See follow up Vol 4 of 2015: No facility in Ireland for teenager detained in UK
Summary
An Emergency Care Order was refused in the District Court for a teenager with complex needs who was in voluntary care and kept absconding from her residential unit.
The solicitor for the CFA told the court that A had gone into voluntary care in late 2012 but had absented herself from her residential unit since late last year. She had assaulted a member of staff at the unit and picked up criminal charges. An up-to-date psychiatric assessment had been sought and she had been found to have severe ADHD with Asperger’s Syndrome.
She had gone back and forth to live between her paternal and maternal grandparents since leaving the unit and had assaulted her maternal grandparents and her mother. Her behaviour at times could be very extreme and violent. She was at present with her paternal grandparents, but needed a secure therapeutic environment.
The court heard her mother had first noticed unusual behaviour when the girl was four and had sought help from the HSE then, but had received very little help until she expressed a fear that her daughter would kill her, or she would harm the daughter. The HSE then became involved.
A psychiatrist who was a neuro-developmental specialist said the girl had very complex needs and could be tipped into psychosis without the appropriate therapeutic intervention. However, lawyers for her and for her mother said that returning her to the unit from which she had absconded, and where she did not want to be, would not solve the current problem. The proposed solution was not better than the status quo, they said.
The judge ruled that the threshold in terms of immediacy and necessity for an Emergency Care Order, in order to place the child back in the residential unit from which she had absconded, had not been met. “I’m quite satisfied [the CFA solicitor] has established on the evidence it’s a chronic situation, a serious situation for a considerable number of years, which has not enormously escalated in last six months, but the immediacy has not been established.”
CFA case
The CFA had brought the Section 13 (Emergency Care Order) application due to the immediacy and seriousness of the recent diagnosis as well as the fact that the girl had now gone to live with her paternal grandparents, who would not engage with the social work department. A statutory basis was now needed to place her in care as the wider family dynamic was undermining her placements.
The teenage girl (A) was joined as a party to the proceedings and had separate representation; however her solicitor agreed it was in her best interests that the application be made ex-parte (without her presence). Her solicitor told the court that A did not want to go back to her residential unit because allegations there had been brought to a criminal forum. Her behaviour was very challenging with her family and there were huge difficulties in terms of her involvement with professionals.
The mother contested the ECO and did not want A to return to her residential placement as she could incur further criminal proceedings. However, she was not in a position to look after her on her own and her own parents also found it difficult at times.
The solicitor for the CFA told the court that the maternal grandparents had tolerated a huge level of assault and there was a significant culture of minimisation. When the psychiatrist had gone to the maternal grandparents’ house to assess her last weekend she had climbed out of the skylight and onto the roof. She had been verbally abusive and afterwards she had told her grandparents she would kill them if they got another doctor again.
Her current residential placement was not a secure unit but it was a therapeutic one, it was a low to medium support unit, a psychologist and psychiatrist were available to her and it was close to her school and an extra-curricular activity she was involved in.
A secure therapeutic placement had been suggested by the consultant psychiatrist. Voluntary care had been tried and was not successful. The CFA solicitor told the court that when she ran away from her unit she was facilitated by family members. They also brought her chips to the unit late at night if she demanded them.
The judge said the CFA proposition was that the situation was immediate and serious but the only proposal was to place her back in her residential unit where she had already incurred serious issues. There could be the possibility of further provocation and her mother was also concerned about that placement. It would not produce a positive result.
The CFA solicitor said the unit had so many things going for it, she felt there had to be some planning done at an executive level outside A’s family. “They clearly can’t manage despite their best endeavours.”
Social worker
The social worker told the court that the extended family were consciously and subconsciously undermining the girl’s placement. A secure unit placement was not ready, therefore her residential unit was being suggested in the meantime. The social worker had made three attempts to meet with A and introduce herself but A had been abusive and threatening towards her, had hit her with a tin, spat at her and thrown liquids over her.
It was very difficult to put any plan in place for A while she was in voluntary care, she needed a plan put in place with staff care, which was why they had brought the application today. Furthermore, family members had come to the unit and brought her out when services had been planned for her.
There was a PDDNOS (Pervasive Developmental Disorder Not Otherwise Specified) diagnosis from a number of years ago. An escalation in her behaviour had been seen, including property damage and assaults which were becoming more frequent. The time she could contain herself seemed to be lessening. No parent would be able to manage her behaviours and they would be best met at a residential setting, said the social worker. This was what was recommended by the psychiatrist as she was placing both herself and her family at risk in the family setting.
It was hoped an alternative two year placement for A would be found within a matter of weeks. With an ECO the CFA would have full control over her circumstances, said the social worker. A’s solicitor said they would not, they “would have little control over a 16-year-old who would decide herself when she would come and go as before”.
The judge asked if sending her back to the residential unit “might ratchet up another incident”.
Psychiatrist
The consultant psychiatrist with specialist expertise in neuro-developmental disorders told the court he had tried to meet with A on five occasions to assess her but she had been very evasive. There was a lot of paperwork regarding evaluations from other professionals involved in her care.
He went to visit her last weekend. On entering the house he could hear growling and barking from an attic bedroom, which was her usual pattern of behaviour; she woke up in an aggressive manner each morning. The barking had started in recent years, when she became aware there was a stranger in the house she became silent. Her grandmother called her to come down but she would not come.
He went upstairs and stood in the doorway, she cursed at him, the room was the worst scene of squalor he had seen in a 16 year old girl’s room. There were large coke cups full of urine, “the room was squalid, it was the type of scene you’d associate with someone with a very chronic mental illness who had given up caring for themselves years before”.
Her use of unusual toileting facilities was associated with her tendency to retreat to her room and unwillingness to leave to use the bathroom; this was a pattern which developed over recent years. The rest of the house was very well cared for and her grandmother said she cleaned the room a week before.
CFA solicitor: “Did she engage with you?”
Doctor: “I was able to engage in so far as I’m used to dealing with people who don’t want to talk to me, but at least she did appear to respond directly to my questions albeit in a colourful language. Her main approach was to express her unhappiness I was in the house and she wanted me to leave.”
When he went downstairs for her to follow he realised she had climbed out of the attic skylight. It was quite an old house so it was dangerous.
Once the doctor had gone A left for the rest of the day until very late that night. While she was out her grandparents cleaned up the room and when she returned they had a “blow up” and she left to live with her paternal grandparents. The doctor had tried to contact them for collateral information but their phones were switched off.
His view having assessed her was that she had Asperger’s syndrome exacerbated by ADHD. She was at immediate risk to herself by virtue of her impulsive behaviour though there were no obvious thoughts of self-harm. There was a “risk of violence which could be quite extreme towards her grandparents and mother and staff”. She had hit her grandfather with a wooden chopping board and showed no remorse, which was consistent with an expected very low empathy score associated with Asperger’s Syndrome.
There was a paternal family history of psychiatric disorder which if elucidated would make her assessment and diagnosis easier, but the family would not divulge it. Indications supported a condition of Asperger’s Syndrome with a form of psychosis which presented when people with Asperger’s Syndrome became extremely stressed.
He believed the greatest risk currently posed was to her elderly grandparents and to her mother, as they were the people she had recently assaulted. He thought it was very important that she was not cared for by family because she had no boundaries in relation to committing acts of violence against them.
A substantial multi-disciplinary input was needed which was limited in its availability in Ireland. Otherwise her current Asperger’s Syndrome, ADHD and untreated anxiety would lead to a complete disintegration in her mental state and she was likely to be diagnosed as suffering from an early onset schizophrenia by psychiatrists who did not have specialisation in this area.
Doctor: “She needs to be in a place of therapeutic security managed by appropriately trained staff very familiar with treating people with this severity of autistic spectrum disorder and other neurodevelopmental disorders. Very few of us in this country are qualified to treat a girl of this condition, she needs a level of expertise that to my knowledge is best represented by the team in [named facility]. Her level of violence is escalating, probably in line with her level of anxiety and expressed anger, which is intense. She needs to be in a place where qualified professionals are looking after her.”
He told the court he had “made a tentative diagnosis based on an awful lot of observations by other people,” she had an extremely uncommon condition. He had yet to establish whether it was a similar condition like high functioning autism.
Doctor: “Given she can function in school and engage in normal activities, Asperger’s Syndrome is more likely as a diagnosis, whether or not there is actually a difference between the two hasn’t been decided, it’s more likely there’s an Asperger’s spectrum within the autistic spectrum.
“The noises are a release of anxiety built up during the day, she’d be under a lot of pressure to appear normal to her peers, people with Asperger’s adapt and learn how to behave, it is a condition that changes over time. With the additional stress of the family breakup the input from the [paternal] family hasn’t been helpful, they’ve created more barriers to investigation and assessment of care.
“Asperger’s as it presents in someone like [A] is really the borderline between reality and unreality, psychosis and reality. Under severe stress people display psychotic behaviour, the condition responds better to a reduction in stress rather than medication.”
The doctor believed efforts were being made to create a space or open up another unit so that it met her requirements in accordance with the guidelines for a child in care.
Doctor: “The risk to her grandparents is immediate and on-going. It’s imminent in so far as it’s on-going, it’s really unpredictable. If [A] were to significantly injure one of her grandparents there wouldn’t be any surprise. Her level of violence is escalating. In the last few months she has produced a knife and threatened a member of staff.”
A’s solicitor: “Whatever plan is put in place must be demonstrably better than the status quo, she needs a place of therapeutic security. They have equal weight, wherever this therapy is to take place it must be somewhere where [A] is safe and secure?”
Doctor: “Yes.”
The doctor told the court that the HSE was not in a position to provide the type of service she required, which was a psychiatric service for people who did not have intellectual disabilities. People in Ireland with neurological developmental disorders were treated within the disabilities services, he said.
He could not identify a better alternative to a service that had a facility to treat her condition. He did consider the question of the use of the Mental Health Act [for involuntary detention] and how it would work in her case. He concluded it would lead to admission to a secure environment which was not necessarily therapeutic because training in this area was so limited in Ireland.
The doctor preferred the option of A returning to her residential unit as they could identify the associated risks there. They could not risk-assess her paternal grandparents as they had no access to that home. He acknowledged that the tipping point for A could be the suggested plan of return to the unit. However, the placement suggested was in comparison to what he had no knowledge of – the paternal grandparents’ home – until such time that a place of therapeutic security was identified.
The CFA solicitor told the court that the risk of where she was now was unquantifiable.
Doctor: “It is incumbent upon the HSE to identify as a matter of great urgency a place of therapeutic security so she can move there in a matter of days, the [residential unit] can only be seen as being a short term introduction into a therapeutically secure unit.”
Judge: “Is there any danger of tipping her into a psychosis, due to the acute stress of a short term placement in the [residential unit]?”
Doctor: “That risk is already there due to the nature of her diagnosis. You are dealing with how she copes or doesn’t cope, she hasn’t fully crossed the threshold into psychosis. She has displayed borderline states, but were it to happen it would be in a safe environment, with psychiatric staff to treat her.”
Mother
Themothertold the court that she had first written to a child therapeutic clinic when A was four, when she had noticed her daughter had some obsessive tendencies, but she was told there was a five-year waiting list. She paid for a private psychologist, she sent her to play therapists, even healers, to find out what was wrong, but her behaviours increased as she got older.
When A was 10, the mother went on a holiday and A stayed with her maternal grandparents. There had been “meltdowns” at home leading up to the holiday but when the grandparents saw it happening for the first time they did not know what to do and called an ambulance. They thought she was having a schizophrenic attack. She was brought into hospital and re-referred to the child therapeutic clinic which she then attended for one year.
Her doctor was baffled as to her diagnosis as A could function OK in school. Seven psychiatrists attended a conference and diagnosed her with PDDNOS, (Pervasive Developmental Disorder Not Otherwise Specified). The mother was not really given any assistance in how to deal with it or manage at home. A was getting worse at home and would not engage with the multi-disciplinary team and psychiatrist, so after one year the clinic closed the file.
Subsequently there was property damage at home and there were assaults. The mother went to the HSE herself and told them she could not cope and was not managing at home. She was told it was not a child protection matter and sent home, she was advised go to back the clinic. The HSE and the clinic were “passing the buck between them,” said the mother.
Her daughter was making noises at night for five to six hours and neither of them were getting any sleep. She rang the clinic and told them: “I’m afraid I’m going to kill her or she’s going to kill me.” After that a social worker from the clinic got in touch with the HSE and they intervened.
The mother told the court that because she had asked for a residential temporary placement to help her she was accused by the HSE of giving up on her child and abandoning her. The HSE eventually referred A for a 12 week assessment and she placed her into voluntary care in a residential unit for a 12 week assessment which turned into seven months. However the behaviours became worse, she was urinating and throwing it at staff, thumping her head, writing all over the walls, she pulled all the doors off the cupboards and the fireplace off the wall.
Mother: “It was like something from a horror film going into visit her, she hadn’t washed in months, there were lice in her hair, she was sitting in urine in her bedroom, her clothes were soaked in urine. She was only eating chips. I was promised they’d have her eating different foods, they’d sort her out. It wasn’t the case. Then they came up with the placement of the [the current residential centre]. I was told they had a more experienced team, and they would implement a behavioural plan.”
The mother told the court that she had asked questions about secure care but had not requested it. A’s behaviour improved for two weeks after she left the residential assessment centre but then at the current unit a girl began to bully her. A was terrified of her; the girl had threatened to kill her and would burst into her room in the middle of the night. Then A started to abscond regularly and the placement broke down rapidly. That girl was still living in the unit.
A more authoritarian approach to dealing with the teenager provoked her, said her mother. A trigger was touching her belongings, “she would kick off and start throwing things.” She had started to incur criminal charges at the residential unit and would be better protected with her paternal grandparents. Anyhow she would not stay in the unit for longer than 10 minutes. “She will run no matter what time of day or night it is, she will do whatever it takes to run,” she told the court.
Mother: “The ECO won’t achieve anything, it makes no difference to [A], she will still run from the [residential centre], she doesn’t understand. If the grandparents don’t let her in she will smash the windows, they will let her in. It is not true that things are more serious now than they were a few months ago. It would place her more at risk at the [residential centre]. Staying at her paternal grandparents is not ideal, I’m in agreement she needs a therapeutic environment, but what do they mean by secure? I would like them to clarify what they mean by secure.
“She can function so well on so many levels, to deprive her of her liberty in a secure environment will be detrimental to her, she needs to be able to go to school and see her friends, the [residential centre] is too close to her paternal grandparents. I do agree they need to be told to stay away, they need to cooperate.”
Mother’s solicitor: “What is the next best step than the [residential centre]?”
Mother: “I would like them to look at a therapeutic residential placement for [A], her condition is very rare, she is very complex. She has had no therapeutic intervention in the year she was in care, she saw a psychologist twice and a psychiatrist once. I don’t have much faith in the therapeutic environment they are talking about. She would be better off if no professionals had become involved with her, she has become criminalised and traumatised. She said yesterday that she will kill herself if sent back there, that [residential centre] has ruined her life.”
The mother agreed that A was beyond her care but she should stay with the paternal grandparents until the secure therapeutic environment was ready. A found the slightest change very difficult; it was part of her condition. The paternal grandparents would not support a social work plan, said the mother.
The therapeutic residential environment was going to have to be very specialised and well thought out. This year her school attendance had deteriorated, she was excluded a lot and on the periphery.
Mother: “It’s the most important thing to her in her life to have friends and appear normal. The school are very aware of the situation, they’ll do whatever they can to include her, they will look out for her. If she had to move school it will be absolutely detrimental to her, I can’t see her going to another one.
Submissions
Seeking submissions, the judge said: “The issue here is that the court has to be satisfied there is reasonable cause to believe there is an immediate and serious risk to the health or welfare of the child which necessitates her being placed in the care of the health board.
“All parties want a level of intervention. Does this reach the threshold of section 13? The mother is of the view it is as serious now as it was six months ago. The cure is going to be worse than the disease, what is proposed will not deliver a benefit, that is from what I understand [to be] the issue.”
The parties made submissions on the Section 13 threshold. While the CFA solicitor said the serious risk to herself and others was escalating, the mother’s solicitor said the threshold was not met on immediacy of risk but he said the seriousness of the case was admitted. A’s solicitor said the family being non-cooperative (the paternal grandparents) could not lead to the conclusion that it was a family placing her at immediate and serious risk.
A’s solicitor: “The best holding position that the court might consider is where she is at the moment, given she stays for 7-8 weeks [at each grandparents’ house] it gives time to put in place an appropriate placement that in fact meets the therapeutic security that [the consultant psychiatrist] spoke for.
“With the ECO you also get the [residential centre], that’s the consequence. Unless we can suggest who is at immediate and serious risk and the solution is demonstrably better than the status quo than I say the order shouldn’t be made. I don’t see the proposal is demonstrably better than where she is at this time.”
She needed a new fresh start, which could be met with therapeutic security.
Judge’s ruling
Judge: “This is a difficult and complex application. It is difficult for her mother. Sometimes a parent knows exactly what’s going on sooner than any expert, the mother knew from age four there was something amiss, she left no stone unturned until she could find a solution. It is very difficult to provide a solution when you’re not receiving cooperation.
“I’m quite satisfied [the CFA solicitor] has established on the evidence it’s a chronic situation, a serious situation for a considerable number of years which has not enormously escalated in last six months, but the immediacy has not been established. It is not clear at all there is a necessity [the doctor could not assess the paternal grandparents], or that what is proposed is a better short term scenario than what is proposed at the moment.
“I accept that this young person must present tremendous strain in the [paternal grandparents’] household. Professionals are trained in holding techniques, there’s no question that a parent or grandparent can have the same level of skill.
“An ECO application was made ex-parte, that threshold was met but it is designed [Section 13] to meet a specific statutory need, it appears the threshold had not been meet in terms of immediacy and necessity of making the order in terms of placing the child in the [the residential centre] where she has indicated she is deeply unhappy. Staff may have been able to deal with her had only there been cooperation, we do not know.
“This child needs a secure therapeutic environment to meet her needs, she has major difficulties that need to be resolved. She is less mature than the average 16 year old. She needs to be cared for. The evidence adduced in court so far doesn’t reach the threshold.”
The Emergency Care Order was refused.
An application under section 18 is warranted, said the CFA solicitor. The judge agreed, but said: “The reality is you have to have a care plan, a firm diagnosis and an assessment of the [paternal grandparents].”
