IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF CALIFORNIA

Bibiche Makangu Lubante,
Petitioner,
v.
U.S. Department of Homeland Security
(“DHS”); U.S. Customs and Border
Protection (“CBP”); U.S. Citizenship and
Immigration Services (“USCIS”); U.S.
Immigration and Customs Enforcement
(“ICE”); Kirstjen Nielsen, Secretary of DHS;
Jefferson Beauregard Sessions III, Attorney
General of the United States; Kevin K.
McAleenan, Acting Commissioner of CBP;
Thomas Homan, Acting Director of ICE; L.
Francis Cissna, Director of USCIS; Pete
Flores, San Diego Field Director, CBP; Greg
Archambeault, San Diego Field Office
Director, ICE; Fred Figueroa, Warden, Otay
Mesa Detention Center,

CASE NO. _____________________

Respondents.
DECLARATION OF LISA R. FORTUNA
I, Lisa R. Fortuna, MD, MPH, M.Div., make the following declaration based on my personal
knowledge and declare under the penalty of perjury pursuant to 28 U.S.C. § 1746 that the
following is true and correct:
1.! I have not directly treated the Petitioner but was asked to give this declaration based
on my knowledge as a psychiatrist with over 20 years of experience working with
vulnerable children and families, including immigrants and trauma survivors.
2.! I am a graduate of Yale University (BA in Psychology 1991); I earned a Doctor of
Medicine (MD) degree from New Jersey Medical School in 1996; a Masters of Public
Health (MPH) from Hunter College School of Public Health, City University of New
York in 2000, a Masters of Divinity in 2012 and I completed a Pediatric Health

 Services Research Fellowship at Harvard Medical School, Boston in 2003.
3.! I am board certified in general psychiatry and child and adolescent psychiatry
(Diplomat of the American Board of Psychiatry and Neurology), and addiction
medicine. I am a health services researcher and have been an investigator on both
national and international studies of immigrant and refugee mental health and the
impact of trauma and post-traumatic stress in children. My work has contributed to
the field’s understanding of treatment needs and interventions for immigrant and
refugee children and adults. My clinical training and experience in the practice of
psychiatry and child and adolescent psychiatry offers me skills and specialization in
the psychological and social development of individuals across the life span and the
impact of biology, traumatic stress and environment on mental health.
4.! I am the Director of the Section (Division) of Child and Adolescent Psychiatry for the
Boston Medical Center (BMC), and Assistant Professor in the Department of
Psychiatry at Boston University School of Medicine, where I conduct child
behavioral health and disparities research and practice clinical psychiatry (treating
children and youth ages 3 to 21). Our clinical division includes offering child-parent
psychotherapy, a dyadic approach for young children (0-5 years of age) and parents
who have both experienced trauma. In this latter context I have developed clinical
experience in working with young immigrant and refugee children who have
experienced trauma, including witnessing violence and traumatic separations.
5.! My clinical career has focused on treating a range of childhood psychiatric disorders
and I have particular interest and expertise in Post-Traumatic Stress Disorder (PTSD),
access to care, and quality of treatment for underserved and vulnerable populations

 including children, immigrant and refugee populations. I am a cofounder of the
Refugee Immigrant Assistance Center Community Counseling (RIAC-CC), a mental
health clinic in Boston. My clinical work at RIAC involves the mental health
assessment and treatment of immigrant and refugee patients. I have served as a
clinical investigator on several National Institutes of Health funded research projects
with most of this work focused on immigrant mental health. I conduct collaborative
research with colleagues both nationally and internationally, including most recently
a clinical intervention research study of Latino immigrants in the United States and
Spain.
6.! I have published several articles and a book in the field of psychiatry, largely on
issues related to immigrant (including unaccompanied minors) and minority mental
health, PTSD and adolescent substance use disorders. I have included my curriculum
vitae with this declaration, attached hereto as Appendix 1. The following are select
publications relevant to this declaration:
a.!

Fortuna LR, Porche MV, Alegria M. Political violence, psychosocial
trauma, and the context of mental health services use among immigrant
Latinos in the United States. Ethnicity & Health 2008 Nov;13(5):435!63.
PMCID: PMC2771411.

b.!

Porche, MV, Fortuna, LR, Lin, J. & Alegria M. (2011) Childhood trauma
events and psychiatric disorders as correlates of school dropout in a national
sample of young adults, Child Development. 82, 982-998. PMCID:
PMC3089672.

c.!

Fortuna LR, Alvarez K, Ramos Ortiz Z, Wang Y, Mozo Alegría X, Cook

 BL, Alegría M. Mental health, migration stressors and suicidal ideation
among Latino immigrants in Spain and the United States. European
Psychiatry. 2016 Aug; 36:15-22. PMID: 27311103.
d.!

Ramos Z, Fortuna L.R, Porche MV, Wang Y, Shrout PE, Loder S, McPeck
S, Noyola N, Toro M, Carmona R, Alegría M. Posttraumatic Stress
Symptoms and their Relationship to Drug and Alcohol use in an
International Sample of Latino Immigrants. J Immigrant and Minority
Health. 2016 May 5. PMID: 27150593.

7.! To prepare this declaration, I reviewed the scientific literature in addition to relying on

the knowledge accumulated during my education, research and clinical experience
described above.
8.! It is my opinion that immigrant and refugee young children who have faced

psychological trauma are at heightened risk of suffering from irreversible,
psychological harm and especially if a child also experiences a traumatic separation
from their parent. Based on my review of scientific and medical literature, as well as
my practice in the field, my opinions are as follows.
Separation for a Primary Attachment Figure is Psychologically Hazardous for Young
Immigrant and Refugee Children
9.! Children who are detained are at risk of a variety of psychosocial and developmental
problems linked to their detention experiences. A variety of factors contribute to the
distress experienced by children who are held in detention, including previous trauma
experienced in their home country or during migration, disruption of the family unit,
separation from parents and poor and unsafe conditions of detention (Young & Gordon,

 2016).1
10.!The study of attachment has illuminated the critical role of early caregiving
relationships in fostering healthy development and forming a basis for future
relationships and mental health well-being (Ainsworth, Blehar, Waters, & Wall, 2015;
Bowlby, 1988; Freud & Burlingham, 1943; Lyons-Ruth, 1996; Lyons-Ruth, Zoll,
Connell, & Grunebaum, 1986). The loss of a parent is a severe hardship for any child;
children who have suffered traumatic stress and other losses as many refugee/ asylum
seeking children have, are particularly vulnerable to negative psychological
consequences related to separation from parent.
11.!Risk factors known to be especially hazardous for children include separations from
their primary attachment figure and loss or disappearance of a parent, exposure to
traumatic events such as abuse, and damaging social environments (Carlson, 2012).
12.!In my clinical practice, I have evaluated several children asylum seekers whose anxiety,
depression and post-traumatic stress are worsened during periods of uncertainty, times
of separation from primary caregiver and when he or she is unable to have the physical
and emotional protection from his or her parent.
Children Who Have Experienced Traumatic Loss are at Risk of Suffering Irreparable
Harm to Their Brain Development
13.!Severe stress such as traumatic separations in infancy and childhood may have serious,
long-lasting effects on a child’s brain development, affecting future manifestations of
negative emotions, maladaptive behaviors, and conflictual attachments. As a result,
children thus affected operate in a survival mode, rather than learning to flexibly adapt

1

Complete citations for medical literature cited herein is referenced in Appendix 2.

 to environmental demands
14.!Factors such as the level of supervision, familial and social support make a difference
in the level of distress children experience. Hodes et al., (2008) discovered that PTSD
and depressive disorders were significantly higher in children with low-support living
arrangements as compared to those with good social supports and attachments.
15.!In addition to the issue of support, a host of risks and influences create and exacerbate
mental distress among children including if children have lost their home, belongings,
family and friends (Carlson et al., 2012). Other influences on stress include language
barriers, uncertainty about asylum status, fears of deportation, the process of
immigration itself, and the lack of personal and structural support all contribute to the
distress experienced by a child and the long-term risk to their cognitive and emotional
development (Bronstein & Montgomery, 2011).
16.!The mental health risks thus far described may surface or be aggravated when children
are placed in confined, institutional settings and are also separated from family
members (Lee, 2012). Social isolation and being deprived of ones caretakers are risk
factors for poor psychological outcomes (Ehnthold & Yule, 2006; Ellis, et al., 2008;
Grove & Zwi, 2006).
Children Who Have Experienced Traumatic Loss Are at Risk of Suffering Irreparable
Harm to their Mental Health
17.!Traumatic exposures, especially long term and recurrent, combined with the loss of
attachment figures and social instability can impede personality and identity
development and subsequently impair functioning (Howard et al, 2011; Smid et al.,
2011).

 18.!Bronstein and Montgomery (2011) examined the developmental impact on refugee
immigrant children highlighting the uncertainty that is created for these children due to
separations from attachment figures and the challenges this presents to their learning,
functioning and well-being. Without parents, family and others who care about them
to fill emotional needs, a child’s adaptive processes are impaired by their uncertain
future prospects (Chavez & Menjivar, 2010). In the long term, this can result in school
failure, drop out, persistent poverty and hopelessness and even suicidality later in life
(Fortuna et al., 2016; Porche et al., 2011).
19.!Children of families seeking asylum have by definition experienced traumatic stress,
often severe in nature. The more terror inducing the trauma is and the longer its duration
is, particularly when combined with the absence of a parent, the more devastating its
effects on children (Boothby, 1994). Trauma exposure in children and adolescents can
impede personality development, causing disturbances in sense of self, impairment of
basic trust, attachment disorders, and sharp deterioration in functioning (van der Kolk,
1996; Carlson, 2012). This adversely impacts interpersonal attachments and
developments in the future (Moro, 2003).
20.!It is my opinion that when refugee and immigrant children, especially young children
are separated from their parent and primary attachment figure, they are placed at
significant risk for irreparable harm in regards to brain development, psychological
health and thus a trajectory of poor mental health, learning and development throughout
their life. I treat children in my clinical practice who range the ages of 3 to 17 years old
who are still recovering from past separations and traumatic losses. Children who are
seeking asylum who are accompanied by their parents, should be maintained together

 with their parent/ primary attachment figure. Imposing a traumatic separation upon a
child and their parent further increases the risk that the child will develop long-term
psychological consequences and that the dyadic relationship will be harmed.
Clinical Recommendation
21.!Based on my clinical experience and the foregoing analysis, it is my opinion that
separating children from their parents has a real and substantial risk of leading to
long-term (and irreversible) physiological, developmental and psychological
problems. If children and parents are detained it is absolutely necessary, that they are
not separated from one another.

I declare under penalty of perjury under the laws of the United States of America that the
foregoing is true and correct, based on my personal knowledge. Executed in Boston,
Massachusetts on February 17, 2018

Lisa R. Fortuna, MD, MPH, M.Div.

 Appendix 2
Ainsworth, M. D. S., Blehar, M. C., Waters, E., Wall, S. N. (2015). Patterns of attachment: A
psychological study of the strange situation. New York: Psychology Press.
Boothby, N. (1994). Trauma and violence among refugee children. In A. J. Marsella, T.
Bornmann, S. Ekblad,& J. Orley (Eds.), Amidst peril and pain: The mental health and well-being
of the world’s refugees (pp.239–259). Washington, DC: American Psychological
Association.
Bowlby, J. (1988). A secure base. New York: Routledge.
Bronstein, I., & Montgomery, P. (2011). Psychological distress in refugee children: a systematic
review. Clin Child Fam Psychol Rev, 14(1), 44-56. doi:10.1007/s10567-010-0081-0
Carlson, B. E., Cacciatore, J., & Klimek, B. (2012). A risk and resilience perspective on
unaccompanied refugee minors. Social Work, 57(3), 259-269. doi:10.1093/sw/sws003
Chavez, L. and Menjívar, L. (2010). Children Without Borders: A Mapping of the Literature on
Unaccompanied Migrant Children to the United States.”Migraciones Internacionales, 5 (3): 71111.
Ehntholt, K. A., & Yule, W. (2006). Practitioner review: assessment and treatment of refugee
children and adolescents who have experienced war-related trauma. J Child Psychol Psychiatry,
47(12), 1197-1210. doi:10.1111/j.1469-7610.2006.01638.x
Fortuna, L. R., Alvarez, K., Ramos Ortiz, Z., Wang, Y., Mozo Alegria, X., Cook, B. L., &
Alegria, M. (2016). Mental health, migration stressors and suicidal ideation among Latino
immigrants in Spain and the United States. Eur Psychiatry, 36, 15-22.
doi:10.1016/j.eurpsy.2016.03.001
Freud, A. & Burlingham, D. T. (1943). War and children. New York: Medical War Books.
Hodes, M. (2008). Psychopathology in refugee and asylum seeking children. In M. Rutter, D.
Bishop, D. Pine, S. Scott, J. Stevenson, E. Taylor, A. Thapar, M. Rutter, D. Bishop, D. Pine, S.
Scott, J. Stevenson, E. Taylor, & A. Thapar (Eds.), Rutter's child and adolescent psychiatry. (pp.
474-486): Wiley-Blackwell.
Howard, K., Martin, A., Berlin, L. J., & Brooks-Gunn, J. (2011). Early Mother-Child Separation,
Parenting, and Child Well-Being in Early Head Start Families. Attachment & Human
Development, 13(1), 5–26. http://doi.org/10.1080/14616734.2010.488119
Lyons-Ruth, K. (1996). Attachment relationships among children with aggressive behavior
problems: the role of disorganized early attachment patterns. J Consult Clin Psychol, 64(1), 6473.
Lyons-Ruth, K., Zoll, D., Connell, D., & Grunebaum, H. U. (1986). The depressed mother and
her one-year-old infant: environment, interaction, attachment, and infant development. New Dir
Child De v(34), 61-82.
Porche, M. V., Fortuna, L. R., Lin, J., & Alegria, M. (2011). Childhood trauma and psychiatric
disorders as correlates of school dropout in a national sample of young adults. Child Dev, 82(3),

 982-998. doi:10.1111/j.1467-8624.2010.01534.x
Van der Kolk, B.A., Pelcovitz, D., Roth, S., Mandel, F., McFarlane, A., & Herman, J.L. (1996).
Dissociation, somatization, and affect dysregulation: The complexity of adaptation to trauma.
American Journal of Psychiatry, 153(7), 83–93.