Photo caption: Isaac (centre) stands in front of Niagara Falls, with his mother on the right and his sister on the left (photo credit: Supplied by Isaac's father, Roy).
By: Suelan Toye, Senior Communications Associate, Holland Bloorview Kids Rehabilitation Hospital
Isaac, a lively teen who enjoys biking, swimming and long walks, was diagnosed with autism and an intellectual disability at age three. As he grew older, his behaviour became more challenging, and his family struggled to find the right support.
In early 2024, they were referred to Extensive Needs Service (ENS) where Isaac began intensive treatment. He is just one of more than 1,100 children and teens supported by ENS each year, a collaborative initiative between Holland Bloorview Kids Rehabilitation Hospital, CHEO, and McMaster Children's Hospital that provides tailored wrap-around clinical supports to vulnerable children and youth with urgent and complex medical, developmental, and social challenges, and their families.
ENS services included developmental paediatrics, psychiatry, behaviour therapy, speech-language pathology and occupational therapy to support Isaac. His parents received emotional support from a family therapist. The care team also coached them on strategies to better support Isaac at home and in the community, empowering the family with tools to help Isaac navigate daily life more smoothly.
Since ENS's launch in April 2023, Holland Bloorview has expanded the service across the Greater Toronto Area through partnerships with Grandview Kids (Durham Region), Children's Treatment Network (York Region) and Michael Garron Hospital (East Toronto). These partnerships have enabled the program to reach families in communities where the needs are the greatest, providing timely and comprehensive care. In the 2024–25 fiscal year alone, Holland Bloorview and its community partners supported 378 children and youth and their families.
“With provincial funding, we're delivering the specialized, compassionate care that children and families truly need," says Kathryn Decker, program lead. “Our multidisciplinary teams across our network are helping kids thrive - staying in school longer and rediscovering joy. Parents and caregivers are experiencing reduced stress and gaining the support they need to restore balance in their lives."
To ease the burden on families, Holland Bloorview ENS clients are paired with service coordinators from Surrey Place, who assist with appointment management and navigating care.
Through a partnership with VHA Home HealthCare, ENS also extends support into families' homes, offering in-home care for children and youth. Isaac's family is one of many who have received support navigating specialized funding, housing and in-home respite care - helping ensure continuity of care and reducing stress for caregivers.
In January, a community of practice was launched to strengthen collaboration and develop new models of care across their unique disciplines among ENS teams at Holland Bloorview, CHEO, and McMaster Children's Hospital and their community partners, eliminating silos within these organizations. These meetings enable clinicians to share case studies, discuss challenges and exchange best practices—fostering a culture of continuous learning and improvement.
To support clients and families new to the service, Holland Bloorview will offer a welcome package that is available in multiple languages. The accessible resource gives parents and caregivers an overview of their care journey and how their child will be supported by a multidisciplinary team, from behaviour and occupational therapy to nutrition and medication management.
As for Isaac, since his discharge from the program earlier this year, he is staying at a group home to receive full-time support for approximately a year. He and his family are also able to enjoy a few day excursions together.
"With the skill he's learned, Isaac has made great progress," Roy, Isaac's dad, shares. “The program builds on each child's strengths to help them move forward. It feels like a big load is lifted off our shoulders."