26 Octber 2016 The Hn Justice Margaret White AO Chair Office f the Ryal Cmmissin PO Bx 4215 KINGSTON ACT 2604 Email: childdetentinnt@ryalcmmissin.gv.au Dear Justice White Re: Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry The Ryal Australian and New Zealand Cllege f Psychiatrists (RANZCP) welcmes the pprtunity t cntribute t the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry (the Ryal Cmmissin). The RANZCP strngly supprts the purpses f the Ryal Cmmissin t investigate failings in the yuth detentin and child prtectin systems in the Nrthern Territry as well as recmmendatins fr their imprvement. Like many thers, the RANZCP was deeply cncerned at the ftage f the Dn Dale Yuth Detentin Centre that prmpted the establishment f the Ryal Cmmissin. Given the significant link between trauma in childhd and future psychiatric and scial prblems, the RANZCP advcates fr attitudes and practices within bth the yuth detentin and child prtectin systems that are guided by cmpassin and funded n a cmmitment t ensure that supprtive, caring and nn-traumatising early experiences are prvided fr all children and yung peple. The RANZCP further advcates fr the adequate prvisin f develpmentally apprpriate mental health care t children and yung peple in yuth detentin, with at least equivalence t best-practice cmmunity standards. The RANZCP represents arund 3700 psychiatrists in Australia, many f whm have specific interest and expertise directly relevant t this inquiry. In develping this submissin, the RANZCP has wrked clsely with its expert cmmittees and members, t ensure that the recmmendatins made reflect clinical excellence, cmmunity experience and insight. This includes cnsultatin with the RANZCP Faculty f Frensic Psychiatry and Faculty f Child and Adlescent Psychiatry, as well as ur Nrthern Territry Branch and the RANZCP s Abriginal and Trres Strait Islander Mental Health Cmmittee (which includes cnsumer and carer membership). The recmmendatins cntained within this submissin are therefre based n the expertise and clinical experience f ur cmmittees and members, including pre-eminent child and adlescent, and frensic psychiatrists. 309 La Trbe Street, Melburne VIC 3000 Australia T +61 3 9640 0646 F +61 3 9642 5652 ranzcp@ranzcp.rg www.ranzcp.rg ABN 68 000 439 047
Please see the attached submissin which we hpe will be f assistance in the inquiry. If yu wuld like t discuss any f the issues raised in the submissin, please cntact Rsie Frster, Senir Department Manager, Practice, Plicy and Partnerships via rsie.frster@ranzcp.rg r by phne n (03) 9601 4943. Yurs sincerely Prfessr Malclm Hpwd President Ref: 0499
Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry Octber 2016 maximising pprtunities fr recvery 309 La Trbe Street, Melburne VIC 3000 Australia T +61 3 9640 0646 F +61 3 9642 5652 ranzcp@ranzcp.rg www.ranzcp.rg ABN 68 000 439 047
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry Abut the Ryal Australian and New Zealand Cllege f Psychiatrists The Ryal Australian and New Zealand Cllege f Psychiatrists (RANZCP) is a membership rganisatin that prepares dctrs t be medical specialists in the field f psychiatry, supprts and enhances clinical practice, advcates fr peple affected by mental illness and advises gvernment n mental health care. The RANZCP is the peak bdy representing psychiatrists in Australia and New Zealand, and as a binatinal cllege has strng ties with assciatins in the Asia-Pacific regin. The RANZCP has mre than 5000 members, including arund 3700 fully qualified psychiatrists and almst 1200 members wh are training t qualify as psychiatrists. Psychiatrists are prminent amng clinical leaders in the prvisin f mental health care in the cmmunity and use a range f evidencebased treatments t supprt a persn in their jurney t recvery. The RANZCP is guided n plicy issues by a range f expert cmmittees whse membership is made up f leading psychiatrists with relevant expertise, and cnsumer, carer and cmmunity representatives. Executive summary There is a significant bdy f evidence dcumenting the links between mental health issues and incarceratin, as well as between childhd trauma and future psychscial prblems. Withut adequate levels f develpmentally apprpriate mental health services, at-risk children and yung peple face significant bstacles in their paths t recvery and staff in yuth detentin centres face significant difficulties in managing children and yung peple in their care. It is therefre critical that children and yung peple knwn t child prtectin services and/r the juvenile justice system are prvided with meaningful treatments and interventins. The RANZCP affirms the significant benefits f a justice reinvestment apprach t criminal justice invlving measures t decrease rates f incarceratin and recidivism by investing in services in the cmmunity. The value f a justice reinvestment apprach lies in its ptential t direct resurces away frm prisn building and int cmmunity building, thereby strengthening and empwering cmmunities t help peple at risk f develping mental health issues and reduce ffending. Mental health is the third largest burden f disease in Australia and yet perhaps the mst underfunded f all diseases in terms f that burden. Mental health funding in the Nrthern Territry is amng the lwest f all jurisdictins with the Nrthern Territry scring the lwest n mst measures f resurcing including the availability f bth inpatient beds and cmmunity residential placements as well as staff. Furthermre, there is n yuth- r adlescent-specific frensic mental health service in the NT at all and existing child and adlescent mental health services d nt have capacity t prvide sufficient in-reach services t yuth detentin centres. Early interventin strategies targeting the mental health f children and yung peple, particularly thse wh have experienced significant trauma and adversity, reduce the likelihd f adverse utcmes in relatin t future ffending. Thus, the develpment and implementatin f early interventin strategies fr the preventin f psychiatric disrders assciated with increased incarceratin rates is critical in effrts t reduce ffending and guide juvenile ffenders twards recvery and rehabilitatin. The RANZCP therefre advcates fr the increased prvisin f mental health services t children and yung peple knwn t the child prtectin and juvenile justice systems, as well as fr attitudes and practices within bth systems that are guided by cmpassin and funded n a cmmitment t ensure that supprtive, caring, and nn-traumatising early experiences are prvided fr all children and yung peple in ur care. Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 1 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry Summary f key recmmendatins It is the RANZCP s psitin that the detentin f children shuld nly ccur as a last resrt, fr the shrtest pssible perid f time and with the decisin infrmed by the best interests f the child. When/if detentin des ccur, the RANZCP recmmends: the develpment f lng-term strategies aimed at reducing, and where pssible, eliminating the use f seclusin and restraint n children and yung peple in detentin facilities adequate facilities and freedms prvided t secluded detainees including: cnsistent and unbstructed access t drinking water respect fr privacy when shwering and tileting facilities fr hand washing in cells with tilets temperature cntrl the establishment f prtcls pertaining t crisis interventin which: are specific t children and yung peple, taking int cnsideratin their develpmental needs cver the need fr seclusin and restraint t be used nly as a last resrt include mechanisms t ensure a high level f accuntability when using seclusin and restraint, including the mnitring f critical incidents include reference t negtiatin and de-escalatin techniques as well as the prper use f PART (Predict, Assess & Respnd t Challenging/Aggressive Behaviur) are incrprated int staff training arrangements the develpment f strategies t ensure that yuth detentin facilities are funded n traumainfrmed appraches t treatment and rehabilitatin imprved educatin and training f staff in yuth detentin facilities arund the mental health needs f children and yung peple, including apprpriate respnses t threats r actual instances f self-harm the inclusin f relevant facts abut past harmful practices, and evidence f their nging impact, in the cre training curriculum f yuth detentin staff members, including hw t be sensitive when dealing with individuals affected by harmful practices in the past, and t understand the cnsequences f traumatic memries in the present imprved educatin and training f staff in yuth detentin facilities arund cultural cmpetency including specific training in Abriginal and Trres Strait Islander cultural cmpetency and trauma-infrmed care, including the effects f transgeneratinal trauma n the develpmental and mental health f Abriginal and Trres Strait Islander children and yung peple increased supprt f yuth detentin staff members t ensure they are psychlgically equipped t deal with crisis situatins and ther wrkplace hazards investment in a Yuth Frensic Mental Health Service t meet the treatment needs f children and yung peple in detentin as well as the educatinal needs f staff emplyed by yuth detentin centres Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 2 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry prvisin f in-reach mental health and drug and alchl services, delivered by lcal child and adlescent mental health services, that are trauma-infrmed and include screening t assess the mental health, drug and alchl and develpmental needs f children and yung peple in detentin plicies guaranteeing equivalence f health care fr thse with mental illness in the criminal justice system, taking int accunt the higher prevalence f mental disrder amngst individuals in custdy when cmpared t the general cmmunity implementatin f the recmmendatins made by the Children s Cmmissiner and the Department f Crrectinal Services Vita reprt review f the functining f fficial visitrs, as enshrined in Part 9 f the Yuth Justice Act. With regard t child prtectin services, the RANZCP recmmends: age-apprpriate screening and assessment f mental health cncerns and risk factrs in all children and yung peple knwn t child prtectin services, including children entering ut-fhme care, with reference t the New Orleans Mdel which has demnstrated effectiveness internatinally mechanisms t ensure that recmmendatins arising ut f the mental health assessments f children and yung peple knwn t child prtectin services can be implemented, ideally via referral t age-apprpriate, evidence-based clinical interventins grunded in trauma-infrmed and culturally apprpriate appraches t care the prvisin f systematic and mandatry training fr ut-f-hme care service prviders and fster carers frm pint f entry int the residential care sectr delivered by experienced facilitatrs, incrprating: infrmatin n the particular vulnerabilities f children in ut-f-hme care infrmatin n healthy develpmental stages attachment thery and practice backgrund t the psychpathlgy experienced by children in ut-f-hme care an verview f the cmpunding effects f neurlgical, psychlgical, emtinal, behaviural and relatinal sequelae and hw this relates t the prvisin f care the reparative parenting training mdel empwerment t set develpmentally apprpriate limits n the mvement and affiliatins f yung peple in ut-f-hme care infrmatin n prblem sexual behaviur regular, nging supervisin fr ut-f-hme care service prviders and fster carers imprved educatin and training f staff in child prtectin agencies arund cultural cmpetency and cultural respnsiveness, including the effects f transgeneratinal trauma n the develpmental and mental health f Abriginal and Trres Strait Islander children and yung peple Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 3 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry appraches that prmte the preservatin f ties between Abriginal and Trres Strait Islander and culturally and linguistically diverse (CALD) children and yung peple and their cmmunities and cultures the use f prfessinal interpreters where there are language barriers strengthening the implementatin f the Abriginal and Trres Strait Islander Child Placement Principles thrugh: increased recruitment f Abriginal and Trres Strait Islander carers and supprt fr their skill develpment additinal investment in develping Abriginal and Trres Strait Islander leadership and participatin in decisin-making and mnitring prcesses imprved linkages between cmmunities and gvernment including imprved cmmunicatin and educatin regarding the intent f the Principles. In recgnitin f the significant links between mental health and juvenile ffending, the RANZCP als recmmends: significant investment in preventin and early interventin prgrams fr children and their families thrugh partnerships between mental health, maternal and child health services, schls and ther related rganisatins built-in, frmal ecnmic evaluatins fr all trials f preventin and early interventin prgrams fr children and yung peple t determine whether they have prvided value in terms f justice reinvestment specific attentin paid t at-risk grups including the screening f vulnerable children and yung peple fr early identificatin f mental illness and/r psychscial difficulties the develpment f targeted preventin and early interventin prgrams fr at-risk children and yung peple, including Abriginal and Trres Strait Islander peples. Further recmmendatins are prvided in the relevant sectins f the submissin belw. Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 4 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry Cntents Abut the Ryal Australian and New Zealand Cllege f Psychiatrists... 1 Executive summary... 1 Summary f key recmmendatins... 2 Intrductin... 6 Yuth detentin systems... 7 Backgrund... 7 The prvisin f mental health care t children and yung peple in detentin... 8 Institutinal practices and the mental health needs f children and yung peple in detentin...11 The imprtance f cultural cmpetency in the care f children and yung peple in detentin...15 Gvernance structures t safeguard the mental health f children and yung peple in detentin..18 Child prtectin systems...20 Backgrund...20 The rle f child prtectin systems with regard t mental health care...21 The imprtance f cultural cmpetency in child prtectin systems...25 A justice reinvestment apprach...26 Backgrund...26 Mental health and recidivism...27 At-risk grups...28 References...30 Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 5 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry Intrductin The Ryal Australian and New Zealand Cllege f Psychiatrists (RANZCP) welcmes the pprtunity t cntribute t the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry (the Ryal Cmmissin). In develping this submissin, the RANZCP wrked clsely with its expert members and representatives including the Faculty f Child and Adlescent Psychiatry, Faculty f Frensic Psychiatry, Sectin f Child and Adlescent Frensic Psychiatry, Sectin f Yuth Mental Health, Abriginal and Trres Strait Islander Mental Health Cmmittee and the Nrthern Territry Branch members. The recmmendatins cntained within this submissin are based n bth the expertise and clinical experience f ur members, including pre-eminent child and adlescent, and frensic psychiatrists, as well as the experiences and insights f cmmunity members, including members f Abriginal and Trres Strait Islander cmmunities. The RANZCP strngly apprves f the purpses f the Ryal Cmmissin t investigate failings in the yuth detentin and child prtectin systems in the Nrthern Territry. Increasing demands n yuth detentin systems require apprpriate resurcing and management s as t ensure the prper prtectin and care f detained children and yung peple. The develpment f rbust prtcls and plicies in yuth detentin facilities are especially imprtant nw given recent calls in ther states t establish behaviural management units similar t the Dn Dale Yuth Detentin Centre (ABC News, 2016). While the RANZCP recgnises the gegraphical scpe f the Ryal Cmmissin, it als recgnises that many f the issues t be discussed, and recmmendatins t be made, are relevant acrss the cuntry. Given the significant links between mental health issues and incarceratin, the RANZCP believes that adequate resurcing fr mental health care is imperative t stem the tide f yuth incarceratin. This is true in relatin t bth yuth detentin centres and child prtectin services, where large numbers f atrisk yung peple may be identified and prvided with suitable services t aid them in their recvery and/r rehabilitatin. Unfrtunately, these systems all t ften prvide experiences which cmpund trauma and mental health issues, rather than alleviate them. Given the well-dcumented cnnectins between childhd trauma and future psychscial prblems, the RANZCP advcates fr attitudes and practices within bth the yuth detentin and child prtectin systems that are guided by cmpassin and funded n a cmmitment t ensure that supprtive, caring, and nn-traumatising early experiences are prvided fr all children and yung peple in ur care. The RANZCP further ntes the under-resurcing f mental health care in the Nrthern Territry where mental health funding is amng the lwest f all jurisdictins. The Nrthern Territry scres the lwest n mst measures f resurcing including the availability f bth inpatient beds and cmmunity residential placements as well as staff. Furthermre, there is n yuth- r adlescent-specific frensic mental health service in the NT at all and existing child and adlescent mental health services d nt have capacity t prvide sufficient in-reach services. As such, the RANZCP affirms the significant benefits f a justice reinvestment apprach t criminal justice invlving measures t decrease rates f incarceratin and recidivism by investing in services in the cmmunity. The value f a justice reinvestment apprach lies in its ptential t direct resurces away frm prisn building and int cmmunity building, thereby strengthening and empwering cmmunities t help peple at risk f develping mental health issues and reduce ffending. Early interventin strategies targeting the mental health f children and yung peple, particularly thse wh have experienced significant trauma and adversity, reduces the likelihd f adverse utcmes in relatin t future ffending. Thus, the develpment and implementatin f early interventin strategies fr the preventin f psychiatric disrders assciated with increased incarceratin rates is critical in effrts t reduce ffending and guide juvenile ffenders twards recvery and rehabilitatin. Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 6 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry Yuth detentin systems Backgrund Befre examining the particular cnditins f yuth detentin facilities, it is imprtant t nte the effects f detentin itself n the mental health f children and yung peple. The remval f a child frm their hme is a highly stressful experience encmpassing the child s lss f liberty, persnal identity and familiar landscape, cmpunded by the lss f scial supprts and cping mechanisms including family and friends, schl, sprts and ther activities. Events f this kind will place psychlgical stresses n any child with at-risk children and yung peple mre vulnerable t the effects f psychlgical trauma. Studies f children in immigratin detentin facilities is telling. Althugh there are many differences between these ppulatin grups, sme pints nevertheless bear mentining. A bdy f evidence exists demnstrating the detrimental effects f immigratin detentin n the develpment and mental health f children including the ptential f prlnged detentin t cause lng-term damage t scial and emtinal functining (RANZCP, 2014b). While even shrt perids f detentin have been fund t impact children s functining (Fazel et al., 2012; Dudley et al., 2012), children detained fr lng perids f time have been fund t be at high risk f suffering mental illness and pst-traumatic stress symptms. There is als clear evidence establishing a relatinship between the length f detentin and the severity/cmrbidy f psychiatric disrders (Bull et al., 2012). Detentin has als been fund t cmpund distress in children with prir experience f trauma, trture r neglect (Burrell, 2013). Many children and yung peple in yuth detentin centres have prir experiences f trauma which are difficult t address in detentin settings where cntinued expsure t stress is likely t impact adversely n recvery. The prtectin and strengthening f a child s attachment relatinships is central t prmting healthy develpment and well-being. Many children and yung peple wh cme int cntact with the juvenile justice system have already experienced significant disruptins t their attachments, and their relatinships with caregivers are ften tenuus at the time they enter detentin. The separatin engendered by detentin is likely t further disrupt the abilities f children and yung peple t maintain their attachment relatinships, causing significant psychlgical harm. Cmprehensive assessment f children in detentin shuld therefre examine the effects f traumatic expsure, the rle f envirnmental deprivatin and the availability f parental emtinal supprt in cntributing t mental and develpmental well-being. Mental health functining in child and yung peple in detentin shuld be assessed by child and adlescent psychiatrists r ther mental health specialists with apprpriate expertise. Where mental illness is identified, it shuld be managed utside the detentin envirnment whenever pssible. Given the significantly higher rates f mental illness, as well as general health prblems, amng children and yung peple in the juvenile justice ppulatin, all children and yung peple wh enter custdy shuld, at a minimum, receive a screening health assessment upn entry t custdy. If mental health cncerns are identified, then that persn shuld be ffered a cmprehensive mental health assessment including referrals fr apprpriate treatment. Wherever pssible, children and yung peple wh have cmmitted ffences shuld be managed in cmmunity settings with primary caregivers t ensure their attachment relatinships are nt threatened. When this is nt pssible, there needs t be an assessment f the impact f family separatin and the availability f alternate attachment figures. This is particularly significant fr Abriginal and Trres Strait Islander peples given the cmplexity f their family relatinships arising frm systems f kinship. Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 7 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry It is therefre the RANZCP s psitin that the detentin f children shuld nly ccur as a last resrt; where it des ccur, it shuld be fr the shrtest pssible perid f time and with the decisin infrmed by the best interests f the child. When detentin des ccur, it is abslutely imperative that children in detentin be treated with dignity and respect, and have adequate access t health care and nn-clinical supprt t supprt their develpment and, where relevant, recvery. Under the current mdel f yuth detentin, hwever, the RANZCP is cncerned that detentin is mre likely t cntribute t adverse mental health utcmes. The prvisin f mental health care t children and yung peple in detentin The need fr mental health services within yuth detentin centres There is a significant bdy f evidence which demnstrates that children and yung peple in detentin exhibit higher rates f mental health issues than the general ppulatin. While much f the evidence is nt specific t the Nrthern Territry, RANZCP members have expertise and experience t attest t the relevance f natinal and internatinal data t the situatin at hand. Prisners experiencing mental illness are mre vulnerable t ther prisners and pse a higher suicide risk; they als pse a cnsiderable challenge t prisn management. Bth crrectinal and health agencies have respnsibilities in relatin t prisners but their cmpeting pririties can be difficult t recncile. The crrelatins between mental ill health and incarceratin are well dcumented (White et al., 2016), attesting t the imprtance f prviding apprpriate mental health care t detained children and yung peple with the dual gals f treatment and rehabilitatin. Yuth incarceratin has been fund t be assciated with increased risks f suicidality and psychiatric disrders including depressin, substance use, and behaviural disrders (Barnert et al., 2016; Schufelt and Cczza, 2006; Casian et al., 2016). Epidemilgical studies in the US indicate that 40 55% f detained adlescents meet the diagnstic criteria fr behaviural disrders including cnduct disrder and ppsitinal defiant disrder, 60 70% meet the criteria fr nn-behaviural mental disrders while 45 50% meet the criteria fr a substance abuse disrder (White et al., 2016). Australian studies have fund less prnunced but nevertheless significantly abve-average rates f mental illness amng yung peple in detentin (Kasinathan, 2015). Furthermre, risk factrs fr suicidality amng children and yung peple are mre prevalent amng detained children and yung peple (Natinal Actin Alliance fr Suicide Preventin, 2013). The principle f equivalence affirms the rights f individuals t access t health care which is apprpriate t their needs, regardless f their legal status. As such, it is imperative that children and yung peple in detentin facilities have cnsistent access t high-quality mental health care t address their individual needs. Cnduct disrder bears particular mentin here as it is a cmmn childhd disrder marked by a persistent pattern f disruptive behaviur that infringes upn the rights f thers r vilates scial nrms. Yung peple with cnduct disrder may cause serius physical and psychlgical harm t thers and are verrepresented in detentin systems. Epidemilgical studies shw a crrelatin between thse wh experience psychiatric disrders in childhd and adulthd with children and yung peple with cnduct disrder at particular risk f develping further mental health prblems later in life (Kim-Chen et al., 2003). Behaviural prblems experienced frm as early as 3 years f age can be predictive f adult psychiatric prblems. Early interventin significantly reduces the psychiatric mrbidity experienced in children and yung peple and may well reduce the prevalence and severity f psychiatric disrders later in life. Hwever, the mental health needs f at-risk children and yung peple in the Nrthern Territry can be difficult t address prir t their entry int the juvenile justice system cnsidering the relative lack f Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 8 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry mental health funding in the Nrthern Territry which scres the lwest f all Australian state and territries n mst measures f resurcing including the availability f beds and staff. Child and adlescent mental health services in the NT are already verstretched meaning that there is little capacity t reach at-risk children and yung peple befre they cme int cntact with the juvenile justice system, especially in remte areas including Abriginal cmmunities. Furthermre, the capacity f these services t prvide in-reach treatments t children and yung peple in detentin is limited. The prvisin f mental health services within Nrthern Territry yuth detentin centres The RANZCP is cncerned abut reprts it has received regarding the unmet mental health needs f children and yung peple in detentin. Initial screening f children and yung peple entering detentin in the Nrthern Territry is undertaken by a general health nurse withut any specific screening f mental health issues. Detainees then have access t a GP but referrals fr psychiatric assessment are usually nly made when there is an identified risk, at which pint they will be referred t a hspital emergency department fr assessment. There is n yuth- r adlescent-specific frensic mental health service in the NT and the adult frensic mental health team will nly see children and yung peple in situatins f acute risk and with limited prvisin f treatment. The RANZCP is aware f situatins where psychiatrists have made recmmendatins fr the treatment f children and yung peple in detentin which have nt been implemented, smetimes many mnths later. Given the significant prevalence f mental health issues amng children and yung peple in detentin, it is critical that detainees have the ability t receive timely interventins delivered in the setting. Access t mental health care is necessary, nt nly because f the high prevalence f psychiatric disrder amng children and yung peple in detentin, but als due t the increased psychlgical stresses f the detentin setting. This is because even when the diagnstic criteria fr a psychiatric disrder are nt met, the detentin setting still heralds serius implicatins fr the healthy psychscial develpment f children and yung peple in detentin. Furthermre, what is ften interpreted as delinquent behaviur within detentin facilities may in fact be the nrmal functining f children wh have experienced abuse and/r neglect and thus assumed the respnsibility fr taking care f themselves (Burrell, 2013). The RANZCP therefre recmmends the embedding f mental health assessments int yuth detentin prcesses in rder t ensure that the varying mental and develpmental health needs f detainees are adequately addressed. Children and yung peple with cnduct disrder and/r ther mental health issues which may result in behaviural difficulties d nt appear t be receiving adequate treatment in yuth detentin facilities. The Nrthern Territry Crrectinal Services Directive 2.4.5 apprves the use f management regimes fr: a prisner [wh] thrugh his/her attitude, cnduct and behaviur cntinually jepardises the gd rder and security f a prisn, threatens the health and safety f staff, ther prisners r themselves (Children s Cmmissiner, 2015) The RANZCP expresses cncern that management regimes may be applied t children and yung peple with cnduct disrder withut due regard fr their health-care needs. Particularly cncerning is the implementatin f management regimes at the Dn Dale Yuth Detentin Centre utilising lng-term seclusin withut cnsultatin with case wrkers r health prfessinals, as was reprted by the Children s Cmmissiner (2015). The RANZCP believes that management regimes shuld nt be applied withut the apprpriate screening f children and yung peple with behaviural issues fr mental disrder. Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 9 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry It shuld be nted that the Natinal Statement f Principles fr Frensic Mental Health states that legislatin shuld nt allw cercive treatment fr mental illness in a crrectinal setting (AHMC Mental Health Standing Cmmittee, 2006). The principle f equivalence als requires that if invluntary treatment is necessary, it must be perfrmed in hspitals t ensure that prper safeguards apply and vulnerable prisners are nt placed at risk f direct harm. As such, where children and yung peple in detentin centres are diagnsed with cnditins requiring interventin but refuse treatment, they shuld be treated utside f the crrectinal setting. Hwever, there is n child and adlescent inpatient psychiatric unit in the Nrthern Territry, meaning that children and yung peple requiring inpatient care will usually be hused in a paediatric ward r an adult inpatient setting, neither f which are at all suited t the treatment f child and adlescent mental health issues. It is imperative that children and yung peple in detentin facilities have cnsistent access t highquality mental health care including the invlvement f child and adlescent mental health services. In recgnitin f the imprtant rle which mental health services have t play in the yuth detentin system, the Natinal Cmmissin n Crrectinal Health Care in the USA has released guidelines recmmending that yuth detentin facilities implement behaviural screening within 14 days f intake fllwed by daily treatment services upn request (Cmmittee n Adlescence, 2011). It is the RANZCP s psitin that mnitring by psychiatric prfessinals shuld be mandated fr all children and yung peple in detentin. Cmprehensive assessment f children in detentin shuld examine the rles f envirnmental deprivatin, availability f parental emtinal supprt and traumatic expsure in cntributing t a clinical disrder. Psychiatric illnesses in child and adlescent detainees shuld be assessed by child and adlescent psychiatrists r frensic psychiatrists with adlescent experience. Where pssible, identified psychiatric illnesses shuld be managed utside the detentin envirnment as cntinued expsure t traumatic stress assciated with the detentin envirnment undermines treatment and the pssibility fr recvery (RANZCP, 2014b). Recmmendatins Pursuant t the evidence abve, the RANZCP recmmends: imprved educatin and training f staff in yuth detentin facilities arund the mental health needs f children and yung peple, including apprpriate respnses t threats r actual instances f self-harm investment in a Yuth Frensic Mental Health Service t meet the treatment needs f children and yung peple in detentin as well as the educatinal needs f staff emplyed by yuth detentin centres prvisin f in-reach mental health and drug and alchl services, delivered by lcal child and adlescent mental health services, that are trauma-infrmed and include screening t assess the mental health, drug and alchl and develpmental needs f children and yung peple in detentin plicies guaranteeing equivalence f health care fr thse with mental illness in the criminal justice system, taking int accunt the higher prevalence f mental disrder amngst individuals in custdy when cmpared t the general cmmunity. Furthermre, the RANZCP recmmends: mental health screening f all children and yung peple in detentin t assess their mental health, drug and alchl and develpmental needs: Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 10 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry upn intake prir t the implementatin f management regimes whenever the use f seclusin and restraint are emplyed at regular intervals mechanisms that enable children and yung peple in detentin t be diverted frm detentin centres int apprpriate mental health settings if they are in need f invluntary mental health treatment. Institutinal practices and the mental health needs f children and yung peple in detentin Cruel, inhumane and degrading practices The RANZCP strngly cndemns the use f trture r ther cruel, inhumane r degrading treatments r punishments under any cntext (RANZCP, 2015a) and fr any age r racial/ethnic cultural grup. The United Natins Cnventin against Trture and Other Cruel, Inhuman r Degrading Treatment r Punishment, ratified by Australia in 1989, defines trture as: any act by which severe pain r suffering, whether physical r mental, is intentinally inflicted n a persn fr such purpses as btaining frm him r a third persn infrmatin r a cnfessin, punishing him fr an act he r a third persn has cmmitted r is suspected f having cmmitted, r intimidating r cercing him r a third persn, r fr any reasn based n discriminatin f any kind, when such pain r suffering is inflicted by r at the instigatin f r with the cnsent r acquiescence f a public fficial r ther persn acting in an fficial capacity (UN General Assembly, 1984) (emphasis added). The RANZP therefre expresses extreme cncern at ftage dcumenting what it cnsiders t be the cruel, inhumane and degrading treatment f children and yung peple at the Dn Dale Yuth Detentin Centre 1. Tear gas, r rthchlrbenzalmalnnitrile (CS) gas, is a chemical agent and its use n unarmed children and yung peple is unjustifiable. The lack f adequate attempts at negtiatin t reslve the incident n 21 August 2014 withut the use f frce, as dcumented by the Children s Cmmissiner (2015), is similarly unjustifiable. Subjecting children and yung peple t these extreme measures withut due regard fr all alternative methds is nt merely equivalent t child abuse, but in fact cnstitutes severe child abuse, and the RANZCP expresses its disapprbatin f such actins in the mst extreme terms. The rights f all children t be treated with respect fr their individual human wrth and dignity must nt be waived in any circumstance, regardless f an individual s histry f ffending r their behaviur while detained. Seclusin and restraint The damaging effects f slitary cnfinement n children and yung peple is well dcumented (HRW and ACLU, 2012; Gallagher, 2014). Seclusin nt nly exacerbates pre-existing mental health cnditins but has lng been knwn t even create new nes (HRW and ACLU, 2012; Mitchell and Varley, 1990). Children and yung peple have fewer cping mechanisms when faced with slitary cnfinement and have reprted adverse effects t seclusin including extreme anxiety, rage, depressin, self-harm, suicidal thughts, suicidal attempts and hallucinatins (HRW and ACLU, 2012). Islatin may evke 1 Even Dn Dale staff have described the treatment as inhumane (Children s Cmmissiner, 2015). Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 11 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry memries f past traumas, reawaken feelings f fear, pwerlessness and lneliness and/r leave children and yung peple alne with negative thughts; thus, the use f seclusin may well be traumatising fr individuals with prir expsure t trauma (Simkins et al., 2012; Burrell, 2013). In recgnitin f the develpmental vulnerability f children, the United Natins General Assembly frbade the use f seclusin n detained children and yung peple thrugh adpted reslutin 45/113 which clearly states: All disciplinary measures cnstituting cruel, inhuman r degrading treatment shall be strictly prhibited, including crpral punishment, placement in a dark cell, clsed r slitary cnfinement r any ther punishment that may cmprmise the physical r mental health f the juvenile cncerned. (UN General Assembly, 1990b) Seclusin and restraint have lng been used in mental health-care settings as emergency measures t manage vilent behaviur r agitatin. Studies have reprted substantial deleterius physical and mre ften psychlgical effects n bth patients and staff (Fisher, 1994) with patients experiencing the use f seclusin and restraint as emtinally unsafe, disempwering and ptentially (re)traumatising (Muskett, 2014). Adlescent psychiatric units, unique settings wherein children and yung peple are frequently held against their will, therefre prvide a useful pint f cmparisn regarding the institutinal use f seclusin and restraint n children and yung peple. In mental health-care settings, seclusin and restraint shuld nly ever be used as a safety measure f last resrt where all ther interventins have been tried r cnsidered and excluded. Under these circumstances, seclusin and restraint shuld be used within apprved prtcls by prperly trained prfessinal staff in an apprpriate envirnment fr safe management f the patient. Seclusin and restraint shuld nt be used as a substitute fr inadequate resurces (such as lack f trained staff r accmmdatin) nr as a methd f punishment. Hwever they are still deplyed fr these purpses far t ften, albeit ineffectively. Seclusin and restraint are thus being phased ut in many psychiatric inpatient settings, either cmpletely r except in the mst extreme circumstances. The RANZCP expresses cncern at allegatins f the inapprpriate use f seclusin and restraint at the Dn Dale Yuth Detentin Centre. A reprt frm the Children s Cmmissiner investigating these allegatins evidenced a patterned use f seclusin as a methd f punishment cmpunded by: inhumane and unhygienic cnditins within the secluded area lengthy stays withut clarificatin frm staff regarding the length f time t be spent in seclusin the nn-terminatin f seclusin after the reslutin f behaviural issues which led t its use in the first instance a lack f mnitring and supervisin f children and yung peple in seclusin (Children s Cmmissiner, 2015). Use f seclusin in this manner is unlikely t reslve behaviural issues; instead, it serves t reinfrce the sense f mistrust experienced by children and yung peple wh have experienced trauma. The RANZCP expresses further cncern at allegatins regarding the indiscriminate use f restraint measures, including handcuffs and spit hds, n children and yung peple. As experiences in mental health care have demnstrated, seclusin and restraint shuld be minimised and eliminated wherever pssible. Their indiscriminate and systematic use is cause fr very serius cncern with regard t the develpmental and mental well-being f the children and yung peple invlved. With the emergence f trauma-infrmed care, there is increasing recgnitin f the need t reduce cercive practices including restraint and seclusin. All Australian jurisdictins have intrduced laws, Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 12 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry plicies r guidelines fcusing n reducing seclusin and restraint events, time spent in seclusin and trauma assciated with seclusin and restraint. In 2005, Australian health ministers endrsed the Natinal Safety Pririties in Mental Health: a Natinal plan fr reducing harm which identified fur pririty areas fr natinal actin including reducing use f, and where pssible eliminating, restraint and seclusin (Natinal Mental Health Wrking Grup, 2005). The RANZCP is als cmmitted t reducing, and where pssible eliminating, the use f seclusin and restraint in mental health-care settings (RANZCP, 2016b). Reductin f seclusin and restraint is certainly pssible, as demnstrated by studies such as thse in the United States which have reduced use cnsiderably withut additinal resurces (Huckshrn, 2005). The RANZCP wuld strngly encurage rganisatins in relevant settings including the criminal justice system t cnsider the significant harm caused by seclusin and restraint and make all reasnable attempts t minimise and, where pssible, eliminate the use f seclusin and restraint n children and yung peple in detentin facilities. Trauma-infrmed care in yuth detentin facilities While it may smetimes be necessary fr the prtectin f the individual and/r the cmmunity, detentin f children is in cntraventin f respnsibilities under the United Natins Cnventin n the Rights f the Child, ratified by Australia in 1990, when it is nt aligned with the fllwing: Article 3(1): the best interests f the child must be a primary cnsideratin in all actins cncerning children Article 37(a),(c): children in detentin have the right t be treated with humanity and respect fr the inherent dignity f the persn Article 6(2), 39: children have the right t enjy, t the maximum extent pssible, develpment and recvery frm past trauma. Trauma-infrmed appraches t care are fundamental t best-practice mental health care and their relevance within the criminal justice system is becming increasingly recgnised. A trauma-infrmed apprach t yuth detentin is based first and fremst n an understanding that juvenile ffending is best addressed thrughut treatment and rehabilitatin. The assumptin that punitive measures deter children and yung peple frm criminality has been largely refuted by scientific studies and evaluatins f juvenile crrectins systems (Burrell, 2013). As such the RANZCP supprts a trauma-infrmed mdel replacing the deterrence mdel t ensure that the yuth detentin system has adequate supprts t facilitate the recvery and rehabilitatin f children and yung peple in its care. The Children s Cmmissiner s investigatin int the Dn Dale Yuth Detentin Centre uncvered a number f failings with regard t the prvisin f trauma-infrmed care. As centres f rehabilitatin, yuth detentin systems shuld have rbust prgrams t ensure adequate health care, educatin and recreatin fr all detained children and yung peple. Reprts f the Dn Dale facility lacking a cmprehensive structured day, which includes elements f wrk, prgramming, recreatin, cleanliness, hygiene and schling (Vita, 2015; als see Children s Cmmissiner, 2015) is therefre cncerning. Accrding t the Children s Cmmissiner (2015), there is n frmal prcess in place t infrm the yung peple f their right t cntact and make a cmplaint t Children s Cmmissiner. Even when an individual is knwledgeable abut their rights and acts upn them, their cmmunicatin may nt be annymus. Withut assuring children and yung peple in detentin f their safety, feelings f insecurity are likely t aggravate psychscial difficulties. Many children and yung peple in detentin wh have suffered trauma have nly had experiences f adults failing t prtect them and s have an Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 13 f 35
Ryal Australian and New Zealand Cllege f Psychiatrists submissin fr the Ryal Cmmissin int the Prtectin and Detentin f Children in the Nrthern Territry inherent mistrust f caregivers; thus, it is imperative that the detentin setting prvide a cunterpint t that fr rehabilitatin t ccur. The physical envirnment is further cause fr cncern. Ntwithstanding apprpriate requirements fr cntrl and safety, detentin centres shuld cultivate an envirnment f safety t facilitate the healthy develpment f detained yung peple and children. Descriptins f the Behaviural Management Unit at the Dn Dale Yuth Detentin Centre attest t the need t drastically imprve the physical envirnments in yuth detentin: The cells d nt have any air-cnditining, r fans. There are n facilities fr the yung persns t access drinking water, nr are there any facilities fr hand washing after using the tilet, r befre eating meals. There are n windws which allw direct natural light, r ventilatin There is a shwer [in the exercise yard] partially enclsed by a three-quarter height wall in the crner, and a water tap. The shwer is nt private, as persns in sme f the cells can see directly int the shwer (particularly, cells 5, 4 and 3) Peple behave differently when they are placed in freign envirnments and the use f unsettling jail-like envirnments in yuth detentin centres are likely t create feelings f insecurity and unsafety in children and yung peple wh are detained there. This will, in turn, disrupt their healthy develpment and prevent the meeting f their psychscial needs. Apprpriate staff training is required t ensure that staff pssess adequate knwledge and skills t fllw a trauma-infrmed apprach t their wrk. Fr example, the RANZCP supprts the use f Predict, Assess & Respnd t Challenging/Aggressive Behaviur (PART) t help with de-escalatin, particularly nting its utility fr the minimisatin f seclusin and restraint. In health-care settings, apprpriate staff training regarding the early warning signs f aggressin, including hw t use structured vilence risk assessments, has been shwn t result in reductins in vilence and the use f seclusin and restraint (Kasinathan et al., 2015). As such, the RANZCP strngly recmmends the further develpment f risk assessment prtcls within the cntext f yuth detentin facilities. Increasingly, criminal justice refrmists are advcating fr cmmunity-based treatments and ther alternatives t incarceratin in the hpe f aviding the institutinal retraumatisatin f juvenile ffenders within detentin facilities. Where cmmunity-based treatments are nt pssible, detentin facilities wuld d well t be infrmed by Burrell s (2015) cmprehensive verview f trauma-infrmed appraches t care in yuth detentin facilities. Recmmended mechanisms include frnt dr screening and rientatin, institutinal values, staff training, behaviural interventin techniques and adjustments in physical envirnment t reduce ptential expsures t trauma. Burrell als elucidates several key elements in a trauma-infrmed apprach t yuth detentin including that: Staff are sensitive and alert t whether a yung persn is in distress, and apprpriate steps are taken t address cncerns. Yuth are infrmed that their needs will be recgnized; fr example, that safe zne signs are psted t help LGBTQ yuth feel mre at ease, and yuth are infrmed f nn-discriminatin plicies. Interviews abut sensitive infrmatin ccur in private areas. Yuth are infrmed abut safety in the facility, fr example, hw gang issues are handled, what prtectins there are t assure safety, and hw t cnfidentially reprt any prblems. Searches are n mre intrusive than needed fr intake Yuth are screened fr trauma, and further assessment ccurs where needed. Yuth receive all f the infrmatin they need abut their rights and the institutinal rules in a frm they can understand. Ryal Australian and New Zealand Cllege f Psychiatrists submissin Page 14 f 35