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Issues

Models of residential care provision vary considerably across Ontario. Some service providers have invested significantly in introducing evidence-based practices, while others have engaged in iterative processes to learn from their own experiences. Service providers range in size from one-program organizations to multi-service, multi-site agencies with considerable human resources and physical infrastructure. In group care contexts, the implementation of evidence-based practices has been challenging. The Panel heard from many young people and also from front line staff that the philosophies, values and approaches embedded in evidence-based practices are not readily evident in every day experience of residential care. Some young people indicated a lack of empathy, personal attention, and meaningful engagement as symptomatic of their experience in group care settings. Staff members in group homes were at times unable to explain their approach to practice, and made few references to any particular theoretical framework, evidence-based practice or purposeful strategy in their work. In many cases, service providers, including supervisors themselves, were unable to articulate any supervision model that might assist and support front line staff in their complex work.

Perspectives from Young People

Although not all youth the Panel spoke with were dissatisfied with the quality of care they were receiving, the Panel found that young people with extensive exposure to group care were most distressed about their experiences, regardless of whether these unfolded primarily within children and youth mental health residential treatment settings, CAS-operated group homes, or group homes operated by private residential service providers. Young people with mostly foster care experience expressed greater variation in the quality of their experiences, and in some instances reported very positive experiences. Nevertheless, most teenaged young people the Panel spoke with shared very negative experiences about either group care or foster care at some point in their lives, even if currently their experience was significantly more positive.

From the perspective of young people, many rules and regulations in group care settings appear unreasonable.

Examples of this include one service provider where young people are allotted a set amount of shampoo each month and then must pay for additional shampoo out of their allowance; in another setting, young people are required to spend inordinate amounts of time in their rooms without any direction of what to do during these times other than to occupy themselves quietly. Many young people we spoke to were concerned about their lack of access to the internet, and related hardware such as phones and tablets, pointing out that they are often left out of generationally ‘normal’ means of peer to peer communication. Youth also expressed major concerns about a lack of privacy in their lives, both in a physical context (no privacy for phone calls, peer to peer conversations, meetings with family members) and in a figurative context (no privacy for identity development, emotional ups and downs, sadness or other very personal experiences). Many young people expressed significant dissatisfaction with point and level systems in group homes, which they identified as very impersonal, objectifying ways of staff imposing control over them.

In the context of foster care, we heard stories from young people about being rejected because of their sexual orientation, discharged because of behaviour, left unsupervised, yelled at, not listened to, and in several instances being subjected to what was described as racism. In the context of residential treatment under the auspices of children and youth mental health centres, we heard many stories of having medications imposed without proper information about their purpose or their side effects, and we heard stories about restraints that young people deemed unnecessary, and levels of control and expectations of compliance that young people experienced as unhelpful. We also heard from foster parents about young people, and in particular First Nations youth, who were prohibited from speaking their language in a secure treatment context lest they were planning subversive activities. In general, young people’s understanding of treatment in a residential context related largely to medication and control. Of the nearly 300 young people the Panel spoke with, only very few, perhaps less than 10, connected treatment to a meaningful engagement with their families.

In the context of youth justice custody, the Panel encountered significant variations in young people’s descriptions of the quality of care they were experiencing. In a large, directly operated secure institution, the young people we spoke to were critical of much of the care they were receiving, and described their everyday experience as boring, not relevant to their needs, and discouraging in terms of their future prospects. In other (transfer payment) secure custody facilities, the Panel was surprised to hear from young people a high level of satisfaction and appreciation for the safety, care and empathy offered to them on a day-to-day basis. Based on conversations with youth, staff and management, the Panel noted that these facilities were all characterized by a highly developed understanding of relational child and youth care practice that permeated throughout all levels of human resources. In some instances, the level of creative program elements and youth engagement (including, for example, animal assisted initiatives and organized chess tournaments) impressed the Panel.

Transitions remain, as they have for many years, a major issue for young people in out-of-home care, whether these are transitions out of family and into care, transitions from one care setting to another, or transitions out of care and into emergent adulthood. The Panel found it troublesome that some features of such transitions that have been cited for decades as problematic continue to occur. This includes, for example, the use of garbage bags to transport young people’s belongings between placements. It also includes the lack of notice and preparation young people receive before being moved. In several cases, the Panel heard stories of young people being given no notice at all and instead being told they are moving only when the worker arrived to carry out the move. We heard of one young person being told that he would not be returning to his foster home on the return drive from summer camp, and he was moved into a new foster home right then and there. Some young people told us that they were tricked into believing that they were going out with their worker for lunch when instead they were moved from one placement to another. In the context of transitions out of care, young people overwhelming reported a lack of preparedness, insufficient supports and the very strong reactions to the loss of relationships with previous caregivers. While the Panel is encouraged by the MCYS investment in transition workers distributed across the province, and also by recent initiatives to support young people pursuing post-secondary education, much more needs to be done in this respect. Ultimately, the age of termination of funded residential service for young people in out-of-home placements, set at 18, may simply not be sustainable as the trend for the average age of young people in the general population leaving home continues to rise and is currently at 26 (Statistics Canada, 2015).

Perspectives about Treatment and Types of Care Settings

Based on targeted conversations with multiple service providers, the Panel found that residential services in Ontario are subject to a complex nomenclature that includes formal and informal designations such as residential treatment programs, specialized foster homes, treatment foster homes, intensive residential services, secure treatment, family-based care, family-based treatment and other terms (MCYS, 2015b). While some service providers have written statements about what they mean by treatment (Kinark, 2015), in its consultations, the Panel was unable to solicit a meaningful definition for residential treatment, and how it might be distinguished from other forms of residential care. Regardless of whether we asked executive management, front line staff, or young people themselves, descriptions of treatment rarely provided substantive comments beyond the imposition of structure and control on the one hand, and the availability of multiple disciplines on the treatment team on the other hand. No service provider we heard from distinguished between having multiple disciplines represented and offering an inter-disciplinary approach, suggesting that the concept of treatment currently remains somewhat nebulous in its meaning and application. Aforementioned references to evidence-based practices on the part of agency leaders were often not confirmed by front line staff, although there were some examples of a more thorough, and community-wide implementation of such practices in some instances, notably the Ottawa region where Collaborative Problem Solving has been introduced as a whole community framework for working with young people (Youth Services Bureau, 2015).

One element of critical importance in any therapeutic services context is the presence of excellent, consistent and meaningful supervision geared toward relational practice service settings with appropriate reflective and clinical content, including elements of supporting front line caregivers in the context of compassion fatigue, vicarious trauma, and self care. No service provider the Panel spoke with was able to identify a supervision model with any specificity; instead, the Panel heard vague references to performance management and case consultation in some service settings. The lack of emphasis service providers placed on the supervision process, and the apparent lack of supervisors with specific training in supervisory practices geared toward relational practice context is troubling.

The Panel explored in detail the residential services offered through a large children and youth mental health centre that focuses on assessment and treatment recommendations, and found that the residential services themselves appeared to be well regarded by young people, parents, as well as clinical and management staff. However, the services offered are short-term assessment services that end with clinical recommendations that parents told us can often not be implemented post-discharge. In spite of a very high level of parent satisfaction with the residential service itself, therefore, young people, parents or even the clinical and management staff could not confirm the usefulness of these services beyond the short term, and some parents suggested that the situation post-discharge became worse than pre-admission. Management and clinical staff readily acknowledged the lack of sustainability of outcomes of their residential service to be a major problem, but were unable to offer any solutions moving forward.

The various designations of other types of care settings often appeared somewhat ad hoc. We heard examples of treatment foster homes that were so called because one foster parent had earned an undergraduate degree in psychology in the 1960s; no other rationale was provided for referring to this home as a treatment foster home. Also, the Panel found a ‘family-based’ foster care that was teeming with paid shift staff, typically hired to work as one-to­one workers under Special Rate Agreements. We also met foster parents designated as Specialized Foster Homes who were themselves unable to explain in what ways their home was specialized. On the other hand, we also met foster parents designated as Regular Foster Care who were able to describe their approach to care in ways that far exceeded what we heard from treatment or specialized foster homes.

Perspectives on Occupancy and Population Mix in Group Care

The maximum occupancy for group care programs outside of youth justice custody is dictated by the operator license issued by MCYS (MCYS, 2015c). In most cases, the Panel found that the maximum occupancy for group care programs ranges from a low of six to a high of 10, but can at times be as low as four and as high as 12 (MCYS indicated to the Panel that licensed occupancy ranges from a low of 3 to a high of 20, however, the Panel did not encounter these outliers and MCYS did not identify them). The Panel found significant variations in the occupancy trends across the group care sector (see Chapter 7, Youth Justice for comments on open and secure custody). For example, occupancy in some children and youth mental health operated residential care is low and in private residential services, occupancy is high in some instances. However, the occupancies are falling in most cases, resulting in a rationalization of traditional privately operated group homes and an emergent trend for new, often unlicensed, smaller programs for young people with complex special needs. The Panel heard from both service providers and placing agencies that such unlicensed small programs are increasingly ubiquitous and provide an option for customized service for particularly challenging placement needs. The Panel is very concerned that such unlicensed programs often have untrained live-in staff supported by one to one workers under Special Rate Agreements, with limited oversight over quality of care or even safety considerations. The Panel notes that a young person died in one such program in Fall 2015 during a physical restraint.

The Panel heard consistently from all service providers that the profile of their clients has changed over the course of time, and all service providers without exception suggested that they serve only ‘the most complex young people in the system’, a phrase that was often followed up with ‘the ones that no one else is able to serve’. The logical improbability of these claims notwithstanding, the Panel is troubled by the mix of young people being served in group care. We found no evidence that group care programs are prepared for, qualified for, or in any way suitable for all of the clients they admit. During site visits at several agencies, the Panel encountered young people impacted by autism, FASD, developmental challenges, emotional disturbances, suicidal ideation, externalizing behaviours, various psychiatric disorders and also young people simply unable to receive care in their biological families all living together under the same program rules, routines, services, and supports, cared for by staff with limited training and pre-service education, and attending section 23 or private school programs on the premises or operated by the service provider in the community. While there is no comprehensive data available on client profiles in particular settings, the Panel believes that such a mix of young people is common practice across residential services. Further complicating the issue is what MCYS reports to be nearly 50% of youth beds being occupied by adults.

Explanations provided by management, supervisory or front line staff as to the relevance of therapeutic services to each of the young people residing in a particular program were altogether not compelling. CAS workers as well as case workers associated with young people identified as having complex special needs frequently used the term ‘warehousing’ as their way of describing the placements for the young people in their care. The Panel also received no meaningful explanation of how section 23 classrooms could meet the education needs and learning potentials of such a diverse group of young people.

Perspectives on Violence and Criminalization of Young People

The Panel did not specifically focus its review on serious occurrences, and in particular physical restraints, nor on the issue of cross-over kids and youth, thus referred to because of their simultaneous involvement with child welfare/ children and youth mental health and youth justice. The Panel did hear from young people and from case workers that the criminalization of behaviour, and also the criminalization of young people impacted by autism, FASD and developmental challenges, continues to be concerning. During the Panel’s work, another major project was launched referred to as the Cross Over Kids Project, led by Dr. Judy Finlay from the School of Child and Youth Care at Ryerson University, and Justice Brian Scully from the 311 Court in Toronto. The preliminary work of this project, which is steered by a large community group involving all major youth serving sectors, MCYS, as well as a youth group representing lived experience as cross over kids, identified the on-going criminalization of young people in child welfare as a major concern (Finlay & Scully, 2016). The Panel supports the on-going work related to this project as a step forward in creating systemic change in this regard.

Also during the Panel’s work, the Provincial Advocate for Children and Youth, in association with Dr. Kim Snow from the School of Child and Youth Care at Ryerson University, undertook a review of serious occurrences in Ontario’s residential care sector (PACY, 2016). The preliminary results of this review, released to the Panel as documents of interest, indicate a troublesome level of violence in the form of physical interventions carried out by staff in some residential care settings and impacting in particular younger children and youth with significant developmental disabilities. Also during the Panel’s work, another young person died in an unlicensed residential program during a physical restraint. The Panel did review a series of child death inquests involving death by physical restraint and is deeply troubled by the repetitive and still unresolved recommendations for change from one inquest to the next (the Panel reviewed a total of eight inquests into the deaths of young people in care from 1998-2011).