August 7, 2006

The Honorable Robert L. Ehrlich, Jr.
Governor of Maryland
100 State Circle
Annapolis, Maryland 21401
Re:	 Investigation of the Baltimore City Juvenile

Justice Center in Baltimore, Maryland

Dear Governor Ehrlich:
I am writing to report the findings of the Civil Rights
Division’s investigation of conditions and practices at the
Baltimore City Juvenile Justice Center (the “Justice Center”), in
Baltimore, Maryland. On June 30, 2005, we notified you of our
intent to conduct an investigation of the Justice Center 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”).
CRIPA and Section 14141 give the Department of Justice authority
to seek remedies for any pattern or practice of conduct that
violates the constitutional or federal statutory rights of
children in juvenile justice institutions.
In September and October 2005, we conducted on-site
inspections of the Justice Center with expert consultants in
various disciplines. Before, during, and after our site visits,
we reviewed a wide variety of relevant State and facility
documents, including policies, procedures, and juvenile
corrections and other records relating to the conditions of
confinement of hundreds of Justice Center residents. During our
visits, we also interviewed Justice Center and State
administrators, professionals, staff, and residents, and observed
youths in their living areas, in activity areas, in classrooms,
and during meals. In keeping with our pledge of transparency and
to provide technical assistance where appropriate regarding our
investigatory findings, we conveyed our preliminary findings to
State counsel and to State and facility administrators and staff
during verbal exit presentations at the close of each of our onsite visits.

- 2 

We would like to express our appreciation to the State for
the extensive cooperation and assistance provided to us
throughout by officials from the Department of Juvenile Services
and by the Justice Center administrators, professionals, and
staff. We also appreciate the State’s receptiveness to our
consultants’ on-site recommendations. It is particularly
noteworthy that after our initial investigatory visits the State
immediately corrected, or developed corrective action plans to
address, many of the issues identified during our tours. Indeed,
on February 6, 2006, the State provided us with a list of 17
specific improvements made at the facility since our last
facility tour. Many of these items purport to address issues
identified by our consultants and reflected in this letter.1 We
applaud the efforts by the State to promptly address the
identified areas of concern. Given the systemic nature of many
of these problems however, it will understandably take time to
fully correct many of these problems. To be clear, our findings
of conditions at the facility reflect information available to us
and evaluated by our consultants at the time of our investigatory
tours. We hope to continue to work with the State and officials
at the Justice Center in the same proactive and cooperative
manner going forward.
Consistent with our statutory obligations under CRIPA, I now
write to advise you formally of the findings of our
investigation, the facts supporting them, and the minimal
remedial steps that are necessary to remedy the deficiencies set
forth below. 42 U.S.C. § 1997b(a). Specifically, we have
concluded that a number of conditions and practices at the
Justice Center violate the constitutional and federal statutory
rights of its youth residents. In particular, we find that
children confined at the Justice Center suffer significant harm
and risk of harm from the facility’s failure to: (i) adequately
protect children from youth violence; (ii) adequately safeguard
youths against suicide; and (iii) adequately provide behavioral
1


For example, the State indicated that since the time of
our tours, the Maryland State Department of Education has assumed
responsibility for educational services at the facility, the
State has developed and implemented a new suicide training
prevention program for facility staff, and the State has
implemented a “watch tour” system at the facility where staffconducted room checks and seclusion checks will now be
electronically documented. Additionally, the State indicated
that it was planning on issuing a request for proposal for a
qualified provider of mental health services at the facility with
provisions for additional staffing and staff hours and with a
target implementation date of July 1, 2006.

- 3 

health care services. In addition, the facility fails to provide
required education services pursuant to the Individuals with
Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482
(West, Westlaw through July 3, 2006).
In the course of our investigation, we also reviewed staff
use of force, medical care, environmental health conditions, and
fire safety. We found no systemic constitutional deficiencies in
these additional areas, and commend the State for its commitment
to ensuring that youths at the facility are subject to adequate
conditions in these areas.
I.

BACKGROUND

The Justice Center is a 144-bed facility for boys aged 12 to
18, with an average age of 15. The facility opened for operation
in October 2003. It is operated by DJS and serves as both a preadjudication facility and as a facility for youths who have
already been adjudicated delinquent and committed to DJS care but
are awaiting placement elsewhere in a treatment facility. On the
date of our last visit the residential population was 112. The
average length of stay at the Justice Center ranges from 15 to 19
days, but some “awaiting placement” youths have remained at the
facility for as long as four months. The layout of the facility
includes three pods with one pod containing primarily youths
awaiting placement, and the other two pods housing youths in
detention. Each pod includes four separated living areas.
II.

LEGAL STANDARDS

As a general matter, states must provide confined juveniles
with reasonably safe conditions 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); Slade v. Hampton Roads Regional Jail,
407 F.3d 243 (4th Cir. 2005). 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. 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. 20 U.S.C.A. §§ 1400-1482
(West, Westlaw through July 3, 2006). See Wilson v. Fairfax
County School Board, 372 F.3d 674, 678 (4th Cir. 2004). As
described below, the State has fallen short of these
constitutional and federal statutory obligations.

- 4 

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 Youngberg 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
Youngberg, 457 U.S. at 323.
III.
A.

FINDINGS

INADEQUATE PROTECTION FROM HARM

Our investigation revealed constitutional deficiencies in
the protection from harm measures in place at the Justice Center.
In particular, the facility fails to adequately protect youths
from youth-on-youth assaults and suicide risks.
1.

Inadequate Protection from Youth-on-Youth Violence

Generally accepted professional standards require that
juvenile detention facilities must protect youths from assault by
other youths. Facilities must maintain sufficient structure,
safeguards, and staffing to ensure safety. The Justice Center
experiences unacceptably high levels of youth-on-youth violence.
The number of youth-on-youth assaults at the facility was 47%
higher than the national average. According to Performance Based
Standards ("PbS") data for the October 2005 semi-annual reporting
cycle, the Justice Center reported a rate of assaults per 100
days of youth confinement at 0.745.2 The national field average
rate was 0.396. This data represents an improvement over the
April 2005 PbS reporting cycle data indicating that
youth-on-youth assaults were 59% higher than the national
average. Inadequate staffing levels, an ineffective behavior
management plan, and the availability of environmental weapons,
have contributed greatly to the high level of youth violence.

2


Performance-based Standards for Youth Correction and
Detention Facilities is a self-improvement and accountability
system used in 31 states and the District of Columbia to better
the quality of life for youths in custody. PbS gives agencies
the tools to collect data, analyze the results to design
improvements, implement change, and measure effectiveness with
subsequent data collections from within the facility and against
other participating facilities. See http://www.pbstandards.org.

- 5 

Adequate staffing levels and effective incentives for good
behavior are particularly important in maintaining a safe
environment. A lack of these tools at the Justice Center results
in a high number of group altercations. We reviewed several
incidents involving several attackers and lone victims. The
attacks appeared to be both brazen and premeditated. This
reflects that the system is so ineffective that certain youths
feel comfortable in orchestrating such activity. For example, in
a June 2005 incident, the facility experienced a large-scale
group disturbance in three separate units that required the
intervention of the Baltimore City Police Department in order to
restore order. In a July 2005 incident, six youths repeatedly
kicked and punched a victim in the presence of staff. In another
July incident, three youths repeatedly hit and kicked a victim,
also in front of staff. Both victims required medical treatment.
Adequate staffing levels are also essential to ending youthon-youth assaults quickly before serious harm occurs. We
reviewed several incidents where youth altercations resulted in
serious physical injury requiring treatment at a local hospital
emergency room. Consider the following examples of incidents
resulting in emergency room visits:
•	

In a September 2, 2005 incident, a youth assaulted another
youth striking him several times in the face with a closedfist. The victim sustained injuries to his left eye, which
was swollen and bleeding, a laceration to the corner of his
left eye and nose, a laceration on the lower lid of his left
eye, a bloody nose, and injuries to the back of his head.

•	

In an August 31, 2005 incident, one youth struck another
youth several times in the face with a closed-fist. The
victim sustained injuries to his left eye, lip, neck, and
shoulder. The victim’s left eye was injured so severely
that he could not see out of that eye.

•	

In a June 4, 2005 incident, as officers were escorting
youths back from recreation, two youths began arguing.
Staff directed the youths to separate, but one youth
ultimately struck the other youth. During the ensuing
melee, the victim fell back, “splitting open the back of his
head.”

As discussed above, the pervasiveness and seriousness of the
violence at the Justice Center appears to result primarily from
an inadequate behavior management plan, chronic shortages in
trained direct-care staff, and the presence of environmental
security hazards. Each of these topics are discussed below in

- 6 

detail.
a.

Inadequate Behavior Management Plan

Generally accepted professional standards require that
facilities confining youths provide 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 within the facility. For youths identified
as having behavioral health problems, behavior management
programs need to be coordinated with a treatment plan. The
behavior management plan needs to be based on proven techniques
and focused on achieving lasting change through the integration
of evidence-based (or scientifically measurable) outcomes.
Facilities must continuously track behaviors of their juvenile
population and adjust their behavior management plan to achieve a
desired result.
At the time of our visit, the Justice Center's behavior
management system did not appear to be adequate to the task of
managing children at risk and preventing youth violence and
aggressive and planned group behaviors. The available sanctions
at the Justice Center appeared demonstrably ineffective at
deterring deliberate premeditated behaviors. On December 5,
2005, the Justice Center implemented a modified Point System
(“New System”). Because the New System was implemented several
weeks after our tours of the facility, we are unable to properly
evaluate its effectiveness.
At the time of our tours, the Justice Center was utilizing
an incentive-based behavior management point system (“Point
System”). The Point System had three levels. Each level
provided a continuum of incentives including, among other things,
additional telephone calls, television and radios on the living
units, video gaming privileges, and evening recreation time.
Level three youths were also permitted to use points to purchase
incentives such as additional visitations, movie night
attendance, and commissary items.
If a youth received no point deductions for negative
behavior, the minimum length of time required to achieve the
second level was seven days, and the minimum length of time
required to achieve the third and highest level was 20 days. The
average length of stay in the facility fluctuates between 15 and
19 days. As a result, many youths were unable to achieve the
program’s most prized incentives. Sanctions for negative
behavior were limited to point deductions under the Point System.

- 7 

Due to Maryland regulations, disciplinary confinement is not
available as a sanction.3 The maximum number of points that may
have been deducted from a youth in a single day is 60. By
contrast, a youth earned 50 points in a single day for good
behavior. Accordingly, available rewards under the Point System
appeared to be inadequate at encouraging positive behavior, and
available sanctions appeared to be entirely inadequate at
deterring serious aggressive and assaultive behavior.
Under the New System implemented in December of 2005 youths
must earn points by demonstrating positive behavior, instead of
points being awarded automatically with deductions for negative
behavior. With consistent good behavior, a youth may reach the
second level after three days, and the third level after a total
of seven days. Also, youths at all levels can now earn tokens to
purchase incentives such as extra telephone calls and additional
visitation. Sanctions for negative behavior now include verbal
correction, inability to earn points, social separation,4 and a
deduction of tokens. Youths who fail to advance under the New
System are referred to the treatment team for possible
intervention. As indicated above, we have not had the
opportunity to properly assess the New System. However, based on
documents the facility recently provided, the New System appears
to be a significant improvement from the old Point System.
b.

Staffing Levels

We commend DJS for working diligently to secure adequate
staffing levels at the facility. Current staffing levels permit
DJS officials to comply with their goal of 1:6 staffing ratios
and avoid problems associated with staff frequently being
required to work double shifts. We strongly encourage DJS to
maintain these appropriate staffing levels.
The absence of sufficient numbers of trained and skilled
staff in a detention facility makes it virtually impossible to
3


COMAR 16.05.02.03. Use of Locked Door Seclusion
A. A facility employee may not place a youth in locked door
seclusion as punishment. B. A facility employee may place a
youth in locked door seclusion only: 1) When it is clearly
necessary to protect the youth or other individuals or to prevent
escape; and 2) After less restrictive methods have been tried or
cannot reasonably be tried.
4


The New System defines “social separation” as the
practice of moving a youth to his room, with the door open, for
up to 59 minutes.

- 8 

provide youths with consistent care, maintain custody and
supervision, and provide a safe environment. Until recently,
chronic understaffing at the Justice Center contributed to
violent and dangerous conditions. Typical vacancy rates for
effective juvenile facilities are between five and 12 percent of
budgeted staffing levels. Based on the number of Justice Center
direct-care staff positions budgeted at the time of our review,
approximately 146, the facility direct-care staff vacancy rate
has been as high as 50%, and averaged 42% for the last six months
of 2004. As recently as July 2005, the direct-care staff vacancy
rate was 23%. Facility direct-care staff have historically been
required to work frequent double shifts in order to provide
minimal coverage to compensate for staffing shortages.5
Prolonged continuation of mandatory overtime generally reduces
effective supervision, creates significant morale issues, and
contributes to increased numbers of adverse incidents.
Despite a chronic history of severe understaffing, the
Justice Center has recently been able to significantly increase
staffing levels and reduce vacancy rates in most categories of
employees, including direct-care staff. Direct-care staff
vacancies for the last six months of 2005 have averaged 10%.
During our second facility visit, we were informed by Justice
Center personnel that all direct-care staff vacancies had been
filled as of October 16, 2005. Further, overall facility
staffing levels have increased 41% in the last six months of 2005
compared to the last six months of 2004.
c.

Environmental Security Hazards

Certain environmental hazards have exacerbated the
seriousness of incidents of youth violence at the Justice Center.
For example, and as partly illustrated by the examples below,
removable chairs were used as weapons in at least eight incidents
of assault, brooms were used in at least three incidents of
assault,6 and shanks (improvised sharp weapons) made from
toothbrushes were present in at least two incidents of assault.
In at least two incidents involving chairs, youths required
5


“Direct-care staff” includes Resident Advisors,
Resident Advisor Supervisors, Group Life Manager I, and Group
Life Manager II staff. See Memorandum from Rodney Pegram,
Director of Detention, to All Staff, dated May 2, 2005, re:
Staffing Levels for Direct Care Staff.
6


On February 6, 2006, the State informed us that since
the time of our tours, all potential weapons such as brooms, have
been removed from unsecured rooms into secured closets.

- 9 

treatment at hospital emergency rooms and one of the victims
required emergency surgery for apparent brain trauma. Consider
the following illustrative examples:
•	

In an August 25, 2005 incident, two youths began fighting
and one youth was struck in the face with a chair. The
injuries were so severe that the victim required treatment
at a local hospital emergency room.

•	

In an August 3, 2005 incident, two youths began arguing.
Despite staff attempting to separate the youths, one youth
picked up a chair and threw it at the victim hitting the
victim in the face. The victim’s face began to swell very
badly and the Justice Center physician ordered the victim to
immediately be taken to the hospital emergency room. The
victim needed emergency surgery, and may have sustained
internal injuries to his head and neck.

•	

In a June 8, 2005 incident, three youths assaulted another
youth, who was seated in the unit, by punching him in the
face and throwing chairs at him. The victim responded by
brandishing a plastic shank and attempting to stab one
assailant in the throat. The victim was then struck in the
face with a chair and required medical treatment.

These known environmental security hazards should be
eliminated by replacing these items with immovable or unliftable
chairs, better control of brooms and cleaning equipment, and
toothbrushes made with shorter handles and flexible nylon.
Additionally, frequent and thorough cell searches could reduce
the use of weaponized contraband.
2.	

Inadequate Protection from Risks of Suicide

Suicidal behavior in juvenile detention facilities
represents a major threat to the lives and well being of the
youths. Generally accepted professional standards require
juvenile institutions to protect youths from self harm. By
permitting known environmental suicide hazards and by failing to
properly monitor youths in seclusion and youths on suicide watch
status, the Justice Center fails to meet this requirement.
a.	

Environmental Suicide Hazards

There are a host of known environmental suicide hazards at
the Justice Center. These hazards pose an unacceptably high risk
of self harm for youths at the facility. The suicide hazards
include mezzanine railings in the housing units, the design of

- 10 

the bed frames in the sleeping units, and the configuration of
the bathroom safety rails. We reviewed numerous incidents and
reports of youths tying ligatures around their necks and
attempting to hang themselves from the second-story railings. In
two unrelated incidents on April of 2005, two youths attempted
suicide from the railing on the same day. We also reviewed
several reports of youths trying to commit suicide by tying
themselves to the bed frames. One incident requiring emergency
resuscitation and emergency room treatment resulted from a youth
hanging himself from a bathroom hand rail.
The danger posed by the mezzanine railings is of particular
concern. The facility has been aware of this hazard at least
since January 2005. In quarterly reports released on January 14,
2005 and March 11, 2005 by the then Office of the Independent
Juvenile Justice Monitor (“Independent Monitor”)7, the
Independent Monitor expressed concerns about the risk posed by
the railings. In his June 27, 2005 report, the Independent
Monitor recounted several prior warnings to the facility
administration about the dangers posed by the railings.
Notwithstanding the Independent Monitor’s admonitions and several
subsequent suicidal behaviors involving the railings, the hazard
had not been remedied as of the date of our last visit, six
months after the date of the report.
Indeed, in the monitor’s report for the period ending
December 31, 2005, the JJMU expressed concern about the railings,
and indicated that the danger caused by the railings “decreases
the number of beds legitimately available [at the facility] to
only the lower tier, which will house 72 [youths].” The JJMU
further reported:
Although this Office has repeatedly insisted that the
second tier railings be suicide proofed and although
this issue was addressed again in a Special Timely
7


The Office of the Independent Juvenile Justice Monitor
was a State office created to monitor conditions in all DJS
facilities and report its findings to the Governor, the Maryland
General Assembly, and the DJS Secretary. Staff members visited
the facilities, conducted announced and unannounced tours, and
authored detailed reports of their findings, recommendations, and
DJS responses. Independent Monitor officials have previously
identified similar violations as those identified in this letter
and reported those problems to DJS. This office has been
restructured and is now the Juvenile Justice Monitoring Unit of
the Office of the Attorney General (“JJMU”) pursuant to Maryland
House Bill 1342 which became law on January 19, 2006.

- 11 

Report submitted on 8/5/05 and again in last quarter’s
report, the upper tier railing system is still not
suicide proof. Attempts to commit suicide and other safety
concerns regarding the upper tier railings continue.
The design of the facility bed frames has also been a
longstanding concern of the Independent Monitor. In his
quarterly report released on June 14, 2004, the Independent
Monitor recommends that:
DJS should secure the services of a professional
architectural and design firm specializing in secure
correctional facilities in order to review all equipment and
furnishings to ensure that it meets acceptable standards for
a secure detention facility.
In that same report, the annual report for the period ending
June 30, 2004, and the quarterly report released on January 14,
2005, the Independent Monitor indicated that the existing bed
frames posed a suicide hazard and should be replaced. Indeed, in
the January report, the Independent Monitor admonishes:
The protruding posts and openings on all the bed frames must
be eliminated. The beds have a number of openings on the
frame similar to the openings on the bed used in the March
2002 completed suicide at the Waxter Children’s Center in
Laurel. The beds also have protruding posts extending from
the frame, which may also be used to tie off from in a
suicide attempt. On August 22, 2004, a youth [at the
Justice Center] was found with a sheet tied to a bed frame
around his neck. Supervisory staff performed CPR and first
aid on the youth.
The same longstanding concerns regarding unsafe bed frames
and the mezzanine railings voiced by the Independent Monitor
remained unresolved as of the date of our last tour. The State
recently acknowledged the threat posed by the bed frames in its
Facilities Master Plan.8
b.

Inadequate Suicide Watch and Seclusion Monitoring

Residents in seclusion or identified as suicide risks are in
significant danger of self harm. To mitigate the danger to
youths in seclusion, generally accepted professional standards
and DJS policy require that direct-care staff monitor residents
8


Released January 16, 2006; Appendix A-15 (“The metal
cots in the rooms could be a suicide threat.”).

- 12 

in seclusion every ten minutes and record their rounds on a door
sheet or log.9 There is insufficient documentation to confirm
that the checks at the Justice Center are consistently performed
in accordance with policy or within generally accepted
professional standards.
We found several cases where cell checks for youths who were
in seclusion for significant periods of time were not adequately
documented. For example, on September 20, 2005, youth KJ10 was
placed in seclusion for over 24 hours. During the entire length
of seclusion, cell checks were documented for only a two-and-a
half hour period. In addition to missing documentation regarding
cell checks, we found numerous discrepancies between the DJS
seclusion observation policy and the Justice Center’s practices.
Of the 12 cases of seclusion documentation we reviewed, only
three indicated that staff had performed all required cell
checks. In at least three cases there were discrepancies between
the unit log book entries and the door sheets. For example, in
at least four cases, there were no recorded checks by the nursing
staff. In two cases, we were not even able to determine the
length of time the youths were held in seclusion.
Like youths in seclusion, youths identified as having
suicidal tendencies are in significant danger of self-harm.
To mitigate the danger to suicidal youths, generally accepted
professional standards and a DJS directive require juvenile
detention centers to provide close observation of youths who
exhibit suicidal behaviors.11 The Justice Center utilizes a
three-tier suicide watch level system which provides for a
continuum of observation for at-risk youths. At a minimum the
system requires that staff observe suicidal youths six times per
hour, and at staggered intervals of between one and ten minutes
apart during waking hours. Youths deemed to be at particularly
high risk of suicidal behavior must receive continuous
observation during waking and sleeping hours. All observations
and monitoring must be coherently documented.
The Justice Center has not consistently adhered to generally
accepted professional standards and DJS policy regarding the
9


See DJS Policy number 03.14.04 re: Limits on Use of
Restraints and Seclusion, eff. February 18, 2000.
10


To protect the privacy of youths referenced in this
letter, initials have been used in place of actual names.
11


See DJS Secretary’s Directive number SD E2270-01-01 re:
Suicide Prevention Policy (revised 11/06/02).

- 13 

observation and protection of youths at risk of committing
suicide. We found numerous examples of youths on suicide watch
where there were no documented staff observations or
consultations by the mental health staff. Moreover, none of the
cases we reviewed contained any graduated step-down release plan.
Among the cases we reviewed for September 2005, five of the
youths were on the highest suicide watch status, requiring
continuous one-on-one staff observation. Of these five cases,
the facility was unable to document staff observation for
significant periods in four of the cases. The facility also was
unable to document psychological consultations with the youths in
four cases. In one case, we found observation gaps totaling 43
hours. In two other cases, we found gaps totaling more than 20
hours.
These apparent gaps in seclusion and suicide watch
monitoring create a very high risk for self harm among known
suicidal youths.
B.

INADEQUATE MENTAL HEALTH CARE

The Justice Center is lacking in several areas with regard
to mental health care. Deficiencies include inadequate mental
health assessments, inadequate mental health treatment and case
management, inadequate communication and record keeping, and
inadequate confidentiality safeguards.
As a preliminary matter, it is worth noting that many of
these deficiencies described below are attributable to staffing
shortages. Three part-time fellows in child psychiatry from the
University of Maryland provide only ten hours of psychiatry
services per week. At the time of our tour, the Justice Center’s
mental health personnel were roughly half the number needed to
meet generally accepted professional standards. Four of eight
social worker positions were vacant, three of four addiction
counselor positions were vacant, and two of three supervisory
positions were vacant. Although the supervising psychologist has
considerable experience providing mental health care to youths in
detention, the front-line clinicians tend to be very
inexperienced. These staffing limitations inevitably affect the
quality of mental health care.
1.

Inadequate Mental Health Screening and Assessments

Generally accepted professional standards require that all
youths entering secure facilities receive a reliable, valid and
confidential initial screening and assessment to identify

- 14 

emergent suicide risks and psychiatric, medical, substance abuse,
developmental, and learning disorders. Staff should refer youths
for any required care. To do this, staff must 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 then be communicated
to appropriate personnel so that each youth’s needs are
appropriately and timely addressed.
Initial mental health and substance abuse screening occurs
as youths are admitted into the Justice Center, and the
standardized questioning during that process appears to be
thorough and consistently applied. The intake worker first
administers the Facility Initial Reception/Referral Screening
Tool – Health Care (“FIRRST-HC”), which asks whether the youth
is conscious, coherent, intoxicated, and/or thinking of harming
himself or others. Subsequent tests include the Massachusetts
Youth Screening Instrument (“MAYSI”), a 52-item yes/no
questionnaire designed to discover symptoms of mental illness,
and the Adolescent Substance Abuse Subtle Screening Inventory
(“SASSI”), a questionnaire designed to identify youths with a
high probability of having a substance abuse disorder. Screening
with positive results (especially regarding suicidality) triggers
a rapid and more extensive assessment by a clinician, but it is
not entirely clear what criteria are used to identify a need for
further immediate assessment. Moreover, potential dangers
revealed in youth responses to the questionnaire are not
systemically detected. In particular, the manner in which the
intake case manager uses the MAYSI includes no follow-up inquiry
in response to answers that reflect thought disorders, trauma
exposure, or answers that might be ambiguous.
Youths with identified mental health needs should be
provided a full mental health assessment (subsequent to the
intake assessment), and such assessments should include actual
opinions (with support and reasoning) on a five-axis psychiatric
diagnosis, risk assessment and management, and specific mental
health treatment recommendations. The Justice Center’s records
generally do not contain such information. Most youths admitted
to the detention center are evaluated by a clinician on the day
of admission or the following day. However, the assessment
process is unstructured, consisting of informal interviewing and
casual information gathering. The assessments are not thorough,
are poorly documented, and are often internally inconsistent.
The records do not reflect clear mental status data nor do they
contain explicit diagnostic or functional analysis. Assessments
do not include any tests or other structured instruments beyond
the initial mental health and substance abuse screening tests.
We were told that the school psychologist conducts psychological

- 15 

testing in the context of individual educational planning, but we
did not see any evidence of such testing in any of the mental
health records we reviewed. Assessments are particularly lacking
with regard to substance abuse: no substance abuse evaluations
of any kind are conducted beyond the initial screening.
As discussed further below, the Justice Center’s assessments
often do not include information regarding prior treatment in the
community or at other residential facilities and hospitals.
Similarly, the facility’s efforts to engage residents’ families
in overall assessment and in mental health assessment and
treatment are inadequate. We understand that some families may
not be interested in, or responsive to, outreach from facility
clinicians. However, families are an extremely important source
of clinical information, and it is not possible to conduct an
adequate overall functional or mental health assessment without
including current and historical information from families.
2.

Inadequate Mental Health Treatment and Case Management

Treatment planning requires the identification of symptoms
and behaviors that need intervention and the development of
strategies to address them. Such planning is a critical part of
generally accepted professional standards and it is necessary for
effective treatment of serious mental illness. As noted above,
mental health assessments often lack necessary diagnostic
information, thus it is not surprising that treatment plans fail
to target specific symptoms or articulate meaningful strategies
and provide no mechanism for measuring whether the plan is
working.
Mental health treatment at the time of our visit consisted
of informally-scheduled individual contacts with clinicians and
participation in psycho-educational groups. There is some effort
to note particular functional problems (though not with
diagnostic clarity) and to supply supportive or educational
services roughly addressing these problems. However, we observed
no effort to articulate particular individual characteristics or
strengths in youths that would dictate the provision of specific
treatment approaches. And, as noted previously, there is little
family involvement in treatment.
Substance abuse treatment is even less targeted, consisting
largely of non-specific psycho-educational groups for all youths.
Staff also provide informal individual counseling designed to
improve awareness of the emotional bases for substance abuse, and
staff sometimes counsel youths about community resources

- 16 

available to substance abusers. However, staff generally do not
examine individual patterns of use, abuse, addiction, or
motivation, nor do they instruct youths in alternative stress
management or abstinence support techniques. Accordingly,
substance abuse treatment services are inadequate.
Clinical interventions are organized around crisis issues
such as suicide risk evaluation but, even in cases where such
risk is recognized, records do not reflect implementation of
specific treatment aimed at alleviating the youth’s discomfort
and reducing the risk (beyond the suicide watch process). There
is no standard format for assessment of suicide risk, or for
assigning a watch level. When we asked to see the approved
suicide risk scale used by clinicians in assessing appropriate
suicide watch status, we were told that such a scale did not
exist. This is a stark departure from generally accepted
professional standards. Because there is no suicide threat
scale, the Justice Center’s policy sets almost no threshold for
responding to suicidality, i.e., the staff are required to
respond to seemingly minor risks. Nonetheless, the vast majority
of recorded incidents include explicit and substantial suicidal
behavior, suggesting that there may be a lack of sensitivity to
voiced indicators of risk that occur prior to such behavior. A
well-developed assessment system typically would identify a
higher percentage of suicidal youths before they actually attempt
suicide. The Justice Center policy calls for regular follow-up
and assessment of suicidal youths by clinicians, but the
documentation of clinical visits for this purpose was
inconsistent.
The Justice Center’s own internal review of cases of
suicidal youths revealed that the frequency of clinician meetings
with youths on suicide watch often was less than required by
generally accepted professional standards and DJS policy. That
review further revealed that documentation and implementation of
intervention plans often was incomplete. In one case, a suicidal
youth returned from hospitalization on the highest watch level
and was discharged to his appointed placement two days later.
There was no indication that he was seen by mental health staff
during those two days. Three other youths were put on watch
levels and were never seen by mental health clinicians at all.
At least one youth on the highest watch level was released
directly into the community without any plans for follow up or
community treatment.
In general, mental health planning and treatment for
suicidal youths has been inadequate. Communication among staff
and documentation of watch level assessments is poor, and mental
health staff have failed to provide proper notifications to

- 17 

families and community workers when a youth is put on suicide
watch. Facility staff have had difficulty coping with cases
involving co-occurring problems of depression, irritability,
suicidal ideation, and manipulativeness, as well as cases in
which professionals have disagreed regarding the nature of the
disorder and the degree of risk it represents.
In general, psychiatric treatment services at the facility
are inadequate. According to Justice Center policy, mental
health staff and nurses refer youths to a psychiatrist for
pharmacological assessment and treatment whenever a youth arrives
from a psychiatric hospital; whenever a youth has been on the
highest suicide watch level for three days; whenever a youth has
been on the lower suicide watch levels for seven or more days;
whenever a youth arrives taking psychiatric medication; whenever
a youth asks to see a psychiatrist; whenever a youth has a
“recent history of psychotropic medication” (“recent” is not
defined); and whenever a youth displays “behavioral signs of
symptoms suggestive of a mental health or behavioral disorder.”12
Psychiatrists have limited, or no access, to previous psychiatric
records or summaries and lack necessary background information to
treat patients effectively. They are not involved in treatment
team meetings and do not have direct access to residential staff.
Accordingly, psychiatrists are isolated from other mental health
clinicians at the facility and lack appropriate background
information to provide for adequate levels of care.
Psychiatric attention to youths who require psychotropic
medications appears reasonably thorough, with well-documented
assessments, adequate follow-up, and reasonable treatments
prescribed. However, family involvement in the development of
patient history is lacking, and staff sometimes fail to obtain
the consent of a parent or guardian to treat a patient.
Psychiatry fellows would benefit from closer supervision and
should bring to their supervisor notes and contributing
information for each patient at least once per week. As noted
previously, psychiatric involvement in the overall provision of
mental health care is inadequate. In order to meet generally
accepted professional standards, a facility such as the Justice
Center should budget at least 16-18 hours per week for on-site
psychiatric care.
3.

12


Inadequate Communication and Record Keeping

The latter criteria is so broad that, if implemented,
it would require the referral of virtually every youth in the
facility.

- 18 

Generally accepted professional standards require that
records be kept to aid in patient diagnosis and treatment, and to
measure patient progress. Most of the mental health clinicians’
progress notes showed evidence of having been introduced to the
standard “SOAP” format, but the entries suggest these personnel
were not trained to implement it properly. The SOAP format
divides a note into four parts: “S” (subjective) describes the
patient’s subjective account of problems and symptoms; “O”
(objective) describes findings observed by the clinician or
learned about from others; “A” (assessment) provides the
clinician’s understanding and opinion of the current situation
based on the subjective and objective findings; and “P” (plan)
provides the clinician’s recommendations for intervention. Notes
in the records we reviewed commonly included a line or two of
information following “S”, another line or two following “O”
(with no distinction between them in terms of the type of
information), and then considerably more information following
“A” (but no actual assessment, formulation, or opinion), with
some recommendation then following “P.”
More importantly, critical information often was not
included in the charts or was overlooked in subsequent
interviews. The case of HC is illustrative:
HC was admitted twice in the Spring of 2005. HC’s first
assessment noted that he had a history of psychiatric
medication and hospitalization. The second assessment
reflected no history of psychiatric contact or
hospitalization. HC was admitted again for a week in August
and then released to a group home. There is no mental
health note from this period. HC was re-admitted on
September 14, 2005 with higher MAYSI scores than those
recorded in previous stays, including a high score for
suicidal ideation. Nonetheless, a mental health evaluation
regarding his suicide watch level said the “boy has never
had suicide ideation.” The clinician did not inquire into
the boy’s two positive responses on the MAYSI thought
disorder scale. The next day he was seen by a different
clinician, who noted that he showed a depressed mood, had
been hospitalized in 1999, and had been receiving
psychiatric medication previously. The latter clinician
referred HC to psychiatry, but he was not seen until one
week later.
A psychosocial assessment included some cursory history
about school problems, his hospitalization at age nine, and
vague information about substance abuse. The report
included no attention to his trauma exposure, and no
attention to the issue of suicide ideation or risk. When

- 19
the psychiatrist saw HC, the patient was described as having
no history of hospitalization and no history of medication.
The treatment team process provides a valuable opportunity
for routine informal information sharing among clinical staff,
which should then result in appropriate, specific action plans
for each youth needing care. However, the current team process
does not produce detailed assessments nor does it produce
specific treatment plans.
4.	

Inadequate Confidentiality Safeguards

Generally accepted professional standards require that
mental health information be kept confidential. This standard
protects the privacy of patients, and it allows them to speak
freely and to disclose all the information necessary for
diagnosis and treatment. We were told by Justice Center mental
health staff that they inform youths that the youths’ information
will be kept in confidence, except for information about risk of
harm to themselves or others, and except for information sharing
among treatment team members. Youths may, or may not, also be
told that the clinician may be called to court to answer
questions. We were assured that the Justice Center would not
produce a youth’s mental health record to the court, but we were
also told that these records are routinely made available upon
request to the clinicians working on behalf of the court to
conduct forensic mental health evaluations.
This is a distinction without a difference. If records are
made available to an agent of the court, or if Justice Center
clinicians are compelled to testify, then patient records are not
confidential. Accordingly, under generally accepted professional
standards, youths should be told that their communications with
clinicians may be revealed to the court. Moreover, when a youth
refuses non-confidential treatment or when a clinician determines
that confidential treatment is in the patient’s best interest,
the Justice Center should provide third-party or otherwise truly
confidential mental health services. In any event, youths should
receive complete and accurate information regarding the extent to
which the information they provide will remain confidential.
C.	

INADEQUATE EDUCATIONAL INSTRUCTION OF YOUTH WITH
DISABILITIES

Youths with disabilities have federal statutory rights to
special education services under the IDEA. In states that accept
federal funds for the education of children with disabilities,

- 20 

such as Maryland, the requirements of the IDEA apply to juvenile
facilities. See 20 U.S.C. 1412(a)(1); 34 C.F.R.
§ 300.2(b)(1)(iv). At the time of our tour, 45 percent of the
Justice Center’s youths had been identified as qualifying for
special education services under the IDEA. The average age for
youths at the Justice Center is 15 and the median reading level
is fifth grade. Many of the youths have been truant, suspended,
or expelled from their previous schools and, consequently, may
not have been in school for some time prior to their detention.
The Justice Center violates the rights of youths with
disabilities secured under the IDEA by failing to provide such
youths with adequate special education and resources.
Specifically, the education program at the Justice Center is
deficient in that it fails to provide adequate access to
education by youths who are eligible for special education
services and fails to provide adequate development and
implementation of Individualized Education Programs (“IEPs”).
At the outset, we note that there are several positive
aspects of the educational program at the Justice Center. For
example, the Justice Center’s teachers are dedicated,
knowledgeable, and enthusiastic. A new computer lab has been set
up and a new reading curriculum has been introduced. Moreover,
the Maryland State Department of Education has recently assumed
control of education programming at the facility and there are
plans for space expansion for classroom use. Nevertheless, our
investigation revealed that the Justice Center fails to provide
adequate special education services required under IDEA.
1.

Inadequate Access to Special Education

The IDEA requires that all students with disabilities have
access to free and appropriate public education (FAPE) which
meets the standard of the State education agency. 20 U.S.C.
§§ 1401(8)(b) [eff. July 1, 2005: 20 U.S.C. §§ 1401(9)(b)];
1412(a)(1)(A). See also 34 C.F.R. § 300.600(a)(2)(ii). Maryland
state education standards require that school teams with
responsibility for developing IEPs meet to review existing data
and instructional interventions and strategies utilized for the
student. See COMAR 13A.05.01.04(A)(2). Although retrieval of
student records to provide information on special education needs
should be completed within five days of arrival at the Justice
Center, we determined that educational records were delivered
within five days for only four of 36 special education students.
The failure to secure these records on a more timely basis delays
students with disabilities from access to appropriate educational
services.

- 21 

Even in cases where the educational plan has been clarified,
there remain significant problems with access to services.
Students with disabilities, in particular, require consistent
attendance at school in order to access the general education
curriculum and have an opportunity to achieve academic success.
In general, the Justice Center’s population has substantial
academic deficits and many students are at risk for academic
failure. Despite these risks, the Justice Center documentation
indicates that students with disabilities do not consistently
attend school. Among the examples we uncovered: entire units
were kept away from school for days at a time; on July 19, 2005
an episode of vandalism closed the school for the entire day; on
May 24, 2005 a lock-down closed the school; on May 27, 2005 unit
43 attended school for only three hours of the five hour school
day. While visiting a class at the Justice Center, we noted the
class was dismissed 15 minutes before its scheduled dismissal
time after the students “reminded” the teacher that it was the
time when class routinely ends. The Justice Center’s failure to
provide adequate instructional hours to students with
disabilities deprives them of opportunities to receive an
appropriate education.
Furthermore, students with disabilities were denied special
education services when they were placed in restricted settings
such as segregation or lock-down. We were told that such
students were provided with educational packets by a resource
teacher. Five students reported to us in interviews that they
had not been given educational materials while in segregation.
Whether the packet was delivered or not, we find that the
delivery of educational materials by a teacher who stays with the
student for a few minutes does not constitute a full lesson.
Moreover, such students in lock-down status are not permitted to
have a pencil with which to do the school work in the packet.
Given the correlation between time spent on instruction and
academic success, the Justice Center is contributing to students’
failure by denying students with disabilities the minimum amount
of academic instruction that they would receive in a community
public school.
The typical public school system offers a continuum of
services for students with disabilities, including all-day or
partial-day instruction in self-contained resource rooms, and all
day instruction in general education classrooms with support from
special education teachers. To its credit, the Justice Center
operates an inclusion school model, as envisioned under IDEA,
34 C.F.R. 300.550(b)(1), where special education students, who
comprise 45 percent of the student body, spend most of their
school day in general education classes. However, the IEPs of
some students indicate that they need special individualized

- 22 

instruction outside the regular classroom. Those students do not
receive appropriate services at the Justice Center. Our review
of the Justice Center’s records revealed several instances where
a youth’s individual special education services were dramatically
lower at the Justice Center than at his previous educational
setting. For example: H.A. received only 40 percent of
educational time in differentiated instruction outside the
regular classroom, rather than 66 percent as required by his
prior IEP. C.C.’s and S.J.’s prior IEPs call for at least 98
percent of instructional time outside regular class, but both
students received no resource time outside the regular class at
the Justice Center. Drastic reductions in services such as the
foregoing, without adequate justification, suggest that the
Justice Center is tailoring the instruction of students with
disabilities to what is available, rather than to the students’
individualized needs. The Justice Center’s practice of providing
fewer than required hours of appropriate instruction denies
students the special education to which they are entitled.
2.	

Inadequate Development and Implementation of

Individualized Education Plans


The IDEA requires that each student with a disability have
an IEP, and it describes the IEP components required to ensure
that each student receives adequate special education services.
34 C.F.R. §§ 300.346, 300.347. The IEPs that are used to guide
the delivery of special education services at the Justice Center
do not adequately address the students’ needs. For example,
goals and objectives on IEPs written at public schools may no
longer be appropriate for students in a correctional setting and
may need to be reformulated. To effectively assist students in
achieving the goals and objectives listed in the IEPs, the goals
and objectives must be written in realistic, measurable terms
based on individualized needs. Many of the IEPS that we reviewed
contained goals which cannot be objectively evaluated. For
example, there are no criteria listed for evaluation of progress
on a Justice Center goal such as, “[t]o improve math skills.” In
several instances, the goal in the IEP referenced the baseline
skill but did not set any specific target or an identified
measurement tool. For example, one goal we discovered, “J. will
increase broad reading skills from a 2.1 grade level,” does not
set out any specific goal or a way of measuring improvement
toward the goal.
In general, instruction for students with disabilities at
the Justice Center is not implemented to align with the students’
needs. The IDEA requires that students with disabilities receive
specially-designed instruction in which the content, method,

- 23 

and/or delivery of instruction is adapted as necessary to meet
the unique needs of the student, and to ensure the student’s
access to the general curriculum. 20 U.S.C. § 1401(29);
34 C.F.R. 300.26(a). Justice Center students are grouped for
classes by their housing unit rather than academic criteria such
as grade level, credits earned, skill levels, or cognitive
abilities. In the inclusion model operating at the Justice
Center, the general education teacher typically is responsible
for implementing the instructional adaptations identified in the
IEPs. However, we observed teachers giving lectures to the
entire class, i.e., to both general education and special
education students alike, and using the same books and materials
for all students. When asked, some teachers were unaware of
which students in their classes even required special education
services and were not able to specify the individual IEP goals of
their students. The lack of differentiated instruction at the
Justice Center for students with disabilities adversely affects
their ability to succeed in their schoolwork. The inclusion
service delivery model that we observed at the Justice Center is
not sufficient or appropriate for students with disabilities.
In addition, IDEA requires that students with disabilities
receive related services to address their specific needs and
allow them to benefit from instruction. 34 C.F.R. 300.24.
“Related services” include transportation and such developmental,
corrective, and other supportive services (including, but not
limited to, speech-language pathology and audiology services,
psychological services, physical and occupational therapy,
recreation, social work and counseling services, and orientation
and mobility services) as may be required to assist a child with
a disability to benefit from special education. The term also
includes school health services, social work services and parent
counseling and training. 20 U.S.C. § 1401(26); 34 C.F.R. 300.24.
Our investigation revealed that there were two students at the
Justice Center whose IEPs indicated they needed speech and
language therapy and who were not receiving those services. We
were told that the Justice Center had been unable to develop a
contract with a speech and language therapist to provide these
services. Another youth’s IEP required the provision of
occupational therapy, but the Justice Center has not been able to
retain a therapist to provide that related service. The Justice
Center’s failure to implement IEPs by providing identified
related services violates the right of students with disabilities
to receive an appropriate education.

- 24
IV.

REMEDIAL MEASURES

To remedy the identified deficiencies and protect the
constitutional and statutory rights of Justice Center youth
residents, the State should implement promptly, at a minimum, the
remedial measures set forth below:
A.	

B.	

C.	

Protection from Youth Violence
1.	

Ensure that youths are adequately protected from
physical violence committed by other youths.

2.	

Ensure that the facility maintains sufficient levels of
adequately trained direct-care staff to supervise
youths safely.

3.	

Ensure that there is an adequate and effective behavior
management system in place, and that the system is
regularly reviewed and modified in accordance with
evidence-based principles.

4.	

Remove and replace known and identified environmental
security hazards, e.g., chairs that can be used as
weapons or toothbrushes that can be made into shanks.

Protection from Risk of Suicide
1.	

Remove and replace, or remedy, known and identified
environmental suicide hazards.

2.	

Ensure that youths placed in seclusion are monitored
consistently and that such monitoring be consistently
documented in accordance with DJS policy and generally
accepted professional standards.

3.	

Ensure that youths placed on suicide watch are
monitored consistently, and that such monitoring be
consistently documented in accordance with DJS policy
and generally accepted professional standards.

Behavioral Health and Psychiatric Services
1.	

Ensure that mental health staffing (including case
managers, clinicians, and psychiatrists) levels are
adequate to meet the mental health needs of youths.

2.	

Provide adequate mental health and substance abuse
screening and assessment.

- 25

D.	

3.	

Provide adequate mental health and substance abuse
treatment and case management.

4.	

Provide adequate mental health record-keeping and
communications between and among the treatment teams,
psychiatry staff, and the youths’ families.

5.	

Ensure that youths are provided with accurate
information regarding the confidentiality of
communications with the Justice Center clinicians.

Special Education
1.	

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

2.	

Provide students with disabilities adequate special
education instruction.

3.	

Develop and implement adequate individualized education
programs and provide necessary related services.
* 	

*

*

As stated above, we appreciate the cooperation we have
received from DJS officials and facility staff throughout this
investigation. We hope to be able to continue working with the
State in an amicable and cooperative fashion to resolve the
deficiencies found in the Justice Center’s protection from harm
measures, mental health care services, and special education
services. Provided that our cooperative relationship continues,
we will forward our expert consultants’ reports under separate
cover. Although these reports are the consultants’ work – and
does not necessarily reflect the official conclusions of the
Department of Justice – the observations, analyses, and
recommendations contained in the reports provide further
elaboration of the issues discussed in this letter and offer
practical assistance in addressing them.
In the unexpected event that we are unable to reach a
resolution regarding our concerns, the Attorney General is
empowered to institute a lawsuit pursuant to CRIPA to correct the
deficiencies of the kind identified in this letter 49 days after
appropriate officials have been notified of them. 42 U.S.C.
§ 1997b(a)(1).

- 26 

We would prefer, however, to resolve this matter by working
cooperatively with you. We have every confidence that we will be
able to do so in this case. The lawyers assigned to this matter
will be contacting your attorneys to discuss this matter in
further detail. If you have any questions regarding this letter,
please contact Shanetta Y. Cutlar, Chief of the Civil Rights
Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,
/s/ Wan J. Kim
Wan J. Kim
Assistant Attorney General
cc:	 The Honorable J. Joseph Curran, Jr.
Attorney General
State of Maryland
Kenneth C. Montague, Jr.

Secretary, Department of Juvenile Services

State of Maryland 

Rodney Pegram, Director

Baltimore City Juvenile Justice Center

The Honorable Rod J. Rosenstein

United States Attorney

District of Maryland 

The Honorable Margaret Spellings

Secretary

United States Department of Education 

Mr. John H. Hager
Assistant Secretary
Office of Special Education and Rehabilitative Services
United States Department of Education
Mr. Troy Justesen

Director

Office of Special Education Programs

United States Department of Education