Review: 17-year-old Makayla 2015 December

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MAKAYLA: An Investigative Review 1

17-YEAR-OLD MAKAYLA:SERIOUS INJURY

An Investigative Review

DECEMBER 2015



Under my authority and duty as set out in the Child and Youth Advocate Act (CYAA),

I am providing the following Investigative Review regarding the serious injury of a17-year-old youth who was, at the time, receiving services from the Government of Alberta.

Consistent with Section 15 of the CYAA, the purpose of this report is to learn from this sad

circumstance and recommend ways of improving Alberta’s child intervention system.

While this is a public report, it contains detailed information about children and families.

Although my office has taken great care to protect the privacy of the youth and her family,

I cannot guarantee that interested parties will not be able to identify them. Accordingly, I

would request that readers and interested parties, including the media, respect this privacy

and not focus on identifying the individuals and locations involved in this matter.

In accordance with the CYAA, the names used in this report are pseudonyms (false

names). Finding an appropriate pseudonym is difficult because a young person’s name

is part of who they are. However, it is a requirement that my office takes seriously and

respectfully. In this situation, the young person has chosen to call herself, Makayla.

We met with Makayla and her care providers through the course of completing this review.

Their thoughts and experiences were critical to our understanding and are incorporated

into this report.

Makayla is a young woman of First Nation ancestry who was seriously injured when she

attempted suicide. She had significant involvement with Child Intervention Services and

was first removed from her parents’ care when she was about seven years old. When she

was only 12 years old, there were extended periods of time when her whereabouts were

not known. She had over 20 placements by the time she was 17 years old. While Makayla

has recovered physically from her injuries, she still has difficulties emotionally.

This review highlights the importance of stable relationships for young people. It is critical

that their life experiences and traumatic events are considered in case planning. I am

making two recommendations that will improve services for Alberta’s children and youth.

[Original signed by Del Graff]

Del Graff

Child and Youth Advocate

#600, 9925 109 Street NW, Edmonton, AB T5K 2J8 | www.ocya.alberta.ca | 800 661-3446 | 780 422-6056



EXECUTIVE SUMMARY ..................................................................................................................5

INTRODUCTION ...............................................................................................................................8

The Office of the Child and Youth Advocate ...........................................................................................8

Investigative Reviews ...........................................................................................................................................8

ABOUT THIS REVIEW ...................................................................................................................10

BACKGROUND ................................................................................................................................ 11

About Makayla........................................................................................................................................................ 11

About Makayla’s Family ..................................................................................................................................... 11

MAKAYLA’S HISTORY OF INVOLVEMENT

WITH CHILD INTERVENTION SERVICES ................................................................................. 12

Makayla from Birth to 11 Years Old .............................................................................................................. 12

Makayla from 12 to 14 Years Old ................................................................................................................... 12

Makayla at 15 Years Old ..................................................................................................................................... 13

Makayla from 16 to 17 Years Old ................................................................................................................... 13

Makayla — Current Circumstances ..............................................................................................................14

DISCUSSION.................................................................................................................................... 15

The Effect of Loss and Trauma on Children and Youth .................................................................... 15

The Importance of Reducing Placement Moves ...................................................................................16

CLOSING REMARKS FROM THE ADVOCATE .......................................................................... 19

APPENDICES.................................................................................................................................. 20

Appendix 1: Terms of Reference ................................................................................................................... 21

Appendix 2: Committee Membership .......................................................................................................23Appendix 3: Summary of Makayla’s Placements .................................................................................25

Appendix 4: Bibliography ...............................................................................................................................26

CONTENTS




EXECUTIVE SUMMARY

Alberta’s Child and Youth Advocate (“the Advocate”) is an independent officerreporting directly to the Legislature of Alberta, deriving his authority from the Child and

Youth Advocate Act (CYAA). The Advocate has the authority to conduct investigations

into systemic issues related to the serious injury or death of a child receiving designated

services.

In 2014, 17-year-old Makayla (not her real name)1 was hospitalized after a suicide

attempt. At the time, she was residing in a Room and Board2 situation and was the

subject of a Permanent Guardianship Order.3 Makayla has recovered from the injuries

related to her suicide attempt; however, she continues to struggle emotionally.

The information gathered through this Investigative Review revealed two issues related

to the systems that serve children and families:

1. The Effect of Loss and Trauma on Children and Youth

2. The Importance of Reducing Placement Moves


Makayla experienced many losses and traumatic events. She was physically, sexually

and emotionally abused, had several placement moves (both planned and unplanned),

and she was separated from her siblings. In addition, when Makayla was 17 years old her

mother died. Over time, she lost contact with her brothers and sisters; and, after eachmove, her involvement with her care providers ended. Makayla was unable to maintain

relationships with those whom she felt closest to.

Continuity in relationships, recognition of trauma and supports to address that trauma

are essential components to a child’s success and development as they grow into

adulthood. It is imperative that past trauma be acknowledged and addressed; and,

relationships be considered when children are removed from their parents’ care.

1 All names throughout this report are pseudonyms to ensure the privacy of the child and family.

2 A placement in which, for a fee, a youth is provided with a place to live and meals.

3 An order in which the court awards guardianship of the child to the Director on a permanent

basis. The child is in the care of the Director and remains in an approved placement. The

guardianship of any former guardian is terminated and the Director is the sole legal guardian of

the child.



6 OFFICE OF THE CHILD AND YOUTH ADVOCATE


Makayla had over 20 placements during her involvement with Child Intervention

Services. A psychological assessment indicated Makayla would benefit from a

placement with clearly defined rules and boundaries. It was also recommended that

potential care providers be assessed prior to her placement to determine if they had

the capacity to meet her needs.

Makayla had a number of placements with extended family members through kinship

care4 arrangements. Care providers were often not aware of her behavioural issues and

needs; assessments were not completed prior to placement. Kinship placements did not

appear to have the structure that Makayla required; nor, were care providers given the

supports and resources that might have made Makayla’s placement successful.

Child Intervention Services has policies regarding factors to consider when placing a

child. These include information sharing, assessing care provider capacity and providing

resources to care providers and children when they are struggling.

The number of placements Makayla experienced and the rationale for the moves is

concerning and likely affected her ability to attach and bond with her care providers.

To address these issues and to help improve the effectiveness of Alberta’s services to

children, the Advocate makes the following two recommendations:

Recommendation 1

The Ministry of Human Services and its service delivery partners should ensure

that:

a) Young people involved with Child Intervention Services are assessed to

identify the impact traumatic events have had on them;

b) Case plans should detail interventions to directly address the identified

trauma including resources required and expected outcomes; and,

c) Interventions are reviewed on a regular basis and progress documented.

4 Refers to a home that is approved to care for a child in need because of a family connection or

significant relationship with the child (e.g., grandparent, aunt, close family friend).




Recommendation 2


that placement moves for children and youth are planned. In situations where

unplanned moves are unavoidable, mitigation strategies to address the impact

of such moves are identified and documented.




INTRODUCTION

The Office of the Child and Youth Advocate

Alberta’s Child and Youth Advocate (the “Advocate”) is an independent officer

reporting directly to the Legislature of Alberta. The Advocate derives his authority from

the Child and Youth Advocate Act (CYAA),5 which came into force on April 1, 2012.

The role of the Advocate is to represent the rights, interests and viewpoints of children

receiving services through the Child, Youth and Family Enhancement Act 6 (the

Enhancement Act ), the Protection of Sexually Exploited Children Act 7 (PSECA), or from

the youth justice system.

Investigative ReviewsSection 9(2)(d) of the CYAA provides the Advocate with the authority to conduct

Investigative Reviews. The Advocate may investigate systemic issues arising from a

serious injury to or the death of a child who was receiving a designated service at

the time of the injury or death if, in the opinion of the Advocate, the investigation is

warranted or in the public interest.

Upon completion of an investigation under this section of the CYAA, the Advocate

releases a public Investigative Review report. The purpose is to make findings regarding

the services that were provided to the young person and make recommendations that

may help prevent similar incidents from occurring in the future.

An Investigative Review does not assign legal responsibilities, nor does it replace other

processes that may occur, such as investigations or prosecutions under the Criminal

Code of Canada. The intent of an Investigative Review is not to find fault with specific

individuals, but to identify key issues along with meaningful recommendations, which are:

• prepared in such a way that they address systemic issue(s); and,

• specific enough that progress made on recommendations can be evaluated; yet,

• not so prescriptive to direct the practice of Alberta government ministries.

5 Child and Youth Advocate Act , S.A. 2011, c. C-11.5.

6 Child, Youth and Family Enhancement Act , RSA 2000, c. C-12.

7 Protection of Sexually Exploited Children Act , RSA 2000, c. P-30.3.




It is expected that ministries will take careful consideration of the recommendations,

and plan and manage their implementation along with existing service responsibilities.

The Advocate provides an external review and advocates for system improvements

that will help enhance the overall safety and well-being of children who are receiving

designated services. Fundamentally, an Investigative Review is about learning lessons,

rather than assigning blame.




ABOUT THIS REVIEW

In 2014, the Advocate received a report of serious injury regarding 17-year-old Makayla.She was hospitalized after attempting suicide. Makayla has recovered physically, but she

continues to struggle emotionally. She engages in self-harming behaviours and does

not have a stable placement. Makayla voiced that she has difficulty with feeling a sense

of belonging.

The Advocate thoroughly reviewed file information provided by the Ministry of Human

Services. An initial report was completed that identified potential systemic issues. The

Ministry was subsequently notified that there would be an Investigative Review.

Terms of Reference were established and are provided in Appendix 1. A team gathered

information and conducted an analysis of Makayla’s circumstances through a review of

relevant documentation, interviews and research. The team also met with Makayla and

her care providers.

A preliminary report was completed and presented to a committee of subject matter

experts who provided advice related to findings and recommendations. The list of

committee members is provided in Appendix 2. Committee membership included a

First Nation Elder and experts in the fields of social work best practices, high-risk youth

and engagement with Aboriginal communities.




BACKGROUND

About Makayla

Makayla is petite and soft-spoken. She is an avid athlete who enjoys playing team

sports. She is interested in becoming an aesthetician. One of her favorite pastimes is

spending time with friends and family.

Makayla is the third of a large sibling group and lives in her First Nation community.

There were periods when she lived away from her community and longed to be with

her family.

About Makayla’s Family

Makayla’s mother, Sharon, experienced many traumatic events. She had difficulty caring

for her children because of substance abuse, family violence and suicidal behaviours.

Although Sharon worked cooperatively with Child Intervention Services, she continued

to struggle and as a result, her children became subjects of Permanent Guardianship

Orders. Sharon died from addiction-related causes when Makayla was 17 years old.




MAKAYLA’S HISTORY OF INVOLVEMENTWITH CHILD INTERVENTION SERVICES

Makayla from Birth to 11 Years Old

During her first six years, Makayla and her family had sporadic involvement with Child

Intervention Services.8 The children remained at home or with extended family members.

Makayla was first placed in foster care, with her siblings, when she seven years old

due to her mother’s addictions. The children remained in the foster home for about six

months and then returned to their mother’s care. About one year later, when Makayla

was eight years old, she and her siblings were apprehended when Sharon was arrested.

They were placed together in a foster home outside of their home community where

they stayed for four years. Makayla felt safe living with her brothers and sisters, but sheacted out in school. She did not understand why she was in care. School staff identified

that she was academically delayed and felt she needed an assessment and counselling.

Approximately three years after coming into care, Permanent Guardianship Orders9 were

granted on all the children.

About one year after the guardianship orders were granted, Makayla’s sister alleged that

their foster father abused them and they were removed from the home. Makayla and her

younger sister were placed together, but their other siblings were moved to different

placements and contact between them became sporadic.

Makayla from 12 to 14 Years Old

After the move from her first foster home when she was 12 years old, Makayla had four

placements over the course of one year. All of her care providers asked for her to be

moved because they were unable to manage her behaviours and they felt that extended

family members were interfering. Supports were not offered to maintain the placements.

Each time Makayla moved, she said she felt more disconnected and that

8 The family received Child Intervention Services from a Delegated First Nation Agency (DFNA).

The province has given delegations of authority under the Enhancement Act necessary to enable

First Nation agencies to provide child intervention services within the geographical boundaries of

the Reserves of their respective First Nation members. The Department of Aboriginal Affairs and

Northern Development Canada (AANDC) funds the agencies for the provision of Child and Family

Services on-Reserve.

9 An order in which the court awards guardianship of the child to the Director on a permanent basis.

The child is in the care of the Director and remains in an approved placement. The guardianship of

any former guardian is terminated and the Director is the sole legal guardian of the child.




no one really cared about her. She wanted to be with her family and see her brothers

and sisters. It was during this time that Makayla’s whereabouts were not always known.

Caseworkers noted that she went AWOL (absent without leave) and had “unknown

placements”.

From kinship care, Makayla moved to a group home where she stayed for almost a

year. She started cutting her arms and tried to hang herself. About one week after

the attempted hanging, she was taken to the hospital for suicidal ideations and

was diagnosed with Adjustment Disorder with Mixed Disturbance of Emotions and

Conduct.10 No resources or supports were offered to help Makayla or her care providers

deal with this diagnosis.

A month later, Makayla was placed with her aunt in her home community. After six

months, she was moved to a residential centre11 because she was abusing substances,

running away and having trouble at home and at school. Makayla said that she pushed

boundaries to test her aunt’s commitment to her.

Makayla at 15 Years Old

During her time at the residential centre, 15-year-old Makayla underwent psychological,

educational and behavioural assessments. The results indicated that she struggled with

aggression and was at increased risk of substance abuse. She required a placement

with clear rules and defined boundaries. It was recommended that Makayla stay

connected to counselling and positive outlets and supports, such as sports and a youth

worker.

After two months, Makayla was moved back to her aunt’s care. Shortly after, her aunt

expressed concerns because Makayla was having suicidal thoughts. Support through

respite care12 was offered but her aunt did not feel this was adequate. She could not

provide the level of care Makayla required and requested that she be moved. Makayla

was moved to a group home and felt another loss.

Makayla did well in the structured environment of the group home. She enjoyed school

and felt connected to staff and peers. Five months later, she was moved to a kinship

home where she did not follow the rules. She abused substances and skipped school.

Makayla wanted to see her brothers and sisters whom she had not seen for several

years. After four months in the kinship placement, she was moved to another group

home.

10 A short-term condition that occurs when a person is unable to cope with, or adjust to, a particular

source of stress, such as a major life change, loss, or event. With Mixed Disturbance of Emotions

and Conduct is a further category of Adjustment disorder based on specific symptoms.

11 A staffed placement that provides care for a child.

12 A support provided to caregivers whereby the child is cared for by another individual for a limited

period of time.




Makayla from 16 to 17 Years Old

When she was 16 years old, Makayla told her caseworker that she felt like killing herself

because of the uncertainty in her life. Placements and people were constantly letting

her down. She felt unwanted and unloved. A behavioural assessment was completed

that recommended Makayla be placed in a structured setting with defined rules, receive

counselling and that an assessment of any proposed kinship home be completed before

Makayla was placed.

Shortly before her 17th birthday, Makayla cut her arms and was taken to the hospital. She

said she wanted to make the pain inside go away. Six months later, Makayla disclosed that

she and her sisters were sexually abused in their foster home when she was eight years

old. The foster father admitted to the abuse and was charged. No supports or resources

were offered to help address her trauma.

Five months after her placement in the group home, Makayla moved to a Room and

Board13 placement. Over the next seven months, she had three Room and Board

placements. She said each time she moved, she lost a bit of herself.

Two months before her 18th birthday, Makayla was taken to the hospital for cutting

her wrists. A week later, her mother was found deceased. Within weeks, Makayla was

seriously injured and hospitalized after attempting suicide. She voiced that since coming

into care, she wanted to end her life. Despite being surrounded by people, she felt alone

and unloved. Makayla has since recovered from her physical injury but continues to have

emotional difficulties.

After her discharge from hospital, Makayla moved to a Room and Board placement with

family friends. For the first time since coming into care, Makayla said she felt like she was

home. She called the family friends “mom and dad” and felt they were committed to herand would not give up on her. They argued and made up much like other families. They

indicated that they never wanted Makayla to move out. In turn, she was committed to

them. Despite some ups and downs, Makayla did well in her new home and at school. She

was involved in sports and very connected to her culture.

Makayla’s sister moved in with her after a year. They had a volatile relationship, often

arguing and making up. Seven months after her sister moved in, Makayla cut her arms. She

said she could not handle the conflict with her sister and was having difficulty coping.

Makayla – Current Circumstances

After approximately 18 months, Makayla left the Room and Board placement. Her care

providers felt they could not keep her safe. Makayla’s whereabouts are currently not

known but she maintains contact with them and indicated that she is still in her First

Nation community; however, she is not enrolled in school.

13 A placement in which, for a fee, a youth is provided with a place to live and meals.




DISCUSSION

Two systemic issues were explored through the Investigative Review and discussedbelow:



The Effect of Loss and Trauma on Children and Youth

Makayla experienced many losses and traumatic events. She was physically, sexually

and emotionally abused, had several placement moves (both planned and unplanned),

she was separated from her siblings and her mother passed away when Makayla was 17

years old.

Research indicates that “cutting” (self-harm)14 is a coping strategy for some to self-

regulate.15 Makayla experienced significant disruptions in her formative years and

struggled to cope. When she was distressed, she said she could not see any other

options but to self-harm, a pattern that continued.

The acknowledgment of significant or traumatic events and providing supports to

work through the associated emotions can develop resiliency in children. Resiliency

in turn, can act as a protective factor. Exposure to adverse childhood experiences is

related to poor outcomes in all realms of adulthood including mental and physical

health, education and employment.16 Protective factors like connection to culture,

positive outlets (e.g., sports, art, etc.) and sense of self-mastery, along with placement

stability assists children in decreasing some of the impact of childhood trauma. Makayla

experienced many forms of loss and abuse which put her at a higher risk of suicide.

Occasionally, she received counselling, had a youth worker and was connected to her

culture. She indicated that it was during these times that she felt the most stable. These

resources were not available on a consistent basis.

In order for service delivery to be effective, there needs to be an awareness of a young

person’s history and experiences and how these have impacted them. Caseworkers

and caregivers must have an understanding of typical developmental milestones and

14 The act of deliberately harming your own body, such as cutting or burning yourself. It is typically

not meant as a suicide attempt. Rather, self-injury is an unhealthy way to cope with emotional

pain, intense anger and frustration.

15 Klonsky, 2009.

16 Bellis, et al., 2013.




the impact of maltreatment on development.17 It is essential that the impact of these

experiences are at the forefront of decision-making along with an understanding that a

child’s history influences their behaviour. Appropriate interventions ought to be utilized

to address the presenting behaviours, as well as the underlying trauma. In Makayla’s

circumstance, she required supports to help her deal with the loss and abuse she

suffered.

Recommendation 1


that:

a) Young people involved with Child Intervention Services are assessed to

identify the impact traumatic events have had on them;

b) Case plans should detail interventions to directly address the identified

trauma including resources required and expected outcomes; and,

c) Interventions are reviewed on a regular basis and progress documented.

The Importance of Reducing Placement Moves

Makayla had more than 20 placements. Her longest was in a foster home where she and

her siblings stayed for approximately four years.

Research indicates that greater numbers of placement changes are linked to poor

outcomes for children.

18

Consistency in care providers results in secure attachment andhelps children develop emotional regulation and self-confidence and the child learns to

function competently and autonomously. Multiple moves have a negative impact on a

child’s ability to develop trust.19 Children are less likely to form meaningful attachments

when they do not know what to expect and have little or no sense of stability.

Makayla said she tested her care providers’ commitment to her through acting out. She

wanted to know if they truly loved her and would be there through good and bad times.

Many of her placements were with extended family. When these placements broke

down, the impact was more significant because she felt rejected by family members.

17 Alberta Human Services, 2015.

18 Barber, Delfabbro & Cooper, 2001.

19 Casanueva,et al., 2013.




Research indicates that providing appropriate supports to care providers can prevent

placement breakdowns.20 A theme that emerged in this review was that care providers

were not aware of Makayla’s behavioural needs or her history. Aside from respite

care, additional supports and resources were not available to help them deal with her

behaviours. They felt a significant loss when Makayla moved because their contact with

her ended. Kinship care providers are in a difficult position because the children theycare for are family members and breakdowns impact the family dynamics. A continuum

of supports and resources must be available to maintain a child’s placement. Providing

training, supports and resources to kinship care providers is a recommendation that

was previously made in “Remembering Brian, An Investigative Review.”21

Makayla had a number of group home placements in which her behaviours stabilized.

There were several assessments that recommended a placement with clearly defined

rules and boundaries. When she was in a placement that could provide this structure,

Makayla excelled academically, socially and behaviourally; she was connected to

positive supports like counselling and a youth worker. The instances of self-harm

decreased and her high-risk behaviours diminished.

There was also a recommendation from an assessment, that potential care providers be

assessed before Makayla was placed with them to determine their capacity to care for

her. Research indicates that building care providers’ capacity to manage children with

difficult behaviours can lead to preventing placement breakdowns.22 Makayla was often

placed with extended family members, some of whom she did not know. Thorough

home assessments were not completed so it was not known if they had the ability to

provide the level of care that she required. Also, the lack of supports and resources,

especially during times of crisis, led to the breakdown of several of these placements.

It is imperative that when a child comes into care, Child Intervention Services staff

and caregivers are aware of the child’s specific needs. When exploring potential

care providers (kinship or foster care), caseworkers need to assess their skill level to

determine if they have the knowledge, skills and abilities to meet the child’s needs. If

they cannot, then supports and resources need to be provided so that the placement is

successful and long-lasting.

As previously mentioned in “Two-Year-Old Teanna: Serious Injury, An Investigative

Review,”23 ongoing assessment of a care provider’s capacity is essential to ensuring

the success of a placement. In addition, “8-Year-Old Ella, An Investigative Review,”24

20 Terling-Watt, 2001.

21 Office of the Child and Youth Advocate – Alberta, June 2013.

22 Dore & Eisner, 1993.

23 Office of the Child and Youth Advocate - Alberta, November 2015.

24 Office of the Child and Youth Advocate - Alberta, July 2015.




recommended that the Ministry of Human Services identify a continuum of placement

options for children and youth.

Child Intervention Services has a number of policies regarding factors to consider when

placing a child that include information sharing, assessing care provider capacity and

providing resources to care providers and children when they are struggling. There

are also policies related to standardized training, supports and resources specifically

for kinship care providers. And, there is a discussion paper, Foundations of Caregiver

Support25 that specifically addresses capacity building with care providers.

If the recommendations from previous Investigative Reviews are implemented, existing

policies adhered to and the philosophies outlined in the Foundations of Caregiver

Support are promoted, children will be less likely to experience multiple moves and

therefore, have the opportunity to form secure and healthy attachments.

Makayla said she lost a bit of herself each time she moved. She felt distant and

disconnected.

Recommendation 2


that placement moves for children and youth are planned. In situations where

unplanned moves are unavoidable, mitigation strategies to address the impact

of such moves are identified and documented.

25 Alberta Human Services, 2015.




CLOSING REMARKSFROM THE ADVOCATE

I would like to thank Makayla, her care providers and other professionals who spoke

with us and provided some insight into her life and her experiences. This helped us

understand the systemic issues that arose from this terrible circumstance.

Makayla’s story is distressing; however, not uncommon for children involved with the

child intervention system. Unfortunately, there are young people who experience

several placement moves and lose connections with those closest to them, including

their brothers and sisters. I am not making a recommendation related to the importance

of maintaining sibling relationships because it is addressed in child intervention policy.

However, I cannot emphasize enough the importance of the loss that Makayla felt when

she lost contact with her brothers and sisters.

Since 2012, my office has released five Investigative Reviews regarding young people

who have died by suicide or have had serious injuries resulting from suicide attempts.

I have made several recommendations related to improving service delivery for young

people like Makayla. Government must act upon them. When even one child feels that

ending their life is a way to make their pain stop, it is one too many!

[Original signed by Del Graff]

Del Graff

Child and Youth Advocate




APPENDICES




APPENDIX 1: TERMS OF REFERENCE

Authority:

Alberta’s Child and Youth Advocate (“the Advocate) is an independent officer reportingdirectly to the Legislature of Alberta. The Advocate derives his authority from the Child

and Youth Advocate Act (CYAA). The role of the Advocate is to represent the rights,

interests and viewpoints of children receiving services through the Child, Youth and

Family Enhancement Act , the Protection of Sexually Exploited Children Act or from the

youth justice system.

Section 9(2)(d) of the CYAA provides the Advocate with the authority to investigate

systemic issues arising from a serious injury to or the death of a child who was receiving

a designated service at the time of the injury or death if, in the opinion of the Advocate,

the investigation is warranted or in the public interest.

Incident Description:

In 2014, 17-year-old Makayla was hospitalized after a suicide attempt and the Advocate

subsequently received a Report of Serious Injury. The decision to conduct an

investigation was made by Del Graff, Child and Youth Advocate.

Objectives of the Investigative Review:

• To review and examine the supports and services provided to Makayla

• To comment upon relevant protocols, policies and procedures, standards and

legislation

• To prepare and submit a report which includes findings and recommendations

arising from the Investigative Review

Scope/Limitations:

An Investigative Review does not assign legal responsibilities, nor does it replace other

processes that may occur, such as investigations or prosecutions under the Criminal

Code of Canada. The intent of an Investigative Review is not to find fault with specific

individuals, but to identify and advocate for system improvements that will enhance the

overall safety and well-being of children who are receiving designated services.




Methodology:

The investigative process will include:

• Examination of critical issues

• Review of documentation and reports

• Review of Enhancement Act policy and casework practice

• Review of case history

• Personal interviews

• Consultation with experts as required

• Other factors that may arise for consideration during the investigation process

Investigative Review Committee:

The membership of the committee will be determined by the OCYA Director of

Investigations and the Advocate. The purpose of convening this committee is to review

the preliminary Investigative Review report and to provide advice regarding findings

and recommendations.

Chair: Del Graff, Child and Youth Advocate

Members: To be determined but may include:

A psychiatrist

An expert in the area of children’s mental health

A specialist in the area of child intervention best practices

Reporting Requirement:

The Child and Youth Advocate will release a report when the Investigative Review has

been completed.




APPENDIX 2: COMMITTEE MEMBERSHIP

DEL GRAFF, MSW, RSW (COMMITTEE CHAIR)

Del is the Child and Youth Advocate for the Province of Alberta. He has worked in avariety of social work, supervisory and management capacities in communities in British

Columbia and Alberta. He brings experience in residential care, family support, child

welfare, youth and family services, community development, addictions treatment and

prevention services. He has demonstrated leadership in moving forward organizational

development initiatives to improve service results for children, youth and families.

ELDER MARTIN EAGLE CHILD

Martin is from the Kainai First Nation, also known as the Blood Tribe of the Blackfoot

Confederacy. He grew up on the Blood reserve where he attended St. Mary’s residential

school. At the age of 19, Martin moved to Edmonton where he lived and worked for

several years. When he returned to the Blood reserve he became a farmer and rancher.

Martin has also represented the Kainai Nation members as a councilman. In later years,

he was employed with St. Paul’s Treatment Centre and the Blood Tribe Police. Martin is

a Medicine Pipe holder supporting Blood Tribe members in learning traditional songs

and ceremonies. He is also involved with the Catholic clergy and visits patients at the

Lethbridge Regional Hospital.

ELDER FRANCIS WHISKEYJACK

Francis is an Elder who is employed by the Edmonton Public School Board. He wears

a coat of many colours at Amiskwaciy Academy in his capacity as Elder, traditional art,

song and Cree instructor and Community Cultural Resource Advisor. He has been with

Amiskwaciy Academy for the past 13 years. Fluent in both English and Cree, Francis is

also an Adjunct Professor and Cultural Advisor at the University of Alberta.

BRUCE MACLAURIN, MSW, PhD (cand)

Bruce is an assistant professor with the Faculty of Social Work at the University of

Calgary. He was the co-investigator on the three cycles of the Canadian Incidence

Study of Reported Child Abuse and Neglect, as well as the Principal Investigator

for provincial studies in British Columbia, Alberta, Saskatchewan and the Northwest

Territories. His research and publishing has focused on child maltreatment, child welfare

service delivery and outcomes, foster care, youth at risk and street-involved youth. He

has more than 15 years of front-line and management experience in non-profit child and

family services in Alberta and Ontario.




FLORENCE GAUCHER

Florence is the Program Manager of Foster Care and Kinship for Métis Child and Family

Services. She has been employed with the agency for 15 years. Her experience in

working in the Human Services field started fresh out of college in the rural area of the

Peace River country 40 years ago. Florence has worked as a frontline worker delivering

all services to clients and later into supervisory and management positions. She is fluent

in Cree with real life experiences of living in a Métis community.

BRIANNA OLSON, BSW

Brianna is an Anishinaabe/Métis woman, registered social worker and member of

Wikwemikong First Nation, currently residing in Treaty 6 territory, Edmonton Alberta.

As a lifelong member of the inner city and Indigenous community and having practiced

over 10 years working with vulnerable youth populations, Brianna brings her lived

experience, identity, and critical approach to social work practice to her work. An

alumni of Grant MacEwan University, Brianna completed her Bachelor of Social Work

with an Indigenous specialization at University of Victoria in 2011. She is currently

working as a manager at iHuman Youth Society and has been the recipient of a number

of professional awards related to her work with high-risk youth.

CHRISTOPHER LALONDE, PhD

Christopher is a developmental psychologist and Professor of Psychology at the

University of Victoria. He is acting Vice-Chair of the Human Research Ethics Board at

the University of Victoria and the Graduate Student Advisor for the Department of

Psychology. He is currently collaborating with First Nations in British Columbia and with

the Assembly of Manitoba Chiefs in a research program that aims to better understand

how the promotion of First Nations cultures and the pursuit of self-determination are

associated with decreased youth suicide and injury rates.

STACEY RUNNING RABBIT, BPE, BEd

Stacey has been the teacher for the Siksika Medicine Lodge (SML) since January 2011.

She holds a Bachelor of Physical Education (BPE), Major in Leadership and a Bachelor

of Education (BEd), Major in Physical Education and Minor in Social Studies, both from

the University of Alberta. Prior to working at SML, she worked in both the provincial

and federal education systems, within Alberta and the Northwest Territories. Stacey

began her teaching career in Inuvik, NWT and has made her journey eventually to

southern Alberta. Stacey has vast experience in the multi-grade classroom environment

and programming for youth with learning difficulties.




6 Years Old

Kinship Care for 4 months

8–11 Years Old

Foster Care for approximately 4 years

13 Years Old


Residential Group Care for 11 months

17–18 Years Old


3 Room and Board Placements

15 Years Old


Placement Unknown* for 2 weeks


Placement Unknown* for 1 month

7 Years Old

Foster Care for 6 months

16 Years Old



12 Years Old





AWOL** for 1 month

14 Years Old

Foster Care for 1 day

AWOL** for 10 days


Kinship Care for 1 month

Kinship Care for 5 monthsResidential Treatment for 2 months

APPENDIX 3: SUMMARY OF MAKAYLA’S PLACEMENTS

* Placement Unknown - Notations on Makayla’s intervention file; it was not clear where she was

during these periods of time. Makayla recalled that she “bounced around”.

** AWOL (Absent Without Leave) - A term used by Child Intervention Services when a young person

leaves a placement without permission, often their whereabouts are not known.




APPENDIX 4: BIBLIOGRAPHY

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June_2015_Final.pdf

Barber, J.G., Delfabbro, P.H. & Cooper, L.L. (2001). The predictors of unsuccessful

transition to foster care. The Journal of Child Psychology and Psychiatry , 42, 785-790.

Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/1469-7610.00775/pdf

Bellis, M., Lowey, H., Leckenby, N., Hughes, K. & Harrison, D. (2013). Adverse childhood

experiences: Retrospective study to determine their impact on adult health behaviours

and health outcomes in the UK population. Journal of Public Health, 36(1), 81-91.

Retrieved from: http://jpubhealth.oxfordjournals.org/content/36/1/81.full.pdf+html

Barth, R.P. (2002). Institutions vs. foster homes: The empirical base for a century of

action. Chapel Hill, NC: University of North Carolina, School of Social Work. Retrieved

from: http://resourcecentre.savethechildren.se/sites/default/files/documents/2344.pdf

Casanueva, C., Dozier, M., Tueller, S., Dolan, M., Smith, K., Webb, M.B., … (2014). Caregiver

instability and early life changes among infants reported to the child welfare system.

Child Abuse & Neglect , 38 (2013), 498-509. Retrieved from: http://ac.els-cdn.com/

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00000aacb35f&acdnat=1445974453_b2fc086a9d82d15762640e26b4e28786

Child, Youth and Family Enhancement Act , Revised Statues of Alberta 2000, Chapter

C-12; current as of December 17, 2014. Alberta Queen’s Printer. Retrieved from: http://

www.qp.alberta.ca/1266.cfmpage=c12.cfm&leg_type=Acts&isbncln=9780779784585

Dore, M.M. & Eisner, E. (1993). Child-related dimensions of placement stability in

treatment foster care. Child & Adolescent Social Work Journal , 10, 301-317.

Enhancement Act Policy Manual, Revised April 2011.

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humanservices.alberta.ca/documents/Enhancement-Act-Policy-Manual.pdf

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London, England: Department for Education. Retrieved from: https://www.gov.uk/

government/uploads/system/uploads/attachment_data/file/182508/DFE-RR156.pdf

Klonsky, E.D. (2009). The functions of self-injury in young adults who cut themselves:

Clarifying the evidence of affect-regulation. Psychiatry Research, 166, 260-268.

Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723954/




Lieberman, A., Chu, A., Van Horn, P. & Harris, W. (2011). Trauma in early childhood:

Empirical evidence and clinical implications. Development and Psychopathology , 23,

397-410.

Lo, A., Roben, C.K.P., Maier, C., Fabian, K., Shauffer, C. & Dozier, M. (2015). “I want

to be there when he graduates:” Foster parents show higher levels of commitment

than group care providers. Children and Youth Services Review , 51, 95-100. Retrieved

from: http://ac.els-cdn.com/S0190740915000481/1-s2.0-S0190740915000481-

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Investigative Review . Edmonton, AB: Author. Retrievable from: http://www.ocya.alberta.

ca/wp-content/uploads/2014/08/InvRev_8-Year-Old-Ella_2015August.pdf

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An Investigative Review . Edmonton, AB: Author. Retrievable from: http://www.ocya.

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Office of the Child and Youth Advocate of Alberta. (2015, May). 16-year-Old Sam –

Serious Injury - An Investigative Review . Edmonton, AB: Author. Retrievable from:

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Sam_2015May27.pdf

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00000aacb361&acdnat=1445897638_fac3cae680842c2b6f2a6db98f5dc916



17-YEAR-OLD MAKAYLA: SERIOUS INJURY

AN INVESTIGATIVE REVIEW

NORTH OFFICE

#600, 9925 109 Street NW

SOUTH OFFICE

#406, 301 14 Street NW

www.ocya.alberta.ca

1 800 661 3446

Review: 17-year-old Makayla 2015 December

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