Children and Youth — Issue No. 10 — Wednesday, June 11, 2014 (HTML)

2800 CN Strategy Room, Segal Building, Simon Fraser University
500 Granville Street, Vancouver, B.C.

Present: Jane Thornthwaite, MLA (Chair); Carole James, MLA (Deputy Chair); Donna Barnett, MLA; Mike Bernier, MLA; Doug Donaldson, MLA; Maurine Karagianis, MLA; John Martin, MLA; Dr. Darryl Plecas, MLA; Jennifer Rice, MLA; Dr. Moira Stilwell, MLA

3. The following witnesses appeared before the Committee and answered questions:

5. The following witnesses appeared before the Committee and answered questions:

7. The following witnesses appeared before the Committee and answered questions:

9. The following witnesses appeared before the Committee and answered questions:

11. The following witnesses appeared before the Committee and answered questions:

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
CHILDREN AND YOUTH


CONTENTS
Page
Presentations	272
S. Mathias
K. Anderson
J. Wilson
P. Lam
B. Clifton Percival
A. Smith
Y. Jetha
J. Staub-French
K. White
S. Smith
S. Soden
C. Waddell

J. Thornthwaite (Chair): Good morning, everybody. I'm Jane Thornthwaite. I'm the Chair of the Select Standing Committee on Children and Youth.

Part of the committee's mandate is to foster great awareness and understanding of the B.C. child and youth service system. Towards this end, the committee agreed last November to undertake a special project examining youth mental health. Youth mental health has been a recurrent and high-profile issue in the province, one that sometimes has very tragic results. Youth mental health also has been raised in recent reports by the Representative for Children and Youth. With this in mind, the committee began work last fall to raise awareness of this important issue.

Some of the key questions we are seeking to explore are: what are the main challenges around youth mental health in B.C.? Are there any gaps in service delivery? What are the best practices for treating and preventing youth mental health issues? Where should resources be targeted in the future?

Today's meeting is the second of two public meetings. The first meeting was held on June 4 in Victoria. There we heard seven excellent presentations from expert witnesses and key stakeholders in the field.

Yesterday the committee had a special closed-door meeting with youth and families with firsthand experience dealing with mental health issues. To respect confidentiality, the names of the participants are not being disclosed. However, I would like to take this opportunity to thank everyone who took part. It was very important for us to hear directly from people affected by youth mental health. On behalf of the committee, thank you for coming forward and sharing your personal experiences with us. We are extremely grateful.

I'd also like to express thanks to Dr. Cindy Holdsworth. Dr. Holdsworth provided professional psychiatric support during the meeting and helped us create a safe and respectful setting where witnesses could speak openly about their challenges.

Today we have a full slate of ten presenters that have been invited for their expertise and experience working in the field of youth mental health. They come from a range of backgrounds and include mental health professionals, service providers and academic experts. Thank you to everyone who agreed to participate. We look forward to hearing from you.

I'd also like to remind everyone that the committee is accepting written submissions. Anyone who is interested can share their ideas in writing until the deadline of Friday, July 25. To make a submission or learn more about the work of the committee, please visit our website, www.leg.bc.ca/cmt/cay.

I'll now ask the committee members to introduce themselves, starting with the Deputy Chair, to my left.

C. James (Deputy Chair): Thank you very much. Carole James. I'm the MLA for Victoria–Beacon Hill and the critic for Children and Families.

M. Karagianis: Good morning. I'm Maurine Karagianis. I'm the MLA for Esquimalt–Royal Roads, on the Island, and I am the critic for women's issues, child care and early learning.

D. Donaldson: Good morning, everyone. Doug Donaldson, MLA for Stikine, in the northwest part of the province. My critic portfolio is Aboriginal Relations.

J. Rice: Hello, I'm Jennifer Rice. I'm the MLA for North Coast. I'm the critic for northern and rural health and a deputy critic for Children and Family Development.

D. Barnett: Good morning. I'm Donna Barnett, and I'm the MLA for Cariboo-Chilcotin.

K. Ryan-Lloyd (Deputy Clerk and Clerk of Committees): Good morning. My name is Kate Ryan-Lloyd. I'm the Clerk to the committee.

J. Thornthwaite (Chair): Special thanks also go to Kate and her staff, as well as Hansard, for coming over to Vancouver to allow these proceedings to occur here.

Today's proceedings will consist of 20-minute presentations from each of our invited witnesses. Each presentation will be followed by 20 minutes for questions by committee members. The proceedings are being recorded by Hansard Services, and a transcript of the entire meeting will be made available on our website.

With that, I will now turn over the floor to our first invited presenter, Dr. Steve Mathias.

S. Mathias: Thank you very much. I'm happy to be here, hoping that certainly by the end of the 20 minutes you'll have a greater understanding of some of the issues that I see facing not so much our children as our youth. I think that's a focus that I've had in my career now.

I'm a child and adolescent psychiatrist, trained here at the University of British Columbia and then fellowship-trained at the University of Melbourne in Australia. I have a fellowship in child and adolescent psychiatry, and I also have completed training in concurrent disorders or addictions, which is probably fitting given the population I tend to see.

I am the medical manager and the founder of the inner-city youth program, which is an outreach service from the St. Paul's Hospital where we see marginally housed and homeless youth, and we have been doing so for about seven years. I think I have some experience with the gaps in services that we have seen emerge with this population. I'm also the infant, child and youth mental health and addictions lead for the regional program at Vancouver Coastal Health.

I'm just going to jump into my presentation. The background — I'm sure most of you are aware that 75 percent of mental health problems occur before the age of 25. This is something to think about. If we had cancer appearing by the age of 25, we would have a great deal of services focusing on this population.

Mental health symptoms typically present starting in teenage years, and substance-use issues — about 80 percent of them — will present by the age of 20. Now, whereas 14 percent of young people aged 12 to 17 will have a mental health problem in any given year, a quarter of people aged between 18 and 24 will suffer from mental health issues. Mental health and substance-use disorders account for about 60 percent of the non-fatal burden of disease among young people aged 15 to 34.

Experientially, I don't think there's a graphic that's ever really summarized this issue as much as this one. If you look across the lifespan of disability, each colour represents a different disability type. Yellow represents mental health and substance-use disability. Really, when you look at the age between 12 and 30, maybe even to 35, yellow is by far the greatest cause of disability in this population. Yet really, at this point, is where we see the least number of services.

Less than 20 percent of youth with mental health concerns access treatment. Less than 2 percent with mental health concerns will actually access specialist care — one in 50. Youth have limited access to GPs, and we know that youth mental health services are fractured at the worst-possible point of transition. I think Stan Kutcher probably summarized this best when he said "a non-system of non-care." It's as if every door is the wrong door on clear entry points. Parents are often the de facto case managers, or at least that's their experience.

Our fragmented services have no overlap in models of care. They really don't. I think it's akin to this: having a young person looking to buy a car. The first car they've just had was, you know, a four-door Toyota Corolla — buzzing around town with that. They go to the car lot, and all they have as an option is a family van. We expect that young person, that 21- or 22-year-old, to jump into the family van.

The family van meets different needs. It's a different vehicle. And that's what adult mental health services are. They're designed for chronically ill individuals — average age of 40 to 45 — and we're asking young people to access adult mental health services when they graduate from child services.

We keep talking about not having transition protocols or being able to transition young people from child services to adult services properly. That's not the issue. The issue is that we're asking them to buy family vans. We're asking them to access and use services that are not designed for them.

At MCFD we have a child and adolescent psychiatrist for every 11,000 children. The standard is for every 4,000. We have a significant deficit in child and adolescent psychiatrists. We're not graduating enough, and the funding for the fellowships for child and adolescent psychiatry is annual, year to year. They're not guaranteed year to year. So they vacillate between three and four on an annual basis, and they do not have long-term funding.

The Ministry of Health provides in-patient services. Often pediatric units are where you'll find our youth when they come into hospital. If you're 16 or below, you come into a pediatric unit. You can think about a manic young man masturbating every hour next to a family struggling with a nine-month-old with respiratory syncytial virus. That happens in our pediatric units. It's not the right place for the nine-month-old; it's not the right place for the 16-year-old. But that's where we put them.

When they turn 17, we have a choice of any one of 14 units in the Vancouver Coastal Health Authority area, none of them designed for youth. So 17-year-olds are being co-located with adults — 35, 45, 55 — who have histories of chronic mental illness. That is sometimes the first experience that our young people have when they come into hospital.

Our GPs and pediatricians have identified that there's a massive knowledge gap in this area, but they're often the first door that young people will walk through. Our social services often have time-limited funding and run in a parallel system that's not integrated with our health authorities.

Our transition points are fraught with gaps and barriers. We have multiple electronic record systems, which I'm sure you're well aware of, sometimes within the same
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health authority.

The gap occurs at a time that's most critical in the development of these young people. It leads to lower educational achievement, substance use and abuse, violence, poor reproductive and sexual health, impaired or unstable employment, poor family social functioning, exposure to stigma and discrimination, and mortality through suicide.

Let's not forget that the second leading cause of death in this population is by suicide. Cancer kills one-third of the suicide rate. So kids are three times more likely to die of suicide than they are of cancer.

This is where I need your help, because I'm still struggling to understand this. In British Columbia we invest in child mental health to the tune of $78 million at the MCFD level. It makes up 0.45 percent of our health budget. By 2016-17, if you look at the document put out by MCFD, those numbers aren't expected to change, whereas the health budget is expected to increase by $2.5 billion. So our share will drop to 0.41 percent.

We already know that approximately one in three youth in this province gets services, whereas two in three do not. Those are statistics shared with us by Stephen Brown about a year and a bit ago, when he was deputy minister of MCFD.

Where I struggle, though, is that early-years services get $256 million, and this is expected to go up by $50 million in the next three years. So we're investing in early-years services. The issue for me is that early-years services have never been shown to change the course of bipolar disorder, nor has it ever been shown to change the course of schizophrenia, depression or anxiety in any meaningful way when you look at the numbers that we're talking about.

Special needs receives about $301 million; children in care about $498 million. But I don't think this is the issue because we at least invest $78 million in child and youth mental health, or about $3,000 per person receiving services. But when we actually look at youth mental health, 17 to 25, we have no money earmarked for this population. We have approximately 125,000 youth in need with no in-patient units, no designated community access points with the exception of student health, no integrated models of care and with early psychosis intervention being the only specialized intervention for this age group.

What does this look like on the ground? I asked my colleagues to look at the Vancouver community mental health teams, to look at the numbers that we have in our mental health teams. Mental health teams are places with specialized care, places where adults are supposed to go to get services.

I asked a simple question. What proportion of clients are aged 19 to 24 in the mental health teams designed to serve adults with mental health problems? When you include the numbers from the early psychosis intervention programs, this is what you get: 311 of 6,000. So 5.2 percent of our community mental teams in Vancouver Coastal have youth between the ages of 19 and 24. We have 125,000 kids in this province that have mental health problems and are in this population. This is what our answer is with our community mental health teams.

It gets better. If you take out the kids getting the early psychosis intervention treatment, the 150 kids in this age category, this is what you're left with: 158 young people out of 5,700, or about 2.5 percent.

This is why we have a gap in services. You could argue that it's not actually a gap. It's an absence of services. So where do they go? Well, look no further than an emergency room. This is where they show up, folks, and we know that. It's getting worse. Since 2008-2009 it's almost tripled in terms of numbers. Certainly, it's doubled. We're seeing more and more young people between the ages of 17 and 24 coming into emergency rooms, looking for help.

I think it's fair to say that for most of us in this room, if we had a young person looking for help, the emergency room would be the first place to go. It's no fault of the emergency rooms, but they're not designed to help young people with mental health and addiction problems. But this is where they go.

When you ask folks, "What are the barriers?" what do they say? Well, the first thing they say is that they hoped that the problem would go away. So 56 percent answered that, which is interesting, because I was at my chiropractor's office the other day, and there was a sign that was on the wall that said that 50 percent of people just hope that their back pain would go away. So I actually think that this is not something that is reserved for mental health. I think it's reserved for a lot of health issues.

But then the next thing is: "Didn't want parents to know." Interestingly enough, parents are often the first people they'll actually go to. So there's somewhat of a dichotomous idea there.

"Didn't know where to go" — which I think is really concerning. What that heralds for me is…. Are we advertising mental health services in this province? I'm not sure if any of you guys take a bus, but some of us do. When was the last time you were at the SeaBus terminal or a B.C Transit bus stop and you saw advertising for a young person that stated to them where they could go for help? They don't exist.

MCFD does not advertise youth services, nor does the health authority. They don't know where to go because we don't tell them where to go. They're afraid that "someone I know might see me," afraid of what a doctor might say or do or "I didn't think I could afford it."

We talk about stigma, but I think we have to move beyond the conversation of stigma. I think we've de-stigmatized mental health to an extent, but in the absence of services designed for youth, we are stigmatizing mental health. If we're telling someone, "You're ill, and you
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have to go to the emergency room as your first stop for this illness," we have stigmatized it. If we're telling someone that they have to hang out with folks who have been ill for 20 to 30 years and they're four months into their first psychotic episode, we are stigmatizing mental illness. We continue to do that here.

This, I believe, is the confusion. Secondary services, tertiary services — how do we get there? Well, I think I've shown that we don't actually ever get there.

I come from the inner-city youth program, and the inner-city youth program was designed basically to pick up the homeless and marginally housed youth that were coming in to our streets. What we discovered was that the youth were being discharged from the emergency room at St. Paul's Hospital without any follow-up. Last year we had close to 1,800 young people present with mental health and addiction issues. One in five individuals walking through the emerg with mental health and addictions were young people.

Unfortunately, up to about six or seven years ago they had nowhere to go. So we designed a program specifically dealing with that population, working in shelters, working as an outreach team, and we started to understand what the challenges were.

First of all, CLBC doesn't work. CLBC does not work in this province. We have young people who we pick up who do not come with a sign saying that they have intellectual disability or severe cognitive disorders. We discover that, and when we discover that, it takes sometimes 2½ years and counting to get any kind of services from CLBC, because once you house someone, even in low-barrier housing, CLBC decides that they fall down the list of priorities.

Over that 2½-year period we have youth who become gang involved. We have youth who get beaten up. We have youth who become victimized. We have youth who become sexually assaulted. That's because we can't move them through.

One of the populations that we see are neurocognitively delayed folks. They've come to us and become homeless because there was no neuropsych testing in school, and then they dropped out when they were 14 or 15 because they got too frustrated, and they moved on.

We have youth with substance-use disorders who were told: "You've got to hit rock bottom before we can actually help you." We have youth with mental illness that tried to get help but were turned off or were turned away, and we certainly have the foster care kids. About 40 percent of our youth come from ministry care.

So the youth are there, and they have various problems, and they have various pathways to homelessness. There's not one pathway to become homeless. But we struggle, because it's so overwhelming.

Last Tuesday morning we had five referrals by noon. We're averaging a referral a day of young people who are homeless and marginally housed.

What we did is we designed a service. We started off with grants and donations, and finally, hallelujah, last November we got some funding from the Ministry of Health, which was fantastic.

We have ten nurses and social workers, psychiatrists and a psychosocial rehab team committed to this issue, and we support 80 low-barrier housing units in partnership with B.C. Housing.

This is the biggest program of its kind in North America, and we have it here in Vancouver, so we need to talk about it. We have strong partnerships with social services. We partner with Covenant House and Coast Mental Health. This is a model, I think, that works.

The ideal is that you move people through. You move them from primary care to secondary care to tertiary services. There are models out there that exist. I think that we need to look at these models, and we need to think of them for our children and youth.

The idea that we continue to revamp MCFD and we continue to revamp child services and put transition protocols and the exact same money into this population and think that we're going to have a different outcome is the definition of insanity. I'm telling you right now. We've been insane on this issue for several years now.

When I look around the world and look at promising models, I look at headspace and Headstrong, models of care that have been introduced in various jurisdictions — Australia, Israel, Denmark, Ireland, United States.

Now, the first people to look at this criticized it and said: "Well, we don't need an Australian model. Why would we look at Australia? Why don't we do something here?" Well, interestingly enough, Australia has very similar demographics to us. They have aboriginal populations, they have families, they have children, and they have immigrant populations — very similar to us.

They also have seven years of experience with this model. So when you sit down with them, they'll tell you where they screwed up. They'll tell you where they've made the mistakes, and they'll tell you what to do differently. We don't have to reinvent the wheel. We can actually get guidance from other folks.

This is what the inside of a mental health team looks like. Unlike a North Vancouver mental health team that I walked into the other day — which was a brown door that I had to be buzzed into, a concrete staircase that smelled like urine to get up to the second floor and get buzzed in again, and the first door I saw was a washroom — this is what these centres look like.

They're bright. They're welcoming. They're youth-friendly. If you're 30-plus, you feel a little bit uncomfortable in these centres. Welcoming staff, obviously. Bright colours. Have you ever seen a doctor's office that looked like this? Have you ever seen a mental health team that looks like this? This is what they've invested in with their population.
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It started in 2006 as a national youth mental health initiative. The federal government initially funded 30 communities of youth services, and they've gone from there to 60 that are now in existence. They've also added an eheadspace, which I'll talk to in a minute.

They've invested about $245 million and counting in this area. Their objective is to have 100 centres with 16 EPPIC Centres, early psychosis intervention centres, linked to what they call EPPIC Centres — large centres where youth can get help and specialized care.

In smaller communities they may have sort of a small storefront where you can see an alcohol and drug counsellor, a mental health clinician, and you might be able to get some help from central services. The idea is that this is a model that works for both urban and rural, and it's a plan. It's an actual model of care.

Their stated goals are to increase access to mental health and addiction services, have service cohesion and quality, and have health and social outcomes. They have minimum data sets, so they're actually collecting data.

They have a lead agency. It doesn't have to be health, but it's a lead agency — wherever they are — that takes charge of the centre and that creates the collaborations and the partnerships with other social services to create these centres.

The health services on site are general practitioners, psychologists, psychiatrists, social workers, mental health nurses, sexual health nurses, vocational consultants. Here in Vancouver those are in five or six different buildings. That's how we've partitioned all of these services.

A young person who sees a GP and is told to show up for an alcohol or drug counselling service has to go to a different building, and they don't show up. Same with alcohol and drug counselling — they go to a counsellor, and then they get set up for a mental health appointment three months later, and they don't show up.

That's just the way youth are. We have to wrap our heads around it. They like integrated services. They want things under one roof, and we need to offer that to them.

The eheadspace also has an on-line counselling service with vocational, family and mental health services. You actually get counselling. It's not a referral service.

They have school inreach. They have a national anti-stigma awareness campaign. They've created a strong brand, which in Australia is the second-most-recognized brand for mental health services, second only to beyondblue. And beyondblue is there strictly for that — brand recognition for mood and anxiety disorders. They've created brand recognition, which I think is so critical for youth.

Their evaluation is actually quite strong. Each one of these centres sees about 1,000 to 1,200 individual youth per centre, and that's growing. Nearly half are male. That's important, because men do not access mental health services. Boys do not access them. Yet they are the ones who are carrying the mental health burden forward. They really are.

This is a model that seems to pull in a lot of young people, a lot of young men. Forty percent were self-referrals. They come in off the street. They don't need to go see a GP first. They don't need to go somewhere else. They just come in off the street. Thirty percent are also referred by primary care.

And eheadspace, which is this on-line component I mentioned, has 3,000 new youth per month signing up. They have 60 counsellors dedicated to this service. Again, they've got a group of kids that are unwell, that are struggling — about six to eight times what you would expect in a population in terms of psychosis presentation. Lots of depressed youth, lots of distressed youth.

It's not only mental illness. Kids struggle. They need counselling, and they can go there and access the counselling. When they do, you start to prevent the onset of future depression, future disability. This is the ideal.

These are my recommendations. I threw this out there to the West Van community last week. It was one of those funny moments. I actually quoted Gandhi before I threw them out. I said that first they laughed at me, then they ignored me, then they attacked me, and then I won. So here goes.

B.C. needs a minister of youth health. That was the representative's recommendation over a year ago. We do need a minister of youth health. We need somebody who's going to take charge of this issue. We can't keep expecting MCFD to do this, and we certainly can't expect the Ministry of Health to carve out a chunk of their budget without someone who has some sort of authority over this issue.

We need to invest in our youth. This is what I'm suggesting as a starting point: that we invest $100 million, or 0.5 percent, of the Health budget on youth mental health. Now, the Health budget is scheduled to increase from $17 billion to, I believe, $19.5 billion in the next couple of years. Let's put $100 million aside for the youth.

Let's really start thinking about what we can do for this population. Let's start making a difference for these guys. The money should focus on 12- to 25-year-olds. I'd like to see us open 15 to 20 integrated health centres for youth across the province, similar to but not the same as the headspace model.

I'd like to see us back-end clinics with early psychosis and intensive case management services. For those youth who are already in trouble, we'd put boots on the ground for these kids. I'd like to see us establish transition services with focus on community reintegration, not on transition to an adult mental health team. That's not what we should be doing.

We shouldn't be focusing on transitioning kids to adult services. We should be focused on transitioning kids to community and reintegration and psychosocial rehabilitation and focusing on cognitive learning disabilities and
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severe illness and making sure that these kids don't fall through the cracks and end up on our streets.

We create a minimum data set. We monitor outcomes, and we hold agencies — their feet — to the fire when they're providing these services, which we don't do in this province.

Fund on-line counselling and referral services. Incorporate telemedicine in all our centres. Partner with other provinces on the issue of youth health, and brand services which incorporate anti-stigma and awareness dissemination.

Now, I'm not volunteering for this position, but I'll certainly consult with anyone who gets it. Why? Because there's a return on our investment, folks. This has been clear for a long time, which is why I don't get why we don't do this. If we don't, by 2041 we are going to be crippled by the number of folks with mental illness — not so much dementia but people with mental illness in their 50s, 60s and 70s that will cripple our system. We're not talking about that burden.

For every dollar that we spend on treatment, we save $3.60. For every dollar we spend on best practice, we save five bucks at the end. Improving a child's mental health from moderate to high has been found to result in lifetime savings of $140,000. Two years ago we took 22 kids off the streets in two weeks. We had rooms that had come available. In two weeks we took $1 million off the docket for Health, because that's the cost of a homeless person: $50,000 per. I was just taking 20 homeless kids and putting them into housing. It's not rocket science, but it does require an investment.

I would really like us to think about this concept of recovery referring to living a satisfying, hopeful and meaningful life even when there are ongoing limitations caused by mental health problems. With the right combination of services, treatments and support, many people who are living with even the most severe mental illness can experience significant improvements in symptoms and quality of life. I believe that, because I see it all the time with the young people that we work with.

The future for our program is exactly what I've just described. We will be attempting to open an integrated health centre. We have the back end. We have the intensive case management. We're now looking at adding primary care, addiction and counselling to the program that we already have. We're planning on opening this up in October, hopefully, or November. I think Premier Clark will, hopefully, be invited to be there, because they have funded the clinic space.

This is something that we will do. We'll do one in this province, but I'd really like to see us do more. Alberta, Ontario and Quebec are very interested in this, and there is a commitment growing right now to do this in their provinces — to have these integrated youth health hubs there. I think we should do this in B.C., but it's going to take a commitment, and a financial one, to do it.

J. Thornthwaite (Chair): Thank you very much. That was really good — very short and sweet and succinct. I just have a quick question before we go to Darryl. When you say that you would like to invest in these integrated clinics, you said your goal would be to be similar but not the same as the headspace. Can you describe what you would do better?

S. Mathias: I would have a lot more family involvement, family engagement. They're very good at peer engagement, and the youth really direct the colours and the logo-ing. I think that we would certainly look at collecting data and evaluating the services a lot sooner than they did. They waited a few years before they actually did that, so they fell behind.

I think that the other thing, too, is that our model is slightly different than theirs in that the federal government in Australia pays for psychologists, psychiatrists and social workers. So the funding is federal in a lot of places in the clinic. We have to have a slightly different funding model, but I think that it's very doable here.

D. Plecas: Steve, thanks for the presentation. It's pretty obvious that there's a gap there, a pretty significant one. I like your recommendations. The problem, as you know, is: when does it end? Will we ever have enough money to come close to what the need is?

When I think about the need, as you describe it, it's one in four young people. I also heard recently that one in five British Columbians present themselves with a mental health issue to a doctor each year. It's just so hard for me to wrap my head around how that could be true. Maybe you could tell us: what are we talking about when we're talking about mental health issues?

What percentage of these are actually described as serious? We're not talking about anxiety and depression — not that that isn't serious, of course. It seems to me that if we're really talking about one in four, and there are some indications that this is going to increase despite our best efforts, we're not going to get a handle on this problem.

S. Mathias: No, you're right. You know, when you look at, say, the 125,000, that group of youth with mental health concerns, you would probably say that about 35,000 to 50,000 of those have pretty severe mental illness — moderate to severe mental illness.

There's going to be mild. You're going to have mild. But in terms of moderate, we're starting to push it up because we're not addressing the mild. We're not getting to the mood and anxiety. We're not getting to those young people who start to self-medicate with cannabis at the age of 16 or 17 because they have anxiety and it's
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not getting addressed.

There are some really interesting statistics from the Mental Health Commission looking at if you invested enough to just start addressing 10 percent of this issue and what you could actually do in terms of the financial impact and the social impact.

Going back to those community mental health teams, it's not that…. We just have no services for these guys. We're not even able to do early intervention or prevention, because we've got no model for it, which is kind of nice, actually, because that means you can do anything. You don't have to section 54 anyone. You don't to have to kind of move services around. You can start something fresh and do something right.

You're right. We're always going to have mental health concerns, but the sooner people get help, the better.

You sort of touched on it — the whole matter of the relationship between drugs and mental health. There are 1,800 people you say you dealt with last year. How many of those 1,800 came to you with an addiction issue or a drug use issue, as well as their mental health issue?

S. Mathias: I'm just going to go back to the slide that breaks that down. When you look at this population here, you're looking at probably about 20 to 30 percent that are related to substances. It varies, depending on which hospital you're at. These numbers are, you know, all comers. But addictions are not nearly the player that we're concerned about here. This is underlying mental health issues that are layered with addictions on top of them.

I think of the path that I see where kids with neurocognitive deficits, learning disabilities, are kind of passed on, year after year, and don't actually get the help that they need. By the age of 14 or 15 they're so frustrated in school — they're falling behind — that they start to smoke weed and they start to get anxious.

By the time we see them at 17, 18, 21 or 22, they've got seven or eight years of cannabis on board, with an underlying anxiety. Then they start getting psychotic, right? The problem now is that at five and seven years, you're not talking about smoking too much weed in one sitting and you're psychotic because of it. It's because you've had seven years of cannabis washing over your neurons, and your neurons have changed so they work differently. So we have new-onset psychotic features and new-onset psychotic disorders, because we didn't do anything upstream.

Whether the addiction…. You can wash substances out of someone's system, but they're still going to be anxious, they're still going to be depressed, and they're still going to be psychotic in a lot of cases. We see that all the time.

Given the relationship between cannabis use, especially amongst young people, and mental health issues and psychosis — it's my understanding that that's fairly well documented now in the research — one wonders why we don't have a stronger voice against cannabis use from the medical profession or people in mental health. What am I missing there?

S. Mathias: I think that what's missing is that a lot of our folks in addictions don't have mental health backgrounds, quite frankly. I think that's a recurring theme, from what we've seen — that we have to do a better job of developing addiction psychiatry as a field in this province. I think this is an area where…. Most of the psychiatrists I'm working with on my team have a very strong addiction background, so they understand the interplay.

Number 1, the shortage of psychiatrists. Given that this government funds residency training and fellowships, what happens when you go to interact with the medical school around residency training spots and the fact that there's a need? In other words, why don't we have more spots?

S. Mathias: That's a Ministry of Health decision. As far as I understand, it's at the Ministry of Health level. Recruitment is an issue, too, because with this population it makes more sense to put them on service contracts. The service contracts that have been tendered, as far as I understand, have an opportunity to range between 1,600 and 2,400 hours a year.

Whoever has written the contracts has decided that it should be 2,000, and a lot of psychiatrists would like to not work 2,000 hours. They'd like to work closer to 1,600. We've lost a lot of recruitment opportunities because of that. So there are some basic policy issues that get in the way.

The second thing is that I was interested in the Australian model that seemed to have…. You indicated that it was looked at to work in rural areas as well, which is a very important issue in B.C., as you know. So I want to link that to telehealth. I don't know if it's in your experience what our current telehealth offerings are. Is there another place…? I understand, for example, Ontario has an excellent telepsychiatry program. What would you say about telepsychiatry in general?

S. Mathias: Well, I think it's underutilized, definitely. If you look at trying to get…. As Darryl mentioned, I think that if you've got this very large burden, you need to get the expertise out there. Certainly, we need to do a better job of shared care and training our GPs and training our
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pediatricians, for instance, in this domain.

I think that what I like about this model is that it allows you to have centres of excellence in towns where you're dealing with young people. You can have an overlying e–mental health component which starts to address the mildly anxious and depressed young people, and you can actually start to see the more complex folks using telepsychiatry.

M. Stilwell: I just want to emphasize that I understood that the e-health model in Australia is counselling. It's not just a referral line.

S. Mathias: No. It's counselling. It's not a referral process. They can help direct kids to storefronts.

S. Mathias: It's an actual…. They have mental health counsellors. Again, when you talk about how we could do things differently here, I think a lot of that centralized brain trust could actually do telepsychiatry as well, and that's not something that they're doing yet there.

I'm reminded of an article that's in press with the Canadian Journal of Community Mental Health — that youth from impoverished backgrounds are three times more likely than their wealthier peers to experience mental health challenges. So I congratulate you on the housing approach, which is one aspect of impoverishment. I think there's a lot more to be done there.

My question follows along the lines of Moira's around telemedicine and your slide that was up on that. I come and represent remote rural northern communities. I'm curious. I'm interested in studies about the efficacy of telepsychiatry. I have encountered some skepticism from pediatricians in my area around how effective it is as a tool, a means. It's obviously not as effective as in person. What are your thoughts on that?

S. Mathias: I provide telepsychiatry services to Portage, which is a treatment centre in Keremeos for young people with addictions. As it turns out, a lot of them have mental health issues. It's quite effective. It may not be as effective for pediatricians, but I think the technology can catch up. Certainly, you can have nurses or nurse practitioners on the ground doing physical exams, with pediatricians sitting in on a telepsychiatry.

This is part of the issue too: looking ahead, how do we use nurse practitioners, right? I think nurse practitioners are going to be an incredible resource if we use them right. I think these are situations, with telepsychiatry, where you can have nurse practitioners in rural settings linked in to care networks of pediatricians and specialists that could support that.

As far as psychiatry goes, I actually find — and this is anecdotal — that about 85 to 90 percent of the youth that I work with are fine with it. The first thing I say is: "You know, I wish I could give you a joystick so that you could blow up my head, and you'd probably enjoy this a lot more. But let's see how it goes." And usually by about ten or 15 minutes in, they're enjoying it. We can do very good care as long as we have a nurse on the ground that's supporting us.

D. Barnett: Thank you for your presentation. It appears that we still are working in silos in government, when I see what you've presented here.

One of the questions and concerns I have is for your project that you've put together and the funders that you have, both with government and other. Is this a one-time funding at this point, or has the ministry committed ongoing funding?

S. Mathias: We've been lucky. Until November last year…. This was announced under the SAMI announcements, the severely addicted and mentally ill population, the 120-day kind of timeline stuff that came out in November. At that point we were 90 percent funded by donors, and with the annualized funding, that has shifted to 40 percent. But the money committed by the Ministry of Health, as far as I know, is annualized.

C. James (Deputy Chair): Thank you, Steve, for your presentation. Thank you for reinforcing what I think we've heard over the last couple of days, which is that we need a system that meets the needs of the youth and the families, instead of the youth and the families having to meet the needs of the system.

I think you've emphasized the issue of youth-focused — whether it's the space, whether it's the branding, whether it's telehealth. I think that's a perfect example where the adults feel more uncomfortable about it than the youth do.

The one area you haven't mentioned that I'd be interested in, which a lot of people talked about, is often the first place where youth connect around some mental health issues — maybe having a school, an education. I wonder if you have looked at all at the headspace program or otherwise — about how they connect with the education system and how they connect with school.

S. Mathias: Going back to how we would do things differently…. One of the strengths of the initial collaboration that this created is to decide who the lead agency is and then how it moves forward. That collaboration has the opportunity to bring schools in and to look at how they link into schools.
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The fact is that when you ask a 15-year-old where they want to get help, they often will tell you they don't want it in school, for whatever reason. They don't want to step out of class to get counselling. They don't want peers to know. They don't necessarily feel like that's where they want it. They want school to be school — right? — which is kind of like me. Would I want my counselling service to be down the hall from where I work? Not necessarily. Some kids really do like that. Other kids really scream at it.

What's interesting about headspace is that they had far more younger teens using the service than they expected. So for whatever reason, the 14- and 15-year-olds like this type of space. I think it's critical that it's integrated in schools.

I would really like to see neuropsych and neurocog testing brought back and that we start thinking about how we can integrate what we learn from that into communicating it to the families and parents and communicating it to youth to understand what it means to have processing speed in the first percentile, working memory in the first percentile. We don't do that. That really would incorporate schools.

I think early vocational programs need to be incorporated into this as well. My experience with so many of the vocational programs that we have is that they're too highbrow. They're not low barrier.

We're kidding ourselves. We send kids away. They manage to sit through four weeks of training. Then they have a job, and that's it. They go right back to where they were before. I see that as something that we haven't really kind of integrated into our model of care. Vocation and education really need to be integrated into all the services we provide with youth.

Siloing exists not only within Health, and from Health to MCFD, but within all the other services that fall under MSD. I think that that's something that we need to look at: how do we cross those silos?

That's why I really like the representative's idea. It seems crazy that we would have a minister of state for youth health. But when you look at all the ministries that are involved in that critical time, if you don't have somebody overseeing what's going on, there's just no way that you can guarantee and assure that you have the services that you need for those folks.

J. Thornthwaite (Chair): Thank you, Steve, very much. We're actually out of time. We're actually over time. We're officially ten minutes late. I appreciate your presentation. Could we get a copy of your presentation? Okay.

Then to give you one thing to perhaps respond on later with regards to the amount of…. You had a slide up there with regards to the funding that you're aware of that comes from different areas to do with child mental health. If you could give us an appreciation of: if we did provide the integrated services that you're requesting…. What I gather is that the model you're working on right now, with the opening that you're thinking of in October or November, would be one site. Is that correct?

J. Thornthwaite (Chair): So can you kind of give us a feeling of how much — if you know, with your expertise with the numbers that you showed us before — that would cost, given that, obviously, if we were to even consider an Australian model, we would have to consider areas in the rural areas as well. It would be a huge investment, but by the numbers that you've said, we're already spending that investment in other areas.

J. Thornthwaite (Chair): That would be appreciated. Thank you very much for coming.

Keli, you're from the Institute of Families for Child and Youth Mental Health, FORCE Society for Kids Mental Health. Thank you very much for coming. Carry on.

K. Anderson: Great. Thank you. I really appreciate the invitation to be here today. It's especially hard to follow Steve. Steve and I met several years ago with a family in particular that he was working with and I was trying to help.

At present I am the president and CEO of the national Institute of Families for Child and Youth Mental Health that I founded with Dr. Jana Davidson here in B.C. in 2010. Prior to that, I co-founded and was executive director of the FORCE Society for Kids Mental Health.

The FORCE came about because my son was at Children's Hospital. He was only ten, and he was in the psychiatric ward. I couldn't believe what I had stepped into. I thought: "I don't know if the public knows what it's like for families of children who have psychiatric issues." I went public with my story, and another mother saw me on TV. She had lost her son to suicide at 16.

She and I got together, and we talked about the loss of her son, and then we talked about preventing the death of my son, because our stories were almost exactly the same. When Steve talks about there being things in the early years, my experience with thousands of families in 14 years in this province is we don't have things in the early years for child and youth mental health.

For most of the parents that come into contact with
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me, their problems didn't start with their kids when they were teens. Their problems started when their kids were little, and they didn't get help. By the time they became teens, the problems were out of control, the family had imploded, the kid wasn't living at home anymore, and the parents were now dealing with young people who were coming home with substance use problems, stealing, threatening the family.

What I'm going to speak about today is where it really starts and the place that, after 14 years, I still can't believe we're not seeing — that if a kid shows up with anxiety at five, it's only got one place to go. I know for sure that my son would not be here as a thriving 25-year-old if I had not invested when he was ten. I know that. I've had families on my same journey who don't have their children anymore.

What I wanted to start with is where mine starts. I always start talking about my son and where he was, and that was at ten. But what I've never done before was actually lay out his journey that got us to ten and realizing that his problems actually started at birth, where I knew something wasn't quite right and he didn't settle, and I didn't know why he wasn't settling.

I would go to various people. Most of the time it was like: "You need to relax. It's something you're doing." It was never about what my husband was doing, though, which is an interesting thing that also exists in child and youth mental health. Usually it's about the mothers and something that we haven't done.

You're already new at the game. You're already feeling like: "I thought I knew what I was doing in parenting, but obviously, I don't know what I'm doing." But then you're also blamed and judged. I think that it's pervasive. It is part of what has stigmatized mental health. It's part of what has created the place where families divide over what to do.

At that very early juncture…. I would like to bring up the journey of just seeing how many touchpoints you have. I think that you raised it. One of them was school. Outside of the Ministry of Children and Family Development, the biggest challenge for families is schools.

I would say that for 90 percent of the families that come to us, their problem with their kids' mental health is their inability to be able to get something happening in the schools so that their kids can stay and attend. When they do attend, the schools don't know what they need to know. They don't know how to manage it, so the kid is either kicked out or ostracized or bullied by the other kids, and it becomes this very unhealthy place. It's no wonder.

We talk about putting up centres. I'm thinking: don't we already have schools? I know that lots of kids don't want their mental health services in schools. There were a couple of young guys in Cranbrook that did a video. They were talking about, in their schools, if they go into the clinic, into the centre in their school…. They said: "We'll say we're going in there because we think we hurt our leg, but what we're really talking to them about is 'I'm having suicidal thoughts.'"

I see that we need centres, but I also see that we've got centres in every community right now that are completely not connected into mental health. I'm the co-chair of the B.C. School Centred Mental Health Coalition. We talk about it all the time. How do we bring things out, from all out there where we're asking people to go to, and how do we bring them into our schools? The teachers want it. The parents want it. We don't have any connection anymore to be able to use our existing spaces.

For children, they are in the schools. That K to 7 — they're there. It was one of the places that we have found that when we've been able to connect families in…. Through the FORCE, we have 14 Parent in Residences that are in all the regions other than the north. What they do is they go and connect in with the schools, with the health care system, with the parents. They go and try to integrate so that the parents can come in the building, so the kids can come in the building, so they can work with the teachers on what the different needs are of the kids.

It is a role that, before we founded the FORCE, didn't exist in this province. After 14 years the capacity has become so big for the FORCE that without something different going forward for them, they won't be in this province anymore. Many of you have been around for a long time, and you will know that the child and youth mental health plan that we did in 2003 would not have been the same. It would not have been agreed to by treasury without the FORCE. We were strong advocates to have a child and youth mental plan in this province, and it wasn't just about youth. It was about children and their families.

We have just seen so many places where, if we had been able…. Even my own family. People look at me, and they go: "This couldn't have happened to you. You're so put together." The moms and I used to get together and call it the imposter syndrome. We'd show up at meetings all put together, and it looked like: "You can't be representing those families that have kids that are explosive." I remember one teacher saying to me: "You know, Mrs. Anderson, if you can't pick up your son's homework, I don't know how you expect us to give him an education."

That was in his school file. I didn't know at the time I could actually access the school file, which was great education. I looked at the date on that, and I realized that was one of the days that he had attempted suicide. I thought: "You might think you understand my life and think that at nine years old, this is not our life. This is our life."

It was in those moments that we realized how important it is to go out and connect with families so they're not so isolated. I don't think that people expect that anxiety and depression can kill in children. It does. My son
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wanted to kill himself at ten. His anxiety was so deep that he just couldn't take it anymore. That doesn't just happen in teens.

I have seen anxious kids at five that by the time they get to where the letter grades are in grade 4, their anxiety levels are off the charts in the schools. It gets worse, and then they get depressed. I'm thinking: "Why didn't we…? We knew that kid was anxious at five years old." We knew it. I knew it, and I had to wait until he wanted to take his life at ten to get him into the Children's Hospital. It made no sense to me.

When we look at the different things that we'd like this province to do…. I was going to go to some of your questions that you asked. One of them is: what are the gaps?

Well, I can tell you…. It still happens, and I'm hopeful it doesn't happen a lot. What families get for respite if you have a child with mental health challenges is you get foster care. You get a voluntary care agreement. Imagine when my son was ten and I said our situation, what they offered was they would take my son away or my daughter away. Now, I don't know how many of you are parents, but my children didn't need to be taken away from me. It happens all the time. We are offered voluntary care agreements. For people to not know that…. They need to know that. I'll never forget it.

This was my son. He looks like a lot of ten-year-olds. I'm going to step out from where Steve is. I'm actually asking: why are we waiting? Why are we waiting till they're teenagers? I can't stress to you enough how many parents come to us and say: "I knew it when they were children."

I just wanted to give you a couple of visuals. You did get them in handouts, but this gives you an idea of what my family's journey was. We ask families to draw out their journeys. We have rooms full of families that have drawn out their journeys like this. You can see how many touchpoints there are between pediatricians and doctors.

At Gymboree they told me: "Your son's not a fit here." Where do I go with that? "What do you mean he's not a fit?" But nothing offered to me as to what could be done for me. Five to nine gets a little bit worse. A few more people, the psycho-ed, the neurological test that Steve talked about. I knew my son needed a neuro test — an 18-month wait in our school system.

Can you imagine losing 18 months of a child's life at that point, knowing that there's something significantly wrong with him? So 18 months. If I had had to go and buy it myself, it was $2,500. I had already had to quit my job because of my son, so getting a test was out of the question.

Then, of course, it escalates to where we've got the police at our house. Imagine police coming and finding a little ten-year-old, and saying: "This is not the call we expected. Is anyone helping your family?" I said: "No, I'm trying to see a GP and a pediatrician, trying to figure our where we go, what we do with school. He's not really going to school anymore. Nobody even knows he's not going to school anymore. School hasn't phoned me in six months."

I'm showing this because it's one thing to talk about a story. I say to people it's not just my story; it's my life and my son's life and my husband's life and our daughter's life. There's no patient in children's mental health. The family's the patient. My son could not have taken care of his mental health needs at ten years old. Our whole family was impacted.

This is when I met the other mom, and I said, "What are we going to do?" because nobody's talking about children's mental health. A psychiatrist met us, and he said: "You girls need to start a non-profit." I had worked for Vancity for 14 years. I had worked my way up into HR. I had a great job, great benefits, pension.

I thought: "I only know how to make money. I only know what to do with money. What does non-profit mean?" I've learned what non-profit means now, in 14 years. We work ourselves seven days a week. We never turn away a family. We are absolutely exhausted, but it's the best work I've ever done.

The beauty of the work that we do is that we aren't just parents who are reaching out to other parents. We're actually reaching out to the systems and saying: "Can we talk to you about things that could be done differently, that would have a better impact on our families?"

That's how I met Steve Mathias. It's how I met Jana Davidson — sitting across from them with a parent who had a youth with mental health problems. What can we do to work together to really make a difference, for not just this family but maybe changing how we do work in the system? Jana and I had talked about modelling — modelling bringing professionals together with families — and that's why she and I started the Institute of Families. That was in 2010.

You've heard from Steve this morning on the places that we're failing. What I wanted to stress to you today is that we look at those, and we look at doing things earlier with children and families — much, much earlier — and that we lean in to them. I get a lot of parents who say to me: "Keli, I don't understand. They won't listen to me." I say: "Because when you talk, everyone is leaning away from you."

We try to mentor parents and say: "Invite people to lean in to you. You'll be heard." It's one of the things that I think we've done really, really well in this province, probably better than any other province in this country. The family voice in this province — it's really strong because of us.

We do. We invite people to lean in to us, because we don't think that you want things to be working the way they are. We don't either. How can we, together, say: "What can we do to make this difference?"

The tolerance level, I'll tell you, is…. We've been toler-
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ant for a really long time as families, and I can see that tolerance is waning.

People come to us a lot to say: "Keli, can you help us navigate this really challenging case or agenda?" Yeah, we will step into it. But we're always going to remember that we have to meet the needs of the families, and they know what they need. People tried to tell my family what I needed. What I really needed to do was I just needed to keep my son alive.

This is the FORCE. I'm going to give you a little bit of information on both. The FORCE was founded in 2000 by myself and another mother. Now we have the 14 parents-in-residence working for us, and we have two youth-in-residence, and they work at Children's Hospital and at the Kelty Centre.

When you think of it, the whole province has somewhere to phone. They phone in to Children's Hospital. It's a provincial line, but the people answering the phone are the FORCE employees. You have two parents-in-residence and two youth-in-residence taking the calls from all over the province. We have never had that in another province.

Last week I met with Kids Help Phone, and we were talking about what Kids Help Phone does versus what we do at the Kelty Centre. The difference is that we've got people with lived experience answering those calls.

I'll tell you, they know how to navigate a system better than anybody that works in it. They know every piece. They know the nuance. They can tell the youth and families: "This is what it's going to look like when you walk in here. Here's what you might be expecting is going to happen. That's not going to happen for you there. You need to go over there for that."

They are absolutely excellent navigators, and that's been the beauty of the partnership between the health services and the FORCE. It's not very normal circumstance that you would have non-hospital employees working in a hospital. So it's been a really great partnership with us. Thousands of families every year have a place to call, including all those families from the north. They have somewhere to call.

J. Thornthwaite (Chair): Keli, we want to have opportunities for people to ask questions.

K. Anderson: Where we've moved from the FORCE, which is very much about meeting families and working with the systems here, is that in the Institute of Families we have what we have started building the model for, which is FamilySmart. FamilySmart is about practice and policy.

It is very different than the work the FORCE has done. It is very much about us looking at what our current practices and policies are for children, youth and families in mental health and how those are being informed by children, youth and families.

We had a consensus conference on May 2 and 3, and we have now got consensus statements. From there, we are going to be building a model, and that model is not just for B.C. It's going to be for Canada. What we are explaining FamilySmart is…. It's been developed by families. It hasn't been developed by a system that says: "This is what FamilySmart is." It's about families and young people saying: "This is FamilySmart to us."

When we asked the young people in the room at the consensus conference what FamilySmart is to them, they said "caring adults." For them, they want caring adults in their life. We went: "If that's all we do, if we could just even do that in our schools…." On May 7 it was Child and Youth Mental Health Day, which was founded by myself and another mom. Our "I care about you"— that has had huge impact across the country in just bringing into our conversations in our schools the fact that we've got to step up. They need caring adults in their life, both at home and in schools and communities.

Your questions. When I was looking at your questions and gave them lots of thought and went back to the youth and parents that are in the FORCE to ask them these questions, it comes back to my point: please look at kids earlier.

We need to have a model of care. As Stan Kutcher said, it's a non-system of non-care. We actually don't have a model of care in this province. We have the fact that child and youth mental health is in the child protection ministry. I will say I was one of the people that was phoned back in the summer of 2004, I think, when it flipped for one day. Child and youth mental health flipped to Health from MCFD, and they called me and said: "Keli, what do you think?" I said: "I think it's the wrong time to flip it. We just got a child and youth mental health plan. The ink isn't even dry. Let's see how it works." That was ten years ago, and I can tell you it's not working for us for no reason other than the fact that all you have to offer for respite is a volunteer care agreement. It's disgusting.

Our B.C. schools have a key role in our kids' lives; I mean a key role. What are we doing? Well, all the protective factors…. The McCreary report was really clear about the role of schools and that kids want to be connected to their family and to their schools. That's what they said. Where are we putting the resources? Not into our schools and not into our families.

The Ministry of Children and Family Development — I'm not seeing a lot of family development. That's what my family needed. We had to do our own family development and go and pay for it.

Training and support. Steve mentioned it in his slide: people don't know what they don't know. They don't know what they don't know. Parents don't understand.
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Telling a kid to suck it up, because they're so anxious that they can't even leave the house. There's no sucking that up. How do we reach them? How do we talk to them about angst? How do we deal with families who are anxious? We can do all the work we can with the kids, but if we're not doing it in our homes, we've actually reversing any of the other stuff the kids might be learning.

The Friends program was a great example. When they brought it in the province for the schools, FORCE said: "You need a parent component." We can teach the kids the Friends in the classroom, but if you don't reinforce it with the parents at home, they can undo all the things that would actually help their kids.

That program — the schools can decide whether they want to do it or not. It's a hugely researched, effective program. Without them doing it in schools, we lag behind. We can't do it with the parents because it's not being done in the schools.

I love the fact that in the Interior the Child and Youth and Substance Use Collaborative has been so collaborative with us, with the FORCE. They want that collaborative to be driven and to be guided by the experience of young people and families. We have done that in a way that we've not done in any other way in this province.

When we talk about changing protocols, ER protocols and so forth, the youth and families are going: "Here's what it needs to look like for me." So the action teams are going: "We need to build our models based on what the youth and families say is important to them."

We are thrilled to be involved with the collaborative. It is a place; it is a model. Is it going to fix everything? No. But I'll tell you what it is forcing. It's forcing relationships, and it's enforcing partnerships. And one thing I can say when people say, "What has been your greatest learning, Keli, in 14 years? What has allowed you to move even the little bit that we've moved child and youth mental health?" — partnerships and relationships. It is, hands down, why my son is alive as well.

Every family says: "I had a relationship or a partnership with someone who cared about me." The young person will say: "The guy seemed interested in me. He was curious to ask me the questions nobody else has asked me." These are not things that are high-cost. But I'll tell you: in a way, they are, because they're invaluable. They're the very pieces we don't invest in. We don't invest in that stuff.

The FORCE has no way to gather the impact we've had because there's no money to measure the impact we've had. But I'll tell you: if you talk to the families, it's been pretty profound. And are they excited about FamilySmart? They're excited. That one we're going to make sure we start measuring. As Steve said, what do you learn from Australia? We're going to start measuring. There are lots of things we could be doing that have high impact, and we could be doing a lot sooner.

How about resources? Well, I can tell you that when we look at the things that we're measuring and some of the indicators, there aren't great indicators for child and youth mental health in this province or in this country. And none of them have been informed by young people and families.

So I say: "We're measuring what? We're measuring things that matter to who? And that's what we're going to invest in?" I say we've got to back up and — you know what? — figure out what it is we should be measuring. Lots of it has zero results for our families, so I don't know why we're doing it. And then saying, "We did it because we met this," but none of that matters to me.

I remember Jana Davidson told a story about a youth who came in and met all the criteria for severe depression. So she said: "You do all the screening, put him on the meds that were the medication he should have been on." He came back about four weeks later, six weeks later, was improving, seemed to be on the right track for treatment. And then Jana said: "So is there anything else that we need to talk about?" And he said: "I still can't go to school." "Oh. So that would have been an outcome that was really important to you."

A clinic doctor asked my son the other day: "So what do you take all these pills for?"

He went, "Huh. How is that for you?" and he leaned into him: "How is that for you?"

"You know, I'd be willing to take you on," and he goes: "That's if you decide you like me. You might walk out of here and then say, 'I don't like that dude.'"

It's that kind of stuff that we need to really…. There's the serious stuff that Steve's talking about, and it's not an and-or. It's both. It really is both.

We were talking about who's going to lead this in this province. I'll tell you. The children, the youth and the families — we sure want to lead this. I think it's right that they lead it, and I think that they're good partners for you. As I said, it's not about us sitting, expecting somebody else to do this, but we sure want to inform. We want to inform what gets done.

I think that we've been working really hard in this province. We've had lots of support from the government here. We need to have some leadership around this, whether or not it's a minister of state.

Personally, leaving children out of youth, to me, is a
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mistake. I know that the youth is a big problem, but I also know that if we start with children and we put our efforts, we may see a difference. We may see differences in what's happening with our youth if we can get to them earlier and get to their families. I sure hope there's going to be some kind of joint leadership that comes together around child and youth mental health and that you don't lose the child in the child and youth mental health.

J. Thornthwaite (Chair): Thank you very much, Keli, for a very impassioned presentation. We have a first question from Darryl.

D. Plecas: Well, Keli, you're such a wonderful spokesperson. We are so lucky to have you.

Can you tell us two things? In your mind, given that you've been at this for 14 years, what are the biggest hurdles that you find in terms of getting progress? Two, how much is it going to cost? How much money do you need to get some legs here?

K. Anderson: I would say the biggest hurdle is that there is no other place, if you have something so serious where you can't function, right? These kids are not functioning. They're not functioning at home, they're not functioning in schools, and they're not functioning in their communities. If that was happening in any place else, you would have a coordinated team that comes around that kid and family. That does not happen for us. There is no such thing as a coordinated, collaborative care model for child and youth mental health. Without that, that's a big problem.

What that's going to cost I don't know, but I certainly know that there are people like Steve and there are people like Val Tregillus. They've done the economic model. We're going to work on our own economic model around what would change if we had FamilySmart practice. We're going to overlay it with an economic model. Certainly, I could get that back to you, because we are working on that. That is what we need.

K. Anderson: Yeah. Over and over, someone's: "You've got to go here and here and here and here." None of it talks to each other, and I'm just sick of hearing that. We work in isolation. It shouldn't be tolerated anymore. There are too many kids and families imploding just because we don't know how, and we don't have a model that forces us to work together. How can we not be doing that?

M. Stilwell: Thank you for your presentation. Certainly, your plea for a coordinated system and easier navigation is a repetitive theme.

Another repetitive theme is mothers quitting their jobs. The people we've heard from so far have been mothers like you who have left good jobs to be their child's navigator and to keep their kids safe. Tell me about the families you deal with where there's only a mother, and she can't quit her job.

K. Anderson: Exactly. That's going to be part of our economic model. I was fortunate enough that I could quit. It didn't mean our life stayed the same. But we do have lots of families who can't quit their jobs. And do you know what? They're counting on…. On top of it, their kid's not going to school anymore, and they're on their fourth daycare, because no one can manage the kid.

So she's left with sometimes leaving the kid alone, sometimes getting anybody…. Grandparents, a huge contingent of external family, if you have it, have to come into your home and help you.

It is a really, really good question, and one that we are, again, with the economic model, looking at. What is this really costing us?

I'll tell you. I was contributing pretty good to the workplace. It's a different contribution in the non-profit now. But I'm going to become a consumer of the non-profit sector as a senior because I have no benefits, no pension. I have nothing. That's what happens to a lot of us who do leave our jobs and who come into the non-profit sector. So as you can see….

C. James (Deputy Chair): Thank you, Keli, for your presentation, and thank you for your work.

Just a question around access. I think you've identified it well. It's about relationships, and if you happen to make the right contact, you end up getting some support that you might not have known was out there.

How are people making contact with you or with FORCE right now? Where do you get most of your contacts from?

K. Anderson: We've got a good network. We don't advertise. Much like MCFD, if we advertised, we wouldn't be able to…. Where do they hear about us? They hear about us through the Kelty. They hear about us through their schools. We do lots of presentations to school districts. The schools don't know what to do with the families either, so they send all the families to us.

MCFD sends out our flyers for most of the people who do intake. Then those families connect in with us, and we literally carry them until they can get another service. But we don't take on cases. We absolutely can't.

The service we provide — people say they don't know
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how they would have done it without us. They're not alone anymore. They understand the system, and we are somewhere where they can keep coming back to. We don't say, "Okay, we're done with you now," because their kids get a little bit better. Then their kids fall back, and they come back to us. We're there for them.

It's word of mouth, mostly. Do we wish we could take on more? For sure. But in actual fact, we'll be taking on less.

M. Stilwell: I have one more question, Keli. One of the things that struck me about mothers with children who have problems and where mothers recognize that something is not right…. In the Dark Ages when I was training in medicine, one thing you learned in pediatrics, the foundation was: always listen to the mother.

I am wondering if you have thought about — obviously, you have much work on your plate — more collaborations and partners and training family physicians and pediatricians to listen about that.

K. Anderson: That's part of the FamilySmart. As we're looking at the rollout of the model of FamilySmart, there is absolutely a training and education piece there.

You would not believe the calibre of mothers that we have who have already started developing workshops, training — the things that had tremendous impact on them when they walked in: "Here are the questions you could have asked me that you didn't."

We're also talking to the next generation of parents — those young people right now, young men and young women, around 25 to 34. We're talking to them about the next generation of parents and what needs to happen for them to know more about mental health and what they need to know about their own mental health in raising a child.

It's such rewarding work, and it's so upstream. It's the place that, if we could get that right, you don't have a next generation coming in like I did, not knowing. My mother's anxiety was so…. I didn't know what it was called. So when I saw it in my son, I didn't know. I didn't know. I wished I'd known. But he'll know now, as the next generation of parents, and so will my daughter.

That's the piece where you're right. I think there is a tremendous amount of things that we could do around FamilySmart that could really change things from where they are now.

J. Thornthwaite (Chair): Thank you very much, Keli, for your presentation as well as for the huge amount of work that you're doing in trying to educate us all on what's going on and how we can improve things. I think you and all the other presenters…. There's a huge theme here, and we're getting many, many similar messages from all of the folks.

Just following up from what Darryl had asked and also what I had asked Steve, if we could quantify it, then it will give us a little bit more information to go the ministries — because it's not just one ministry — involved.

We really, really appreciate you coming in, and thanks very much for your work and your expertise.

J. Thornthwaite (Chair): The next presentation is from Jules Wilson from the Federation of B.C. Youth in Care Networks.

J. Thornthwaite (Chair): We'll resume our presentations. I'm happy to welcome Mr. Jules Wilson from the Federation of B.C. Youth in Care Networks. Welcome, Jules.

J. Wilson: Good morning. My name is Jules Wilson. I'm the executive director of the Federation of B.C. Youth in Care Networks. For myself and on behalf of the board and our membership, we're very honoured to be here today, in large part because we feel like we have a slightly different experience with child and youth mental health to share with all of you today and to hopefully help in your decision-making process.

What I'd like to do is sort of go through and start off and just briefly explain who our organization is. We're a youth-driven provincial non-profit organization that serves youth labelled "in and from care" between the ages of 14 and 24. One of the things that we've got as sort of a broad standing….

Our definition is: youth who have received government care. You could be adoption. You could be child and youth mental health. You could be in foster care. You could be involved with youth justice. We come across young people from a variety of different walks of life and different communities and their families as well. Really, our focus is on how we can improve their lives and their experiences.

We've been around now for 21 years. We're very happy about that. What I'd like, to start off, is to just explain how we come across our information so that you know where we're coming from and what our lens is and what our angle is.

Fundamental to all of the work we do in our organization is the concept of youth engagement. As much as possible, in all of our processes and procedures we in-
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volve young people. They're involved in planning around budgeting. They're involved with decision-making around strategic focus for the organization. They're involved in all aspects of our organization. They're on board committees. They help us run our key pieces of work.

They're sort of heavily woven into everything that we do, which is really great because when we have opportunities like this, we also get an opportunity to go back to them rather quickly and get some feedback.

One of the things that we recently did was a steering committee meeting, which is an opportunity to bring in young people in and from care between the ages of 14 and 24 from all across the province. Together we do consultations, we do workshops and a variety things like that. This little tidbit happened to be on the agenda for the SCM that I just got through on Sunday. We had some young people who were able to share, so you're getting, live and direct, their voices here. They had a lot of input into how to structure this. I think you'll see that as we move forward.

We also provide one-to-one support services. Through all of our encounters with young people, we're always asking: "How are you doing? Where you at? What's going on with your life?" Through that direct service planning, we gather their thoughts and information.

We're also an agency — one of the few out there — that don't cut off right at 19. We get to see them where they were at when they come in, around 14 and 15, and what their experiences are, what their challenges are. But we also get to see how they make it through that transition period and head off into adulthood. I can talk for days about that, but we'll get a bit of a sense of some of those issues as we're exploring the various questions that you guys have laid out.

We do outreach group presentations. We have a group of young people that are trained to go out and speak to other young people and community professionals. We also do research and reports at various times. We've done things like a report card whereby young people take a look at what the top five needs, issues and ideas are for young people in and from care.

At the same time, they sort of rank how well the Ministry of Children and Family Development is doing in that area, how well our organization is doing in that area, how well adult allies and young people are doing in that area, and then make recommendations for things that we can do differently to help move forward and improve their lives.

Belonging 4 Ever was a report that we had done, as well, exploring the concept of permanency, which I think cuts quite nicely into…. Child and youth mental health services have a big impact on what your outlook is for permanency and how well you can obtain that.

I'm just going to go over a few stats here, some of the basic realities for these young people that we're talking about. At any given moment you'll hear numbers between 8,000 and 10,000 children and youth in care. It varies.

On top of that, we have youth that are on what we call youth agreements. It's a separate arrangement by government with young people to help cover off their costs, but they're not formally in care and their parents still have some guardianship responsibilities. There are about 800 young people who fall into that — approximately 55 percent of children and youth in care at any given point. You hear between 50 and 55 percent, generally, are aboriginal children and youth, so there's an overrepresentation there.

In terms of youth that are aging out annually, the last stats that I got in January were that there are about 700 young people that they're anticipating. Then for those who are on agreements who will be turning 19, you're looking at 460.

Some more fun facts and realities for young people. Youth who age out of care and access income assistance within six months is about 47 percent. Youth who age out, access income assistance within six months and who also qualify for the criteria of persons-with-disabilities status is about 66 percent. Youth who are on agreements and turning 19 and accessing income assistance — you're looking at about 23 percent. So that would 23 percent of the 460 or the 700 that I had mentioned. These are all sort of relative to January.

Youth aging out of care without a high school diploma. Unfortunately, we're looking at about 67 percent. Same reality for youth who are on agreements who are turning 19 — still looking at about two-thirds of them who don't have high school diplomas at that time.

Percentage of youth who are in care and who are diagnosed with a mental health issue before the age of 19 is about 65 percent. Again, the concept of child and youth mental health, and those services are vitally important to this group.

The number of youth in and from care between the ages of 15 and 24…. There's about a 12 percent unemployment rate for those folks. At last count, the general population is a little more than half of that.

One of the big issues that youth in and from care have is sort of the concept of changing placements. In terms of changing placements, one of the big challenges there is that you're looking at trying to re-establish yourself in a new community, a new school. You may be moving further and further away from family contacts or key connections that you have and also with friends.

That piece is particularly important when you look at the impact on mental health. There were some comments that young people made on the weekend that I'll share with you later that are sort of like: "Yeah, it really hits you. Like, wow." This can be a big issue, right?

And 20 percent of youth in care in McCreary's adolescent health survey — I understand you're going to hear from
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McCreary later on, so I won't steal their thunder too much — reported experiencing three or more moves in the last 12 months. So you can imagine…. That's 20 percent of youth in care as per the McCreary survey, so not as per the earlier numbers that I provided for youth in care.

It's obviously self-reported. I believe there were about 30,000 respondents, and about 3,000 of those had indicated that they were youth in and from care.

Of course, we've had the RCY's report, the Representative for Children and Youth, On Their Own. This is just a really nice summary. Those that don't have transitional supports at age 19 are more likely to have mental health problems, become parents at an early age, experience trouble with employment, be involved in the criminal justice system, receive social assistance, experience homelessness and/or have substance abuse issues.

Obviously, we can do better in transitional supports. We'll talk about the recommendations that young people had around that, in terms of where to focus your resources, a little bit later on.

One of the things that I asked young people on the weekend was…. "I'm about to meet with a bunch of political folks who are examining this issue of child and youth mental health. What is something that you want them to keep in the back of their mind as I'm spitting out all this information to them? There's going to be a lot of stuff that's coming. I'm going to try to keep it your words as much as possible. What do you want them to know?"

They said: "You know what? We're worth the investment, and we're worth early intervention. We're not just worth helping out once a problem occurs. We want to live a healthy lifestyle. We want that opportunity. We're all unique, you know. We're not all cookie-cutters. We don't all have the same problems, the same challenges, and even though we may at times have similar problems or similar challenges, our ability to move through those varies with the type of support we get."

Living in care, unfortunately, they also said, hasn't necessarily been kind to their mental health. I think we looked at the number of placements and moves, and I'm sure it's pretty easy to figure out why that would be really, really challenging. Plus, generally, a large percentage of young people that are coming into care are as a result of some form of abuse or neglect, so there's already trauma at play — plus coming in, plus attachment. So significant challenges there.

They want to be successful. They want to transition into adulthood, and they want to be supported, and they want to know that they're loved and they're cared for and that people believe that they can make a positive contribution to society. They feel very strongly about that, and they speak out to the stigma.

For those of you who hopefully had an opportunity…. This is my quick plug. B.C. Child and Youth in Care Week was last week, and hopefully, people got an opportunity to either participate in a provincial event that came out or saw some other activities in their communities. It speaks specifically to the stigma issues that we'll explore a little bit more later.

Now getting into your four questions, I'll do my best to respond to them based on the information that I've collected, as I've mentioned, from board, staff, other reports and, most of all, young people.

Key challenges. Community Living B.C., the IQ requirement — always hear a lot of comments around that, the need for the combination of low adaptive functioning and an IQ 70 or below. On a good day, sometimes they don't hit 70, right? On a bad day…. Well, it's a different story. The adaptive functioning piece and the amount of weight that it's given in the assessment — most families believe that that's more significant.

Just to sort of qualify myself, as well, I was involved in delivering child protective services for a dozen years in this province before moving over to this position a couple of years back. I would have families, and I would be in the room when other resource workers would say: "You're going for your test tomorrow. I want you to stay up late. I want you to play video games, chat with your friends. We really need you to do poorly on this test tomorrow." It seems backwards that we would encourage somebody to be at their worst just so that they could get the help and support that they need. So that's a significant challenge, and I know there's been lots of discussion around the eligibility criteria for years.

Equitable services available across the province. Depending on who you talk to or what young people come to one of our steering committee meetings, we get a sense and a flavour of what's going on in their communities and what's accessible and what isn't.

Stigma of having a diagnosis and being a youth in care. A lot of young people will say to me, when we're talking about child and youth mental health, that people refer to them as whatever diagnosis they have. They don't even call them by their name. On top of that, you also have people who are marginalized who are being defined by, "Hey, you're bipolar," or "You've got schizophrenia," or what have you.

On top of that, they're also youth in care, so they feel the sort of judgment that goes along with that. They feel the instability that unfortunately comes with being a part of that system. On top of this, they've got this diagnosis that they're trying to manage amongst other competing interests that they may have based on their lifestyle choices, which also add to that.

Fewer service options. A lot of young people spoke around having accessibility to perhaps a clinician but not really being given a chance to sort of explore goodness of fit or getting a sense of who that person is. It's just: "Here's who you've got. You take it or you don't." It's not: being able to shop around or at least have a sense of who
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might be good for you in your situation before heading in.

Focus on crisis rather than on early intervention, the pharmacological approach. Young people speak quite strongly about feeling like they're just pumped up on a lot of meds and that other aspects of their health and well-being are ignored, and other aspects that could possibly help balance out some other symptoms that they're experiencing.

A reliance on self-regulation behaviours to manage symptomology. What I mean by that — and very common for us — is we'll see young people who are involved with cutting, with drug and alcohol use, who are trying to control their eating. They're engaged in all these other behaviours where they believe they can have some sort of control as a way to keep their mind off of what their mind does, right? Because they don't want to be on pills, they try and manage what they're feeling in other ways, with mixed levels of success. Obviously, there are pros and cons to that.

The challenges involved with just societal factors, poverty. How many people are struggling and have to make a decision around: "Do I eat or can I afford these medications?" "Can I afford to go to an appointment? I'm a parent, and I can't afford child care"? Dealing with all those sorts of issues that come up, as well, is a big challenge for people accessing service.

The next one is really significant. There's a strong feeling that if they get the help they need through child and youth mental health and if they ever have a family or if they already have a family, the system will treat them differently and that'll come back to bite them. A lot of people will not seek out service — and will avoid it at any and all cost — because they don't want somebody to call in a report around their inability to parent and for the ministry to find out that they've been accessing counselling services. They believe that they'll be treated negatively based on that and that they'll be prejudged, as well, as being a former youth in care. Again, it's those two pieces together.

Looking at when you're in a certain mental state, the likelihood that you're going to be chosen for gang involvement, child exploitation and prone to addiction…. People who are experiencing certain things and have a greater difficulty, perhaps, with connecting with their peer group are oftentimes viewed as acceptable to being identified and being ideal targets for being involved in these various areas.

The service provider openness to training and upgrading skills. There is a strong belief that there are some really good practitioners. There are some really good foster parents in the system, but there are also quite a few that don't believe they need to upgrade their skills. They believe that what they learned in the past was good enough. This is a big challenge for young people, in particular when they get that initial response that's coming from that place. Oftentimes they'll just sort of disconnect and say: "You're not in touch with reality today. How can you help me?" Right?

J. Thornthwaite (Chair): Jules, can we…? We, obviously, want to have opportunities for questions, so if you could….

J. Wilson: Okay. I've got a lot to say. I'll just maybe touch on a couple of slides in each of the areas and then get down, because I want to make sure that I have enough time to show you a video that young people have put together just for folks like you.

In terms of service delivery gaps, the big things that they talked about was youth engagement practice. They were talking about having housing options, both supported and independent housing. They were talking about having people involved in their planning. Transition planning was a big thing. In particular, when you're transitioning over from a youth to an adult system, oftentimes the adult service providers aren't involved in the actual planning themselves, and so that leads to some interesting directions once they do enter the adult system.

After-hours services. I had a young person say: "Everything happens in the evenings and on the weekends, and there's nobody available to me at that point in time."

A holistic approach. We already talked about that, and also looking at a customized model rather than a cookie-cutter. I heard the speaker before speaking to the value of connecting with the young person and trying to find out what their needs were, what their wants were and what a desired outcome was. So it's just little things like that.

Services to address stressors. A lot of young people talk about being involved in different systems, particularly the legal system, and not having the supports in place for that.

Proper information-sharing. Oftentimes caregivers who are supporting young people with mental health challenges don't feel like they're getting the information or the support when they come out and they transition. They may go into the ER for a matter, but then when they come out, the family is still dealing with that process and dealing with that issue.

In terms of best practices, some of the things that were identified are: removing wait-lists for assessment and service — so trying to get young people seen quicker and striking while the iron's hot. There's that mode and that opportunity.

Extending youth-friendly services past 19. People talk about the big gap in approach between the youth and the adult services, so if there's a way in which that can be amended, they'd be appreciative.

Exploring what you can do on line is a big one for young people. Shorter attention spans — they need quick-hit information. Is there a way the child youth and
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mental health system can accommodate that, whether it's for workshops or appointments?

Removing barriers. Young people talked about having supported child care so that they can attend appointments; transportation and text reminders, which is something we do all the time at our office for young people. It's something they just need to show up and be involved. We talked about some of those other pieces.

In terms of future considerations for resourcing what youth want, there were examples of good services that were provided, services that young people felt were helpful. In particular, they all had the qualities of coming at it from a holistic point of view, having accessibility to doctors, dieticians, mental health practitioners — really, that care plan approach — and also not ignoring the spiritual and physical needs of the individual. Young people talked about the value of being involved with their culture, getting an opportunity to be active as a way of processing the various things that they were experiencing and going through.

They also spoke around having somebody who was prepared not just to do visits in an office but to come out to them and have visits — so that outreach component, the after-hours services. More counselling services for those over the age of 19. Access to basic health, dental and vision care. A lot of these things produce stress for young people and put them in a position where they have to make decisions and make tough choices, which then generally does not help their overall mental health, particularly if they've got another diagnosis in place. These can be triggering events for them.

There was a concept or a suggestion produced by the RCY, which was a youth secretariat, a cross-ministry effort, bringing young people together and taking a look at transitions and the various different ministries that could help support a healthier transition — young people really love that idea — and then, of course, looking at any sort of legislative changes that might be appropriate, whether it's extending the age of care or just extending the type of support that's available, and in doing so, also being really clear around the rights that young people have in order to access that care and those supports.

A lot of people talk about accessing services but not being in a position where everybody gets it. It's not equitable. It's not fair. Some do; some don't. Where you live matters, and I speak at length about that.

Just general qualities: easy to understand; wider service time frames; accessible, non-invasive, flexible service that acknowledges the barriers that children and youth experience as they're trying to access and deal with these issues. Something that's holistic and non-judgmental and something that comes from more of a relationship-based approach, with a developmental lens.

One of the real important things that young people have mentioned was: "Look, we go through all this stuff where we experience trauma, and we come into care. We experience more trauma and placement moves while we're here. Some of us also still experience further abuse or neglect by those who are left in charge to care for us. So in terms of our development, we tend to be a little bit behind the general public, but at 19 we're on our own.

"We're encouraged to develop a system of supports with professionals, which disappears at 19. We're not really encouraged to develop a system of peers, because you never know when your placement is going to change, when there's going to be a move or when you're going to go try and live with that family relative." They get a rough deal — a rough deal.

Now I want to just quickly show you this video, because young people made it specifically for service providers. It's only about three minutes long. Hopefully, that works for you. Let's give this a shot.

J. Thornthwaite (Chair): Thank you, Jules. That's a good way to end it. Questions or comments?

D. Donaldson: Thanks for that presentation and especially the video at the end. It's really inspiring to hear directly from the youth in there. They were so articulate. Very cool.

We heard earlier in the day from Dr. Mathias, on his project and his inner-city youth mental health program through St. Paul's, that 40 percent of the youth that he's dealing with come from ministry care. We heard a lot of presentations yesterday, when we were in camera, from parents who are advocates for their children who have experienced mental health issues.

I'd just like to hear a little bit more from you. I mean, you're representing a group of young people through your organization that actually accesses — at least, we heard from this morning — the services that are needed the most. What's your perspective on that, around what's needed and just the fact that you're the voice for the youth?

J. Wilson: Yeah. Specific to that program itself or specific in general to programs? What do young people really need?

D. Donaldson: Yeah, in general. We've got advocates from parents' perspectives, but it seems to me that the group that your organization represents is the biggest user of potential services that we'll be considering in the
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report. What are the implications of that, from your experience?

J. Wilson: Yeah. I think, in general, young people just really want a shot at a normal life. That's what they want, and they believe that at various times in accessing child and youth mental health services, they've been steered in a direction — in part because people weren't willing to listen to what they really have to say or people were afraid to engage them in a conversation around what their needs really were and what their goals really were for participating.

One of the challenges you have with child and youth mental health services is that they're voluntary, right? You can get away for a certain amount of time with sort of bringing them to the office and hoping they'll actually sit through an appointment. But there comes a time when if they're not being engaged, they'll just say: "I'm not interested in this."

I think it's really important, whatever programs and services are in place, that they're willing to say, "Hey, we want to include you in this conversation, and we want to partner with you to deliver this service, this help that you need," right? If they view it like there's this big jump between the two, then I think that's where people get lost. They want to feel like they're being listened to. They have many spaces in which they engage where they feel like they're not being heard, that their rights are not being upheld or their rights aren't being communicated to them.

We can't afford to have a system with child and youth mental health that looks to do the same. These young people are fragile, but when they're supported and engaged and you focus in on their strengths and what their goals are and what they want to see happen, you can find a way to make it happen in some way, shape or form. It may not look the way they wanted it to, but they'll respect you for trying, and they'll keep coming back. That's what our experience has been.

C. James (Deputy Chair): Thanks, Jules, and thanks for your work. You mentioned the fragility of kids in care, and I think the flip side of that is the resiliency of kids in care and the knowledge and the strength and the experience of kids who survived the system — the exact opposite of what we should be looking at.

They shouldn't have to survive the system; the system should be there to meet their needs. I think you've emphasized what we're hearing a lot of, which is the importance of the integration of services and the importance of not just looking at one piece of the youth mental health system — but as you've pointed out, the number of moves, the instability for these kids and the other challenges.

One of the things I just wanted to mention is that we are taking written submissions. If there are youth who want to have their voices heard, we can make sure we get the link to you — I think to give that opportunity to youth to be able to be heard themselves.

C. James (Deputy Chair): We'll take the information that's here, but I think it would be really helpful for them to have the opportunity to be able to have their voices heard. We can take those submissions as written submissions, as videos, as whatever the youth want to put in. I think it might be a great opportunity to have those voices resonate around the committee.

J. Wilson: Awesome. Yeah. Thank you for highlighting that. We'll definitely post something on Facebook when I get out of here. They'll love that.

J. Thornthwaite (Chair): Thank you very much, Jules, for coming in. As the committee has heard over the last two days — this is the third of three days — there are very common themes with regards to recommendations and things that we could do better and where the gaps are. We very much appreciate you coming in and giving us a presentation.

J. Thornthwaite (Chair): We're still running a little bit late, so we still kind of want to get things started. Our next presenter is the division of adolescent medicine at B.C. Children's, Dr. Lam.

P. Lam: Thank you very much. First of all, I caught the end of Jules's presentation, and that was amazing, so thank you. I have to say that working in the division of adolescent health and medicine at B.C. Children's, we encounter a lot of what he presented, so it was great to hear that as well. I'm glad you got a chance to hear that too.

Anyway, my name is Dr. Pei-Yoong Lam. It's a bit tricky to pronounce, so I thought I should say it up front. I just want to also say that it's an honour and a privilege to be able to address this committee, and I thank you for giving me a chance to talk about something that I'm really passionate about.

My area of work in research is in children and adolescents with eating disorders, which is a bit different, I see, from what you've been hearing about this morning. I do that at B.C. Children's Hospital.

Perhaps the best way for the committee to know about this area is through a story of a typical referral that my team and I would receive on a very regular basis, sadly. I want to emphasize that the story I'm telling is a composite. It's not about any one person. It's a composite of various patients that I've managed, but Alice's story is one
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that I hear all the time.

Alice is 15. She lives in a rural community. She was top of her class two years ago and really actively involved in volleyball and track and field. Her mom, Evelyn, noticed that in December of 2012 Alice was talking about wanting to lose weight so that she could run faster. She wanted to go on a healthy diet to be at her best in sports.

She started looking into healthier alternatives, looking on the Internet about dieting. She started to cook the family dinners. Initially, her mom was really kind of pleased and proud that her daughter was doing such a healthy thing. She was really taking the initiative. But by March of 2013 she realized that Alice was losing weight quite quickly and that she'd stopped having her periods. She wasn't really going out with her friends, either.

She tried to talk to Alice about this but didn't get anywhere, so she dragged Alice — dragged — to the family doctor in April of 2013. The doctor examined her and did some blood work. It showed that Alice's heart rate was low, but the blood work was okay. The doctor said to Mom, Evelyn, that "she just needs to eat a little bit more, and don't worry about the heart rate. It's low because she's just really fit."

Over the next three months Evelyn watched Alice eat less and less. She tried to cook her favourite foods, tried to do whatever she could to encourage her to eat but really got nowhere. She took her to the doctor again. This time Alice was diagnosed with an eating disorder, and the doctor put a referral in to the local eating disorder service. But then they were told that the wait period was six months because there's only a part-time clinician that does that. It's now August of 2013.

Alice continued to see the family doctor weekly. Week by week the family doctor watches Alice's weight drift lower and watches her heart rate drift lower and lower. The doctor became worried that the heart rate was actually getting quite dangerously low and referred Alice to the provincial eating disorders program.

We received the referral early October of 2013. We set the intake assessment date for mid-October, but as we do that, we're informed that Alice has collapsed at school, and she's admitted to the local hospital. Our team arranged an urgent video teleconference with Alice, Evelyn and the local team. Alice was transferred after the teleconference to B.C. Children's Hospital, as her local hospital did not have the expertise or the resources to manage her appropriately.

When Alice arrived at B.C. Children's, her heart rate was dangerously low because of her months of malnutrition. She looked emaciated, and she could hardly speak. She had also developed fluid around her heart as a complication of that malnutrition. She's lost a third of her body weight.

At this stage, Alice and her family have spent 11 months without treatment of her eating disorder. Like a cancer left unchecked, Alice's eating disorder has had 11 months to carve itself into her brain and her body. She will spend a further three months in hospital and will require weekly follow-up on discharge, locally.

Children and adolescents with eating disorders are particularly challenging to manage, as very often the physical complications of their mental illness have long-term consequences. Eating disorders in childhood and adulthood have also been shown in research to have the highest mortality or death rate of all mental illnesses, including schizophrenia.

Complications such as stunting of growth and height, stunting of puberty and poor bone health resulting in adult osteoporosis and infertility have long been known. However, recent medical research shows that from the age of ten to 25, teenage brains continue to develop and change, so being malnourished in that time period for whatever reason can alter that process. The long-term impact of this is still unclear, but it may involve vulnerability to further mental illness and may also impair cognitive functioning.

I work within the provincial eating disorders program at B.C. Children's Hospital. In the past four years that I've worked there, I have seen improved access to provincial treatment via a streamlined intake process and a shorter wait time to receiving services. Our program is nationally recognized. We've gotten referrals from the Yukon, Alberta and even Nova Scotia in the last four years. In fact, from 2010 to now we've admitted over 220 in-patients and put over 100 kids through our day treatment program. Many of the in-patients come from rural communities where resources and expertise are limited.

The provincial eating disorders program uses a family-based approach that's evidence-based. We continually re-evaluate our practice to ensure that we're providing best practice based on current evidence. We also firmly believe that early and aggressive treatment results in better prognosis and better long-term outcomes.

In my role within the program, I interact daily with family doctors, pediatricians, nurse practitioners and allied health professionals, including mental health professionals, throughout the province. I provide advice and consultation, and I try to be available to them as much as I can.

In the past four years I've also been working on implementing consistent guidelines for medical management of children and adolescents with eating disorders that present to acute medical settings — for example, local community hospitals and emergency departments, especially the ones at B.C. Children's Hospital.

Many health practitioners, including pediatricians and family doctors, tell me that they feel uneasy treating eating disorders, especially in children and adolescents, because they have not received the training for it. I have also encountered many myths out there that are
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prevalent even among medical professionals. For example, low heart rates are normal if you're athletic. For example, eating disorders are a choice. For example, eating disorders are just a phase. For example, eating disorders only happen if you're white and upper middle class. That's not true.

Through Kelty Mental Health Resource Centre and the eating disorders community of practice, we're trying to provide professional development and updates for rural and metropolitan community practitioners in B.C.

The B.C. adolescent health survey for 2013 was recently released. I read that in the past year 5 percent of males and 10 percent of females vomited on purpose to lose weight. The incidence, compared to the 2008 survey, has risen by 2 percent for both sexes. We have seen 97 boys in the past eight years, and I know this because I'm doing a research paper on it. The incidence is rising, yet due to poor recognition, boys tend to present later and so are more acutely compromised because of that.

I also know that over the past four years, I've seen more and more children and teens who present with life-threatening complications of their eating disorder, who are more acutely sick and require intensive medical interventions and monitoring due to their malnutrition.

Our program has evolved and continues to evolve to meet those needs. But in the current structure it continues to be a struggle to have an appropriate space and appropriate staffing and resources that will meet both the intense medical and psychiatric needs of these very, very unwell kids. They're medically and psychiatrically unwell.

I'm also confronted very often with the stigma of treating young people with eating disorders. The perception within the medical and non-medical community is often that this is just a mental illness and therefore requires only psychiatric treatment. Unfortunately, many children and adolescents present initially to family doctors and pediatricians in the community, not mental health professionals. It's the physical complications that are the signal to parents and to schools and to teachers that something is not right.

I am fortunate to be working with a fantastic and dedicated multidisciplinary team. Sadly, many of my colleagues within the community don't have the support that they need. I know they have barely time to see all the referrals that they receive, much less the time for training and updates. Lack of resources in secondary mental health services means long wait times, differently trained professionals and mixed messages to families and young people who are in crisis. Confusion and inconsistency allow eating disorders to thrive.

Local mental health services, particularly those in rural communities, deserve training, support and resources. I personally try to be as available as I can to family doctors and pediatricians, particularly in the rural communities, because I know what it's like to be left kind of being the only person holding the ball, as it were. So I hand out my phone number liberally to those people.

Where does this leave Alice? She does spend three months with us. Her parents receive education and training on how to support her. Her weight slowly increases, and in turn, her heart rate improves, and the fluid around her heart subsides. These are all reversible.

Arranging discharge and follow-up, though, with her community is more challenging, as there is only one part-time clinician working there. Her family doctor and I exchange phone numbers so that we can remain in contact. Her parents are worried but hopeful and promise to be vigilant.

There are kids who don't progress as smoothly as Alice for a multitude of reasons. These are the ones that I worry about. These are the ones where I wake up at 3 a.m. and think: "What do I do?"

The combination of intensive medical and psychiatry intervention is sometimes required simultaneously, not one at a time. You're not treating the head, and you're not just treating the body. You're treating a person, and it's best provided, at times when it's that severe, by an in-patient unit that can combine acute medicine and psychiatry with a multidisciplinary team.

If this intervention isn't provided early and aggressively enough, it drags out the course of illness into adulthood. I don't have to tell you the health dollars that have to go into that if you are seeing someone with a chronic illness that could have been prevented if treated early enough.

The long-term medical and psychiatric complications, I feel, rob a very talented and creative individual of their opportunity to develop to their full potential, and that is very often what I see — a young woman or a young man who is robbed of their adolescence.

I hope that this has been quite short and sweet, and I thank you again for the committee allowing me this opportunity to speak.

Now, you did comment earlier in your remarks about how the health aspect of services has improved over the last couple of years. Generally, the theme of what we've heard here, and you'd then referred to it later on in your remarks, is that the mental health supports are not as….

P. Lam: When I talked about the improvements, I was referring to my particular service that I've worked in for the last four years at the provincial specialized eating disorders program. It is a centralized program. It's provincial, so
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we get referrals from all over. I've seen that service change significantly in the past four years — streamline their access, streamline their availability and kind of shorten the wait times that we see patients personally.

Where we're now encountering stumbling blocks is when we try and refer kids back into their community, because we can't see everybody, right? There are secondary eating disorder services within the community, but they're very patchy — kind of what Jules was saying before. It does matter where you live.

Sadly, it does matter where you live in a rural community too. We know of rural communities that are located in one spot but are serving this geographic area that is huge. So for patients to be able to come and see them and for services to be offered, it is difficult. We try and use telehealth as much as we can, and we encourage people to use telehealth, but it can only do so much.

One of the things I thought I heard you say is that you handle 200 patients a year.

P. Lam: No, no. We've admitted over 220 patients since 2010, to 2014. Those are the stats that I'm currently aware of. We have admitted over 100 kids through our day treatment program.

D. Plecas: But in that, you also said that you have referrals from as far away as Nova Scotia. I'm not saying that you shouldn't do that, but at the same time, I'm thinking…. Presumably, one of the things that you're wanting us to give attention to is the need for more resources.

P. Lam: Well, the Nova Scotia referrals…. I have to stress that in the last four years we've admitted two or three kids from Nova Scotia. That's it.

P. Lam: I believe the arrangement is that the government over there pays for our services.

D. Plecas: Okay. Again, what is it that we can be specially attentive to? It sounds like you're doing great work, but what is the dollar cost?

P. Lam: You want to talk about the dollars? To me, I think where we need more resources is in two areas. The first area is the creation of an acute combined medical and psychiatric unit where there can be acute medical intervention along with acute psychiatric intervention.

Right now, I believe, that is still not happening, although our unit and adolescent medicine and child and mental health psychiatry work very closely together. We try and do that, but we do not actually have a space, for example, where we can monitor someone with telemetry and nasogastrically feed them whilst providing a therapeutic milieu for them. That is not available right now.

We recognize that those acutely unwell people are not common. In fact, it's a small handful, but it is that handful that may end up getting referred outside of the province for treatment because they're just so acutely severe that they're beyond the realm of normality. Sadly, I've seen more and more of these kids.

One of my dilemmas is that I want to provide a certain type of service but the constraints mean that it's not possible. That's one thing.

The second thing is secondary mental health services within communities. Eating disorder services, I think, over the last few years have actually gradually reorganized and are making themselves more accessible, as well, and are trying their best to provide the services that are required within the community.

However, when you live in 100 Mile, there's just a dietitian. I'm sorry. I don't mean to name names, but there's just one person there, and there isn't anyone else. It's that dietitian and the poor GP that have to manage people in a radius of…. I don't know how big, because I don't come from B.C. The same situation occurs if you live in Kitimat or if you live on the Island. There are vast areas that are not serviced by an eating disorders specialist, and patients who have to travel long distances.

In these areas that are, the poor clinician is overwhelmed by the services, because they often have not just that area; they have to provide other mental health services too. So they are overwhelmed.

M. Stilwell: We have heard recurringly the issue of youth who do receive services but then go back to no real care plan and no informed follow-up. I have a couple of questions. You suggest that the underlying need is increasing. I'm interested in knowing: what is the longest wait-list for in-patient therapy currently?

P. Lam: For our service right now, it's actually not that long because of all the changes that we've made.

M. Stilwell: Are you confident that that streamlined access…? What we've also heard is implications, or sometimes it sounds like so-called streamlined access to get the wait-list down and get the demand down actually results in people who need service not getting served. I'm interested in your opinion about the quality and consistency of the assessment to get to you — that you're confident that it's working.

P. Lam: I actually think that that piece is working, because the time from referral to assessment is often less than a month.
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P. Lam: Yeah, we do two assessments minimum per week right now for the provincewide service, and we do, I would say, a third of them by telehealth so that patients don't have to come down. Of course, there are urgent consults that occur with patients that randomly appear at the Children's Hospital that are suddenly discovered to have an eating disorder, so we do those consults as well.

The majority of our assessments do end up receiving some form of treatment with us. I think the community is picking the correct people to refer, so that's not the issue there. When they get in, that's also not an issue, because we do have that flexibility to see people and admit people fairly quickly. It's what happens when they go home.

M. Stilwell: Can I just ask a second question, please? Recently in my favourite medical journal, the Globe and Mail, there have been several articles citing new research into eating disorders suggesting that day programs or usual care by a family physician or perhaps a multidisciplinary team is as effective. I'm interested in your comments about the worth of that research.

Also, other than the handful, the relatively rare group, that require medical therapy, who…? Can we do more day treatment is one, versus…? Because it is long distance for most patients to get to Children's.

And then I'm linking that. We've been talking a lot about care at schools, and given that I'm sure you've heard that there's a lineup in the girls' washroom at noon to throw up, it seems like this is not necessarily a greatly stigmatized issue among high school girls.

P. Lam: I'll address the first one and then…. Initially, with your comments about out-patient treatment, the current evidence in literature, which is why our unit has moved towards a family-based approach, is that it is out-patient therapy that is the first treatment of choice. That is why I'm also emphasizing that if you can get that done in the secondary mental health service, if everybody can be trained to deliver that service, we will probably have less business.

I think if there's adequate training for family-based approaches or family-based therapy, which is the current most highly researched and most positive evidence-based approach that is out there, that would be amazing.

Having said that, it does not work for everybody. There will always be a group of kids that are quite severely unwell. I would say family-based therapy would work if it's delivered early enough, fast enough and well enough and with appropriately trained people. It would keep 50 percent of kids out of hospital. But there is still the 50 percent that present late, that present unwell for a multitude of reasons, whatever that is, and for which family-based therapy does not work.

Don't get me wrong. This therapy is difficult to do. It requires a lot from parents. It is hard work, emotionally draining and very, very painful at times. It is not easy. Not everybody can do this. I'm sure if you spoke to a parent who's gone through it, you will get exactly that comment: not everyone can do this.

For those parents that cannot, our program has support, has the option of in-patient admission or day treatment to support parents through this — but still trying to empower parents, trying to have them take control and move forward with a view towards eventually transitioning them to home.

From that point of view, I can speak to out-patient therapy. With regards to day treatment, the evidence is growing but still very scant in comparison to family-based therapy. We know that kids do better when they're at home. We know that kids do better when they're with their parents and with their community. We try as best we can to facilitate that, and day program is part of that, trying to facilitate it.

You're right. It's hard to do day program if you live on the Island. But having said that, we have many people who actually move here temporarily, Monday to Friday, and go home on the weekends. We had a kid come from Bowen Island. Every day she would do the commute from Bowen Island to attend our day treatment program. It's not impossible if the parent wants to make it happen.

We do say that a parent has to live with the kid for the X number of months that they're doing the day treatment program, but it is doable. It is doable. But it requires commitment and sacrifice from the family as well.

Day treatment I think is definitely an avenue worth exploring. But right now, from an evidence perspective, it's a little thin on the ground.

Your next question is schools. You don't know how many phone calls I get from school counsellors.

P. Lam: You talked about a lineup outside the bathroom. I talk about the lineup outside the school counsellor's office.

There is still a stigma, though. Even though there is a lineup, the kids still call each other names. They know who's got anorexia and who doesn't. They'll call…. They're mean. It just is a fact of life that some kids are mean, and they will point out differences. So these kids tend to end up not wanting to go to school, shutting themselves always from their community and turning themselves away.

In terms of school counsellors, they are often stuck.
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The kid will say: "I want you to help me. I want to get services, but I don't want my parents to know." This is the dilemma. What I often say to the school counsellors is that when you have a kid like this who's medically compromised, you have to let the parents know. You have to negotiate it. You have to wangle it somehow.

In terms of improving access to services, school counsellors then need quick and clear access to local resources — local mental health services, local doctors who know not to dismiss this. There's nothing worse for a parent or a teacher or a counsellor or a kid than to go to a doctor and then have them say: "It's okay."

D. Barnett: Thank you for your presentation. This is a topic that I've had a little bit of experience with because I've had parents, friends, who have had to actually send their children from rural British Columbia, from 100 Mile House — I'm from there — down to the Lower Mainland. The difficulty they had many times…. It's not just one time they had to send them. It's maybe seven, eight, nine, ten — many, many times.

The problem is getting these young people into a facility when they've come from rural British Columbia into the urban centre. They quite often get pushed back. They don't have the availability of the doctors to really push from these rural communities.

Is there better access now than there was, say, three years ago for people from outside the urban centres to get help in these facilities? How many beds are available for these young people with this disease? I call it a disease because it is.

P. Lam: It is a disease, yes. I agree with you. I think that, compared to when I first came, I've certainly seen a prioritization for rural communities. If we have someone stuck out there, we try and make the telehealth happen sooner rather than later. The stumbling block is for them to get the referral to us. A doctor in the community has to do that — has to recognize the severity of the illness, and then has to realize that they need to call us, sooner rather than later, if they can't do this within the community.

In terms of the changes that I've seen, I think for sure we're doing much more telehealth. Our initial assessment we will often do — if someone comes from 100 Mile or someone comes from Terrace — by teleconference. We will not mandate that they come down. Once that telehealth conference has happened, we ascertain what resources are available within the community.

If it's pretty clear that it's not going to work out in the community, they get a bed. We have 14 beds now on the in-patient service — where, I understand, before my time there used to be eight. It has improved access dramatically. With the introduction of family-based therapy and the day treatment program being up and running, I would say that about 50 percent of the kids are not from Vancouver. Not that we reserve beds, but I would say that just the flow of things is that 50 percent of the kids are not from Vancouver.

J. Thornthwaite (Chair): I've just got one question, and then we'll have to wrap it up.

I did have people come to my office a couple of years ago. My data might be old, so you can correct me. The question was not the great treatment that they got at Children's — or I think in this case it was actually St. Paul's — but what happened to them after. They would talk about the facility on Galiano and getting access to that facility to help them heal, long term. Do you have any comment on that?

P. Lam: I don't work at that facility, so I can't comment about it, but I am aware of it. This is, again, back to Jules's comments about continuity of care. Our mandate ends at 18, or at graduation.

We certainly have some 18-year-olds who are in their final year of schooling and who access services with us, but then the transition to Galiano, as I understand it, is that it's a secondary residential service. You have to have a referral from your local eating disorders team. We, as a tertiary service, can't refer to them. Those are the rules right now, and I didn't make them. I understand that you have to get either your local doctor to put in a referral or your local eating disorders team to put in a referral.

I think their concern — and rightly so, from Galiano's perspective — is that we need to have a team to discharge this person to, because it doesn't end when you leave the facility. Having the team set up and ready to go when you leave is just as important as being able to get there. I just want to emphasize that I think if everybody was on the same page in terms of the type of therapy and the type of training that you need, the approach, then there wouldn't be this inconsistent, mixed message that's floating around.

J. Thornthwaite (Chair): Well, thank you very much for coming and presenting. We very much appreciate it.

Our next person is Beverley Percival, from the First Nations Child and Family Wellness. We'll just give a minute or so for the transition.

J. Thornthwaite (Chair): All right, I think we'll resume, because we are consistently on a time frame here.

Welcome, Beverley, to our committee. We would like to welcome Beverley Clifton Percival from the First Nations Child and Family Wellness Council.

I want to acknowledge my MLA, Doug Donaldson, whom I voted for in the last election. I also want to acknowledge Carole James, who has also done a tremendous amount of work in the north on the advocacy of children and families. I want to acknowledge the territory of the Coast Salish.

My name is Gwaans, Beverley Clifton Percival. I am one of the co-chairs of the First Nations Child and Family Wellness Council. I'm also a negotiator for the Gitxsan Hereditary Chiefs in northern British Columbia. Thank you for your invitation to appear today.

I would like to start by passing along the regrets of Chief Bob Chamberlin. Chief Chamberlin is my other co-chair on the First Nations Child and Family Wellness Council. He is unavailable today due to some health problems, and I wish him a speedy recovery.

What are the main challenges? The first challenge for on-reserve children and youth mental health services is the lack of federal programs that would match child and youth mental health services provided to people off reserve.

At the federal level and where federal government is responsible for First Nations services under the Indian Act, child and youth mental health is considered a health issue, not a child and family issue. As a result, Aboriginal Affairs and Northern Development Canada does not provide funding for these services on reserve.

Health Canada is reluctant even to talk about them or fund them. Nor, to our knowledge, is funding provided to the First Nations Health Authority to provide new services, though certainly their holistic approach to health and wellness will eventually allow for services to perhaps be shaped so that they may address the four areas of mental, physical, spiritual and emotional health — a holistic approach.

A secondary challenge is at the provincial government level, where the Ministry of Children and Family Development has routinely changed ministers, deputy ministers, structures, goals and policies to the detriment of people receiving or trying to deliver services. Our council is an example of that — this regular change in direction.

We were created by the First Nations Leadership Council and the First Nations Chiefs in Assembly through resolutions of the B.C. Assembly of First Nations, the First Nations Summit and the Union of B.C. Indian Chiefs.

An action plan was in place as the council was formed, with representation in each of the five regions of the province selected by the First Nations leadership of that region.

In 2009 the Ministry of Children and Family Development agreed that the wellness council would be the link between the province and First Nations for discussions on its program areas, including child and youth mental health. Not only did the ministry never live up to the commitment contained in the 2009 recognition and reconciliation agreement signed by then Minister Tom Christensen; it recently unilaterally defunded the wellness council without any prior notice or consultation, after assurances that it would not take decisions without consultation.

The exact same thing occurred with the five aboriginal authorities that ran for five years and were ended after millions of dollars spent and no results achieved because of the government decision-making and the lack of an aboriginal framework to address issues such as aboriginal child and youth mental health. I was the chair of the north region, and it was by far the biggest region in this province. It's the size of France. We did not receive any funding that would adequately address any of the issues that were presented to us by First Nations leadership in our region, as did all the other regions.

At this point First Nations leadership is wanting service delivery that moves to wellness and prevention. The medical model was not working for us. Each region was developing models that were based on traditional ways of caring for our own. Reclaiming our jurisdiction over our nations was always the goal.

During all this time the ministry was undergoing transformation after transformation. They implemented an aboriginal framework in an insular fashion, when the opportunity to work with First Nations could have been a positive movement forward. There is still no framework to deal with aboriginal peoples in this province, but the fear of giving First Nations control over their future is still in play.

The costs of this are very real, as our children lose services, prevention or any kind of family support to deal with mental health issues, and as we continue to see high suicide rates, violence, mental health issues and increasing numbers of our children going into care.

It has done the same thing with the Indigenous Approaches organizations. In this province we have 18 community-based projects, which cost the province less than $10 million annually and which were undertaking direct services to communities. Many of them focused on providing better services, cultural development and expanded opportunities for the youth they worked with. Then defunding again took place with absolutely no consultation and based solely on the most recent report of the representative. It really hadn't gone deeper into the issues we face as indigenous people, with a focus more on the government.

First Nations individuals and organizations strongly believe in the representative's role. However, it appears that many of the reports put forward are topics of discussion for a few days and never heard from again. How are they being implemented? Where are the results? Does anyone even know what is being done with them? The situation in British Columbia has not shown
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any improvement for First Nations children over the past decade.

This same report led to the defunding of the various groups and organizations that were attempting to make change. If the government continues to view these reports as little more than confirmation that it allows the reports to be written, then, there will continue to be a lack of progress. The fact that government policy can be criticized does nothing to change the policy for something that can used more successfully. We need considerably more to carry through than what we have been seeing.

I also want to acknowledge that I'm a member of the multidisciplinary team that investigates the deaths of children in care. It is a very complex situation, but I bring forward a perspective from community — more specifically, First Nations community. It is often very sad to see how many times the children have been left to fall through the cracks, and families have suffered as a result.

There's been nothing to do to mediate or change or direct any policies that would give a really good, positive chance to a child, an aboriginal child in this province. There's a lot of focus these days on service gaps and the government's status quo: funding the system inadequately and taking no responsibility for the lack of results. There is no concerted effort on wellness and prevention.

The First Nations Child and Family Wellness Council has attempted to address the gap by proposing a leadership interministerial table to discuss related First Nations child and family issues. We wanted to have a holistic approach from the government side and to meet with the necessary departments that are responsible for various services and programs that are meant to address our needs at the community level.

The ministry made no effort to respond. They were in one of their many, many elections. But it continued to make decisions without input by the acknowledged body and then just simply cut funding.

As well, there continues to be a lack of cultural competency. There is no pan-Indian approach. Culture, tradition, language, child-rearing laws are different for First Nations, as they are for the many people here in Canada. We have different languages, cultures — many differences.

A person cannot sit in a Victoria office and make practical, well-informed decisions about people. They have to come and meet us and have a dialogue with us. Creating programs without consultation is the almost surefire way to guarantee that the program will face opposition and, ultimately, have no success.

As recent debates over the number of legislative proposals for industry development have shown, B.C. First Nations are not waiting for decisions to be thrust upon them. They want a voice at the table to create the solutions that will work in their communities. In the case of children and families, that voice has been largely ignored and, finally, silenced.

It should be noted that all three provincial-territorial organizations — the First Nations Summit, the Union of B.C. Indian Chiefs and the Assembly of First Nations for British Columbia — have criticized the defunding decisions. The summit and the union have passed motions asking the province to bring chiefs together to discuss an issue that is so important to their communities.

The ministry's response has been that it's unlikely that money will become available for such a meeting or discussion or gathering. When a couple hundred thousand dollars becomes more important than the future of our young people, we have a problem with our priorities.

To end on a positive note, there are solutions to these barriers faced by First Nations children and youth. Communities are more aware of mental health issues, and programs such as the aboriginal suicide crisis and intervention response team are giving people options and reducing the stigma.

Some of the more damaging components of mental health issues, substance abuse and lateral violence are being met head-on by leadership and community members. The province can support these efforts. We recommend above all else that the provincial government, along with its federal counterparts, create funding models that support multi-year programming. This will help with staff retention and program development, as well as allow for real research to occur and for outcomes to be properly monitored.

As already repeatedly learned, the current approach of maximum one-year funding envelopes and constantly changing priorities is not helping First Nations children and youth. As the fastest-growing segment of Canada's population, this is creating a demographic difficulty that is best dealt with now.

There have been, and remain to be, jurisdictional issues between the federal and provincial government agencies that further exacerbate this issue. Dr. Cindy Blackstock is currently embroiled in a human rights tribunal that proves such issues. Using experts in several fields, she has identified the issues with sound data and shown the challenges facing aboriginal children and the indifference of Canada on such matters. How much is this costing us as citizens of British Columbia and Canada?

Real change requires effort on the part of British Columbia: (1) to work with the First Nations Child and Family Wellness Council to implement the 2009 MOU; (2) to work with the indigenous approaches to address cultural and preventative measures dealing with issues such as mental health; (3) to provide stable resources to community-driven indigenous approaches; and (4) to create the leadership interministerial committee to deal with indigenous people in a holistic way.

C. James (Deputy Chair): Bev, thank you for your work and for your advocacy for children and families.

I think you've identified a couple of pieces that we've heard consistently as well. One of them, as you pointed out, is the lack of focus, the lack of commitment, the lack of long-term policy, rather than short-term, changing policy.

I was interested, though. You made a mention of the fact that youth mental health isn't recognized — whether it's a health issue or a children and families issue — and therefore falls through the cracks, just as an issue. Will any of that be addressed by or have there been discussions around the new First Nations Health Authority — around the issue, directly, of child and youth mental health? Is there a discussion table anywhere that's looking at pulling it in so that it does get recognized somewhere and does get acknowledged as an issue?

B. Clifton Percival: I think that the First Nations Health Authority to this point has been dealing with a huge transition, so I think it's on the radar, but it hasn't gotten direct attention yet.

During the regionalization process the government did develop an aboriginal youth and mental health program. But again, it was done without the partnership of any aboriginal people. While there might be something that's there, it could be something that's used to reinvigorate and use in partnership with First Nations people. I think the health council does have it on its agenda, but it's also got a great amount of other stuff on its agenda as well. But we remain committed to it.

D. Donaldson: Thanks, Bev, for the presentation. As a committee, we're going to make a report based on the presentations and the input we get on youth mental health challenges in the province. One of the questions that we've been posing is targeting the resources for the future.

We've heard presentations already, and we know that 55 percent of the children in care are of aboriginal descent. There's a program that was highlighted this morning where 40 percent of children in care are accessing it here in Vancouver. We know that children who come from impoverished backgrounds are three times more likely to have mental health challenges than other parts of the population, and we know that First Nations communities are impoverished.

Given all that context and the fact that there is likely a limit to resources and a limit to how much reorganization could take place, I'd just like to get your comments on how you think that can be reflected in our report, as far as recommendations for targeting resources into the future.

B. Clifton Percival: I think what I've seen over the last decade, in my involvement in advocacy, is that there's always an impoverished view. It particularly comes into play when we're talking about our children, yet our children are overrepresented in the system. So I think that there needs to be a way to meaningfully distribute resources that allow for access.

I remember 12 years ago when I was involved in health, they said that Mary and Joe had to get access to services wherever they were in the province. I feel that's the same for child and youth mental health. I think we're experiencing far more rates of suicide and lateral violence and substance abuse.

I know that in the Hazeltons the child and youth mental health person is three days a week, but they serve a huge population of us. You know that they're your people, Doug. I think they deserve fair service. They deserve full-time service. They deserve continual service, as well, because you can't just do it from nine to five and Monday to Friday.

All of this stuff takes place in homes and in community when services may or may not be available. There have to be trauma teams that are in place for children and youth when they're experiencing trauma. And whatever they deem a trauma…. I think we often just make these boxes and expect everyone to fit into them. I think for resources, we have to look at the rural and remote communities in that they don't have the access.

For eating disorders, our kids, frankly, wouldn't be able to get down here. Their parents wouldn't have the wherewithal. But if someone could come to them, even for an extended period of time or whatever it could be….

Children are really important. I think the Children's Hospital here is wonderful. I've had the opportunity to work with them and use their services. But in the north it's not something that's easy. For me to get here I have to drive an hour to Smithers, get on a plane for an hour and 45 — that's if the plane lands — and that's often our case. People who are in the coastal parts of British Columbia, where you have to take a seaplane for an hour and a half — again, if the plane can land….

All those considerations have to be built in. It can't simply be a formula. That is what the Crown likes to do — a formula: "I'll give you 50 bucks for every kid you've got." That's not it. There are a lot of other considerations that I think should be included in that, and there should be a remoteness and rural factor so that kids can have it.

M. Karagianis: Thanks very much, Beverley. One of the things that we've heard consistently is a message from everybody that we've talked to in our forum — the lack of follow-up, the lack of services after there's been a diagnosis or if there's been any kind of treatment.

I'm just wondering: in your case, what are the implications for people who are living away from the communities? Obviously, if they need some kind of support, they've got to come back to their family community to get
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it. I mean, we do see the challenges around urban First Nations crises — all of those challenges.

Is that part of what you take into consideration? Your comments seem to be fairly broad around the jurisdictional challenges around the ever-changing face of government from your perspective. How do you see that interaction?

B. Clifton Percival: I think one of the biggest issues in dealing with children and youth is a more holistic approach. The child also belongs to a family. That family belongs to a community. What kinds of supports are in play to take them out and then put them back in? What kind of real supports are there? They have to be long-term supports. It can't be: "We've decided that you can have four weeks of aftercare, and after that you're on your own." That simply doesn't work.

The same is true for children who age out of the system. There's nothing for them. They just walk out the door one day. I think that we have to look at care plans for children and youth that are really carried out and really resourced as well. The aftercare plans also have to involve the families to give the families support for dealing with the tremendous amount of stress and pressures that they're dealing with.

I think it has to be a bigger approach. It has to be more of a safety net. That's why we wanted to have this interministerial committee so that we could look at all aspects of a child, whether it's their school or their doctor or their services that they're using. It has to be a bigger approach to it so that they have a whole circle around them.

M. Karagianis: It's interesting. You haven't really touched on — well, you touched on a little bit — the challenges of getting down here to access places like Children's Hospital. Recently Carole and Jennifer and I drove Highway 16 to experience the challenges there around transportation.

M. Karagianis: I see that as a significant challenge as well for the communities that are more remote. I mean, the follow-through, the follow-up, even as a support system, is very challenging if you cannot get into a centre where there's help.

B. Clifton Percival: The community I come from is Gitsegukla. That's about 20 minutes west of Hazelton. If I didn't have a car, I'd have to take the bus. If I took the bus, it's only three days a week and a certain period of time. So if I can get my appointment and my services in that period of time, I'm okay. But if I can't, I'm not. That is very real.

The safety issues around transportation. The public transit runs only during the daylight hours. It's often maybe times at night that we need things or a little later on or a little earlier. We don't have that resource.

M. Karagianis: That adds to the story that we need to tell on that as well. Carole usually says it at this point, but you know we're taking written submissions until into July. Written submissions from yourself or any of the community leaders or anybody in your community would be very gratefully accepted here to talk about the personal experiences and these challenges — to highlight the very specific details around….

In writing you can have a plan, but if it doesn't work on the ground…. If you can't actually get people to connect with those services on the ground, I think that that needs to be included in our considerations. So for yourself or anyone else who wants to do written submissions, we'll gratefully accept all of that as well.

D. Plecas: Thanks for your presentation, Beverley. One of the things the committee has heard from an earlier witness was that, thinking in terms of the First Nations Health Authority, the problems would appear to be concentrated, for the most part, in 10 percent of First Nations communities. There's an overrepresentation amongst about 10 percent of First Nations communities.

D. Plecas: Obviously, there's a need across First
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Nations communities in general, but given that there is this tendency for some First Nations communities to have greater needs than others, and given that your council's focus is on community-based, then it leads me to wonder: to what extent could we perhaps be more help by the leadership within some of those communities? Or is that not, in your mind, the primary issue?

I guess it's just, again, what is it that the communities themselves can be doing more of that's not happening? I only say that because it would seem to me that at least part of the reason we have the issues that we do is a function of the environment that exists in a small percentage of First Nations communities.

I'm also mindful that there are First Nations communities which have done a spectacular job from a community-based perspective in dealing with the issues. Maybe you could just comment on that and tell me if I'm completely off base.

B. Clifton Percival: No, I don't think you're off base. But I think what happens here, especially when you're talking about the jurisdictional issues, is that you have youth and mental health at the federal level under Health. But here in the province it's under the Ministry of Children and Families. It's like two ships passing in the night, if it were that.

Our role as a provincial organization is to advocate. So if communities come forward and have an issue, we can help point them in the right direction, point them to resources that are available. But our role has also been to highlight good tools of practice, good practices that have been working in that community. We've been able to bring leadership together in regional dialogues to talk about what's going really good and what really needs help.

That's what our role is as a council. We see our role as political advocacy and helping leadership to take the steps to improving the lives of their citizens. What happens here in this province is that we're stuck under a model of delegation. If you're in delegation, you have access to not a whole bunch of resources but some resources, and you get those resources through the federal government transferred through the province.

If you're not in delegation…. In British Columbia with 203 First Nations, 84 of them aren't in delegation. So they aren't serviced. They're serviced by the province, and we know that the province isn't living up to good services for them. They're not getting the same services as other British Columbians. So those kinds of issues have to be addressed.

Our goal as a wellness council is to have a tripartite table with Canada and get these issues on the table and dealt with in a meaningful way that means the leadership in Cache Creek, or wherever they may be, can actually address these in a good way, and it makes some change for their people.

J. Thornthwaite (Chair): Thank you very much. That leads to my question as well, because we have recognized that because of the different jurisdictions, there are vast differences in help or assistance.

One of the reports that Mary Ellen brought forward a month or so ago, the suicide of the young woman in northern British Columbia…. One of the issues that kept coming up is these so-called no-go zones. If a social worker is called to a reserve, oftentimes they're not allowed to come in and help. So issues are recognized as being issues that need to be dealt with, but yet the help that is called isn't allowed access.

I was really impressed with what you had said about the differences in services that are available — or the delegations, as you called them — depending on what the First Nation is. What is your group, the Family Wellness Council…? Would you be involved in assisting with the relationships with levels of government to at least allow access to these reserves where maybe access hasn't been allowed?

B. Clifton Percival: I think that would be the purpose of having a tripartite table to talk about those jurisdictional issues. Unfortunately, you even have, amongst ourselves…. Those that have subscribed to the delegation protect that, but we all know it's not working. Sadly, I sit at these meeting and those investigations and listen to a child and a family that have fallen through so many cracks, you're amazed that they're still standing. But often they're standing with a loss. So it's incumbent on all of us, if we say we're leadership, to deal with the issues.

If we had a tripartite table, then Canada would be forced to address that jurisdictional…. They can't keep punting back and forth, because kids die as a result of that, and that's something we shouldn't have.

J. Thornthwaite (Chair): I very much appreciate your comments and your presentation. I think that really encompasses a lot of what we've been hearing, particularly with Mary Ellen's report but in general. I'm not seeing any more hands, so miraculously we're back on time.

We very much appreciate your succinct report, because we are actually back on time. Thank you very much, Beverley, for coming. We very much appreciate your input.

B. Clifton Percival: I thank you very much for the opportunity, and I hope that we can start a dialogue. We're certainly willing to work with the representative's reports and her recommendations as well.

J. Thornthwaite (Chair): I think we're going to take a…. We've got a half-hour. The next person that is going to be presenting is at 12:50, which is in exactly half an hour. If the committee could please come back in, probably, 25 minutes to get organized, that would be very much appreciated.
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J. Thornthwaite (Chair): We'll bring the committee back together. We don't want to get behind. We know we're going to get behind, so we don't want to start behind. Thank you very much, everybody, for being here. Our next presenter is Annie Smith from the McCreary Centre Society.

Annie, we've got our next presenters at 1:30, but we definitely want to have chances to have questions and answers from the group. That seemed to be the most meaningful. So fire away.

A. Smith: What I thought was that I would share data from the 2013 B.C. adolescent health survey. Then I thought it might be helpful to…. We did two studies last year with young people who were in the mental health system or who were not accessing the mental health system but potentially probably should have been. So I'm going to start big and then go kind of smaller, if that's okay.

In terms of the B.C. adolescent health survey, just to give you a sense of what it is, it was distributed across the province in mainstream public schools, grades seven to 12. We got 29,832 useable surveys. That's 1,645 classrooms, and 56 of the 59 school districts participated. It was distributed by 325 public health nurses and nursing students. That's important, because when teachers administer surveys, young people are not often honest. When nurses do it, they do believe it's confidential and anonymous.

The survey. We've worked with Stats Canada, and it's considered to be representative of 98.5 percent of students in grades seven to 12. Those are the school districts that didn't take part. But the far northeast has only about 50 young people, so it is considered representative of young people in the province.

What it told us in terms of the profile of young people: they're coming from increasingly diverse backgrounds. Less young people speaking English as a first language. More young people are recent immigrants. Less young people are identifying as straight; more as bisexual, lesbian and about 1 percent as transgender.

Definite changes in living arrangements. Less young people are living with their parents. If they're not with parents, they tend to be with grandparents or other relatives, but we did see 2 percent living with adults outside their family and 1 percent living on their own.

We also saw that 20 percent cared for a relative on a daily basis — a disabled relative or a younger sibling — which was a lot higher than we were expecting.

In terms of their home life, 1 percent were currently in a foster home or a group home, and 1 percent who were eligible were living on a youth agreement.

We also saw that 9 percent had run away from home in the past year, and one in five had moved from one home to another. We see poorer mental health among those young people who are losing connections to school and community, things like that.

In terms of youth in care, I don't know if Jules spoke to this this morning, but one in five people in care have moved three or more times in the past year. There was a huge difference in the mental health picture of young people in care who didn't move at all in the past year and those who moved once, twice, three times. It just kind of stepped up in terms of risk behaviours, and things like that.

In terms of health conditions and disabilities, over a quarter had at least one health condition or disability, and most commonly, it was a mental health condition or long-term conditions such as asthma or diabetes. We saw that girls were three times more likely to report a mental health condition than boys, and we also saw that for many young people, their condition was debilitating. So for about half the girls, it stopped them doing things that their friends could do.

We asked about technology for the first time. We saw that nine out of ten students had a cell phone, and there was a real difference in the profile of young people who had a phone and those who didn't. Those who didn't were less likely to have close friends, less likely to have an adult that they could turn to, but they were also more likely to be happy at school. I have no idea why.

We saw real positives and negatives with cell phone use. If young people were using it for positive things like staying in touch with parents and guardians, they were more likely to be able to identify supportive adults in their life and also more likely that their parents knew what they were doing in their free time. However, if they were using it for sexting and things like that, they were more likely to have met somebody who made them feel unsafe on the Internet and also more likely to have been cyberbullied.

That's kind of an overall quick profile. In terms of positive trends that we saw which I thought might help to put the mental health stuff in context, we definitely saw a number of positive trends. Physical health ratings improved. More young people are rating their health as good or excellent, we saw decreases in students who were injured to the point of requiring medical attention, and we saw decreases in students who needed medical care and weren't able to get it.

We saw decreases in every type of substance use that we asked about. You can see the three major ones there — alcohol, marijuana and tobacco. But it was everything that we asked about.

We asked for the first time about why young people use substances, and the top three are the ones that you would kind of expect: "Everybody's doing it" and "I wanted to experiment" — typical adolescent things. But then we saw…. For example, you can see a quarter of girls were
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using substances because they were stressed.

We saw that if young people had ADHD, they were more likely to be using other substances to try and help them focus. If they had any sort of mental health stuff going on that was medicated, they were more likely to be trying to alter the effects of other substances.

Some other positive findings. More young people are eating their fruit and veggies. Less young people are going to bed hungry, but aboriginal youth are still three times more likely to be going to bed hungry.

We saw decreases in STIs, early pregnancies, increases in young people wearing condoms, things like that.

We saw that young people felt safer in every area in the school, which was really positive. Surprisingly, for a lot of people, we saw decreases in cyberbullying. For the first time in a long time we saw decreases in physical and sexual abuse as well.

Now the areas of concern. Mental health was by far the biggest. Young people were less likely to rate their mental health as good or excellent than their physical health. You can see the gender differences. Boys were far more likely to rate their health as excellent than girls.

When we look at suicide, we can really see those sorts of differences. The percentage of boys who seriously thought about suicide decreased. The percentage who attempted stayed about the same, whereas for girls, we saw a big rise in thinking about suicide and also in suicide attempts.

We know that having a family member or a close friend attempt suicide is one of the major risk factors for attempting yourself. You can see the percentages there of young people who have that. It's more common among youth in rural areas across British Columbia than in urban. I just threw this graph in, because I thought it showed that sort of real contrast. The 30 percent is the percentage who attempted suicide who had both a family member and a friend attempt suicide, compared to a friend, a family and neither.

In terms of self-harm, we saw 22 percent of girls had self-harmed. That's higher than we see in a lot of school-based surveys across Canada, and it's also higher than Washington State and roundabout. About 8 percent of boys had, which is pretty common across the country. If girls are going to self-harm, they tend to self-harm a lot more than boys do. If boys do it, it's once or twice; if girls do it, it's six or more times.

In terms of other mental health concerns, boys were more likely to report ADHD, girls more likely to report any of the other conditions that we asked about, the DSM-IV-type conditions — PTSD, kind of all of them. We asked some questions about experiencing stress or despair to the point where you can't function properly. You can see there that there are no gender differences in the 12-year-olds, and then the gap really starts to go.

What we see in a lot of our stuff is that when young people get to around 14 or 15, if they're going to start using drugs or alcohol, that's when it happens — the kinds of risky behaviours and things. We're seeing it linked to the stress and despair. We see that, incidentally, whether it's in a high school and elementary school system or whether it's in a middle school system.

We had some positive news in that boys were less likely to go without mental health care than in previous years, but we saw no improvements for girls. What was really worrying was that in 2008 the reason they missed out on care, the major reason, was because they thought or hoped the problem would go away — again, kind of typical of adolescence. This time the most common reason was not wanting their parents to know, and that was it for two-thirds of young people. That was the reason why they didn't seek care.

In terms of sleep and its correlation with mental health, for every hour of sleep that young people got, they reported better mental health. We also saw that 82 percent were on their cell phone after their parents thought they were asleep.

Other areas of concern that kind of relate to this: 16 percent had experienced a concussion in the past year, which was, again, the first time we'd asked and a lot higher than people were anticipating. Although cyberbullying decreased and they felt safer at school, in-person bullying actually increased — so teasing, social exclusion, physical assaults, and those kinds of things.

We saw a rise in the percentage of people who were overweight or obese. Probably not unlinked, we saw that exercise participation decreased.

That's kind of like a whirlwind tour through the results. We also looked at some protective factors, what was improving the lives of even the most vulnerable young people. We saw, as we see repeatedly, school, family, community and cultural connectedness. If young people have any one of those, it definitely makes a difference in terms of suicide, self-harm, ratings of positive mental health, future aspirations, all those kinds of things.

We also saw that having an adult outside the family was key, and for girls in particular, they're less likely to be able identify somebody within their family. Older youth in general are less likely to be able to identify somebody inside the family. So if they had a supportive adult…. It didn't matter if it was an aboriginal elder or a sports coach or a religious…. Just anybody made a difference.

Peer relationships were quite interesting, because if young people's friends objected to them doing risky behaviours, they didn't do them, which is kind of what you'd expect. But we see in all our data that if young people had one adult in their life, it made a difference. We didn't see that for friends. So having one or two friends didn't seem to make much impact compared to having no friends. But if you had three or more friends, then we really saw a difference, and definitely in all the markers of mental health
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I just mentioned but also in things like bullying.

Then, again, as you would expect, we saw better mental health among young people who had good nutrition, participated in sports and other activities, got some exercise, if they were getting eight or more hours sleep and if they were living in a stable home.

Just to sort of sum the adolescent health survey stuff up, young people are generally making better choices about their health in terms of things that they can control, but mental health and bullying are among the areas where we've seen fewer advances. And definitely for girls, the mental health picture is particularly worrying. But we have been able to identify these protective factors. Hopefully, Sarah spoke to some of those yesterday, the youth engagement and things like that, that can really make a difference and play a key role in improving outcomes for young people.

I'll move now quickly to the other two reports. These were all young people who had experienced mental health challenges. One project was 70 young people aged 15 to 25 who identified as having a mental illness and as using mental health services. The other one was young people aged 14 to 25, and they identified as kind of having a substance-use problem and a mental health issue. One project was looking specifically at the mental health system, and the other one was looking at how young people could get more involved in service planning, particularly mental health but others as well — 150 youths in total.

We asked them about the kinds of barriers to accessing services. A lot of them were internal — the stigma, the fear, the denial that they had a problem. That was huge, and definitely, a lot of young people said that they had to be into early adulthood before they could kind of recognize and be prepared to accept that they were having issues.

Confidentiality concerns were huge, particularly for young people in small communities, where an auntie works on reception and things like that.

There's a real worry that if young people are living independently, they would lose their home or that if they were in foster care, they would lose their home if they sought out any sort of treatment — and definitely a real sense that if they went for help, they would end up being admitted. Young people didn't seem to think that there might be community alternatives where they could be treated in the community.

They talked about not being able to seek help until their basic needs were met. If they needed to be getting a meal tonight and they needed a bed for the night, they weren't going for care.

They were really put off by a long waiting list. They wouldn't go to services that weren't immediately available.

Then a real sense that they had no clue of what was out there or where to go for help. There's definitely some talk about services advertised, but they don't ever advertise what they do. So you don't actually know what you're going to, when you walk in the door.

There was a real misunderstanding about consent laws. They thought that their parents had to give consent and that their parents would be informed about everything that went on — a real worry that they would lose control of their own information. This was particularly true for young people whose parents had been through the mental health system as well.

Also, a real worry about peers not being supportive. Again, in rural areas there was no option to have a different peer group. If your peer group has a negative perception of mental health services, you're not going. Again, like I've said, a lack of clear information about what would happen, where to go for care.

They really didn't like services that combined adults and young people and also when services were not youth-friendly. If the doctor or the psychiatrist set an appointment at eight o'clock in the morning, they're not going to make it.

Lack of transportation was really bad. That was in urban areas as well as rural ones.

A bad first experience. That included calling when the place was shut or a rude receptionist, things like that. Anything like that and they wouldn't go past the door.

We asked them what services they had asked. It was quite horrifying that the ER was the most used service, even in Vancouver, when there's a whole range of services available.

Things that had worked well. Having a family advocate — somebody within the family who could really help them to negotiate the mental health system — or a supportive social worker. Often social workers had kept young people on their caseload long after they really should have discharged them. It came down to those kinds of individual relationships. It's the same with proactive school staff — school staff who had gone to them, noticed they had an issue and linked them into services — and then professionals in places like housing agencies and things like that.

What I thought was interesting, because we always think that this generation wants everything on line, were the in-person supports. There's a quote there. What we heard over and over again is that young people will go on the Internet for information. They won't go on it for mental health counselling or support.

Having access to positive peer groups was considered really key to young people. They talked about the problems of running mental health facilities simply for young people, where they're only interacting with peers who also have mental health issues. They wanted to interact with peers, without challenges.

When they had trained and supported peer mentors who'd come out the other side, it was really helpful. But
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if they had peer mentors who were still close to their own problems, it was actually worse than not having that situation. So if those peer mentors weren't probably trained and supported, it didn't work well. If they were, it was a real asset.

For aboriginal youth in particular, connections to culture, seeing themselves in services when they arrive was key. They really wanted activities that provided structure and routine, that give them a reason to get up, a reason not to use substances — things like that.

We have some further suggestions about what might help improve the mental health system. We heard this from every single one, from 150 of them, which was: don't end the services at 19. And then the other one we heard in every single group was the need for a navigator, but somebody who's qualified and skilled, who knows the different departments, who knows income assistance as well as the mental health system, who can pull everything together. There was a lot of talk of almost like a PTSD effect of having to go to all the different places and tell your story over and over again.

Definitely the need for individualized services. Don't just put people in a group together. Offer the individual support as well.

Improve the information-sharing between the different departments. Young people said they were happy to sign consent forms for different people to have information about them so that they didn't have to keep telling their story.

"Advertise who you are, what you do and where you do it" was kind of key, and then, also, to give young people the tools to be able to manage their own mental health condition — they felt that often the information was given to parents or to adults; it's not really given to them — so that they can recognize their own issues.

And then just train people within the mental health system and the ER and places like that to work with youth. I know that in Victoria they actually did some work in the ER just after this project came out to try and work with those kind of front-line people who are seeing young people when they come in.

We finished it all by asking them to design what youth services would look like. This was just an example. It's really central. It's close to everything. There's housing nearby. There's a separate space for young adults. Adults and youth are not mixed together. So they had some concrete ideas around what spaces might look like and how they could also access service. If it was in with other youth services or even things like a laundry, people might not know what you're going for. So you could just be in this one-stop shop sort of space, and that it was staffed by people who wanted to be there was key.

Just to sum it all up, then, I think, pulling the adolescent health survey data and that together, the upstream approaches that build protective factors and reduce the risk factors are key. If young people are struggling with challenges in general, we need to reduce the stigma and increase the knowledge about what's out there. They really do need the individualized supports as well as the group stuff and for services to continue past their 19th birthday. We also really saw from the latter two projects that young people can identify the best practices, and we should be including them in all the decisions about their care.

I'll just end with a quote from one of the young people that really talks to that need for a kind of navigator through the system. "Just someone to take you by your hand and show you what services there are and that they actually are relevant to you."

C. James (Deputy Chair): Thank you, Annie, and thank you to McCreary for the surveys. I was on the school board when McCreary first started doing their surveys, so I remember the controversy around that. I'm glad it's continued, and I'm glad we continue to have the data.

C. James (Deputy Chair): Exactly. I think it's so helpful when people are putting services together.

I wonder whether you do any kind of regional breakdown of the statistics. I think it's interesting. I think there's a lot of consistency from the presentations we've had over the last few days, but I wonder whether you see any wild swings or any real differences region to region or rural versus urban, etc., in the province.

A. Smith: Yeah. Rural versus urban definitely, whichever region — whether it's provincially or we go down to the regional differences. Generally, what we see is that young people in rural areas are physically more active, more healthy in the sort of physical components, but we do see higher rates of suicide and self-harm and substance use.

In terms of geographical region breakdown, we're just in the middle of doing those analyses now, so we haven't finished all 16 regions. But we definitely are seeing a very different picture in the north to what we're seeing in Richmond, Vancouver and places like that, and differences across the Island as well — the north Island, in terms of mental health, not doing as well as south Vancouver Island.

D. Donaldson: Thanks. It's very informative. I think it'll be really helpful for our final report and the recommendations because it's coming directly from youth, which is the important voice here.

I have two questions, and they're both pretty quick.
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I'll just put them together for you. The first one is on the first slide. I'm a little bit dismayed, I guess, that two out of the three school districts in the constituency I represent weren't part of the survey. I'm wondering, for those two black areas up there in the northwest, if the responses would have been picked up through the public health nurses and nursing students — that's one question — to compensate for the fact that the school district didn't seem to participate.

The second part. I think Jules earlier pointed this out. The 1 percent currently in a foster home or group home in the survey, which I guess would be approximately 300 that responded…. We know there are quite a few more in the foster or group home situation in the province — 8,000 in care.

I guess my question on this is similar to Carole's. Would you be able to break out those 300 to see if their responses were anything surprisingly different from what we got from Jules? I see the aging-out issue is similar, but compared to Jules's presentation, to what I've seen here, there are some differences in recommendations coming from the youth.

A. Smith: Right. The first question, in terms of the non-participating school districts. One was just political. It was a change in superintendent, I think. The previous superintendent had agreed, and the next one didn't.

Then what is the bigger challenge for the small school districts: the other one didn't participate because we'd have to suppress so much of the data because of the confidentiality rules and then they'd get lost in the bigger picture. So in terms of what they had on their agenda, it just didn't seem like a priority for them. They didn't think they would get any information they could use, given the small numbers.

The public health nurses were essentially shut out of those school districts. They didn't go in and do anything. Hopefully, next time.

A. Smith: In terms of…. I mean, I think the picture is different from what Jules sees because these essentially are young people in care who are doing well, so they're in the mainstream public school system. A lot of young people in the care system are either in alternate education or not in school at all, or we didn't catch them on the day of the survey because they're moving so much. So it's an under-representation, I think.

We did do a report after the 2008 survey and found some major health disparities between youth in care and youth not in care.

What we did see, interestingly, this time was young people in the care system way more engaged in cultural and traditional activities than we'd seen previously. I think some of those attempts to reintegrate young people back to their culture definitely look in the data like they're working.

We're doing some analysis for the Office of the Representative for Children and Youth right now, looking at some of the health disparities between the two groups. But definitely, we see way higher rates of abuse and those sorts of things that lead young people into care in the first place, and then higher rates of risky behaviours and higher rates of poor mental health — and less likely to plan to go on to college and less likely to think they'll finish school.

What was interesting as well — just one last point on that — was that we had one school district where the superintendent rang up in a bit of a panic because they had a lot of young people in care and she didn't think we'd captured that in the data, because in their communities pretty much everybody is in care. So they don't actually…. You know, like: "I'm just living with Uncle So-and-so this week." They move around, and she was saying: "Should we tell them that they're in care?" I was saying: "Not for the sake of the survey."

D. Plecas: Thanks, Annie. Drilling down on the data, are there any particular differences across different regions in the province with respect to anything that we should be paying particular attention to?

A. Smith: Some of that's hard to say because we haven't finished it yet, unfortunately.

I mean, definitely the north-south difference in terms of the mental health and the suicide and the hope versus hopelessness sorts of things, I would say.

D. Plecas: Are you going to be producing a report or something then that would give attention to that?

A. Smith: Yeah. We produce 16 regional reports, and then we've done some comparative analysis for various different things. I could pull stuff out if it would be helpful. I could send along the pieces.

J. Thornthwaite (Chair): Thank you very much for your presentation, Annie. I have two questions. One is: when you're doing these surveys, does the question ever get asked as to why? The reason why I'm asking that is because you've indicated in your graphs that the incidence of considering suicide or attempted suicide as well as the incidence of self-harm are significantly higher in girls and that girls are the ones that would be most likely to seek out help. Do we know why it's girls so much more than boys?
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A. Smith: Not really. I mean, it's what we see. New Zealand did a very similar survey — it's sort of the same stem — six months before ours, and they saw exactly the same thing. The Nova Scotia and New Brunswick surveys saw exactly the same thing.

We take the results back to youth and do workshops with them to get their…. It's stymied by the teachers strike right now, so we haven't got as much data from that as we normally would. But just young girls talking about the kind of pressure around relationships and the stress of…. I mean, when we look at their caretaking, it's predominantly girls who are looking after relatives and things, so I think there are those added pressures for that.

J. Thornthwaite (Chair): Is there any difference between the urban and rural, the fact that…? It's obviously higher with girls, but is there anything that stands out differently depending on where you live?

A. Smith: In terms of the gender difference, rarely. Occasionally…. I was just looking at south Vancouver Island this morning, and there are no gender differences in having a supportive adult and its impact for boys and girls. We've found one everywhere else, which was…. It's just those odd kinds of things. But consistently, we see that gender difference.

J. Thornthwaite (Chair): My last question. You said: "…other positive findings." One of them was that cyberbullying was decreased. How many times have you asked that question? How many years?

J. Thornthwaite (Chair): Oh, five years. I see what you're saying: between surveys. Okay. That's interesting, although there was one other slide where you said bullying in person had increased.

A. Smith: In-person bullying increased, yeah. I've taken those…. Sorry. I didn't mean to cut you off.

A. Smith: Yeah, we've taken those results back to the school district, and they weren't surprised at all.

A. Smith: They weren't, because they've invested so much in bringing people in. Cyberbullying has been such a hot topic that so much effort has gone into raising awareness. Young people know when they're doing it now, whereas often they were getting involved in those behaviours and not even realizing the consequences of it.

I spoke to Patti Bacchus from the Vancouver school board. They feel safer at school, and she was saying it totally makes sense. We've put so much effort into making the washrooms safe and having people patrolling the corridors. We focused on the physical building and just making it a safe experience physically, but we haven't put the same amount of effort into the emotional safety and the relationship safety and things like that.

J. Thornthwaite (Chair): Okay, interesting. Thank you very much for your presentation, Annie. Thank you also very much for sending your very inspiring young lady yesterday. She was really good.

We're motoring along. Our next presenters are from Vancouver Coastal Health: Yasmin Jetha and Dr. Mathias.

Y. Jetha: Thank you for the opportunity to present to you. We're presenting today, obviously, from a Vancouver Coastal Health lens and really wanted to share with you…. When I thought about what the key areas are that we're focusing on and what to present, it really made me think about child and youth mental health but within context — within the context of family, within the context of the system, but also within geography because our health authority does span urban and rural environments. That's kind of the focus we'll be taking here.

In doing so, I found this quote from the Mental Health Commission of Canada that I thought was really important. The first part I know you've heard before. It really talks about the fact that more than two-thirds of adults living with mental health problems reported that symptoms first appeared during their youth. For me, the more important aspect, what goes along with this, is quite vital. The next sentence says that "establishing the foundation for healthy emotional and social development is vital."

When we think about that foundation, that really is family. So one of the areas we focus a lot on within Vancouver Coastal Health is providing care within the context of family. When you think about child and youth mental health, it really is child and youth and family mental health. In doing so, one of our communities of care, Richmond particularly, has really focused on a program around supporting families where there is parental mental illness, because we know that when there is parental mental illness, that does impact the family.

We need to know how to support from that lens. What we did is we met with family members who have been supported by our services and did a number of family-journey maps. I want to share this one with you. The themes are similar across the board, but I just wanted to share this one with you. It spans a time of a young boy's
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life from birth until about grade 1, really going through what the family experienced.

In this instance you'd look at starting off with the mom, who was diagnosed with major depression at the age of 15 and was not on medications but knew she had depression. Shortly after, she met the young man who she married and ended up in an abusive marriage, and they had a child. The son was born and, as normal, the public health nurse came to the home, and what she did, when she came home, was she focused on breastfeeding, because oftentimes our system is such that you come in and you do this part of the work.

What the mom said is: "Nobody really asked me about me, my mental health, what's going on in the family." So she struggled. She struggled for a while, didn't know what else to do, and she ended up getting into drugs. She started using drugs to cope and got pretty severe in her drug use. Again, she didn't know what to do, worried about calling MCFD as her child would be taken away, so she called poison control. Calling poison control is how she was linked in to the methadone clinic, but in Vancouver, not in Richmond. You imagine this young mom who wanted to get some help and she's got this young little infant in tow and they go off to the methadone clinic.

The thing was that the methadone clinic was great, and there she ended up connecting with a really good GP. The GP ended up being a very key support for her.

She said what was interesting in all of this is that no one asked her: "So how is it being a parent?" She said: "That part of my life, no one really asked." She said she understood later that it wasn't because they didn't want to know. They were worried that if they asked her, she might not come back. They were worried about her response.

She continued on, and all this time she was still married and still in an abusive relationship. You'll see that police came to the house, and every time they came, she said: "Everything's fine." No one asked about the child needing help, and she wasn't referred for any services.

The GP suggested later on, because she continued to be quite depressed, antidepressants. She said no. He provided weekly counselling sessions, but she was not referred to a transition house. Then one time there was a very, very serious violent incident. Police came to the home, and the husband was arrested. But again, it ended there. Health Services or MCFD were not called to support her. She went to go live with her parents. From a police perspective, she was now in a safe environment.

It's more around that people have their scope. So they put her in a safe place. She's with her parents. There she was able to then think: "Well, what do I do now?" She actually started going to the Family Place in Richmond. She and her son went there and found some support there in that community, a safe environment where she didn't feel judged.

She was going to the pharmacy for her methadone. At this point her son now is in kindergarten. He started kindergarten, so we're talking five years. Her son's in kindergarten, and he's having some challenges, and now he's beginning to show signs of anxiety. At this point still no one has really asked her about her parenting, what she needs, and by grade 1 the son had very serious anxiety, and now he's been referred to the child and youth mental health services as the identified problem.

It's not an uncommon story. But what we do know is that the family environment matters. Where parents have a mental illness, whether it be anxiety, depression or more on the serious end of mental illnesses, we need to pay attention to families.

When we talked to the families, we just wanted to understand some of the themes. One of the things families unanimously said is that, again, having a key person is important for their ongoing support. Interestingly, in a majority of the cases, that key person is their primary care physician. Their GP is the person they trust, and it's the person that they continue to go to. That, I thought, was really important, because it really does speak to what we need to be looking at for an integrated system and where we need to put some of our supports.

Community collaboration was critical, and that lack of information and communication breakdowns created more stress to the family. Again, what this highlighted for us is that as service providers, we worry a lot about breach of privacy, information-sharing, what we can share, what we can't share. Families really want us to share, because it's too much for them to have to hold on to information. I'm sure you've heard this before. They want us to share.

What also was interesting is that they asked for service providers to have education and training around working with families, working from a family-centred lens. They said: "You know, it's okay for you to ask me if I'm a parent. It's okay to ask if I'm in a parenting role." Again, that's interesting, because when we talk to our intake clinicians from the service end, they always wonder, they worry: "If I ask right at the first time I meet this person, will they come back? Will they wonder why I'm asking?"

It's a very interesting paradigm there. It's more around how you ask and how you engage. Those are some things around some of the training and really understanding what's family-centred practice and moving to a place where we start thinking about child, youth and family mental health.

Then subsequent to that, or along with what we're doing here in terms of the families we're mapping, we also have an initiative that's now well-established in Richmond. It's about probably five years in. It's a program where we focus on supporting families with parental mental illness. It's an initiative that started off in partnership between MCFD and Health.

It's not by any means an expensive initiative in any
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way whatsoever. What it cost was basically one coordinator that would work for that community. That person's role was to begin to integrate across services and begin looking at what families need. We started off with developing groups for parents with mental illness to help them understand how they talk about their mental illness to their children. What's the impact of mental illness on the family?

Then simultaneous to that we had children's groups running, where the kids could start understanding…. And at different age groups. We'd have a group, I think, six to 12 and then above 12, because at different stages of development, kids understand differently, right?

Helping them have the language or an understanding of mom or dad's depression or paranoia — whatever that looks like — and realize they're not alone…. We would find that often kids in grade 11 and 12 would really worry that they were a reflection of their parents or would be getting ill and start having different struggles. These were kids who were already going through a challenging time at that age. And then to have to worry about this…. It impacted their school, and it impacted many things.

We started supporting them because they actually were remaining in school and were actually attaching further. They were feeling like they were part of something.

This collaboration included MCFD, Health, schools…. The school counsellors were just thrilled with this, and it was very low barrier to get in. It didn't require a lot of referral forms. It didn't require a lot of identifications. Basically, if you identify yourself as needing help, you're welcome.

Oftentimes grandparents were in the parenting role, so grandparents would come. It's been a fabulous initiative. It's taken on a life of its own at the non-profits. Everybody has sort of come together now and jointly shares the groups, so it's a community coming together, identifying resources and identifying high-risk families. It just kind of naturally comes through where you know now where the families are, because we're working together.

We're also finding that the number of youth that are apprehended by MCFD because they have parents with mental illness has decreased in Richmond. So we're able to support families staying together. It's been an initiative that I think we would love to see moved into more communities and see funding for that key collaboration — the coordinator that can collaborate.

The coordinator also did a lot of education with psychiatrists and other physicians and will go on to in-patient units where we know there's a parent. She will go in and say: "Can I help you? How do I help you explain to your family what's going on?" It's something that we need to incorporate and have across the board, from my perspective.

The other area that we've been focusing on within our organization, obviously, is providing care within the context of the system.

This slide I know you've seen earlier this morning with Dr. Mathias. But I just think it's an important enough slide to show again, because it really does highlight that gap when we move from MCFD services to Health services at a very critical time in a young adult's life. It's a time when they actually need stability and foundation, and that's a time when we transition — not only transition services but transition different cultures of care. I think that's a really important piece, because the cultures are different.

What happens then is that we end up having people fall through the cracks. And the impact for us in the system…. I'm just going to give you an example of one of our communities, which is the North Shore. The impact of the fragmented services is…. I'll give you an example. We end up seeing these kids now in emerg departments. Rather than seeing them upstream, we see them in emerg departments.

If I look at stats for '12-13 with Lions Gate Hospital, we have 337 youth between the ages of 12 and 18 come through the emerg department. That's more than Richmond or Vancouver or St. Paul's. Again, we have different systems in those areas.

Of the 337: 59 percent had no prior connection to child and youth mental health or a community psychiatrist; 30 percent had a primary presentation of substance use; 55 percent substance use presentations were between the ages of 12 and 16; and 45 percent of the youth presented were actually between the ages of 17 and 18. That's transition-aged youth, which we need to pay attention to.

The primary presentations were depression, suicide risk, substance use and anxiety. Again, for us this is a real concern. We looked at this in context of this community compared to our other communities, and this is an outlier. We have spent time really focusing on this community and understanding how we are going to address the gap.

One of the things that we need to do is to develop a youth crisis response team that bridges emergency departments, acute care and community. It needs to be available seven days a week, and the team needs to actually come into emerg departments and do assessments.

What we have in Richmond and Vancouver are the crisis teams. What we find is that in fact we get the call from the school, and we'll see them in the school environment. We will catch them in other places before they need to come to an emerg department. Again, North Shore not having this, we are working on and trying to work with the ministry around the new mental health plan to see if we can get some shared funding from the ministry to move this team forward in a very short matter of time.

Again, our hope is that if we do this right, we'll eventually have less of these interventions in the emerg and will do more of them in the community. We also need to connect this team up with the primary care physicians, like we do in Vancouver or Richmond. Again, that is a key place.

We've also brought on board Dr. Mathias as our regional leader for child and youth mental health across the region as well as in North Shore, because we really need to engage psychiatrists and build that capacity.

Lions Gate is also our hospital that supports our rural areas. We're beginning to build capacity in the rural areas, and I'll talk about that in a moment. The other big piece across the health authority, what we're focusing on — again, starting in North Shore — is really beginning to work with the primary care physicians.

We need to have an integrated community of care. We need to start with the primary care physicians and support them at that level. Because even with the kids that we catch through our crisis team, whether it be in Vancouver or Richmond, the majority of them don't actually need to go on to a youth mental health team. What they need is the intervention. They need the support, and then they need to be supported in different ways.

What we find is that if we can do the right work, not everyone needs that level of wraparound, of a mental health team. You can do it differently. We're beginning to look at that integrated continuum. What does it look like? What does each community need to have? What do we need to have across Vancouver Coastal Health, and what do we need to have access to provincially? B.C. Children's beds, substance-use residential care — we're really looking at how we do that.

The other area that we've been really focusing on, as I mentioned, is around building capacity in the rural communities. When you think about context, with the rural communities, they are all very different. The history and community context matter in a rural environment. The history lives, right? People know each other, and it's a small community.

When you start practising, you need to understand as a service provider that that relationship is important. Trust is important. That is a bit different than an urban context.

What often happens…. What we will see is that the rural communities will have a lack of resources, oftentimes because they may not have the volume of referrals. But when they need the help, they need it. When they need the help, it's needed immediately, but they don't have the constant volume.

What our rural communities find is difficulty in transitions. Often what will happen is that they'll have that urgent case, and they need help, and they need help right away. What can happen is that we can get everything ready….

A couple of scenarios happen. We get everything ready. We've got the child. We're ready to accept into whichever service it is in the city and, all of a sudden — you'll see that slide there with the clouds — it's so fogged in you can't get the plane to fly out.

Now you need to have the capacity to be able to manage that child in their environment. We need to ramp up there and educate the staff and support them with standardized care and protocols so that that youth can stay there until we can get them out.

The other challenge that happens is we will get them out, and we'll get them into — whether it be Lions Gate or VGH or Children's — wherever it is we get them to, and when we do the discharge planning, that discharge plan often doesn't make sense in the rural environment.

We need to start talking about the rural communities, to say what makes sense. The reality is that, a lot of times, they can do what they need to do in their own environment.

We've got an example of Pemberton, which Steve will share with you, where we actually went to the communities and figured out: "How do we do it in your context rather than bringing everybody into the city?" Those are some of the challenges that we've seen. We've also got some successes of what works.

S. Mathias: The challenge of being in my position is…. How many rural communities do we have in our province? Just a couple. We've got our large centres, and for each little rural community, we have challenges.

The process that we had to go through in Pemberton was laborious and lengthy. To get to where we were, and this was a huge victory for us, took over six months — over six months. The issue was this: there's a lack of access to urgent psychiatric assessments. Pemberton does not have an emergency room. It has an urgent care clinic. It closes its doors at what time? At 5 p.m.

You get someone who comes in at four o'clock in the afternoon, and they're suicidal. What do you do? You feel for those folks. You feel for the GPs working in that situation, the nurses working in that situation. You have someone who's just driven in an hour from Mount Currie, and you're closing at five.

At that point they had no response. They didn't know what to do. There were some situations where they were basically telling folks, parents: "Get in a car, and drive your kid down to Children's." That was their answer, because there were no other options for them.

The barriers were simple. We're closing at five. We don't have a bed for you beyond five. Okay. You're going to be certified. We certify you as a patient, meaning you're under the Mental Health Act.

Well, Lions Gate is refusing to take them, and Children's won't take a transfer from us. Where do we go?

In some cases, they were refusing to certify someone — even though they were certifiable — so that they could just get into a car and drive down. "If I want a psychiatrist to see you, that's under MCFD, and we're Health. We have no idea how to get an appointment for that person." This happens in every rural community that we know of, these types of obstacles. They may be slightly different.

The way our system is set up right now, what we had
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to do is go through a process of journey-mapping, sitting down and understanding where all the barriers were, with MCFD team members, emergency or urgent care or response team members — so some of the primary care GPs. Folks had to drive up from North Van, because that's our area, to sit down and figure this out.

We went through this journey-mapping, we identified all the barriers, and then we actually had to look at provincial guidelines, provincial protocols, for life and limb: the idea that you've got a life-and-limb emergency, so you start up in the ambulance, and then you decide what hospital you go to, right? Well, certification wasn't a life-and-limb issue. In other words, you had to wait for a place to transfer someone before you would actually get in an ambulance. We looked at changing that, and we were successful in changing that.

There were psychiatrists working in Pemberton. They just weren't MCFD psychiatrists, and they weren't child psychiatrists. But when we sat down and approached them, they said: "I see teens in my private practice. I'm happy to see teenagers in Pemberton." So then the question was: "Well, what office space are they going to use?" "Well, they don't have a contract with us, so they can't work at the youth clinic." "Well, we don't see children in the adult clinic."

I mean, just one obstacle after the next. Sometimes when you're overseeing this process, you just kind of want to say: "Folks, can we see the kid at McDonald's? Can we just do that work there?" It'll happen.

We managed to get the adult community mental health team to agree to put an hour slot aside every week for urgent assessments so that the kids would be seen by adult psychiatrists. The physicians are now aware at the urgent health clinic, and the child and youth mental health team has access to those time slots.

I won't tell you what we had to do about dictation services and who's covering that. That was an issue. I won't tell you about how the psychiatrists get covered if there's a no-show for an appointment. That was also an issue. Adult psychiatrists, MCFD; MCFD telling us that there was no sessional coverage or no money for a psychiatrist who has an empty slot if someone no-shows. All of these barriers come up when you're trying to just get a kid seen so they don't have to drive down to Children's Hospital.

The experience, typically, is that they go down to Children's. Overwhelmingly so, they show up at 10 p.m. at night, and by the time they get seen at 1 a.m., guess what. "I just want to go home and sleep." It's over. Yes, we've done a great job of disseminating that crisis, an amazing job, but the only lesson learned was there's nowhere to go for help, and certainly there's no follow-up. This is where we've kind of had to work at this. This took six months to do, and now we have weekly urgent assessment time slots, we have the provincial life-and-limb protocols that have been modified, and we've got improved communication role definition for on-the-ground clinicians and services in Pemberton.

Y. Jetha: I think just the other thing that weekly appointments.… What's also really key is that we have the MCFD clinicians sit in on those appointments so that we have someone who can look after these youth when they're not with psychiatrists, which is really important. The other piece is that when the child now needs something beyond that urgent assessment, the psychiatrists are part of the system, so they know who to call at Children's or at Lions Gate, or we've got life-and-limb protocol. Now it's integrated, but to get there, as Steve said, wow.

Again, there's all the culture. The MCFD office was across the street from the urgent clinic, and yet they didn't know each other. It's a matter of getting people together and relationship.

S. Mathias: What's working? Well, we certainly have a great practice support program in this province that's been developed by some of our experts in child and adolescent psychiatry. We've had literally hundreds of GPs trained up in child and adolescent psychiatry. I think that this is a program that needs to continue to evolve. It's obviously been a part of the collaborative in Interior Health.

We have divisions of family practice on board. Divisions of family practice are identifying that this is a significant issue. A lot of our youth are unattached. Going back to the model of care that I proposed earlier this morning — the integrated model of care, the headspace model, having GPs that are there that are youth friendly, that can engage young people in the issues that are front and centre to young people, attaching them to primary care physicians — that kind of process has been shown to decrease emergency room utilization and decrease walk-in clinic utilization. This is something we really have to think about. How do we get youth attached to GPs?

Co-location of health services, I think, is the way to go. We've talked about that. We've made sort of trial and error and steps. We've had youth hubs created in the past. But I think that until you actually get on the ground and you think about how you actually integrate services there — how do you make sure that the services are there for youth to use? — and you map it out, then it's really left up to the local community to come up with a process. They need guidance.

It's not enough to just say: "Okay, we're going to get an addictions service and a counselling service together, but we're not going to have mental health. We're not going to have primary care. We're not going to have vocational services." There are just too many gaps there, and they don't have the resources to fill them. We need to really think about, on the ground, how much effort is required to get someone from Pemberton to the Lions Gate Hospital and how much work we can do provincially to
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support that instead of having to do a deep dive every time you have an issue come up.

Our relationship with local First Nations communities is something that we really have to develop, especially for the young people. We know that our First Nations communities have disproportionately high numbers of young people. We need to make sure that we're providing them the services that they need.

Obviously, again, as I discussed this morning, our outreach services need to go beyond B.C. Children's Hospital. We need to really find local health authority solutions where we have centralized core services and we are able to do that outreach into the rural communities from there.

Y. Jetha: Just in terms of summary and next steps, I really would like to reiterate the importance of looking at this from a family context and from a community context and really investing in supporting families where there is parental mental illness. Also investing in integrating a service that really focuses on primary care and GPs, because they are the trusted individuals for families. We need to at least look at what the role of primary care is and how we integrate that further into our services.

J. Thornthwaite (Chair): Thank you very much. I just have a quick question, and then Doug's next, with regards to Pemberton being part of Vancouver Coastal Health — and also the North Shore, for that matter. Why is it that within Vancouver Coastal Health, Richmond seems to be okay and Vancouver seems to be okay, relatively, but it falls off the rails on the North Shore when we're actually in the same health authority?

S. Mathias: We're in the same health authority, but our funding is different. For Richmond and Vancouver, MCFD has a contract with the health authority to deliver services on the ground. On the North Shore we do not have a contract with MCFD, so services are delivered by MCFD for the Sea to Sky corridor. We have additional health resources that have been allocated to youth mental health on the North Shore that fall outside of MCFD, and we have direct control over that — about ten full-time positions.

This is a very hybrid model. It's very odd. It's very challenging for people on the North Shore to navigate. It's really a historical anomaly that when the decision was made for the MCFD money to go to Vancouver and Richmond for distribution or for contracting, the North Shore didn't follow. Coastal services are actually delivered by MCFD.

The area I represent has more First Nations communities than non-First Nations communities, and nobody can hop in a car and drive to BCCH because it would be about 16 hours, probably. I would really be interested in if you have case study or some kind of learning put together from the Pemberton model. That would be very helpful for me to take back to my area on what you've been able to navigate there and do. It's great.

We're talking about medical and community and schools a lot — those three areas — in the presentations and the need to communicate between those three areas. But now the need to communicate just within the medical part of the system is pretty phenomenal. There are some gaps there.

I was talking with a doctor up in my area who has referred people with psychiatric illnesses down to hospitals in the Lower Mainland. What he says is that once an acute patient is in a facility, he's found that when that patient's next step happens, whether to transfer or not, there's oftentimes very little communication back to the GP who actually referred them. So there's disconnect right away.

I was wondering if that is a kind of experience you've encountered in your research as well.

S. Mathias: I can say that clinically, absolutely. That experience still happens within St. Paul's Hospital. I am not aware, sometimes, when my patients come into the emergency room until they show up a week later, and they've got an emergency room bracelet on. They've kept it because it's cool. I ask them, "What did you go in for?" and they tell me. I don't want to make light of it, but in fact that is, unfortunately, a lot of the way it works.

We are working on it. I know Doctors of B.C., the BCMA, are looking at that issue. I know that's been a priority for them. I think within MCFD we have to remember that child psychiatrists are contracted. There isn't a medical director for all of MCFD. MCFD cares for 25,000 children, and they do not have a medical director on staff — which blows my mind.

They have no one who's in charge of making sure that the services delivered by their physicians, who are all on contracts, are quality services. So we've continued, and we've maintained this. This is a really outdated model, when you think about it. Child and adolescent psychiatry started, really, in the '70s. That's really kind of when it started. We didn't really have services back then, and at that time we didn't have a lot of interventions either.

So we've had this kind of outdated model. It's not to say that we need a medical model, but we certainly need physicians to be part of the model of care and to understand where they fit in instead of just being parachuted in as consultants and then kind of removed once the dictation is completed. I think that's a real problem. We need to have physicians be part of the solution but also take ownership for the actions that they have.
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Y. Jetha: The point you make around being aware of when someone's in hospital or how quickly they get the discharge note — that is something the divisions of family practice have identified as a really key area of focus. It's the one, with all the divisions of family practice within Vancouver Coastal, that we are working on, particularly around a new electronic health record where we can right away have a discharge, certainly, sent to the GPs.

It'll take some time to get there. I think the North Shore will be the first to go out, in the next year to 15 months. It is something that has been highlighted as a key.

Again, what will happen is they'll know when the patient leaves. We don't always know when the patient's in the hospital, right? That's the issue.

M. Stilwell: You talked a lot about access to different services, but one thing we've heard a lot of is that sometimes youth — no matter how many hubs and spaces there are, all of which we're interested in — don't come. The parents have a child who's not going to school, won't come out of their bedroom, won't leave the house or maybe has run away — whatever. Somebody has to go to the child.

How do you see that working? What is the volume and scope of that group of people? How do you see that being solved? What we heard from were families that were exhausted, that were very able to work the system but still couldn't find care.

S. Mathias: It really is up to the service in question to decide how assertive they're going to be and, also, how they're going to use the Mental Health Act. A lot of folks will say that we have one of the more aggressive mental health acts in the country. It may be true. Certainly, I think that when it comes to children and adolescents, we really have to look at our Mental Health Act and understand whether or not we are using it to its full extent.

I agree. I think that we leave too many children in their homes for six and nine and 12 months depressed and anxious. But because they're not suicidal or they're not saying that they're going to kill somebody, the parents are left to their own devices and paralyzed by that.

M. Stilwell: Can I just ask a follow-up question? One of the things we heard, and I spoke to you briefly this morning about it, was that there was a feeling that there was a layer of so-called mental health workers who really functioned to keep kids out of hospital. There would be cursory assessments by non-medical people who would blow it off. Then the parents felt they were stuck because they couldn't get by a gatekeeper. Does that make sense to you? Is that your experience? Is that relatively rare?

S. Mathias: I don't know how rare or how common it is. There aren’t a lot of people in the system who are specifically trying to….

M. Stilwell: Yeah, I don't mean that as their goal, but the end result to the parent appears that there are people who are not helpful.

S. Mathias: Right. I think even just the intake process is cumbersome and difficult and makes the system at times inaccessible. I think that in mental health we tend to simply…. I'll say wash our hands. But we tend to simply decide that this person doesn't need follow-up anymore if they stop coming to their appointments.

If you're an orthopedic surgeon and someone stops coming to their appointments, then they probably are walking around, and they're okay. But with mental health, it's often the opposite. It's great if you call and just make sure that the person is fine and that they're doing okay. But we often don't make that phone call. We often close the file.

J. Rice: I noticed on one of your earlier slides that you talked about relationships with First Nations, and then you had Bella Coola in brackets. So I was curious if there was a case study or an example that you could speak about.

Y. Jetha: I did speak with the MCFD community service manager out in Bella just to understand what's working. It sounds like they've made a lot of inroads with the First Nations community there. I can definitely get a case example for you.

I think what's also working is that Dr. Matt Chow, through B.C.'s Children's Hospital, has been doing telepsychiatry up there. It has taken a while to take hold. With telepsychiatry — again, the relationship is equally important through that mode as it is face to face.

What they've now found is that they've built enough of a system, enough of a relationship that he can support them to keep the youth in the community. But when the kids need to be pulled, he knows them well enough that he can just pull them and directly admit them to an in-patient bed. It's not, "Come to emergency," but "Now I have enough of a relationship, rapport. You come to the unit" where he himself works, right?

So it's a really good model. It's taking hold. I can definitely get you more information on that. But it's working.

C. James (Deputy Chair): Just a follow-up on Pemberton, and it kind of follows on Doug's question, as well,
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around that example. I think that the things you've learned from there are terrific and would be helpful for other communities. But you mentioned the time it takes, and I think that it's a lot of relationships, a lot of making those connections.

Do you think, having gone through that experience, that it would take the same amount of time in other communities, or do you think there are things that you've learned along that way that would make the process a little bit more streamlined in other communities now?

S. Mathias: You certainly can learn from those experiences. I think they're important, because they're not going to be dissimilar. A lot of other communities are going to have those experiences.

I think what I learned from it, though — unfortunately, or fortunately — is that (a) it required us to put resources into someone to kind of manage those meetings and put the pathways together. So you have to have funding for that, and that's often outside of a regular budget. And (b) it also requires people on the ground to actually care enough to have an ability to make a decision — right? — and the ability to actually say: "Okay, yes, we'll cover the dictation costs if you cover the costs of the physician."

My concern, when you're dealing interministerially, is that you don't always have those people who are willing to do that. We were lucky that we did.

But again, when you're talking about siloed care and you're talking about different services being provided by different people, you can quickly lose sight of what you're trying to accomplish. Our hesitation with the way things are set up right now, with one ministry taking care of kids up to 18, 18½, and another one stepping in at 19 is….

As Don Duncan once said in Kelowna, the problem is that everybody starts to pull away from the edge. The more you pull away from the edge, the bigger the gap gets. That's why we keep saying that we actually need somebody who overarches that and services that overarch that, not just expecting this to work.

C. James (Deputy Chair): They may also have staff change, who've been in those positions who now say: "Those were the rules then. Now I'm going back to the rules that were there."

S. Mathias: Absolutely. I know that the collaborative in Interior Health has been held up on several occasions. I really do believe in what they're doing. But even in the six months that I've been involved, we've had three ADMs change, and we've had one of the two key leaders in the collaborative change jobs as well.

If you're coming and investing your time and energy into the process, and the people who are basically giving their governance to this are changing, how much outcome are you expecting to have when there are no new resources going into that process? There are definitely challenges.

J. Thornthwaite (Chair): Thank you very much. Again, can we get a copy of your report?

J. Thornthwaite (Chair): You can just send it to us, and then Kate will make sure that everybody gets a copy.

J. Thornthwaite (Chair): You've given us a lot of information to consider and to include in our report. The good news is that we've got this today on Hansard, so we've got a total record of everything and can refer back when we prepare our report. We very much appreciate you coming in.

I guess our next one is Julia Staub-French at Family Services of the North Shore. Please let's welcome Julia Staub-French from the Family Services of the North Shore.

Maybe, Julia, you could introduce your co-guests as well and then carry on. Our next presenter is at 2:50, but obviously we want to make sure that we've got chances for the committee to ask questions. So don't take up your whole time that way. Carry on.

J. Staub-French: Exactly. That was our plan, because these two are the main event.

Let me first say how much we do value the opportunity to make this presentation to our very own MLA, Jane Thornthwaite, and Chair of the committee. Your leadership on these issues and many other issues within our community is so appreciated and needed.

And to all of you committee members for the Select Standing Committee on Children and Youth, thank you so much for all of the work and for having us here.

We feel that our time here with you today is best used to describe the challenges and opportunities we see relating to children and youth within a community-based, non-profit counselling context, such as ours at Family Services of the North Shore.

It was interesting, even in a lot of the dialogues…. We got here early on purpose, because you can hear that there's a lot, especially on the North Shore…. Fair enough, there's the MCFD or Health, and we say: "We're here too."
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I am Julia Staub-French, executive director of Family Services of the North Shore. I'm a trained counsellor and psychotherapist, and I was the former clinical director at Family Services of the North Shore, with over 16 years of experience.

I also have Karen White, who is our current clinical director and supervisor of our child and youth counselling and prevention programs.

Most importantly, we have two of our youth leadership advisory board members, Samantha Smith and Sasha Soden, who work alongside ten other youth with us, who volunteer at our agency to develop outreach strategies to reach their peers with mental health issues.

We sort of did a mini-thing of what you're doing now, which is we knew we needed youth's voice to help us know what's happening. We're in our second year, and this group is amazing.

It was interesting, too, because when Steve Mathias got on the radar on the North Shore, I gave him a call, and I said: "Why don't you come down and see us?" He said: "Great. I'd love to." He came down, and we had this great connection, because we invested the time in that. You can't always do it, but we did.

We said, "You have this great Youth LAB" — youth leadership advisory board. He came down and spoke to them. So it's interesting. It's hard to keep that up all the time, but you can do these things, and I think he was quite pleased to hear from all of you and kind of give him your version.

I do want to be clear that as we speak today…. We're discussing many changes that we'd all like to see across service providers, but as is our nature at Family Services of the North Shore, we want to be clear that we're looking closely at ourselves and the barriers that we put up for clients within our own organization, including youth, and some of the things that are very hard to get through.

I do want to spend just a moment to talk about what we do at Family Services of the North Shore, mostly because it will give you a sense of all the types of mental health services that community-based organizations like ours are doing.

I thought it was very interesting that in that last slide talking about the youth that come into the hospital who they look at, 59 percent have no LGH or child and youth mental health services. The follow-on to that — because many of them are with us; they're coming to Family Services — is, if we actually do our job right, they don't go into the system.

I think that's kind of the framework which we're talking about here. We want to say, "We have an important role to play. We think we're having good impact that actually saves a lot of the very expensive treatment downstream," although many of the youth that we work with also do need psychiatric help and other things. Karen will cover that a little bit later.

As Family Services of the North Shore, we've been serving our community for over 60 years. We serve over 7,400 people per year. We provide a wide range of services for children, youth and their parents, including family preservation and support services that are funded by MCFD, and also the sexual abuse intervention services that are funded by MCFD child and youth mental health. So that money is flowing into community organizations in other ways, like ours.

We also provide a sliding scale for children, youth and their parents who are struggling with a broad range of mental health issues, including anxiety, depression, eating disorders, bullying, grief, school stress and any of the other issues that youth and parents need support with. A lot of times we are the ones who say, "Who should you call? Well, call Family Services," and they call us. We also refer out about 100 people every month as well.

We're seen as that first place where people can get the experience. It also helps to not be called mental health sometimes. If you have a kid, you kind of…. "They just need some counselling." Counselling seems to be okay. Youth like to call us their shrinks every once in a while.

We also provide services to women and children impacted by intimate-partner violence through our Stopping the Violence contract through the Ministry of Justice and through other funding sources that we have. We are one of the seven B.C. partners for mental health and addictions information through our Jessie's Legacy eating disorder prevention program, which is funded by B.C. mental health and addiction services, part of PHSA.

We are also unique — and this is very unique — in that we fundraise over $1.4 million each year in order to provide new and innovative programs, such as our youth leadership advisory board. So we have a lot of resources to bring to the table, some that you flow through us and some that we bring ourselves, which ends up making us, actually, one of the leading mental health providers on the North Shore. But sometimes we're outside of that Health, MCFD umbrella. We kind of do it quietly, and hopefully, people get better and go on back to school and into their homes.

I'll say this because it relates to something I'll say later. We have been chosen by our community to be the lead proponent for their early-years centres RFP that's out from MCFD. It builds on our current expertise, because we also run two family research programs and parent ed services.

We wanted to highlight all of these programs because it is important to our overall philosophy and assessment of a significant challenge for youth. That is, in order to support children and youth, we must support parents and siblings. We talk about families sometimes, and we think about parents. Siblings also sometimes need a lot of support when mental health issues are going on. Or they're the kid that's doing okay, and the older sibling is having the identified problem. It also gives us a chance
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to get in there early.

We also want to say…. It was great — that presentation with VCH. Agreeing with them, as we do on the North Shore often, that parent mental health, violence in relationships, addictions and poor parenting competency must be addressed at the same time we're serving our children and youth. It is, again, something that community-based organizations like ours uniquely can do, because we have these different funding streams and many, many different programs.

We know if we can help a mom, for instance, who's in violence, and that child, who can deal with their symptoms of post-traumatic stress disorder, and build up some resiliency in that kid and the relationship with the parent, they can actually get through some of that that's happening to them and not end up in full-blown mental health services or addictions or all the other things that happen.

I wanted to say that the question, too, that came up earlier when we just came in was about self-harm and why. I think you asked that question. You know, there's a great psychiatrist who came to West Vancouver, Leonard Sax. He highlighted this, and we know it from our clinical practice, which is that self-harm is often, in girls, not about suicide; it's about anxiety and coping. Girls go internal; boys go external to other ways. It's also not attention-seeking behaviour, which creates all kinds of excitement around that, instead of anxiety and coping. I wanted to kind of bring that back forward.

We also see ourselves as one of the places for early intervention related to all of these social, individual and familiar issues, including our upstream prevention work. What can happen with working with a mom with a two-year-old? What needs to happen at that point to prevent later mental health issues?

I have forgotten to use my PowerPoint, because we sometimes don't like these very much. I actually don't like these anymore — I like talking to you; it's the therapist in me — but we felt we need to do a little bit.

Another significant challenge we see for parents and youth is the lack of understanding, which you heard again — I'm sure you've heard it the whole way through — of how all of our services fit together. They did talk about this. It's child and youth mental health through MCFD and the child and adolescent program. These are all great clinicians, by the way. We sometimes swap each other. We're all the same people doing a lot of the services. I think so many of them are excellent, as I think ours are too. But for parents to understand who's who is really, really hard.

The lack of service knowledge, which we can admit is a barrier for parents and youth, is also a really big barrier for community organizations and service providers, who actually can't keep track and don't have time to know when the certain group for anxiety, the Cool Kids group, is running or when something's happening in West Vancouver. You get overwhelmed, and then you go this way: internally. I think it's natural.

The idea that everyone could stay up to date on everything really seems like an impossible thing. So what we did…. We went through this issue during the early-years proposal that our community looked at. I thought I'd present this because this is also a simple way that we might be able to do this for children and youth. It's a community service expert, a service expert consultant who can be there.

In this case it's looking at a person who anyone from an organization…. As you all know, it's a lot of people like me or Karen who go to meetings, but then to flow all that information down to our own staff is really hard. I mean, it just is. So someone in the midst of all this who actually has a handle on all the different services who you can call. It may have to be two people so that there's some sustainability in it.

Also, I thought this diagram is exactly how it feels for parents and service providers. If you have to be in connection with every single person and you scale that up to 100, 200, 300 people, it's impossible. We don't need to solve that problem with education for everyone to know everything that's happening. Or even directories — we have a lot of those. What if we had a person who was our expert on the North Shore — particularly on the North Shore? It seems like there's a lot of interest, and they were talking about it in kind of a different way. It seemed like we're talking about the same problem.

I'm going to keep it really right there and pass it over to Karen White, our clinical director — again, because we want to get to our youth, and I didn't. I did take longer than I thought.

K. White: There was a perfect segue on Yasmin's slide when she referred to a mental health commission and talked about the fact that 70 percent of adults with mental illness report that their first onset happened before the age of 20. The other part of that is that we also believe that less than 20 percent of youth receive the appropriate treatment. So you can see what happens is that you have these one-in-five youth who access services, and the rest of them go on with a mental illness until it's in full-blown emergence into their 20s, 30s, etc. That's one of the major gaps in service.

Now, there appear to be three compelling reasons for the reluctance, hesitancy and inability of youth to access service for mental health issues. One is education — even knowing what the warning signs are for many of the major mental illnesses.

Lack of awareness of available resources. Someone mentioned there are a lot of resources out there. Why is it that youth still don't know how to access them?

The third one is inadequate access to services. We still need to address the stigma of mental illness. It still has this stigma that gets lost in a culture of silence and
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shame. We don't talk about it. It's interesting. We'll talk about physical illness. We have a much easier time speaking about cancer than we do about depression, anxiety, schizophrenia, eating disorders, etc.

Now, I believe a lot of this could be accomplished by embedding mental health promotion into school health activities. There's physical health being taught, but what about mental health?

I also, as a past teacher in secondary school, don't want to stress that we need to add more to the curriculum. I know how overworked teachers are, and they're caught into the constraints of curriculum. But I also believe that physical and mental health need to be taught together — it's that whole collaborative piece — because they do often impact one another.

In a few moments you're going to hear from the Youth LAB, and you're going to see a video that the Youth LAB last year actually created. Then they take it into schools in the youth-led presentations, to actually present education on mental health.

We know that early detection and intervention are crucial for addressing mental health issues for youth. However, access to youth-friendly — and I do mean youth-friendly — affordable and accessible mental health services is often met with barriers.

One of them has to be — and Steve Mathias referred to it as well — when mental health opportunities are open. Kids are in school during…. They need services that are provided in the afternoon, in the evenings, on Saturdays, on Sundays, and most mental health providers are nine to five. At the agency we do provide service in the evenings, five days a week. We're also looking at trying to expand Saturday clinics, knowing that for many youth, that would be an even better opportunity.

Psychiatric services are cost-prohibitive, and the wait-lists are long. We even have trouble finding psychiatrists that we can connect with to provide assessment of many of our high-risk students. Private counselling services are also cost-prohibitive for many youth and their families.

Access to services also needs to be expanded, as you heard earlier, to include youth from 19 to 25. We all know now, with a lot of the current brain research, that the brain is not fully developed — not, as we earlier had thought, at 18. Somewhere into the mid-20s the executive functioning is still being developed, so mental health issues are still developing during this time. They need more support.

We do provide counselling for youth beyond the age of 19 in our child and youth program. Sometimes, at low cost or no cost, we transfer them into the adult program.

There also need to be intermediate steps, as you've heard before, between isolation with a lack of service and the hospital emergency room. I had an opportunity one time to go with a youth, who was 14, to the Lions Gate emerg. We spent six hours waiting in the emergency room, going through the necessary assessments. Then the 14-year-old youth was placed in the psychiatric unit with adults — not a pleasant experience. What would be helpful would be some rapid-access critical response unit, much like what Steve talked about earlier.

It would also be beneficial if teachers, youth workers, doctors — anyone who works with youth — were able to increase their awareness of the first warning signs of mental illness — depression, anxiety, any of those — so that they'd have a better sense of encouraging youth to get help.

When youth are often asked who they would tell about their mental health issues such as anxiety or depression, they overwhelmingly report that they would first tell their friends. It shouldn't surprise any of us, except that knowing that youth will talk to youth first, we need to expand youth knowledge and understanding of mental health issues so that they can support their peers and encourage them to access resources. They'll take referrals from their friends before they're going to take it from anyone else, as the Youth LAB has told us many times.

We also need to help parents deal with their own mental health issues. Many children with mental health issues have parents with mental health issues, so helping the parents as well as the youth would help. Also, having a greater understanding of the cycle of intergenerational abuse would be helpful in helping families as a whole to seek support.

Now, we do offer counselling on a sliding fee scale. That's as a result of our generous donors and our fundraising efforts.

When therapeutically appropriate, we work with parents, caregivers, siblings, significant extended family members, anyone in the family that can help support the youth. As opposed to just…. Some parents will say: "Well, just fix the kid. I'm having problems with the kid. Just fix him." But we know that if you just fix the child — which, of course, we can't do — the child goes back into the same environment, and it's perpetuated. So there needs to be a system and a family approach, which we do use at family services.

Lastly, it's the piece around…. When youth are in crisis and at high risk and in many ways fall outside of the scope of our practice, we sometimes have to hold on to those youth because there isn't anywhere else for them to go, and we also lack the psychiatrist and the psychiatric services to provide assessment and proper treatment of the mental illness.

J. Staub-French: I'm going to go right to the video. This is partly the video that Samantha's year beforehand had created to do presentations in the schools, so we decided we'd do two sections of them.

After that I'm going to hand it over to you guys. This
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is your video, and you can talk about it.

These are actually our Youth LABers from the year before, who acted in it too, which was so fun.

This is Sasha and Samantha. What we do sometimes when we do presentations is I pose questions to them, and it takes less of the presentation off of it, even though they can do a better presentation than I can. Honestly, these kids.

You've talked to us a lot about the need to receive real information at school or real information in general. Can you say just some more about that and tell the committee about that?

S. Smith: Personally, I've found that, with schooling, we're kind of sheltered from the truth. They don't want to be telling us. I'm not quite sure why. But I'm finding more about mental health from my friends and their real life, where I should be getting educated in it at school. Just like Karen had talked about, I find that mental health is just as important as physical health. I don't see why we don't have a full class that focuses on it throughout high school. To me, it's just ridiculous because there are more kids that are suffering from it, and we're just not getting the proper education.

S. Soden: Yeah, when you look at the classes we're given in school at vulnerable times in our education, such as planning 10, what we're told about mental health is never completely equivalent to the amount we get taught on physical health. We're often given just face value rather than details and where to get help and how, which obviously isn't good enough when you look at the statistics of who's suffering.

J. Staub-French: You both have talked about — I'm going to get through these quick, because their questions are more important — the need for peer support. Karen alluded to it. You're providing that now, both of you — peer support. So do you want to talk about that a little bit?

S. Smith: With the Youth LAB, I can't even begin to explain how helpful it's been for me. Going through high school being a girl is difficult, and then when you have friends who start to go through different things, everyone kind of starts to jump on the train, and no one really knows the truth. So it's really helpful to have the tools to teach them that you can go get help and that it's not bad to ask for help, that it can benefit you more than you'd even imagine.

Just being able to have the tools and to help everyone. I mean, I'm not a counsellor. I'm not going to start telling them what to do and how to do it and when, but at least I can guide them and tell them and just be a supportive friend. That's basically how amazing it's been. It's definitely changed the way that my friend group has been able to interact with each other.

S. Soden: Yeah, pretty much the same as what Sam said. Also, what I've found as a girl in high school is a lot of us in our friendship groups will talk about our problems with each other but will never tell each other how to get help, because we don't know how to do it. Specifically, since starting with Youth LAB, I've been able to act in a way as a referral and been able to give my friends far more detail in where they can get help and how, which is obviously great, because now we not only know the problems, but we know that somebody is potentially getting assistance with those problems.

J. Staub-French: Can you say a little bit about this darn sticky-note campaign that you came up with this year?

S. Soden: One of our Youth LAB members mentioned that they had a friend whose therapist had been helping them, I believe suffering with depression, and they had been making small sticky-notes and stars with congratulatory messages for little achievements, like "You got out of bed this morning, and you ate something. That's great." We took and bought that idea and decided to develop it further into a campaign to post around the schools that we're attending and the schools in the district with small messages like "You smiled today" — quotes on the sticky-notes, which we then posted around some of the schools.

As far as I'm aware, we got really good responses from those, and people really liked the idea because it was new and it was different and it wasn't just posters on a wall.

S. Smith: What we were trying to achieve with the little messages we had in bold printing: "You ate today…." Then if someone didn't really suffer from an eating disorder, they'd be like: "Yeah, so? I ate breakfast." But if someone was suffering, it would catch them differently, and they'd be like: "Well yeah, I did eat breakfast today." Then they might look more into it, and then we had the need to help. If they did need help, they could go and reach out to that. We did get really good feedback from it.

J. Thornthwaite (Chair): Thank you very much, Julia, and thank you very much for bringing Samantha and Sasha as well — and you too, Karen, of course.

I just have a quick question. You're connected to the
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Youth LAB that the Family Services of the North Shore obviously is funding, right?

J. Thornthwaite (Chair): How do you decide where you're going? How often do you go? What schools do you go to, and how many classes? How many youth, for instance on the North Shore, are you actually reaching?

S. Smith: There are ten of us this year, and we range from Seycove, Sutherland, Handsworth, Argyle, West Van and Sentinel. We're making a pretty good range. Each of us is supposed to do a presentation to our schools, and we reach quite a few youth, I believe. Last year I did a presentation, and there were about 60 kids I talked to and did the presentation in front of.

J. Staub-French: It was a lot higher. It's interesting, because we'd been talking about whether we'd try and embed this in the schools — a Youth LAB idea in the schools. We didn't feel like we were ready this year because we wanted another time in there. But it is an interesting idea, and we've talked with our superintendent from North Vancouver about doing that in the schools.

It's interesting — their ideas about keeping it simple, giving the positive messages, the resiliency that we need to have for people. A lot of the kids who they're reaching out to, who are struggling, won't hit Lions Gate Hospital. But they'll be significantly impacted if they don't get help either through their peers or through outreach through organizations like ours.

You can ask them anything, too, not just about youth. They're brilliant. This influences quite a lot, you know.

D. Plecas: My question is to both Samantha and Sasha. Samantha, you mentioned that there are certain things — that it's not like you're getting the truth. Youth aren't getting the truth. It's like a superficial kind of treatment of it all.

I sometimes wonder if, because adults sometimes are kind of dumb…. They have these lame responses. Do you think that in some ways, because it's adults trying to drive things, they're kind of out of touch with what's really going on with youth? Like you said, the way they talk to you…. Not these people here.

J. Staub-French: No, no. Same with us. That's why we brought them in — because we're not cool anymore either. Trust me.

D. Plecas: Often the way they present information…. Sometimes I wonder if that's what perpetuates the negativity and the discrimination. We need to change people's attitudes towards mental health. Well, maybe it's because of the way the information is coming to youth. Anyway, if you could just say something about that.

S. Smith: What I meant by being sheltered by the information — how we're not really getting what we deserve to know…. I think that a lot of teachers and parents and other people just don't realize that we're going to figure it out either way. We're going to find out the hard way if you don't teach us it.

In a way, it's quite silly that they're trying to protect us from it when we're, without a doubt, going to go through it at some point. I mean, high school is stressful. University is stressful. If it's not grades that are going to get us, it's friendships, it's relationships, and it's family. We should learn earlier.

I mean, in elementary school there should be something starting way further back for us to be more educated on it. I'm talking about little things just to embed it in us, for us to know what an eating disorder is. I didn't know what one was until grade 9. It's young, but it's late, and I should have known more about it. Then when I did, it was too late for me to be able to help anyone that was suffering from it.

We're growing up so quickly now that we're not that young when we're 12 anymore. We're so exposed to so many things that I don't see why we aren't exposed to mental illness earlier, when it can be prevented earlier.

In terms of warning signs — I guess, to both of you — in growing up, you must see your fellow students and friends, and you say to yourself: "Whoa, something doesn't seem quite right there." How often would that happen, that you would say, "I think that person's got something going on where they need to get help," and then how would you go about handling that?

S. Soden: : I'll go, I guess. I know I've seen friends of mine…. Within my very close friendship group at school I've seen people change on a weekly basis. In some parts of the school year I have seen people at least once a week, and I've thought: "Something needs to be done. I need to get them in contact with someone." It happens a lot, I think.

D. Plecas: What do you do? When you see that and you say, "Something is weird here," then what do you do?

S. Soden: Well, last year I would have talked to them myself. I wouldn't have been able to address the situation properly, but that's what I would have done. As I've learned more about the services that are around, both at school and outside, I've been able to talk to school counsellors,
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people at Family Services — I've spoken to one person even — and help put the friend or whoever I'm around in contact with someone who can help them further.

I think varying the amount of education you're given on what can be done is really the thing that…. It helps you refer somebody over and helps with the changes that your friend is going through, I guess.

J. Staub-French: If I could just follow up on that. When a youth has come and talked to us, one of the things is that if you're a trained counsellor, you don't kind of go explosive and scared on the issues that come in, like cutting or something. What's happened before and we've talked about before is that someone comes in to a school counsellor who's not prepared for that. They hear about that, and it just gets explosive. The parents get notified, everyone gets really excited, and then the kid goes right in, and then they're not accessible anymore.

Some of it is also just capacity-building within schools and other settings so that they know what's normal and how to just be present with them instead of getting scared. I think that's what they know with us. We don't get scared, because we've seen so much. We've seen the worst.

M. Stilwell: Thank you, Julia. If I could ask you a drier question or questions. I think it would be wonderful if every community could have something like your Family Services at the base of the pyramid. Certainly, your point is well taken that many people can come in at the base and don't necessarily need to be escalated and, in fact, probably shouldn't be escalated into a very medicalized and tertiary care model. And I don't doubt it saves money.

My question is…. From some of the presenters we've heard today, the data, however, is not there, and the indicators maybe are not consistent from organization to organization, so it's hard to compare and contrast and understand what works well and how we know that.

On the other hand, my experience in government is that there are seas of data, but it's all inputs. It's, you know: "We saw 36 people. This is how old they were, and this is where they were from." But at the end of the day, you're not sure how many people are better. How do you evaluate yourself and your organization to inform that?

J. Staub-French: Well, we had the same issue, and what we do report to government is how many people we saw and how many visits there were. That can be interesting data for all of you to look at. I think it might be more interesting if you…. We do outcome measures. We did it as a part of accreditation but also because we just wanted it ourselves. We went ahead and created, with a consultant, outcome measurements for each of our programs. In some we've used standardized North Carolina inventory for family preservation.

We created our own so that we can say that in our child and youth program 80 percent of the kids feel more safe, that they have less symptoms. We're hitting that sort of 70, 85 percent mark for kids who do come in. So we can say with….

I didn't go into all that because we didn't want to do all that on our services. We didn't want that to be the focus here, specifically. But you do need to know that. You need to know whether you're helping anyone. I mean, what's the point of all the money we put into everything if the kids aren't getting better in the short term?

What we do know is that kids are very resilient. They get some help, and then they get through it. They have less symptoms. They know how to keep themselves safe, especially around sexual abuse. Then they go, and if they need to come back at some point to check in, they can. But we do. Those are outcome measures, not outputs. We'd be happy to provide those. We're quite proud of that. It might save RFPs if you know you're already doing a good job.

D. Barnett: Thank you very much for your presentation, and it's sure great to see young people becoming involved. It will help. I know it will sincerely help. There are lots of youth centres, I know, throughout rural British Columbia, but I don't think they're being involved like you are. So if you can outreach to some of those, I think it would be a great model.

My question is to the Family Services of the North Shore. Are you under contract from the Minister of Children and Family?

D. Barnett: Do you have a long contract, a short contract? You put all these services in place, and then up comes your contract for renewal. Of course, I guess every so many years you're concerned. How is that working for you?

J. Staub-French: It's very stressful. It is. We have a unique model on the North Shore where we work quite closely, with our community service manager and our executive director of service, with four organizations that came together to create a model under the MCFD contract that I think really works well. They meet each week to talk about the services and exchange cases and things like that. There's a lot of collaboration that happens because of that model, and I think we're very unique on the North Shore for that.

We've had our contract for a while. We are hearing, as you know, from the Ministry of Justice. Those contracts are going…. We've been told that there is a consultation process now, and we'll be going up for potential RFPs. But we don't know yet.
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It is very stressful. It's very stressful internally, but we understand it at the same time. It comes back to the outcome piece. If we could show we are doing really effective work, you might have the data that you need for that, and we wouldn't have to go through that. I know it's very layered — the procurement process and the need for that. It does, internally, create a lot of stress for us.

If all of our clients…. Imagine all of our family preservation clients. We see 35 families a month. If all of a sudden they had to go to new service providers and if that happened provincially, what chaos that would create in some of the most vulnerable families across the entire province — if it happened at once. It's very hard on the service and the families.

How do you find that other agencies collaborate with you, like ministerial agencies? Do they work well with you through this process?

D. Barnett: No. If they just work well with you. You have a contract to do certain things, and then you've got other ministries of social delivery of services for youth. Do they collaborate with you at all times?

J. Staub-French: It varies differently. Our contract with PHSA around prevention of eating disorders — very closely collaboratively done. Our MCFD — quite closely collaborative. If the North Shore could take care of the North Shore, and if those folks who we work with could make those decisions…. But it gets taken up to a different level. Then those relationships aren't really the ones…. We're not making the decisions together, so it becomes…. The current relationship that we have is great. Then, in the larger picture, it kind of feels like you go out of our hands, and that can be very stressful.

C. James (Deputy Chair): Thank you, all of you, for your presentation. The first question is for Samantha and Sasha, and then the second question is for all of you, I guess.

First to Samantha and Sasha. I'm just curious what brought you to Youth LAB? Why did you get involved as peer counsellors? What was it that drew you?

Then the question for all of you is just: what do you hear most often as the two or three reasons that youth aren't accessing services or aren't coming forward — or families?

S. Smith: For me personally, I was in grade 9, and I was with a group of friends. There were 16 of us. By the end of the night it turned out that four of my friends admitted having an eating disorder. That was one-fourth of my friends group, and I just remember feeling so overwhelmed and having no idea what to do.

My immediate reaction, because one of them was my best friend…. I went to my school counsellor with this huge burden and just felt like I had no idea what to do. I had no tools. I went to my school counsellor and told her.

Right away she was like: "What's her name? I need it right now. I'm taking her out of class. We're calling her parents." I just sat there. "No, I can't do that." Then it ended up being this huge thing that exploded, and it just got so much worse.

Maybe about two weeks later there was the article in the paper for Youth LAB. I read about it, and then one of my school teachers recommended to me to apply. So I was: "Okay, I might as well." Then I realized how I really wanted to get in, because I needed these tools.

Once I got in, I was so happy. I didn't really think I would for some reason, because there were so many people. Then when I did, it was just so amazing to be around these people who have the same interests, and then you're learning about the same things. For me, I really wanted to be in so that I could help my friends.

For me, I've just been passionate about mental health. It's really bothered me how it's not…. It doesn't seem like a big deal, and there's just this stigma around it. I can't stand it. I don't understand why we can talk about cancer but we can't talk about depression. I just think we need to start growing up with that. Our generation needs to see a change.

S. Soden: I've been through two school systems. I went through the British education program and then moved here in 2012. In both countries I've lived in — I find, actually, more here on the North Shore since I moved — I've got a lot of friends who suffer a lot from various mental health issues, with depression and anxiety being probably the main ones.

During the summer of 2013 I saw the ad for Youth LAB go around in a big chain e-mail. I caught it off chance and applied. It was after applying that I realized that I really want to learn about this stuff. I want to be able to help reach my friends.

One of the reasons there were so many of my friends who were struggling is because they don't know where to go. They don't even know that these services are available. And they're scared of going because they don't want to be judged. They don't want their other friends to judge them, and they don't want their parents to judge them.

That was probably a key thing. Can I use this to help my friends and to educate myself a bit more? A good opportunity.
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K. White: You know, another one we've talked about, Carole, is Youth Friendly. You've heard that again and again. I can't tell you the number of youth that came in to see me when I was doing counselling. I don't do it as much anymore. They would come in and go: "Oh my god, it's not as scary as I thought it would be."

Even walking through the door can be scary. There are so many barriers — talking to a strange person on the phone, at intake, having to come in, afraid their parents might find out or maybe their parents bring them. I even have had several youth tell me: "You need to do a video of your office and show people what everything looks like, because then it wouldn't look so scary."

J. Staub-French: Ours doesn't look scary, but some do. They really do. You walk up, and you go: "Whoa. I feel like I'm in Girl, Interrupted or something." It's not good.

We have our own barriers. We tried to do some texting at first, but it's really hard. If you have a suicidal youth on the other end of the texting, it's not a great ethical moment for you. They would prefer it, I think — right? — for texting. So we're kind of between that. That's what I mean about our own barriers that we have, for our own worries.

J. Thornthwaite (Chair): Well, thank you very much for coming in and sharing your story, what you do. I've learned a lot, and I'm from the North Shore, so there you go.

Thank you, specifically, to Samantha and Sasha for all that you do. You probably have no idea how many people you've helped, directly or indirectly, but the fact that you're there is great. Kudos to you for making the Youth LAB happen.

As I heard, one of the messages is: "Advertise in the paper." That's where they're seeing it.

J. Thornthwaite (Chair): Or those massive e-mails or however you are…. But the way that you get to them is how they get help. And if you've got student leaders like this who will help others, we've got a lot of positive stuff to look forward to. Thank you very much for coming.

J. Staub-French: That full video, too, is on our website. It's interesting to see it all through.

J. Thornthwaite (Chair): Our next presenter is Dr. Charlotte Waddell, from SFU, faculty of health sciences. We'll just do a quick switcheroo, and then we'll begin.

J. Thornthwaite (Chair): Thank you very much, everybody, for being patient. When you don't get that many breaks, we need to take breaks in between. So thank you very much for being very patient.

Our next presenter is Dr. Charlotte Waddell from SFU, faculty of health sciences. Welcome.

C. Waddell: Thank you. I just want to draw your attention…. We've passed around a copy of my slides, which is this document here, so you have a complete record of everything that I'll move through quite quickly in the presentation. There's a brief report that we'd actually prepared for MCFD, and we've given you a copy of that too. Quite a bit of the background information is in the report, and we'll just leave that with you for later reference.

Thank you so much for inviting me to come today, and thank you for the work that you're doing, focusing attention on this area which is so vital. It's been a population that has been so underserved, as I'm sure you've heard from many of your presentations.

I just wanted to say that when we talk about improving the mental health of B.C.'s children and youth, I'm going to speak as an academic, in part. I'm the Canada Research Chair in Children's Health Policy with a focus on mental health. But I'm also going to speak as a child and adolescent psychiatrist. Every Friday afternoon I see kids in a clinic in Victoria serving those who've been through the foster care system and also who are in the youth justice system. The two perspectives I'll bring you are going to be the big picture from the research take on things but also from the hundreds of children who I've cared for and whose voices, frankly, inform everything that I do.

Just some quick definitions to start. What is mental health? The World Health Organization and many of us simply define it as social and emotional well-being — a resource for living and learning, something that's obviously essential for all kids to be able to flourish and go on to meet their potential as adults.

In contrast, mental disorders are clinical conditions that cause serious symptoms. They cause serious impairment, and they prevent kids from going through the developmental tasks and thriving and doing well at home, at school and in the community. They are serious mental health problems.

By serious mental health problems…. There are some names on this list that you've been hearing about, but I just wanted to give you a list of, really, all of the major mental disorders that do affect children and youth. This table shows a recent update that our research group did on the prevalence of the mental disorders in young people. The list on the far left — you've got this in your slide handout and also in the report, and academic references are in the report if you want to look at those.

Basically, everything from anxiety to attention deficit
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or ADHD, substance use, conduct disorder, depression, autism, bipolar, eating disorder, schizophrenia — that's the full list. That's what we're talking about, all of the things that do affect kids.

If you look across the very bottom of the table, our latest calculations…. These are 2014 updated figures. This is defining disorder as kids who have serious symptoms and serious impairment, so it's quite a strict threshold. About 13 percent of British Columbia kids are experiencing one or more of these at any given time — total population affected: about 84,000 at any given time. What we're serving right now across the province is one-third, about 26,000. We're going to come back to that one-third later in the presentation.

When do these disorders actually start? In my invitation to come and speak with you, the invitation talked about youth mental health. But in fact, speaking as a child and adolescent psychiatrist, so much starts way before adolescence. Certainly, most of it starts before adulthood.

This slide just shows you how in the very early years we see the emergence of autism, anxiety, troublesome behaviours, attention deficit. In the middle years, seven to 12, we see most of the anxiety disorders emerging by that point and then conduct disorder, which is the serious antisocial behaviour. Then in the teen years we see, in most cases, substance use, depression, bipolar, eating disorders and schizophrenia really, unfortunately, take hold.

What is the impact? I mean, you heard about the impact on young people from two of the people that just spoke with you. But when we look across the spectrum, all of those disorders on that list, the impact is enormous on that young person: distress, social exclusion, increased risk of suicide. Obviously, that causes enormous distress and cost for families — unspeakable. If we think even just, say, about the case of Amanda Todd, unspeakable losses, unspeakable severity are what we're talking about.

For most of these young people, if we don't intervene effectively — (a) if we don't intervene and (b) if we don't intervene effectively — these disorders persist, and they carry on throughout adulthood, so that young person doesn't finish school, or they don't do as well as they could have. They may not go on to university. They may not be able to participate in the workforce and contribute to the greater good for all of us. They also have increased physical health problems, and early mortality is significantly increased in people with mental health problems. Very, very serious impact for the individuals, but the collective impact is also very serious.

You may have heard this statistic from others, but just when we look at our province as a whole, mental disorders are the leading cause of lifelong disability. It's affecting all of us. It's affecting our workforce. It's affecting our health care costs. It's the number one issue, frankly. The costs exceed $50 billion annually in Canada. We don't have B.C. figures, but these are enormous figures. What's very painful about these figures is that most of these costs may be avoidable.

Just take the case of conduct disorder, severe antisocial behaviour. If we prevent just one case, and we look at the costs saved from childhood through to the end of adulthood…. Just one case of prevention could save $2 million to $5 million. Where does that money come from? It comes from health care — emergency room, all kinds of hospitalization, health care visits. It comes from unnecessary child protection and foster care costs. It comes from special ed, income assistance and, of course, the justice system — all aspects of that: police, courts, victim services.

Just to back up even further into the big picture, just to remind us all, basically children and youth always grow up in a series of layers of contexts. Children are always embedded in their families and their communities and their cultures and the larger environment. Really, we always need to look at the well-being of: how are families doing? How are the communities doing? How are we as a broader society doing to really look after children and youth well?

This is a different, maybe, a policy version or a policy map of that big picture I just showed you. This is a diagram just showing all of the aspects, on a policy level, that we need to address if we're actually going to tackle this problem effectively. We've tried to capture everything on this map that's really essential. Across the top, looking at all the age groups — early, middle and later childhood or adolescence — looking at the determinants of health, not just the end points, things like socioeconomic inequalities.

In the business pages of the Globe and Mail today a headline was that Canada once again is leading the world, among developed countries most certainly, in terms of increasing inequalities. These contribute, in turn, to things that affect the mental health of children and youth.

So determinants of health and then the mental health status of the kids. Across the bottom of this diagram the three-picket fence there shows you just the different types of interventions: universal for all kids, targeted for kids at risk, clinical treatment services that reach just a smaller number upstream, downstream.

What I can tell you: right now in B.C. almost of the money — and there's a shortage of investment, but almost all of it — is concentrated in that bottom right-hand corner. We're not doing very much covering this whole policy map, if you will.

Now, what could we be doing? I'm going to take you through some successful examples of interventions.

But just the general types of things that we can be doing — one is prevention programs. This is the kind of program that addresses risks before kids ever get disorders.
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You heard a bit about that from the previous presenters: reduce the number of cases ever needing treatment. Because we do know how to do this, it's a very promising new avenue.

Treatment services, obviously — addressing symptoms and helping kids not become so impaired after disorders develop. Across all of it, support for children, youth and families is vital.

I just want to say a word about what I mean by evidence-based interventions, because there are lots of different interpretations of that word. By evidence-based, I mean research-based and, basically, fully acknowledging, as a researcher, that research evidence is only one of many things you, as policy-makers, have to consider. You have many different and often competing sources of input into your decision-making processes.

Research is one crucial way that you can basically…. It's something crucial that you can turn to, to ensure that you're funding or overseeing the most effective possible things for kids. With scarce resources, this becomes more and more important. Within the research community, randomized controlled trials are the gold standard. They are the effective way to say if something does work or not and does cause harm or not. That's the basis that we use to really assess what works.

Then, on a different level it's all really about asking and answering this question, over and over again, from Peter Drucker: how do we know that we're doing the right things and that we're doing them right? Research can help you answer that question.

Fortunately, there are many, many excellent options for treating everything in that list I gave you, in the table of all of the disorders affecting children and youth. I'm just going to take you through some examples very, very quickly. I'll go in descending order, from most prevalent to least prevalent — so how many kids, going from a great number affected to fewer and fewer. But in each case there are a number of effective interventions that we could implement.

Anxiety — the most common disorder in childhood. Fabulous prevention programs. Something like the Friends program, which is running in B.C. schools. MCFD has taken the lead on that for about ten years now. Cognitive behavioural therapy–based. A simple, really elegant technique, 16 weeks in the classroom, taught by teachers, can also be delivered in clinics and homes — very, very effective in lowering the number of new cases of anxiety.

CBT also works well for treating anxiety if kids have developed disorders and so do some neurofeedback kinds of interventions as well. It's kind of training the body and the brain to lower responses to anxiety. Some anti-depressants can work when those other treatments fail.

Treating attention deficit. Good treatments here too: behavioral therapy, CBT again, parent training, neurofeedback, some medications.

Treating and preventing substance misuse — about 8,000 children affected. We know how to prevent this. We're not doing very much to prevent it. But things like simple resistance skills training in school classrooms can help kids be prepared with healthier approaches when things come along later — in high school, for example.

Parent training, CBT and family therapy work really well, also, to help parents and families model healthier approaches, whether it's to substance use or just the health of the family in general.

Conduct disorder is a big-ticket item because there are a lot of kids affected, and these are the kids that then end up in the justice system and lead to not just health care but also justice costs. Conduct disorder is actually the poster child for prevention. Because there are so many effective programs, there is actually no need for us to have anything close to 14,000 children affected.

Parent training and social skills training are the two biggest ways to prevent this. Nurse-family partnership, or NFP, is a nursing program that starts prenatally and gives intensive supports to young, low-income first-time mothers. There are a couple of different parenting programs — very, very effective, especially in the early years.

Treatment is also effective. Parent training, CBT again. CBT comes up over and over, kind of the magic bullet for child and youth mental health, and sometimes medications, where those other things haven't worked.

What about depression? Also a large number of children and youth affected and yet another disorder that carries into adulthood. CBT, once again — really effective for prevention. That's something we're not funding right now at all in B.C. CBT works for treatment, also, along with other kinds of psychotherapy and antidepressants.

Eating disorders can also be prevented. Media literacy training, for example, in high schools works really well to help young kids — like the two that were speaking with you earlier — just to know about and be able to practise healthier approaches to eating and to body image. Family therapy also works to help families create healthy relationships with food and body image.

Then there are other disorders that are not as common, where we don't know much about prevention but where the treatments are still very good. Autism is one where intensive behavioural interventions in the very early years work well. B.C. has been funding these interventions on an individualized basis, with the dollars going directly to families. B.C. has been doing that for some time, as you may know. Medications may be used if the behavioural interventions haven't worked.

Obsessive-compulsive disorder, a particularly severe variant of anxiety, can be treated very well. Again, CBT is the leading treatment.

Bipolar disorder and schizophrenia may involve more severe situations such as psychosis and where kids may
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sometimes need hospitalization. Thankfully, not too many children and youth are affected. There are effective medications — with side effects. But nevertheless, they can work. And the families and the children need intensive supports for these disorders.

Now, what about costs? We're not funding most of this. We're only reaching one-third of the kids that need these things. Why is that? Is it to do with cost? Well, there are some great examples from the research of interventions being highly cost-effective.

Just to use nurse-family partnership, or NFP, as an example. This is the program that starts in pregnancy, targets really young, first-time, low-income mothers and gives them intensive nursing supports in their homes until the kids turn two.

This program has been shown to prevent child maltreatment, including long-term use of foster care, and also to prevent adolescent or teen conduct disorder. It may also reduce child anxiety, depression and substance use. It's a blockbuster prevention program. It also increases mothers' participation in the workforce, their ability to be economically independent.

The long-term economic evaluations of this program show that it actually saves $3 to $6 for every dollar invested. Now, I don't know about your pension plans, but that's certainly a far better return than I'm getting on mine.

Those savings are calculated across the multiple sectors. We've heard other speakers…. When I first came in, I heard people talking about silos. You've probably heard a lot about that. But across health care, child protection and foster care, special education, income assistance and the justice system — if you look at savings across all of those sectors, that's how much can be saved.

Now, other policy-makers at the federal level have noted the shortfalls in children's mental health and have made quite stark statements. Roy Romanow, more than ten years ago, talked about mental health overall being the orphan of health care. Michael Kirby, less than ten years ago, talked about children's mental health being the orphan's orphan.

But what are these stark service shortfalls? Just to bring you back to the overall number of kids affected in B.C., we estimate, from the latest updated figures, 84,000, but we're only reaching about 26,000. It's actually less than a third — 31 percent of those.

Prevention programs could reduce this number, but we fund very few of them across the country. We fund a couple in B.C. B.C. is actually doing better than many provinces that way, but far, far more could be done.

Sometimes people say: "Well, it's simply because we don't have enough resources." When I look at the data, I have to question that, because we are a wealthy nation. We spend a lot, as a result of that, on health. The Canadian Institutes of Health Research reports on annual spending across the country on health and tells us in the latest reports that $200 billion is spend annually — about $3,000 to $20,000 per Canadian. Now, most of that doesn't go towards prevention.

Only about 6 percent goes towards public health, including prevention, and 94 percent goes towards health care. Most of that goes to older Canadians, to our seniors. Health budgets provincially, as you all well know, are running upwards of 40 percent going towards health care at this time.

In the middle of all that, children and youth do not seem to be a priority, yet there does seem to be a lot of money in the system. In the child and youth mental health world, the shortfalls, very, very unfortunately, are compounded by some systemic inefficiencies that we've allowed to continue.

Many effective interventions remain unavailable. You heard me mention CBT, cognitive behavioural therapy, over and over again for most of those mental disorders, either for prevention or treatment. It's still not widely available in this province. All kids should be able to get it when they come in the door or are at risk of anxiety, depression, behaviour problems or substance-use problems.

We also have a lot of untested therapies still being offered, still being paid for publicly. Why is that? Why would we settle for that when we wouldn't settle for that in the physical-health world?

Then, I think we all know that the programs and services are fragmented across Health, MCFD, Education or other child-serving sectors. We also fragment developmentally. Some people only talk about early childhood. Some people only talk about youth. You've got to look at the whole spectrum. Some people fragment according to programs for certain diagnoses. Some people only do autism. Some people only do substance use. Or some people say: "Substance abuse — that's the other ministry. That's not my ministry." We've got to look at all of it.

The bottom line is that we're tolerating these stark shortfalls — reaching only 30 percent of the kids who need it — that we would not tolerate for cancer or diabetes. For example, I cannot imagine anyone saying that it was acceptable to have only 30 percent of kids with cancer receiving treatment when we had a host of effective treatments. But that's what we're doing with mental health problems.

Now, B.C. has taken a number of steps that are very positive. It's been a question, perhaps, more of sustaining those steps and making sure they're intensive and comprehensive enough. Back in 2003 to 2008 MCFD led the child and youth mental health plan for B.C. Substantive new investments went into, certainly, treatments — including things like CBT in these community settings. That one effective program I mentioned, for preventing anxiety, was funded in B.C. schools. That is still running — very cost-effective. It's delivered by teachers and folded into the curriculum.
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The problem here is that we haven't sustained this investment. After 2008 the senior leadership changed. A lot of the coordination, the intensity — a lot of the money, frankly — has flowed away, and a lot of the good effort has dissipated. We didn't sustain this. It was great. We were leading the country at the time. This was the first significant child and youth mental health plan in Canada, and it was let go, really, in many ways.

A couple of years after that, Healthy Minds, Healthy People, the new ten-year plan, came along. This is terrific, because it's coordinated across Health and MCFD, two big lead ministries. There is an acknowledgment of prevention and treatment across the lifespan from the beginning of life through to the senior years, and new prevention investments have been made through that.

B.C. is now running a randomized-control trial of the nurse-family partnership program across the province. It's going to reach 1,000 mothers and children. That's a significant new project, but it's not nearly intense enough. It hasn't made up for the resources that were lost from the first child and youth mental health plan — so a ways to go here.

To try to wrap all this up into a handful of recommendations that come from the research, I guess, really, from myself and the people I work with in our research group, we wanted to just make a handful of recommendations to you — count them on five fingers — what you could do to really make a difference.

One is to acknowledge that mental disorders and the origins of those start at the beginning of life. You have to start early in childhood, and you have to sustain those efforts across the lifespan.

Another concrete recommendation would be to make new investments in effective prevention programs and set some targets. How about reducing the prevalence by a third? We talked about only reaching 30 percent. Let's try to lower prevalence. It actually should be feasible with intensive and new prevention investments.

How could you do that? The way to get that gain is to focus on the four most common disorders that are preventable: anxiety, substance misuse, conduct disorder and depression. They affect thousands and thousands of kids. There's great prevention evidence. This would be a really high-yield strategy.

Then a third recommendation would be to consider: how about doubling our investments? If we're only reaching one-third, could we stretch and try to reach two-thirds? So double investments in treatment, because every kid with mental disorders actually needs treatment, just like every kid with cancer needs treatment, and we know there are effective treatments.

Just as I was thinking about this and walking over here today and sitting in the back listening to your other speakers…. If I could, I would like to change the slide and actually say that doubling isn't ambitious enough. Why not triple? Why not reach 100 percent of the kids with disorders like we try to do with cancer and diabetes? Just something to consider.

The other issue is to really look at providing a comprehensive range of things. Don't just pick one area. Don't pick one age. Don't pick one disorder, one ministry. Look at the whole thing. It's a challenge, but that's the only way to really pull this together. And make sure that evidence-based approaches are the ones that are used.

Stop funding things that don't have good evidence, because we have so many randomized control trials showing benefits in kids. And then keep it going. The early child and youth mental health plan was a great start, but it wasn't sustained. Whatever happens has to be sustained, because these problems aren't going away, obviously.

Then maybe the fifth recommendation is a truism, but monitor and report on comprehensive child and youth mental health outcome indicators. You were talking with the earlier speakers about inputs. Not very interesting. It's outcomes and how we do that.

There are several great ways to do it. You're already implementing some of them in B.C. — we are: things like the early development instrument, being used with all kindergarten children to assess level of risk and level of readiness for school and general social and emotional well-being. That could be coupled with another indicator like the brief child and family phone interview, which is a quick, 30-minute assessment that can assess for risk of disorder. That would be a way to do monitoring across the whole population quite cost-effectively.

Then report on it. Let's measure how we're doing. I guess what we're really proposing here is an overall population strategy and an organized, integrated framework, promoting healthy development for all kids, preventing disorders wherever there's risk and providing treatment for all the kids with disorders, and then track how we're doing.

I want to end with just a note about child and youth rights. It's been 25 years now since we as Canadians endorsed the U.N. convention on the rights of the child. That convention states that all children and youth have the right to safety and nurturing and to opportunities to flourish and contribute. Mental health fits squarely within this, and I think we're failing. I think we're failing in the numbers that keep persisting, and I think we're definitely failing if only 30 percent are getting interventions, when we know that there are effective interventions.

Investments in the mental health of young people are among the most important investments that any of us can make.

D. Plecas: Charlotte, thanks. That was an awesome
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presentation, and encouraging, because it sounds like you're saying: "We know what to do. Let's just start doing it."

A couple of questions. One is: how do we fare compared to other jurisdictions in the world in terms of the relative number of youth who have one disorder or another? That would be the first question. And then in thinking in terms of your policy map — I think it was your eighth slide — how do we fare in terms of the amount of money we commit to doing something about each of these areas?

Then my third question is…. The two-thirds that we're not giving services to — are there some significant differences between that group of people and the one-third who are getting services?

C. Waddell: Thank you for those questions. The prevalence numbers in that table…. The person who actually pulled these numbers, Cody Shepherd, is sitting in the back, one of the researchers in our group. I'll just acknowledge Christine Schwartz and Jen Barican, and Daphne Gray-Grant is here today too.

Basically, the numbers in that prevalence table that's in your slide handout and also in your report actually come from a coterie of wealthy countries. That's outlined in the report, but basically, there are no Canadian data on prevalence. Because B.C…. Indeed, no one in Canada has done a prevalence survey for many years.

What Cody did was pool the numbers from countries that have done those kinds of very good quality surveys — Great Britain, the U.S. and from around the world — with similar wealth levels to our own country. Based on that, the 12.6 applies across all of the countries that were included in those studies. So we're estimating B.C. and Canada figures, extrapolating from the research evidence that is available. The numbers would be similar across all those countries.

D. Plecas: Okay. Then, the second question is in terms of how much money we commit in B.C., relative to what we would find if we were in the U.S., the U.K., Australia or New Zealand.

C. Waddell: I don't have an answer on that, but I could try to get you one. I don't think that we're all that different in many ways. I would say that neglect of child and youth mental health is a universal problem in wealthy countries. I think everybody is struggling with this to some extent or another.

For example, Ontario — I've had a number of conversations with people in that government recently. They're now trying to pull together a plan that emulates B.C.'s 2003 plan, to try to bring new money in.

I do think that for B.C. in 2003 to 2008, that five-year window, we were definitely the lead in the country in terms of the amount of funding and the coordination of services. It was a great shame that we lost that.

I could get you those figures, though, for other countries. I don't have them offhand.

D. Plecas: I guess just to finish up on that question. Then, since it looks like we're not that far away from being a leader in terms of our response, it's just a function of: let's put more resources into it.

C. Waddell: Yeah. It's more resources plus more coordination because the dollars can't keep going out in this fragmented way. And they can't keep going out to….

D. Plecas: The other part of it is the group of people who aren't getting services, in your experience and opinion. How are they different from those who are?

C. Waddell: Two responses. One is that a lot of that two-thirds are getting some support services. They're getting programs in schools. They're getting things…. You heard something about school counsellors. They're getting supports from primary care. But I think we also know…. I mean, primary care is very stretched. I'm also a family doctor. I don't practise that anymore, but I hear a lot about it from the kids that I care for as a psychiatrist — that people are stretched too thin and cannot provide the detailed care.

So the two-thirds are not getting the specialized mental health services that are actually required when you're talking about severe anxiety, depression, substance use, psychosis, for instance. What they may be getting are supports. But they're not getting the kind of intensity and the follow-up they need.

For the one-third that are getting the specialized services — through MCFD's child and youth mental health teams, child and adolescent psychiatrists, through the whole network of people who provide those specialized services — what we know from the research studies is that the outcomes are good.

All of these young people can, with those effective interventions…. Their symptoms can be reduced, and they can return to functioning. These treatments, as well as the prevention programs, are very powerful and something that, on a humane level and on the child and youth rights level, are so imperative because they really do work.

D. Donaldson: Thanks for the presentation. Lots of food for thought for our final report in there, so thanks for being so specific.

Just a general comment on the growing socioeconomic
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gap in Canada — and, I would add, in B.C. — and how that relates to a population health framework for child and youth mental health that you pointed out. That really resonates with me in remote and rural communities in B.C., especially First Nations communities. I think that's something that we have to consider in our context, as well, in the final report.

NFP, nurse-family partnership — I hadn't heard of it. It sounds very interesting. The randomized control trial…

D. Donaldson: …that you mentioned — when is it due to start or be completed? Is there a funding commitment for taking the results of that and expanding it into actual practice, continual practice?

Secondly, you did put the red herring in there, so I'll have to bring it up: the systemic inefficiencies, untested therapies. I would ask you: what are some examples of untested therapies that we may be funding at this point?

C. Waddell: Thank you for those questions. Nurse-family partnership — yes, the RCT has started. This RCT is primarily being funded by the Health Ministry with support from MCFD. Our centre is actually leading this evaluation. We did a pilot program just over the past couple of years and launched the actual evaluation last fall. We are planning to enrol 1,000 women and children across five health authorities — Northern, Interior, Vancouver Island, Vancouver Coastal and Fraser. Basically, it's rolling.

The commitment has been made by the Health Ministry, MCFD and also the health authorities. It's the health authorities who really sponsor the nurses to go into the homes. They sponsor the training for the nurses. Those five health authorities have made a commitment to carry this on should the program prove successful, and also, with adaptations that we'll learn about through the B.C. evaluation.

It'll be a couple of years before we have results. We're going to look at things like child maltreatment and how we can reduce that, the child behaviour problems. We're going to look at the mother's economic status and evaluate that — how the mothers are doing. We're going to look at pregnancy outcomes, like substance use in pregnancy. Can this be a possibility for reducing things like fetal alcohol even?

So a wide array. As I said, it's kind of a blockbuster of a prevention program, so we'll be looking at that very carefully.

Your comment about untested therapies. There are two types of untested therapies. One is the type where we just don't have any evidence that it works or people haven't put it through its paces yet. There are a number of kind of low-intensity, low-key supportive approaches that we just don't know if they're worth doing because they've never really been tested.

The trouble with…. I mean, that might seem like a harmless thing to do, but when it takes energy and resources away from effective interventions and when we're not delivering effective interventions, there's an opportunity cost, as the economists say. You could be delivering CBT. You could train your workforce. You could make sure everybody's comfortable doing that, offering that, but you're not. You're offering more diffuse kinds of, for example, play therapy or things that just haven't been tested.

Now, there's another response to your question, and that is using treatments that are actually potentially harmful — so using, for example, medications that are inappropriate. There's plenty of that going on. That's where physicians do need more oversight perhaps. Or where things like practice guidelines or how we monitor physician behaviour…. And how parents themselves know and can learn to say: "Why is my child being prescribed an antipsychotic for a mild behaviour problem when I should be getting CBT for that behaviour problem?"

D. Donaldson: Thanks. And that was — I should correct, for the record — not a red herring but a red flag. It's getting late in the day.

M. Stilwell: Just following up a bit on what you said about drugs, it's interesting. My question is about the training of psychiatrists and general practitioners and then other people who can help. For each of the disorders you talked about, basically, treatment — non-pharmacological — and then for those who don't respond, pharmacological.

It may be anecdotal, but from my kind of friends and people who talk about their kids who have issues, the way they're entering the system, because of the parental sense of urgency, they end up — at least, I think, from the middle class — going to the top of the pyramid into child psychiatrists or, perhaps, adult psychiatrists or both.

What happens is they get put on drugs, and there's no follow-up. You have what feels like an enormous number of parents who say, "Well, are the drugs helping?" and they say: "I don't know." They're afraid to go off; they're afraid to stay on. There's a prevalence of anecdotal opinion that psychiatrists are not being taught therapy anymore, that it's become pharmacopsychiatry and that there's a big gap there.

Can you comment on how you see this through your work and what your feelings are about that?

C. Waddell: Well, I think that the problem you describe…. You put it very eloquently — what happens and how parents of middle-class kids can shake the tree a little bit and get more services. If we doubled or tripled
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the effective treatment services available to kids across this province, we could do away with that problem. Kids could come in earlier, and they could be offered something much more effective, like CBT, early on.

Something like CBT — any reasonably well qualified mental health practitioner can be trained to do a very good job of that. Teachers can do it in schools. The Friends program is testimony to that. Social workers, nurses, psychologists and psychiatrists can do that — a kind of a team approach, where you have different players on the child and youth mental health team each doing their piece of it.

Other ways to be more efficient and reach the kids so that this problem doesn't arise. Offer CBT in groups. One person could be delivering it to ten kids. A teacher can deliver it to 20 kids in the classroom. If we were to double or triple the funding and take an evidence-based and coordinated approach, the problem you've talked about doesn't have to exist, basically.

Then what is the role of psychiatry in that? A psychiatrist absolutely is an important member of the mental health team. Many psychiatrists are very comfortable and competent providing things like CBT and other kinds of psychotherapy. That's certainly part of the child and adolescent psychiatric training. Many family doctors have received extra training and can do CBT as well. It's not only psychiatrists.

In a team setting, if you have fewer psychiatrists and more social workers, you want to have an efficient use of resources. So maybe the psychiatrist consults; maybe the social worker or the nurse delivers CBT. Maybe if you have more teachers doing it in the classroom, you have fewer kids coming in the door to need treatment in the first place.

J. Thornthwaite (Chair): Thank you very much for coming and sharing your research and your experience with us. We very much appreciate it.

We are still waiting, actually, for our last presenter, who was supposed to here at 3:30. Maybe what we'll do is take a five-minute recess and then take it from there. If everybody's back here in about five minutes, hopefully, she'll have shown up.

J. Thornthwaite (Chair): Thank you, everybody. It appears that our last committee presenter has been unable to join us. So I would encourage Dr. Nancy Lanphear to give us a written submission, because we're going to have to wrap it up.

After saying that, I'd just like to say a personal thank-you to all the committee members, obviously, to Kate and the Hansard and all the help that we've got that put this together, and welcoming John from the rep's office. Thank you very much for joining us all day.

We'll probably reconvene at some point to talk about maybe a follow-up with regards to what we're going to do with the information that we have. I think it would be worth having another brief meeting so that we can talk amongst ourselves, perhaps, just moving forward.

C. James (Deputy Chair): I think the committee will need to figure out a way for all the written submissions to get out to committee members as well. So you'll have some reading over the summer. There'll be opportunities for everybody to be able to get those written submissions. Just my constant refrain to remind people to put in written submissions. You have the opportunity until we get into July, so people do have the chance to be able to put in written submissions.

And just a thank-you to all our presenters over the last few days. I think we've had an incredibly diverse group of people present to us. We've had everyone from academics to parents to youth themselves, and I think that's been incredibly valuable to us as a committee. So a huge thank-you to all the presenters who presented, and I'm looking forward to reading the written submissions as well.

J. Thornthwaite (Chair): All right, and also seconded by Darryl — Donna and Darryl.

Hansard Services publishes transcripts both in print and on the Internet.
Chamber debates are broadcast on television and webcast on the Internet.
Question Period podcasts are available on the Internet.

Chair:	* Jane Thornthwaite (North Vancouver–Seymour BC Liberal)
Deputy Chair:	* Carole James (Victoria–Beacon Hill NDP)
Members:	* Donna Barnett (Cariboo-Chilcotin BC Liberal)
	* Mike Bernier (Peace River South BC Liberal)
	* Doug Donaldson (Stikine NDP)
	* Maurine Karagianis (Esquimalt–Royal Roads NDP)
	* John Martin (Chilliwack BC Liberal)
	* Dr. Darryl Plecas (Abbotsford South BC Liberal)
	* Jennifer Rice (North Coast NDP)
	* Dr. Moira Stilwell (Vancouver-Langara BC Liberal)
	* denotes member present
Clerk:	Kate Ryan-Lloyd
Committee Staff:	Aaron Ellingsen (Committee Researcher)
	Byron Plant (Committee Research Analyst)

Witnesses:	Keli Anderson (FORCE Society for Kids Mental Health; President and CEO, Institute of Families for Child and Youth Mental Health)
	Beverley Clifton Percival (Co-Chair, First Nations Child and Family Wellness Council)
	Yasmin Jetha (Vancouver Coastal Health Authority)
	Dr. Pei-Yoong Lam (B.C. Children's Hospital)
	Dr. Steve Mathias (St. Paul's Hospital; Vancouver Coastal Health Authority)
	Annie Smith (Executive Director, McCreary Centre Society)
	Samantha Smith (Family Services of the North Shore)
	Sasha Soden (Family Services of the North Shore)
	Julia Staub-French (Executive Director, Family Services of the North Shore)
	Dr. Charlotte Waddell (Simon Fraser University)
	Karen White (Family Services of the North Shore)
	Jules Wilson (Executive Director, Federation of B.C. Youth in Care Networks)

1) Inner City Youth Mental Health Program	Dr. Steve Mathias
St. Paul’s Hospital

2) Institute of Families for Child & Youth Mental Health;	Keli Anderson
The F.O.R.C.E. Society for Kids’ Mental Health

4) Division of Adolescent Medicine	Dr. Pei-Yoong Lam
BC Children’s Hospital

8) Family Services of the North Shore	Julia Staub-French
	Karen White
	Samantha Smith
	Sasha Soden

REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON CHILDREN AND YOUTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
CHILDREN AND YOUTH