Aggregate Report Provides Valuable Snapshot of B.C. Youth At Risk of Suicide and Self-harm

For Immediate Release
November 15, 2012

Chronic instability at home, mental health issues and unaddressed trauma are among the common experiences of British Columbia youth at risk of suicide or self-injury, shows a report released today by the Representative.

The aggregate review of 15 B.C. youth who committed suicide and 74 who selfinjured over a three-year period beginning in June 2007 also reveals varying degrees of compliance with Ministry of Children and Family Development (MCFD) practice

standards as well as a significant over-representation of Aboriginal children. All of the youth who were part of this review received services from MCFD in the year prior to their suicide or self-harm incident.

“This report is not intended to assign blame, as not all suicides or serious injuries are preventable,” said Representative Mary Ellen Turpel-Lafond. “However, the youth whose life circumstances were examined for this report had a long history of
involvement with MCFD which means, for most, there were many opportunities to improve chances of a positive outcome – opportunities that were too often missed.”

Trauma, Turmoil and Tragedy: Understanding the Needs of Children and Youth at Risk of Suicide and Self-Harm is the Representative’s second aggregate review. Such reports are based on data from files and other administrative records that provide a broad overview of a group rather than specific information about individuals. These aggregate reports are intended to identify trends in order to help improve B.C.’s child-serving system and inform public policy. The full report is at

Instability was a significant factor for most of the youth in this report. Of the 89 youth whose files were reviewed, 58 were in care of MCFD at the time of the incident reported to the Representative. Those 58 youth experienced a combined total of 776 moves while in care. Five of them had each been moved more than 30 times.

Research shows frequent moves can further traumatize already vulnerable children; therefore the Representative recommends that MCFD develop clear strategies to reduce the number of moves and disruptions experienced by children in care.

“The youth in this review who had been in care had experienced an average of a dozen moves while in care,” Turpel-Lafond said. “This level of instability in the lives of these vulnerable youth contributes to their inability to form positive social
attachments and the meaningful relationships necessary to thrive.”

The youth in this report had commonly been subject to trauma. Despite domestic violence being a factor in more than half the files reviewed for this report, it does not appear that issues such as grief, loss, or recovery from violence are a primary
consideration when children first come into care or receive MCFD services.

The Representative recommends that MCFD take steps to address trauma experienced by these children, including conducting a thorough assessment whenever a child is taken into care in order to identify past trauma and plan services to address its effects.

This report does not repeat recommendations made by the Representative in previous reports. A number of those recommendations remain unfulfilled (see Backgrounder). But the Representative requests that government act on those recommendations and also begin to report regularly on outcomes for children in care. “I urge the Minister to commit to that reporting for all children in care, including Aboriginal children, and to indicate when my office and the public can expect to receive the first report.”

The Representative is concerned that 58 per cent of the youth in this review were Aboriginal. While acknowledging the strength of Aboriginal communities and the challenges they face, she said more must be done to build capacity and ensure these communities have necessary resources to help their children.

Mental health issues were identified for nearly 70 per cent of the youth. The Representative is completing a comprehensive review of Child and Youth Mental Health services, with further recommendations, to be released in the coming months.

“The lack of clarity of mental health systems and services for youth in the province is concerning,” Turpel-Lafond said. “It is not always clear which youth are eligible for which services and under what conditions they will be admitted.”

Lack of attachment to school was another common finding – less than half the youth attended school regularly. Romantic conflict was also a recurring theme – about one-third of the youth experienced this type of conflict shortly before their incident.

The report shows that compliance with MCFD practice standards varied from file to file and within individual files. Comprehensive Plans of Care (CPOC) were current in only 69 per cent of the files. More than one-quarter of Aboriginal children in care did not have a CPOC and fewer than half were in an Aboriginal placement. In the coming months, the Representative will also release a comprehensive audit of plans of care.

“This is a situation that must improve,” Turpel-Lafond said. “When government takes a child into care, it assumes a great responsibility and it must fulfill that responsibility by adhering to justifiably rigorous practice standards to protect the most vulnerable.”


In previous reports, the Representative has made a number of recommendations that address issues faced by the youth in this aggregate review. The following pertinent past recommendations made by the Representative have yet to be fully implemented:

Supporting Children in Care
• That whenever a child or youth in care or in the Children in the Home of a Relative program has more than three changes in placement outside of the parental home within one 12-month period, a report is made to the Regional Director of Integrated Practice. (Recommendation 1, from Kids, Crime and Care, Health and Well-Being of Children in Care: Youth Justice Experiences and Outcomes, February 2009)
• That MCFD revise existing policies and practices to ensure that specialized training, appropriate supports and resources are available to foster parents and adoptive parents, to support and care for children with mental health and behavioural issues. (Recommendation 2, from Kids, Crime and Care, Health and Well-Being of Children in Care: Youth Justice Experiences and Outcomes, February 2009)

Supporting Families
• That the Government of British Columbia engage the Federal Government and First Nations leadership and communities to develop a plan to reduce Aboriginal child and family poverty in B.C. This plan must include concrete measures and policies, and provide for resources and monitoring of progress. (Recommendation 1(b) from Housing, Help and Hope: A Better Path for Struggling Families, July 2009)
• That MCFD, working with the delegated Agencies and partners in Aboriginal child welfare, including the Federation of Aboriginal Foster Parents, develop and implement an aggressive strategy throughout the province to recruit, assess, qualify, retain and monitor Aboriginal foster homes. (Recommendation 3(a) from Housing, Help and Hope: A Better Path for
Struggling Families, July 2009)
• That MCFD, starting with (the North) region as a model and eventually province-wide, develop a routine mechanism for tracking and reporting on efforts to find Aboriginal placements for each Aboriginal child that comes into care. Such recording and reporting is necessary to be able to demonstrate improvement over time. (Recommendation 3(b) from Housing, Help and Hope: A Better Path for Struggling Families, July 2009)

Supporting the Child-Serving System
• That MCFD immediately take steps to strengthen its audit program and report to the Representative for Children and Youth on progress . . .(Recommendation 6 from Amanda, Savannah, Rowen and Serena: From Loss to Learning, April 2008)

Note: Comprehensive and detailed reporting of services provided, especially for children in care or those living out of the parental home, is essential in order for MCFD to build public confidence. The Hughes Review (2006) called for such reporting in Recommendation 23. Such regular (annual or more frequent) reporting should include moves in care, education outcomes, participation in early childhood education, health status, contact with the justice system, recurrence of maltreatment, advocacy services sought and received, number of face-to-face meetings with guardianship workers, and status of plans of care.

• That the North region of MCFD begin to publicly report on the safety and well-being of children in care semi-annually . . . (Recommendation 7(a) Amanda, Savannah, Rowen and Serena: From Loss to Learning, April 2008)
• That MCFD prepare the same semi-annual public report for children in the care of a delegated Aboriginal Agency in collaboration with the Agency. (Recommendation 7(b) Amanda, Savannah, Rowen and Serena: From Loss to Learning, April 2008)
• That MCFD . . . publicly report on key measures for Aboriginal children in care or receiving services by the North region. (Recommendation 7(c) Amanda, Savannah, Rowen and Serena: From Loss to Learning, April 2008)
• That the Government of British Columbia, after community consultation, establish an Aboriginal Children’s Council for the North region. This Council should provide a focal point for the analysis of the safety and well-being of vulnerable Aboriginal children, including Aboriginal children in care, in order to implement broad based and practical supports to improve their safety and well-being. (Recommendation 7(d) Amanda, Savannah, Rowen and Serena: From Loss to Learning, April 2008)
• That MCFD, and the Ministry of Health, jointly examine recommendations of the Canadian Paediatric Society cited in this report, and evaluate and report . . . on any barriers or roadblocks to their full implementation . . . (Recommendation 9(e) from Amanda, Savannah, Rowen and Serena: From Loss to Learning, April 2008)

Media Contact:
Jeff Rud
Communications Director
Cell: 250-216-4725
Office: 250-356-0835
[email protected]

To view a copy of this report, please click here.


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