Tuesday, January 16, 2018

BOARD OF DIRECTORS
President
Peter B. Edelman
Georgetown University Law
Center
Vice President
Christopher Wu
Casey Family Programs
Secretary
Brian Rocca
Morgan, Lewis & Bockius LLP
Treasurer
James D. Weill
Food Research & Action Center
(FRAC)
Mary Bissell
ChildFocus
Alexander L. Brainerd
Judicial Arbitration and
Mediation Services, Inc. (JAMS)

Sarah B. Fabian
Office of Immigration Litigation – District Court Section
P.O. Box 868, Ben Franklin Station
Washington, DC 20044
Judith Haron
Department of Health and Human Services
Office of the General Counsel
330 Independence Ave., S.W., Room 4280-Cohen Bldg.
Washington, DC 20201
Via email.
Re: Flores, et al., v. Sessions, et al., No. CV 85-4544 DMG (C.D. Cal.).
Dear Counsel:

David E. Brown
The Annie E Casey Foundation

Thank you for considering measures to address the inappropriate administration of
psychotropic medications to children in the custody of the Office of Refugee
Resettlement (“ORR”).

Thomas Ehrlich
Stanford University School of
Education

Psychotropic medications have profound and long-lasting impacts on children. As
federal District Court Judge Laughrey recently explained,

Laura K. Lin
Munger Tolles & Olson LLP
Jack Londen
Morrison & Foerster LLP
Walter Patrick Loughlin
K&L Gates LLP
Mary E. McCutcheon
Farella, Braun + Martel LLP
Ryan J. Smith
The Education Trust-West
Jory C. Steele
Stanford Law School
Executive Director
Jesse Hahnel

Psychotropic drugs are powerful medications that directly affect the central
nervous system. They are particularly potent when administered to children.
Children administered psychotropic medications are at particularly serious risk
of long-lasting adverse effects. They are more vulnerable to psychosis,
seizures, irreversible movement disorders, suicidal thoughts, aggression, weight
gain, organ damage, and other life-threatening conditions.
M.B. v. Corsi, No. 2:17-cv-04102-NKL, 2018 U.S. Dist. LEXIS 3232, at * 4 (W. D.
Mo. Jan. 8, 2018)
Many psychotropic medications have limited or no approved uses by the Food & Drug
Administration (“FDA”) for children and adolescents. For example, while a few
antipsychotic medications have some FDA-approved uses with older children or
adolescents, some, including several of those administered to the youth described
below (e.g., Lurasidone and Ziprasidone), have no FDA-approved uses for persons
below age 18. In addition, many antidepressants have a “black box” warning for
children and youth. A black box warning is the strictest warning put in the labeling of
prescription drug by the FDA when there is reasonable evidence of an association of a

 serious hazard with the drug. The black box warning for antidepressants advises that they may increase the risk
of suicidal thinking and behavior in some children and adolescents.
As described in Plaintiffs’ letter of December 19, 2017, class members with special mental health needs,
particularly those housed at the Shiloh Residential Treatment Center (“Shiloh RTC”), are regularly placed on
multiple psychotropic medications, told little or nothing about these medications, and often suffer negative side
effects from such medications without recourse. The evidence also shows that children are often medicated at
Shiloh RTC without the consent of parents who are present in the United States and accessible to facility and
ORR staff.
During the parties’ meet-and-confer of January 2, 2018, Defendants requested that Plaintiffs supply specific
examples of these allegations; we do so below.

came into federal immigration custody on February 21, 2016. Attachment 1.
He was transferred to Shiloh RTC on March 14, 2016, Attachment 2, where he remained until April 12, 2016.
Attachment 3.
While at Shiloh RTC,
was prescribed multiple psychotropic medications: Prazosin, Quetiapine,
Sertraline, and Olanzapine. Attachment 4. This combination of drugs includes two antipsychotics, an
antidepressant, and an antihypertensive (sometimes prescribed for adults for anxiety or posttraumatic stress
disorder (“PTSD”)). The concurrent administration of more than one antipsychotic medication and/or multiple
classes of psychotropic medications conflicts with professional association guidelines. Children administered
multiple psychotropic medications at the same time suffer from an increasing number and severity of adverse
effects. Published research also confirms that the administration of an antipsychotic and antidepressant
concurrently to children or youth substantially increases the likelihood they will develop Type II diabetes and
other cardiovascular problems.
Parents of youth prescribed these drugs are cautioned to weigh carefully the risks and benefits of taking them.
For example, the National Institute of Health cautions parents of youth prescribed Quetiapine as follows:
“[Y]our parent, or your caregiver should talk to your doctor about the risks and benefits of treating your
condition with an antidepressant or with other treatments. You should also talk about the risks and benefits of
not treating your condition. You should know that having depression or another mental illness greatly increases
the risk that you will become suicidal.” National Institute of Health, U.S. National Library of Medicine,
available at Medline Plus, available at https://medlineplus.gov/druginfo/meds/a698019.html.
Plaintiffs’ review of
ORR file, produced December 27, 2017, uncovered nothing to indicate this his
mother had consented to
being given psychotropic medications. Nothing prevented Shiloh RTC from
seeking
mother’s consent to medicating him. Shiloh RTC knew that Lutheran Social Services had
already begun evaluating
mother as a potential custodian for him, Attachment 5, and that his mother
resided in Nebraska. Attachment 6. Shiloh RTC also logged
numerous phone calls to his mother,
Attachment 7, foreclosing the possibility that Shiloh RTC staff could not have reached her via telephone.
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 Plaintiffs’ review of
s ORR file uncovered nothing to indicate that at Shiloh RTC
himself had
consented to taking psychotropic medications. When he was later transferred to Yolo County Juvenile
Detention Facility, his ORR file notes that “he does not want to continue taking the medication as he feels it is
pointless.” Attachment 8. The Yolo County case management notes report the following response to
objection: “I informed youth that we continue to work towards his goal of reunification but has to do his part in
... being medication compliant.” Id.

came into federal immigration custody in January 2016. He was transferred to
Shiloh RTC in June of 2016 where he remained until December 2016.
During his time at Shiloh RTC,
was placed on numerous psychotropic medications including Duloxetrine,
Clonazepam, Olanzapine, Geodon, Latuda, Divalproex, and Haloperidol. Attachment 9. This combination of
drugs includes four different classes of medication, the majority of which, four of the six, are antipsychotics
with very limited FDA-approved uses in children and adolescents. The use of multiple antipsychotic
medications at the same time is inconsistent with medical guidelines. Moreover, the use of Clonezepam (trade
name Klonipin) indicates that the other drug combination may have caused significant adverse effects – such as
akathisia, a severe movement disorder.
ORR Records indicate that, at times,
was simultaneously placed on six psychotropic drugs, plus two
additional drugs “as needed.” Attachment 9. In addition to the regular psychotropic medications he was placed
on,
was forcibly medicated on several occasions at Shiloh RTC, as well. Plaintiffs’ review of
file
revealed nothing to indicate that either
or any family members provided consent for any of these
medications.
An independent psychologist who evaluated
concluded that the multiple diagnoses
was assigned
while at Shiloh RTC were not justified based on his behavior and clinical presentation. For example,
was
diagnosed with Psychotic Disorder when he displayed none of the typical features of a psychotic disorder, but
instead presented with autoimmune encephalitis and pneumonia. During his time at Shiloh RTC, the Shiloh
psychologist identified multiple diagnoses, including Psychotic Disorder, Obsessive Compulsive Disorder and
Bipolar Disorder assigned to
that were inconsistent with his behavior. These diagnoses resulted in the
prescription of inappropriate medications that had adverse side effects, including weight gain of almost 100
pounds. After
arrived at Yolo County Juvenile Detention Facility, the Yolo psychologist recommended
that he taper off of his medications. Attachment 10. Records indicate that
health and behavior
improved after his medications were reduced. Attachment 11.
The foregoing examples are no aberration, rather they are representative of medication practices prevailing at
facilities in which ORR regularly places class members. Detaining class members at Shiloh RTC—as regards
the administration of psychotropic medications and in numerous other respects—is peculiarly at odds with
Defendants’ obligation to house children in facilities that are “safe and sanitary and that are consistent with [a]

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 concern for the particular vulnerability of minors.” Flores Settlement ¶ 12. We accordingly urge ORR to stop
placing class members at Shiloh RTC entirely. 1 Should it decline to do so, ORR should at a very minimum

1

The Shiloh RTC is owned and operated by the same entity that formerly operated Daystar Treatment Center,
also in Manvel, Texas.
In December 2015, the U.S. District Court for the Southern District of Texas had this to say about the Daystar
facility:
[Texas Child Care Licensing] has closed one facility in the past five years, but it is a story of horror
rather than optimism regarding enforcement. The Daystar facility in Manvel, Texas had a capacity of
141 children. Between 1993 and 2002, three teenagers died at Daystar from asphyxiation due to physical
restraints. In most cases, the children were hog-tied. Beyond these deaths, there were reports of sexual
abuse and staff making developmentally disabled girls fight for snacks. Numerous stakeholders,
including the district attorney, spoke out against Daystar, but the facility kept its license. In November
2010, a fourth child died in what was ruled a homicide by asphyxiation due to physical restraints.
Daystar’s license was still not revoked until January 2011. [Texas Department of Family and Protective
Services] allowed this facility—that was responsible for four deaths, numerous allegations of sexual
abuse, and unthinkable treatment of developmentally disabled children—to operate for 17 years. ... The
Court understands DFPS’s concern that enforcement might affect placement availability. The Court does
not understand, nor tolerate, the systemic willingness to put children in mortal harm’s way. The Court
finds that [Texas Department of Family and Protective Services'] inadequate licensing and inspecting
causes an unreasonable risk of harm to [Licensed Foster Care] children.
M.D. v. Abbott, 152 F. Supp. 3d 684, 803-04 (S.D. Tex. 2015).
In December 2014, the Houston Chronicle published an expose about the Shiloh RTC itself. Carroll, Federal
agency’s shelter oversight raises questions, Houston Chronicle (US & World), Dec. 19, 2014, available at
www.houstonchronicle.com/news/article/Federal-agency-s-shelter-oversight-raises-5969617.php (last visited
December 28, 2017).
Shortly thereafter, Congresswoman Sheila Jackson Lee, a senior member of the House Homeland Security and
Judiciary Committees and Founder and Co-Chair of the Congressional Children’s Caucus released the
following statement:
I am appalled by record of abuse and mistreatment of children at the Shiloh Treatment Center in Manvel
documented by the Houston Chronicle in an expose published December 19, 2014. The abuses
documented in that report – ranging from physical violence, unreasonable and excessive use of physical
restraints, administering emergency medications without notice to governmental authorities, and several
deaths of minor children while in custody – is not reflective of the quality of care and support that
should be provided to the at-risk children, including the dozens of unaccompanied immigrant children,
committed to its care.
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 dramatically increase its scrutiny of the treatment and conditions children experience during ORR custody at
Shiloh RTC.
We look forward to Defendants’ response to the foregoing.
Sincerely,
Leecia Welch
One of the attorneys for Plaintiffs

jacksonlee.house.gov/media-center/press-releases/shiloh-treatment-center-in-manvel-should-be-closed-by-hhsfor (last visited December 28, 2017).

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