u. S.

Department of Justice

Civil Rights Division

Office of rhe AssisIanr ArIomey General

Washing lOll, DC. 20035

April 9,

The Honorable Robert L. Ehrlich,
Governor of Maryland
100 State Circle
Annapolis, Maryland
21401
Re:

2004

Jr.

Investigation of the Cheltenham Youth Facility in
Cheltenham, Maryland, and the Charles H. Hickey, Jr.
School in Baltimore, Maryland

Dear Governor Ehrlich:
I write to report the findings of the Civil Rights
Division's investigation of conditions at the Cheltenham Youth
Facility ("Cheltenham") and the Charles H. Hickey, Jr. School
("Hickey").
On ,i\ugust 30, 2002, we notified then-Governor Parris
Glendening of our intent to conduct an investigation of
Cheltenham and Hickey pursuant to the Civil Rights of
Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, and
the Violent Crime Control and Law Enforcement Act of 1994,
42 U.S.C. § 14141 ("Section 14141").
As we noted, both CRIPA and
Section 14141 give the Department of Justice authority to seek a
remedy for a pattern or practice of conduct that violates the
constitutional or federal statutory rights of children in
juvenile justice institutions.
Between April 28 and June 12, 2003, we conducted on-site
inspections of Cheltenham and Hickey with expert consultants in
juvenile justice, medical care, mental health care, education,
and sanitation.
We interviewed staff, youth residents, medical
and mental health care providers, teachers, and school
administrators at both facilities.
Before, during, and after our
visits, we reviewed an extensive number of documents, including
policies and procedures, incident reports, youth detention
records, medical and mental health records, grievances from youth
residents, investigations of the Department of Juvenile Services'

- 2

-

("DJS") Office of Professional Responsibility and i\ccountability
("OPRA n ) , reports of the Office of the Independent Juvenile
Justice Monitor ("Independent Monitor") , I unit logs, orientation
materials, staff training materials and school records.
Following each tour, we conducted exit conferences with facility
and DJS officials, during which our consultants described their
initial impressions and concerns.
We commend the staff of both facilities and the DJS central
offices for their helpful and professional conduct throughout the
course of the investigation. 2 Once granted access, we received
full cooperation with our investigation.
We also appreciate the
State's receptiveness to our consultants' on-site
recommendations.
Consistent with the statutory requirements of CRIPA, we now
write to advise you of the findings of our investigation, the
facts supporting them, and the minimum remedial steps that are
necessary to address the deficiencies we have identified.
As
described more fully below, we conclude that certain deficiencies
violate the constitutional and federal statutory rights of the
youth residents.
In particular, we find that children confined
at Cheltenham and Hickey suffer harm or the risk of harm from
constitutional deficiencies in the facilities' confinement
practices, suicide prevention measures, mental health and medical
care services, and fire safety.
In addition, the facilities fail

This office is created by statute, Md. Code, Art. 49D, § 41,
to monitor conditions in all DJS facilities and report its
findings to the Governor, the Maryland General Assembly and the
DJS Secretary.
Several staff members are assigned by region to
visit the facilities, conduct announced and unannounced tours,
and write detailed reports of their findings, recommendations,
and DJS responses.
Independent Monitor officials have identified
similar systemic violations as those identified in this letter at
both facilities, and reported these problems to OJS and others.
Their reports reflect continuing frustration at DJS's failure to
institute effective remedies to the patterns cited.
Our tours of Cheltenham and Hickey were initially delayed
nearly seven months by negotiations with the State regarding the
terms of our access to the facilities and confidentiality of
documents.
Shortly after we met with DJS Secretary Kenneth C.
Montague, Jr. in March 2003, we were able to commence our
document review and on site facility tours.

-

3

-

to provide required education services pursuant to the
Individuals with Disabilities Education Act ("IDEA"),
20 U.S.C. § 1401, and Section 504 of the Rehabilitation Act of
1973 ("Section 504"), 29 U.S.C. § 794.

I.

BACKGROUND

At the time of our tours, Cheltenham was a 180-bed facilitv
for boys aged 12 to 18. 3 The facility, which is operated by DJS,
serves primarily as a pre-adjudication detention center.
Some
youth confined at Cheltenham have already been adjudicated
delinquent and committed to DJS care, but are confined at
Cheltenham "pending placement" in a treatment program elsewhere.
A youth's average length of stay at Cheltenham is approximately
25 days, although some youth are there in excess of 200 days.
Hickey is a facility for boys aged 12 to 20 that is owned by
the State but which, at the time of our tours, was operated by a
private company, Youth Services International (YSI), through a
contract with DJS.t, Hickey has a 330-bed capacity, and at the
time of our tour, had a total of 263 youth in residence.
The
facility consists of two separate campuses, one within a secure
fence and one outside the fence.
Within the secure area, there
is a detention facility for youth awaiting adjudication, and two
programs for youth committed to DJS care:
the Intermediate
program (6-10 months) and the Enhanced Program (12-18 months).
Youth who have been adjudicated delinquent and are pending
pl~cement in other treatment programs are confined in the secure
campus at Hickey.
Outside the fenced area is a short term
program (30-90 days) for committed youth, known as the Impact
Program.
The average length of stay for a youth at Hickey lS 325
days, although some youth have been there in excess of 700 days.s

The State reports that it has closed a number of housing
units and that the population at Cheltenham is now under 60 youth
residents.
At the time of our tours, Cheltenham housed 216
youths.
The State reports that it is has taken over management of
Hickey, as it has not renewed its contract with YSI, which
expired at the end of March 2004.
We are aware that the General Assembly is currently
considering legislation which may alter the future plans for
serving youth in DJS custody.
These efforts appear aimed, in
part, at reducing the size of facilities such as Cheltenham and
Hickey and, presumably, improving the quality of care for youth.

- 4

-

II. LEGAL STANDARDS
As a general matter, States must provide confined juveniles
wi th reasonably safe condi tions of confinement.
See Youngberg v.
Romeo, 457 U.S. 307, 315-24 (1982); Bell v. Wolfish, 441 U.S.
520, 535-36 & n.16 (1979).
Such constitutionally mandated
conditions include the right to adequate medical care, a concept
that embraces both mental health treatment and suicide prevention
measures.
See Patten v. Nichols, 274 F.3d 829, 835 (4th Cir.
2001); Shrader v. White, 761 F.2d 975, 978 (4th Cir. 1985);
Gordon v. Kidd, 971 F.2d 1087, 1094 (4th Cir. 1992).
Further,
confined juveniles are entitled to protection from physical
assault and the use of excessive force by staff.
Youngberg,
457 U.S. at 315-16.
The State is also obliged to provide special
education services to juveniles with disabilities pursuant to the
IDEA.
As described below, the State has fallen well short of
these constitutional and federal statutory obligations.
In assessing whether the constitutional rights of
institutionalized juveniles have been violated, the governing
standard is the Due Process Clause of the Fourteenth Amendment.
See You:lgberg v. Romeo, 457 U.S. 307, 315-16 (1982); Patten,
274 F.3d at 840-41.
Accordingly, the proper inquiry focuses on
whether the conditions substantially depart from generally
accepted professional judgment, practices, or standards.
See
Youngbera, 457 U.S. at 323.

III.
A.

FINDINGS

PROTECTION FROM RARM

Our investigation revealed major constitutional deficiencies
In the harm protection measures in place at Cheltenham and
Hickey.
In particular, both facilities fail to protect youth
from:
(i) staff violence; (ii) unsafe restraint practices;
(iii) youth violence; (iv) excessive isolation; and (v) other
abusive practices.

1.

Staff Violence

The evidence unearthed in our probe indicates a deeply
disturbing degree of physical abuse of youth by staff at both
Cheltenham and Hickey.
The following examples are illustrative:

-

5

-

In January 2004, the Maryland State Police filed
criminal assault charges against four Cheltenham staff
members who allegedly restrained a youth and beat him.
The police investigation reveals that after the youth
resisted going to bed early, four staff members grabbed
him.
The unit supervisor put the youth's arms "in a
chicken wing hold N over his head while other staff
members punched him in his face and kicked him in the
ribs and back.
By the end of the incident, staff had
dragged the youth back to his room and his pants and
underwear had been ripped and pulled down to his
ankles.
Medical records document injuries to the
youth's forehead, eye area and lip.
In addition, the
youth reported pain in his ribs.
The youth was sent to
the hospital for care.
In January 2004, the Maryland State Police filed
criminal assault charges against two Hickey staff
members for assaulting a youth.
A police investigation
revealed that the youth, upset because a routine staff
search of his room left it in disarray with some items
missing, kicked his door.
A staff member then slapped
the youth in the face with an open hand and attempted
to wrestle him to the ground.
Although two staff
members attempted to intervene to stop the assault,
another staff member grabbed the youth from behind and
began striking him with a closed fist.
The youth was
left injured in his room for three hours before being
seen by the nurse.
Photographs taken by the nurse
reportedly depict injuries to the youth's face and body
consistent with being grabbed around the neck and being
struck in the face.
In a May 2003 incident, Child Protective Services found
that a Hickey staff member struck a youth in the face,
which another staff member witnessed.
In a May 2003 incident, a Hickey staff member assaulted
a youth who refused to leave a school classroom.
The
staff member grabbed the youth around the neck and
slammed him against the wall outside the classroom.
The youth then threw a plastic chair towards the staff
member, but missed him.
The staff member slammed the
youth to the ground, choking, punching and kicking him.
During our visits, we observed injuries to the youth's
face and neck.

- 6 -

In a March 2003 incident, a youth at Cheltenham was
involved in an altercation with a staff member at the
school.
After another staff member restrained the
youth and escorted him to a transportation van, the
staff member involved in the altercation entered the
van and struck the youth with his fist.
In a March 2003 incident, a Hickey staff member,
breaking up a youth-on-youth fight, hoisted one of the
youth in the air and "slamJned him to the floor,
injuring his left arm.
The facility failed to inform
the youth's parents, who filed a report with Child
Protective Services after seeing a cast on their son's
arm on visiting day a week later.
Staff reports failed
to describe any injuries to the youth.
OPRA
investigators described the incident as "another
example of [Hickey] staff trying to conceal incidents."
fI

In a February 2003 incident at Cheltenham, a youth,
upset that a staff member had thrown his breakfast
away, tried to push past the staff member to get out of
his room.
The staff member grabbed him by the throat
and pushed him back onto the bed, choking and cursing
him.
The youth was treated for injuries to his neck
and pain in his throat.
Our interviews with direct care staff, youth, and other DJS
employees confirmed that the above examples are representative of
recurrent problems at the facilities and are not aberrational.
Our review of incident reports and information from OPRA
investigators reveals that incident reporting by staff frequently
fails to provide any detail regarding the incidents.
Indeed,
most OPRA investigations are not initiated by staff incident
reports, but rather from informal sources of information.
The
recurrent nature of the incidents reflects a lack of appropriate
training, reporting, supervision, and quality assurance practices
at Cheltenham and Hickey.
While incidents that come to light are
appropriately investigated by OPRA, and often lead to
disciplinary measures against involved staff, the facilities have
failed to implement systemic measures to ensure that similar
incidents do not recur.
In addition, our investigation revealed that individuals
with felony convictions and histories of excessive force against
juveniles may, at times, be hired as staff members at these
facilities.
Notably, we found several instances where we believe

-

7 -

that staff with either felony convictions or previous histories
of excessive force in a juvenile detention facility were involved
in incidents of abuse.
This is, quite obviously, entirely
unacceptable.
2.

Unsafe Restraint Practices

Although restraint may be an appropriate tool when used
properly, the methods used by staff at Hickey to restrain unruly
youth depart substantially from generally accepted practices and
create grave risk of harm to youth.
In a technique the facility
terms "lock and drop," staff take a youth to the ground and force
him into a prone position (lying with stomach to the ground) ,
placing weight on the youth's upper torso to hold him to the
ground.
This position, demonstrated to us by training staff, can
prevent the youth from breathing and cause asphyxiation. As we
informed staff in our exit interviews, the practice should cease
immediately.
Staff and youth also reported seeing staff members grab
disruptive youth by the neck, another inappropriate method of
restraint.
One youth described his restraint experience as being
"slammed on the neck and arms bent way back." Another youth
described the experience as "they put a knee in your back, one
hand on the back of your neck and the other hand bends your arm
up in back."
The danger associated with this practice is not merely
theoretical; our investigation revealed an incident in which a
youth required treatment at the emergency room following a
restraint.
Another youth restrained in March 2002 vomited and
appeared to have inhaled some of the vomitus, triggering a loss
of consciousness. He was sent to the emergency room where he was
diagnosed with transient asphyxia. An Independent Monitor
official has also documented various incidents at Hickey in which
youth were harmed during restraint.
In one incident, a youth
suffered neck and shoulder injuries.
In another restraint, a
youth suffered a seizure and required hospitalization.
In still
another, a 300-pound staff member sat on a youth and the staff
mocked the youth when he complained that he could not breathe.
These incidents reflect a serious risk of harm to youth.
The State must establish a safe method of restraint and ensure
that staff are trained in its'appropriate and safe use.

- 8 -

3.

Youth Violence

Generally accepted professional practices require that
facilities confining youth must protect youth from assault by
other youth.
Facilities must maintain sufficient structure,
safeguards, and staffing to ensure safety.
Both Hickey and
Cheltenham experience unacceptably high levels of youth-on-youth
violence.
Consider the following illustrative examples:
The Independent Juvenile Justice Monitor reported that
six fights broke out in a single day in November 2003
at Cheltenham.
During our June 2003 tour of Hickey, we were made aware
of a fight on the Kennedy Unit in which three youth
allegedly assaulted another individual, who required 30
'stitches to close the wound on his face.
In a May 2003 incident, a youth at Cheltenham assaulted
another youth who was sleeping in the day room during
free time, resulting in a fracture of the youth's left
orbit.
The one staff member responsible for
supervising the day room had fallen asleep and saw none
of the incident.
This staff member had worked several
forced double shifts that week, and could not stay
awake due to exhaustion.
In a May 2003 incident at Hickey, one youth received
stitches in his head after several youth assaulted him
In the day room and hit him with a wooden chessboard.
In an April 2003 incident, a group of youth at Hickey
assaulted another youth.
The assault lasted for a
period of minutes without staff intervention.
The
youth had a bruised forehead and swollen finger, but
staff did not refer him for medical care.
Staff also
failed to report the incident as required by policy and
procedure.
In another April 2003 incident, a youth at Hickey
suffered a broken jaw after youth attacked him with a
stick during outdoor recreation time.

- 9
In a third April 2003 incident, a youth at Cheltenham,
intending to punch one particular youth, struck a third
youth who was knocked unconscious.
The injured youth
was hospitalized for 2 days.
In March 2003, Cheltenham experienced a riot to which
local law enforcement authorities had to respond in
order to regain control of the facility.
The incident
began during a program in the facility gymnasium for
youth from all of the units.
Youth from Rennie cottage
attacked youth from Whyte cottage, after which they
were separated.
However, some youth from Rennie ran
out of the gym and chased and assaulted staff and youth
from other cottages.
Two youth were hospitalized, one
with a head injury and another with bruised ribs.
Other youth were physically assaulted and forced to
remove their clothes.
Youth were able to use a
crowbar-like object to pry open some room doors.
OPRA
issued a report which included recom~endations for
corrective action.
The measures had not been
implemented at the time of our tours.
In a January 2002 incident at Cheltenham, three youth
attacked one youth, resulting in eye injuries that
required hospital treatment.
The pervasive violence at Cheltenham appears to result, 1n
part, from the lack of sufficient numbers of adequately trained
staff.
Youth-to-staff ratios at Cheltenham have been as high as
20:1 during the day and 60:1 at night.
These ratios deviate
substantially from generally accepted professional practices.
Many states require one staff per eight youth during the day and
one staff per sixteen youth at night.
Further, due to the
physical layout of the housing units and the multiple supervisory
responsibilities for each staff member, staff are not always
present when youth-on-youth violence occurs.
Furthermore, due to
the volatile nature of the youth, staff report that they are
often too busy attempting to maintain a minimal level of control
in the housing units to engage in meaningful activities to help
youth develop more acceptable behavioral skills or to develop
relationships with youth.
Thus,staff abilities to identify
problems and intervene meaningfully to avert violence are

- 10 -

limited. 6 Furthermore, staff are frequently required to work
double shifts, often without advance warning, leaving them tired,
short-tempered and less alert.
At Hickey, inadequate training of staff contributes to youth
violence.
Our investigation revealed that staff at both
facilities lack skills and training in de-escalating crises and
youth-on-youth conflicts.
This absence of training impedes the
ability of staff to intervene successfully in volatile situations
of which they are aware, and can even lead to escalation of youth
aggression during a crisis.
Staff at both facilities also fail to report many serious
incidents that occur.
A DJS internal investigation revealed that
Cheltenham staff were reporting only 27 percent of incidents that
required reporting.
At Hickey, staff reported only 66 percent of
incidents requiring reporting.
Furthermore, even those incident
reports that are submitted lack important information such as
details of who was present during the incident, what happened
during the incident, and what precipitated the incident.
The absence of an adequate classification system is another
contributing factor to the frequency of youth assaults.
Generally accepted professional .standards require that youth be
housed and supervised in accordance with their classification.
Reliable classification systems take into consideration such
information as a youth's age, charged offense, history of
violence and escape, gang membership or affiliation, health and
mental health concerns, and institutional history.
Neither
Cheltenham nor Hickey has an adequate classification system.
At Cheltenham, staff do not separate violent and non-violent
youth.
Youth are classified by age and, for some age groups,
seriousness of charged offenses, but youth who should be housed
separately often are not.
For example, two youth at Cheltenham
required hospital treatment following a fight; one boy had
serious injuries to his face.
The youth returned to Cheltenham
at different times, but were both housed in the infirmary where

The lack of sufficient staff even impacts the ability of
youth who are injured to obtain prompt medical care.
For
example, Cheltenham staff reported that one youth who was in a
fight on a Saturday night and sustained a shoulder injury had to
wait until Sunday night to be taken to the hospital for medical
treatment.
Staff reported that a lack of security/transportation
staff caused the delay.

-

11

-

they were in close proximity.
While the youth did not continue
their assaultive behavior, the facility apparently undertook no
preventative measures in response to the incident.
The youth
were not reclassified to ensure their separation nor were staff
caring for them informed that these youth were prone to violence
against one another.
We are likewise very troubled by the fact that, at Hickey,
youth with identified mental illness are placed on the same units
with youth who have poor impulse control and other behavioral
disorders.
This practice places the youth with serious mental
illness at an especially high risk of victimization.
The high degree of youth violence at Hickey and Cheltenham
is a partial byproduc( of inadequate security measures.
At
Hickey, youth are not sufficiently supervised, allowing them to
tamper with locking mechanisms on youth room doors, disable the
locks, and enter other youth rooms to assault one another.
tor
example, one youth at Hickey was able to enter another youth's
room undetected and urinate in his bed.
The victim of this
incident was then able to enter the perpetrator's room and
defecate in his bed.
Following this incident, the original
perpetrator then entered the original victim's room to assault
him, all of which occurred without staff intervening to defuse
the escalating conflict and prevent harm.
A further example of insufficient supervision occurred jn
April 2003, when staff from the Independent Monitor's office
visited a Hickey living unit.
The monitor reports that he asked
to inspect a batllroom where the showers appeared to be running
and had a foul smell.
The bathroom was locked, and when the
monitor asked the staff member on duty why the showers were
running, the staff member indicated that no youth were in the
locked bathroom, but that the showers sometimes do not turn off
completely.
When the bathroom was unlocked, however, two youth
were found showering, unsupervised, locked ill completely without
staff knowledge.
In addition to incubating an environment extraordinarily
receptive to violence, the lack of sufficient staff supervision
also contributes to opportunities for youth to attempt escape.
tor example, a youth at Hickey attempted to scale the fence on
July 1, 2003, but became caught in the razor wire.
The fence
alarm sounded 23 times, but the youth's attempt to scale the
fence went undetected.
Supervision was so poor that the youth
was able to return to his unit, severely bleeding, and hide in
the bathroom before staff discovered his injuries or his attempt
at escape.

12 -

Meanwhile, on May 22, 2003, two youth at Cheltenham escaped
through the perimeter fence with the help of an individual on the
other side.
During the previous night, the fence security alarm
had sounded numerous times, but staff failed to detect that the
fence had been cut.
4.

Excessive Use of Disciplinary Isolation/Lack of
Procedural Protections

The facilities' isolation 7 practices substantially depart
from generally accepted professional practices in that juveniles
are isolated for excessive periods of time, for minor offenses,
and without appropriate procedural protections.
Isolation should
be used only to the extent necessary to protect youth from harm
to themselves or others or to maintain institutional discipline.
Youth placed in disciplinary isolation are entitled to notice of
their charges, a hearing before an independent decision-maker,
and an opportunity to present evidence in their defense.
Hewett
v. Jarrard, 786 F.2d 1080, 1089 (11th Cir. 1986); fvlary and
Crystal v. Ramsden, 635 F.2d 590, 599 (7th Cir. 1980).
The facilities have no procedure for providing due process
to youth who are isolated for more than 24 hours.
No hearing
procedures exist at either facility.
Facility and DJS staff
described to us policies under which (i) an upper-level manager
must approve isolation of youth, and (ii) the youth must be
released when he is back under control.
However, interviews with
staff revealed that, while the supervisory staff might come by
and check in on youth, supervisory staff are not actively engaged
in deciding when it is appropriate to end an isolation.
Instead,
the staff member who places the youth in isolation decides when
he may be released, resulting in a substantial departure from
generally accepted practices by allowing the involved staff
member -- rather than some neutral party -- to make this
decision.
The result is that youth remain in isolation, often

Isolation includes all times in which a youth is placed
alone in a locked room for the purposes of discipline or due to
out of control behavior.
Staff at Cheltenham and Hickey
generally use the term isolation to refer to locking youth alone
in their own rooms, and use seclusion to describe locking youth
alone somewhere other than their rooms.
Professionals use the
terms isolation and seclusion interchangeably to refer to both
practices.
We choose the term isolation in this discussion for
the sake of clarity.

- 13 -

sleeping, long after they are in complete control of their
behavior.
In addition, youth isolation is not consistently
documented in log books; during our visit to Hickey, senior staff
were unaware of some isolation incidents that occurred.
5.

Other Abusive Practices
a.

Inappropriate Staff-Youth Relationships

Our investigation revealed incidents of misconduct at both
facilities in which female staff were found to have engaged in
inappropriate relationships with male youth residents as young as
14 years old.
For example, in June 2003, during an investigation
of a physical assault by a staff member on a youth at Hickey, the
staff member admitted to sexual abuse of another youth.
In
February 2003, a missing youth was found driving a car registered
to a female staff person at Hickey.
In April 2002, a staff
member resigned after it was revealed that she had engaged in
sexual intercourse wlth a youth resident at Cheltenham.
Relationships of this variety clearly violate the Constitution.
Unfortunately, the facilities have failed to institute adequate
measures to prevent incidents such as these from recurring.
b.

Denial of Access to Bathrooms

Youth must have opportunities for personal hygiene including
the use of toilets.
Because only a small number of cells at
Hickey and Cheltenham are equipped with toilets and sinks, most
youth must request that staff let them out of their rooms to use
the restroom.
Staff at both facilities fail to meet this
fundamental need.
Youth frequently wake in the middle of the
night and are unable to attract staff attention to let them use
the restroom.
Several cells smelled strongly of urine during our
visits; we learned that youth sometimes urinate on their window
sills or into bed linens if they are not permitted to use the
restroom.
Aside from the obvious sanitary problems of such
behavior, leaving youth to resort to such humiliating measures lS
unconscionable.
B.

SUICIDE PREVENTION

Juvenile institutions must protect youth from self-harm.
Cheltenham and Hickey fail to protect youth in the following
ways:
(i) staff fail to assess suicidal youth adequately;
(ii) youth on suicide precautions receive insufficient mental

- 14 -

health services; (iii) youth at risk of self-harm are housed in
unsafe circumstances; (iv) supervision of youth on suicide
precautions and in seclusion is insufficient; and (v) staff lack
preparation to respond appropriately to suicide attempts.

1.

Insufficient Assessment of Suicidal Youth

At Cheltenham, security staff consistently identify youth in
suicidal crisis and place them on appropriate levels of security
precautions to prevent self-harm.
However, initial evaluation by
mental health staff is often delayed, particularly if a youth is
placed on suicide precautions over the weekend, thus restricting
the youth's activities without providing needed care.
At Hickey, staff often fail to use the instrument available
to assess potential lethality either before a youth is placed on
suicide precautions or when deciding whether to change the level
of suicide precautions.
While the State of Maryland (including
Cheltenham) uses a reliable measure of lethality -- the Inventory
of Suicidal Orientation (ISO-3D) -- staff at Hickey use an
untested screening tool that may not accurately assess lethality.

2.

Insufficient Mental Health Services for Youth on
Suicide Precautions

Youth on suicide precautions should receive appropriate
follow-up care from mental health staff to assess whether there
is an ongoing need for the youth to be placed under the
restrictions associated with such precautions, and to provide
treatment if necessary.
In addition, a competent mental health
professional must be available for consultation during hours when
staff are not scheduled to be at the facility, and should be able
to respond promptly when a youth requires crisis evaluation.
At Cheltenham, staff provide only inconsistent follow-up for
youth on suicide precautions.
Youth often spend many days in the
n
"Observation Room of the Infirmary without the benefit of
regular clinical contact, despite a department policy which js
consistent with generally accepted standards, requiring that
youth be seen daily by mental health staff.
Nor do staff help
youth develop any skills to reduce their suicidal ideations or
behaviors.
At Hickey, staff also fail to monitor youth on the highest
suicide precautions with sufficient frequency.
Responsibilities
for care of youth in crisis during hours when mental health staff
are not routinely at the facility have not been clearly defined.
Infirmary staff reported that pages to on-call mental health

15 staff often are not answered for extended periods of time.
Psychiatric backup is not provided when the staff psychiatrist is
unavailable, despite a commitment by the facility to have 24-hour
psychiatric on-call coverage.
The person assigned by the
contract mental health service provider to be on call during nonbusiness hours and on weekends, who is also the clinical
director, is a physician not currently licensed to practice in
the United States either as a physician or mental health
professional; she has not even completed a psychiatric training
program approved in the United States.
Therefore, the facility
fails to provide on-call crisis care in keeping with professional
standards.

3.

Unsafe Housing of Youth at Risk of Self-Harm

It is widely known that the first 48 hours that individuals,
particularly youth, are detained In an institution present
especially dangerous risks for attempted suicide.
Institutions
must ensure that intake area staff monitor newly arrived
individuals closely to maintain their safety.
At both Cheltenham
and Hickey, staff are unable to maintain an appropriate watch on
youth residents in the intake areas to ensure their safety.

At Cheltenham, the intake area has one holding cell.
At
times during the day, the staff member expected to monitor this
area is also responsible for answering the telephone for the
entire institution, questioning newly arriving youth about their
medical, mental health, and physical conditions, and logging
activity on the unit.
The office in which that person is posted
does not provide a sight line into the holding cell, so a youth
could be attempting self-harm, or one youth could be harming
another, and staff would likely not see it while attending to one
of their many other duties.
Indeed, the staff member has too
many duties to provide adequate security.
Furthermore, because
there is only one holding cell, staff are unable to separate
incoming youth in this area to protect them from one another.
At Hickey, there are more cells avallable for youth in the
intake area, but the one staff member assigned to this area is
also responsible for helping process youth being transported out
of the institution and youth arriving at the institution, as well
as overseeing the area in which youth on suicide precautions and
disciplinary seclusion are confined.
While facility management
may assign additional staff to monitor youth on suicide
precautions, youth on disciplinary seclusion present a heightened
suicide risk as well.

- 16 -

In addition, we found that the cells at both facilities had
fixtures on which youth could hang themselves.
We warned staff
at Hickey that the exposed sprinkler heads in the
intake/seclusion area cells posed opportunities for youth to
attempt suicide.
We learned later that youth in two incidents
seven weeks apart attempted to hang themselves from these
sprinkler heads in this area, thus evidencing that the risks
described above are quite real.
In a July 21, 2003 report, the
Independent Monitor recounted the two attempted suicides by
hanging in the seclusion area:
On April 26, a youth tied a sheet around his neck and
around a sprinkler head.
Staff observed the youth
hanging and intervened.
On June 15, another youth tied his bed sheet to
sprinkler head.
Staff again intervened.
In the report, the Independent Monitor also acknowledged our
warnings to the State by stating that the "federal government
auditor had also cited the facility for the exposed sprinkler
head in May," and warned, "a youth v-,ill lose his life if
sprinkler heads are not covered as required."
In addition, at
Cheltenham, the beds were constructed in such a way that youth
could hang themselves.
DJS administrators did inform us before
the end of our tours that new beds had been ordered for seclusion
1 '
ce~.ls.

Furthermore, at Cheltenham, youth on heightened suicide
precautions are frequently housed in the infirmary, where their
opportunities to participate in programs and outdoor activities
are restricted.
At Hickey, youth on suicide precautions are
sometimes housed in the infirmary or seclusion area, where
similar restrictions exist.
At both facilities, such housing may
be brief, but it sometimes lasts for two weeks or longer.
Such
restrictive housing for lengthy periods of time may exacerbate
youth's suicidal and self-mutilation behaviors, especially when
they are not receiving consistent mental health services, as
discussed above.

4.

Inadequate Supervision of Youth on Suicide
Precautions and in Seclusion

It is a generally accepted professional standard to require
staff conducting perIodic checks of youth on suicide precautions
or disciplinary seclusion to document their observations and the
times of their checks on youth.
At both facilities, we observed

-

17

-

that staff certified on forms that they had conducted checks at a
certain time well before that time actually arrived, for example
writing at 9:30 a.m. that a check had been done at 10:15 a.m.
Because these forms are to be completed when an actual visual
check has been conducted, pre-completed forms suggest that staff
assigned to these high-risk youth were actually not monitoring
them in conformance with safe practices.
This falsification of
records calls into question the reliability of supervision for
youth on such special security status, and suggests that
supervision is insufficient to ensure that staff uphold these
serious responsibilities.
We also observed forms in which staff
documented checks that were too far apart to comply with their
own policies or accepted standards for suicide precautions.
And
we found, not unexpectedly given the documentation discrepancies
identified above, that staff could not keep track of certain
youth on suicide precautions.
For example:
One youth at Cheltenham housed in the infirmary after
an attempt to overdose on hoarded medicine still
managed to acquire glass and cut his arm in a second
suicide attempt while allegedly on the highest level of
suicide precautions.
One of the youth's roommates had
to inform custody staff that this youth was lying on
the floor of the dorm room bleeding.
At Cheltenham, there were youth listed in the log book
to be monitored but they were no longer in the
infirmary.
One youth on SUICIoe precautions at Cheltenham was
housed in his unit, but the unit staff were unaware
that he was supposed to be on precautions.
We observed one youth at Hickey who was moved between
units and inadvertently dropped from suicide
precautions.
Despite recent updates to DJS suicide policies, insufficient
training, supervIsIon, coordination of care and staffing levels
contribute to these unsafe circumstances.

5.

Lack of Preparedness for Suicide Attempts and
Other Self-Harm

Staff must be prepared with adequate skills and appropriate
tools to intervene should a youth attempt self-harm.

- 18 -

Staff lack knowledge and strategies for de-escalating youth
engaging in self-harming behaviors.
At Cheltenham, even staff
assigned to monitor youth on the highest level of suicide
precautions have no guidance as to how to respond to youth who
make statements indicating they are considering self-harm.
The facilities lacked cut-down tools for staff to use if
they encountered youth attempting to hang themselves.
One staff
member explained she would have to wait for someone to bring
scissors from the infirmary, several buildings away, if she found
a youth hanging.
Staff at both facilities lacked guidance as to
how to respond if they found a youth hanging.
When we raised
this emergent concern, senior DJS administrators promptly ordered
cut-down tools for all staff, and were preparing to distribute
them and train staff by the end of our visits.

C.

INADEQUATE MENTAL HEALTH CARE

Neither Cheltenham nor Hickey provides adequate mental
health care for youth with serious mental health needs.
Deficiencies include:
(i) inadequate mental health screeninq,
identification and assessment; (ii) inadequate clinical
assessment, treatment planning, and case management;
(iii) inadequate medication management practices;
(iv) inconsistent and ineffective mental health counseling; and
(v) the failure to place youth in appropriate treatment settings
even when ordered by a court.
1.

Inadequate Screening, Identification and
Assessment

Generally accepted professional standards require that all
youth entering secure facilities receive a reliable, valid and
confidential initial screening and assessment to identify
emergent suicide risks and psychiatric, medical, substance use,
developmental, and learning disorders.
Staff must refer youth
for needed care.
Staff should gather available information such
as a youth's previous records from past admissions and glean
important information needed to care for and treat the youth.
The information must be communicated to appropriate personnel so
that a youth's needs are addressed in a timely manner.
At both Cheltenham and Hickey, the initial screening and
assessment process fails to achieve its primary goals; the
process does not identify youth who need immediate services,
refer them for services in a timely manner, screen out youth who
should be hospitalized rather than admitted to the institution,
or gather and disseminate necessary information to share witll

-19 -

staff caring for the youth.
Mental health staff do not share
appropriate information with personnel such as security staff,
education staff, case managers or health care staff, all of whom
need this information in order to supervise youth safely and meet
their needs.
Although good screening forms and policies have been
developed, the intake process at Cheltenham is inadequate.
We
observed staff at Cheltenham asking youth important questions at
the same time that they were being strip searched.
Further,
areas of the intake unit were chaotic, loud and unsettling.
The
environment and manner of interviewing were not conducive to
obtaining important information about recent drug use, treatment
by arresting officers, feelings of suicidality and current
medical conditions.
During hours when intake officers do not staff the
facilities, security staff may be responsible for administering
intake questionnaires and providing important information to
youth upon admission.
These officers have not been trained in
these intake functions and do not ask questions or provide
information consistently.
On certain shifts at Cheltenham, the
person asking the intake questions must supervise the holding
cell and answer the telephone while administering the intake
screening.
These circumstances present the risk that staff will
lack information needed to protect youth from harm and ensure
that youth receive needed services.
Some youth whose serious mental health needs cannot be met
at the facilities are admitted anyway.
While DJS policy (as well
as generally accepted practice) dictates that youth with emergent
medical or mental health needs will not be admitted to the
facilities, this policy is implemented much more consistently for
physiological emergencies such as acute intoxication or
observable physical injuries than for mental health crises.
Because mental health professionals do not playa role at intake
to determine the appropriateness of admitting youth who display
serious mental health symptoms upon arrival, youth who are
suicidal or otherwise experiencing serious mental illness are
admitted despite policy and the facilities' inability to provide
the services these youth need.
Security staff administering the
brief questionnaire given to every youth upon arrival are
insufficiently trained to ask the questions and interpret answers
in order to screen out youth with emergent mental health needs.
Thus, some youth in need of psychiatric hospitalization are
admitted to the facilities and present special challenges for
staff -- challenges the staff is systematically unable to meet.

- 20 -

Our review of records consistently demonstrated that
ntake
screening was not functioning as needed.
for example, a 1 -yearold youth with a diagnosis of schizophrenia was discharged from a
hospital and admitted to Cheltenham.
According to the Intake
Database face Sheet for this youth, while the youth was in the
intake area, he was yelling, "I'm going to hurt myself,
and
reporting that he was "not mentally stable.
Despite this
youth's overt symptoms, the admissions officer conducting the
screening answered "No" to questions on the intake screening form
asking whether the youth was exhibiting bizarre or unusual
behavior
whether the youth was thinking about hurting himself,
and whether he showed any sign of current suicide risk. 8 Thus,
even though the screening instrument provides that "Yes
answers
to any of these questions require refusal of admission and
transport to a hospital for immediate care, this youth was
admitted to Cheltenham.
II

II

I

ll

At HickeYI a youth with both substance abuse and mental
health disorders was admitted with an active prescription for
Adderall, a medication for Attention Deficit/Hyperactivity
Disorder ("ADHD").
It took five days to restart his medication
following his arrival.
Despite the fact that he arrived at this
facility after failing to complete a court-ordered residential
substance abuse treatment program he was only referred for
"Substance Abuse Education classes rather than the treatment his
substance abuse history required.
No one administered the mental
health screening tool to him, and it was a month before he began
treatment.
l

ll

Furthermore, youth who arrive at the facilities on weekends,
when mental health staff are not on site except for emergencies,
may not receive mental health screening for several days.
Delays
in conducting these screenings place youth who are in need of
treatment at risk for self-harm and may pose risk to others,
since they may be placed into any housing unit without receiving
mental health services.
Other youth often target youth with
mental illness, putting them at risk for physical and emotional
abuse.
Because custody and health care staff lack training to

Nor was there any indication of malingering by the youth.
While we of course acknowledge the possibility that some youth
may fabricate symptoms to avoid incarceration, there must be some
sort of clinical or documented follow-up before the type of
symptoms exhibited here (which, on their surface, appeared to be
entirely legitimate) can be dismissed.

- 21 -

recognize signs and symptoms of mental illness and substance
abuse, youth may not receive needed services until they are
screened or experience crises.
In addition, many youth who might not meet the criteria for
hospitalization nonetheless have serious mental health needs that
go far beyond the current capacity of the facilities to pro~ide
adequate treatment.
Both our file review and reports from staff
indicate that there are youth at these facilities whose needs go
well beyond the facilities' capacity to provide care.
At both
institutions, security staff complained of the number of youth
whose mental health conditions present them with serious
challenges in controlling behavior, communicating with the youth,
and maintaining safeLy.
We heard consistently from staff at both
facilities that they wished there were a mental health unit at
each facility.
2.

Inadequate Clinical Assessment, Treatment
Planning, and Case Management

Generally accepted professional standards require timely
specialized clinical assessment of those youth with potential
mental health needs, development of treatment plans to guide
youths' care, and implementation of those plans.
Mental health
providers at Cheltenham and Hickey fail to provide appropriate
clinical assessments or treatment plans.
a.

Clinical Assessment

Youth who are identified at intake as exhibiting behaviors
associated with mental illness and/or substance abuse disorders
must receive a timely assessment that includes the gathering of
prior assessments, treatment history, and other information in
order to confirm a diagnosis and determine an effective course of
intervention.
This process does not occur at Cheltenham or
Hickey, and the consequence for youth is haphazard and
uncoordinated care.
At neither facility are staff identifying which youth need
services most i~~ediately so that their care can be prioritized.
As a result, some youth with serious immediate needs slip through
the cracks and receive services far too late, or never, due to
insufficient staffing levels.
We reviewed files of youth being treated by the
psychiatrists.
The assessments we reviewed were grossly
inadequate.
They lacked sufficient information to support a
diagnosis or formulate a viable treatment plan.
Instead,

- 22 -

medication treatment decisions are based on superficial
impressions gained through brief interviews the psychiatrists
conduct with the youth.
The psychiatrists rarely seek to review
prior treatment records or contact community therapists, parents
or probation officers for critical developmental and treatment
histories.
I~any files of youth at Cheltenham on psychotropic
medications contained no diagnosis at all.
These practices are
substantial departures from generally accepted standards of care.
Clinical assessments should guide all mental health clinical
interventions for a youth, and should identify target symptoms
that psychotropic medications are designed to address in tandem
with other clinical treatment.
The psychiatric assessments at
Cheltenham rarely address any clinical intervention other than
medication management.
They are superficial and barely legible.
The benefits of psychotropic medication are lessened without a
coordinated therapy approach, as youth rarely have mental
disorders that are remedied by medication alone.
The evaluations at Cheltenham conducted by contract mental
health staff from Johns Hopkins were more comprehensive and
clinically useful.
However, the roles of these clinicians in the
provision of services at Cheltenham was not effectively
coordinated and their involvement appeared marginalized partly
based on the assumption that their contract was near termination.
Assessments at Cheltenham rarely identify Post Traumatic
Stress Disorder ("PTSD") as a diagnosis, even though a high
percentage of youth (60%) score in the "\rJarning" range on the
Trauma Scale in the intake mental health screening instrument.
Symptoms of this disorder often manifest themselves in increased
irritability, difficulty trusting adults, and depression, which,
if untreated, could leave youth without the tools to cope with a
juvenile detention environment.
Similarly, youth in the juvenile
justice system with Fetal Alcohol Syndrome experience treatment
resistant impulsivity and cognitive problems.
No evidence was
observed that appropriate interventions are recommended or
conducted to help youth \vith these disorders function in this
environment.
The clinical assessments and mental status examinations
conducted by the contract mental health service provider at
Hickey generally fail to gather the requisite developmental and
diagnostic information that would justify the interventions that
are proposed.
Thus, mental health interventions may not be
addressing the actual histories and problems of youth.

- 23 -

Some youth require additional assessment over time, to
clarify a diagnosis or determine whether a youth is experiencing
a cognitive or neuropsychological impairment.
At Cheltenham, we
found no psychological or cognitive assessments administered
after the initial assessments, despite the fact that some of the
most troubled youth stay at Cheltenham for many months.
The
following examples are illustrative:
One youth at Cheltenham in May 2003 had a history of
depression, substance abuse and migraine headaches, for
which he had received medications when detained at the
facility only three months before.
Despite mental
health staff assessments that the youth was becoming
increasingly agitated, he did not receive a referral
for psychiatric assessment which might have provided
for his medications to be restarted.
At Hickey, we encountered a youth who had been admitted
to DJS facilities multiple times, with a significant
history of aggressive and out of control behavior, as
well as suicide attempts.
His diagnoses include ADHD,
chemical dependency, impulse control disorder, mixed
anxiety, and depression, with suicidal and homicidal
ideation.
His arrival at Hickey created an immediate
crisis in how to handle his behavior.
He was placed on
suicide precautions multiple times and was restrained
on at least three occasions after making a variety of
self-harming gestures, including attempting to hang
himself on at least one occasion.
At one point the
psychiatrist attempted to hospitalize this youth, but
he was not admitted by the hospital and returned to the
facility.
The psychiatrist, mental health and health
care staff attempted to de-escalate this youth's
explosive and violent behavior at various times, but he
remained in seclusion for extended periods of time,
without a coordinated plan for meeting his needs.
During our visit, staff decided to place this youth
back on his unit, which engendered further suicidal
threats and other crisis behavior.
It took more than
three weeks after this youth's admission to the
facility for staff to complete an admission assessment,
and another three weeks for a psychiatric evaluation,
which provided no guidance as to new treatment
strategies to redirect the uncoordinated, chaotic care
he had been receIvIng.
Generally accepted practice for
the care of a youth with these needs would include

24 -

development of a crlsis plan that would clearly guide
staff in responding to and managing this youth's
crises.
The lack of such a plan was confusing this
youth and exacerbating his behavioral disorder.
Another youth at Hickey had been diagnosed at various
times with psychotic symptoms, ADHD, behavioral
problems, substance abuse, and destructive behaviors to
himself and others.
The psychiatrist treated this
youth on a complex combination of medications without
conducting a psychiatric assessment.
Without a
determination of his actual needs through assessment,
this youth's treatment could not be tailored to meet
his needs.
This youth continued to experience
hallucinations and inability to control his aggressive
behavior.
b.

Inadequate Treatment Planning and Case
Management

Treatment planning, including identifying symptoms and
behaviors as targets for intervention and strategies for
addressing them, is a critical part of effective treatment for
serious mental illness.
But treatment plans at both facilities
fail to target specific symptoms or articulate meaningful
strategies, and provide no mechanism for measuring whether a plan
is working. At Hickey, treatment plans rarely identify cooccurring substance abuse disorders as primary goals of
treatment, even though effective treatment of mentally ill youth
with substance abuse disorders must address these issues hand in
hand.
Case managers should com~unicate treatment plans for
mentally ill youth to all staff involved in the management of
youth in a detention facility, and coordinate their
implementation. Although all youth at both facilities are
assigned case managers in their residential units, these
individuals have no mental health training, and they serve
primarily as liaisons between the facility and the probation
officer, rather than focusing on coordinating care at the
facilities for mentally ill youth.
They write "treatment plans
for all youth, but these are generally uniform sets of exercises
designed to help youth develop insights about their delinquent
acts and their future plans, and are unrelated to mental health
treatment.
Many case managers were unaware of even the diagnoses
of mentally ill youth on their caseloads.
N

- 2S Custody staff and others who come in daily contact with
youth must have sufficient information about youth's mental
health symptoms so that they can understand and respond
appropriately when youth manifest them.
Communication between
mental health staff, health staff, custody staff, teachers,
community probation officers and parents regarding the treatment
of youth at both Cheltenham and Hickey is manifestly inadeauate.
Custody staff do not receive guidance about the behaviors that
mentally ill youth display which stem from their mental
illnesses.
As a result, staff misconstrue psychiatric symptoms
as intentional behaviors, and inappropriately apply ineffective
discipline to reduce the troubling behavior.
Other youth often
target these youth and exacerbate their symptoms as well.
At
Cheltenham, mentally ill youth are transferred between units and
to other DJS facilities with minimal attention to critical issues
related to their psychiatric status and without consultation with
mental health staff.
Youth with receptive language deficits often misunderstand
staff orders and end up being punished because staff think they
are refusing to comply, when they actually do not understand.
Similarly, youth with ADHD frequently have difficulty staying on
task and following directions.
We found no indication that staff
were given information so that they could understand the
differences of youth with mental health or developmental
disabilities or make appropriate modifications in their handling
of such youth.
One youth at Cheltenham had an IQ placing him in the
borderline range of intellectual functioning.
He was
consistently disciplined for using profanity and oppositional
behavior.
There was no indication in his education, mental
health or detention files that any staff understood the
difficulty he would have understanding verbal requests and
following expectations, or what accommodations might be
appropriate.
Records of another youth at Cheltenham with ADHD
showed that he was routinely disciplined for non-compliant
behavior despite his inability to follow directions consistently.
Furthermore, contrary to generally accepted professional
standards of care, neither Hickey nor Cheltenham staff complete
periodic treatment summaries or discharge summaries with enough
information to facilitate treatment in future placements.
Such
failure to communicate the goals and successes and failures of
treatments tried at the institutions may compromise future
attempts at treatment in other settings.

-

26

-

Insufficient security staffing at Cheltenham also
contributes to the lack of adequate mental health care.
Mental
health workers are unable to use the offices assigned to them
within the secure area of the facility for counseling sessions
because security staff is not available to monitor the area and
they do not feel safe from youth residents.
Instead, mental
health staff use space outside the secure area, requiring
security staff escorts to transport youth.
3.

Inadequate Psychotropic Medication Management

Generally accepted professional standards include the use of
psychotropic medications to augment a comprehensive mental health
treatment plan with the youth's compliance and active
participation.
Medications prescribed should have a known
benefit to treat the symptoms identified, based on a valid
diagnosis and understanding of the root causes of the illness,
and medication changes should follow documented monitoring of the
effects of previous medication choices and reasons for abandoning
a previous approach.
Generally accepted professional practices
require that youth and their parents or guardians b
informed
about the benefits and risks of medications and give informed
consent for their use. 9 Careful monitoring through laboratory
tests is necessary to ensure that youth do not experience harmful
side effects of many psychotropic medications.
At both Hickey
and Cheltenham, staff fail to carry out these essential
responsibilities.
At Cheltenham, some youth'are placed on medications that are
not designed to impact the symptoms they are experiencing.
Other
youth are not provided with medications to treat the symptoms
they have.
Psychiatric assessments fail to meet generally
accepted professional standards, and at times do not result in
any diagnosis; even though the psychiatrist may prescribe several
medications, at times the files reflect no conclusion as to what
condition is being treated.
Medication treatment decisions
appear to be based on superficial impressions, gained through
brief interviews with the psychiatrist, who has limited input
from other sources of information.
Many files lack records of

9
Under Maryland law, youth aged 16 or older have the same
capacity as adults to consent to treatment for a mental disorder.
Maryland law also allows treatment staff to inform parents,
guardians, and custodians about treatment needed by minors aged
16 and older.
Md. Code Ann., Health-Gen. II § 20-104 (a) (1),
(b) (2003).

- 27 -

even the most basic of clinical observations, the mental status
exam.
Such departures from appropriate care not only fail to
provide relief to youth, but can cause youth to become resistant
to medications and treatment.
The psychiatrist appears to
function in a clinical vacuum, rarely interacting with other
mental health staff, often increasing, adding, or discontinuing
medications based only on brief meetings with youth, without the
benefit of input from clinicians, custody staff, or teachers who
may work with the youth on a daily basis.
One youth at Cheltenham was diagnosed with a
schizophrenic disorder and reported experiencing
auditory hallucinations.
Even though he had a history
of taking antipsychotic medications, the psychiatrist
did not prescribe a medication to alleviate his
hallucinations.
There was no notation in the record
indicating that the psychiatrist attempted to address
these symptoms.
Another youth had ADHD and passive-aggressive
personality disorder.
The psychiatrist placed him on a
mood stabilizer and an antipsychotic agent used for
significant behavioral difficulties, which were not
appropriate medications for treating the condition that
had been diagnosed.
Another youth was prescribed Strattera, a new
medication used to treat ADHD.
The FDA has not
approved this medication at more than 60 mg per dose.
Yet this youth was receiving 80 mgs in a single dose
per day, rather than 40 mg twice a day.
This practice
can increase the risk for side effects, such as
headache, nausea, vomiting, diarrhea or sleepiness.
Physicians sometimes prescribe medications "off-label"
(in a dosage or manner not approved by the FDA), but
physicians must inform youth and their parents of the
risks and benefits associated with such choices.
There
was no such informed consent regarding the use of
Strattera in this manner for this youth.
At Hickey, psychotropic medications are frequently
prescribed without the benefit of appropriate evaluations or
systematic physiological monitoring.
Medication decisions appear
to be directed at behavior control rather than improved
functioning, a practice that represents a substantial departure
from generally accepted standards of treatment.
For example,
youth are often prescribed sleep medications with little
justification.
These medications are often administered late ln

- 28 -

the afternoon, thus unnecessarily sedating youth early, making
them less able to participate in evening programs.
In addition,
the psychiatrist reported that the average time he spends with a
youth, even for an initial evaluation, is less than 15 minutes,
grossly below the amount of time needed to do an adequate
evaluation.
The psychiatrist often changes medications with no
indication in the medical or mental health chart as to the
justification.
The records also do not identify target symptoms
for the medications.
Some examples of questionable medication
practices are:
Several youth at Hickey were treated with Neurontin, an
anticonvulsant medication, for the purpose of
controlling impulsive-aggressive behavior or bipolar
disorder.
This medication is not designed to treat
these disorders.
Furthermore, research has not
supported its effectiveness for these purposes.
At Hickey, some youth prescribed medications such as
Wellbutrin, an antidepressant medication, were
maintained at subtherapeutic doses that failed to
resolve their symptoms.
Contrary to generally accepted professional practices, at
neither facility do medical or mental health staff routinely
discuss benefits and risks of medications with the parents or
guardians of youth being treated, although some files do indicate
such discussions.
At Hickey, a staff member obtains consents
from both youth and families.
While she routinely checks off on
a form that she reviewed and explained the goals and potential
side effects of the medications, she was unable to articulate
knowledge of these matters, and could not produce any reference
materials which she would consult.
Our records review
demonstrated that staff at Cheltenham also fail to fulfill this
necessary function.
Furthermore, although nurses dispense psychotropic
medications to youth, they do not monitor youth for unwanted side
effects of medications and do not dispense medications in a
setting where confidential discussions could occur.
Nurses we
interviewed could not articulate even the most dangerous
potential side effects of the medications they were
administering, and did not engage in any such discussions with
youth during medication distribution.
The following examples are
illustrative:

- 29 -

Youth at both Cheltenham and Hickey were prescribed the
antidepressant medication Trazodone to aid with sleep.
A less common potential side effect of Trazodone is
preapism (a painfully persistent erection).
There was
no evidence in the file that the youth or their parents
or guardians had been warned of the potential risks of
this medication.
A youth at Cheltenham refused to take his Ritalin, a
medication cOumonly used to treat ADHD.
While the
nurse asked him to sign a refusal sheet, the nurse did
not question him about why he was refusing, or explain
the potential risks of abruptly discontinuing this
medication.
Such risks include agitation and the
possibility of impulsiveness.
Youth at Hickey on neuroleptics, medications used to
treat psychotic disorders and sometimes prescribed offlabel for behavioral control, did not receive
sufficient information regarding cOumon and serious
side effects of these medications.
Furthermore,
documentation did not evidence explanation to these
youth of the reasons why they were being placed on such
medications.
Among the more dangerous potential side
effects of neuroleptics is tardive dyskinesia, a
potentially irreversible movement disorder.
The psychiatrist at Hickey frequently prescribes
Wellbutrin to treat ADHD, despite the lack of FDA
approval to use the medication for this purpose.
Many
files we reviewed lacked sufficlent discussions with
youth and parents or guardians when medications are
used off-label.
The psychiatrist at Hickey placed a youth on
medications for impulsive-aggressive behavior, ADHD and
sleep disturbance.
This youth had a history of
oppositlonal behavior, altercations with other youth on
his unit and needing frequent redirection by staff.
The youth frequently refused all medications.
There is
no documentation that the psychiatrist discussed with
him the potential physiological and behavioral
consequences of inconsistent medication compliance.
Psychiatrists at both facilities also fail to order and
perform needed follow-up regarding appropriate laboratory work to
monitor the emergence of problematic side effects.
For example:

-

30

-

At Cheltenham, youth on Imipramine, a tricyclic
antidepressant medication which can cause cardiac
arrhythmia including cardiac arrest, did not have
electrocardiograms to ensure that such symptoms were
not present.
Youth on Depakote, a mood stabilizing medication that
can affect the white blood cell and platelet counts and
cause liver damage, do not routinely receive necessary
liver and blood tests.
Youth on Lithium, a mood stabilizing medication that
can cause kidney damage and alter thyroid functioning,
do not receive kidney function and thyroid tests as
needed.
Medications such as Guanfacine and Clonidine used to
treat ADHD, may lower blood pressure.
Youth are at
risk for fainting when they stand up if blood pressure
and pulse are not monitored.
None of the psychiatric
files we reviewed contained evidence of blood pressure
monitoring (e.g., blood pressure and pulse
measurements) .
Furthermore, many of the medications administered to youth
require that a certain level be maintained for them to be
effective.
The facilities' failure to test blood levels
increases the possibility that the medication will be ineffective
or potentially toxic.
Youth at Cheltenham are discharged from the facility without
medication or prescriptions, thus making it likely that youth
leaving the facility to anywhere other than an institution will
experience disruption in those medicines that require consistent
intake.
4.

Inadequate Mental Health Counseling and Other
Rehabilitative Services

Generally accepted professional standards require that
mental health counseling be provided frequently and consistently
enough to provide meaningful interventions for youth.
Treatment
should utilize approaches that are generally accepted as
effective.
Youth with mental illness should receive treatment in
settings appropriate to their needs.

- 31 -

At Cheltenham, mental health counseling is inadequate to the
needs of mentally ill youth in both frequency and content.
The
limited counseling records that exist do not evidence consistent
use of effective treatment strategies.
At Hickey, despite some
caring, dedicated counselors, interventions are not structured
toward specific goals and do not consistently involve approaches
accepted as effective.
Even for youth who are regularly placed
on suicide precautions, counseling frequently fails to identify
strategies to deal with problems of self-regulation or
depression.
For others, mental health staff failed to utilize
strategies to deal with identified anxiety, hyperactivity or
trauma.
Many youth are prescribed psychotropic medications to
manage their behavior, but receive no counseling whatsoever.
The
school lacks any mental health professionals to provide services
directed at the goals and objectives set forth in the
Individualized Education Programs (IEPs) of youth with such
needs.
A representative of the contract mental health provider
for the facility reported that these mental health staff do not
address special education-related needs in their treatment.
For example:
A 15-year-old youth admitted to Cheltenham with a
documented history of ADHD and bi-polar disorder
receiv~d only one crisis intervention visit from a
mental health counselor during three weeks in which he
repeatedly angered easily and got into fights,
resulting in his being disciplined.
The only
intervention this clinician prescribed was to see the
therapist assigned to his unit on an "as needed basis. H
Despite this youth's inability to control his behavior,
no additional counseling was reflected in his chart.
A youth at Cheltenham with current prescriptions for
Depakote and Risperdal required surgery for an
undescended testicle while detained in April 2003.
Such surgery will likely result in a variety of mental
health concerns, including anxiety and being at risk
for harassment by peers.
Thus it would be expected
that both the psychiatrist and a mental health
counselor would provide services to this youth
following his return from the hospital.
The youth's
chart reflects only one mental health visit, charted III
his medical records, in which the youth appeared to be
quite concerned about his future ability to father
children, and the possibility that the doctors had

-

32 -

found cancer.
Although the social worker wrOLe that
the youth should receive continued mental health
follow-up and supportive intervention, his records
reflect no further mental health counseling.
The psychiatrist at Hickey ordered Cognitive Behavioral
Therapy (CBT) for a youth with impulse control
disorder.
Nothing in the youth's records suggests that
the youth received such treatment.
A youth with conduct disorder as well as potential ADHD
and substance abuse was prescribed three medications by
the psychiatrist, who also ordered individual therapy
twice a week and group therapy twice a week.
Instead,
this youth received only one individual therapy session
everyone to two weeks.
A youth at Hickey with ADHD and history of substance
abuse since age ten, as well as prenatal cocaine and
alcohol exposure, received no substance abuse
treatment.
Mental health staff must keep records in a manner that
allows future providers to track treatment previously provided.
The lack of adequate record keeping could place youth at risk in
circumstances requiring prompt intervention, particularly when a
youth threatens self-harm.
Records of prior interventions are
important in order to guide staff about effective ways to
intervene in crises.
Counseling records at Hickey lack
sufficient specificity, while records at Cheltenham are
disorganized and at times nonexistent.
At both facilities, group treatment sessions are often
cancelled.
Security staff are insufficient in numbers to provide
needed supervision during group sessions to ensure a safe and
productive atmosphere.
At neither facility do counseling staff
routinely involve youth's families in their treatment
interventions, thus reducing the effectiveness of any attempt at
rehabilitation for youth who plan to return to their families
following detention.
At Cheltenham, confidentiality in group
settings is often compromised.
This circumstance leaves youth
unwilling to communicate sensitive personal concerns where
professional and custody staff cannot assure protection from
teasing and recrimination.
Furthermore, some youth with mental
illness are expected to participate in groups that are
inappropriate for their illnesses.

- 33

-

Youth with developmental disabilities are not receiving the
care they need at the facilities.
For example, one
developmentally disabled youth whose testing indicates that the
youth's performance "falls within 1 st percentile and is within
the Mentally Deficient range of intellectual functioning
frequently got in fights on his unit.
This youth was
consistently disciplined for engaging in behaviors which were
largely a function of his developmental and cognitive deficits.
His treatment plan includes no guidance for custody staff on \vhat
strategies can help this youth function more successfully with
his peers and staff.
While there was useful information
available through his school records that. could benefit both his
mental health care and his care on the living unit, there is no
indication that the information was shared outside the school.
U

Generally accepted professional practices require that
facilities confining youth provide opportunities for
rehabilitation that include effective behavior management
systems.
Effective behavior management systems generally involve
incentive-based programs for promoting appropriate behavior
throughout the day, and clearly defined guidelines that are
consistently applied across each institution.
For youth
identified as having behavioral health problems, behavior
management programs need to be coordinated with a treatment plan.
Appropriate rehabilitative services for youth confined in
juvenile justice facilities include programs that address family
conflict, substance abuse, anger management, gang affiliation and
other issues that involve them in the juvenile justice system.
At Hickey and Cheltenham, however, the behavior management
systems have little or no input from the mental health staff.
Thus, goals of cust
y staff and mental health treatment
providers are not coordinated, and youth do not benefit from
mental health treatment gains within the unit structure.
Moreover, both facilities lack an effective behavior management
system that is consistently applied and that provides approprlate
opportunities for youth to regulate their behavior.
5.

Failure to Place Youth in Court-Ordered Treatment

Once a court has ordered that a youth be placed in a
suitable facility for treatment and rehabilitation, it is
incumbent upon the State to find timely placements for such
youth.
In the meantime, these facilities are left with many
youth whose mental health needs cannot be met by the resources
available at the facllity.
The frustration and anger youth
develop from lack of appropriate treatment makes them difficult
to manage, and leaves them less receptive to future
interventions.
Youth may be detained at Cheltenham and Hickey

-

34

-

awaiting placement into other DJS or private treatment progra~s
for six months or longer.
The State must find alternatives to
meet the mental health needs of these youth whom the courts have
ordered DJS to serve.
D.

INADEQUATE MEDICAL CARE

Facilities must provide confined juveniles with medical care
consistent with generally accepted professional practices.
The
programs for providing medical care at Cheltenham and Hickey are
inadequat~ and substantially depart from generally accepted
professional standards in the following areas:
(i) access to
medical treatment; (ii) health assessments; (iii) treatment of
chronic conditions and physical injuries; (iv) medication
administration practices; and (v) dental care.
1.

Inadequate Access to Medical Treatment

Youth at Cheltenham are not provided timely access to
medical care.
The following examples are illustrative:
A youth requested sick call on July 25, 2002.
He was
seen on July 26 and complained of a sore throat lasting
two weeks.
He was referred to the physician, but not
seen until July 29.
By that time, his condition had
deteriorated and the youth was hospitalized with a
peritonsillar abscess, a serious deep tissue throat
infection.
Timely attention by a medical practitioner
and treatment with antibiotics would likely have
prevented his hospitalization.
A youth with severe asthma was admitted to Cheltenham
in May 2003.
At the time of admission, the youth's
respiratory rate was 20, indicating acute asthma and
the need for further assessment by the physician.
Nothing further was done to evaluate or treat his
asthma at the time of his admission.
Untreated asthma
symptoms can result in respiratory crisis.
At Cheltenham we encountered a youth in disciplinary
seclusion who had been in a fight with another youth.
His tooth had been left very loose as a result of the
fight, but he had not received medical care for this
injury when we spoke with him.
The dentist was due to
be at the facility the next day for his weekly visit,
so a senior administrator who was accompanying us on
our tour instructed a nurse to ensure that the youth
got to see the dentist the following day.
We checked

-

35 -

back with this youth mid-afternoon the following day,
and found that no one had spoken with him further
regarding his tooth.
We were able to intervene just in
time to catch the dentist who was packing up to leave
for the day.
The dentist had received no word that a
youth housed just down the hall needed his care.
For juvenile facilities to provide adequate medical care,
generally accepted professional practices require that there be
sufficient medical staff.
Our investigation revealed that there
was insufficient medical staff at both Cheltenham and Hickey to
provide an adequate health program, given the needs of the youth
housed there.
At the time of our tours, at Cheltenham there was one nurse
supervisor and four nurses during the day shift, three nurses
during the evening shift, and one nurse during the overnight
shift.
Nurse staffing at Hickey was virtually identical,
although the facility housed more youth.
Our observations,
document review, and interviews with staff and youth confirmed
that these levels of medical staffing contribute to the medical
care deficiencies described in this section.
In addition to a
shortage of nursing staff, physicians are not on-site for
sufficient hours.
At Cheltenham at the time of our tours, a
physician was on-site for only three and a half days each week,
which was largely spent on initial examinations of newly admitted
youth.
This schedule and staffing pattern left physicians little
time to devote to the care and treatment of acute and chronically
ill juveniles.
The shortages also explain why juveniles at both
Cheltenham and Hickey complained that requests for sick call are
unanswered for days.
Insufficient security staffing similarly impacts the
delivery of medical care for youth at Cheltenham and Hickey.
A
youth at Cheltenham sustained a shoulder separation during an
April 2003 incident.
Although the youth required x-rays, he \vas
not transported to the hospital for more than 24 hours because of
security staff shortages.
Medical staff at Hickey reported that
youth often miss outside appointments that are very difficult to
reschedule, such as optical and dental appointments, due to lack
of security staff to transport youth.
In the satellite medical
office at Hickey, the nurse reported that there was insufficient
security staff to supervise youth and also provide adequate
security for her.
As a result of this lack of security, the
nurse conducts sick call through a window from behind a locked
door, significantly limiting her clinical interaction with youth.

36

2.

-

Inadequate Health Assessment

Generally accepted professional standards require that a
standardized health evaluation be performed upon admission.
This
evaluation is necessary to ensure that youth are maintained on
necessary medications, that significant health problems are not
overlooked, and that tuberculosis skin tests and laboratory
screening to detect co~municable diseases are performed.
Significant health problems should be identified on a "problem
list" so that appropriate treatment and follovJ-up care is
provided.
Medical records from prior placements should be
obtained promptly for appropriate assessment, and current medical
records must be maintained adequately and updated in a timely
manner.
The failure to treat an unrecognized health problem can
result in serious medical harm.
Both facilities fail to conduct
adequate initial health assessments and document the health
records adequately.
At Cheltenham, we found several examples of the failure to
continue required medications on admission, the adverse health
consequences of which can be severe.
For example, a youth with a
history of seizures \,,'as admitted on March 28, 2003.
The nurse
noted that he was being treated with Tegratol, an anti-seizure
medication.
Nothing was done to continue the youth on this
medication, even though the medication was available on-site.
On
March 30, the youth suffered a seizure.
Notably, his problem
list, where all significant health problems should have been
listed, and his physical examination form were left blank, even
though his condition was known to the facility.
Our file review at both Cheltenham and Hickey revealed that
important medical information, such as medical problems and
treatment provided, is not documented so as to be readily
identifiable, representing a substantial departure from generally
accepted professional practices.
For example, a Cheltenham
youth's February 2003 initial medical assessment indicated "none"
for allergies, alth6ugh a prior chart entry from the previous
July reported allergies to penicillin and aspirin.
Youth with
histories of scoliosis (curvature of the spine), high blood
pressure, and prior positive tuberculosis skln tests reported
their histories to medical staff, but these medical problems were
not documented on the youths' problem lists so that they would be
readily observed by medical care providers. The failure to
document youths' medical problems and courses of treatment
clearly in their medical files impedes medical practitioners from
providing adequate care, and places youth at risk of receiving
medical treatment which could actually harm them.

-

37

-

Medical staff at Hickey and Cheltenham fail to perform
needed follow-up regarding abnormal lab results.
Urine tests are
a standard screening test given to youth as part of the initial
health assessment.
Abnormal results may be indicia of serious
medical conditions.
The presence of protein or blood in the
urine can indicate chronic kidney disease; the presence of white
blood cells and nitrate in the urine may indicate bladder or
kidney infection.
Our file review revealed that staff received
such abnormal laboratory results for youth at both facilities,
yet failed to take appropriate steps as a result of this
information, thus placing youth at risk of harm.
Generally accepted professional standards also require that
the immunization status of youth be assessed and immunizations be
brought up to date.
Neither Cheltenham nor Hickey has an
organized immunization program.
The facilities do conduct
routine antibody testing for Hepatitis B for all admissions;
however, youth whose antibody tests do not show that they have
developed immunity should be vaccinated.
Our review revealed
youth at both facilities who had no in®unity, yet no vaccine was
ordered for them.
Youth should also be screened to determine
whether they have active Hepatitis B or C infections.
Hickey
staff fail to determine whether youth have active infections of
these contagious diseases.
Similarly, youth who have not had chickenpox are at risk for
more serious complications from the disease, including chickenpox
pneumonia and chickenpox encephalitis, which can result in mental
retardation and seizures, if they contract chickenpox when they
are older.
Youth who have not had the condition should be
vaccinated.
Youth at both Cheltenham and Hickey reported never
having chickenpox but were not vaccinated.
Common sense dictates that screening for active infectious
diseases, such as tuberculosis, be a part of any correctional
setting.
Yet when tuberculosis screening tests are ordered at
Hickey, there often is no follow-up by nursing staff to determine
whether a youth tested positive.
This failure to track and
appropriately treat youth who need care places both staff and
youth at risk of contagion from untreated youth.
Finally, medical staff fail to take sufficient steps to
obtain complete medical records from prior facility placements,
even those within DJS.
At Hickey, a nurse tracks whether medical
records are received, but does not assess the completeness of the
records.
For example, a physical examination record may be
received without laboratory results, but no follow-up would be

-

38

-

done to acquire these results.
Nurses apparently assume that
tuberculosis screening tests are conducted at prior placements,
but often this has not occurred and there is no documentation of
tuberculosis screenlng from the previous facility.
3.

Inadequate Medical Treatment of Chronic Conditions
and Physical Injuries

Generally accepted professional standards require that
appropriate treatment be provided for youth with chronic medical
conditions.
A common, yet serious, medical condition among youth
is asthma.
At Cheltenham and Hickey, staff fail to provide
critical aspects of asthma care consistently with current
standards.
Health staff only see youth for asthma symptoms,
rather than at regular intervals to monitor the illness.
Staff
do not review how youth are responding to treatment, assess
airflow using a peak flow meter, review side effects of
medications, provide patient education, and adjust the management
of the disease to achieve the least disability.
Peak flow meters
are available at the facilities, but rarely used.
Certain types
of asthma inhalers are prescribed for use when patients find
themselves urgently short of breath.
The documented use of such
inhalers is necessary to manage this serious medical condition,
as the use of inhalers for urgent relief more than twice a week
is an indication that providers should consider intensification
of the daily treatment regimen.
Although custody staff confirmed
that they store asthma inhalers, which youth use on the housing
units, the medical charts we reviewed contained no documentation
of administration of asthma inhalers on the housing units.
Youth with other chronic illnesses receive inadequate care
at both facilities.
For example, two youth at Hickey had sickle
cell anemia.
Generally accepted professional standards call for
daily folic acid supplements to support the bone marrow's rapid
production of red blood cells in sickle cell patients.
Neither
youth was prescribed these preventative measures.
In another
example, a youth who tested positive for Hepatitis C was not
provided a vaccine for Hepatitis A.
Such vaccination is a
standard treatment for youth with Hepatitis C, since they are
more susceptible to liver infection from other hepatitis strains.
Our investigation also revealed a number of youth with diabetes
at Cheltenham and Hickey.
Generally accepted standards of care
for this serious disease call for routine testing to monitor
diabetics for eye and kidney complications, but records contained
no indication that these tests were ordered.
A special urine
test to detect small amounts of protein in the urine is

- 39

-

appropriate for youth who have had diabetes for 3 years or more,
but records contained no indication that this test is ordered.
Additionally, at Cheltenham physicians fail to order appropriate
diets for diabetics.
4.

Inadequate Medication Administration Practices

Prescribed medications are not administered appropriately at
either facility.
Our review of medication administration records
revealed many significant gaps in medication that were
unexplained.
The following examples are illustrative:
A youth did not receive his Paxil, an anti-anxiety
medication, and Risperdal, an antipsychotic
medication, on two dates in June 2003.
A youth was prescribed Keflex, an antibiotic,
three times a day, but missed two doses every day.
A youth who had his jaw wired shut was prescribed
Ensure, a liquid protein supplement for
nourishment.
Over a three week period, he
received only 31 of 100 cans ordered.
A youth was prescribed Risperdal to help control
his anger, and reported that the medication was
he 1p f u 1 . [fJ hen hew a sin t e r vie VJ e don J un e 1 0 ,
2003, he reported that his medication had been
stopped without explanation at the end of May.
He had made a sick call request to discuss this
medication interruption and was still waiting to
see the medical staff. A review of his chart
revealed that the medication had been stopped
because both nursing and mental health staff had
failed to flag it for renewal and the prescription
had expired unintentionally.
A youth's medical chart revealed that he suffered
from chronic inflammatory bowel disease for which
he was prescribed mineral oil daily.
On two
occasions his mineral oil prescription expired
without renewal and he had to pursue sick call
requests to continue this medication.

-

4

a -

A youth with high blood pressure was treated with
the medication Atenolol, a beta blocker commonly
used to treat this condition. After his admission
to Hickey, his medication was stopped for two days
because staff failed to renew it.
The sudden
cessation of Atenolol may cause chest pain or
heart attack.
These practices represent substantial departures from
generally accepted standards of care.
5.

Inadequate Dental Care

In keeping with generally accepted practices, services to
restore and maintain dental health must be available to youth.
'see Ramos v. Lamm, 639 F.2d 559, 576 (10th Cir. 1980).
Both
Cheltenham and Hickey fail to provide adequate dental care.
At Cheltenham, our review of dental records revealed an
absence of routine dental examination on admission, and a lack of
restorative and preventative care.
At the time of our tours,
Cheltenham had a dentist on-site once a week for 6-8 hours.
There was no dental assistant or dental hygienist.
The dentist
provides only acute care when youth are referred to him by SiCK
call request.
According to the dentist, services are basically
limited to emergencies.
No preventative services, such as
cleaning, scaling, or topical fluoride application, are provided.
Given the length of stay for
some youth at Cheltenham, the failure to provide preventative
care falls outside generally accepted professional standards.

Hickey has no on-site dental staff, and preventative
services are not provided.
Dental services are provided by a
community dentist, who limits the number of appointments per
week.
Our review of dental referrals, medical files, and
interviews with staff revealed significant delays in necessary
dental treatment for youth in pain and with serious dental needs.
The failure to treat dental conditions such as cavities can
result in need for more extensive root canal therapy or tooth
loss.
For example:
A youth submitted sick call requests on May 20 and 21,
2003 for dental pain.
He was not scheduled to be seen
by the dentist until July 9, the next available
appointment.

-

41

-

A youth requested dental care for pain on May 1, 2003,
but was not referred to the dentist.
On May 15, he
complained of severe pain, and only then was he seen by
the dentist.
A youth had a dental exam on February 13, 2003, which
showed five cavities.
At the time of our April 2003
tour, he had received no treatment for these cavities.
A youth was suffering from a dental abscess on May 22,
2003 and was treated with Amoxici11in, an antibiotic.
At the time of our June 2003 tour, the youth had not
seen the dentist and no appointment was scheduled.
Hickey also fails to provide dental care for chronic
conditions.
For example, we interviewed a youth at Hickey with
severe disabling displacement of his teeth (the youth had
numerous teeth growing out of his gums above and perpendicular to
his front teeth) but he was not referred for orthodontic
evaluation.
A nursing assessment at intake described this
youth's mouth as "normal," indicating that this nurse had
received inadequate training in dental screening.

E.

INADEQUATE EDUCATION INSTRUCTION OF YOUTH WITH
DISABILITIES

With regard to the education provided to confined youth, the
facilities violate the statutory rights of youth with
disabilities by failIng to provide them with adequate special
education instruction and resources.
In states that accept
federal funds for the education of children with disabilities, as
does Maryland, the req~irements of the IDEA apply to juvenile
facilities.
See 20 U.S.C. § 1412(a) (1) (A); 34 C.F.R.
§ 300.2(b) (1) (iv).
The deficiencies we observed stem from:
(i) inadequate assessments of youth who are eligible for special
education services; (ii) inadequately developed Individualized
Education Programs ("IEPs"); (iii) lack of related services;
(iv) lack of adequate instruction for youth with disabilities;
and (v) inadequate vocational instruction for youth with
disabilities.
1.

Inadequate Assessment

Pursuant to the IDEA, staff at Cheltenham and Hickey are
responsible for screening, evaluating and identifying youth with
qualifying disabilities that would entitle them to special
education services.
Prevalence data from national studies

-

42

-

suggest
that between 20% and 60% of youth in juvenile justice
facilit es have an educational disability.lO At the time of our
tour on y 15% of youth at Cheltenham were identified as having an
educational disability and only one youth was identified with a
qualifying disability of other health impaired (OHI).
The OHI
designation is used for children with ADHD, a commonly identified
qualifying disability.
Indeed, observations by our psychiatrist
and psychologist indicate that the facility had not identified a
number of youth with this condition who likely were entitled to
special education services.
At Hickey, we found that a number of youth had significant
mental health diagnoses, such as psychotic disorders, major
depression and schizophrenia, yet many of these children did not
have IEPs.
Assessments failed to include intelligence and
achievement testing.
At Cheltenham, we found that the special
education coordinator was new to this position and plans for
assessing youth were still in the formative stages.
One 17-year old youth at Cheltenham diagnosed with
schizophrenic disorder experienced auditory
hallucinations.
Despite these severe symptoms that
would clearly interfere with his ability to learn, he
was not identified or assessed for special education
services.
Another 17 year-old youth at Cheltenham, who had been
placed there at least four times, who had a history of
prior psychiatric hospitalizations, and who had been
identified with a learning disability, emotional
disorder, and behavior disorder, was not receiving
adequate special education services.
Despite receiving
some special education services, his most recent
testing found he had only a first grade level in
reading and spelling, and a third grade level in math.
In his April 2003 progress report, his teacher noted
that he was not attending class and that when he did,
he failed to do the work.
He received failing grades

J0

Robert B. Rutherford, et ~., Youth with disabilities in the
corrections system:
Prevalence rates and identification issues
(2002) .

- 43 -

in all subjects except keyboarding.
Such lack of
success requires that additional interventions be
attempted for such a youth, but no such interventions
were put into place.
Another I7-year-old youth at Cheltenham had been
diagnosed with a mood disorder, anxiety disorder, AOHD,
and cannabis dependency.
He had been receiving special
education services since the fourth grade for
behavioral problems.
However, a recent court
evaluation reported that the youth was at only a third
grade reading level, which may indicate learning
disability.
The facility did no IQ testing or further
attempt any new educational interventions.
One I7-year-old youth at Hickey with polysubstance
abuse and conduct disorder tested at seven to eight
years below grade level in reading, math and spelling.
Such lack of educational achievement would indicate an
underlying learning disability.
This youth received no
special education services.
A I4-year-old youth at Hickey with a verbal IQ of 67
was receiving limited special education services for an
emotional disability.
Despite the fact that the
emotional disability was the condition that made him
eligible for special education services, the one hour
per week of mental health treatment that the youth
received was provided by the facility's contract mental
health provider, which was neither monitored by the
school nor coordinated with his educational needs.
In
addition, the youth's testing, which showed him to be
seven years behind in reading, indicates a likely
learning disability, which was not being assessed or
addressed at all.
An I8-year old youth at Hickey with impulse control
disorder and likely ADHD had notes on his most recent
IEP indicating that he was rarely on task, often failed
to complete work, and was argumentative with peers and
adults.
Despite this youth's testing at five to seven
years below grade level in spelling and math, and
reports that current interventions were ineffective at
improving his school performance, the IEP team
determined that he did not requIre any further
evaluation.

- 44 -

Section 504 of the Rehabilitation Act of 1973 prohibits
discrimination against persons with a disability by any agency
receiving federal funds.
The protections of this law, which
apply to state prisons, see Pennsylvania Dep't of Corrections v.
Yeskey, 524 U.S. 206 (1998) (holding that the terms of Title II
of the Americans with Disabilities Act, the relevant provisions
of which are identical to Section 504, are applicable to the
states), are extended to any person who:
(i) has a physical or
mental impairment that substantially limits one or more of such
person's major life activities, (ii) has ~ record of such
impairment, or (iii) is regarded as having such an impairment.
The law requires that an accommodation plan be developed for
students who qualify for services under Section 504.
Our
investigation revealed no assessment measures and, consequently,
no accommodation plans for youth who would not be covered under
the IDEA, but who may be eligible for accommodations under
Section 504.
2.

Inadequate Individualized Education Programs

The IDEA describes the required components of an lEP,
including that each lEP must include measurable goals.
34 C. F.R. § 300.347 (a) (2) (2004).
Many of the IEPs VJe revievJed at
Hickey lacked measurable goals and obJectives.
For example, one
rEP objective stated, "[t]he student will display empathy towards
peers and adults with 80% criteria." Other IEP objectives
included criteria stated as percentages, but did not describe the
quanta being measured.
For example, an 80% criteria could refer
to 80% of opportunities during free time, 80% of observed
interactions during class time, or 80% of interactions during
lunch over three consecutive days.
Without more concretely
stated measures, "an 80% criteria" is meaningless.
Indeed, the
criteria, even without a required percentage, would be incapable
of measurement.
The rEP goals and objectives we reviewed lacked
realistic and measurable terms, based on individual needs.
At Hickey, IEPs include recommendations for mental health
treatment, but the school has no mental health professionals.
A
representative of the contract mental health services provider
reported that they do not routinely coordinate mental health
treatment with youths' rEP goals and objectives, even where
youths' eligibility for special education is based on emotional
disability.

-

3.

45

-

Lack of Related Services

The IDEA requires that students with disabilities be
provided with related services to address their specific needs.
Our investigation revealed that students at Cheltenham whose rEPs
indicated that they should receive speech and language therapy
once a week were not receiving these services because Cheltenham
had not contracted with a speech and language therapist for some
time.
Successful rehabilitation of mentally ill youth must
involve coordinated efforts of mental health and education
professionals, and this does not occur at either facility.
Educational mastery, for many detained youth, is the
cornerstone of their rehabilitation.
Many youth at Cheltenham
and Hickey have mental illnesses which impact their educational
performance, but do not receive appropriate special education
related services to address their educational deficits.
In
general, mentally ill youth often have poor school attendance and
performance due to shame over their lack of skills or histories
of failure and conflict in school settings.
Therefore,
coordination between mental health professionals and educators is
essential for youth at both facilities.
Such coordination does
not occur at Cheltenham or Hickey.
At Hickey, although the majority of youth served by the
contract mental health provider also receive special education
services, the mental health staff rarely attend IEP meetings or
provide information regarding management of the youth's mental
illness and treatment goals.
The school frequently lists mental
health services among the interventions a youth will receive when
officials write IEPs, even though the school does not provide
these services.
School officials believe that the youth are
receiving mental health services somewhere in the institution,
but school officials do not ensure that such care is provided, or
that it coordinates with the other IEP goals and objectives.
Since school behavior is often the target of medication
management, it is a generally accepted professional practice for
psychiatrists to work with educators in the treatment of youth.
The lack of this important collaboration undermines the
rehabilitative function that the youth's detention is supposed to
achieve.

4.

Lack of Adequate Instruction for Youth with
Disabilities

The IDEA requires that students with disabilities be
provided an appropriate public education.
Students with

- 46 -

disabilities at Hickey are served in the general education
classrooms under an inclusion model.
These students receive
assistance from special education teachers in the classroom.
Student education records revealed a number of students who were
reading far below grade level.
For example, a 17-year-old youth
was reading at a 2.8 grade level.
A 16-year-old youth was
reading at a 2.2 grade level.
Students like these, with profound
reading deficits, require more individualized instruction than
what was being delivered at Hickey.
Students with disabilities at both Cheltenham and Hickev are
also denied appropriate education when they are placed in
"
restricted settings.
Our illvestigation revealed that youth in
the segregation units at both facilities received no academic
instruction.
Youth housed in the infirmary for medical reasons
or to provide them with protective custody, received extremely
limited academic instruction.
At Cheltenham, youth in the
infirmary reported that teachers of four subject matters each
spent approximately one-half hour per day with them, and that
most of the time was occupied watching movies.
During our tour,
we saw youth watching "The Matrix U during regular school hours.
Youth on some units at Cheltenham attend school only three hours
a day.
This level of educational services for youth with
disabilities is a substantial departure from generally accepted
practices.

5.

Inadequate Vocational Education for Youth with
Disabilities

The IDEA also requires that students' IEPs emphasize special
education and related services designed to meet their unique
needs and prepare them for employment and independent living.
IEPs for students at both Cheltenham and Hickey lack
consideration of career planning, job training or other
employment goals.
Vocational classes are offered at Hickey through the
Alternative Learning Center, a facility at which courses are
offered in auto mechanics, printing, agriculture and barbering.
While providing these courses is laudable, our observations
revealed that the quality of instruction and materials was
inadequate and that students were not engaged in the lessons.
In
the auto mechanics class we observed, the instructor was seated
at his desk while four students watched a video and two students
slept.
The print shop equipment is outdated and in need of
repaIr.
While we were told that most of the printing work is
done on computer, the students we observed were using the

-

47

-

computers for playing games because the system was down.
Our
observations of the agriculture class revealed two students
moving dirt and a plant around a turtle, two students studying a
catalog, and a fifth student who told us he was "just chilling
out."
Cheltenham offers no vocational or career education
courses.
F.

INADEQUATE FIRE SAFETY

Inadequate fire safety precautions at both Cheltenham and
Hickey place residents at an extremely serious risk of harm.
Indeed, in October 2000, State inspectors noted in a report that
"[e]xisting doors and locks are damaged beyond repair, [and]
cannot be opened in case of fire for ventilation.
Most of the
locks are not secure to doors." The report goes on to note under
"Consequences":
"Possible loss of life in case of fire, or other
emergencies that may occur. fIll
Because these buildings were
projected to be demolished eventually, the State did not provide
funding for these important safety repairs. 12 This report
evidences that the State knew about both the safety and security
risks involved in not repairing door locking mechanisms in these
cottages; however, the State did not repair them.
Additionally, a number of residential cottages at Cheltenham
lacked appropriate fire and smoke suppression systems.
Hickey
has a campus-wide automated fire alarm system, but the failure to
maintain that system places youth at risk of serious harm in the
event of a fire emergency.
In the March 2003 inspection of the
fire alarm system, numerous deficiencies that are easily remedied
but nonetheless serious and could result in the loss of life were
identified:
fire control panels were not functional; batteries
needed to be replaced; heat and smoke detectors did not work; and
many sprinklers were painted over which caused them to be clogged
and unusable.
In view of the broad range of serious defects
identified by the inspectors in both the 2002 and 2003
inspections, it is apparent that the fire alarm system is not
kept functioning at an acceptable level on a regular basis.
Unless these conditions are remedied, there is a grave risk that
any fire at the facilities will lead to a significant lnjurles,
including deaths.

11
Project Justification Form, October 4, 2000, submitted by
Maryland Department of Juvenile Justice to Maryland Department of
General Services, October 24, 2000.
12
We understand that a number of these cottages are not
currently used to house youth.

-

IV.

48

-

REMED IAL MEASURES

In order to rectify the identified deficiencies and protect
the constitutional and statutory rights of youth confined at
Cheltenham and Hickey, these facilities should implement, at a
minimum, the following remedial measures:
1.

Ensure that youth are adequately protected from physical
violence committed by staff and other youth, and sexual
misconduct by staff.

2.

Ensure that there is sufficient, adequately trained staff to
safely supervise youth.

3.

Ensure that staff are adequately trained in safe restraint
practices, that only safe methods of restraint are used, and
that restraints are used only in appropriate circumstances.

4.

Ensure that staff adequately and promptly report incidents.

5.

Ensure that personnel officials engage in appropriate
background and reference checks for all staff.

6.

Develop and implement an adequate classification system to
place youth appropriately and safely.

7.

Ensure that adequate security systems,
room door locks, are maintained.

8.

Develop and implement policies and procedures to ensure the
appropriate use of isolation, to include adequate due
process protections.

9.

Ensure that there is an adequate and appropriate behavior
modification system in place.

10.

Ensure that youth have adequate access to restroom
facilities.

11.

Develop and implement adequate suicide prevention policies
to identify and assess, safely house and supervise, and
adequately treat suicidal youth.

12.

Provide staff with adequate training and equipment to
identify and supervise youth at risk for suicide, and to
intervene effectively in the event of a suicide attempt.

including individual

-

49

-

13.

Provide adequate mental health treatment to include
appropriate mental health screening, identification and
assessment, adequate specialized mental health assessment,
treatment planning, case management, psychiatric services
and counseling, and provide for placement outside Cheltenham
and Hickey for those youth whose mental health needs cannot
be met adequately at the facilities.

14.

Ensure that mentally ill youth are not unfairly disciplined
for behavior resulting from their disabilities.
Ensure that
appropriate acco~~odations are made so that mentally ill
youth can participate in programs and services at the
facilities.

15.

Develop and implement appropriate rehabilitative and drug
treatment programs, including opportunity to communicate
with family members.

16.

Ensure that youth are timely placed in appropriate treatment
settings as ordered by courts.

17.

Develop and implement policies, procedures and practices for
appropriate discharge planning.

18.

Provide youth with adequate access to medical treatment,
including youth with acute, emergent and chronic medical
conditions.

19.

Ensure that adequate health assessments are conducted and
documented for all youth admitted to the facilities.

20.

Develop and implement policies, procedures and practices to
ensure that adequate medication administration practices are
followed.

21.

Develop and implement policies, procedures and practices to
ensure adequate documentation of youth medical records,
adequate laboratory analyses, appropriate immunizations, and
appropriate screening for communicable diseases.

22.

Provide adequate dental care.

23.

Ensure timely and appropriate assessment and identification
of students with disabilities for special education
services.

24.

Provide youth with disabilities adequate special education
instruction.

- 50 -

25.

Develop and implement adequate individualized education
programs; provide necessary related services; and provide
vocational education for youth with disabilities.

26.

Develop and implement appropriate Section 504 plans for all
eligible youth.

27.

Implement adequate fire safety measures.

During the exit interviews at our on-site tours, we provided
State officials with preliminary observations made by our expert
consultants.
State officials and facility staff reacted
positively and constructively to the. observations and
recommendations for improvements.
The collaborative approach the
parties have taken thus far has been productive.
We hope to be
able to continue working with the State in an amicable and
.
cooperative fashion to resolve deficiencies previously noted.
In
addition, due to the State's cooperation in this matter and State
officials' expressed desire to improve conditions, we will send,
under separate cover, reports from our consultants that provide
their more detailed findings and recommendations to address the
inadequacies they found in the operation of the facilities.
Although the expert consultants' evaluations and work do not
necessarily reflect the official conclusions of the Department of
Justice, the observations, analyses, and recommendations of our
consultants provide further elaboration of the issues discussed
above, and offer practical assistance in addressing them.
In the unexpected event that the parties are unable to reach
a resolution regarding our concerns, we are obligated to advise
you that 49 days after receipt of this letter, the Attorney
General may institute a lawsuit pursuant to CRIPA to correct the
noted deficiencies.
42 U.S.C. § 1997b(a) (1). }"ccordingly, ive
will soon contact State officials to discuss in more detail the
measures that must be taken to address the deficiencies
identified herein.
Sincerel v,
/s/ R. Alexander Acosta

R. Alexander Acosta
Assistant Attorney General

- 51

cc:

-

The Honorable J. Joseph Curran, Jr.
Attorney General
State of Maryland
Kenneth C. Montague, Jr.
Secretary, Department of Juvenile Services
State of Maryland
Martin Fahey, Superintendent
Cheltenham Youth Facility
Leo Hawkins, Facility Administrator
Charles H. Hickey, Jr. School
The Honorable Thomas M. DiBiagio
United States Attorney
District of Maryland
The Honorable Roderick R. Paige
Secretary
United States Department of Education
Mr. Robert H. Pasternack
Assistant Secretary
Office of Special Education and Rehabilitative Services
United States Department of Education
Ms. Stephanie S. Lee
Director
Office of Special Education Programs
United States Department of Education