolescent mental health compared to adults, and compared to other areas of medicine and social sciences. That needs to be understood when researchers go out there and try to get their feet wet. Due to funding criteria, we still have a lot to learn, and we have to play catch up or develop new methods of investigation for young people.

Another area of concern to me and to colleagues is the application to children of therapies that have not much value, therapies that have either been disproved to be effective or are unproven — they have not been properly researched — therapies that have been wasteful in terms of resources; therapies that have provided false hopes for children, adolescents and their parents; therapies that at times could be harmful.

We need to go by the existing evidence and expertise and, therefore, apply best practices, and we need to do the research to create evidence where it does not exist as yet.

We are truly still applying therapies to large numbers of young people that are entirely ineffectual and do not stand up to scrutiny. We need to review theories of disease causation.We used to, years ago, blame mothers. Mothers were blamed for just about everything. We made mistakes in looking at a disorder like autism and said, "Autistic kids are that way because of what their parents did to them.'' No. These are neurobiological, neuro-developmental kinds of disorders. We used to have incredibly fanciful psychosexual theories about obsessive compulsive disorder, and again vilified people as a result of that and applied therapies that did not work.

As a resident, I had to do therapies of that kind. I was told that it likely would not work, but we had to do it. That was the kind of baptism you had to go through, but it was bad clinical practice.

We have better therapies now. We know that cognitive behaviour therapy works for a number of conditions, especially anxiety disorders. We know that multi-systemic therapy, although expensive, works with children with severe cognitive disorders. We know some of the kinds of treatment interventions that are supported by evidence and that we can further develop and refine; and we know the areas that need to be researched.

I think we need to have the courage to step away from ineffectual therapies and be open with the public and with our colleagues in saying, "You are wasting your time, and you need to do something new. You need to change.'' I agree with what was said earlier about early intervention methods as well.

We need to know what works and what does not. Some of the treatments have tremendous emotional appeal, and some even have tremendous cognitive appeal. It appeals to your sense of what seems to be fair and correct, but as a result of that sense the studies have not been done. At the moment, community-based, community-centred therapies are where it is at, and that has an appeal, but it has to be proven to be effective. It has to be compared to other kinds of interventions.

The last thing I want to say is that I saw discussion in the report about models, looking at the provinces or other countries that have developed models of care and which should we acquire. Which should we apply to our Canadian populations? I would like to promote having an open mind about that, and trying on different models in different situations. Primary care models, children's health centre models, community-based models, may all have valid evidence if we study them properly.

We should not take a cookie-cutter approach and say, "We will do this on the cheap for children, and this will work for all of them.'' We have tried that in the past. It has not worked. We had a mental hygiene movement for children and child guidance and it did not take care of everything. Children are complex and they need a range of comprehensive services.

Dr. Wade Junek, IWK Health Centre: Senators, I will state first that I am the "and now for something completely different'' section. I am a very visually oriented person. I did give you a handout, and I think it will be easier if I just walk you through a few pages of that — and there will just be a few pages.

I am a child and adolescent psychiatrist, and for 12 years I was the director of mental health services for the Province of Nova Scotia, so I have a background in government.

The work that I am presenting arose from the work of a federal-provincial-territorial committee, which I co-chaired, on the development of the concept of self-regulating services delivery. It is relevant to much of what you are hearing today, and in particular to some of the questions you have raised in your own report, about coordination and cooperation. It also can present you with hypotheses about why the research that Dr. Orlik orDr. McGrath talks about does not get used, because that also fits in with some of the concepts here. It is a population health model.

You raised questions yourselves that I have noted on the bottom of page 2, but the history of those questions goes back for decades, if not back to the 1800s. On page 3 there are more relevant questions you could have asked, but I will not go through them.

My goal is to speak about why the collection of services that you people discovered exists for mental health remains a collection and not a system; to provide a means to answer some of the questions you raised; and provide some options that I hope can help things evolve a little further.

On page 5, I start with what happens. All children and youth become adults, and the whole purpose of everything we are doing in government with children and youth is to intervene in some way with the hope that we will help them attain optimal well-being and functioning by adulthood. However, you face three major challenges.

On page 6, for instance, are the stakeholders — well known to you. Those interventions, decisions and actions are made by a large number of stakeholders with complex interrelationships, including, but not limited to, the people you see on that page; the governments, jurisdictions, et cetera.

Page 7, challenge number two, all of those stakeholders have environmental influences on the decisions and actions they take, including, but not limited to, the other stakeholders, the resources they have, the legislation they have to operate under, political pressures, media, et cetera. In total, all of these influences on the decision makers act as positive, negative, and, sometimes, perverse incentives for the kind of decisions they will make. Many of their decisions may have little to do with whether or not our children will be optimally functioning by adulthood.

They know this, of course, so they move onto challenge number three, the strategies used in attempts to get a better outcome. I have just categorized them under three major strategies. There is a good list on page 25, but I am not asking you to go there.

Essentially, there is the strategy to increase resources. We all know that has a limit.

There is improved efficiency, which is the strength of the free market model in business, the powerful force of ever more profits driving creative and cooperative strategies for ever improving products. What are the incentives for ever improving mental health status of our children and youth?

There is improvement in cooperation, and that is one you have identified. That is also ongoing at the levels of patients, programs, policies, organizations and governments. Governments try legislating it, pleading for it, begging for it, but it is still a problem, which you people have already identified.

On page 8 you go back to that fundamental goal. How will we know if any of our stakeholders, environmental influences or strategies is helping us get there? The only way we will know if we are getting ongoing improvements in the mental health status of our children and youth is if we measure it. If you take a look on page 10, you need to take some kind of information out of that process, on adult citizens, and feed it back into those management strategies, environmental influences and stakeholders to affect their decisions and actions and allow corrective action to get improvements. We do not do that.

On page 11, the challenge then is how do you reach goal number two? If the fundamental goal is to improve the mental health status, or maintain even what we have, for our children and youth, one, we have to measure that status to determine if the actions are having an effect. We have to have outcomes and measures. Two, we have to incorporate information about those measurements into our decisions to allow for corrective action, so we have to evaluate the measures and give feedback. Three, we have to make baseline improvements in these measurements as the most significant and important environmental influence on the decisions and actions.

In the way we look at our sum total of incentives, disincentives, perverse incentives and rewards, we have to make them powerful and chain them as positively as possible to outcomes.

Page 12 tells you what we do not have in a system. Frequently, we do not have a vision of where are we going with our children and youth, the adulthood outcome. We do not measure the outcomes. We do not provide feedback for corrective actions. We do not attach powerful incentives and rewards, or make use of what we do have and force it into outcomes.

When you put those in place, if you will turn to page 13, you suddenly see that the decisions and actions are constrained by everything else, forming a system.

Going to page 14 — and this is not what I would do, but it helps illustrate the point — in practical terms, if you want to reduce the number of young offenders, you need to identify these kids in the early school years and bring in child welfare and mental health professionals to help work with them, getting drug dependency people involved because many of them are likely to get themselves involved with drugs. You cannot do this without cooperative programs, but also you cannot force that cooperation.

If we set that as our goal, "reduce your baseline rate,'' let us take 1 per cent of our total provincial spending on children and youth and set that up as an incentive or reward. Administrators like to have money for their services, and if reducing their baseline rate brings them an extra million dollars in operating expenses for their region, that is a powerful incentive. I am saying that it is not what I would do, but I want to illustrate the point. That at least brings about the need for cooperation when it does not exist.

Similarly, you can do the same thing for preventive programs, as I pointed out with the one on community prevalence rates with drugs. You can use that same method.

Now, there is much more that can be done about this. However, in conclusion, I would state that there are additional models to add to our repertoire of services delivery methodology. The self-regulating services delivery model is an option that we hope can add to the thinking about health care services, mental health services, services to children and youth. It is a way of turning a collection of services into a system of care.

On page 16 is what I am not telling you because I only had so much time. Thank you.

The Chairman: I must say, in response to your comment on incentives and rewards, our entire previous health report was built on the notion that you could only change behaviour in a system that complex by offering incentives. I think we described it as putting in place incentives such that rational persons operating in their own self-interest would exhibit the behaviour we want them to exhibit. That same principle will clearly underline this one, so thank you for that.

Susan, where can we get a copy of the provincial standards for mental health services? Whom do we phone?

Ms. Mercer: I brought a copy, but it is also on the provincial government website.

The Chairman: I share the frustration about the amount of research that is being done on mental health issues, whether as practice research or into specific mental health issues, as opposed to what I would call basic science of neurology. The research institute that Rémi Quirion heads has two parts to it. It has a mental health part and a neurological science part. We have been trying to roughly calculate the allocation of resources, but somewhere between two-thirds and three-quarters goes to the neurological part and somewhere under a third to the mental health part. You also all made the observation that something clearly needs to be done to correct that imbalance. I have a question for you, and I want to take off the table the easy answer, which is to get the federal government to put a lot more money into research. Let us suppose that the total CIHR pie does not change. Expanding the pie is a simple solution, so let's take that off the table. From a straight economic return for the dollar standpoint, more money in mental health research will be infinitely more helpful than a lot of the other things they do, which is not to knock those other things. How do we get there?

Dr. McGrath: There are 13 institutes. The institute budgets are only about 30 per cent, a small percentage, of the total budget. Most of the money is given on the basis of individual investigators submitting a grant, and that goes into a large pot. I can submit a grant on anything I want, and then it is peer reviewed and I just designate which institute it goes to. However, the institutes do not control the money at all. Most of the money is in"CI trust central,'' to use that term, and in the individual investigator-initiated grants. It is not only the mental health institute that would fund mental health research. I received a grant from Gender and Health on postpartum depression. Some of the money coming from —

The Chairman: That was from the Institute —

Dr. McGrath: — of Gender and Health. It was on postpartum depression. I recently got a grant from the CIHR on rural health, and you can see how some of my work would relate to rural health. That was not from any one institute. The institute that I am most familiar with is the Institute for Human Development and Child and Youth Health, and I just helped draft a large RFA — I am on their institute advisory board — on the developmental trajectories of children, of which mental health is a very important one.

It is very difficult to find out exactly how much money goes to mental health research, and part of it is a push by the CIHR in terms of making money available to the individual institutes, but part of it is a pull from people in the scientific community developing grants and asking for money. It is a complex, interwoven issue. It is true that most of the CIHR budget is for basic science. That is across the board. That is historic, because the CIHR came out of the NRC. It is only three or four years since it took over from the NRC, expanded its base from basic biomedical science and lab-based research, did some clinical work and moved on into health services and psychosocial epidemiological research. It is not as simple as looking at the budget of the Neuroscience, Mental Health and Addictions Institute. Just looking at the printouts, it is hard to know how much money is devoted to neuroscience research. I am sure that CIHR can begin to look at that and I would be interested in looking at it with you.

If you want more research, you have to provide more money. You have to give mental health researchers money. That is what it takes, and that will move them in the direction you want. If you target money for mental health, they will come. You can see that very clearly in the research on HIV/AIDS and on breast cancer. Money moved researchers toward doing that work. Initially, it was hard to find enough good researchers to take the money. However, in the last 10 years we have seen a flood of good research into HIV and into breast cancer.

The Chairman: What you are saying to me is — I just want to be clear, when you said more money — we should say to CIHR, "You have to target X per cent of your budget, whatever the number is, to issues directly related to mental health.''

Dr. McGrath: I think that the way to do it is to help CIHR partner, for example, with others to increase the pie. We do not have enough money in Canada in health research. We are still, even though it has improved dramatically, in the lower third of the G8 countries. It is not a matter of the CIHR having a lot of funding and they could just target that. Certainly targeted funding within CIHR is one good way, but I think it is more useful to collaborate with CIHR and try to grow the pie.

The Chairman: Sorry, I do not disagree with that, but my fallback would be to ring-fence the money, even if it meant decreasing the amount they are spending on other things.

Dr. McGrath: I think that would be one strategy.

The Chairman: I did not mean to monopolize the conversation here. Anybody else want to comment? Because I think it is a critical question.

Ms. Mercer: Just quickly on research, we have several clinicians who work daily with kids and would like to advance the research, but again it comes back to our wait-lists are so long we cannot even free them up one day a week to do the research. Therefore, after putting funding into the actual research grants, you then do not have the resources to be able to carry out that research.

Dr. Junek: If you want adults who will look after their health and their mental health, you need to start with children, and you need to start with their mental health. It should be the number one priority. You cannot get there if you do not look after their physical health. However, many people will stop at physical health and forget about mental health.

If you make mental health of children the number one priority that in turn ensures that you are more likely to get adults who will care about and look after their health. That is an argument from my perspective for putting research money into children, and into children's mental health. Furthermore, children constitute roughly 25 per cent of the population, but I can assure you we do not get 25 per cent of the service delivery money or the research money.

The Chairman: I understand why you may not want to identify specific practices that you described as unproven therapies and with which there are problems, because there may be people taking them. However, how the heck do we attack your best practices?

Dr. Orlik: On the research side first, CIHR also from time to time invites people to make proposals in an area that CIHR is interested in, or in which somebody has suggested that CIHR should be interested. To some extent, it is feeding that information into CIHR in a consensual manner. If we have large national organizations that could have influence on that, we could have consensus conferences about what is required in terms of a research strategy regarding child and adolescent mental health, feed that information to CIHR and increase the number of proposals that would result.

The other part is Dr. McGrath is a very successful researcher in many ways because of his output, the grants and his expertise. There are not enough Dr. McGraths around. There are many young researchers who have a hard time getting off the ground and need the mentoring of a Dr. McGrath, a research environment, and to stand up to what Sue Mercer was talking about regarding the service pressures. How do we develop a cadre of young researchers who will be mentored, supported, and not be discouraged from clearing what are sometimes very high hurdles in order to get a CIHR grant.

CIHR is the big national organization. I think we need to think of some other kind of funding mechanism. Nova Scotia has made a small start with the Nova Scotia Health Research Foundation; there is the Canadian Psychiatric Research Foundation. There are other kinds of funding bodies, and perhaps in regards to children and adolescents, with the help of investments, other research bodies could make it somewhat easier for people to get their feet wet in research and develop the initial expertise that will then give them a leg up on the big CIHR grants.

Switching to the ineffectual kinds of therapies, the largest proportion of kids that we tend to see are those with a group of disorders that we call disruptive behaviour disorders. These are children with oppositional defiant disorder, conduct disorder, attention deficit disorder. We have a lot of evidence that money is being spent by organizations, by government agencies, by child welfare agencies, by private practitioners, by families — from private sources and even through insurance money — on providing individual psychotherapy for these children. There is absolute evidence that individual psychotherapy does not work with any of these children. Analytic models, psycho-dynamic models, do not work with these children. A great deal of money is spent on those kinds of therapies that could long ago have been reinvested in all kinds of other areas.

The Chairman: You mean, for instance, when someone decides to take an 8-year-old or a 10-year-old to a clinical psychologist for counselling sessions?

Dr. Orlik: If that 8- or 10-year-old is breaking societal rules, is violent with his mother, is controlling younger siblings and is disruptive in the classroom, then individual counselling will be a waste of time.

Dr. McGrath: It is worse than a waste of time. Dr. Orlik is right. It is harmful.

Senator Cook: Then why are we doing these "best practices''?

Dr. Orlik: Because we had a culture that said thatpsycho-dynamic therapies are the answer to humanity's ills. We had leaders who were charismatic in their practices, impressive in what they did and who espoused therapies that made good sense, or sounded so complex that people said, "Well, it must be correct.'' These practices have been in place for a long time, and as in other cultures, it has been difficult to change things around. This culture has resisted, also through medical-political means, if you like, research interventions to study its outcomes. It has said, "Our outcomes cannot be studied. Double-blind trials, control trials, do not apply to what we do. The outcome is very long term. You cannot study in eight weeks or twelve weeks or three months what the outcome is. You need to be involved in this kind of therapy for three years, for five years,'' and things of that kind. There has been an anti-evaluation component to that culture, and a perpetuation by a large number of people who have huge investments in it, not the least of which are financial investments, because you can make good money as a private practitioner by hanging out your shingle and saying, "I provide this kind of counselling.''

The Chairman: What do we do about it?

Dr. Junek: Well, I will often speak from the standpoint of a self-regulating service delivery model. The point that I would make here is that if you are a regional jurisdiction responsible for the delivery of services to the children within your region, there is no incentive to use a method of service delivery that will be effective. Your incentives are much more structured around whether or not the child gets to a service, and whether or not the volume of services is roughly meeting the number of children and the waiting lists are too long. Incentives do not exist to find out whether the children in your region are actually functioning better this year than they were five years ago or better than in region A or region C. There are no incentives to incorporate the latest research. It is as though we said to the Ford Motor Company, "We want to make sure you are making cars, but we do not pay attention to whether or not you are making cars that work and that people want to buy. Our job is to set up the factories to produce.''

Senator Cook: I sit here and hear that a child is in need. A service is available, but does not meet the needs of the child. Within the concept of a health care profession whose motto is do no harm, how do we find ourselves in a situation where we are giving inappropriate services with no measurable outcomes? I am confused.

Dr. Orlik: I said that these kinds of therapies can be harmful. The proponents of the therapy, the parents, agencies that acquire that service on behalf of their clients, would not look at that issue at all. They would look at what Dr. Junek is talking about, which is that they are getting a service, it is accessible to them, and surely, because they are paying good money for it, they must be getting a good service. The notion of harm or ineffectuality does not even enter into it. It is very difficult to debate with those kinds of practitioners in those kinds of environments.

Senator Pépin: I am confused. We heard how important it was to have the children see a doctor, not to have too- long waiting lists and things like that. Now you tell us that the child should not be seen alone, if I understand you. What then is the best treatment for those children?

Dr. Orlik: I can give you an example of the kids I talked about before, the children with disruptive behaviour disorders. The parents who look after these children need to learn a skill set to manage their children's behaviour. They need to learn where they can inadvertently make the behaviour worse. They need to desist from certain kinds of practices and reflexive interventions with these children, and they need to learn in a number of different ways.

Dr. McGrath talked about one model of care that he successfully developed. They need to learn skills to manage disruptive, provocative, interfering, aggressive behaviour on a behavioural kind of model, rather than on a psycho- dynamic, psychoanalytic kind of model. They need to do it with their kids and to do it properly. Dr. McGrath has a system which is manualized, meaning there are procedures to follow. There is a lot of research to show that if you follow manuals, that if you follow directions, the outcomes are a great deal better. You can do comparative kind of studies as a result of that, rather than if you just follow your own intuition or your own charismatic approach to something. There are a variety of very effective ways.

More severely disturbed young people can be placed in amulti-systemic kind of environment where you address various parts of the system that contribute to the difficulties. For example, children with disruptive behaviour disorders get ejected from everywhere. They get ejected from school. Now you have a child who has a behaviour disorder with a parent who is ineffectual. The school's answer is zero tolerance. The child gets sent home to a parent who does not know how to manage that child, the child does not get any education, and when he or she comes back to school, is now disconnected from the rest of the children. You have perpetuated the problem.

In a multi-systemic approach you would look at aspects of the system. You would look at the school, the community services, at community-based facilities, at parenting skills, at the child learning temper management, temper control, and things of that kind. Put it together into a package and away you go. Those are effective therapies.

Dr. McGrath: Yes, the type of thing that you would do is to teach the parents first of all to pay attention to a four- year-old who is disruptive — not the 12-year-old who is burning down houses or stealing cars. Almost every one of those kids was afour-year-old who was disruptive, as Dr. Orlik was saying. You teach them first of all to pay attention to good behaviour. It is a very simple concept, but very difficult to teach. How do you give attention in difficult, complex environments? Then you might look at teaching positive pro-social behaviour by using behaviour charts, by using consequences. Then you might teach how to use different forms of negative punishment, not severe, but just some immediate consequences. Then you teach them to problem solve. You teach them how to deal with the school. That is what you do for parents of kids with disruptive behaviours.

They are difficult to work with because many of them have the same types of problems as the children. God does not randomly assign children to parents. She gives the toughest kids to the parents with the fewest skills. We have to figure out multiple ways, not just the program that I developed. There are entire groups of different types of evidence-based interventions that are all similar.

Now, you do involve an anxious kid in the therapy, and the fundamental psychological treatment for anxiety is exposure. It is exactly what your mother said, "You fall off the bike; you get back on.'' However, you have to teach some skills in order to get them there. You use different therapies for different problems, and if you look at the research evidence, it is very clear. The psycho-dynamic individual approach, where you see kids with disruptive behaviour face to face in your office, is disastrous.

When the kids tear up our manuals or hide them on the parents, that is the major impact they have in terms of dealing with our treatment. We do not talk to them at all because that is not what works. Now, if future research shows that a different approach works, that is what we should do.

However, we have to do research. We have to continue to do research, not only in the universities, but that is integrated with the health system, closely allied with the health system, where decision-makers are involved right from the beginning so that we can actually have an impact on services. When Dr. Orlik talks about the non-evidence-based practice, it is not so much in the provincial health system. There are some provincial health programs in some provinces that do not have evidence-based practice, but they are very interested in looking for that in Nova Scotia and in Ontario. I do not know about all the other provinces, but B.C. is the same. However, there is an entire history of, "We cannot evaluate this. We cannot apply science to it. Just do as I say.''

Ms. Mercer: We have a couple of small teams that work with children in this way. We have a day-treatment program that works very closely with the schools and with the families. We have an intensive community-based treatment program where five workers work with the families. These workers and clinicians are working with very small caseloads because they are not just seeing one child. They are seeing the family, the teacher, the school and the neighbours. You know the saying it takes a village to raise a child. Well, it is the same with mental health difficulties

When you look at the money in relation to the number of children served, it is an expensive program. However, I said the children who sit on our wait-list are those with behaviour disorders and conduct disorders, and what we have to meet their needs is very small.

It takes a shift in thinking and involvement of families right from the beginning. When I say "families,'' it could be foster families, it could be the neighbour who takes care of the child every day because especially with children and adolescents, they cannot sit in an office for an hour and take with them what they learned. However, they are more expensive approaches than the traditional office-based treatment.

Senator Cordy: As a former elementary schoolteacher, it is music to my ears to hear you talking like this, because I remember the frustration level with one particular case. The foster mother and I had a wonderful dialogue about the child not having the skills to deal with a group of over 30 children in a classroom. The doctor was continually saying, "The child is doing fine when he is alone with me.'' Until the child was being peeled off the ceiling in the doctor's office and the doctor said, "I thought I told you to give him his medication before you brought him to see me.'' The foster mother said, "I gave him a double dose just before we left the house.'' The doctor said, "Then I guess we had better start to talk about what is really happening.'' To hear you speaking today is a breath of fresh air.

What happens so often is these children who desperately need socialization skills are removed not only from the school setting, but, as you mentioned, from sports, Brownies, Cubs, et cetera. Nobody wants to deal with them because they have not developed the socialization skills. Then these children often learn quickly that receiving negative attention is far better than receiving no attention at all.

Am I right, from what you said, that there is greater cooperation between the education system and the health system? Or is that a stretch?

Dr. Orlik: There must be better cooperation. Some of that has been upset by funding cycles. While we may complain in health that we have had insufficient funding, it has been worse in education, and more recently in this province, it has also been worse in community services. We had in the past better collaborative relationships with education, with school boards. We had teachers from the school board placed into mental health settings. We had mental health people go to educational settings. Each side has stepped away from this to some extent, and we have to redevelop those kinds of relationships.

Again, if that was somehow incentive based and there was a collaborative approach, rather than developing those kinds of silos, I think we could make some advances. If schools were funded to keep children in school if it were difficult and if mental health systems were funded to provide the collaborative expertise to the schools, to work together on it, rather than, let us say, putting children in institutions, then we might see a change. However, we have to almost reinvent relationships with the school system.

Dr. Junek: I can speak about many of the same issues, but I do not want to perpetuate the topic. I happen to be the consulting psychiatrist for the day-treatment services in the IWK, and I work a lot with children with disruptive behavioural disorders. You have heard enough about that, so I will not speak about what I do.

What I would note is that the Department of Education withdrew the $20,000 it used to spend to allow children to come to our day-treatment service, even though we were taking them out of their schools four days a week so they could have relief. They thought the $20,000 to transport the kids from all around the metro area was too much. As a result, only parents do this now.

I have surveyed the province and services in Canada on this, and there is only one other day-treatment service in Canada that I could find where the parents were responsible for that expense. In all the rest at least 50 per cent was paid by the Department of Education, if not 100 per cent.

In most of the other day-treatment services across Canada, it is also the education department that provides the teachers. In the day-treatment services that I am with, it is the health people again.

Senator Cordy: I keep thinking I will not be surprised at the comments, but you know what, it blows me away when I hear things like that.

Dr. Junek, I am really interested in your self-regulating health care system and in your vision comment. You said, "Without a vision we do not establish where the system is going.'' I think it was Yogi Berra who said, "If we do not know where we are going we might end up somewhere else.''

With any plan, you look at the vision-measures-feedback-reward. We learned this while at university. Is this your model?

Dr. Junek: In my role as Director of Children's MentalHealth Services for the province I attended a number offederal-provincial-territorial meetings as the Nova Scotia representative for children's mental health across Canada. During one of those meetings I presented the rudiments of this system to people in equivalent positions, struggling with the same issues again and again. In conversations with colleagues it became apparent that we were the only group that understood the problem that we were facing.

One day I did a presentation to tie together the concepts that we were talking about, fiddling with, et cetera. After one particular presentation I was asked to develop my ideas into a more complete document, and as a result, Gus Thompson, and I co-chaired the federal-provincial-territorial subcommittee onself-regulating services. That developed into the document that you will see on page 30 of my brief. It is a Health Canada publication, and available on the Health Canada website.

That document was sent to every minister of health, every community services department, the Department of Justice, every department of education and to a number of researchers. In my cover letter I wrote that any questions or comments would be welcome.

Senator Cordy: How large is your file?

Dr. Junek: It is a huge file.

Having worked in government, I have some forgiveness of this for a couple of reasons. One of them is that people and committees receive documents like this all of the time. This document, like many others is dry reading and I have learned that the best way to get it across is to do it in PowerPoint presentations with a lot more colour involved. I make it come alive, and it usually takes me 20 minutes to 30 minutes to do a presentation, after which we have a half an hour discussion and people begin to grasp the complexity of it, and the way so many things interrelate. There are 17 potential benefits to that kind of system, which is item 12 on the list. So that is sort of the history of it, and that is partly where my role is in it.

Senator Cordy: What is your definition of feedback?

Dr. Junek: The essential thing you need to do is decide whether you or are you not getting changes in your baseline and then you have to take that information and feed it back to the people responsible for making decisions. You also have to give them a reason that attending to that information and making those changes ought to be the most powerful influence on all the decisions you are making about your organization, in comparison to that other list of all the environmental influences on decisions. These are all things that effect organizations.

When I went into the government the best influence, the most powerful influence, on the decisions of the budgets of hospitals was, guess what? If we go into debt the government picks up our debt, so it does not matter if we overspend. Now, I was not in government, and I naively thought they understood some simple things about life, that you know, when you reward people for bad behaviour they will keep it up. Those are more powerful influences.

Senator Cordy: Ms. Mercer, this morning someone told us that there has been a patient in the IWK since October only because he has nowhere else to go. When I think about collaboration and cooperation between departments, this example suggests to me that it is not happening because the cost of keeping a child at the IWK for a month would be more than enough to put him in an apartment with a support person and food.

Ms. Mercer: The funds come from different budgets.

Senator Cordy: It does not matter.

Ms. Mercer: No, that is the rationalization.

Senator Cordy: Food, an apartment and a support person for a year would be costly.

Ms. Mercer: I am a very strong believer everyone should be able to live on their own with the right level of supports no matter what they are experiencing. This young man is no different from several others, where in order to have them placed either with foster family, on their own with supports, or in existing supportive housing, requires the intervention of senior level people everywhere. It is wrong. I totally agree.

We have raised this, and we have met with government officials, and we are really trying to come together to make this a seamless system because it is not their kid or our kid. It is someone who, not just this person, but several examples, who needed treatment or not, but somehow ended up in an inpatient unit and had nowhere to go.

You are absolutely right: It comes down to different budgets and different criteria. What some of these young people need does not exist for them.

Senator Cordy: Is there anybody who can make that decision? Would it be the premier? Is that where you would have to go?

Ms. Mercer: I am sure it has probably gone to the premier. What it takes is the ability to create what some of these kids need because for some of them it is so unique that they are notgoing to fit into existing foster homes. Children between 16 years and 19 years are too young for the child welfare system, and they do not kick into the adult system until they are 19.

I think it has to happen, and I think it has to be a mandate of all of us, including the IWK. All three agencies must come together to solve that without it having to go up to a VP, a director, a senior director, or any of those agencies. I hear this across Canada, so I know that it is not just us. Even in provinces where it is all under one ministry, I know there is the same difficulty. You are right, it seems like logic should come in here.

Senator Cordy: Thank you.

The Chairman: Having been trained as a mathematician, which is logical, and given all of the public issues I have looked at on and off for 30 years, this is without doubt the most complex issue, full of completely illogical components, than any other I have ever seen.

Ms. Mercer: Yes.

Senator Cochrane: Are you talking about ADD, FAS, the bullying disorder, the autism disorder? Are you talking about all of these, or are there more?

Dr. Orlik: No. I think we are talking about an example of a large sub-population of children who have so-called disruptive behaviour disorders into which could fall fetal alcohol syndrome, into which could fall attention deficit disorder, with or without hyperactivity, children with conduct disorders and so on. Children with autism and related disorders need a different approach.

Children with anxiety disorders, as Dr. McGrath said, have evidence-based kind of interventions of what works for them. Under the anxiety disorders are a large numbers of disorders including phobias, social phobias, post-traumatic stress disorder and obsessive compulsive disorder. You have a large number of conditions that have certain things in common and yet also other kind of differences that require a somewhat different kind of management approach.

You have a range of mood disorders, and they again, by and large, require different approaches, although, there is a certain kind of commonality. Some of the medications can work for mood disorders in selected young people, and may also work in depression in young people. Certain forms of therapy, properly adapted therapy called "cognitive behavioural therapy'' is effective in anxiety disorders and in mood disorders, although in mood disorders some other kind of psychotherapies are available as well. A large portion of our funding should focus on these large groupings of disorders in their various stages.

Dr. McGrath's suggestion to identify them early, and develop skills in the parents to manage these in a collaborative approach between preschool settings and the later on school settings is sound. If on the other hand, these children get more seriously ill, then you need to invoke other kinds of systems of therapy, or combination therapies, or expertise to assist in their recovery.

So, for reasons of providing an example, I, when I presented, talked about this group of disorders of so-called disruptive behaviours disorders because they happen to be very large, and probably that group has had thrown at it more ineffectual therapies than any other.

Senator Cochrane: Susan, have you had groups of parents or individual parents come in to deal with some of those disorders in their children?

Ms. Mercer: As a therapy?

Senator Cochrane: Yes.

Ms. Mercer: We have certainly attempted to offer groups, and it is a discussion we have had. We need to work with the families, the community, and the public because sometimes people believe that phone-based therapy, Internet- based therapy, or group therapy is not treatment and prefer to be on a wait-list.

Actually, I met yesterday with a group of staff to talk about how we need to get out there more, work with parents, and explain that the traditional method of treatment is not available. Best practice shows that for some of these disorders group therapy is the best method of therapy.

Dr. Junek: With respect to our day treatment services, we bring in 10 kids at a time. We have the compulsory part of it that all the parents come to a child management training program for eight sessions, two hours a session. So we do work with the parents in groups. We do teach them the child management skills in groups, and any of the parents will tell you, and I have taught them myself over the years, that they actually gain a lot more out of that kind of a session and especially by doing it in groups where they share their experiences with other parents. It is a very powerful learning experience.

We start exactly where Dr. McGrath pointed out, training them to observe and reward appropriate behaviour. It is a very useful way to do this, and we certainly do it as part of the program.

Senator Cochrane: After three to five years, are they back in a normal setting where they can function independently?

Dr. Junek: I think the answer I would give you is yes that can happen, especially if you have children where the major difficulty is in the child management training that the parents need in managing the children. That group can benefit especially well from child management training in groups. In our circumstances, we are frequently dealing with children who started withpre-existing attention deficit hyperactivity disorder, then developed oppositional behaviour, and in some cases are moving on into conduct disorder in the community. It depends on the degree of severity and complexity of the disorder, the child, the family and the community in which they live. In some cases, many years later, we receive positive feedback that they are doing very well, while we are aware that others are going to go downhill even further. Perhaps the researchers that are more involved in it are people like Dr. Forehand and Dr. Patterson who are psychologists who have good long-term follow-up studies, demonstrating that these techniques are useful.

Dr. Orlik: I brought along some books from other jurisdictions where resources are available for that type of research.

An imminent monograph series, the Child and Adolescent Psychiatry Clinics of North America is devoted to evidence-based practice in child and adolescent mental health, so we do have documentation of things that work.

We cannot rest and we have to do that work in Canada. We do have different environments, we do have different demographics, we do have different resources, and we do have different political contingencies and funding patterns. We need to do that work here as well.

Dr. McGrath: You have to understand that we have not funded people to do research very well in Canada. The CIHR has been a big improvement, and that is why I maybe am a little bit defensive about the CIHR, but you know people like Michel Tremblay in Quebec, is a world leader. Chuck Cunningham in Hamilton has done some outstanding work on large-group parent training where you do 50, 60 parents at a time. I think if you look across Canada there are a small number of researchers that are doing this type of work.

It is often hard to get enough funding, and it is often hard to keep them. I mean, one of the most distinguished researchers in this area is now in Philadelphia. He started off in Kingston. I knew him very well many, many years ago. We just lost a Dan Waschbusch, who was doing a very innovative school-based program up in rural Nova Scotia. I mean part of the issue is that is has only been very recently that we have invested in any research. There is not a large cadre of researchers in child mental health. We do need more resources to attract them.

I am always looking for more funding, so if your committee wants to fund that type of research, I would be glad to accept. I think the issue is we have only recently begun to invest in health research of the non-basic science type and three or four years are not enough to show a huge difference.

There has also been some very good work done here in terms of linking up and this issue, I think, is very important. Linking up the people who are delivering service like Sue and Herb, and linking them up closely with researchers is vital to the success of these programs. Instead, my job is to get papers published, not to change behaviour in the environment, not to make the children and youth of Nova Scotia healthier. Sometimes we work at cross purposes but there has been some very good progress.

The Chairman: You clearly need to change your incentives, you understand that?

Mr. MacGrath: Yes, that is what we have to change. I did this work because the CIHR said they would give us money and we are no different from anybody else in that way.

There a lot of good people working in this field, as you know. You have said it yourself, "Child mental health is the orphan of the orphan.'' I thought that was a very good phrase in your report, and I encourage you to really push for that because early diagnosis is possible for most of the serious problems. Some problems do come on in late adolescents but even in there, early intervention with psychosis is incredibly effective.

Senator Pépin: Dr. McGrath, you spoke to us about your clinical trial that you are doing with videos, books and via telephone. Could you elaborate a little bit on that and explain the targets?

Dr. McGrath: We have five modules. Some of them are easier, because I needed some easy wins. So we do bedwetting, which people say is not a mental health problem, but if you are 10 years old and wetting the bed, it is a mental health problem, I will tell you. We also do the disruptive behaviour, both attention deficit and oppositional defiant disorder, and anxiety disorders.

The whole approach is that in the trial we are taking referrals from family doctors so we go and detail the family doctors and tell them about the program. They send a one-page referral with little "tick'' boxes so that it is easy for them to refer.

Then we do an assessment, and it is a more elaborate assessment than we would do if we were just providing a service, because it is a trial. We would move to the assessment system that Sue was mentioning, Chuck Cunningham's approach, if we were just doing a service.

Then what we do is we contact the family and we talk to them on the phone. We send them the manuals, the videos, and we deliver service to them in their homes at times that are convenient to them. My staff works weekends and evenings. I am on-call for that service. This service is delivered to them in a way that is easier for them to make it, especially with the disruptive disorders, but also with anxiety, you have chaotic families that are hard to reach, even when you make an appointment. It's at seven o'clock on Thursday night. Well, they are out then, or somebody has just come in, or something has happened. We have to be persistent.

This approach is only one approach; it is not a panacea. It is not for everybody. Sometimes large-group interventions, using basically the evidence-based treatments that have been shown to be effective, which we have done, are the best way to go. So, I am not saying that this approach is the best approach. It is one approach.

Senator Pépin: Have you had many families involved in that process?

Mr. MacGrath: We have had about 280, I think. Some of our trials are closed now and we are finishing the rest of them. So we should be finished the trials in 18 months.

Senator Pépin: How long do they have to stay on the program?

Mr. MacGrath: The treatments are about 12 weeks long and then we follow up with the families. We give some booster sessions to follow up afterwards.

We would like to expand this to look at other problems. The school-based part of it is not as strong as we would want, but much like what Dr. Orlik was saying, we want to follow, we want to look at the data first. I can convince people to do it, but we want to look at the data to see what works. As Dr. Junek said, if there were incentives for us to do what works, and if they really covered the whole system, then it would really be quite a bit more effective.

Ms. Mercer: I have one last quick comment about Pat's program.

Recently in Nova Scotia the wait-list for child and adolescent mental health has hit the media. Dr. Orlik has been doing the radio station circuit, and because of that when the provincial government announced their funding for increased mental health services this year, $2 million for the province, they added wait-list reduction criteria to it. We are able to apply for funding for this program this year because of that increase.

We really believe that we are doing a good job with the seriously mentally ill, but these children that sit on our wait- list, who wait to become seriously mentally ill, will benefit from this latest development. We are hopeful that with the media attention and a little bit of money we will be able to work this group into our system so that we can start to target that population.

The Chairman: That is all the time we have. I thank all of you for coming this afternoon. I know we took longer than we said we would, but that always happens to us. You have been very helpful to us.

The committee adjourned.