Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue No. 47 - Evidence - October 17, 2018
OTTAWA, Wednesday, October 17, 2018
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:15 p.m. to examine and report on issues relating to social affairs, science and technology generally (topic: study on child and youth mental health.
Senator Chantal Petitclerc (Chair) in the chair.
[English]
The Chair: Hello, everyone. Good afternoon. Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[Translation]
I am Chantal Petitclerc, a senator from Quebec. It’s a pleasure and a privilege for me to be chairing today’s meeting.
[English]
Before we give the floor to our witnesses, I would like to invite my colleagues to introduce themselves.
Senator Seidman: Senator Judith Seidman from Montreal, Quebec.
Senator Ravalia: Hi. I’m Senator Mohamed Ravalia from Newfoundland and Labrador.
[Translation]
Senator Mégie: I am Senator Marie-Françoise Mégie from Quebec.
[English]
Senator Munson: Senator Munson from Ontario.
Senator Omidvar: Senator Omidvar from Ontario.
[Translation]
The Chair: Today, we are continuing our pre-study on child and youth mental health.
Last week, as you may have heard, the World Health Organization revealed that half of all mental illnesses begin by the age of 14. That gives you an idea, then, of how important this problem is.
[English]
We are on a tight schedule due to a deferred vote at 5:30, so we will have only 45 minutes per panel.
Starting with our first panel, today, we will hear by video conference from Joanna Henderson, Executive Director, Youth Wellness Hubs Ontario, Centre for Addiction and Mental Health. We are also pleased to welcome with us Dr. Sophia Hrycko, Past President, Canadian Academy of Child and Adolescent Psychiatry. Welcome both of you. I would ask that you begin with your opening remarks, and try to keep it under seven minutes. From video conference, Dr. Joanna Henderson, please go ahead.
Joanna Henderson, Representative, Executive Director, Youth Wellness Hubs Ontario, Centre for Addiction and Mental Health: Thank you very much, chair and honourable senators, for the opportunity to speak with you today. At the Margaret and Wallace McCain Centre for Child, Youth & Family Mental Health at the Centre for Addiction and Mental Health in Toronto, we are conducting and supporting clinical research, with the high promise of practice and policy impact, and with a core commitment collaborating with youth, family members and service providers. The centre fits within CAMH’s broader commitment to drive social change through excellence in clinical care, innovation, research and knowledge translation.
We all know we have many challenges in our child and youth mental health sector. CAMH’s long-running Ontario Student Drug Use and Health Survey recently found that 14 per cent of high school students report having seriously contemplated suicide in the past year, and 4 per cent of students report having attempted suicide in the past year. In addition, over one third of students are experiencing moderate to severe psychological distress, and almost one third of students report that there was a time in the past year when they wanted to talk to someone about a mental health problem but did not know where to turn.
Our long-standing conventional approach to mental health and illness has been one based on symptoms, diagnosis and a specialist model of care. This system is essential in the context of certain disorders and at certain levels of severity, but this emphasis on disorders and specialists can also contribute to long lags in service engagement for youth. Youth and families do not necessarily equate their distress or their concerns to mental health disorders. And at the service end of things, long wait times arise as all youth receive the same level of specialized care, regardless of the level of need.
Often youth’s difficulties have to escalate significantly, including repeated self-harm and suicidal ideation, before they receive treatment. Clearly we need innovation and new models of service delivery, but to get to a different result we need to use a different approach.
In this area, there has been really encouraging progress. There has been recognition that new models of service delivery must be co-created with youth with lived experience. If we want a system that engages young people and meets their needs, they must be involved in the development process. They must guide us in understanding the outcomes that are meaningful to them, they must weigh in on the attributes they look for in treatment, and they must guide us in determining the sectors that need to be brought together.
This is exactly what three major teams of youth, family members, service providers and researchers across Canada have been working on for the past four years. At CAMH, a group of dedicated youth with lived experience, community partners, myself, Dr. Peter Szatmari, the chief of adolescent psychiatry for CAMH, Sick Kids and University of Toronto have been funded by the Ontario SPOR initiative to develop and rigorously evaluate an integrated, easy to access model of service delivery for youth ages 12 to 25, delivered through a walk-in platform and offered in youth-friendly hubs that include primary care, mental health, substance use, vocational housing and other community and social supports. All in a one-stop shop model of care.
Most recently, Youth Wellness Hubs Ontario has been launched to evaluate this model in 10 communities across Ontario, exploring the adaptations that are required for rural, francophone and Indigenous and other contexts. Simultaneously, ACCESS Open Minds, funded through CIHR’s national SPOR initiative, has been testing a similar youth co-created model in 14 communities across Canada, half of which are Indigenous communities. In B.C., Foundry Initiative is bringing integrated youth services to 11 communities across B.C., with commitments from government for additional scale-up.
These initiatives are creating innovative disruptions to our conventional system that are required to achieve the best youth mental health outcomes we desire. Services are accessible, available on a walk-in basis, including evenings and weekends when youth and need and want services. Services are stepped or staged in response to level of need, and outcome measurement is embedded in routine care every session. Services from across sectors and non-specialist service providers, like peer support workers, are integrated into a cohesive service package and family support is provided.
Of particular importance, while these initiatives are operating in different jurisdictions with varied funding streams, they have been able to come together to identify common values, shared service elements and overlapping measures. This is achieved through Frayme, a federally fund NCE international knowledge translation platform focused on youth mental health service delivery led by Dr. Ian Manion. Frayme provides support to these and other jurisdictions, like Alberta, Quebec and Newfoundland, that are interested in developing and implementing integrated youth services.
So what is missing? Where are the gaps? In order to fully leverage the potential of this movement that has become national in nature, greater investment needs to happen in age-specific mental health services research that involves collaboration across sectors, requires the engagement of young people and families, and partners with on-the-ground services that reflect the real world service delivery context.
For example, we need to develop better evidence-based approaches to integrating mental health and employment supports for youth not engaged in education, employment and training, sometimes called NEET youth. These youths represent a major miss in terms of economic potential if we do not effectively support them in reconnecting to our systems.
We need more research to better understand suicidal ideation and how to best intervene when youths are in crisis. We need to understand how to effectively teach all children and youth to cope with stress and achieve mental well-being.
We need to build the evidence base regarding how personalized or stepped mental health care approaches and non-specialist roles, like peer support workers, improve cost efficiency and contribute to positive outcomes. We need better evidence on the question of how to effectively scale up and sustain youth service innovation over time and across jurisdictions.
Through various HUB initiatives we have an opportunity to look at these questions across jurisdictions, across Canada, and this is an unprecedented opportunity.
Thank you for the opportunity to speak to you today. I look forward to your questions.
The Chair: Thank you very much, Dr. Henderson.
[Translation]
Dr. Sophia Hrycko, Past President, Canadian Academy of Child and Adolescent Psychiatry: Thank you very much. It’s a pleasure and a privilege to be here with you today.
[English]
I appreciate the comments from Dr. Henderson, and will not elaborate on all of the great initiatives that you have mentioned, but certainly something that could be discussed.
On behalf of the Canadian Academy of Child and Adolescent Psychiatry, I thank the committee for this opportunity to share with you the significant mental health needs of our children and youth, but also to talk about their amazing strength and resiliency.
The Canadian Academy of Child and Adolescent Psychiatry is our national organization of child and adolescent psychiatrists, and other professionals in Canada, which is committed to the advancement of mental health in children, youth and families through the promotion of excellence of care, advocacy, education research and collaboration with other professionals. Our biggest resource is our passion and our dedicated volunteers. We have one staff, and that’s it.
I would like to give you an idea of how challenging it is for children, as well as their caregivers, to access timely, evidence-based services when they are struggling with mental health challenges — or worse, when they are in the midst of a crisis. It is an enormous effort for those who live in urban areas and have the cognitive skills, education, and knowledge of services available to them. Consider then how daunting it must for a parent who lives in poverty in a rural area, who belongs to a minority, suffers from mental illness and is caring for a child with an intellectual disability.
Let’s take the case of a boy called Tom, a francophone with severe ADHD, intellectual disability and a genetic anomaly. Imagine that you have become Tom’s caregiver, following a car accident that put his parents in the intensive care unit. Tom was adopted by very caring parents and lives in a rural community. He cannot function in a regular classroom since he struggles to understand what is expected of him. He is affected by very small changes and becomes overwhelmed when there is any change in his routine. This results in physical aggression, which is clearly not acceptable in the school setting.
Last year, Tom was allowed to attend school for an hour a day, the entire year. As a result, his father had to quit work to take care of him. This past summer, his father needed to have neck surgery and he was unable to care for his son. He was in a brace. Tom was suspended on his third day back to school this September, a new school because he is 12 and this is the transition year. When he was allowed to return, he was suspended again for 20 days because he was aggressive, which was his second suspension in less than a week of school. His mother had to take a leave of absence from her job in order to care for him.
In this kind of situation, where do you start? Who can help you? Who can manage and help you manage Tom, and how will you continue to work and fulfil your other responsibilities? It seems insurmountable.
You will discover that, despite some of the great initiatives that are happening, there is still lack of coordination, integrated single-point entry where you can start and to assist you with Tom’s journey, and to provide support and services as his needs will change.
Our children and youth are our future and our most precious resource. We must work together to address the needs of people like Tom and his family, who I describe as the orphans of the orphan. Who are these orphans? They are the most vulnerable of the vulnerable. The 1 per cent of the population affected by intellect disability and/or autism.
They are the ones who will struggle, many unsuccessfully, to reach a state of independent living and will continue to rely on the support of their families long into their adult lives.
They are also the one in five Canadians who suffer from mental illness. They are the children of a mentally ill parent who are 30 to 50 per cent more likely to develop a mental illness. Did you know that Canada has over half a million front-line mental health care workers who are under the age of 12 who are left alone to cope with a parent suffering from a mental illness?
Someone struggling with a disease of the brain, or mental illness, needs all the support we can provide. Mental illness is not like breaking a leg. You know if you break a leg, you will have pain. You might need surgery or a cast. You will definitely be affected. You will require services ranging from accommodation at home, at school, and with daily activities. You will need physiotherapy. This is assuming that you have a smooth recovery, as it is termed, and that you have timely access to services and no complications.
As opposed to a leg fracture, a brain fracture also brings pain. You suffer from anxiety and depression, and you have a severe learning disability. The problem is it hasn’t been diagnosed yet because it isn’t visible. As a child or youth, you can’t express what is happening to you. Even if you can show through your behaviour that you are suffering, getting timely access to services will be a painful journey for you and your parents. It will often leave you scarred since the stigma is always there, present at every level of our society.
We would all benefit from embracing the concept of mental wellness defined by the First Nations Mental Wellness Continuum Framework. It states that mental wellness is the balance of the mental, physical, spiritual and emotional. This balance is enriched as individuals have purpose in their daily lives, hope for their future, a sense of belonging and connectedness within their families, a sense of meaning and an understanding of how their lives and those of their families and communities are part of the creation and a rich history.
Mental wellness is essential and should be a right for all Canadians regardless of their gender, ethnicity, sexual orientation or economic status. We all understand that a child comes into being at birth. In fact, the child starts prenatally since maternal health and care is important and can optimize healthy infants. Sadly, substance abuse during pregnancy continues to impact our children — nicotine and a link with ADHD, alcohol and the alcohol neurodevelopmental effect.
When is a child no longer a child? A youth no longer a youth? It depends on the jurisdictions. Sometimes it’s age 18. In other jurisdictions, it’s 19. It really should be 25 — and I would argue maybe older — as the brain continues to develop and mature until at least that age. The emerging adult with mental illness faces unique challenges and is often left unprepared to manage the reality of adult mental health. The system itself does not have the knowledge or resources to provide timely, developmentally appropriate mental health services in a seamless fashion.
According to one survey, children ranked mental health and bullying along with poverty as their top concern.
In 2015 Canada had one of the highest teenage suicide rates in the world — over 10 per 100,000 teens. It is the second cause of death in children aged 1 to 17. Suicide rates are five to seven times higher for First Nations and six to 11 times higher than the national average for Inuit youth.
Canada has a human resource crisis in mental health care. We have a nationwide shortage of children and adolescent psychiatrists. A study by the Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association estimated that we will need 300 new psychiatrists by 2030 to fill this growing need. We can also expect a decrease of 15 per cent by 2030.
We have heard that 70 per cent of mental health problems begin during childhood so early intervention is key. Canada needs 1,500 child and adolescent psychiatrists to serve this growing segment of the population.
First, we must ensure that all children, youth and emerging adults have timely access to mental health services that are culturally sound, trauma-informed, evidence-based, regardless of their location.
Second, we need integrated, coordinated, single-point entry for mental health care that can address all levels of need. We need to integrate research, ongoing evaluation, quality improvement in the services we provide so we can continuously improve what we do.
We need a national database that will inform our nationally funded, evidence-based practice and clinical guidelines based on specific research in the field.
Finally, we need to ensure that youth and family are at the centre and included in all the steps of these processes.
Thank you so much. I’m happy to elaborate.
The Chair: Thank you to both of you.
Senator Seidman: Thanks both of you for your very valuable input as we begin the first stages of our study on youth mental health.
I’ll put a statement to you and get your reaction, if I might. It has been said that global issues, social media and the Internet, and a rapidly evolving world — including, today, the legalization of cannabis — have given rise to new challenges to young people’s mental health.
Might you tell me if you think this is the case? If so, what would you say these particular challenges might be?
Ms. Henderson: Absolutely, young people today are facing unprecedented challenges that adults and youth have not faced before. The young people who are in their teens now have grown up with social media throughout their childhood and teenage years.
It won’t surprise you to hear me say that we need to engage youth in the solutions because they are most in touch with their experiences. When we engage them to plan solutions, we can better understand what might help.
We also need not to see technology as the enemy. It is true that it creates many challenges for young people, but for other young people it is what has drawn them into service and given them a sense of belonging to a community that may not be present in their geographic location.
We need to understand how to leverage that technology, that connection to social media, to provide service using those formats and extend our reach, especially in a geographically vast country like Canada, where young people may not be able to present physically to an integrated youth service hub or to a hospital for service.
Dr. Hrycko: I totally agree about the importance of integrating youth and family in creating the solution.
I also agree that we have to work with technology; telemental health and telepsychiatry have been a wonderful initiative. Sadly, we do not have the infrastructure to study if this makes a real difference, see how we can maximize the use of it and build some evidence about using this new technology. You have heard about the Foundry project. It is a combination of using electronic platforms and resources. That is impressive because it delivers care in remote areas. It would be ideal if this could be across the entire country and personalized to the specific needs of a community.
I took the liberty of sharing with you, on this interesting day, a poster created by the Association des médecins psychiatres du Québec and subsequently endorsed by the Canadian Academy of Child and Adolescent Psychiatry and the Canadian Psychiatric Association. It nicely illustrates the impact of marijuana on the developing brain. Today is certainly an interesting day today from many points of view.
Senator Munson: Thank you for being here. This is such a big issue. This is a general question because we’re at the exploratory stage. We’re just starting and we have a long journey to go, as senators of this committee, to come up with recommendations.
I’m glad that you brought up the issues of intellectual disabilities and autism. I’ve been working in the field of autism for about 15 years. I always find it disturbing that, in terms of diagnosis, people say this child has been diagnosed with autism, therefore you’ll go into the autism category and file, and therefore we’ll try to treat you in that way. But this child with autism has mental health issues. It’s a major issue.
You talked about a one-stop shop for services. We’ve worked on this. Programs have been funded by the federal government, but not nearly enough. It’s a patchwork of helping out those with autism.
So where do you see the federal government’s role in dealing with the mental health of the tens of thousands of young people who have autism, who are prone to violent outbursts and you name it? I’m not just talking about money; I’m referring to programs. Perhaps at CAMH you can tell me as well how you feel. Doctor, can you give us a road map when it comes to this?
Dr. Hrycko: I wish I could give you one. I was very excited this morning because I heard about the complex service. It’s so new that I can’t even recall the interesting acronym for it. It should be very simple. Basically, it’s a newly created program. It’s federal and it’s supposed to be a one-stop shop for children with at least two care providers. So this would include someone, for example, with Down syndrome and autism.
Today I happened to have seen three individuals who were all referred to it. When I said, “So tell me about it, because this sounds so exciting,” they said, “They haven’t returned our call yet.”
In terms of what might be helpful: have an infrastructure that is well-thought-out; include families in its creation; have enough funding to allow for testing, implementing and modifying to ensure that we build some knowledge about what is needed; and build an infrastructure that can be sustainable. Because, sadly, there are little projects here and there, but I heard three times today, “The worker actually left, so we have to wait.” I also heard, “They lost our file, the specialist we saw who diagnosed our child.” They said, “I will refer you to autism” — and I won’t say which autism group. It is not to point a finger, because it could happen anywhere in the country. This was in May. When they called in August, because they hadn’t heard, they said, “We lost your file. I’m actually leaving, so I’ll put your name to the next person.”
So I think this is what would be needed, that we actually have the infrastructure to deliver and to support the family through the steps.
The Chair: Dr. Henderson, did you want to add something to that?
Ms. Henderson: I agree with everything that was just said. I would also say that I believe the federal government has a role to play in creating expectations and communicating — to Canadian youth, family members, service providers, and administrators — the expectation that mental health services can and should report on service quality and outcomes. We need a national commitment to following through with that.
We need to have data systems that aren’t based on administrative data sets but in fact a purpose-built system that reflects the meaningful outcomes for youth and families, reflects the good work that happens in our specialist and non-specialist service system and meets the needs of government. It has to occur at multiple levels at the service level, but also at that level where we communicate to Canadians what’s reasonable to expect.
[Translation]
Senator Mégie: My question is for Dr. Hrycko, and Ms. Henderson may wish to add her comments afterwards. Children and youth between the ages of 0 and 19 make up the population whose mental health we would like to study. As you mentioned, one-fifth of the country’s population has mental health issues. When young people turn 17 or 18, they are considered to be entering adulthood, but there is a gap. Should they receive adult services or should they continue to receive youth services until they turn 19 or 20? Has any thought gone into that? I’m referring to a situation I experienced more than five years ago. Have there been any new developments since then?
Dr. Hrycko: Yes, absolutely. In fact, Evergreen, a mental health framework developed by Dr. Stan Kutcher and other stakeholders, focuses on emerging adults, youth between the ages of 16 and 25. It was published in 2015 and contains a number of excellent recommendations on the issue. Continuing to provide services tailored to young adults is important because, at 18 or 19 years of age, they are not yet adults. Those who suffer from mental health disorders need support and guidance. There is a break in the system right now, and the reality is something altogether different. I think it’s almost akin to subjecting these young people to trauma when they have to be admitted to hospital.
[English]
The Chair: Did you want to add something to that, Dr. Henderson?
Ms. Henderson: I echo that this is a critical issue.The only piece I would add is that there’s also a significant difference between what we consider suitable for treatment within our adolescent mental health system and what usually gets treated in our adult mental health system. The same difficulty you might be experiencing as a 17-year-old and for which you’re getting support within the system, once you turn 18, you are no longer eligible for service, because the adult system really focuses on serious mental illnesses, like schizophrenia and bipolar disorder. That leaves many young people without service. Not only do they have to change systems, but for many young people, there is no adult system to go to.
Senator Omidvar: Thank you both for being here. I have a set of questions around the suicide rates and the trends that you can possibly help us deconstruct, both between young men and young women, including the ones that Dr. Henderson mentioned — not just suicide rates but young people contemplating suicide. Those trends are worrisome.
Can you comment on the Statistics Canada report that shows that suicide is higher when young females are 10 to 14 but higher among males when they are 15 to 24? What happens? Girls 10 to 14 — boys 15 to 24. How do you explain this?
Ms. Henderson: This is an area in which we definitely need more research, but those findings have been found a number of times.
One of the pieces that goes along with it is that, when we look at the emergence of significant anxiety disorders and difficulties with mood, we actually see parallels. It’s not just suicide risk alone; it’s also that broader context. With that young group of girls, we see that internalizing kinds of disorders, such as mood and anxiety disorders, have high rates in that age range.
For young boys, it’s considerably lower; for the younger adolescent boys, they tend to have more difficulties with externalizing difficulties, such as ADHD, oppositional kinds of behaviours and getting into fights. When we look at that older group of young men, the age range you were talking about, and even 16 to 25, that’s where we see higher rates of internalizing; we start to see those young men experiencing difficulties with mood and anxiety.
These can reflect, and likely do, multiple factors. So you have changes in biology, of course; you have different rates of development that occur for young girls and young boys through adolescence. We also have different pressures that genders experience at different stages. They are also different in the contexts of family, community and social expectations. Those things combine in complex ways to create not just the suicide risk but also that broader mental health context.
Definitely, this is an area where additional research is needed.
Dr. Hrycko: I would simply add that, yes, clearly additional research is needed.
Senator Ravalia: My question is directed to Dr. Henderson. Given the critical shortage of child and adolescent psychiatrists, and the tendency to push for pharmacological modalities to be the primary therapies, do you have any evidence from your multi-pronged, multidisciplinary approach that reducing medications and taking more of an effective multidisciplinary role has better outcomes?
Ms. Henderson: I can’t speak to that from the various integrated youth service hubs that are under way currently, because those are only just under way and we don’t have data to speak to outcomes at this particular point. But there definitely is emerging evidence in a variety of contexts that psychosocial interventions can achieve the same outcomes as medication, and in some cases exceed medications because of their capacity to engage young people more effectively.
Also, psychiatry and specialist level — so psychiatry and psychology — are not necessary to achieve outcomes. This is being shown in multiple contexts, including the global context, where low- and middle-income countries don’t have access to psychiatry — very innovative approaches to working with lay health workers and peer support workers to increase our potential impact.
Not only are they as effective, but as I have already intimated, youth can actually find those approaches more compelling and more engaging. So there’s a twofold piece to it.
Dr. Hrycko: I totally agree. To me, medication is probably the last resort. Addressing the key determinants of health, and engaging youth and their families is probably the best medicine. I agree.
The Chair: One last question for you, Senator Dasko.
Senator Dasko: Thanks to both of you for coming here today. One thing that always interests me when we discuss disease or illness, we spend a lot of time talking about treatment and diagnosis, but I’m always interested in prevention. I’d like your thoughts on the importance of that, and what we can do and what has been done. I know it’s a very broad, large question — what have we done; what can we do? However, I’d just like your thoughts on that topic. In so many areas of illness — cancer prevention — we think about those — there’s a significant component of research. It’s important in so many areas of health that I’m aware of and that I’ve dealt with in my career as a survey researcher. That’s my question to both of you.
Dr. Hrycko: The most important thing is to educate people that the brain is just another organ, and we need to take care of our brain. This means to teach how to express emotion and relate to others. This can be done in a very simple way. Addressing stigma would be prevention in many ways. Teach parents how to foster having their child express their emotions. That would be a wonderful step, because day in and day out, often we see that people are ashamed, they feel guilty, and they struggle with expressing how they feel. That would be my suggestion for one step of prevention.
The Chair: Dr. Henderson, we see you nodding. Do you want to add something?
Ms. Henderson: Absolutely. I agree. Researchers from Canada have been international leaders in prevention. If we look at work like that done by Dr. Patricia Conrod and Dr. Sherry Stewart — Patricia Conrod is in Montreal at Université de Montréal and Sherry Stewart is in Nova Scotia. Utilizing the school system is critical. They’ve developed a program that helps young adolescents develop ability to cope with the challenges they will encounter. It’s a brief intervention, but it has had powerful effects on delaying the onset of substance use, reducing the likelihood of problematic substance use and improving mental health in terms of anxiety and depression.
The ironic thing is that we have the capacity and have developed these interventions that are being used in other countries, but here in Canada, they’re only used in patchy ways. I think it speaks to what was mentioned before — the need for infrastructure and direction to come from the federal government around the key role that prevention can play in promoting mental health amongst our young people.
The Chair: Thank you, colleagues, for your questions. Thank you to our witnesses for their shared expertise.
[Translation]
On that note, honourable senators, the committee will suspend until 5:45 p.m. so we can proceed to the Senate for a vote.
(The committee suspended.)
(The committee resumed.)
[English]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology. We are pleased to have you, we know that we are and you are on a tight schedule so we will start right away with introducing our panellists and hearing their opening remarks.
We are happy to have with us Dr. Sandra Fisman, Professor, Canadian Association of Paediatric Health Centres, and Dr. Chris Wilkes, Professor, Canadian Psychiatric Association. I do ask that you keep your remarks under seven minutes. We only have 45 minutes. I do want to mention to my colleagues that I believe Dr. Fisman has to leave at 6:15. We will do our best to direct our questions to Dr. Fisman, at the beginning. Let’s start with you, Dr. Fisman.
Dr. Sandra Fisman, Professor, Canadian Association of Paediatric Health Centres: I am a child and adolescent psychiatrist, and I often tell our trainees that if I would have my life over again, I would do exactly the same thing. It has been a wonderful career, and I’m passionate about it.
It’s my privilege and pleasure to address this important committee on behalf of the Canadian Association of Pediatric Health Centres. You have a more fulsome briefing note so I will try to keep my opening comments as brief as I can.
In 2017, CAPHC identified child and youth mental health as a priority and, in 2018, established a community of practice to share and learn from one another.
Those of us who care for children and youth have a collective concern. In 2016, CIHI released data indicating a 40 per cent increase in utilization of pediatric emergency mental health services and acute care health care beds, and a 60 per cent increase in the prescription of psychotropic medications for children and youth.
So we have a challenge. How can we do better and how can we invest in a system that will enable us to raise our children to healthy adulthood?
We believe that we must co-create a system that is integrated and seamless. The time has come for a system that is team-based and includes professionals working together, and each to their full scope of practice. Physicians, psychiatrists, paediatricians, family doctors, psychologists, nurses, social workers, occupational and recreational therapists, physical therapists — all of us working as a team and practising fully in terms of our scopes.
We also believe that at a ministerial and governmental level, we need departments that talk to each other. The departments that govern the child and youth network — Health, Social Services, Education, Justice and Culture — all need to be working together, and not in silos.
Most importantly, the child or youth and their family must be at the centre of their care and partners in their care. Gone are the days when we tell people what to do and how to do it. They are our partners.
In order to do this, we need a collaborative culture. A collaborative culture is key in creating system integration. Collaboration is a complex relationship process and it takes ongoing maintenance to sustain itself. It needs to be part of day-to-day experiences of people for it to become part of our culture. There is a need for trust and authenticity that is essential in maintaining effective, working collaborative relationships.
A collaborative culture is especially necessary when contexts are complex, when the future is uncertain and when we’re undergoing transformational change, and these are all very relevant in our current transformation of health care.
As we plan for an integrated child and youth mental health service delivery system, we have to be mindful of our culture and we have to be mindful of a number of givens and challenges.
One, we must understand that the whole young person is a whole young person. There is an interaction and an overlap between physical and mental health processes.
Two, we know that there are shared determinants affecting physical and mental health, including drivers such as poverty and social deprivation and the whole spectrum of child neglect, emotional, physical and sexual abuse.
Three, there is an awareness that children are not static in their development. There is a process of developmental change that occurs naturally over the child to youth to adult trajectory. These changes interact with the environmental circumstances of the individual, which include the kind of environment that they grow up in, life stresses that are predictable and unpredictable and cultural contexts.
So we have some big challenges. We heard mention of the growing incidence and prevalence of self-harm and suicide in our youth and the impact of addictions on the developing brain and body and the mental and physical risks that this poses for our children and youth. And then, of course, these are magnified in our First Nations youth and rooted in a cross-generational sense of hopelessness. How do we break the cycle and how do we intervene in culturally and trauma-informed ways?
I want to say a sidebar about disruptive innovations. We must disrupt our traditional system-driven, prescriptive approaches to care. I don’t know whether you are familiar with his work, but Clayton Christensen, out of the Harvard Business School, wrote around 2002 about disruptive innovations in industry and business. Disruptive innovations are increasingly relevant to health care transformation.
They allow us to create new ways of doing things by developing adaptive models which harness new approaches that are much more congruent with current societal and health care needs.
In your handout, you will find that you have a disruptive model that requires you to take a moment and visualize a pyramid. At the base of the pyramid is a wide platform of front-line health-promoting opportunities. That would be tier one.
As you ascend the pyramid through tiers two, three, four, five and six, services become increasingly intensive, with effective early intervention and prevention geared to minimizing the need for the costlier and more intensive interventions at the top of the pyramid. These would be acute care hospital services and tertiary care programs. In this way, we hope that we can make that into a tip and have very broad base of tier one services.
We do have evolving models of care, in our wonderful country of Canada, that fit this paradigm. The most impressive of these, I believe, is the story of transformation in youth mental health in the Province of New Brunswick. I have taken the liberty of summarizing the development and evolution of this integrated service development and its networks of excellence that were developed from 2009 to the present in New Brunswick, including its outcome, evaluation and key success factors. I would be happy to talk about some of this as we have our discussion.
I think I’m under seven minutes. Thank you for your attention and I look forward to your questions.
Dr. Chris Wilkes, Professor, Canadian Psychiatric Association: Thank you, honourable senators, for this opportunity today. My name is Chris Wilkes. I am a psychiatrist and a lapsed paediatrician. I come from Calgary and am the section chief of child adolescent outpatient services over there and the division head of child psychiatry. I’m also a professor at the University of Calgary in the Department of Psychiatry.
I am pleased to be here today to represent the CPA, the Canadian Psychiatric Association, which is a voluntary professional association of about 5,000 psychiatrists and 900 psychiatric residents. It also has a council of academies, of which the Canadian Academy of Child and Adolescent Psychiatry is one.
Psychiatry is an evidence-based practice granted on the best research we have that allows for the best possible mental health outcomes.
Now, I would like to begin by thanking my colleagues at the CPA, and also you for paying careful and due diligence to this important topic, which is complex with child and youth mental health.
Research has clearly shown that healthy social and emotional development in the early years of life is essential, including in utero, as we know from the history of fetal alcohol difficulties and going back to thalidomide. We also now have research pointing out that toxic stress is very critical. These early years are a foundation for good mental health and resilience throughout life. And now, in fact, in many areas of the world mental health is defined as resilience in the face of adversity.
The Mental Health Commission of Canada has estimated that 1.2 million children and youth in Canada are affected by mental illness, and yet fewer than 20 or 25 per cent receive specialized access to treatment services. The mental health gap, even in a developed country like Canada, is significant, so we are clearly not out of the shadows yet.
Now, recent studies have found that half of all adult mental health disorders have their onset during childhood and 75 per cent really have developed by the time they are 25. So this issue of the developing brain as vulnerable and having multiple adverse child events that expose that developing brain does correlate with mental health adverse outcomes such as addiction, suicide and other disorders such as heart disease, obesity and diabetes in Canada. This is the traumatic spectrum of disorders of health.
Investing in child and youth mental health includes early intervention, improved access to appropriate evidence-based treatments and is essential if we are to avoid lifelong consequences for Canadians.
If we look at the social determinants of health, which are very important, such as food insecurity, inadequate housing, unemployment, racism and poor access to health care, we increase the likelihood of developing mental illness.
Now, Indigenous youth, whom we have heard about several times today, face additional challenges because of the disparities in wealth and also the disparities in access to services. Our Indigenous children and colleagues face historical injustices with an intergenerational trauma, socio-economic conditions and political marginalization.
However, there are innovative projects which we should direct your attention to. There is the Ontario early intervention program, Better Beginnings, Better Futures, and this has demonstrated how investing in prevention and promotion in early childhood can prevent poor developmental outcomes that then require less expensive interventions later on. This also is amply demonstrated and evidenced by the work of Heckman in 2009, which shows that for every dollar invested in early child care, you save $9 later on with reduced costs from education, specialized services being required, child welfare and justice, and increased tax revenue as these people can grow on to be productive members of society.
Now, regrettably, if we look at our resources, in 2015, only 7 per cent of Canada’s total health care spending went to non-dementia-related mental health care, which is far less than other countries like the U.K. and Australia, which spend approximately 12 to 14 per cent.
Now, thanks to public health awareness and anti-stigma efforts, more Canadians are seeking help for mental disorders. You have just heard about the CIHI data indicating increased numbers of visits to emergency room, increased numbers of admissions of youth and increased use of medication.
Now, a survey of Children’s Mental Health Ontario clearly demonstrated that every few years there is a 10 per cent increase of referrals for counselling and therapy. In different parts of the country, the wait list times can reach as long as 6 to 18 months for the most in-demand services. This is not acceptable.
There is still much more that needs to be done to ensure better access to quality care. And as a reminder, suicide is never far from our minds. Suicide remains the second-leading cause of death for youth between the ages of 15 and 24. As you heard, there is an average of 11 suicides per day. But as you go west in Canada and up north to the Indigenous populations, this percentage increases. There is a five or six-fold increase in suicides in these vulnerable youth.
Chronic underfunding has led to inadequate access to comprehensive biopsychosocial care. We need to provide effective interventions in a timely way to children that are based on the best available evidence and delivered by the most appropriate health care provider in a tiered approach system, going from e-mental health, telepsychiatry, other psychosocial interventions and intensive high-needs treatment in hospitals.
Emerging data clearly indicates that the brain continues to develop up to 25 or 26. So, now we are trying to look at the role of youth and emerging adults. These are a particularly vulnerable population as they move from the child and adolescent services into the adult system. We know that about 52 per cent of these young people who are transitioning to adult services disengage at a time when serious mental illnesses are most likely to occur.
Without access to needed assessment and treatment, mental health and social services are going to be vital. There is a great human and economic cost and the evidence-based service delivery approach needs to be implemented and tracked for this population.
With 1.6 million Canadians facing unmet mental health needs and 75 per cent of the children not obtaining appropriate specialized care, it is important to invest in our system. We also to collect data and analyze that data to measure the impact of the strategies we are implementing.
Unfortunately, there is currently a lack of reliable, comparable data that spans children’s services, social services, education, justice and health across the provinces and territories. The electronic health records that do exist often exist in silos and are not compatible.
There has been improvement with increased and sustained funding, and greater progress can be made. One such improvement is the power of partnerships. This builds capacity and mental health literacy. We also heard today about innovations in the school system and in primary care, the shared care model and the CanReach model. These help us to bridge a gap between ministries of health, child welfare and social services and the justice department and work in a comprehensive and integrated manner.
In summary, the four points CPA wants to emphasize are in alignment with the world Mental Health Action Plan of 2013 to 2020. This plan emphasizes the importance of effective leadership for greater investment in child and youth mental health, which includes early intervention and improved access to appropriate evidence-based treatments.
Federally based leadership here could certainly be a great asset. Some Canadian tax revenue from cannabis, which was legalized today, may want to go into mental health.
Also needed is support for the spread and delivery of innovative, cost-effective treatments, which can promote mental health literacy and also prevent mental discords in our vulnerable youth, particularly in schools.
We want improved data collection to promote research and inform policy and measure the impact of our additional resources that we are putting in this area.
We also require increased access to services at the primary care level, mainlining mental health in community care systems so that we have an integrated, comprehensive and responsive system. In short, I’m emphasizing that if we work together, we are stronger and more effective. Thank you.
The Chair: Thank you to both our witnesses. We are ready for questions. I remind you that Dr. Fisman will have to leave. If you wish to ask a question directed to Dr. Fisman first, that would be fine.
Senator Seidman: Thank you very much for your valuable inputs. Indeed, Dr. Wilkes, you said this is a complex subject matter, and this is in fact the first stages of our study on youth mental health, with the hope that we’re going to be able to narrow it down and really focus. We’re looking for something that will be relevant and meaningful, always conforming to the idea that we need to keep the jurisdictional issues in mind. We’re parliamentarians, and we have the tools of federal jurisdiction here.
With all this in mind, I’d like to posit the following, and then have some comment from you. It’s been said that global issues, like dislocation in wars, social media and the Internet in a rapidly evolving world, the legalization of cannabis today, has given rise to new challenges to young people’s mental health. I’m asking you if you believe this is the case, and if so, what would you say are these particular new challenges? I might start with you, Dr. Fisman.
Dr. Fisman: I think we talked a little bit about this in the previous session, and absolutely I think they’ve brought challenges. When I think about growing up and I think about kids growing up now, it’s very different. The way that society is organized is quite different. There has been family disruption in what we knew as the traditional family. That doesn’t make it right or wrong, but it’s changed, and it’s a massive change. Economics have meant that we have two parents working, so we have children who come home to empty houses after school. That wasn’t all of our experiences. Then, as the Internet developed and we began to see the positives and the negatives, certainly in terms of mental health, issues like cyberbullying and its correlation with suicide became an everyday experience for us as health care providers.
These are all given, and what we have to do is develop systems that mitigate change and embrace it in the way that we can and work with new models so that we can grow healthy kids.. I think it’s very tough to grow up now compared with 20, 30 years ago.
Senator Seidman: Thank you.
Dr. Wilkes: It’s a good question and I’d emphasize that whenever we challenge our biology we will lose. Liquid modernity doesn’t always foster easy identification of role and identity. Certainly, we face more problems and challenges with relational poverty rather than material poverty in many populations. It’s the relational poverty, the modelling, which helps emotional regulation skills. A lot of children we see in emergency rooms at the moment have less emotional regulation skills and so they use common substances like pot, alcohol or shopping as a way of making a connection for themselves and making themselves feel better. They search for the “magical other” instead of having an opportunity to have an adult where they can actually develop the skills of building their own personal responsibility and containment. There’s no question that we have difficulties with emotional maturation. That data is already out there. In the last 50 to 60 years there has been an increased number of narcissistic scores and lack of altruism in college students in North America. It takes longer to grow up. The old 18 is now 28 in a lot of cases. There are challenges, and yet you have access to the Internet and immediate gratification and it supports impulsivity. You have a difficult situation where you have delayed maturation of emotional skills, but you’ve got increased access to modern privileges which are dangerous.
Dr. Fisman: We talked about emotional regulation, effect, dysregulation a couple of times today, and that is rooted in early development. It’s rooted in that caretaker-infant relationship and learning to modulate emotion very early on. Given the changes and societal disruption, we see that that emotional regulation doesn’t happen as regularly as it used to happen. The earlier we can intervene in terms of developing coping skills for emotional regulation, the more likely we are to still save our youth from adult psychopathology, and the classic psychopathology is borderline personality disorder.
There is an evidence-based intervention that we’ve tried to grow in southwestern Ontario, to give you a microcosm of something that works well, called dialectical behaviour therapy. We’re doing a longitudinal study at the moment looking at the outcome. The beauty of dialectical behaviour therapy done in its purest form in adolescence is that it involves a caregiver or parent, and the youth. They do a 20-week intervention with modules where they learn the skills together. There is one particular set of skills they learn, a module called middle path, where they learn to negotiate with each other and resolve conflict.
Dr. Wilkes has talked about evidence-based and we’ve heard over people talk about evidence-based. As an example, the emerging evidence base for DBT is really strong. Our program is delivered by nurses. Nurses are skilled. They need to be trained in the intervention. Child and youth workers can be trained. At the moment, however, they’re not a regulated profession, so they can’t deliver DBT. So, we need to change policies to allow freedom, to allow things to happen that disrupt our systems and allow us to do these kinds of interventions, which are very effective at a relatively low cost.
The Chair: Thank you, Dr. Fisman.
Senator Munson: I’m an Ontario senator, but I’m from New Brunswick. New Brunswick doesn’t have a lot of money. You have put in front of us this plan. In layperson terms, can you tell us why this plan is good and why it should be a Canadian model? Has the model been effective in the province of New Brunswick?
Dr. Fisman: The metrics look excellent. The beauty of the program is that it brought together people who could provide funding. Economics is always important. The political will to do something significant is also important. In New Brunswick this started at the top. There was the political will to make a difference, to make a change. A number of departments came together around the child and created a governance model that enabled this.
I think that you need to train people, engage people, create collaboration, which are all things they did. This didn’t happen overnight. It was a process. It was led by two university professors in concert with government and service providers, over time. Their metrics, which are summarized in the two-pager, demonstrate reductions in wait-lists, and an increase in the numbers of people seen, and seen earlier. Then — and I’m going to use the word metastasized — the program metastasized to different parts of New Brunswick and then the province as a whole.
This is over nine years. It’s going to be important to sustain it. But I think it’s a model that’s worth looking at. It’s very impressive.
The Chair: Thank you very much, Dr. Fisman, for being here. I know you have a flight to catch, but we really appreciate that you took the extra time.
Dr. Fisman: Thank you for the opportunity.
The Chair: We have 10 minutes left, so I want to encourage my colleagues and the witness to be short in their questions and answers, if possible.
Senator Ravalia: Thank you very much for that excellent presentation. I was wondering whether you were concerned about the volume of psychotropic medicines that are being prescribed to our youth and mental cohort, and whether you feel there may be some metabolic differences in the way these drugs are handled by different groups, vis-a-vis settler versus Indigenous versus immigrant populations.
Dr. Wilkes: To answer that question the simple way: Yes, we are concerned. There’s a lot more medication being prescribed. I’ll give you an example of a result of discussions over this that have happened in Calgary, Alberta. We’ve had a lot of youth who were users of the emergency room, long stay and patients coming in and not being able to be discharged because of their behaviour. They were on a lot of medication. Some of them have borderline personality disorder, some of them have PDD and ASD, and developmental disabilities like fetal alcohol or autism spectrum.
We found that when we do a wraparound program with child welfare, nongovernment organizations who provide some residential care, and health and mental health working together, we’re able to save 98 per cent hospital days, which added up to about 1,000 when we did our last review. That is very cost-effective when you think that if you save one day at hospital, you save $1,000. So if you’ve saved 1,000, you’ve saved a lot of money.
We know that the wraparound for those children who are using a lot more of the medication is very effective.
We also know that something like 3 per cent of the children who are often in child welfare system are the ones who use the most resources. It’s often those who have the most complex neurodevelopmental problems who are also using the most of the medications. They also have the most disrupted follow-up care; they move from one doctor to another, and no doctor wants to really discontinue and make the situation worse. However, if you have a residential program and you’re working with other partners, you can do that. But without that, doctors are trying to provide safety through pharmacological containment so the child doesn’t run out into traffic, murder a parent or show aggression to others.
But it is an area of much concern for many doctors. We know if there’s a history of trauma, these are often the adolescents who don’t do so well with traditional treatments.
There’s the Sheldon Kennedy Child Advocacy Centre that has pooled together health, mental health, justice and child welfare. When you have that group working closely together, you reduce the amount of medications used.
We have to redefine what we mean by therapy. For example, canine, equine, music and sports therapy are great emotional regulators. If you have a secure base, you can start to use other interventions.
Senator Omidvar: One of your recommendations, Dr. Wilkes — your first one — states that the CPA recommends effective leadership for greater investments in child and youth mental health. I wonder if I could get your comments on the investments the federal government has announced it is making in Budget 2017. I have the breakdown here. It’s roughly $5 billion over 10 years, and it’s parsed out to provinces based on the size of their population. For instance, your province, Alberta, would get over 10 years $586 million. The province of Ontario, where I’m from, would get $1.9 billion.
Would you say this is a good first step? Would you say it’s not enough? Do you have a sense of how much this envelope needs to be enriched, or is it more a sense of how it should be used? “It’s not the absolute amount of money, but it’s deployment.” I wonder if you can help me with that.
Dr. Wilkes: It’s an excellent question. In Alberta, we have been fortunate to lobby and advocate with the corporate community. We often have joint projects where the community has matched the government money to build different projects. We’ve had new hospitals. We’ve got a new mental health centre, which is in the process of being built.
So to the first point, it’s a really good first step, but it is also a question of reminding people that this comes down to a human rights issue. You can have excellent services in cities but very poor distribution and poor access. We have to follow that up with supporting people to use those services: for example, supporting parking and extending the hours that the clinic is open until the evening to accommodate single-parent families. There are a lot of other finer details that make a difference in terms of how a service is delivered and how it is accessed. But it is a very good step.
Senator Omidvar: Since you’re from Alberta, you’ve described the Sheldon Kennedy initiative, which I’m somewhat familiar with, and you have brought together stakeholders to provide wraparound, holistic services. Alberta has been allotted $586 million over ten years, and this amount would be complemented by whatever Alberta and municipalities fund. I want to know if you are at the table as the distribution of this money is discussed in Alberta.
Dr. Wilkes: I would not be at the table. That would be above my pay grade or position, I think. But the provincial government, such as Sarah Hoffman, the Minister of Health, and other parts of the Alberta health services executive would be involved.
Senator Omidvar: Would the CPA be consulted on that?
Dr. Wilkes: Good question. The CPA is not consulted on that specifically. We have physicians who are part of those board meetings, and they are asked their opinions and where the money should be going. There’s a round-table discussion of stakeholders.
Senator Dasko: Dr. Wilkes, you mentioned e-health?
Dr. Wilkes: E-mental health, yes.
Senator Dasko: Do you see e-mental health as an effective, lower-cost method of delivering services, and does it create more accessibility? Is it something you’re promoting?
Dr. Wilkes: In Alberta, we are trying to promote that as being an increased way of accessing information for people in the community to promote mental health literacy. As said earlier, there are a lot of people who struggle with poor emotional regulation. We’re trying to improve community mental health literacy at the schools and in other areas, such as Indigenous areas and reservations. We also want to make sure this is easily accessible for family doctors who can access that information and redirect their patients to these other resources.
There are the ABCs of cognitive therapy, which is a well-known treatment approach for depression — can be available. Resources, if you’re struggling with bullying — resources, if you are struggling with issues of being abused or neglected. So it is trying to empower youth to access services.
Senator Dasko: So it covers a range of areas?
Dr. Wilkes: Yes, and I am at that table discussing how we can roll out e-mental health to try to improve the services. Like any province, the northern areas away from the main cities in the more rural areas have less resources. This is another way of providing help for family doctors, also other psychiatrists who haven’t specialized knowledge of child adolescence but they can access e-mental health.
The Chair: I want to thank our witnesses.
Your input, insight and expertise has already proven to be very valuable to our study, and I want to thank you.
(The committee adjourned.)