Falling through the cracks: BC Medical Journal

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Falling through the cracks: BC Medical Journal
IN THIS ISSUE:                                                        April 2019; 61:3
Cardiac auscultatory teaching and its                                 Pages 101–148
role alongside echocardiography
The value of independent drug assessment
BC’s Tuberculosis Strategic Plan:
Refreshed and focused on TB
                                                        Falling through
                                                            the cracks:
                                             How service gaps leave children
                                           with neurodevelopmental disorders
                                                 and mental health difficulties
                                                   without the care they need

                                                               www.bcmj.org
Falling through the cracks: BC Medical Journal
2019 Winner

102   bc medical journal vol.   61 no. 3, april 2019 bcmj.org
Falling through the cracks: BC Medical Journal
bc medical journal vol.   61 no. 3, april 2019 bcmj.org   103
Falling through the cracks: BC Medical Journal
contents                                                                                                           April 2019
                                                                                                       Volume 61 • Number 3
                                                                                                             Pages 101–148

                                                           106   Editorials
                                                                 Langley City family practice, David R. Richardson, MD (106)
                                                                 Reflections on my first year of independent practice, so far, Yvonne Sin,
                                                                 MD (107)

                                                           109   President’s Comment
                                                                 Are doctors territorial? When it comes to quality care, we better be
                                                                 Eric Cadesky, MD

                                                           110   Letters to the Editor
                                                                 Re: Cannabis use by adolescents, Ian Mitchell, MD (110)
                                                                 Author replies, A.M. Ocana, MD (110)
      O n t he co v e r                                          MyoActivation for the treatment of pain & disability, Suzanne
      There is a lack of specialized
                                                                 Montemuro, MD (111)
      mental health services for chil-
      dren with a dual diagnosis, and                            To sleep or not to sleep, George Szasz, CM, MD (111)
      the resulting inadequate level of
      community support has placed
      the burden of care on families.
      Article begins on page 114.
                                                                 Clinical Article

                                                           114   Falling through the cracks: How service gaps leave
                                                                 children with neurodevelopmental disorders and
                                                                 mental health difficulties without the care they need
                                                                 Erika Ono, MSW, Robin Friedlander, MD, Tamara Salih, MD

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                                                                 James M. Wright, MD, Ken Bassett, MD, Thomas L. Perry, MD, Aaron M. Tejani,
      debate on medicine and medical
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                                                                 echocardiography
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Falling through the cracks: BC Medical Journal
contents
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Amanda Ribeiro, MD                                   135         Council on Health Promotion
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                                                                 Canadian physicians support mandatory alcohol screening
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                                                                                                                  bc medical journal vol.        61 no. 3, april 2019 bcmj.org             105
Falling through the cracks: BC Medical Journal
editorials

      Langley City family practice

      I
          have spent over 25 years of my life                     working at Langley Hospital, where                        worried, because this environment
          as a family physician in Langley                        I have fostered excellent relationships                   fostered closeness and sharing. There
          and have seen many changes in                           with many physicians and staff.                           is always someone around to bounce
      my community during this time. The                              Speaking of relationships, one                        ideas off and listen to concerns about
      population has more than doubled, re-                       constant during all of this growth has                    this patient or that issue. Complaints
      sulting in increased traffic congestion,                    been the welcome presence of the                          are shared, lightening the burden each
      commercial areas, infrastructure, and                       physicians with whom I work closely                       of us carries throughout our busy
      recreational facilities. Langley now                        in our clinic. I feel so lucky and have                   practices. We also regularly laugh and
      has every big-box retailer known to                         been blessed to have shared these                         joke with one another. Fridays after
      Western civilization, including Cost-                       years with these quality individuals.                     work are one of my weekly highlights
      co, Walmart, Home Depot, and the                            Four became five, and now we are six.                     as we settle into the weekend by shar-
      Real Canadian Superstore. What was                          When I first joined the original three,                   ing some drinks and snacks.
      previously a quiet drive into the cen-                      I was surprised to find that our office                       We have seen each other through
      tral core is now a stop-and-go traffic                      desks were in the same room without                       illnesses, accidents, tragedies, divorc-
      light adventure. Despite this, Langley                      any physical barriers to separate them.                   es, aging parents, and so much more.
      has been good to me. My two children                        I found this lack of privacy unnerving                    These people are my rocks and I know
      were raised here and I have made many                       and was concerned about confidenti-                       they have my back through thick and
      good friends over the years. I also met                     ality, interruptions, and noise levels. I                 thin. Now don’t get me wrong; we’ve
      my wife here, twice.* I managed to                          wondered how work would get done                          had our disagreements over the years,
      build a busy family practice while                          in this open space. I shouldn’t have                      but they have been handled with mu-
                                                                                                                            tual respect and care. We hear about
                                                                                                                            practices that have disbanded as a re-
                                                                                                                            sult of differences and disputes. I’m
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106   bc medical journal vol.    61 no. 3, april 2019 bcmj.org
Falling through the cracks: BC Medical Journal
editorials

Reflections on my first year of independent practice, so far

W
              hen 1 July 2018 came           genuine surprise, but some can come           thought that if I passed the exam then
              around, I had done the         across as judgmental. One patient             all the knowledge I needed for family
              countless paperwork and        even talked to me for a good 10 min-          medicine would be there, and, miracu-
paid my dues. I finally got the okay to      utes before he finally asked, “When           lously, between 30 June and 1 July I
venture into the world of family medi-       am I going to see the real doctor?” I         would become the wise, all-knowing
cine on my own. It was, and still is,        could only reply, “Sorry, Mr S., I am         doctor I strived to be. But I woke up
an exciting time, but also a terrifying      who you are seeing today.”                    on 1 July feeling like the same person
time. I spent the first few weekends of                                                    I was the day before.
this monumental year thinking about              I am able to share quite a
                                                                                                There are still many things I do
all the cases I had seen the week prior                                                    not know, so I ask for help from col-
                                               bit of knowledge and pearls
and second guessing myself about                                                           leagues, check resources, and consult
                                               I have gained along the way,
some. I ended up calling several pa-                                                       specialists. I also look back and realize
tients to check on how they were                despite only having been in                how much more I do know compared
doing, and most of them were, first,             practice for a short time.                to only several months ago. I am more
surprised I called and, second, usually                                                    confident dealing with cases and mak-
doing better, and if not, there was a             There will come a time when these        ing decisions. I was hesitant at first to
plan of what to do next. This put my         remarks no longer occur. I’m not sure         teach medical students and residents
mind at ease somewhat. The unknown           if I’m looking forward to that or not.        because I thought I would not have
is still scary, but I know it is a part of   Nonetheless, I remind myself that my          much knowledge to share, but in re-
the growing pains and transition. I’m        training has enabled me to help pa-           ality, I am able to share quite a bit of
also happy to say that my weekends           tients, so being the most professional        knowledge and pearls I have gained
are generally getting better.                and knowledgeable that I can be is the        along the way, despite only having
     Another thing I’ve noticed is the       best response. In the meantime, I may         been in practice for a short time.
many remarks on my age and expe-             as well take them as a compliment.                 This period of transition is an ex-
rience. The remarks I most often get              The one thing I did not truly come       citing time. There are finally no resi-
are, “Oh, I thought I would be see-          to understand fully until recently is that    dency requirements to fulfill but we
ing someone . . . older,” or, “You look      the learning never stops in medicine.         in turn become fully accountable for
like you are in high school!” I have         Yes, mentors and teachers told me that        our patients. To my fellow colleagues
not yet come up with a good response         they are constantly learning something        who have also recently ventured into
to these remarks, so it usually ends         new. But for some reason, when I was          practice, let’s continue to learn and
with an awkward laugh and shrug. I           in residency, the end goal seemed to be       grow together. I look forward to what
think most of the remarks come from          passing the CCFP. A small part of me          lies ahead in our careers.        —YS

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                                                                                      bc medical journal vol.   61 no. 3, april 2019 bcmj.org   107
Falling through the cracks: BC Medical Journal
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108 bc medical journal vol. 61 no. 3, april 2019 bcmj.org
Falling through the cracks: BC Medical Journal
president’s
                                                                                         comment
Are doctors territorial? When it comes to quality care, we better be
                       Being a doctor is   chelation therapy, or consuming herbs        our communities, we fiercely protect
                       no walk on the      such as kava kava. (On a side note,          against wasteful investigation, sha-
                       beach. Certainly    although language is important and           manistic treatments, and fear-pro-
                       it’s rewarding      there are historical reasons for its use,    voking propaganda. And if doing that
                       work and it’s       we ought to find another term for al-        makes us territorial, then let me be the
                       a privilege to      ternative medicine, because the alter-       first to draw a line in the sand.
                       serve others, but   native to medicine is not medicine.)                     —Eric Cadesky, MDCM,
                       recent headlines        We are also territorial in advo-                                   CCFP, FCFP
                       suggest that we     cating for our health care system,6                       Doctors of BC President
have had sand thrown in our faces:         or at least some improved form of it.
• The public is told that nurse practi-    Through initiatives like the Guide-          References
   tioners can provide the same care as    lines and Protocols Advisory Com-            1. Henning C. Nurse practitioners fill gaps as
   family doctors.1                        mittee,7 continuing education, and              family doctor shortage grows. CBC News.
• Naturopaths are legitimized through      many quality-focused organizations,             Accessed 4 March 2019. www.cbc.ca/
   funding to treat patients after a car   we do not have space for those who              news/canada/british-columbia/nurse
   accident.2                              promote unnecessary tests8 or incor-            -practitioners-filling-gaps-family-doctor
• Some pharmacists want to give a di-      rect or imaginary diagnoses.9 We rec-           -shortage-1.4565750.
   agnosis and then sell the treatment.3   ognize cultural humility10 but strive        2. ICBC. Focusing on care, not legal costs.
     Given the expected pushback           to balance that with science, even as           Accessed 4 March 2019. www.icbc
from our profession, I was recently        movements with malicious intent11               .com/about-icbc/changing-auto-insur
asked by a reporter why doctors are        aim to erode our societal constructs of         ance-BC/Pages/focus-on-care-not-legal
so territorial. My initial thought was,    science and medicine.                           -costs.aspx.
who is more collaborative than doc-            It is through this lens of advocat-      3. Ireland N. Pharmacies want to give $15
tors? We work (most importantly)           ing for our patients that we can under-         strep throat tests—but pediatricians say
with our patients and their families,      stand recent actions. We are happy to           they’re not accurate enough for kids. CBC
but also with pharmacists, kinesi-         work with nurse practitioners and do            News. Accessed 4 March 2019. www.
ologists, physio- and occupational         so in many settings, but the skills—            cbc.ca/news/health/canadian
therapists, social workers, speech and     and, quite frankly, the value—of doc-           -pharmacies-strep-throat-tests-second
language therapists, administrators,       tors are unparalleled. Pharmacists are          -opinion-1.4902431.
staff, and many other health care pro-     our medication experts and an im-            4. GPSC. Team-based care. Accessed 4
fessionals. We are asking for support      portant part of the health care team,           March 2019. www.gpscbc.ca/our-im
to develop team-based care4 so we          but the question of conflict of inter-          pact/team-based-care.
can work together complementarily          est12 diverges from the principle of         5. The College of Family Physicians of Can-
and practice to scope.5                    patient-centredness.                            ada. Best advice: Team-based care in the
     But I have further reflected on           And although much online de-                patient’s medical home. Accessed 4
this question. While we aren’t neces-      bate eventually degrades to prove               March 2019. https://bccfp.bc.ca/wp
sarily territorial over who provides       Godwin’s Law, we as doctors cannot              -content/uploads/2015/06/Team-based
care to our patients, happily sharing      stand by while some naturopaths and             -Care-in-PMH.pdf.
it with other health care professionals    functional medicine doctors encour-          6. Nguyen N, Xu Y. Healthy Debate, Opin-
in team-based settings, we are protec-     age people to pressure medical doc-             ions. Why doctors must be advocates.
tive of our patients and of the health     tors to order tests13 so that insurance         Accessed 4 March 2019. https://
care system we work in. We are ardent      will pay for it.                                healthydebate.ca/opinions/doctors
about giving the best care—one need            We enjoy serving our patients               -must-advocates.
only look at the many online forums        and putting them first. We want bet-         7. Government of BC. Guidelines and Proto-
to see how passionately doctors advo-      ter ways to collaborate in teams where          cols Advisory Committee (GPAC). Ac-
cate to protect patients from unproven     each health care professional works             cessed 4 March 2019. www2.gov.bc
or unlikely investigations and treat-      to their full scope. But when it comes          .ca/gov/content/health/practitioner
ments such as magnetic field therapy,      to the well-being of our patients and                                Continued on page 112

                                                                                   bc medical journal vol.   61 no. 3, april 2019 bcmj.org   109
Falling through the cracks: BC Medical Journal
letters
      to the editor

                                                           We welcome original letters of less than 300 words; they may be edited for
                                                           clarity and length. Letters may be emailed to journal@doctorsofbc.ca,
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                                                           All letter writers will be required to disclose any competing interests.

      Re: Cannabis use                                     are absolutely not saying that mari-            Author replies
      by adolescents                                       juana killed that child.”3                      I thank Dr Mitchell for his opinion and
      This article [BCMJ 2019;61:14-19]                        As Dr Ocana notes, it can be dif-           for standing behind the quote, “There
      would be the first in the literature to              ficult to deal with misinformation;             are biochemically distinct strains
      establish different clinical effects                 this is magnified when it is published          of cannabis, but the sativa/indica
      from C. sativa and C. indica strains.                in a medical journal. The three most            distinction as commonly applied in
      While Dr Ocana insists that clinical                 commonly held misbeliefs among                  the lay literature is total nonsense and
      research supports separating these                   physicians are that cannabis overdose           an exercise in futility.”1
      strains because of their different ef-               can be fatal, that cannabis is often                 In effect, Dr Mitchell is saying
      fects (stimulating vs sedating), the                 contaminated with fentanyl, and that            “strain does not matter.” I can’t say
      reference he provided does not sup-                  there are differences in effect between         Dr Mitchell is wrong, but it does not
      port this or even use these differing                C. indica and C. sativa strains.                align with the data we collected.
      strain names. Recent chemical analy-                           —Ian Mitchell, MD, FRCP                    Dr Mitchell proposes that my ob-
      sis of cannabis strains from Washing-                  Clinical Associate Professor, UBC             servations should be viewed more as
      ton State argues against differences in                                     Department of            results of the placebo effect in combi-
      CBD and THC between these strains.1                                  Emergency Medicine              nation with observer bias, especially
      Other cannabis scientists are in agree-                    Site Scholar, Kamloops Family             given the lack of quantification of the
      ment that these terms are better suited                     Medicine Residency Program               cannabis used.
      to marketing than clinical use: “There                                                                    I respectfully disagree. This is not
      are biochemically distinct strains of                References                                      a placebo effect. The data are based on
      Cannabis, but the sativa/indica dis-                 1. Jikomes N, Zoorob M. The cannabinoid         a retrospective chart analysis of a het-
      tinction as commonly applied in the                     content of legal cannabis in Washington      erogeneous population, in a naturalis-
      lay literature is total nonsense and an                 State varies systematically across testing   tic setting, with no exclusion criteria.
      exercise in futility.”2                                 facilities and popular consumer products.    Even after you remove the noise, our
          In Dr Ocana’s article, results are                  Scientific Reports. Accessed 26 February     observations remained statistically
      presented from a cohort interviewed                     2019. www.nature.com/articles/s41598         more likely than expected by chance.
      about their experiences with different                  -018-22755-2.                                     It seems that Dr Mitchell is sug-
      strains; however, the results should                 2. Piomelli D, Russo EB. The cannabis sativa    gesting that our observations are mis-
      be viewed more as those of the pla-                     versus cannabis indica debate: An inter-     information, worse because they are
      cebo effect in combination with ob-                     view with Ethan Russo, MD. Cannabis          published in a peer-reviewed medical
      server bias, especially given the lack                  Cannabinoid Res 2016;1:44-46.                journal. Here’s why I see it differently:
      of quantification of the cannabis used.              3. Silverman E. The truth behind the ‘first     • Before our study, from reading the
          Dr Ocana also states that deaths                    marijuana overdose death’ headlines. The        medical literature, I didn’t even
      have increased with cannabis legal-                     Washington Post. Accessed 26 February           know there were two distinct strains.
      ization. The cited reference mentions                   2019. www.washingtonpost.com/news/           • During our study, I was amazed
      only one death, that of a child who                     to-your-health/wp/2017/11/17/the-truth          how strong the signal remained,
      died of myocarditis. This case was                      -behind-the-first-marijuana-overdose            despite a possible placebo ef-
      controversial enough for the case re-                   -death/?utm_term=.5e8828886558.                 fect, observer bias, and regardless
      port’s authors to publicly clarify, “We                                                                 of the dose. Not only are the strains

110   bc medical journal vol.   61 no. 3, april 2019 bcmj.org
letters

  different, they are opposites.               needles with minute amounts of nor-             To sleep or not to sleep
• After our study, I shared my obser-          mal saline, soft tissue contractures are        One thing that endears me to the
  vations with every clinician at ev-          released.                                       BCMJ is the editor’s page. DRR
  ery conference and everybody said                I am now pain free and back to do-          writes thoughtful, often funny com-
  what Dr Mitchell said, “There is no          ing all of the activities I love to do.         ments about the world around us.
  strain difference.”                              Here are some interesting details           His December 2018 editorial, “Sleep,
    In essence, what our patients              that I picked up during my visits:              when it no longer comes naturally,”
consider a self-evident truth, that sa-        • A detailed history of all past injuries       [BCMJ 2018;60:478] was a bit of
tiva stimulates and indica sedates, is           is considered in terms of myofascial          a departure from his usually joyful
based on millennia of trial and error. It        contractures and scars.                       character, and reading it filled me
should not be a mystery to respected           • A series of standardized movement             with concern and empathy for him.
cannabis scientists. But it is. That’s           tests is used to define painful areas.        It revealed his struggle with antici-
why I knew we had to publish it.               • The most painful sites are treated            patory anxiety insomnia, wondering
    Whether this is a random finding             first, followed by re-evaluation of           each night if sleep is going to come to
or whether it represents the first stone         movements. Then the next painful              him. The last line was: “…if anyone
on the scale that measures the weight            area is treated.                              has suggestions for some good book
of evidence, only time will tell.              • Multiple cycles of injections, fol-           titles, please send them my way.”
—A.M. Ocana, MD, CCFP, ABAM                      lowed by evaluation and further in-                I asked myself, what would be
                     North Vancouver             jections, are carried out at each ap-         a good book for someone awake
                                                 pointment.                                    enough in the middle of the night to
Reference                                      • Tissue realignment takes place the            want to read, but anxious enough to
1. Piomelli D, Russo EB. The cannabis sativa     first few days after treatment, fol-          hope to get back to sleep?
   versus cannabis indica debate: An inter-      lowed by stabilization.                            I scanned my list of 117 BC
   view with Ethan Russo, MD. Cannabis             The technique was pioneered by              physician authors on www.abcbook
   Cannabinoid Res 2016;1:44-46.               Dr Greg Siren,1 a family physician                                        Continued on page 112
                                               with a focused practice in chronic
MyoActivation for the                          pain in Victoria, BC.
treatment of pain & disability                     At the time I write this letter, myo-
Chronic musculoskeletal pain is com-           Activation is also available in Van-                    Seeing my data has
mon in our society. One in five people         couver at the CHANGEpain Clinic,                       given me confidence
suffer with chronic pain in Canada.            the Downtown Community Health                          and a sense of pride.
We need alternatives to pharmaco-              Centre (Downtown Eastside), and the
                                                                                                                   DR STEPHANIE AUNG
logic interventions that are cost ef-          Complex Pain Service at BC Chil-                           Family Doctor, New Westminster
fective, safe, and available to most           dren’s Hospital. It has been shown to
patients. Ideally, these alternatives          be effective in treating chronic pain
would be covered by MSP. Most im-              originating in the soft tissues in the
portantly, alternative treatments could        elderly as well as children.
decrease our reliance on opiates.                  I hope this letter raises awareness
    I am a retired family physician            about this technique. It can be prac-
who underwent right hip replacement            tically delivered in primary care pa-
surgery in 2018. I was skeptical when          tient encounters and could be part of
a colleague suggested I try myoAc-             a multi­disciplinary approach to treat-
tivation during my rehabilitation. A           ment of chronic musculoskeletal pain.
compensatory flexion and adduction             —Suzanne Montemuro, MD, CCFP
contracture of my right hip was slow-                                          Victoria
ing my recovery. I also had weak hip                                                                     Join physicians across BC who
                                                                                                           are using their EMR data for
abductors, hamstrings, and gluteus             Reference
                                                                                                        self-reflection. Learn more and
muscles.                                       1. Lauder G, West N, Siren G. MyoActiva-                         enrol at hdcbc.ca/enrol.
    What is myoActivation? It is a re-            tion: A structured process for chronic
fined injection technique that targets            pain resolution. IntechOpen. Accessed 5
damaged fascia, scars, and other trig-            March 2019. www.intechopen.com/on
ger points in the body. Using multiple            line-first/myoactivation-a-structured-pro
needling with hollow bore cutting                 cess-for-chronic-pain-resolution.

                                                                                          bc medical journal vol.   61 no. 3, april 2019 bcmj.org   111
letters                                                                                                                                                     comment

      Continued from page 111                                                       Trip across Canada:1862–1863                                            Continued from page 109
      world.com, and looked for diaries,                                          Duncan AC. Medicine, Madams,                                                  -professional-resources/msp/commit
      novels, short stories, historical sto-                                        and Mounties: Stories of a Yukon                                            tees/guidelines-and-protocols-advisory
      ries, poetry, and theatrical plays                                            Doctor                                                                      -committee-gpac.
      published between the early 1800s                                           Emmott K. How Do You Feel?                                                8. Carroll AE. The JAMA Forum. The high
      and recent times. I looked for read-                                          (1992 poetry collection)                                                    costs of unnecessary care. Accessed 4
      ing material that was relatively slow                                       Karlinsky H. The Evolution of                                                 March 2019. https://jamanetwork.com/
      paced, interesting but not exciting or                                        Inanimate Objects: The Life                                                 journals/jama/fullarticle/2662877.
      anxiety provoking, and long enough                                            and Collected Works of Thomas                                           9. Abassi L. American Council on Science
      to get sleepy—or bored—while                                                  Darwin (1857–1879)                                                          and Health. Your adrenals are not fa-
      reading it.                                                                 Kenyon A. The Recorded History of                                             tigued, you are. Accessed 4 March
          Here are 10 books I recommend,                                            the Liard Basin, 1790–1910                                                  2019. www.acsh.org/news/2017/09/05/
      written by some of our physician                                            Lee E. Scalpels and Buggywhips                                                your-adrenals-are-not-fatigued-you
      colleagues, in alphabetical order by                                        Leighton K. Oar and Sail: An                                                  -are-11782.
      author:                                                                       Odyssey of the West Coast                                               10. Doctors of BC. Supporting cultural safe-
      Burris HL. Medical Saga: The                                                Swan A. House Calls by Float                                                  ty for First Nations. Accessed 4 March
        Burris Clinic and Early Pioneers                                            Plane: Stories of a West Coast                                              2019. www.doctorsofbc.ca/news/sup
      Cheadle WB. Cheadle’s Journal of                                              Doctor                                                                      porting-cultural-safety-first-nations.
                                                                                  Tolmie WF. The Journals of                                                11. Griffin A. The Independent. Anti-vaccine
                                                                                    William Fraser Tolmie: Physician                                            myths are being promoted by social me-
        Doctors                                                                     and Fur Trader                                                              dia bots and Russian trolls, study finds.
        Helping                                                                       Dear Dr DRR, have a good read                                             Accessed 4 March 2019. www.inde
                                                                                  and a good sleep!                                                             pendent.co.uk/life-style/gadgets-and
        Doctors
                                                                                           —George Szasz, CM, MD                                                -tech/news/anti-vaccine-vaxx-bots
        24 hrs/day,                                                                                   West Vancouver                                            -russian-trolls-twitter-facebook-study
        7 days/week                                                                                                                                             -a8505271.html.
                                                                                  Thank you for your concern, and                                           12. Wilson JA. Pharmacist prescribing:
        Call at                                                                   I really appreciate your book                                                 Good medicine? BCMJ 2007;49:52-54.
        1-800-663-6729 or                                                         suggestions.—Ed.                                                          13. Cole W. Dr Will Cole: The future of natu-
        visit www.physicianhealth.com.                                                                                                                          ral healthcare. These are the 6 labs you
                                                                                  This letter originally appeared as a BCMJ                                     need to run if you are feeling off. Ac-
                                                                                  blog post. Visit www.bcmj.org/blog to                                         cessed 4 March 2019. https://drwillcole
                                                                                  read all of our posts, and consider sub-                                      .com/these-are-the-6-labs-you-need-to
                                                                                  mitting your own.                                                             -run-if-you-are-feeling-off.

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© 2019 Canadian Medical Association                               bc medical journal vol.   61 no. 3, april 2019 bcmj.org   113
Erika Ono, MSW, RSW, Robin Friedlander, MD, FRCPC, Tamara Salih, MD, FRCPC

                                                           Falling through the cracks:
                                                           How service gaps
                                                           leave children with
                                                           neurodevelopmental disorders
                                                           and mental health difficulties
                                                           without the care they need
                                                           Four clinical vignettes illustrate the challenges faced by families of
                                                           children with a dual diagnosis in British Columbia and demonstrate
                                                           the need for a wraparound approach to service delivery.

                                                                                                    T
      ABSTRACT: Children with neuro-                       the specifics of the diagnoses, chil-            he Diagnostic and Statisti-
      developmental disorders are at in-                   dren may be eligible for community               cal Manual of Mental Disor-
      creased risk of developing mental                    support services, outpatient mental              ders (Fifth Edition) defines
      health difficulties, and when neu-                   health services, and inpatient psy-      neurodevelopmental disorders as “a
      rodevelopmental and psychiatric                      chiatry services. However, because       group of conditions with onset in the
      disorders do co-occur, children and                  of system fragmentation and insuf-       developmental period. The disorders
      their families frequently face mul-                  ficient collaboration and commu-         typically manifest early in develop-
      tiple barriers as they try to access                 nication, obtaining these services       ment, often before the child enters
      services and resources. A literature                 can be challenging and many chil-        grade school, and are characterized
      review indicates that there is a lack                dren are falling through the cracks.     by developmental deficits that pro-
      of specialized mental health servic-                 Four clinical vignettes illustrate how   duce impairments of personal, social,
      es for patients with a dual diagnosis,               children and their families trying to    academic, or occupational function-
      and the resulting inadequate level of                access support face barriers, includ-
      community supports has placed the                    ing bureaucratic processes, lack of      Ms Ono is a PhD candidate and sessional
      burden of care on families. Services                 respite, out-of-home service obsta-      lecturer in the School of Social Work at the
      for children in BC with a dual diagno-               cles, and limited specialized training   University of British Columbia, an evalua-
      sis are delivered by different agen-                 for care providers. Policy changes       tion specialist at the Centre for Health Eval-
      cies and programs, primarily under                   are needed to ensure a wraparound        uation and Outcome Sciences, and a social
      the Ministry of Children and Fam-                    approach to care based on integra-       worker at BC Children’s Hospital Psychiatry
      ily Development and the province’s                   tive interagency and cross-agency        Department. Dr Friedlander is clinical head
      health authorities. Depending on                     practices.                               of the Neuropsychiatry Clinic at BC Chil-
                                                                                                    dren’s Hospital. He is also a clinical profes-
                                                                                                    sor in the UBC Department of Psychiatry
                                                                                                    and director of the Developmental Disor-
                                                                                                    ders Program. Dr Salih is a psychiatrist in
                                                                                                    the Mood and Anxiety Disorders Clinic and
                                                                                                    the Neuropsychiatry Clinic at BC Children’s
                                                                                                    Hospital. She is also a clinical instructor in
      This article has been peer reviewed.                                                          the UBC Department of Psychiatry.

114   bc medical journal vol.   61 no. 3, april 2019 bcmj.org
Falling through the cracks: How service gaps leave children with
                    neurodevelopmental disorders and mental health difficulties without the care they need

ing. There is a wide range of de-         disabilities in the community. In this           In addition to making access to
velopmental deficits that vary from       process specialized psychiatric care         specialized mental health services
very specific limitations of learning     diminished.4 Individuals with a co-          difficult, the inadequate level of com-
or control of executive functions to      occurring neurodevelopmental dis-            munity supports in general has placed
global impairments of social skills or    order and mental health difficulties         the burden of care on families. “Car-
intelligence.”1 Major neurodevelop-       could only access generic mental             ing for a child with a disability can be
mental disorders include intellectual     health services in a system not set up       a demanding experience, taxing both
disability (ID), autism spectrum dis-     for easy access to these services. The       the physical and emotional capacities
order (ASD), fetal alcohol spectrum       “generic [mental] health care model,         of the caregiver, as well as the material
disorder (FASD), and genetic condi-       combined with no national guidelines         resources of the family.”8 Challenges
tions such as Prader-Willi, fragile X,    and provincially determined services         include increased caregiver physical
and Down syndrome. Children with          shared by two distinct ministries has        and psychological stress, family dis-
neurodevelopmental disorders are at       translated into poorly coordinated           tress, reduced marital satisfaction,
increased risk of developing mental       care for individuals with intellectual       and inadequate social supports for
health difficulties, with 39% of chil-    disabilities and mental health needs         parents of these children.9 Research
dren with a neurodevelopmental dis-       in Canada.”5 These systemic issues           indicates the need for adequate re-
order requiring mental health services    have “led to misdiagnoses, inappro-          spite (“short-break residential servic-
compared with 14% of children in the      priate treatments and over-reliance on       es”); availability of additional respite
general population.2                      psycho-pharmacological interven-             services in emergencies; accessible
    Children with a dual diagnosis        tions.”6 As Ouelette-Kuntz states,           out-of-home placements; flexibil-
and their families frequently face        “Individuals with mental health prob-        ity in eligibility and service delivery;
multiple barriers when trying to ac-      lems and ID experience ‘double stig-         shorter waiting lists; psychoeduca-
cess support services. Service de-        ma’. . . . Persons with ID and mental        tional support groups for parents;
livery in BC is fragmented, with          health issues are often considered           peer mentoring; on-site health clinics
the health authorities and different      inappropriate for traditional ID com-        for caregiver accessibility, cultural
agencies, programs, and contractors       munity integrated services because           sensitivity; and streamlining, coordi-
providing various kinds of care and       of their psychiatric difficulties but        nation, and centralization of servic-
funding, primarily through the Min-       are also considered inappropriate for        es.10-12 Furthermore, as Goddard and
istry of Children and Family Devel-       usual mental health services because         colleagues note in their study of sto-
opment (MCFD). Service gaps have          of their low IQ. Adding to this stigma       ries collected from parents, “Perhaps
resulted from this model, similar to      is the lack of knowledge of mental           the most persistently troubling system
those seen across Canada (oral com-       health professionals with regard to          for these parents was that of the bu-
munication from V. Dua, psychia-          this population because of deficien-         reaucracy. . . . Parents expressed their
trist-in-chief, Surrey Place [Toronto,    cies in training and the existing barri-     frustrations about how they have re-
Ontario], 7 July 2017).                   ers to practice in this area.”6              ceived the bureaucratic ‘runaround,’
                                              The attempt to integrate individu-       especially from the social welfare
Literature review                         als with neurodevelopmental disor-           system. . . . They described a system
In BC before the 1990s, children          ders into their communities has led          that compartmentalized, that regular-
with neurodevelopmental disorders         to them being “segregated once again         ized, and that fostered fear, confusion,
received services through three insti-    by a failure to address their special-       and frustration.”13
tutions: Woodlands, Tranquille, and       ized medical needs.”6 Social margin-
Glendale. In 1981 the BC government       alization cannot be addressed solely         Current services
announced plans to close all three in-    by a shift to community care. The            Services for children in BC with a
stitutions. This plan was implemented     “work of deinstitutionalization does         dual diagnosis are delivered by differ-
over the next 15 years, with Wood-        not stop at transferring participants        ent agencies and programs. Children
lands3 officially closing in 1996.        into the community. . . unless relo-         may be eligible for a variety of com-
    Following deinstitutionalization,     cation brings with it a fundamental          munity support services, outpatient
services became de-medicalized and        change in the [quality of life] of par-      mental health services, and inpatient
more importance was placed on inte-       ticipants, it creates only an illusion of    psychiatry services, depending on the
grating individuals with intellectual     deinstitutionalization.”7                    specifics of their diagnoses.

                                                                                  bc medical journal vol.   61 no. 3, april 2019 bcmj.org   115
Falling through the cracks: How service gaps leave children with
                                 neurodevelopmental disorders and mental health difficulties without the care they need

      Assessment services for                              outpatient medical psychology de-                      is private fee-for-service psychology
      neurodevelopmental disorders                         partment. Some psychological assess-                   clinics. Assessments for genetic con-
      Regional health authorities in part-                 ments are also conducted in child and                  ditions are undertaken by hospital-
      nership with Provincial Health Ser-                  adolescent inpatient psychiatry units                  based services, including pediatrics,
      vices provide multidisciplinary                      across the province, and a smaller                     medical genetics, metabolic diseases,
      assessments for autism spectrum                      number in the BC Children’s Hospi-                     and neurology.
      disorder and fetal alcohol spectrum                  tal outpatient psychiatry clinics. As-
      disorder through the BC Autism As-                   sessment for intellectual disability is                Community support services
      sessment Network (BCAAN) and                         done mainly through psychoeduca-                       The Ministry of Children and Family
      the Complex Developmental Be-                        tional assessments at schools; how-                    Development provides commun-
      havioural Conditions (CDBC) pro-                     ever, these resources are limited and                  ity support services for a range of
      gram ( Figure 1 ). In addition, a small              many children with intellectual dis-                   neurodevelopmental and psychiatric
      number of children are assessed at                   ability are not assessed during child-                 disorders ( Figure 2 ).
      BC Children’s Hospital through the                   hood. The other option for assessment

           Autism spectrum disorder               Fetal alcohol spectrum              Intellectual disability (ID)             Genetic conditions
           (ASD)                                  disorder (FASD)                     Psychoeducational                        Hospital-based assessment
           BC Autism Assessment                   Complex Developmental               assessment at school or                  through pediatrics, medical
           Network (BCAAN) or private             Behavioural Conditions              private psychology clinic or             genetics, metabolic
           psychology clinic                      (CDBC) Network                      as part of ASD or FASD                   diseases, or neurology
                                                                                      assessment                               services

       Figure 1. Assessment services for neurodevelopmental disorders.

                                                                   Ministry of Children and Family
                                                                       Development (MCFD)

                                                                                                     Key Worker and Parent
                                Children and Youth with Special Needs (CYSN) division
                                                                                                     Support Program
                                For children with a variety of needs, including autism
                                                                                                     For children with fetal alcohol
                                spectrum disorder (ASD) and intellectual disability (ID)
                                                                                                     spectrum disorder (FASD)

                    Autism Funding             ASD or ID services                          At Home Program
                    program                    Respite resources, behavioral               Medical and/or respite resources
                    Behavioral                 consultant services, child and              for children dependent in at least
                    intervention               youth care worker services                  three of four functional activities of
                    resources                  (depending on need and availability         daily living (eating, dressing,
                                               of resources in community)                  toileting, washing)

       Figure 2. Community support services.

116   bc medical journal vol.   61 no. 3, april 2019 bcmj.org
Falling through the cracks: How service gaps leave children with
                      neurodevelopmental disorders and mental health difficulties without the care they need

Children and Youth with Special                   Funding program, which provides                  understand fetal alcohol spectrum
Needs (CYSN). Most of the servi-                  support for intervention services:               disorder by providing education and
ces for children with autism spectrum             $22 000 annually for children under              information specific to the needs of
disorder and intellectual disability are          age 6 (early intervention) and $6000             the child and family. They also help
delivered through the Children and                annually for children age 6 to 18.               families access support, health, and
Youth with Special Needs division of                                                               education services for the child. Local
MCFD.14 Services are often delivered              At Home Program. The At Home                     parent support agencies provide par-
by contracted agencies or individual              Program provides medical and/or                  ent and grandparent FASD training
care providers. Families receive sup-             respite benefits to assist parents with          and parent mentoring sessions, and
port services for children with autism            the costs of caring for a child with             sponsor parent support groups.
spectrum disorder and/or intellectual             severe disabilities at home. To be eli-
disabilities, which can include direct-           gible for the program, children must             Outpatient mental health
funded respite, contracted respite,               be dependent in at least three of four           services
respite relief, homemaker/home sup-               functional activities of daily living            Outpatient services are provided pri-
port, behavioral support, child and               (eating, dressing, toileting, washing),          marily by divisions of the Ministry of
youth care worker support, and parent             have a palliative condition, or meet             Children and Family Development
support. The availability of services             the requirements for direct nursing              and the province’s health authorities
is dependent on which programs are                care provided by provincial Nursing              ( Figure 3 ). In addition, some services
running through contracted agencies,              Support Services.                                are provided by private practitioners
which varies from one location to                                                                  such as psychologists and counselors.
another. Children with ASD receive                Key Worker and Parent Support
additional services under the Autism              Program. Key workers help families

                            Examples of challenges addressed:                                               Private practitioners
                anxiety, depression, attention deficit hyperactivity disorder,                           Psychologists, counselors,
                   aggression, self-injurious behavior, unsafe behavior                                  psychiatrists, pediatricians,
                                                                                                           clinical social workers

               Ministry of Children and Family
                                                                                              Health authorities
                   Development (MCFD)

   Children and       Family support        Child and Youth       Developmental    Provincial            Fraser Health          Island Health
   Youth with         and child pro­        Mental Health         Disabilities     Health Services       Child and Youth        Anscomb
   Special Needs      tection services      (CYMH)                Mental Health    Neuro­                Neuro­                 Program Neuro­
   (CYSN)             Emergency             Mental health         Services         psychiatry            psychiatry             development
   Additional         respite if the        services              Services         Clinic at BC          Clinic at Surrey       Team at Queen
   respite,           child/youth is not                          specific to      Children’s            Memorial               Alexandra
   overnight          eligible through                            children with    Hospital              Hospital               Centre for
   respite            CYSN and there                              intellectual                                                  Children’s
                      are safety                                  disabilities                                                  Health
                      concerns

Figure 3. Outpatient services for patients with mental health and/or behavioral challenges.

                                                                                              bc medical journal vol.   61 no. 3, april 2019 bcmj.org   117
Falling through the cracks: How service gaps leave children with
                                 neurodevelopmental disorders and mental health difficulties without the care they need

      Child and Youth Mental Health                         Developmental Disabilities Men­                 Centre for Children’s Health (Island
      (CYMH). Child and Youth Mental                        tal Health Services. Developmental              Health). The neuropsychiatry and
      Health delivers psychiatric services to               Disabilities Mental Health Services             neurodevelopment teams working at
      children up to age 18. However, this                  is operated by regional health author-          these centres provide assessments and
      service does not provide specialized                  ities to provide specialized mental             limited treatment.
      care for children with a dual diagno-                 health care for youth with co-occur-
      sis. If children with neurodevelop-                   ring intellectual disability and mental         Inpatient psychiatry and
      mental disorders are assessed as “too                 health or behavioral challenges. This           residential services
      severe” or “low functioning,” they are                unique program offers psychiatric               Inpatient psychiatry and residential
      often denied mental health services,                  assessments and treatment, clinical             services are provided by the Ministry
      regardless of mental health concerns                  counseling, music and art therapy,              of Child and Family Development,
      or diagnosed psychiatric comorbid-                    and case management. Eligibility                health authorities, and Community
      ities. Since 2014 the referral process                requirements include a diagnosis of             Living BC (CLBC) ( Figure 4 ). Two
      for Child and Youth Mental Health                     intellectual disability accompanied             child inpatient/day programs and sev-
      has changed to primarily self-refer-                  by severe mental health difficulties.           eral adolescent inpatient psychiatry
      rals. Unfortunately, this has created                 Services are available to individuals           units operate across the province.
      obstacles for many families who are in                starting at age 12 in the Lower Main-           However, there are no specialized in-
      crisis and find applying for services to              land and Vancouver Island and age 14            patient psychiatry units for children
      be challenging. Moreover, most Child                  in the rest of the province.                    and youth with a dual diagnosis.
      and Youth Mental Health offices of-
      fer drop-in intake sessions for only                  Health authority neuropsychiatry                Residential group homes. When
      a few hours 1 day a week. This can                    services. Outpatient child and youth            families are struggling to care for
      create additional barriers for parents                neuropsychiatry services are pro-               their children, placement in a group
      of children with neurodevelopmental                   vided at clinics in three tertiary care         home may be required. To obtain
      disorders, families with English as a                 centres: BC Children’s Hospital                 residential care, parents must apply to
      second language, working parents,                     (Provincial Health Services Author-             the Ministry of Children and Family
      single parents, and families without                  ity), Surrey Memorial Hospital (Fra-            Development. They must then sign a
      transportation.                                       ser Health), and the Queen Alexandra            Special Needs Agreement or a Volun-

                            Ministry of Children and Family                                                              Community Living BC
                                                                                       Health authorities
                                Development (MCFD)                                                                            (CLBC)

           Residential group homes                  Complex care program               Child or adolescent             Inpatient assessment
           Provided by contracted                   Provided at Maples                 inpatient psychiatry units      facility
           agencies organized through               Adolescent Treatment Centre        Hospital-based services         Provincial Assessment
           Children and Youth with                  for individuals age 7 to 18 with   such as the Child and           Centre (PAC) for individuals
           Special Needs or child                   health, developmental, and/or      Adolescent Psychiatric          age 14 and older with
           protection services under a              behavioral needs that affect       Emergency (CAPE) unit at        intellectual disabilities and
           Voluntary Care Agreement or              their ability to function in the   BC Children’s Hospital          mental health or behavioral
           Special Needs Agreement                  routine of daily life                                              challenges

       Figure 4. Inpatient psychiatry and residential services.

118   bc medical journal vol.   61 no. 3, april 2019 bcmj.org
Falling through the cracks: How service gaps leave children with
                    neurodevelopmental disorders and mental health difficulties without the care they need

tary Care Agreement, which places         Alex                                         tion program. The psychiatrist has
the child in the care of the ministry.    Alex is a 13-year-old male with fetal        also recommended respite care and
Families have no options for long-        alcohol spectrum disorder, attention         counseling for Alex’s mother.
term out-of-home care that does not       deficit hyperactivity disorder, post-
require going through Children and        traumatic stress disorder, and a specif-     Gaps in services. Multiple obstacles
Youth with Special Needs or child         ic learning disorder in reading and          have made it difficult to move for-
protection services and giving up care    written expression. Alex lives with          ward with the psychiatrist’s recom-
of their child. Group homes typically     his adoptive mother, who is a single         mendations. Because Alex has an
do not have mental health staff.

Complex care program. The Maples
Adolescent Treatment Centre of-
fers residential care for children with
mental health concerns and troubling
behavior. A complex care program for
                                                      There are two distinct patient populations:
children age 7 to 18 includes individ-                in one the children have few comorbidities
ual treatment and service plans.
                                                        and need limited specialized intervention
Provincial Assessment Centre                         and support, while in the other the children
(PAC). The Provincial Assess-
ment Centre is a designated tertiary
                                                    have significant mental health comorbidities
psychiatric service under the Men-                         and sometimes extremely challenging
tal Health Act, mandated to provide
multidisciplinary assessment and
                                                           behaviors that require intervention for
treatment for individuals age 14 and                       which funding is not readily available.
older with an intellectual disability
and concurrent mental health and/or
behavioral challenges. PAC is part
of Community Living BC, the prov-
incial Crown corporation that funds
and supports services to adults with      parent and has her own mental health         IQ of 84 he is not eligible for servi-
developmental disabilities, autism        struggles. She currently receives in-        ces through Children and Youth with
spectrum disorder, and fetal alcohol      come assistance as a person with dis-        Special Needs, which requires an IQ
spectrum disorder.                        abilities. Over time, the behavioral         of 70 or less when defining intellec-
                                          difficulties stemming from Alex’s            tual disability. Had he met this eligi-
Clinical vignettes                        multiple diagnoses (temper outbursts,        bility requirement, the family could
The following clinical vignettes are      aggression toward his mother and             have benefited from respite care and
fictionalized amalgamations of pa-        peers, stealing) have led to caregiver       the services of a child and youth care
tient symptoms and systemic barriers      burnout.                                     worker and a behavioral consultant.
commonly seen at tertiary outpatient                                                   Alex is also not eligible for care under
neuropsychiatry clinics in British        Services accessed and recom­                 Developmental Disabilities Mental
Columbia. The vignettes do not rep-       mended. The family has access to a           Health Services because he does not
resent actual patients. They have been    community key worker and a psych-            meet that agency’s requirements for
included to illustrate the recurring      iatrist at a tertiary outpatient neuro-      intellectual disability either. Alex’s
issues and gaps in services that chil-    psychiatry clinic. The psychiatrist has      mother, supported by the neuropsych-
dren with a dual diagnosis and their      recommended Alex receive ongoing             iatry clinic, had previously called the
families experience.                      treatment in the community to mon-           Ministry of Children and Family De-
                                          itor his medications and see a therapist     velopment and asked to be considered
                                          for emotional regulation and a behav-        for respite and other support services.
                                          ioral consultant to design an interven-      She was told that because there were

                                                                                  bc medical journal vol.   61 no. 3, april 2019 bcmj.org   119
Falling through the cracks: How service gaps leave children with
                                 neurodevelopmental disorders and mental health difficulties without the care they need

      “no child protection concerns” the                   iatrist at a tertiary outpatient neuro-     neuropsychiatry clinic and receives
      ministry would not open a file, even                 psychiatry clinic for consultation and      benefits through the Autism Funding
      though the MCFD does open files                      short-term treatment. The psychiatrist      program. Previously, community-
      for family support services as well                  has recommended that Leo receive            based consultants who were not ex-
      as child protection services. She then               support from a behavioral consultant        perts in self-injurious behavior were
      used the self-referral intake process                and behavioral interventionist and be       contracted by Children and Youth
      for Child and Youth Mental Health                    started on medication and monitored         with Special Needs to provide in-
      to access required mental health ser-                in the community.                           home behavioral consultation and
      vices for ongoing therapy and medi-                                                              intervention. These interventions did
      cation management for Alex and was                   Gaps in services. Because Leo does          not change Emily’s behaviors. For
      refused services. The reason given                   not have a diagnosis for autism spec-       the past 2 years Emily’s psychiatrist
      was Alex’s diagnosis of fetal alcohol                trum disorder he is not eligible for        has been strongly recommending she
      spectrum disorder. Because of this                   the Autism Funding program, which           see a behavioral consultant skilled
      diagnosis, Alex’s co-occurring men-                  would cover the cost of a behavioral        in managing self-injurious behavior
      tal health conditions were discounted.               interventionist to implement a treat-       and be considered for placement in
                                                           ment plan developed by a behavioral         a residential facility specializing in
      Leo                                                  consultant. Leo cannot be referred to       challenging behaviors. As the behav-
      Leo is an 11-year-old male with Pra-                 Child and Youth Mental Health to ad-        iors continue and worsen, the mental
      der-Willi syndrome, a rare genetic                   dress his mental health concerns be-        health of Emily’s parents is precipi-
      disorder affecting chromosome 15.                    cause his clinical needs require more       tously declining and their marriage is
      Individuals with this diagnosis com-                 than the services of a general mental       under heavy strain. One parent is un-
      monly have insatiable appetite, de-                  health clinician, and he cannot ac-         able to continue working because of
      velopmental and cognitive delays,                    cess a psychiatrist through Child and       the constant care Emily requires.
      hypogonadism, and behavioral and                     Youth Mental Health without seeing
      psychiatric difficulties. Leo has an IQ              a clinician first. In addition, he is un-   Gaps in services. Lack of communi-
      of 67, placing him in the mild intellec-             able to access a psychiatrist through       cation from Children and Youth with
      tual disability range. Leo engages in                Developmental Disabilities Mental           Special Needs initially delayed secur-
      chronic skin-picking and self-harm,                  Health Services because he is young-        ing appropriate supports for Emily.
      typical of the behavioral phenotype                  er than 12, and a private child psych-      While her family now receives bene-
      associated with Prader-Willi syn-                    iatrist will not accept the referral.       fits through the Autism Funding pro-
      drome. He also inserts objects into                                                              gram, the $6000 per year provided
      his rectum and smears feces over his                 Emily                                       does not cover the interventions she
      body, stabs his wounds with sharp                    Emily is a 9-year-old female with           needs. Also, despite the very obvious
      objects, and fills them with dirt. His               autism spectrum disorder, moderate          challenges Emily’s parents face, they
      parents have often had to stay up all                intellectual disability, separation anx-    have had to continuously and tire-
      night to prevent him from worsening                  iety disorder, and Tourette syndrome.       lessly assert their needs and advocate
      the multiple self-inflicted wounds on                Emily must wear a helmet, gloves,           for their child. An additional issue
      his body. Leo exhibits impulsive be-                 and knee pads because of her severe         for this family has been the require-
      haviors and is a flight risk. Leo’s par-             self-injurious behavior. Her parents        ment to sign a Special Needs Agree-
      ents are overwhelmed by managing                     have had to stand by helplessly while       ment for residential treatment, which
      the difficult behaviors associated with              Emily bruises and batters her head          involves relinquishing care of their
      his neurodevelopmental disorder and                  and face. Despite multiple trials of        child to CYSN. This is a difficult step
      co-occurring psychiatric problems.                   medication by several psychiatrists         for the family to take, but is the only
                                                           and community-based behavioral              way to access a specialized residential
      Services accessed and recom­                         interventions, Emily’s self-injurious       program.
      mended. The family has access to                     behavior is worsening.
      Children and Youth with Special                                                                  Harpreet
      Needs services because Leo’s IQ is                   Services accessed and recom­                Harpreet is a 14-year-old female with
      less than 70. Leo has an education                   mended. Emily is under the care of          moderate intellectual disability. Her
      assistant at school and sees a psych-                a psychiatrist at a tertiary outpatient     comorbidities include epilepsy, anx-

120   bc medical journal vol.   61 no. 3, april 2019 bcmj.org
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