Investigation into the Death of Makayla K.
released February 18, 2004
conducted by Connecticut's Child Fatality Review Panel

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Key elements of the report: 

On May 21, 2002 Makayla’s mother held her teenage daughter in her arms and rocked her slowly until Makayla’s heart stopped beating and she was dead.  Three days before, the sixteen-year-old had been drinking alcohol at a party and later took the drug known as Ecstasy.  She suffered seizures that would not stop.  Before she died Makayla gained forty pounds of bloating fluids as her liver and kidneys ceased to function.  Makayla, at her death, was unrecognizable to her mother.  

The Office of the Child Advocate (OCA) and the Child Fatality Review Panel commenced an investigation into the death of Makayla K. on June 19, 2002 upon receiving notice of her death from the state Office of the Chief Medical Examiner.  The notice indicated that the child’s death resulted from respiratory arrest due to seizures lasting five hours that were caused by ingesting Ecstasy. 

Although not a youth well known to state agencies, Makayla did require specific services and supports for education, mental health and substance abuse treatment, running away from home, and ultimately a drug overdose and death. 

Given the manner of her death, the rising and persistent use of Ecstasy among adolescents in Connecticut, and the special needs Makayla experienced, the OCA and the Child Fatality Review Panel agreed to conduct a full investigation.  The purpose was twofold.  First, to review Connecticut systems’ response to adolescent health needs.  And second, to educate citizens about the risks associated with drug and alcohol use, particularly the drug Ecstasy, upon Connecticut youth.  

Findings

Several specific themes were identified in Makayla’s story that reflect a system’s perspective of fatality prevention:

Schools:

• Makayla had identified mental health concerns early on that were not addressed.
• Makayla’s anxiety and depression identified at a young age were then not accommodated in an educational program in accordance with Section 504 of the Rehabilitation Act.  
• School drug prevention programs in Connecticut are outdated and ineffective. 

Health professionals:

·         Primary Care Providers

Makayla’s family physician was not aware that Makayla was abusing drugs and alcohol, that she was troubled by having been raped and exposed to domestic violence or that early school testing identified her patient as suffering anxiety and depression.  During the period that the physician treated Makayla for bed wetting, records indicated that there was an awareness of the neuropsychiatric testing administered by the school.  However, the records also indicated that testing was “negative.”  The findings were clearly not communicated accurately.  The source of the findings is not clear.  There was no evidence in medical records that a comprehensive approach to adolescent care was used, such as the Guidelines for Adolescent Preventive Services recommended by the American Medical Association.  

·         Community-based Therapists

Makayla disclosed her most troubling problems to her therapist.  The community-based therapist communicated all concerns to other providers, the client and the client’s family. Through that communication a referral was made to better suited professionals to address rape crisis intervention.  However, the referral was not facilitated immediately, and ultimately never occurred.  Makayla’s mother responded to news of the rape by first being upset and then dismissing it.  She was not referred for her own counseling and support as the parent of a rape victim.

·         Acute Care Providers (Psychiatric hospital)

Despite Makayla’s condition being identified and/or diagnosed, her therapeutic goals did not fully address her needs, particularly in the area of trauma.  Once stable, she was discharged without a comprehensive discharge plan to address those needs.  The only referral Makayla was given was for a substance abuse program.  There were no referrals for treatment of post traumatic stress disorder, depression or any of Makayla’s other concerns.  All of those conditions may have been triggers to her substance use.  There was also no clarity of crisis management or emergency contacts for Makayla’s family should crisis occur

·         Outpatient Treatment Programs

Makayla’s partial hospitalization program and clinical school chiefly addressed her substance abuse disorder and some of the dysfunction between Makayla and her mother.  Although Makayla discussed her rape in group sessions, there was no PTSD-specific treatment or intervention.  Despite her diagnosis, she was not offered or referred to any form of trauma therapy.  Also, at discharge, there were no referrals for trauma-specific treatment or crisis management.

Public Safety Officials:

·         The police did not accurately inform Makayla’s mother of her rights under the Youth in Crisis Law.  They did not make themselves available in accordance with their authority under that law that allowed them to pick up a runaway youth.

Policymakers: 

·         The police may not have used their authority provided by the Youth in Crisis Law because the law offers no guidance for safe intervention.  Whether the police had an accurate understanding of the Youth in Crisis Law, the law did not carry effective weight for useful intervention when a 16-17 year-old youth is in crisis.

The task of the Office of the Child Advocate and the Child Fatality Review Panel is to identify state system weaknesses implicated in the death of a child. Makayla’s story also had several critical themes that went beyond state systems to a family and community perspective that also warrant attention.

• Although school testing indicated Makayla had depression and anxiety as early as Kindergarten and second grade, her family never recognized any signs or symptoms of those problems.  They described her as quiet and unable to focus but did not recognize those characteristics as possible symptoms of mental illness.
• Makayla was exposed to domestic violence as a young child, both as an observer and a recipient. Although Makayla’s mother moved her children away from her violent partner, she did not appear to recognize the impact of the violence on her young daughter. 
• Makayla’s mother’s history of depressive illness and victimization of domestic violence may have also contributed to her decreased ability to deal with her daughter’s needs.  Makayla never received any kind of therapeutic care to address her childhood experience of violence at home.
• Makayla and her family moved often when she was very young.  The instability of living arrangements may have contributed to her vulnerability to substance abuse.
• A genetic predisposition to substance abuse, as evidenced by her father’s history of alcohol abuse and that of other family members existed.  
• Makayla reported using drugs and alcohol for 3-4 years before her death.  At the party the night she used Ecstasy, many underage persons were seen drinking alcoholic beverages and yet no one stopped them or called the police.  There was/is an absence of community responsibility to protect children from the danger of exposure to substance use.
• When Makayla became ill from using the drug Ecstasy she was with other people who were also allegedly under the influence of the illegal drug.  It is highly likely that people involved in illegal activities do not respond to emergency situations in an appropriate manner. 

Recommendations

Recommendation for Schools –

• Children exhibiting and/or assessed with signs and symptoms of mental illness should be referred to their primary care physicians for follow-up. 
• Parents must be completely informed and assessed for level of comprehension of their children’s needs.  They must also be fully informed of the limitations schools have in forwarding confidential documents to other school systems in transfers. 
• Schools must collaborate with the Alcohol and Drug Policy Council and the State Department of Education to implement recommendations for increasing the effectiveness of school-based drug prevention and intervention programs.

Recommendation for Primary Health Care Providers - 

• Pediatricians and nurse practitioners providing primary care to adolescents in Connecticut should abide by standards set forth by the American Medical Association’s Guidelines for Adolescent Preventive Services. 
• Standards for assessment of child wellbeing should routinely include screening adolescents for substance abuse, depression, sexual and physical abuse, exposure to violence, school performance (including any psycho-educational testing administered), eating disorders, conduct disorders, and stress.  
• Adolescents need to be seen on at least a yearly basis for these complete updates.  Insurance companies must recognize and value the need for a preventive approach to adolescent care as they do early childhood care. 
• Parents or caregivers should be provided with anticipatory guidance regarding the needs of adolescents just as they receive for infants and very young children.

Recommendations for Community-based therapists –

• Appropriate referrals for a child’s special needs and open and comprehensive communication about those needs among providers (within the confines of confidentiality expectations) improve the care a child will receive. 
• Families and providers should be supported and educated to best support a victim of rape.
• Referrals to rape crisis services should be immediate upon disclosure and facilitated aggressively.

Recommendations for Acute Psychiatric

Care Providers –

 

• Inpatient treatment plans must address all identified needs of the child. 
• The diagnosis of post traumatic stress disorder is being ignored. It must be acknowledged and treated appropriately according to clinical guidelines. 
• Discharge planning must be based upon a child’s needs.  All community resources must be tapped and/or parent and clients made aware of them in case of crisis.  Each child should have a well-developed crisis plan and caregivers should be provided with contacts for emergency situations and support.

Recommendations for Outpatient Providers –

• Substance abuse treatment for children must be developmentally sensitive and incorporate treatment of underlying mental illness.
• More research must be conducted to identify effective substance abuse treatment models for children.
• After care programs must be developed according to individual needs and developmental abilities.
• “Safe” outlets and systems of supports must be identified for children with a history of conflict at home in order to assure healthy and supported decisions for coping with stress. 

Recommendations for Public Safety Authorities -  

• Police must be fully informed and cognizant of their obligation under the Youth in Crisis Law.  A review of the law should be mandated for all police officers. 
• Even with a clarified mandate for police to respond to youth in crisis, there is still no guidance for determining safe, appropriate action.  It may be beyond a police officer’s scope of expertise to determine whether returning a youth home at the request of a parent is a safe action.  More consideration should be given to the Youth In Crisis Law. 
• Hold adults accountable for the provision of illegal substances to minors.

Recommendations for Public Policymakers

• Evaluate mental health programs and services for children in Connecticut for effectiveness, outcomes, and follow-up of children served.
• Invest in appropriate, gender-sensitive, culturally competent treatment availability for all youth, with special attention to trauma-specific therapy. 
• Support development and implementation of effective, gender-sensitive prevention programs that recognize the impact of adverse childhood events as a primary factor in subsequent health and behavior conditions.
• Promote health insurance reimbursement for optimal health care screenings in order to facilitate early identification of substance abuse and other mental health problems among adolescents.
• Revise drug and alcohol education law to ensure effective, science-based prevention education for Connecticut students.
• Re-visit the YIC law to determine best effectiveness.
• Implementation of the increased age limit under the jurisdiction of juvenile matters must include the promotion of a continuum of services that address mental and emotional illness.  Specifically, 

-   Wrap around case management and services

-   Expansion of shelter beds and emergency foster care

-   Prioritized specialized residential placements

-   Therapeutic and emergency foster care placements

-   Supportive housing

-   School interventions, including truancy programs

-   An infrastructure of a continuum of mental health services including acute, sub-acute and long term care facilities.  

Recommendations for Parents and Communities -

• More educational programs should be devised and embraced to provide parents with basic information about child development from birth through adolescence and parenting skills. 
• Research should be conducted on healthy, well adjusted children to determine the positive factors that produce those children.  Then those factors should be incorporated into educational programs, social welfare programs, and perhaps most importantly, child welfare programs to better support families.
• Communities must take more responsibility in speaking out about and to the children among them when they see behaviors that place those children at risk.
• Supporting more public service announcements educating teens about the danger of alcohol and drug consumption.  Limit advertising that glamorizes alcohol consumption.