Section 2: Findings and observations

Indigenous young people, their families and communities

Overall, there were many similarities in the histories of the 12 young people, their families, and communities, and in their experiences of care.

Key findings

• Despite complex, traumatic histories and the high-risk nature of these young people’s lives that was evident early-on, intervention and prevention was minimal, and sometimes non-existent despite having been identified early. Responses to young people and their families was largely crisis oriented.
• The identities of the young people were not incorporated into service delivery or care.  Indigenous, Black and LGBTQI2S young people were not consistently connected to identity-based or culture-based programs, nor was their identity incorporated into their care. There was a lack of attention paid to their identities, and minimal efforts toward inclusivity.
• Young people were often not living in environments that fostered a continued sense of purpose, belonging or healthy, long-term attachment to any adult in their lives. They frequently did not appear to have been encouraged to be hopeful about their futures or to have positive aspirations or engage in activities to promote their capacities.

Summary of observations

The experience of complex, multiple traumas was determined to be common to each of the young people. Many of them also came from families that would be assessed as high-risk. Indications of intergenerational trauma were evident in the stories of the eight Indigenous histories reviewed.^{footnote 1[1]} Some of the families questioned whether caregivers in the placements provided adequate support for young people experiencing trauma, grief, loss of loved ones, and who had experienced sexual assault or abuse.

The challenges faced by these young people seemed to be compounded on entry into care. During the Panel’s meetings, one of the Indigenous Elders shared a story about a community ceremony that takes place early in life that provides children with a name, a clan, free will, and a purpose. The Panel reflected that the ceremony encompasses many of the fundamental components that were observed to have been missing from the experiences of the 12 young people - identity; relations, connections and belonging; roles and responsibilities; empowerment to choose their own path; and purpose.

The Panel observed that there was a lack of attention and responsiveness to young people’s identities. Indigenous, Black and LGBTQI2S young people who faced marginalization were not consistently connected to identity-based or culture-based programs, nor did it appear that their identity was considered when determining services during their time in care.

Young people, families and Society workers all identified significant challenges for young people in care in connecting with others.

Young people with lived experience frequently describe social isolation and a lack of meaningful connection. They reflected on the trauma of being removed from families and communities and of having no one they were comfortable talking with or an emotional outlet. Young people described “desperately” needing a bond, and someone to guide them.

Some of the young people described being in a group home as being equivalent to living alone. They reported a lack of supervision, an ability to come and go from placements at will, not enough security, and no counselling or people to talk to.

Some families reported that they believed their children had limited contact with them while in care. One parent reported that their child had to ‘sneak’ calls to their family and consistently expressed loneliness and a desire to go home. Another parent explained that it was difficult for their children to spend holidays away from their community.

The Society workers and staff from placements spoke about the importance of having a goal of reunification with biological families, and noted that placing young people as close to home as possible supports this goal. Connection to families, community and culture were identified as being integral to young people’s sense of identity and belonging.

Specific opportunities for improvement

• Prioritize keeping children with their families of origin for as long as possible.
• Provide biological parents and children with supports early in the intervention process, so that young people do not have to experience a removal from their homes and communities.
• Consider removing parents from their communities for treatment and support, rather than apprehending young people.
• Have staff in placements, Society workers, and caregivers who accept, support, and/or reflect various identities, including those that identify as LGBTQI2S and Indigenous.
• Connect young people to others with lived experience of the child welfare system and with mental health challenges so that they will not feel alone in their experiences.
• Caregivers should operate with the assumption that young people have experienced trauma, understand the impacts of trauma on brain development and employ a trauma-informed approach.

Eight Indigenous lives

Eight of the young people who were subject of the expert panel review were Indigenous and from First Nations communities in Northern Ontario. The Panel took care to acknowledge the uniqueness of these young people, their families of origin and their communities in a way that acknowledged and honored the differences in their lives, experiences and needs. The majority of those communities are remote.

Key findings

• The young people, their families and their communities were impacted by colonization, the legacy of residential schools and intergenerational trauma.
• There were significant structural barriers, a severe inequity for family and child services and limited access to specialized resources in the young people’s home communities. 
• Inadequate shelter, water and food in the young people’s home communities was a striking feature of the young people from remote communities. Many of the young people did not have equitable access to education, healthcare, including mental health care, social services and recreational activities. 
• There was a lack of culturally safe, trauma-informed approaches with a focus on early intervention, prevention and family supports. 
• It did not appear that young people had a safe place to go on-reserve, when it was needed. 
• Particularly after removal from home communities, young people were placed in environments with minimal connection to Elders, land-based teachings, traditional ceremonies and wholistic care, and their placements did not appear to acknowledge and/or provide for their cultural needs. 
• Indigenous Child Wellbeing societies that serve young people and families in remote First Nations communities have distinct restraints to delivering services that other societies do not (e.g. large geographic areas, limited resources).
• Despite historical and current impacts of colonization, the legacy of residential schools and intergenerational trauma, Indigenous communities continue to persevere, to heal and to reclaim their culture and identity. 

Summary of observations

It was overwhelmingly clear to the Panel that there were significant structural barriers and limited access to resources in the young people’s home communities. The Panel heard from Chief and Council in two communities that a lack of sustainable funding is a challenge. In particular, funding to support cultural healing programs was referenced. The inequitable access to resources has contributed to inadequate shelter, water and food. Many of the young people did not have regular access to education, healthcare, including mental health care, social services and recreational activities.

Indigenous young people with lived experience explained that their home communities are often without clean drinking water and fresh fruit and vegetables, resulting in a reliance on less expensive processed foods. They described over-crowded housing units without electricity and running water.

They talked about having no leisure activities available to them, and related this to young people’s mental health and increased substance use. They noted that they need something to do to stay occupied; mentioning that their communities try to have activities available, but often, these are only available on special occasions.

Indigenous young people also described many positive attributes of their home communities - large extended families that they were close with, a sense of home and community, and the opportunity to learn their own culture, customs and language.

Similarly, the Elder panel members spoke of the importance of extended family and connectedness to family and culture. They observed a lack of culturally safe, trauma-informed approaches with a focus on parenting and family supports. The leadership in one of the communities discussed the intergenerational impact of residential schools in their community and familial sexual abuse. They indicated that in order to respond to intergenerational trauma, systemic barriers must be addressed and resources must be sustainable.

Overall, the young people, their families, and their communities were observed to have been impacted by colonization, the legacy of residential schools, and intergenerational trauma.

Indigenous young people reiterated this when they spoke of intergenerational trauma resulting from their family members growing up in residential schools. They explained that because their communities have a recent history of growing up without parents (in residential schools), they do not have any parenting skills. They described a lack of parenting supports and classes in, and appropriate to, their home communities. They talked about westernized parenting classes as “forcing a foreign model onto a culture.” They suggested that a model where families heal together would be a better fit in their communities.

They talked about a community raising a child and noted that the nuclear family model is not in practice in most Indigenous communities. They also noted that parents are often told that they will get their children back when child protection services apprehend but they don’t, contributing to mistrust of the societies in the communities.

The Chief and Council in three of the communities maintained that there needs to be structured, sustainable support on-reserve so that young people do not have to leave for services and if they do, they are supported in their transition home. Prevention services and family supports were rarely available, and it did not appear that young people had a safe place to go on-reserve, when it was needed.

"Indigenous young people indicated that where there are prevention services in their communities, when families try to access those services it frequently results in an apprehension, which discourages involvement."

The Panel saw very little effort to provide wholistic care or to prioritize spiritual needs. When the Indigenous young people were removed from their homes, many of them were placed far away from their home communities. Indigenous families and leadership from three communities spoke of the need to keep young people in their communities, or as close to home as possible. The Panel observed minimal connection to Elders, land-based teachings, and traditional ceremonies, particularly after removal from their home communities.

Indigenous young people spoke of the importance of connection to the land. They described wanting opportunities to go out on the land, and to hunt and fish, when they were away from their home communities. They described this as an important part of their culture and spiritual practices that were are often missing when placed outside of their communities.

Indigenous young people described the culture shock that they experienced when they were removed from their communities – being expected to use transit systems, to adapt to the ways of urban life, and increased availability of alcohol.

The young people also describe facing racism in urban settings – having things thrown at them, being bullied, and being subject to negative comments in person and on social media often on a daily basis. They spoke about the use of alcohol to escape – they indicated that many young people “go out, get drunk and get lost” in the city.

The Panel acknowledged that Indigenous Child Wellbeing Societies that serve young people and families in remote First Nations communities have distinct challenges in delivering services that other societies do not. For example, the geographic jurisdiction of their caseload may be far larger and the resources in the communities far fewer.

Leadership in two communities and young people with lived experience explained that there are challenges related to confidentiality in small communities.

"Young people described the close relationships between Society workers and mental health workers in their communities and the families they serve; indicating that in some cases it was felt that these relationships compromised the integrity of child protection investigations and decision-making."

The Panel suggested that funding to Indigenous communities should be based on the needs of each community and that programs and services should be designed, developed, and delivered by Indigenous communities so that they are more relevant and effective in serving young people and their families. Young people wondered whether a Gladue approach^{footnote 2[2]} could be applied to young people that come into care and whether a restorative justice approach could be taken to child protection within Indigenous communities.

The Panel acknowledged the resilience of the Indigenous young people, their families and communities that were subject of the review; highlighting that despite historical and current impacts of colonization, the legacy of residential schools, and intergenerational trauma, their communities continue to persevere, heal and reclaim their culture and identity.

Specific opportunities for improvement

• Indigenous young people suggested that it might be better to remove parents from their communities for treatment and support, rather than apprehending young people.
• Indigenous young people should be taught about the history of residential schools, colonization, and patriarchy.
• In the event that it is not possible to place Indigenous children in their home communities, Indigenous language classes should be offered.
• The leadership in two of the communities indicated that there should be group homes in First Nations communities and there should be professionals who stay in the community, rather than coming in for a crisis and then leaving. They proposed that it would be beneficial to have a community liaison who knows how to navigate mental health systems.
• The leadership in two of the young people’s communities noted that Jordan’s Principle should always be applied; a concept with which the Panel agreed. Jordan’s Principle is a child-first principle that aims to resolve jurisdictional disputes regarding payment for services between provincial/territorial and federal governments in a timely manner, so that services to First Nations young people are not delayed or interrupted.^{footnote 3[3]}
• The leadership in one Indigenous community maintained that community engagement is very important and communities should determine their own specific needs when funding is available. They should design, develop and deliver their own services to their home community.

“I was always ashamed of being a Native person. After learning about our ancestors I feel empowered.”

Society involvement & placements

The Panel identified many commonalities in the young people’s residential placements including: the distance of placements from their home communities, frequent placement transfers, and common practices and approaches when working with young people.

Key findings

• Many of the young people were placed far away from their home communities, making it difficult to stay connected to their families, communities, and cultures.
• Multiple placements negatively impacted young people’s ability to build relationships and form healthy attachments with their caregivers, teachers, or any other adults.
• Multiple placements impacted young people’s access to a meaningful education. Their absence from school environments contributed to social isolation and gaps in life skills development.
• Physical restraints and 1:1 supervision models are commonly used interventions in residential placements. There does not appear to be a shared understanding of the different intervention models, or a standard or consistent approach to them.
• The implementation of 1:1 supervision models appeared to be used in response to an immediate safety need and did not incorporate meaningful engagement and relationship building with young people.
• The value of 1:1 supervision to support young people beyond a short-term crisis is unclear, but many of the young people were subject to 1:1 supervision for long periods of time.
• There is no minimum standard for capacity, supervision, qualification, training and education for staff and caregivers.
• There is a need to better understand the risk factors, indicators and effective interventions for human trafficking.
• The youth voice is fundamental to the wellbeing of young people. Young people had minimal opportunity to have a voice in their care, their voices were not prioritized, and their attempts to communicate their needs were often overlooked, ignored and characterized as “attention-seeking.”
• The basic needs of young people were inconsistently met.
• The poor quality of the care that the young people experienced throughout their lives had a profound impact on them.
• Young people were not meaningfully engaged in services or programs in the community, including educational programs and mental health services, for significant periods of time – they were often in their placements all day, with very little to do. There were indications to suggest that several of the 12 young people were at risk of and/or engaged in human trafficking.

Summary of observations

Many of the 12 young people were placed far away from their home communities with the longest distance up to 1,600 kilometers.

Young people with lived experience described placements that were far away from their home communities. They spoke of seeking connection – to land, family (including siblings), community and language. They reflected on their desire to return to their home communities at the earliest possible opportunity; for many, this was age 16, when they left care because they wanted to return to their home community.

The Panel noted that when young people are no longer connected to their cultures, families, communities, education, and social supports, they are stripped of one of their strongest safeguards – natural advocates. The Panel suggested that the further the young people were moved from their home communities, the more difficult it would have been for them to maintain connection to the people in their broader communities that cared and advocated for them, if they could not do so for themselves.

In addition, most of the young people had multiple placement transfers. The moves were often unplanned, resulting in emergency placement at the first available location. Sometimes multiple placement transfers occurred in a short period of time. For example, one young person was transferred 18 times in a 20 month period. The Panel and workers noted the challenges to providing quality care, building relationships, maintaining education, and forming healthy attachments with caregivers when young people are transferred so frequently. Society workers and staff from placements described apprehension from families and the trauma experienced by young people being transferred to a new placement.

"Young people reiterated this sentiment and spoke of transferring placements with their belongings placed in garbage bags, describing this as a dehumanizing experience."

In addition to multiple placement transfers, young people talked about placement selection, noting that the children’s aid society or Indigenous Child Wellbeing Societies “try to find a place to stuff kids.” They described placement selections as being determined based on where there are residences, rather than on fit, and a lack of compatibility between placements and their needs – language, culture, and personality. They reflected on times when they felt they were not welcomed or accepted in already established families, and often felt treated as “a paycheque.”

The Panel found that there were common approaches to interventions and practices in residential placements.One of these practices is to implement a 1:1 supervision model when a young person is considered to be at risk of harming themselves. The Panel observed that across residential placements, it did not appear that there was a shared understanding of how 1:1 supervision models are operationalized in residential placements. The staff from placements explained that typically, a 1:1 refers to a staff member providing constant eyesight supervision to a young person, until they are determined to be at a lower risk level. It was explained that the implementation of this practice requires extra staff to be working. This can present challenges when there is not enough staff available during a shift and it can interfere with the care of the other young people in a residence.

While the Panel recognized that there are circumstances where 1:1 supervision models are required to ensure immediate safety, it appeared that this was often the extent of the intervention. The Panel noted that at times, constant eyesight supervision can serve an immediate safety need however; to promote positive wellbeing and create an enriched environment for young people, the staff from placements and caregivers must also engage young people and build meaningful relationships with them. This does not appear to be part of the current approach to 1:1 supervision. The Panel also observed variance in the implementation and cessation of 1:1 supervision models, noting that some of the staff making decisions regarding 1:1 supervision may not have had adequate training in this area.

Another common intervention in residential placements was the use of physical restraints. The frequency of physical restraints in the young people’s residential placements was notably high and was the most common serious occurrence reported in a six month period. The Panel observed that there was inconsistency in the type of physical restraints used and the length of restraint with the longest restraint to a young person lasting up to two hours. According to the MCCSS Guidelines for Serious Occurrence Reporting, any restraint must be reported as a serious occurrence. As part of the report, the less intrusive measures that were used before the restraint must be described. The Panel found that there was variability in the interpretation and/or application of less intrusive measures and in the approaches to de-escalation before the use of a physical restraint.

The Panel, families, Society workers, staff from placements and young people with lived experience all spoke of staff and caregiver capacity in residential placements. Everyone acknowledged the level of skill, expertise, attention, and care that is required to support young people and the significant impact they can have on a young person’s life; whether positive or negative.

The Panel observed that there was an absence of quality care in residential placements. The Panel noted that quality of care is influenced by staff and caregiver training, qualifications, education, compensation and a supportive workplace environment. In particular, the Panel observed that staff from placements, Society workers, and caregivers were not always prepared or enabled to support young people with mental health challenges, substance use, concurrent disorders, fetal alcohol spectrum disorder and/or complex trauma. The Panel also noted that there was significant variability in caregiver capacity. Society workers noted that staff working in residential placements often lack formal qualifications and frequently work part-time in multiple places to make ends meet given the low rates of pay.

Young people described staff in residential placements as lacking adequate training and that there are inconsistencies in group home standards for their staff (e.g. qualifications, education and training). They explained that specific skills are needed to support children and youth, and that staff capacity is an issue stating that, ‘it can’t be just anyone doing the job.’ For example, a young person described that a group home may have multiple youth living with different diagnoses (e.g. oppositional defiant disorder, fetal alcohol syndrome, attention deficit disorder, anxiety, depression etc.). The young person explained that if there is only two to three staff working to support multiple youth with high needs, they are unable to provide adequate support.

Young people also explained that staff from placements have demanding jobs, leading to high burnout rates and staff turnover. They suggested that if efforts were made to make work less demanding, there would be more opportunity to be meaningfully engaged with young people.

There were indications to suggest that several of the 12 young people were at risk of and/or engaged in human trafficking when they were in a residential placement. The Panel recognized that this risk increases when youth do not have a solid and consistent support network. They indicated that human trafficking is largely misunderstood and that it would be beneficial for staff from placements, Society workers, caregivers and police to understand risk factors, indicators and effective interventions if they suspect a young person is being victimized. In particular, the use of the internet and social media in luring young people into human trafficking must be explored.

Youth experiences in placements

The experiences of young people, while influenced by their identities, histories and where they come from, were also significantly impacted by their interactions with systems of care that were intended to serve them. The following details some of what Panel learned about their experiences in residential placements.

Many of the 12 young people did not appear to have had an opportunity to meaningfully provide input regarding their needs, desires and overall care. In some cases, it was apparent that they were explicitly exercising their voice and they were ignored. For example, there was written evidence of a young person explaining their trauma, struggles and perceived barriers to improving their circumstance. This person was doing everything within their power to have a voice, ask for help and articulate what they needed – both from individuals, and from the systems. The Panel observed that the adults within their sphere of care did not prioritize the young person’s voice and did not adequately respond to their pleas for help.

While there was evidence of young people asserting their voice explicitly, the Panel also observed that there were numerous examples of their needs being communicated indirectly and being overlooked by Society workers, staff from placements, or caregivers. At multiple points in their lives, the young people communicated by ‘raising flags’ like self-harming, acting aggressively, or running away. Rather than interpreting these behaviours as communicating a deeper need and responding in-kind, it was, too often, responded to with a punitive approach, dismissed as ‘attention-seeking’ or, with a visit to the emergency department, or a transfer to a new placement.

Young people with lived experience identified many commonalities related to their placement experiences and the quality of care they received. Several of the young people in one geographic area shared experiences of sexual, spiritual and physical abuse at the hands of caregivers, as well as neglect.^{footnote 4[4]}

The young people indicated that they reported this abuse to their workers, only to have their workers be spontaneously changed without follow up. They indicated that the workers never acted upon their reports and concerns, which fostered a lack of confidence and trust. One of them said “I didn’t know who to trust with my words after that.” Another said, “No one comes at the end of the day for kids who cry abuse in the system.” After disclosing abuse, the young people described a lack of documentation of their disclosures, which in turn led to an inability for them to pursue recourse through the judicial system. They described significant impacts of this abuse including, ongoing post-traumatic stress related to their placements, as well as night terrors and other trauma-associated impacts, including an inability to accept or express compassion, or to “learn emotions.”

Young people also spoke of a general lack of thoughtful, attentive and intentional care. Workers, staff and caregivers were described as making young people feel like “just another paycheque.” They described being in care as living out of a suitcase, without a proper address and often being transferred to new placements. They spoke of group homes with “two to three people watching the house, smoking inside and inviting their friends over” (referring to caregivers) and of not being allowed to use the phone, or access anyone outside of the care setting for help. Young people referred to extended society care (formerly known as Crown wardship) as a primarily financial agreement; indicating that not all of their fundamental needs can be met with money.

Several of the young people’s families reported that they did not feel that their children’s placements were supportive, positive environments where they were really listened to. Some questioned whether Society workers prioritized the perspectives of placement caregivers over the perspectives of their kin when making decisions about their care.

A parent described their child to have been unhappy in their residential placement and to have been ‘just living there.’ A number of families reported that their children told them they were forcibly restrained whenever they were angry, that caregivers were ‘not nice’ or that they were threatened by their caregiver.

The Panel observed that young people’s basic needs were not always met. There were young people who were largely absent from the homes they were placed in, and it did not appear, based on available information, that anyone was aware of or concerned about how their time was being spent. The Panel observed that many of them were not meaningfully engaged in services or programs in their placements or in the community. There was little connection to day programs, youth centres, recreational and leisure activities and many instances with no access to education for significant periods of time.

Specific opportunities for improvement

• The youth voice should be considered, valued and respected at all times.
• Young people should be placed as close to their home communities as possible, wherever this does not pose a safety risk.
• Priority should be placed on promoting long-term placements for young people where there are opportunities to form healthy, long-term attachments to adults.
• Society workers and staff from placements should take care to reduce the trauma of apprehension and placement moves as much as possible.
• More research is needed to understand the most appropriate use of physical restraints with young people.
• Staff from placements and caregivers should receive mandatory training in human trafficking, mental health challenges, substance use, concurrent disorders, fetal alcohol spectrum disorder, LGBTQI2S issues, Indigenous culture and culturally appropriate service delivery, and complex trauma for young people.
• Youth should be provided with opportunities to articulate their own needs and for those needs to be taken seriously. Children and youth should be informed of all processes and interventions concerning them.
• No young person should have to move with their belongings in a garbage bag.
• Through a screening process, it should be made clear what the expectations of foster parents are, and what the child or youth’s expectations are. They should be matched accordingly.
• Young people should be grouped and housed according to their needs.
• Efforts should be made to make work less demanding for staff in children’s residences, so that there are lower burnout rates, less staff turnover and there is more opportunity to be spent meaningfully engaged young people.

“I have always wanted to ask my workers, “What if you were in my shoes?”

“You can’t just give someone a cheque and expect them to raise a child – it’s more complicated than that.”

Mental health care

All 12 young people that were subject of the expert panel review struggled with mental health challenges. The following section outlines the Panel’s findings and observations of the mental health services provided to the young people.

Key findings

• Mental health care was fragmented, crisis-driven, reactionary, and in many cases, non-existent.
• There were concerns regarding the availability of long term and intensive mental health care; particularly for latency/early teenage youth.
• There is a need for wholistic, prevention-focused assessment and intervention that is delivered early-on. When a young person was experiencing mental health challenges, there appeared to be a tendency to connect them to hospital emergency departments or psychiatric services (where they are connected at all), without exploring or leveraging the availability of other services that could be beneficial to their mental health and wellbeing.
• There are striking inequities in mental health care availability in northern First Nations communities.
• There seems to be an assumption that the child protection system has the mandate and capacity to provide mental health care and/or to promote young people’s mental health needs being met. The distinction between child protection services and mental health care are not clearly understood by families, children and youth serving sectors.

Summary of observations

The Panel found that there were commonalities in the young people’s interactions with mental health care services. It was notable that the degree to which the young people and their families had access to mental health care varied considerably depending on their geographic location. This variability was also apparent with the experiences of the young people with lived experience and information received from families and Society workers.

Regardless of location, the Panel observed a lack of comprehensive, prevention-focused mental health care in all 12 of the histories reviewed. Throughout these young people’s lives, there were identifiable points where early assessment and intervention may have prevented declining mental health and possibly, apprehension by a Children’s Aid Society or Indigenous Child Wellbeing Society. Some of the young people’s families reported requesting support for their children’s mental health very early in their lives and noted that they were not able to receive what they needed. For those that received mental health care, it was often fragmented and short-term, though based on available information, longer-term may have been more beneficial.

Young people, families and Society workers identified lengthy waitlists to be a barrier to accessing mental health care. Multiple hospital visits prior to receiving care, or multiple hospital visits without any additional care, seemed to be a common experience for many of the young people whose histories were reviewed, in addition to those with lived experience.

Indigenous young people and the leadership in three of the young people’s communities noted that counselling in remote First Nation reserve communities is complicated because of the small size of the population; workers are often community or extended family members acquainted with the young people and their families, causing concerns about confidentiality within the community and creating a barrier to accessing mental health services.

The Panel observed examples of young people who were involved with child welfare not because of child protection concerns, but because all mental health or developmental service options in their communities had been exhausted and families were not able to cope or meet the mental health needs of their children. Families reflected on their belief that the child protection system would be a pathway to mental health care for their children.

"A young person explained that they went into care because of mental health challenges, after their parent contacted the Children’s Aid Society numerous times to ask for support and to be connected to resources. This young person feels that if they had been able to get into supportive mental health programs early, it may have been possible to continue living with their parent."

In the histories of the young people reviewed, the Panel found examples of young people who appeared to have a developmental disability and did not receive an official diagnosis, despite descriptions of symptoms in the documentation. In other examples, young people were likely experiencing a developmental disability, and were being assessed as having mental health challenges, and treated as such. In particular, the Panel noted that there seemed to be a lack of understanding about the most effective treatment options and support for young people living with fetal alcohol spectrum disorder.

Both staff from placements and Society workers reported that when young people have involvement with child protection, parents and community service providers such as teachers, school boards, nurses, doctors, assume that their mental health needs will be met. They also expect streamlined access to mental health resources by virtue of this involvement. Each group explained that these are unrealistic expectations of the child protection system, and that consequently, young people’s mental health needs are not being met.

Similarly, staff from placements and Society workers explained that in a crisis, young people are often discharged from hospitals because they are not considered at risk of suicide in that moment. For example, a young person who is consistently self-harming by cutting will be discharged because the doctor says ‘cutting is rarely successful (in dying by suicide)’ or they are dismissed as ‘attention-seeking.’ Staff from placements and Society workers described young people routinely being discharged without a safety plan. When a safety plan was recommended, it was usually to implement 1:1 supervision. Staff from placements noted that the implementation of this type of recommendation requires additional staff and approval from the Society that cannot be secured immediately, resulting in a gap in the safety of the young person. The workers and staff articulated the challenges this represents to providing sustainable responses and to preventing further mental health crises by securing long-term treatment for young people. The Panel observed that 1:1 supervision was often insufficient to keep young people safe, and provided no support to the young people in improving their mental health or wellbeing, calling into question the effectiveness of 1:1 supervision overall.

The Panel observed that all of the 12 young people should have had have mental health assessments early-on and on a routine basis thereafter, however; many of them did not. Staff from placements explained that when young people are in crisis and are taken to the hospital, the degree and nature of assessment is reported to vary considerably, even where self-harm and suicide ideation are present. In some cases, the staff from placements reported that there are young people who are ‘blacklisted’ (a term reportedly used by hospital staff) from admission to the hospital. Placement staff members were of the impression that this meant young people would not be admitted or appropriately assessed when they presented in hospital in some circumstances. When asked, hospital staff did not confirm the use of the term, but explained that some young people do not benefit from hospitalization, and that the hospital often assumes that young people are receiving the support they need in their placements and/or through the child protection system. There was no information available to guide this determination.

While the Panel observed fragmented and reactive mental health care for some young people; they found a complete lack of mental health care for others. In particular, the Panel observed inequities in mental health care in northern First Nations communities. In some cases, there was no access to a doctor or a mental health worker in the community. In the event of a mental health crisis, young people would be taken to a nursing station. If young people were determined to need more care and support, they would be transported to the nearest city, which was often a considerable distance away. Families and the leadership of one of the communities described the need for young people to receive culturally appropriate services. They also explained that when young people are removed from their communities for care, they struggle to maintain progress when they return to the same environment.

Young people explained that sometimes there are mental health workers in First Nations communities who are not formally trained, but can take young people out on the land, which can be of significant benefit to their mental health.

The Panel observed that where psychiatric services were unavailable in First Nations communities, young people were sometimes connected to psychiatric services through telepsychiatry. The Panel acknowledged that while this model can bridge immediate service gaps, without understanding the context of the community, it is challenging to make realistic, culturally appropriate and sustainable recommendations to support young people’s mental health.

Indigenous young people from Northern Ontario candidly described suicide attempts, self-harming behaviours, and friends who had died by suicide. When asked about mental health supports, many of the young people were unable to articulate having ever been offered any form of mental health support. They described talking to their workers and being told to “get over it.” They described foster parents that did not report suicide attempts to children’s aid societies or others for months, because of concerns that the child would be removed from their care (which would have consequential impacts on the financial supports they receive). One young person described a suicide attempt by overdosing on medications; they indicated that they were mistaken for being intoxicated on alcohol and “thrown in the drunk tank overnight.”

The Panel felt that the 12 young people subject of this review were often considered in isolation of their families, communities, environments and broader social structures surrounding them. It was suggested that wholistic, team-based mental health care, including assessments and treatment that consider the whole child (i.e. physical, emotional, spiritual, and mental) in relation to their environment could have benefited the 12 young people immensely. The Panel also felt that innovative therapies should be explored, and that in particular, innovative and original Indigenist ways should be supported and validated. With a wholistic approach to mental health, the impacts of intergenerational trauma, systemic racism, or socio-economic and structural barriers are less likely to be interpreted as mental health challenges that are particular to the individual young person.

The Panel and families discussed the need to better understand young people’s use of the internet and social media and its relationship with their mental health. There were concerns about the internet being used to facilitate suicide pacts and incidents of cyberbullying. The Panel and families also recognized that while the internet sometimes presents safety concerns, there could be opportunities to better support young people through the internet and social media.

Specific opportunities for improvement

• Wholistic, team-based and preventative screening and assessment tools should be developed at the local community level to enhance relevance, cultural appropriateness and effectiveness.
• Prevention of mental health challenges requires going beyond typical mental health care to include access to basic needs, education, recreation and community programs.
• Mental health care should consider the whole child (i.e. physical, emotional, spiritual and mental) in relation to their environment (family, extended community, etc.).
• More research and training with regard to opportunities and risk factors of young people’s internet use. In particular, suicide pacts and cyber bullying.
• Some families identified the need for mental health care that is targeted towards young people who are survivors of sexual abuse.
• Mental health services should include traditional ceremonies appropriate to the community such as the use of feathers, sacred circle meetings and pipe ceremonies.
• When medication is used to treat mental health, it should be coupled with additional therapeutic supports. 
• There should be a phased approach to transitioning out of mental health services.
• There should be more basic training for workers and caregivers to understand mental health so that it is not misinterpreted as behavioural challenges (e.g. anger).
• Out-patient treatment should be prioritized, wherever possible.
• Counsellors and workers should avoid having young people retell traumatic stories, wherever possible.
• Staff from placements suggested that extra support is required from hospitals to de-escalate and ensure appropriate follow-up care when a young person is in crisis, even if the young person does not need to be admitted to the hospital.

“I wasn’t mad at the system, I was mad at the fact that I wasn’t safe while I was in the system.”

Service systems

The interactions that the 12 young people and their families had with service systems greatly influenced their wellbeing. The following section will consider those service systems, how they intersected, and their impact on young people and families.

Key findings

• Young people did not receive enriched, meaningful or quality care with a focus on family preservation.
• Roles, relationships and communication structures in the child protection system are not clearly defined.
• There was an apparent lack of transparency and information sharing between Children’s Aid Societies or Indigenous Child Wellbeing Societies, children’s residences, and other child and family services.
• There was a lack of service integration at the local community level (e.g. schools, cultural programs, community recreation, and local supports and treatment).
• There is variability in access and availability of children’s residential beds and treatment beds, and a lack of clarity regarding the meaning of a ‘treatment bed’
• The overall cost to support young people in the child protection system cannot be ascertained and is not recorded in one consolidated place.
• The service systems the young people were involved with did not focus on family preservation.

Summary of observations

Service system integration

The Panel found that the roles, relationships, and communication structures between the various serving organizations, and types of serving organizations (i.e. child protection and community mental health) were not clearly defined.

Oversight structures were also unclear. Staff from placements and Society workers seemed to have limited understanding of initiatives underway by MCCSS.

There appeared to be a lack of transparency and information sharing between societies and those providing care to young people in homes or residences, in particular Outside Paid Resources (many of which are for profit operators). Society workers and staff from placements explained that because there is no formal process for information sharing between societies and placements, important information about young people such as information from assessments and their historical and social context does not always make it to the frontline staff who support young people, creating a gap in their ability to provide quality care. The Panel noted that information sharing about placement availability and quality was limited and societies had variable access to residential and treatment beds. While interagency service protocols do exist, information sharing and communication still appeared to be an issue where multiple societies were involved with the same children and families.

The Panel noted that in some cases, jurisdictional issues between societies and other child and youth serving agencies caused a barrier to young people accessing the services they needed, or to accessing quality care. The Panel asserted that Jordan’s Principle should be applied in all circumstances where jurisdictional boundaries cause delay in service delivery or impact a young person’s care.

Many societies were perceived by other agencies in the community as having capacity to provide prevention services, protection services, and care to young people and their families. In some cases, societies endeavoured to provide a spectrum of services beyond child protection (i.e. prevention services), while others did not. Some societies formally deliver a continuum of services; these societies are referred to as ‘multi-service agencies’. The Panel felt that one service agency should not be in a position to solely deliver both prevention and protection services however; the child and family services within many communities were fragmented thereby making an integrated service response challenging and creating a gap that some societies endeavour to fill.

There appeared to be a lack of clarity regarding the role of child protection, hospitals, community mental health, and secure treatment; and how they intersect when servicing the same young people and families. There was also an apparent lack of service integration at the local community level (e.g. schools, police, recreational programs, cultural programs, and local treatment). An example of service integration could be a cross-disciplinary team that meets to discuss the intersection of services for an individual, family, or community.

While there was a lack of integrated services in some of the communities, many remote First Nations communities had no access to resources and services. The Panel noted that when societies are the only service providers available in a community, families seeking support often come to their attention. The Panel felt that the absence of additional service providers in these communities likely contributes to the overrepresentation of Indigenous young people in the child protection system.

The cost to support young people in the child protection system and in particular, placements in outside paid resources is not recorded in any one consolidated place. The Panel proposed that recording this information would allow for a cost analysis to compare the current model with a wholistic, community-based wrap around service model. This would include the per diem rates for each young person, Special Rate Agreements, and the amount of hours each staff is working.

experiences of service systems

The Panel observed that the young people did not receive quality care from the service systems they interacted with. There were examples of thoughtless and inattentive care from hospitals, schools, child protection workers, caregivers, and staff. The Panel felt that many of the young people were not consistently treated with dignity and respect and did not receive a basic level of care from many of the care providers they interacted with. Young people went months without education, were shuffled through placements without apparent thought to appropriateness, and were not engaged in enriched and meaningful environments.

Young people described their care as having a ‘punishment-focus’ rather than a ‘correction-focus’ that emphasizes strengths, solutions, and progress. They felt that services and supports were not personalized to focus on their individual needs and instead, they described being treated the same as any other young person with a similar family history or diagnosis. Young people reflected on having very few opportunities for positive activities to look forward to while they were in care (e.g. music events, sports events, etc.).

Staff from placements suggested that there should be more supports for young people who are transitioning out of care to independent living or adult services. Staff from placements spoke of the need for a phased approach that would require collaboration between the children’s sector and the adult sector.

Young people echoed this sentiment when they reflected on their own transitions out of care. A young person talked about suddenly being in ‘semi-independent’ living because of their age, but not yet feeling ready for that level of independence. Following discharge from care, young people reported that there were no more casework visits and no follow up. Some of the Indigenous young people described their discharges from care as “being sent home”, and noted that they give you a clothing allowance and other things when you’re in care, but when you reach 16 “they throw you out.”

The Panel found that in the 12 young people’s cases, there did not appear to be a focus on family preservation in the service systems they interacted with. Families rarely received supports before their child was removed from the home, and the documentation did not suggest that Society workers, staff from placements, and caregivers facilitated or encouraged communication between young people and their families following apprehension. Many of the families described their communication with children’s aid societies or Indigenous child wellbeing societies to have been sporadic; explaining that they were not informed of their children’s care plans or of their overall wellbeing. Community representatives in four of the young people’s communities identified the need for structured and sustainable support for families and communities both before apprehending and when young people return home.

"Young people also described poor communication between children’s aid societies or Indigenous child wellbeing societies and their parents/families. They felt that biological parents should get more visits with their children. Young people described that often parents are told that they will get their children back, but then they don’t."

Indigenous young people from Northern Ontario explained that family service systems do not meet the needs of the families in their communities and suggested that traditional ways would be more effective. One participant noted, “We know that when people are connected to their communities they do better.”

The young people articulated that there needs to be a process to help Indigenous young people based on traditional ways and said, “Don’t colonize the process, don’t colonize the solutions.” They also noted that government or any other social service should engage young people when their work impacts their communities. Engagement should start at the development and planning stage and follow through to implementation.

Specific opportunities for improvement

• There should be increased coordination and information sharing between MCCSS, children’s aid societies or Indigenous child wellbeing societies, and placements.
• Systems at the local community level should be integrated, and should include health, mental health and wellbeing, education, recreation, child care, children’s mental health, early intervention services, prevention services, developmental services and other special needs services. This type of integration could involve a cross-disciplinary team with an identified lead.
• Jordan’s Principle should be applied in all circumstances where jurisdictional boundaries cause a delay in service delivery or impact a young person’s care.
• Integrated and community-based wrap around services with a focus on prevention and family preservation should be provided to children and their families.
• There should be resources available to young people as they age out of care.
• Traditional Indigenous approaches should be incorporated into child and family services because they are more effective in meeting the needs of Indigenous families in Ontario.
• When government or social services undertake initiatives with Indigenous communities, Indigenous young people should be involved from the beginning to the end. Once Indigenous young people have been engaged and have provided insight into an initiative, they should be regularly updated on the progress and the status of that initiative.
• Young people should be provided with more positive opportunities (e.g. music events, sporting events, etc.) while they are in care.
• Services and supports to young people should be personalized based on the individual young person’s strengths and needs.

“When kids get out (of the child protection system), there are suicides and drugs …It’s not the kids, it’s not the staff; it’s the system that is failing us.”

System oversight

The following section provides a summary of the Panel’s findings with regard to oversight and accountability of the care provided to the 12 young people.

Key findings

• There are young people placed in residences that are not inspected by MCCSS.
• Despite commonly used terms for placement environments (i.e. group home, staff-model foster home, foster care treatment, etc.), there are no clear definitions for the differences between them or the distinct services that they may or may not provide.
• While licensing may monitor compliance with operational standards in the facility, there is no process to monitor the quality of care that is being provided to young people.
• There are no minimum educational standards or pre-service qualifications for staff working in children’s residences.
• Training for foster parents and caregivers does not appear to be consistently updated to reflect the current needs of young people in care (e.g. mental health, substance use, developmental challenges, fetal alcohol spectrum disorder, human trafficking, and social media and internet use for young people).
• There are no mechanisms to monitor and track the length of young people’s placements or the number of placement transfers they have incurred.
• Case files and documentation were disjointed with gaps in information, unclear service trajectories, discrepancies between agencies, and inconsistent definitions.
• Trends in serious occurrence reports and other documentation have not historically been monitored at the provincial level to identify opportunities for improvement.
• Documentation did not appear to focus on the young person’s strengths or provide a sense of who the young person is.

Summary of observations

The Panel found that many residences, both licensed and unlicensed may not have been inspected by the MCCSS. This is because operators were issued a license based on 10per cent of their homes. Of the young people subject of the expert panel review, two were residing in family homes under a customary care agreement; three were residing in agency operated homes that were not inspected by MCCSS licensors, one was residing in an unlicensed staff-model home, and six were residing in licensed homes, including group homes, residential treatment, and staff model foster homes.

The names used for different types of placements varied considerably and led to substantial confusion. The Panel observed terms such as group home, parent-model foster home, staff-model foster home, agency operated home, and foster care treatment are commonly used in child protection and children’s residential services. Both the Panel and Society workers determined these terms to be misleading, because the constellations of the homes may or may not be materially different. For example, ‘staff-model foster homes’ and ‘group homes’ both have staff on rotating shifts supporting young people. Society workers, who are responsible for placing young people, explained that because of misleading terms, they do not always have a full understanding of where they are placing young people, what the differences are between different types of environments, and whether certain types of placements are licensed or unlicensed. For example, if it is a treatment foster home operated by a Society that only has two beds, many workers will assume it is licensed when it is not. Agency operated homes caused particular confusion; workers did not understand licensing requirements, and when the Panel sought clarification from MCCSS as to the licensing of these environments, the response was also unclear– leading the Panel to the observation that agency operated homes exist in a grey space where no one is clear about licensing or accountability requirements. The Panel was not able to ascertain what the licensing process is for children’s aid societies or Indigenous Child Wellbeing Societies, if any.

Where environments were licensed, the implications of licensing reviews and outcomes were not well understood by workers. Society workers explained that when a residence is provided with a ‘provisional license’ from the ministry, they are unaware of what the non-compliance issues were that prohibited the issuance of a full license. They explained that this creates challenges in matching young people based on their individual needs, noting that they would benefit from more transparency in the licensing process. Through a review of licensing documents, the Panel found that with the issuance of a ‘provisional license’, a children’s residence may or may not have remaining issues pertaining to the safety of young people or the quality of their care.

Some of the residential staff expressed concerns regarding MCCSS’ approach to licensing. They explained that the approach to licensing should be collaborative and supportive rather than punitive and compliance-focused. When MCCSS employees visit a children’s residence for a licensing inspection, they are required to interview the young people residing there. Residential staff were concerned about the skill sets of the MCCSS employees that speak with children and youth. It was suggested that they should be required to have trauma-informed and child development training before interviewing young people.

The Panel found that while the current licensing model may promote compliance with operational facility standards, there are no systems in place to monitor and ensure that young people are receiving quality care in an enriched environment. Society workers and staff from placements felt that standards in children’s residences need to be raised and need to be consistent. They took care to note that the standards should allow for the diversity in resources and practices across the province. The Panel felt that quality of-care standards were necessary as well.

The Panel observed that there are no minimum educational qualifications for staff in children’s residences and inconsistent training for foster parents and caregivers to support the current and complex needs of young people (including mental health, substance use, developmental challenges, fetal alcohol spectrum disorder, human trafficking, social media and internet use).

The Panel also observed that there is no process to monitor the length of young people’s placements or the number of placement transfers they have, which could serve as indicators of a young person’s experience and wellbeing.

The Panel noted that every young person in care deserves the same level of review and accountability from oversight bodies. An extended society care review (formerly a Crown ward review) was referenced as an opportunity to monitor quality, however, the Panel observed examples of the reviews failing to identify challenges with young people’s care. Since not all of the 12 young people were in extended society care (i.e. were not Crown wards), the Panel was not privy to the same level of documentation for each young person that an extended care review can sometimes offer. Additionally, young people in long-term customary care are not subject to these types of reviews, which was seen as a missed opportunity to monitor quality for Indigenous young people specifically.

The Panel also indicated that there is a need for culturally appropriate oversight that is developed by Indigenous communities and takes into consideration structural barriers (e.g. lack of funding and resources, inadequate housing and infrastructure).

As part of the Panel’s work, an extensive review of the documentation surrounding the 12 young people was completed. The Panel questioned what the intended purpose of some of this documentation (e.g. serious occurrence reports, incident reports) was and whether it was being used effectively. It was apparent that MCCSS has not historically tracked trends in serious occurrences at the provincial level, which offers the potential to indicate challenges in care and areas for improvement. There is work underway, however, to assess risk based on data in serious occurrence reports.

The Panel observed that documentation was disjointed with gaps in information, unclear service trajectories, inconsistent definitions and discrepancies of information between agencies. The approach to documenting incidents and serious occurrences was often inconsistent and occasionally careless. There were examples of sections that were copied and pasted, sometimes not even pertaining to the subject young person. In other cases, there was a complete lack of documentation, making it difficult to fully appreciate the young person’s circumstances or their wellbeing.

Young people spoke of a lack of documentation, which in turn led to a perceived (and potentially actual) inability to report challenges with their care. For foster care operators with multiple residences, the operators often completed the report and the main office was recorded as the address, leaving the reader without any understanding of where the young person was actually residing. Unlicensed residences, including agency operated homes, are not required to submit serious occurrence reports to MCCSS. The Panel also noted that much of the case files and documentation do not give the reader any sense that staff or operators are taking a strengths based approach when working with young people and instead, the young person is often presented as difficult. Young people reiterated this perspective when they explained that serious occurrence reports created an opportunity for negative perceptions of young people to be fostered amongst staff.

The young people suggested that new staff in group homes should not read about serious occurrences until they have spent time with each young person, so that they can form their own opinions, instead of ‘reading about us through someone else’s eyes.’ It was proposed that until new staff members have spent time with young people, they should only be informed of safety concerns. It was also noted that serious occurrence reports are one-sided and that they are written to show that staff did everything they could, sometimes missing context about the young person.

Specific opportunities for improvement

• New staff in children’s residences should not read serious occurrence reports until they have spent time with each young person, so that they can form their own opinions of them. New staff should only be provided with information that is necessary to ensure their personal safety, the safety of the young person and others.
• All young people should have an equitable review of their care and should receive equitable accountability from oversight bodies.
• There is a need for culturally appropriate oversight structures that consider structural determinants of care and where applied in Indigenous homes, should be developed by Indigenous communities.
• Measurable standards should be implemented in children’s residences so that staff, operators and oversight bodies are able to understand what is expected of them and whether the standards are being met.
• Society workers suggested that the minimum standards in children’s residences should be raised, however; they should allow for diversity in resources and practices across the province.
• Society workers suggested that there should be more transparency in licensing so that when placing young people, they have access to the areas of non-compliance in a children’s residence’s licensing reviews.
• Residential staff suggested that ministry representatives who are responsible for conducting licensing interviews with young people should be trained in child development and trauma-informed approaches.

“I was traumatized in the system – who is accountable for that?”