Review: 17-Year-Old Makayla 2015 December

17-YEAR-OLD MAKAYLA:
SERIOUS INJURY
An Investigative Review
DECEMBER 2015
MAKAYLA: An Investigative Review
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 a
17-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 Albertas 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 persons 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 Albertas 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
CONTENTS
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 Makaylas Family...................................................................................................................................... 11
MAKAYLAS 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........................................................................................................ 23
Appendix 3: Summary of Makaylas Placements.................................................................................. 25
Appendix 4: Bibliography................................................................................................................................ 26
EXECUTIVE SUMMARY
Albertas Child and Youth Advocate (the Advocate) is an independent officer

reporting 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 each
move, 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 childs 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.
All names throughout this report are pseudonyms to ensure the privacy of the child and family.
A placement in which, for a fee, a youth is provided with a place to live and meals.
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.

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 Makaylas 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 Albertas 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) Y
oung people involved with Child Intervention Services are assessed to
identify the impact traumatic events have had on them;
b) C
ase 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.
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).
OFFICE OF THE CHILD AND YOUTH ADVOCATE
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

Albertas 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 Act6 (the
Enhancement Act), the Protection of Sexually Exploited Children Act7 (PSECA), or from
the youth justice system.
Investigative Reviews
Section 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.
Child and Youth Advocate Act, S.A. 2011, c. C-11.5.
Child, Youth and Family Enhancement Act, RSA 2000, c. C-12.
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 Makaylas 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.
10
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 Makaylas Family

Makaylas 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.
11
MAKAYLAS HISTORY OF INVOLVEMENT

WITH 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 mothers addictions. The children remained in the foster home for about six
months and then returned to their mothers 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 she
acted 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, Makaylas 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
12
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.
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 Makaylas 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 aunts 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 aunts 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.
13
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 her
and 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.
Makaylas 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. Makaylas 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.
14
DISCUSSION
Two systemic issues were explored through the Investigative Review and discussed
below:
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 selfregulate.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
persons 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.
15
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
childs history influences their behaviour. Appropriate interventions ought to be utilized
to address the presenting behaviours, as well as the underlying trauma. In Makaylas
circumstance, she required supports to help her deal with the loss and abuse she
suffered.
Recommendation 1
that:
a) Y
oung people involved with Child Intervention Services are assessed to
identify the impact traumatic events have had on them;
b) C
ase 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 and
helps children develop emotional regulation and self-confidence and the child learns to
function competently and autonomously. Multiple moves have a negative impact on a
childs 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.
16
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 Makaylas 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 they
care for are family members and breakdowns impact the family dynamics. A continuum
of supports and resources must be available to maintain a childs 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 childs 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 childs 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 providers 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.
17
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.
18
CLOSING REMARKS
FROM 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.
Makaylas 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
19
APPENDICES
20
APPENDIX 1: TERMS OF REFERENCE
Authority:
Albertas 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). 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.
21
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 childrens 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.
22
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 a
variety 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. Marys 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. Pauls 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.
23
FLORENCE GAUCHER
Florence is the Program Manager of Foster Care and Kinship for Mtis 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 Mtis community.
BRIANNA OLSON, BSW

Brianna is an Anishinaabe/Mtis 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.
24
APPENDIX 3: SUMMARY OF MAKAYLAS PLACEMENTS
6 Years Old
Kinship Care for 4 months
7 Years Old
Foster Care for 6 months
811 Years Old

Foster Care for approximately 4 years
12 Years Old
Placement Unknown* for 1 month
AWOL** for 1 month
13 Years Old
Residential Group Care for 11 months
15 Years Old
Placement Unknown* for 2 weeks
14 Years Old
Foster Care for 1 day
AWOL** for 10 days
Kinship Care for 1 month
Residential Treatment for 2 months
16 Years Old
1718 Years Old
3 Room and Board Placements
Placement Unknown - Notations on Makaylas 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.
25
APPENDIX 4: BIBLIOGRAPHY
Alberta Human Services. (2015). Foundations of Caregiver Support. Edmonton, AB:

Author. Retrieved from: http://www.aascf.com/Foundations_of_Caregiver_Support_-_
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/
S0145213413002111/1-s2.0-S0145213413002111-main.pdf?_tid=488a18d4-7ce1-11e5-b72200000aacb35f&acdnat=1445974453_b2fc086a9d82d15762640e26b4e28786
Child, Youth and Family Enhancement Act, Revised Statues of Alberta 2000, Chapter
C-12; current as of December 17, 2014. Alberta Queens 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.
Enhancement Act Policy Manual, Revised November 27, 2014. Retrieved from: http://
humanservices.alberta.ca/documents/Enhancement-Act-Policy-Manual.pdf
Goodall, J. & Vorhaus, J. (2011). Review of best practice in parental engagement.
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/
26
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-S0190740915000481main.pdf?_tid=5694f782-7c2d-11e5-a5c8-00000aacb35f&acdnat=1445897167_
cdee7648206cdbeeba803e933ff87829
McWey, L.M., Acock, A. & Porter, B. (2010). The impact of continued contact with
biological parents upon the mental health of children in foster care. Children and Youth
Services Review, 32(10), 1338-1345. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC2928481/
Office of the Child and Youth Advocate of Alberta. (2013, June). Remembering Brian:
An Investigative Review. Edmonton, AB: Author. Retrievable from: http://www.ocya.
alberta.ca/wp-content/uploads/2014/08/InvRev_Remembering-Brian_2013June.pdf
Office of the Child and Youth Advocate of Alberta. (2015, November). Two-Year-Old
Teanna: Serious Injury, An Investigative Review. Edmonton, AB: Author. Retrievable from:
www.ocya.alberta.ca
Office of the Child and Youth Advocate of Alberta. (2015, July). 8-year-Old Ella: An
Investigative Review. Edmonton, AB: Author. Retrievable from: http://www.ocya.alberta.
ca/wp-content/uploads/2014/08/InvRev_8-Year-Old-Ella_2015August.pdf
Office of the Child and Youth Advocate of Alberta. (2014, November). 15-year-Old Tony:
An Investigative Review. Edmonton, AB: Author. Retrievable from: http://www.ocya.
alberta.ca/wp-content/uploads/2014/08/InvRev_15-Year-Old-Tony_2014November.pdf
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:
http://www.ocya.alberta.ca/wp-content/uploads/2014/08/InvRev_16-Year-OldSam_2015May27.pdf
Terling-Watt, T. (2001). Permanency in kinship care: An exploration of disruption
rates and factors associated with placement disruption. Children & Youth Services
Review, 23(2), 111-126. Retrieved from: http://ac.els-cdn.com/S0190740901001293/1s2.0-S0190740901001293-main.pdf?_tid=6f5411a8-7c2e-11e5-beb100000aacb361&acdnat=1445897638_fac3cae680842c2b6f2a6db98f5dc916
27
17-YEAR-OLD MAKAYLA: SERIOUS INJURY

AN INVESTIGATIVE REVIEW
NORTH OFFICE
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#600, 9925 109 Street NW
#406, 301 14 Street NW
Edmonton AB T5K 2J8
Calgary AB T2N 2A1
www.ocya.alberta.ca
1 800 661 3446

Review: 17-Year-Old Makayla 2015 December

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17-YEAR-OLD MAKAYLA:

MAKAYLA: An Investigative Review

[Original signed by Del Graff]

Albertas Child and Youth Advocate (the Advocate) is an independent officer

MAKAYLA: An Investigative Review

2. The Importance of Reducing Placement Moves

OFFICE OF THE CHILD AND YOUTH ADVOCATE

MAKAYLA: An Investigative Review

The Office of the Child and Youth Advocate

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.

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

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

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

OFFICE OF THE CHILD AND YOUTH ADVOCATE

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

MAKAYLA: An Investigative Review

ABOUT THIS REVIEW

OFFICE OF THE CHILD AND YOUTH ADVOCATE

About Makaylas Family

MAKAYLA: An Investigative Review

MAKAYLAS HISTORY OF INVOLVEMENT

Makayla from Birth to 11 Years Old

Makayla from 12 to 14 Years Old

OFFICE OF THE CHILD AND YOUTH ADVOCATE

Makayla at 15 Years Old

A staffed placement that provides care for a child.

MAKAYLA: An Investigative Review

Makayla from 16 to 17 Years Old

Makayla Current Circumstances

OFFICE OF THE CHILD AND YOUTH ADVOCATE

The Effect of Loss and Trauma on Children and Youth

MAKAYLA: An Investigative Review

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

The Importance of Reducing Placement Moves

17 Alberta Human Services, 2015.

OFFICE OF THE CHILD AND YOUTH ADVOCATE

MAKAYLA: An Investigative Review

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

25 Alberta Human Services, 2015.

OFFICE OF THE CHILD AND YOUTH ADVOCATE

[Original signed by Del Graff]

MAKAYLA: An Investigative Review

OFFICE OF THE CHILD AND YOUTH ADVOCATE

APPENDIX 1: TERMS OF REFERENCE

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

To prepare and submit a report which includes findings and recommendations

MAKAYLA: An Investigative Review

Examination of critical issues

Review of documentation and reports

Review of Enhancement Act policy and casework practice

Review of case history

Consultation with experts as required

Investigative Review Committee:

Del Graff, Child and Youth Advocate

To be determined but may include:

An expert in the area of childrens mental health

A specialist in the area of child intervention best practices

OFFICE OF THE CHILD AND YOUTH ADVOCATE

APPENDIX 2: COMMITTEE MEMBERSHIP