Health Committee on Feb. 9th, 2023

[The Chair, Liberal, Sean Casey]

I call the meeting to order.

Welcome to meeting number 53 of the House of Commons Standing Committee on Health.

Today we will meet for two hours with witnesses for our study of children's health.

Today's meeting is taking place in a hybrid format, pursuant to the House order of June 23, 2022.

I have a couple of comments for the benefit of our witnesses today.

For those who are participating on Zoom, you have interpretation available to you, and we know now that it is working. You have the choice at the bottom of your screen of either the floor, English or French. For those of you in the room, of course, you can select the desired channel.

Please don't take screenshots or photos of your screen. These proceedings will be made available on the House of Commons website.

In accordance with our routine motion, I'm informing the committee that all witnesses have completed the required connection tests in advance of the meeting.

I would now like to welcome the witnesses who are with us this afternoon. We have Dr. Tracie Afifi, professor at the University of Manitoba, appearing by video conference. From the Canadian Counselling and Psychotherapy Association, we have Ms. Carrie Foster, president-elect, and Lindsey Thomson, the director of public affairs; and from the Offord Centre for Child Studies, we have Dr. Stelios Georgiades, director, and McMaster Children's Hospital chair in autism and neurodevelopment. He's with us by video conference.

Thanks to all of the witnesses for being with us today.

Each of you has up to five minutes for your opening statement. We're going to begin with Dr. Afifi.

Welcome to the committee. You now have the floor.

[Dr. Tracie Afifi, Professor, University of Manitoba, As an Individual]

Thank you.

The most recent UNICEF data on child well-being in high-income countries indicates that Canada ranks 30th out of 38 countries. This, along with our need to support children and youth to recover from the COVID-19 pandemic, emphasizes that now is when we need to fully invest in children and youth to foster healthy development and resilience. This requires several strategies.

First, it's recommended that we invest in long-term funding for youth and child health research. Second, it's recommended that we implement strategies to effectively translate this research into policy and practice. Third, it is recommended that we train and retain health care and social service professionals to develop a network in which systems can share information and collaborate. Fourth, we need to be able connect all children in a timely manner to health care and social services when needed.

However, we need to consider these recommendations within the context of children's environments, in which they live, grow, develop and learn. What does this mean? It means that for optimal health we first need to ensure that children's and youths' environments are both safe and stable. It requires an approach that includes addressing poverty, racism and violence.

Today, I would like to focus on violence and the home environment to demonstrate that healthy child development is actually not possible when children live in unsafe and unstable homes.

The Centers for Disease Control and Prevention in the United States indicates that safe, stable and nurturing relationships and environments are important for preventing child abuse and neglect and fostering resilience, but you might wonder why we need to prevent violence to improve health. The answer is that spanking and child maltreatment are associated with an increased likelihood of mental disorders, physical health conditions and many other poor outcomes. An individual cannot achieve optimal health if they experience violence.

How common is violence in homes in Canada?

Although we don't have representative data on spanking in Canada, we do know from community samples that hitting children as a means of physical discipline is common. We also know that conclusive evidence across decades and over thousands of studies indicates that spanking is related to mental disorders, physical health problems, substance use disorders and thinking about and attempting suicide in childhood and across the lifespan. Children who are spanked are more likely to experience severe physical abuse, sexual abuse, emotional abuse and exposure to intimate partner violence.

Our team has analyzed data from a nationally representative sample of Canadian adults who retrospectively reported on their childhood experiences. We found that 32% of individuals in Canada have experienced child abuse, including physical abuse, sexual abuse and exposure to intimate partner violence.

Let me repeat that: One in three Canadian adults has reported experiencing child abuse.

We further analyzed these data and found that individuals who experienced child abuse were more likely to have depression; bipolar disorder; generalized anxiety disorder; obsessive-compulsive disorder; panic disorder; post-traumatic stress disorder; phobia; attention deficit disorder; eating disorders; alcohol abuse or dependence; drug abuse or dependence; suicidal ideation; and suicide attempts.

Our research has also indicated that spanking, slapping, harsh physical punishment, child abuse and neglect are associated with increased likelihood of several physical health conditions, including hypertension, liver disease, diabetes, cardiovascular disease, gastrointestinal disease, obesity and arthritis.

Please recall the four recommendations that I began with: All these recommendations should incorporate violence prevention to achieve our greatest likelihood of improving health outcomes for children and youth.

To summarize, we have recommendation one: long-term funding for research.

We need ongoing data collection and infrastructure in place to be able to act quickly when evidence is needed, such as in the COVID-19 pandemic. We did not have these research mechanisms in place during the pandemic and we were not able to act quickly to produce the data to improve the health outcomes for children and youth. What is needed is ongoing, longitudinal nationally representative data collection that includes measures of health; violence; other social determinants of health; systemic barriers; access to care; and potential protective factors.

Recommendation two is for knowledge translation and mobilization to connect research to policy and practice related to improving health and preventing violence.

Recommendation three is for training and retaining. We need to train and retain health care and social service professionals and develop a network in which these systems can share information and collaborate.

Recommendation four is for timely access to health care and child protection for all children and youth when needed.

To conclude, violence prevention and early health intervention will yield the best outcomes for children, youth and families in Canada.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Afifi.

Next we're going to the Canadian Counselling and Psychotherapy Association.

Will it be Ms. Foster or Ms. Thomson?

All right. You have the floor for the next five minutes, Ms. Foster. Welcome.

[Carrie Foster, President-Elect, Canadian Counselling and Psychotherapy Association]

Good morning. Bonjour. I am here in the capacity of president-elect for the Canadian Counselling and Psychotherapy Association, or CCPA. I represent more than 12,000 members who provide essential mental health services across Canada.

I would like to speak today about the significant mental health trends affecting children and how the government can take immediate action to relieve some of the burden to Canadians of the cost of mental health care.

Children in Canada are desperate for and yet are struggling to access mental health support. There is clear and growing need for help, but our system is failing these children. Long wait times demonstrate that the demand for services outweighs the capacity of providers.

Counselling therapists and psychotherapists can and are willing to meet the demand. These mental health professionals have had to be the most available during the pandemic, compared to other health professionals.

Strengthening Canada's mental health care supports by increasing accessibility to providers is essential to pandemic recovery and to a thriving and healthy society. Despite health care being a provincially regulated matter, there are small, actionable, and yet impactful federal policies and legislation that can be amended in order to improve supply and access to qualified mental health care providers in Canada.

At present, counselling therapists and psychotherapists are the only regulated mental health service providers that must remit tax on their services. Physicians, psychiatrists, registered nurses, registered psychiatric nurses, psychologists, occupational therapists and social workers are all exempt from GST/HST on their psychotherapy services.

Counselling therapists and psychotherapists are excluded from this exemption. This contributes to reduced access to mental health services for children by creating unnecessary financial pressure.

The profession of counselling therapy/psychotherapy meets the threshold for tax exemption in the Excise Tax Act, as it is regulated in five provinces. However, because the profession does not regulate the same title in all five provinces—title being a provincial decision—the Department of Finance does not accept that counselling therapists and psychotherapists are the same profession in order to meet that minimum threshold.

The profession is the same in all but name. Counselling therapists and psychotherapists across Canada share a common scope of practice, abide by similar codes of ethics and standards of practice, have a comparable training and education profile, and have a commitment and obligation to ongoing continuing education. They are qualified, competent, and available to meet the skyrocketing mental health care needs of children in Canada, and yet the additional cost of GST/HST tax on their services is limiting their capacity to serve their communities and those seeking care.

To ensure universal access to all mental health professionals, services provided by psychotherapists and counselling therapists should be tax-free.

This exemption would enable a child seeking care to access a few additional sessions over the span of a year. These extra sessions could make the difference between a child's ability to fully integrate their learnings and positive changes and habits for improved well-being. We call on the committee to support CCPA's recommendation to the federal government to legislatively amend the Excise Tax Act through a financial bill that adds the profession of counselling therapy and psychotherapy to the list of GST/HST-exempt health care professionals.

Thank you very much. I'll be pleased to answer your questions in French or in English.

[The Chair, Liberal, Sean Casey]

Thank you very much, Ms. Foster.

Finally, we have Dr. Georgiades from the Offord Centre for Child Studies.

Welcome, Dr. Georgiades. You have the floor.

[Dr. Stelios Georgiades, Director, Offord Centre for Child Studies]

Thank you, honourable chair and honourable members of this committee.

Today, I join you from the authentic and resilient city of Hamilton and its surrounding areas, in the province of Ontario.

I am here to represent the members of the Offord Centre for Child Studies, which is a multidisciplinary research institute dedicated to improving the lives, health and development of children and youth. The Offord Centre is affiliated with McMaster University, McMaster Children's Hospital and Hamilton Health Sciences.

Today, I will position my testimony on one strategy for child and youth health that enhances all other strategies related to that.

The late Dr. Dan Offord, founder of the Offord Centre for Child Studies, believed that tracking children's life trajectories was vital to improving their health and well-being. To Dr. Offord, a clinician and researcher who worked at McMaster University—the birthplace of evidence-based medicine—data were key. Data help us identify and understand problems, and lead to evidence that helps formulate, deliver, evaluate and refine solutions.

Our recommendations for the Standing Committee on Health's study on children's health reflect the belief that everything we do to improve, support and sustain the physical and mental health of Canada's children and youth can become more efficient, effective, equitable and sustainable through evidence that builds on high-quality research and data.

The recommendations in this brief are a single, overarching recommendation in five parts. A strong national commitment to research in child and youth mental and physical health needs to build on an infrastructure capable of supporting that commitment. I'm glad these recommendations overlap with the ones noted by Dr. Afifi, earlier today. This is the best strategic path to achieving a significant and sustainable impact on all aspects of child and youth health. That impact can be pervasive, enhancing programs and services at the federal, provincial, territorial and municipal levels, and within not-for-profit institutions nationwide. A single strategic decision can generate multi-faceted and lasting benefits for our children and youth.

I'm now going to outline five high-level recommendations.

Number one, establish long-term funding for research on child and youth mental and physical health as part of a national child and youth comprehensive health strategy.

Number two, establish a national research network to collect, coordinate and harmonize data related to child and youth mental and physical health in a research-accessible system.

Number three, invest in training researchers and frontline staff who can conduct research, translate research into policy and practice, and deliver care that reflects and contributes to research.

Number four, adapt our existing data-gathering practices to accommodate the specific needs of children and youth.

Number five, develop a learning health system in child and youth health to better connect research findings and evidence with the design and deployment of policy, care and training.

To conclude, we currently have inadequate information on a spectrum of health outcomes and factors ranging from child and youth mental health to race, ethnicity, child maltreatment and parental health. Many of the witnesses who testified before this committee have shared this.

Canada needs to invest in the coordinated effort and infrastructure required to generate the essential data, research and evidence leading to evidence-based policies and practices that foster healthier children and youth, a healthier society and reduced inequities. This kind of national investment—one that coordinates data gathering and analysis across provinces and territories—is a mandate that only fits with the Government of Canada. It is very timely within the larger context of the dialogue happening in our country, right now, in relation to health.

As a nation, we need to expand and enrich our ability to coordinate data collection, management and analysis. Then we need to embrace evidence-informed policy and practice to bridge the gap between research and the design and delivery of policy and practice that can improve the lives of children and youth and their families in this country.

I want to end by thanking all of you for your time, commitment and all you do for Canada's children and youth.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Georgiades.

We're going to begin now with rounds of questions, starting with the Conservatives.

Dr. Ellis, you have six minutes, please.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Mr. Chair, with the agreement of the other members of the committee, I would like to take a little time to acknowledge the tragedy that took place yesterday in Laval. I think it's necessary to do that given this committee's mandate, which is currently looking at children's health.

[The Chair, Liberal, Sean Casey]

I agree. We'll observe a minute of silence for the victims of the Laval tragedy.

[A moment of silence observed]

Thank you, colleagues.

Mr. Ellis, the floor is yours again.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you, Mr. Chair.

Thank you, colleagues, for that moment to reflect. I certainly think it's germane given the difficult topics we're talking about here and that we continue to discuss at the health committee.

Chair, I would like to start with Ms. Foster, specifically about the removal of GST and HST with respect to the services of counsellors and psychotherapists.

Could you just give us a brief idea of how that may affect accessibility and also how it may affect a practice? In my province it's 15% extra. Some people might not find that difficult. In my mind the argument is that sometimes the people that need the help the most are those who are suffering the most financially as well.

If you could provide some comments on that, I'd appreciate it. Thank you.

[Carrie Foster]

I think that in this day and age every penny counts with the increasing cost of food and all that. I think that 15%, which it is in my province of Quebec as well, will make a difference. I have clients phoning all the time asking for that.

It's one piece of a larger picture that still needs to be looked at in terms of accessibility to mental health care for all Canadians on an equal basis. Fifteen per cent is a lot for some.

I would suggest that it's an important piece that would allow, at least perhaps, those who can't afford 15%.... It means less to you perhaps than to the clients I work with. I work with victims of violence. I also work with indigenous folks. I work for the federal NIHB program for indigenous and Inuit folks. That makes a huge difference to them.

I think it's one piece—an easy ask—that would allow those who can't afford it more access.

Thank you.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you for that.

Through the Chair, can you talk a bit about the coverage for services?

As we know, many different services of health care providers are covered through the public system. Moreover, for some people who are fortunate enough to have private insurance plans, there's coverage.

Can you talk a bit about the membership of your organization and what percentage of your clients may have coverage through other programs?

[Carrie Foster]

I can't give you the exact number, but I know that counsellors and psychotherapists nationally—and it differs from province to province—aren't necessarily all on par with the insurance companies that are out there. We are working with the the Canadian Life and Health Insurance Association to try to get them to include psychotherapists as much as they include psychologists and social workers.

Our membership, our indigenous folks.... There are creative arts therapists, there are those who work in social justice contexts and in schools. Not all of them will have access to counselling. That's a huge piece. That's a huge ask. We're not even asking for that today, but it's a big piece that needs to be looked at, in my humble opinion, as to how people can get access.

Yes, there is some availability. Not all counselling therapists and psychotherapists are admitted into all of the programs. At this point, we have been removed from the NIHB program. We were added during the pandemic. Presumably when and if the pandemic ends, we'll be taken out again.

That means that indigenous folks who work with us who have their Canadian certified counsellor permit will not be allowed to work in their communities, with their people, because they're CCCs.

I think it's really important that we look at what that is, so that we have not just early access to mental health, but also.... That gentleman in Laval...perhaps if he'd had help earlier on and had had access to services, he wouldn't have been doing what he was doing.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

I understand. Thank you.

Once again, this is through you, Chair. In my mind, we have a mental health crisis in this country. Perhaps a third of people are suffering with difficulties with their mental health.

How impactful do you think it would be if the Liberal government of the day actually transferred the $4.5 billion promised in the Canada mental health transfer? How transformative could that be to the delivery of mental health care services and, obviously, to the mental health of Canadians?

[Carrie Foster]

I'm not a financial expert, and I don't think it would be my place to answer that question. All I would say is that I think those parties involved in getting access for kids, access to mental health and youth access to mental health.... That's the important part. I will let you guys work out how you do it.

Did you have anything to add to that, Lindsey?

[Lindsey Thomson, Director, Public Affairs, Canadian Counselling and Psychotherapy Association]

Can you repeat the question, please?

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Absolutely. I'd love to.

Certainly, we understand that in Canada, there's a significant mental health crisis, with almost a third of Canadians suffering with their mental health. We know that the Liberal government has continued to promise a $4.5-billion Canada mental health transfer, which has not been actioned. In my mind, that type of money could be transformative, not only to the delivery of services, but obviously to the lives of the many Canadians who are suffering.

I wonder if you had a comment on how that may affect the delivery of services and the lives of the people you serve.

[Lindsey Thomson]

Absolutely, I can add to that.

I think the impact that it can have is beyond what we can possibly imagine. Some of the biggest issues that we're seeing are wait times. We know, depending on whether we're urban versus rural, we can be waiting for children's services for up to two and a half years. This is not to be dramatic, but this can literally be a life-or-death situation. We're seeing that the number of mental health struggles among children has increased exorbitantly due to the pandemic, lockdown and isolation and all they cause, as we are very social beings.

With that, it could help to increase standardization of service across the system. We know right now that there are some things that different governments are doing. For example, in Ontario, there's the structured psychotherapy program, which provides short-term psychotherapy and CBT, specifically. It's an amazing program, but let's see how we can bolster that and fill in the gaps.

For me, this is, absolutely, a great idea. It's a starting point to help increase the standardization of access to different services, while also ensuring that we're not only providing certain types of therapies. We have to be able to give people the choice they want. Just because a particular therapist is available, it doesn't mean that they're going to jibe with that client.

Therapy is all about that human connection and that relational connection. It's very different from what we might experience with going to see a physician who does a diagnosis of physical symptoms. We want to make sure it's not just, “Okay, this person is in front of you. Figure it out”, but giving them options to determine what's best for their needs, whether that's cognitive behavioural therapy, arts therapy, sand therapy or whatever that might be.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Thomson.

Next we have Mr. Jowhari, please, for six minutes.

[Majid Jowhari, Liberal, Richmond Hill, ON]

Thank you, Mr. Chair.

Right away I want to acknowledge my colleague's early intervention about the event that happened yesterday and thank him. I also thank you for the moment of silence.

Welcome to all of the witnesses today.

This is a very important topic. It's very important to me as the founder of the all-parliamentary mental health caucus. I am very much invested in this.

I'm going to start with Ms. Foster.

In your opening remarks, you talked about demand outweighing capacity. Naturally, when we look at the study that we are doing, the demand that we are focusing on is children, especially children at the early stages, and the capacity is now where I want to focus. Often when I talk to different professional service providers, especially on mental health and mental wellness, what they're talking about.... If we look at capacity in a much broader sense rather than just the psychotherapist or the counselling therapist and include intervention at the early stages, then we may not be in as bad a situation as we are.

I would like to know your point of view on that.

[Carrie Foster]

I think the earlier we can intervene, going down the road, the less....

I work with kids and families as a couple and family therapist. If I can intervene when they're four, five and six.... I have clients who have had trauma at that age, as the Laval kids will have at this point.... If we can intervene now, then perhaps when they're 12, when they're 20, when they're 40 or when they're 50, they won't need those many services.

The earlier we get to it, the less chance there is of children or young adults reaching a crisis level of need for therapy and not being able, once again, to get the service. Hopefully, in the long-term picture, we can reduce the number of sessions required per capita, if you want.

[Majid Jowhari, Liberal, Richmond Hill, ON]

Ms. Thomson, you talked about bringing in other practitioners. You talked about a cognitive behavioural therapist. You talked about art therapists. I also consider those to be part of the capacity which that demand falls into.

Can you give us your point of view in looking at capacity in a much broader sense rather than just the psychotherapist or just the psychologist?

[Lindsey Thomson]

Absolutely.

I will share that I am also a registered psychotherapist who has been in practice for many years.

I think we need to get a little bit more creative in how we look at psychotherapy practice. A big part of that, of course, is education of the public about the different therapeutic modalities that are offered. From the research I've done, there are over 200 different types of therapy that we could have available, and that is so important to what's available for Canadians.

As an example, I provide cognitive behavioural therapy. Carrie works with children, so it's going to be a little bit of a different angle. It's all about what works for your individual personality. I am a type A, so CBT works for me and for the clients I work with. Some other individuals might prefer to work with—I'll try to give an example—narrative therapy or internal family systems. I'm happy to provide definitions of what all these different therapies mean, because there are many.

When we offer up the scope of the different types of therapies provided, we're giving more access to Canadians at whatever stage they're at, whether they're struggling with substance use, whether they're survivors of domestic violence or whether they've gone through traumatic events. There are so many different types of therapies that research demonstrates do match this particular and unique need.

Another thing I'd like to add to Carrie's earlier point is that if we focus on early intervention and preventative care, that's going to have a huge ripple effect on the cost to the government in the long run, not just the government but also the workforce in terms of absenteeism, the effects on families and how they're able to give back to the economy and be able to participate in Canadian life.

[Majid Jowhari, Liberal, Richmond Hill, ON]

Thank you.

I'm going to go to the partisan part of my question period.

My colleague Dr. Ellis asked how impactful that $4.5 billion could be. Indeed, it is impactful. However, having money thrown out there without having accountability, transparency and measures of where it's been spent has been a challenge. As you know, in 2017 our government spent $5 billion on transfers to provinces for mental health. You testified that you haven't seen any improvement in access. You haven't seen improvement in increasing capacity in dealing with that.

Therefore, I'd like to know your point of view on welcoming the $4.5 billion, as we agreed, and the types of measures you would really like to see that support transparency, accountability and, most importantly, access for our children.

[Lindsey Thomson]

Absolutely.

In terms of measures it's definitely about having some kind of structure and standardization in place, and a set level of criteria of whom the money is being made available to. It's making sure that a certain percentage of the funds are being earmarked directly for community services and agencies to be able to support those who need it most, who don't have the extra 15% on top of the session fee to be able to afford more sessions. For me, it's really about about having structure and oversight.

It's also about having flexibility, because the need province by province is very different. Ottawa as an urban centre is very different from rural Manitoba. It's very different from the state of affairs in B.C. with the opioid crisis there. We really have to make sure that there's structure, but also flexibility, to have a good flow with it.