Investigation of the Arthur G. Dozier School for Boys and the
Jackson Juvenile Offender Center, Marianna, Florida
United States Department of Justice

Civil Rights Division
December 1, 20112
Summary of Findings


Despite Florida’s statewide system of oversight of its juvenile justice
facilities, we found harmful practices at both the Arthur G. Dozier School for
Boys (“Dozier”) and the Jackson Juvenile Offender Center (“JJOC”)1
The youth confined at Dozier and JJOC were subjected to conditions that
placed them at serious risk of avoidable harm in violation of their rights
protected by the Constitution of the United States.  During our investigation,
we received credible reports of misconduct by staff members to youth within
their custody.  The allegations revealed systemic, egregious, and dangerous
practices exacerbated by a lack of accountability and controls.  We found the
following threats to the safety of the youth: that threatened the safety and wellbeing of youth.  Florida’s oversight
system failed to detect and sufficiently address the problems we found at Dozier and JJOC.  We find that many of
the problems we identified at Dozier and JJOC are the result of a systemic lack of training, supervision, and
oversight.  These
problems may well  persist without detection or correction in other juvenile
facilities operating under the same policies and procedures and subject to the
same oversight process that allowed the failures at Dozier and JJOC to persist
until a budgetary crisis forced their closure.  As such, to inform Florida’s
Department of Juvenile Justice’s (“DJJ”) continued care of the juveniles within
its youth facilities, we discuss our findings at Dozier and JJOC in this Report.
Our findings remain relevant to the conditions of confinement for the youth
confined in Florida’s remaining juvenile justice facilities.  

• Staff used excessive force on youth (including prone restraints)
sometimes in off-camera areas not subject to administrative review;
• Youth were often disciplined for minor infractions through
inappropriate uses of isolation and extensions of confinement for
punishment and control;
• Staff were not appropriately trained to address the safety of suicidal
youth and were often dismissive of suicidal behaviors; and
• The safety of Dozier youth was compromised as a result of their
relocation to JJOC, a more restrictive and punitive environment.
• The State failed to provide necessary and appropriate rehabilitative
services to address addiction, mental health or behavioral needs,
which serve as a barrier to the youths’ ability to return to the
community and not reoffend.
                                                         
1
Both facilities constituted the North Florida Youth Development Center
(“NYFDC”).  When discussing both facilities, we will use the term NYFDC.3
These systemic deficiencies exist because State policies and generally
accepted juvenile justice standards were not being followed.  We found that
NYFDC staff did not receive minimally adequate training.  We also found that
proper supervision and accountability measures were limited and did not
suffice to prevent undue restraints and punishments.  Staff members failed to
report allegations of abuse to the State, supervisors, and administrators.  Staff
members often failed to accurately describe use of force incidents and properly
record use of mechanical restraints.

These failures violate the Fourteenth Amendment’s mandate that youth
in custody be adequately protected from harm, undermining public safety by
returning youth to the community unprepared to succeed and eroding public
confidence.  We appreciate the efforts of NYFDC’s leadership to correct
longstanding deficiencies and its responses to recommendations we made
throughout the investigation. In order to avoid another failed facility such as
Dozier and to ensure that confined youth are being treated in a manner
consistent with the Constitution, the State must conduct an accountability
review of its remaining facilities with the assistance of consultants in the field
of juvenile protection from harm and implement effective oversight measures.

I. Investigation

On April 7, 2010, we notified then-Governor Charlie Crist and DJJ
officials of our commencement of this investigation pursuant to Section 14141.  
On July 6-9, 2010 and May 17-19, 2011, we conducted on-site inspection
tours with consultants in the fields of juvenile protection from harm and
adolescent medical care.  We interviewed staff members, youth, medical and
mental care providers, teachers, and administrators.  Before, during, and after
our visit, we reviewed documents, including policies and procedures, incident
reports, youth records, medical reports, unit logs, orientation material, staff
training material, and use of force videos and accompanying reports.  
Consistent with our commitment to conduct our investigations in a transparent
manner and to provide technical assistance where appropriate, we conducted
exit conferences with NYFDC and DJJ officials, during which our consultants
conveyed their preliminary observations and concerns.

We would like to note that the staff and administrators of NYFDC,
including Superintendent Michael Cantrell, were helpful, courteous, and
professional throughout our investigation.  We would also like to express our
appreciation to the DJJ for its cooperation throughout our investigation.  We
are hopeful that State and DJJ officials are committed to remedying the
deficiencies identified in this Report on a system-wide basis as the problems
identified at NYFDC continued due to the failure of the oversight system.
We find that several conditions and practices at NYFDC violated the
constitutional rights of the youth confined to its care.

Specifically, we find that 4
juveniles were subjected to excessive use of force by staff; that youth were
subjected to lengthy and unnecessary isolation; that youth were deprived of
necessary medical and mental health care, including adequate suicide
prevention measures; that youth were subjected to punitive measures in
violation of their due process rights, such as extensions of their confinement at
the facility and, when both facilities were in use, punitive transfers to the more
restrictive facility; that youth were denied rehabilitative services; and that
youth were subjected to unsafe and unsanitary facility conditions.  We also
found problems particular to each of the facilities, including, at Dozier, staff
subjecting youth to unwarranted, intrusive, and excessive frisk searches.  As
detailed below, the conditions we found resulted in youth suffering grievous
harm.  Although Dozier and JJOC are now shuttered, these problems persist
due to the weaknesses in the State’s oversight system and from a
correspondent lack of training and supervision.

II. Background

Our investigation initially focused on Dozier and subsequently expanded
to JJOC.  During our July 2010 tour, the State revealed its plan to merge
administration of Dozier with JJOC while maintaining separate facilities for the
youth.2

 As explained further below, Dozier and JJOC were very different
facilities in terms of restrictiveness level, the length of the youths’ commitment
to each facility, and the level of confinement appropriate for the category of
youth in each facility.  According to the State’s merger plan, the facilities would
be consolidated and renamed the North Florida Youth Development Center,
with staff referring to Dozier as the “open campus” and JJOC as the “closed
campus.”  The facilities shared staff, forms, processes, and procedures.3
By March 2011, however, Dozier started to transition all youths from its
campus to other facilities.  The majority of the youth were sent to JJOC and
the youth in the developmental program were transferred to the Ockaloosa
In Fall 2010, the Dozier campus began to accept a new population of juveniles,
including 15 children classified as “developmentally delayed.”
                                                         
2
A similar merger had occurred for approximately two years ending in early
2009, when Dozier and JJOC operated a joint admission and orientation program.  
Bureau of Quality Assurance Program Review for Dozier Training School at 3
(December 2009) available at
http://www.djj.state.fl.us/QA/programreports/residential/dozier.pdf.  Under this
program, both facilities had independent superintendents who reported to a “complex
facility director.”  Id.  Dozier youth attended admission and orientation programs at
JJOC, stayed there for the period it required to “internalize the rules and exhibit
appropriate behaviors,” and then transferred to the Dozier campus.  Id.
3 While our review was focused on Dozier, we received some documents and
videos regarding JJOC youth.  We also reviewed material involving Dozier youth who
were transferred to JJOC.5

Youth Development Center.  On May 26, 2011, the DJJ announced the
pending closure of both Dozier and JJOC citing budgetary limitations.  The
facilities were officially closed on June 30, 2011.  The remaining residents were
transferred to DJJ facilities throughout the system.
Prior to the eventual closure of Dozier, Dozier was a state operated “high
risk” residential commitment facility.4

Dozier was located on the same grounds as JJOC, a maximum risk state
operated facility for boys who were sentenced to serve a maximum of 18
months.  JJOC was structured like a prison, with locked single-cells for the
boys.  JJOC was more secure and harsher than Dozier and was for “chronic
offenders” who committed “offenses consisting of violent and other serious
felony offenses.”

 It housed juvenile males between the
ages of 13 and 21 who were committed by the court.  Dozier had space for 104
juveniles.  Dozier was surrounded by a perimeter fence and had locking doors
for each individual living unit, called “cottages.” Youth resided in several
cottages within unlocked, single rooms.  The facility, which opened 110 years
ago, was located in rural Florida on 159 acres of property.  The average length
of stay for youth committed to Dozier was 9-12 months.  

5
The relocation of Dozier youth to JJOC before the closure announcement
led to immediate threats to the safety of the Dozier youth.  In particular, there
was an increase in uses of force by staff during the month of the transition.  
Compared to Dozier, youth at JJOC received less counseling and were
The boys were confined to single living areas, referred to as
“pods,” which were similar to a prison hall with individual cells with heavy
metal doors along the corridor.  The beds were made of concrete with a thin
pad serving as a mattress.  The building was surrounded by razor wire.  The
outside areas branching off of the main building were also surrounded by razor
wire, including the areas designated for outdoor activities.
                                                         
4
The DJJ has five restriction levels for placement of juveniles:    (1) minimumrisk nonresidential, (2) low-risk
residential, (3) moderate-risk residential, (4) high-risk
residential, and (5) maximum-risk residential.  Dozier is a high-risk residential facility,
which includes facilities where juveniles are closely supervised in a “structured
residential setting that provides 24-hour secure custody and care.”  Florida
Department of Juvenile Justice website, at
http://www.djj.state.fl.us/Residential/restrictiveness.html.  Juveniles in high-risk
facilities have restricted community access, limited to “necessary off-site activities
such as court appearances and health-related events.”  Florida Department of
Juvenile Justice website, at
http://www.djj.state.fl.us/Residential/restrictiveness.html.  In limited circumstances,
with court approval, the resident may be allowed unsupervised home visits as part of
the transition before being released from the facility.  Id.
5
See Department of Juvenile Justice website at
http://www.djj.state.fl.us/Residential/restrictiveness.html.  6
subjected to more restrictiveness, given the limited access to vocational
education and recreational activities and less freedom of movement overall.  
One youth aptly observed that he felt his punishment was increased as a result
of his transfer to JJOC.

Dozier’s Superintendent, Michael Cantrell, who started on January 4,
2010, was the facility’s seventh superintendent in nine years.  Cantrell’s
predecessor resigned on December 17, 2009, after less than two years in the
position.  During his tenure, Cantrell made some positive changes at Dozier,
such as terminating some staff who were engaged in abusive behavior and
increasing the positive incentive system for youth.  These positive steps were
compromised when Dozier youth were transferred to JJOC.  
Years ago, Dozier was the subject of a class action litigation regarding
the conditions of confinement.6

 The case was filed in 1983 against several
State officials and agencies concerning conditions at some of the State’s
training schools and juvenile justice programs.  With respect to Dozier, the
plaintiffs alleged that youth were hogtied, shackled, and often held in solitary
confinement.  The case settled in 1987 with the parties entering into a consent
decree.  In 1995, the judge dismissed the consent decree against Dozier with
prejudice -- over the plaintiffs’ objections.7

 Dozier has since been the subject of media reports suggesting that juveniles at the facility were subjected to
significant abuse at the hands of staff.8

 On February 25, 2011, the facility
became the subject of another class action lawsuit alleging constitutional
violations, including abusive and unsafe conditions of confinement.9
In part, as a result of the prior lawsuit and resulting legislative reforms,
the DJJ has a very well-developed statewide system of written procedural
protections in the form of written policies and procedures.  While these policies
and procedures are available to State juvenile facilities, including Dozier and
JJOC, our findings show that the ethos behind these policies and procedures
has not adequately translated into action.  Indeed, at Dozier and JJOC, many
of the policies were disregarded and many of the procedures were inadequately
implemented.  Harmful practices threatened the physical and mental well-
                                                         
6
See Bobby M.  v. Chiles, 907 F.Supp. 368, 369 (N.D. Fl. 1995).  At the time, the
facility was called the Arthur G. Dozier Training School.
7
See Bobby M., 907 F.Supp. at 369.
8
See Ben Montgomery & Waveney Ann Moore, 100 Years Later and Its Still Hell,
St. Petersburg Times, Oct. 11, 2009 at 1A.  See Ben Montgomery, Files Verify Boys’
Abuse, St. Petersburg Times, Sept. 24, 2009 at 1A; see also Jim Schoettler,
Summaries Unveil Recent Abuse Cases at Dozier, The Florida Times-Union, Sept. 25,
2009 at B-3.  Allegations of past abuses have also been discussed in non-fiction books
such as The White House Boys:  An American Tragedy by Roger Dean Kiser (2008).
9
See J.B. v. Walters, et al., 4:11-cv-00083-RH (N.D. Fl. 2011). 7
being of the youth committed to these facilities.  These harms were clearly
evident in a number of areas at NYFDC and yet the DJJ’s oversight system
failed to adequately address the safety of the youth.  Despite its policies and
procedures, the State hired abusive staff at NYFDC, failed to provide the
requisite training to staff to ensure that they protected the youth in their care,
failed to ensure that the requisite supervision was in place to prevent and
detect abuses, and failed to have an effective accountability process.  We
therefore believe that the harm suffered by juveniles confined at Dozier and
JJOC is not limited to those facilities.  Accordingly, we are sharing these
findings with the State despite the closure of these facilities.

III. Findings

We find that the State failed to adequately protect youth confined to
Dozier and JJOC from harm and threat of harm by staff, other youth, and selfharm.  The State’s failure to ensure
the adequate implementation of its policies
caused unconstitutional conditions of confinement.  It is imperative that the
State ensure implementation of its policies and reform of its practices to bring
its juvenile detention facilities into compliance with constitutional standards.
Detained youth are protected by the Fourteenth Amendment and have a
substantive due process right to reasonably safe conditions of confinement and
freedom from unreasonable bodily restraints.  See Youngberg v. Romeo, 457
U.S. 307, 315-16 (1982) (recognizing that a person with developmental
disabilities in state custody has substantive due process rights under the
Fourteenth Amendment); Bell v. Wolfish, 441 U.S. 520 (1979) (applying the
Fourteenth Amendment standard to facility for adult pre-trial detainees); H.C.
v. Jarrard, 786 F.2d 1080, 1085 (11th Cir. 1986)(holding that conditions of
pretrial juvenile detainees “affect liberty interests protected by the Fourteenth
Amendment.”).  The Fourteenth Amendment, rather than the Eighth
Amendment, applies to youth confined to juvenile facilities because adjudicated
youth are held for rehabilitation, not punishment.10
                                                         
10
In Ingraham v. Wright, the Supreme Court refused to apply the Eighth
Amendment deliberative indifference standard in a non-criminal context.  430 U.S.
651, 669 n.37 (1977) (“Eighth Amendment scrutiny is appropriate only after the State
has complied with the constitutional guarantees traditionally associated with criminal
prosecutions.”).  Moreover, in Bell, 441 U.S. 520, the Court held that the Due Process
Clause of the Fourteenth Amendment was the appropriate basis to determine the
rights of adults detained by a state, but not yet convicted of any crime.  See also H.C.
v. Jarrard, 786 F.2d at 1085.  At minimum, youth should be accorded the same
protections.

 Conditions of confinement

claims may be based not only upon existing physical harm to youth, but also
on conditions that threaten to cause future harm to confined youth.  Helling v.
McKinney, 509 U.S. 25, 33 (1993) (stating "[i]t would be odd to deny [relief to 8
detainees] who plainly proved an unsafe, life-threatening condition in their
[facility] on the ground that nothing yet had happened to them.").  
To determine whether the Fourteenth Amendment was violated, a
balancing test must be applied: “[I]t is necessary to balance ‘the liberty of the
individual’ and ‘the demands of an organized society.’”  Youngberg, 457 U.S. at
320 (citing Poe v. Ullman, 367 U.S. 497, 542 (1961) (Harlan, J., dissenting)).  
The Youngberg Court went on to hold that “[i]f there is to be any uniformity in
protecting these interests, this balancing cannot be left to the unguided
discretion of a judge or jury.”  Id. at 321.  Instead, the Court held that there
was a constitutional violation if the detaining official substantially departed
from generally accepted professional standards, and that departure endangers
youth in their care.  See id. at 321.

1. Excessive Uses of Force  

Juveniles have a constitutional right to be free from physical abuse by
staff and from assaults inflicted by other juveniles.  Youngberg, 457 U.S. at
315-16 (“the right to personal security constitutes a ‘historic liberty interest’
protected substantively by the Due Process Clause”); Jarrard, 786 F.2d at 1085
(juvenile’s due process rights violated when detention officer slammed him
against a wall and a metal bunk in an isolation cell); Bozeman v. Orum, 422
F.3d 1265 (11th Cir. 2005)(force used against 17-year-old pre-trial detainee
was excessive where the detention officers continued to use force, shackling
him and sitting on him, after he was subdued).  Generally accepted juvenile
justice standards require that juveniles be provided with a safe environment
and that force be used only as a last resort.  Absent exigent circumstances,
lesser forms of intervention, including verbal de-escalation methods, should be
used or considered prior to more serious and forceful interventions.
We learned that despite policies requiring that force be a last resort, staff
subjected youth to force as a first resort.  This violation occurred even though
DJJ provides training that emphasizes a preference for verbal intervention and
de-escalation of conflict.  The DJJ authorizes facilities to train staff on use of
the “Protective Action Response” (“PAR”) measures – which include both verbal
and physical intervention – to address youth behavior.  PAR includes three
different response levels:  level 1 consists of verbal intervention; level 2
includes touch and countermove techniques as well as takedown methods;11
                                                         
11
According to the training director, the primary PAR technique is a “straightarm” take down to the ground
technique.  If a child is already on the ground, a PAR
technique would only be required if the youth’s arms are blocked (underneath) by his
body; this technique involves pulling the child’s arms from under his body.  Staff are
prohibited from implementing force involving punches, strikes, kicks, or pressure
points.

and level 3 involves the use of mechanical restraints.  The DJJ only authorizes 9
physical intervention where “a clear and identifiable risk to safety and security”
is present.12

 Further, DJJ rules require that “counseling, verbal intervention,
and de-escalation techniques are used prior to physical intervention.”13
Despite these rules and the attempts of facility leadership to implement
even stricter rules, such as a zero tolerance rule implemented by Cantrell at
Dozier, the use of excessive force against youth was a persistent problem.  For
example, at Dozier, we learned that staff used force as a first resort against
youth engaged in non-violent and non-threatening behavior.  Staff took youth
to the ground using the dangerous face down prone restraint technique.  Staff
engaged in impermissible uses of force such as choking.  And, finally, staff
used force when a youth was already subdued, including use of mechanical
restraints.  These practices occurred even more frequently at JJOC.  In fact,
the 2011 JJOC rate of physical restraint events was nearly seven times larger
and more than five times greater than the Performance-based Standards for
Youth Correction and Detention Facilities’ Field Average (“PbS Field Average”).
 
14
We also found that many uses of force were not appropriately
documented and were often conducted outside the view of facility cameras.  
Inadequate documentation and recording of use of force incidents leads us to
question whether uses of force at Dozier and JJOC were even higher than the
data suggests.
 
Even more troubling, the JJOC rate of takedowns alone was over 2.5 times
greater than the rate of all physical restraint events in the PbS Field Average.  

a. Unnecessary Uses of Force

The needless imposition of force on a juvenile is a violation of his
constitutional rights.  Jarrard, 786 F.2d at 1085.  Moreover, continued use of
force is excessive where the juvenile is already subdued.  Bozeman, 422 F.3d at
1265.  Youth confined at NYFDC were subjected to excessive force.  While a
number of staff were terminated or placed on “no contact” status as a result of
excessive uses of force, oftentimes improper uses of force were deemed
                                                         
12 DJJ Administrative Rules, Protective Action Response Policy, 63H-1.003.  This
rule is copied on the facility level as well.  For example, Dozier was supposed to follow
a similar rule.  See Facility Operating Procedures (“FOP”), FOP 208 (March 4, 2010).
13
Id.
14
The Performance-based Standards for Youth Correction and Detention Facilities
was developed in 1995 by DOJ, Office of Justice Programs, Office of Juvenile Justice
and Delinquency Prevention (“OJJDP”) to assess conditions of juvenile confinement.  
PbS establishes goals and standards for facilities.  Participating facilities collect
information in an effort to identify problems and improve conditions.  See Council of
Juvenile Correctional Administrators, available at
http://cjca.net/initiatives/performance-based-standards-pbs.  10
appropriate by reviewers, who generally were Juvenile Justice Residential
Officer (“RO”) supervisor or training coordinators.  The following incidents,
which occurred at NYFDC, are illustrative of the pattern or practice of excessive
force staff routinely used against youth.  

• AA15
• On August 20, 2010, BB asserted that a RO injured him during an
unnecessary takedown.  A video of the incident shows the RO
pushing BB to the ground without any apparent provocation.  The
youth had been seated on a table and was fiddling with what
appeared to be a hand towel.  According to the RO’s incident
report, the youth had tried to harm himself with the towel and
refused to release the item.  Although this rationale is difficult to
discern from the video, the facility found that force was
appropriately used.  While use of force may be appropriate to
prevent imminent bodily harm, that does not appear to be the
basis for use of force in this instance.

complained that he was choked during an altercation with a
RO on June 28, 2010.  A video of the encounter shows that after a
brief verbal exchange with the RO, the RO violently pushed AA
onto his back on what appears to be a mattress.  AA was pushed
mostly out of the view of the camera, but his feet were still within
view.  The video shows that the RO remained on top of AA for
about 10 seconds before both were out of view of the camera.  AA
reportedly had scratches on his neck following the incident and is
seen on the video touching his neck once he was within view of the
camera again.  The facility found the use of force to be appropriate
even though the youth presented no apparent danger before the
RO used force against him.

• On September 10, 2010, a RO provoked CC into an argument and
then slammed CC into furniture and onto the ground.  Before the
assault, the RO approached CC as he leaned against a desk in the
common room as other youth milled about the room.  CC appeared
to be somewhat withdrawn, but was not engaged in violent or
disruptive behavior.  The RO continued to address CC and, after
about a minute, shook CC’s arm.  CC did not react to the RO,
keeping his head down.  The RO held on to CC’s arm and then
attempted to force the youth’s left arm behind his back.  At this
point, CC moved to escape the arm lock.  The RO followed CC and
argued with him, moving his chest against the youth’s chest and
shadowing him.  Even though CC moved slowly away and seemed
                                                         
15 We will use pseudonyms throughout this Report to protect the identities of the
youth involved in various incidents.11

to be trying to avoid further confrontation, the RO continued to
shadow CC.  CC was clearly being taunted and aggravated.  CC
responded by arguing with the RO and they ended up bumping
chests.  The RO then pushed CC onto an armchair, sliding both
the youth and the armchair across the room and into a wall,
causing CC to fall to the ground.  While CC was still on the
ground, with his back on the floor, the RO hovered over him and
appeared to strike and choke the youth.  The incident was
reviewed and found to be an improper use of force.16

• In another incident involving CC, the use of force was found to be
appropriate after the RO took the youth down to the ground.  
According to the incident report, the RO verbally directed CC to
remain in bounds but the youth kept walking out of bounds.  In
the video, CC made no aggressive motions and simply appeared to
be disobedient.  The RO then physically forced CC to the ground in
order to get him to comply with the directions.  Once he was forced
to the ground, CC started resisting.  The RO reacted by forcefully
grabbing the youth’s arm and dangerously placing his body weight
on the youth to keep him still.  Eventually, other ROs approached
to assist the initial RO.  This incident developed when the RO
unlawfully used force as a response to a youth who was not
violent, did not appear to be hurting himself, and did not appear to
be threatening towards other staff or youth.
   
• At Dozier, several boys reported witnessing a RO choke another
youth, DD, until foam came out of his mouth.  Choking is an
unlawful use of force.

These examples demonstrate that despite DJJ’s appropriate directives to
only use force when there is “a clear and identifiable risk to safety and
security,” force was often used a first resort and in circumstances where no
risk to safety and security was present.  

b. Dangerous Use of Restraints  

The excessive and unnecessary use of prone restraints places youth at
great risk for harm.  The practice of face down prone restraint is highly
problematic and even more dangerous when force is applied to the prone
youth.  Evidence at NYFDC suggests that staff at Florida’s juvenile facilities are
not properly trained on the use of this technique.  First, incident reports,
complaints of youth, and videos indicate that not all ROs are implementing this
procedure in a manner that ensures youth safety.  Indeed, we reviewed
                                                         
16
There is a reference in the review to the RO being recommended for discipline,
but the final outcome is unclear.12

incidents where staff put their body weight on a child in prone restraint for
several minutes – which can cause suffocation.17

• GG was tackled to the ground shortly after the incident escalated
to use of force.  Two ROs kept him prone on the ground for more
than five minutes.  For most of that time, at least one of the ROs
appeared to be pressing his body weight onto the youth.

 Next, we found that many

ROs had not completed the required training – including refresher training –
compromising the safety of youth upon whom this restraint method is
performed.  For example, over 75% of staff placed on no-contact-with-youth
status during our first on-site tour, due to improper use of force allegations,
had not completed or updated their basic training requirements at the time of
their placement on no-contact status.  Finally, in many cases we reviewed, the
use of prone restraints was excessive in light of the non-dangerous conduct
that led to use of prone restraints by staff.  For example:

• The second incident with CC (described above) also demonstrates
improper use of prone restraints.  In that incident, CC was placed
in prone restraints for the non-dangerous conduct of disobeying an
order.  Once on the ground, the staff also dangerously put their
body weight onto CC to keep him still.

Staff also unlawfully used mechanical restraints as a first response to
youth who did not respond to verbal commands.  While DJJ rules allow for the
use of mechanical restraints in limited situations – such as where youth are
engaged in “aggravated resistance” – the ROs at NYFDC routinely placed metal
handcuffs and leg-cuffs on youth who are merely verbally resistant and did not
pose a risk to themselves or others in the facility.  This is unconstitutional.  
Jarrard, 786 F.2d at 1086 (needless application of force, including mechanical
restraints, where juvenile detainee was “merely giggling” and protesting the
treatment of another detainee unconstitutional).  For example:

• JJ was placed in mechanical restraints for failing to obey verbal
orders.  While a video recording shows that he was in fact placed in
restraints for failing to obey a RO’s command, the incident report
omits any reference to mechanical restraints.  In another incident
involving the same youth, JJ was placed in metal handcuffs and
leg cuffs because he spat on a RO.  In another episode, ROs placed
JJ in mechanical restraints after he refused to return to the
                                                         
17
In a 50-State survey of mental health facilities conducted by the Hartford Courant,
142 deaths occurred between 1988 and 1999 during or shortly after the application of
restraints or seclusion.  Of the 142 deaths, “[t]wenty-three people died after being
restrained in face-down floor holds.”  Eric M. Weiss, Hundreds of the Nation’s Most
Vulnerable Have Been Killed by the System Intended to Care for Them, Hartford
Courant, October 11, 1998, A1.13

common room.  None of these instances rise to the level of
“aggravated resistance,” and thus the use of mechanical restraints
in these circumstances constitute excessive force.

• Staff placed another youth, RR, in mechanical restraints for tying a
sweater around his neck in a gesture of suicidal ideation.  Three
staff members used a PAR technique to take the youth to the floor.  
After the youth was held in a PAR restraint, facedown on the floor
for 48 minutes, he was placed in mechanical restraints for an
additional three hours and seventeen minutes, totaling four hours
and five minutes of restricted movement.

Despite the presence of good written policies, the youth were subjected to
a pattern or practice of unconstitutional uses of force as is evidenced in the
above accounts.  In many instances, youth were subjected to uses of force in
circumstances that required only verbal intervention, and, in other instances,
subjected to altogether inappropriate force, including prone restraints and
unlawful use of mechanical restraints.  Such conduct violates the youths’
constitutional right to adequate protection from harm, reasonable safety, and
freedom from undue restraint.  Youngberg, 457 U.S. at 315-16.

c. Dangerous Off-Camera Assaults

Youth at Dozier were often subjected to staff violence in facility regions
outside of the viewing range of surveillance cameras.  While the administrative
staff made efforts to address force incidents captured on video, they were not
as vigilant when there was no on-camera episode to corroborate a youth’s
abuse complaint.  The facility was replete with off-camera areas, including the
laundry room in each cottage, the area of the hallways leading to the showers,
the immediate area outside of the cottages, and numerous outdoor areas.  
Many of the youth complained that ROs often directed them to off-camera
areas.  Youth reported that their safety was in the greatest jeopardy – primarily
from staff and occasionally other youth – in these off-camera areas.  These
areas were not only dangerous to the youth; they also made adequate internal
and external reviews of abuse complaints next to impossible.  In a complaint to
the Department of Child and Family Services, for example, HH reported that
staff allowed other youth to engage in fights off-camera in the laundry room
(referred to by staff and youth as the “sheet locker”).  The report could not be
verified because there was no video of the incident and no documentation of an
assault.  Other examples include the following:

• Several youth reported that ROs often used force against them “offcamera.”  One youth, FF, referred to the
ROs as being “dirty” for taking
kids out of the view of the cameras and hurting them.  According to FF,
“You’ll learn fast.  Just don’t go off camera and get PAR’d.”  FF was
assaulted off-camera, but refused to identify the responsible RO.14
• A complaint to DJJ’s Central Communications Center by II, that he was
slammed against a bathroom wall by staff – could not be substantiated
because the alleged assault took place off-camera and no other youth
witnessed the incident.

• Youth also reported being assaulted on their way to the isolation unit.  
There was a camera attached to the building housing the isolation unit,
covering several feet immediately in front of the building.  Most of the
distance between the cottages and this building, however, was beyond
the camera’s range and hidden by a thicket of trees.  Many youth noted
that this area was a major source of danger to their safety.
Dozier youth were also at risk from youth-on-youth assaults due to the
design of some of the cottage rooms.  Each cottage had two rooms with a
shared wall that stopped short between two to three feet from the ceiling,
leaving enough space for youth in these rooms to move between the two rooms
and the hallway.  During our tour, we observed that youth had stacked chairs
on the desks in these rooms in order to climb over the short walls.  This
created a risk of harm in several respects.  Youth could climb over these short
walls in order to engage in a fight, engage in sexual relations, or confront a RO
in the hallway.

2. Poor Documentation and Data Collection Efforts

The pattern or practice of excessive force being used on youth at NYFDC
was obfuscated by its poor documentation and data collection efforts, even
though the facilities had the capacity to conduct sophisticated data analysis.  
Many incident reports did not provide a complete account of the incidents and
were therefore not useful for determining specifically what happened, in
preventing future misconduct, and protecting youth from harm.  For example,
our review of 138 Dozier use of force reports from April 2010 identified
problems such as (1) reports that were so poorly written that it was difficult to
determine what behaviors were being reported, (2) reports lacking in details to
establish the appropriateness of the use of force, and (3) underreporting of
problematic responses to youth behavior.  As a result of these reporting
deficiencies, Dozier’s rates for physical restraints, youth-on-youth fights,
confinements, and grievances all appeared to be lower than the national
averages captured in the PbS Field Average.  We do not have confidence in
these rates, however, due to the apparent inadequacy of the documentation
process.  We also found similar documentation problems at JJOC and are
concerned that staff may have underreported incident there too.  
As noted above, the documentation problems were manifested in various
ways, including cursory explanations of the force episodes that omitted key
information that could assist a reviewer in determining whether force was
appropriately used.  The reports also failed to describe the injuries sustained 15
by youth as a result of physical interventions.  The following examples provide
a sampling of the problems.

• One youth, KK, reported to the DJJ’s complaint line that a RO
pushed him, called him a derogatory name, and threatened him.  
Neither the accused RO nor the other RO on duty completed a
report about the incident.  The incident was substantiated by the
DJJ investigator only because it had been captured on video and
other youth verified the account.  

• In another episode involving DD, the incident report noted that he
was subjected to a takedown maneuver because he was disruptive
and failed to obey a RO’s directives.  However, the accompanying
video recording only shows the youth on the ground.  Nothing is
shown of the events preceding the takedown, making it difficult to
discern whether the use of force was appropriate.

• In one incident, ROs placed a youth in mechanical restraints for
failing to obey verbal orders, but the incident report excluded any
mention of the mechanical restraints.  A video recording showed
that the youth was in fact placed in restraints for failing to obey a
RO’s command.  In two other incidents where ROs placed the same
youth in mechanical restraints, the reports failed to note the length
of time he remained in the restraints.

The grievance system also suffered from poor documentation of
incidents.  Youth at Dozier were able to submit grievances; however, contrary
to the facility’s procedures, they were not informed of the outcomes.18
The documentation problem also extended to the medical care NYFDC
youth received.  Oftentimes, the ROs did not call medical or mental health staff
to treat youth who may have been injured as a result of uses of force.  For
 While
the grievances included reports of staff misbehaviors requiring further
investigation, investigative findings were generally non-existent.  This lack of
formal written findings also extended to outside reviews of youth complaints.  
Because of the limited investigation and insufficient documentation, youth
complaints of abuse were often not substantiated.  This problem existed to an
even greater degree at JJOC, where the rate of grievances was 98% less than
the 2010 Dozier rate and one tenth of the PbS Field Average.  The infrequent
use of the grievance system at JJOC is troubling and indicates that youth were
either unaware of the grievance system, unable to access the grievance system,
or as several youths attested, had no confidence in the grievance system.  
                                                         
18
FOP 206 (January 19, 2010).  Under FOP 206, youth grievances are to be
investigated and decided within 48 hours.  The youth is supposedly provided with an
opportunity to appeal the decision.16

example, a review of the incident reports indicated that 90% of the reports did
not include medical or mental health findings.  When the medical staff actually
did treat youth who had been subjected to force, they failed to record the
physical condition of the child.  For example, medical staff did not photograph
youth following a takedown or other physical intervention.  They also did not
diagram the youth’s injuries nor did medical staff follow-up with youth who
had been physically restrained.  

Improved record keeping would enable the State’s juvenile facilities to be
more aware of persistent issues, which in turn would assist the facilities’ efforts
at improving the conditions of confinement.

3. Unlawful Uses Of Isolation

The State may not subject confined juveniles to undue restraint.  See
Youngberg, 457 U.S. at 315-16.  When the State subjects a juvenile to certain
disciplinary procedures, such as extended isolation, the State must provide the
juvenile with an opportunity to present evidence in his or her defense.  Jarrard,
786 F.2d at 1086 (affirming award of compensatory damages for juvenile pretrial detainee placed in isolation for
seven days after laughing and protesting

when another juvenile was placed in isolation); Gary H. v. Hegstrom, 831 F.2d
1430, 1433 (9th Cir. 1987)(upholding district court’s requirement that a
juvenile facility hold “due process hearings prior to confinement in excess of 24
hours”); Milonas v. Williams, 691 F.2d 931 (10th Cir. 1982)(affirming a
permanent injunction on the use of isolation rooms by private school to which
adjudicated juveniles were confined).  The practice of isolation is disfavored for
juveniles as it generally serves a punitive purpose.  See e.g. Santana v. Collazo,
714 F.2d 1172, 1181 (1st Cir. 1983) (recognizing expert testimony that
“isolation for longer than a few hours serves no legitimate therapeutic or
disciplinary purpose and is unnecessary to prevent harm unless a juvenile is
severely emotionally disturbed.”).  Moreover, the use of isolation is highly
disfavored by experts in juvenile protection from harm.  For example, the
Performance-based Standards issued by the Council on Juvenile Correctional
Administrators indicate that isolation should be avoided and only used for a
brief period where it is required.  PbS Standards (April 2010).  Isolation should
not be used as a matter of course and should be used only as a last resort,
should be carefully reviewed, and used only for a limited duration.  See  
American Bar Association, Juvenile Corrections Standards, §7.11 (1980).

The
State’s use of isolation in non-emergency circumstances and for long periods of
time – i.e. as punishment – is a violation of due process.  R.G. v. Koller, 415
F.Supp.2d 1129, 1155 (D. HI. 2006) (finding that juvenile conditions expert
testimony “uniformly indicates that long-term segregation or isolation of youth
is inherently punitive” and that the “use of isolation for juveniles, except in
extreme circumstances, is a violation of Due Process.”).  17

The State subjected youth to unconstitutional disciplinary confinement
by (1) failing to provide youth placed in confinement with adequate due
process, (2) confining youth for undue and excessively long periods of time, (3)
confining youth as a form of punishment for minor infractions, and (4)
depriving confined youth of necessary rehabilitative services.  

Youth at Dozier were subjected to two forms of confinement.  First, a
youth could be placed on “controlled observation” (“CO”) for a two hour “cool
down” period.  According to FOP 210, the CO is “intended to help staff quickly
regain control and order in the program to divert serious injuries, security
breaches, or major property destruction.”  Second, youth could be taken to the
Behavioral Management Unit (“BMU”) for 72 hours to 21 days, depending on
the recommendation of two members of his “treatment team.”19

The isolation units on both the Dozier side and the JJOC side of NYFDC
were particularly harsh environments.  At Dozier, while using different names
to describe the units (CO and BMU), the only real difference in the environment
was the amount of time a youth was required to stay in confinement.  The
CO/BMU consisted of six single cells measuring approximately 9.8 feet by 5.5
feet, with locking doors, a concrete slab serving as a bed, bars on the windows,
and a clear hard plastic window over the bars.  At bedtime, the youths received
a thin mattress to cover the cement slab.  The bathroom was in an area
separate from the cells.   The CO/BMU was located in a building that was a
distance from the residential cottages, over 200 yards through a wooded area.  

 According to
FOP 211, the BMU should be used “only when a youth’s behavior significantly
disrupts the program’s residential community, endangers the safety of staff
and other youth, or threatens major destruction of property, and when used,
youth are protected from self-harm.”  The actual practice at Dozier, however,
was to send youth to the BMU or CO for minor infractions. Use of the BMU was
discontinued during the transition period before the official closure of Dozier.  
At JJOC, youth were placed on confinement in the Intensive Supervision Unit
(ISU), which was designed as a secure unit with four rooms that were used for
a short-term time-out or longer-term isolation.  Despite the change in name
and location, youth continued to be placed in isolation for minor infractions,
and this undue restraint was unconstitutional.  
                                                         
19
A note on nomenclature:  Dozier uses some terms in ways that do not actually
reflect what the terms more commonly denote.  For example, the term “treatment
team” is used by staff to describe any staff person who interacts with the child,
including direct care staff such as ROs and administrative, medical, education, or
recreation staff.  “Treatment teams” may or may not include mental health staff.  In
the context of making a disciplinary confinement decision, two members of a youth’s
“treatment team” may include any two ROs, or a combination of a RO and another
staff member (administrative, case worker, teaching, medical, or mental health).  In
other words, there is no required mental health component to the disciplinary
confinement decision. 18

Youth were walked to the CO/BMU from the cottages or they were transported
there in a van.  The ISU in JJOC was located in the same building as the
regular residences, but in a separate pod.  There were four rooms on the pod
similarly furnished with a concrete slab serving as a bed.  The rooms in ISU did
not have windows.

Our review of incident reports indicates that isolation was oftentimes
used as a punitive measure for minor rule violations.  For example, Dozier
youth were sent to the CO and BMU for “excessive horseplay,” name calling,
“talking to other youth,” “causing a disruption,” and “being uncooperative.”  
JJOC youth were sent to the ISU for similarly minor infractions, including
refusing verbal commands, being argumentative, running “off-bounds” around
a fenced-in basketball court, and horseplay.  While DJJ’s rules appropriately
refer to disciplinary confinement as “the most restrictive method of behavioral
management,” youth were routinely confined in the CO/BMU/ISU for what can
only be described as nuisance behavior.  Additionally, in committing youth to
the disciplinary confinement, staff did not provide youth with an opportunity to
challenge the commitment decision -- in violation of their rights.  Gary H., 831
F.2d at 1433.  Instead, youth were only advised of the “maladaptive” behavior
leading to their commitment and the goals that they must reach in order to be
released.  The length of a youth’s confinement to the isolation units was  also
difficult to discern – the rules only provide for a review every 72 hours after 14
days of continuous confinement and approval by the Superintendent (or a
designee), but do not prohibit unlimited extensions of confinement.  In one
particularly stark example, SS was repeatedly placed in the ISU for
approximately two weeks.  He would be released for several hours after a few
days and then returned to the ISU.  

The isolation units did not serve any rehabilitative purpose.  This is most
apparent in the limited to non-existent role of the mental health staff in the
determinations to send youth to disciplinary confinement.  Specifically, the
mental health staff did not have veto power to prevent a child from being sent
to the CO or to request that a child be released from disciplinary confinement.    
As such, suicidal youth were sent to isolation, although the facility rules
prohibit confinement of such youth.  This practice is very dangerous as
“[i]solation increases the sense of alienation and further removes the individual
from proper staff supervision.”  Lindsay M. Hayes, Suicide Prevention in
Juvenile Facilities, 7(1) J. Office of Juvenile Justice and Delinquency
Prevention, 29 (2000).  Additionally, youth confined in the isolation units did
not consistently receive required services, such as education materials, regular
mental health evaluations, or daily large muscle exercise.  In sum, the
confinement units only served as punishment to uncooperative youth and a
warning to others.  Thus, this practice violated the youths’ constitutional
rights.19

4. Deliberate Indifference To Youth At Risk Of Self-Injurious And
Suicidal Behaviors

The State must provide juveniles held in its facilities with adequate
medical treatment.  Youngberg, 457 U.S. at 323-24 & n.30; Jarrard, 786 F.2d
at  1086 (denial of medical care to juvenile for three days after injury caused by
the guard found unconstitutional); Bozeman, 422 F.3d 1265 (recognizing
deliberate indifference where prison officials ignore inmate’s known serious
medical condition).  This requirement to provide adequate medical care
includes a requirement to provide adequate mental health care.  Cook v. Sheriff
of Monroe Cty., Florida, 402 F.3d 1092, 1115 (11th Cir. 2005).  The due
process right to receive medical treatment “encompasses a right to psychiatric
and mental health care, and a right to be protected from self-inflicted injuries,
including suicide.” Cook, 402 F.3d at 1115 (quoting Belcher v. City of Foley, 30
F.3d 1390 (11th Cir. 1994)); see also Snow v. City of Citronelle, 420 F.3d 1262
(11th Cir. 2005)(same).  As the Eleventh Circuit has recognized, actions that
violate a prisoner’s Eighth Amendment rights, such as those actions that would
be considered deliberately indifferent to a prisoner’s mental health needs, also
violate the greater due process Fourteenth Amendment rights of those
subjected to the state’s custody through a non-criminal process.  Dolhite v.
Maughon, 74 F.3d 1027, 1041 (11th Cir. 1996).  An official may be found
deliberately indifferent where that official deliberately disregards a “strong
likelihood” that a detainee will engage in self-injurious behavior.  Cook, 402
F.3d at 1115; Snow, 420 F.3d at 1268.

The State subjected detained youth at NYFDC who suffered from serious
mental health problems to deliberately indifferent treatment, heightening the
risks of harm for suicidal youth.  While no juveniles at NYFDC completed a
suicide to our knowledge, the lack of a death does not minimize the serious
risk for youth or the unlawful state of mental health care at the facilities.  
Helling, 509 U.S. at 33.  The rate20
                                                         
20
As with the incident reports and data on violent incidents discussed above, we
do not have confidence in the accuracy of Dozier’s reported accounts of youth suicidal
behaviors.  Dozier staff do not adequately document incidents that may include
youth’s self-injurious behaviors or threats.  As such, the numbers of such incidents
may be higher than we were able to discern.

Incidents of suicidal behaviors by Dozier youth was
disproportionately high when compared with the PbS field average.  The Dozier
rate of 0.262 behaviors per 100 bed days was almost five times higher than the
PbS field average of 0.057 behaviors per 100 bed days.  These suicidal
behaviors included suicidal ideation, suicidal gestures, and self-injurious
behaviors.  NYFDC youth were at risk in several respects:  (1) the facility did
not provide adequate mental health screening; (2) staff did not treat suicidal
youth with the appropriate level of seriousness; (3) staff placed suicidal youth
at further risk by putting them in isolation, transferring them to JJOC, or 20
placing them in physical restraints without consideration for their mental
state; and (4) the facility had numerous structural elements that presented a
danger to suicidal youth.

The initial screening of Dozier youth for mental health issues did not
adequately identify the youth’s psychological condition or potential
susceptibility to suicidal behaviors.  This deficiency was illustrated by the large
number of youth diagnosed with the same, unspecified, disorder.  Ninety youth
were “diagnosed” on the facility’s April 2010 Treatment Services Report.  
Eighty-nine of those youth were diagnosed as having “conduct disorder”
without any modifiers as to their particular diagnoses.21

Direct care staff’s laissez faire attitude toward suicidal youth also
jeopardized their safety.  A number of ROs and supervisors were dismissive of
suicidal threats by youth as “attention seeking” and manipulative attempts to
frustrate staff.  Although one youth admitted that he claimed to be suicidal so
that he could get more staff attention, such isolated conduct should not
generate a sense of complacency among staff when a potentially serious
situation could exist.  Complacency is particularly troubling because direct
care staff intervention, knowledge of suicidal risk factors, and attention to
suicidal youth are critical components to suicide prevention.  Hayes, Suicide
Prevention in Juvenile Facilities, 7(1) J. Office of Juvenile Justice and
Delinquency Prevention, 27-29 (2000).  According to another study of youth
suicide in juvenile facilities, approximately half of the suicides occurred during
the evening hours when direct care staff are likely the only staff onsite.

 The extraordinarily
high rate of this diagnosis, particularly in a facility addressing delinquent
behaviors, makes the accuracy of the diagnosis and the methodologies of
diagnoses highly questionable.  And because the treatment programs
established for Dozier youth are based on these unspecified diagnoses, youth
were not receiving appropriate mental health care.
22
This staff complacency further heightened the dangers to suicidal youth
as evidenced by the staff’s willingness to confine suicidal youth to isolation and
 
Lindsey Hayes, Juvenile Suicide in Confinement:  A National Survey, National
Center on Institutions and Alternatives, 25-26 (February 2004).  Direct care
staff investment in suicide prevention is therefore imperative.
                                                         
21
The American Psychiatric Association’s Diagnostic and Statistical Manual of
Mental Disorders, (DSM IV 2000), defines  conduct disorder as a “repetitive and
persistent pattern of behavior in which the basic rights of others or major ageappropriate societal norms or rules
are violated, as manifested by the presence of
three (or more)” criteria including aggression to people and animals, destruction of
property, deceitfulness or theft, and violations of rules (including truancy and
violations of parental curfews).  
22
The study of 110 suicides between 1995 and 1999 found that 50.6% of suicides
occurred during the period from 6:01 p.m. to midnight.21
more restrictive environments without regard to their mental well-being.  In a
number of instances, we learned that youth who had made suicidal gestures or
threats were placed in the BMU.  As described above, the BMU was an
oppressive environment that could aggravate the risk of suicide.  Additionally,
each of the cells had anchor points by the doors that could be used by a youth
to attempt hanging.  

Finally, many of the rooms and facilities at Dozier were not suicide
resistant.  The danger was heightened by the fact that the staff-to-youth ratio
of 1:8 was often compromised, leaving the youth alone for long periods without
supervision.  Youth intent on hurting themselves at Dozier had access to
anchoring points on bed frames, air vent grates in their rooms, handrails in the
bathrooms, sprinkler heads in the shower stalls, and even some of the doors in
the housing areas.  These protruding points present serious risks to youth.  
Notably, many of the doors had small windows, allowing only a partial view of
the rooms; this increased the risk that a staff person would not know when a
child was attempting suicide behind the closed door.  At JJOC, the rooms were
less dangerous, but we found chairs in the bathroom areas that could be easily
used to reach anchoring points.  In the above mentioned national survey of
youth suicide in detention, 98.7 percent of suicides were by hanging.  The
suicide victims used several types of anchoring devices, including door hinges
or knobs (20.5%), air vents (19.2%), bed frames (19.2%), window frames
(14.1%), and shower sprinkler heads (7.6%).  Hayes, Juvenile Suicide in
Confinement:  A National Survey, National Center on Institutions and
Alternatives, 27.  The living quarters in NYFDC, which included most of these
anchoring devices, posed a serious risk of harm to youth.  

5. Disciplinary And Punitive Measures In Violation Of Youth’s  Due
Process Rights

Confined youth have a due process right against restrictions that
constitute punishment.  Bell, 441 U.S. at 535 (recognizing that conditions and
restrictions imposed upon pre-trial detainees that amount to punishment
violate the Due Process clause); Youngberg, 457 U.S. at 315-16 (right to
freedom from undue bodily restraint is a core interest protected by the Due
Process Clause); Jarrard, 786 F.2d at 1085 (“[T]he due process clause forbids
punishment of pretrial detainees.”).  Juveniles are entitled to due process when
their liberty interests are at stake.  Jarrard, 786 F.2d at 1085; Gary H., 831
F.2d at 1433; Milonas, 691 F.2d at 942; Mary and Crystal v. Ramsden, 635
F.2d 590 (7th Cir. 1980) (juveniles have a right to present evidence on their
own behalf for hearings resulting in disciplinary isolation).  Dozier officials
subjected the youth in their care to two practices that served no rehabilitative
purpose and were punitive:  first, officials  increased the youths’ time in
confinement for a period up to 120 days, and, second, officials transferred
youth to JJOC, a facility designed for “maximum-risk” youth.  These practices
functioned as punishment and violated the youths’ constitutional right to 22
freedom from undue restraints.  Both measures were levied against so-called
problematic youth as a deterrent against acting out.  Neither measure had a
rehabilitative function or required the provision of necessary treatment.  In
addition, transfers were made recklessly where, for example, a youth who had
been propositioned for oral sex by another youth was transferred to JJOC
within two months of his tormentor’s transfer to JJOC.  Both practices were in
contravention of the youths’ due process rights, posing an undue restriction on
their liberty without due process and without regard for their safety.  Bell, 441
U.S. at 535; Youngberg, 457 U.S. at 315-16.  Moreover, the measures were
contrary to the requisite rehabilitative purpose of the juvenile system.  
First, the measures posed an undue restriction on the liberty of Dozier
youth.23

The measures were in contravention of youths’ right to due process and
access to the juvenile court.  First, Dozier’s administrators did not institute
sufficient safeguards to ensure the fairness of these measures.  The extension
policy was ostensibly applied only to youth deemed aggressors in fights.  A
review of the incident reports, however, indicated that non-aggressors received
additional time.  One report, involving MM, showed him to be defending
himself; he still received 60 days of additional confinement.  On other
occasions, the facility did not determine which youth was the aggressor and
just extended both detentions.  For example, a report of an incident between LL
and NN noted that both were fighting, but does not identify which youth
started the fight.  Both LL and NN received additional confinement time.  A
similarly vague report of an incident between PP and QQ resulted in both boys

 The youth who received extensions were subjected to prolonged
confinement beyond their release dates.  During a sample one month period,
for example, 15 youth received extended confinement.  Most of the youth
received four months of additional time to their detention at Dozier.  
Additionally, during our July 2010 tour, we learned that approximately 20
youth were subjected to JJOC transfers.  Four additional youth were
transferred in the month following the tour.    
                                                         
23
For youth with disabilities, both practices – prolonged detention and transfers
to a more secure facility – may have run afoul of Title II of the Americans with
Disabilities Act, 42 U.S.C. § 12132, and its governing regulations which prohibit
“unjustified institutional isolation of persons with disabilities.”  Olmstead v. L.C., 527
U.S. 581, 600 (1999).  Under Title II, “no qualified individual with a disability shall, by
reason of such disability, be excluded from participation in or be denied the benefits of
the services, programs, or activities of a public entity, or be subjected to
discrimination by any such entity.”  Dozier youth with disabilities – such as youth
with mental health challenges – face unjustified prolonged and extended detention due
to their failure to progress through the program, in part, because they have not
received the appropriate treatment.  Transfer to a more secure facility may also be
unlawful where the youth’s behavior is connected to a disability for which treatment is
required.23

receiving four months of additional time.  Regarding the JJOC transfers, it was
absolutely unclear what behaviors would lead to a transfer or how a youth
could avoid being transferred.  Our review of the incident reports for some of
the transferred youth suggests that many were being transferred for minor
repeated nuisance issues or because they required more attention for reasons
ranging from being disruptive to suicidal threats.  

The arbitrary application of these punitive measures was compounded by
the fact that the youth were not afforded due process protections.  They were
instead required to attend a meeting with the team of staff members who
imposed the added time or transfer.  A number of the youth reported that they
had no access to attorneys for the meetings, their parents were not notified
before the meetings, and they could not challenge the decision.  These
measures are especially problematic because the State’s juvenile court retains
jurisdiction over juvenile delinquency cases post-adjudication and after
determining the appropriate placement facility for a child.  FLA. STAT. §  §   
985.0301, 985.441, 985.455.  The juvenile code prohibits a child’s extended
confinement to a program for punitive reasons.  FLA. STAT. § 985.455 (3) (“The
child’s length of stay in the program shall not be extended for purposes of
sanction or punishment.”).  Additionally, DJJ must seek court approval and
notify the child’s attorney of its intent to transfer the child between facilities of
higher or lower restrictiveness levels.  FLA. STAT. § 985.441.  The transfer may
proceed without court authorization only if the court fails to respond after 10
days within the receipt of notice.   FLA. STAT. § 985.441.  Moreover, because the
disposition and transfer decisions are within the traditional purview of the
court, the youth have a constitutional right of access to the juvenile court and
access to counsel.  John L. v. Adams, 969 F.2d 228, 233 (6th Cir. 1992).  The
administrators at NYFDC circumvented this process by referring to the planned
administrative merging of the facilities and calling the process a “reassignment”
as opposed to a transfer.  Regardless of how it was labeled, youth at Dozier – a
high risk facility – were being moved to a maximum-risk facility without court
notice or approval.  The later wholesale removal of Dozier youth to JJOC before
the closure announcement was similarly punitive and improper.

Third, the measures did not take into account the safety of the youth
when they are subjected to either lengthened time in confinement or time in
the more restrictive confinement.  While the measures were supposedly
implemented to address fighting and improve safety, such considerations were
absent in the actual implementation of the measures.  Confined youth retain
their right to personal security and safety.  Youngberg, 457 U.S. at 315;
Jarrard, 786 F.2d at 1085; Taylor, 818 F.2d at 795.  At Dozier, youth
automatically received extended confinements if they were deemed to have
started a fight.  There was no consideration of the harm that can be caused to
a youth forced to remain in custody beyond his release date.  There was also no
consideration of the safety risks to youth transferred from Dozier to JJOC.  The
most basic concern, classification separation, was overlooked.  For example, 24
the primary separation appeared to be that youth in different categorization
levels were identified by different colored jumpers.  This form of separation
apparently was not enforced, as we observed youth of different category levels
intermingling at JJOC.  In one particularly egregious instance, a youth who
had been propositioned for oral sex by another youth was transferred to JJOC
along with his tormentor.  According to the incident report, the youth, JJ, told
staff that the other youth made sexual advances toward him.  Staff initially
moved the other youth to a different cottage.  The other youth was
subsequently transferred to JJOC following several infractions unrelated to his
advances toward JJ.  Next, JJ was transferred to JJOC after several rule
violations.  We saw no evidence that the youths’ prior history was factored into
the decision to move JJ to the same facility as his tormentor or to ensure that
they were appropriately separated.

Finally, these punitive measures were counterproductive to the
rehabilitation of Dozier youth.  The extensions and transfers, while ostensibly
serving as a deterrent to fighting, were so unfair that a number of the youth
resorted to self-destructive behavior.  The penalties were an excessive response
to youth who acted out and, instead, contributed to the youths’ aggressive
behaviors.  In this respect, the extensions and transfers contributed to feelings
of hopelessness, anger, and aggression.  In the incident report involving GG, for
example, GG reported that he was upset and ready for prison after he had
received a 120-day extension.  Staff restrained another transferred youth, JJ,
in approximately seven incidents over the course of a few weeks while the
youth was confined at JJOC; some of those incidents involved self-injurious
behavior.  The extensions and transfers did not address the rehabilitative
needs of the youth and violated their constitutional rights.

6. Unconstitutional Frisk Searches

Juveniles do not give up their Fourth Amendment right to bodily integrity
when they are confined to a juvenile facility.  See Bell, 441 U.S. at 558
(applying Fourth Amendment reasonableness standard to searches of pre-trial
detainees); Justice v. City of Peachtree, 961 F.2d 188 (11th Cir. 1992)(noting
that the Fourth Amendment prohibits unreasonable searches even in custodial
searches).  In evaluating the reasonableness of institutional searches, courts
balance the scope of the intrusiveness, the manner of the search, the location
of the search, and the justification for the search.  Bell, 441 U.S. at 559.  Even
a pat down search is “a serious intrusion upon the sanctity of the person,
which may inflict great indignity and arouse strong resentment, and it is not to
be undertaken lightly.”  Terry v. Ohio, 392 U.S. 1, 17 (1968).  Facility searches
must be reasonably based on safety and security concerns and limited in scope
to address those concerns.  Bell, 441 U.S. at 559.  Moreover, the manner of the
search must not be overly intrusive in relation to the justification for the
search.  Id.25

Dozier youth were subjected to frisk searches more than 10 times per
day, purportedly for recovery of contraband.  During the six month period we
reviewed, the most dangerous contraband recovered were pencils, which
constituted 52 percent of the recovered contraband.  Occasionally, staff
uncovered drawings, writing paper, and food during frisk searches.  The
searches occurred as a matter of course -- even when the children were under
constant staff supervision.  For example, in a typical day, youth were frisked (i)
before breakfast, (ii) after breakfast, (iii) after medication rounds, (iv) during a
school break, (v) before lunch, (vi) after lunch, (vii) during a second school
break, (viii) during sick call, (ix) before dinner, (x) after dinner, and (xi)
whenever they left the cottage for recreational activities.  Many of the youths
informed us that some ROs were especially intrusive in conducting the
searches.  We heard a number of reports of youth being groped by ROs during
the searches.  One youth noted, “Some staff rub on your privates.”  Another
stated, staff “touch too much.”  

These repeated searches were unduly intrusive and not supported by the
stated justification.  The repetitive searches were unwarranted, especially when
the youth had not left the grounds, had not been visiting outsiders, and were
under constant observation by the staff.  Moreover, there were simple
alternatives to uncovering contraband without resort to frequent and intrusive
searches.  For example, as the court noted in N.G., 382 F.3d at 234 n.13,
where pencils and other writing material can be numbered and the recipient’s
name recorded so that missing items can be traced to a particular youth, a
more targeted pat-down search of that youth would be reasonable.  Similarly,
the staff could count the silverware before and after meals to make sure that
none was improperly taken.

7. Inadequate  Medical And Mental Health Services

The State must provide juveniles held in its facilities with adequate
medical and mental health treatment.  Youngberg, 457 U.S. at 323-24;
Jarrard, 786 F.2d at 1086; Bozeman, 422 F.3d at 1265; Cook, 402 F.3d at
1115.  Before closing the facilities, the State  had made significant
improvements to the medical care of Dozier and JJOC youth by hiring a
fulltime doctor and additional nurses.  However, additional improvements were
required in several areas, specifically (1) access to sick call (Dozier); (2) delivery
of medical care to youth in the BMU; (3) adequate mental health care (Dozier
and JJOC); and (4) adequate CPR training (Dozier).

At Dozier, youth had to request sick call forms from the direct care staff.  
This presented a problem when youths sought to complain about inappropriate
physical treatment by a RO.  Confined youth should have the ability to
complete a sick call request without the interference of staff.  Second, youth in
the BMU did not receive adequate medical care, assessment of their mental
health after their arrival in the BMU, or assistance in determining whether they
should be discharged from the BMU.  Youth confined to the BMU were severely 26
isolated and required regular medical and mental health care.  Third, the
youths’ mental health diagnoses and care were very suspect given the
predominant “conduct disorder” diagnoses.  The mental health care staff were
not adequately consulted on decisions that were necessary to the mental health
of the youth.  As discussed above with respect to isolation issues, extensions of
confinement, and transfers to JJOC, the insufficient input of the mental health
staff in these decisions was harmful to the mental well-being of Dozier youth.  
At JJOC, youth who had been transferred from Dozier were unable to see their
counselors.  Indeed, many of the boys had not received their individual
counseling or even their group counseling.  Finally, CPR training was not
available for Dozier’s medical staff.  This created an easily avoidable and
unnecessary danger to the youth.

8. Failure To Provide Necessary Rehabilitative Services  

The State is required to provide youth with necessary rehabilitative
treatment.  Youngberg, 457 U.S. at 322 (confined person with intellectual
disabilities is “entitled to minimally adequate training” as may be reasonable to
protect his safety and freedom from unreasonable restraints); Nelson v. Heyne,
491 F.2d 352 (7th Cir. 1974) (holding that detained juveniles have a right to
rehabilitative treatment).  The DJJ failed to do so in several respects.  First,
Dozier and JJOC’s direct care staff were not appropriately trained in adolescent
development and de-escalation measures.  We found that much of the staff had
not been trained in communication skills, de-escalation techniques, mental
health issues, adolescent development, or behavior management.  As the
Supreme Court has recognized, adolescents have unique psychological needs
and should not be treated in the same manner as adults.  See Graham v.
Florida, 130 S. Ct. 2011, 2026 (2010)(noting neurological studies showing that
“parts of the brain continue to mature through late adolescence” and that
“juveniles are more capable of change than are adults.”).  In order to provide
appropriate rehabilitative care, direct care staff working with juveniles and
their supervisors should understand adolescent development processes and
learn how to interact with youth in a manner that reinforces positive
behavior.24
                                                         
24
Staff pay may have been a contributing factor to the direct care staff’s poor
attitude toward their training and developing a better understanding of the youth
within their care.  We learned that the average pay of direct care staff fell below $12
per hour and that some supplemented their salary with a second job.  This is below
the industry average.  According to the Bureau of Labor Statistics of the U.S.
Department of Labor, the median hourly wage for correctional and detention officers is
$18.78, an annual salary of $39,050.  See
http://www.bls.gov/oes/current/oes333012.htm.  The site does not list juvenile
facility salaries.  Other reporters indicate that the minimum hourly rate for juvenile
facility staff is more than $12 per hour.  See e.g.  
http://www.payscale.com/research/US/Job=Juvenile_Detention_Officer/Hourly_Rate  
 27
Next, the basic therapeutic needs of the youth were not being met.  As
noted in the above discussion on suicidal youth, many of the youth were not
being properly diagnosed for potential behavioral disorders.  At Dozier, for
example, more than 98% were generically diagnosed as having a “conduct
disorder.”  The youth need to be properly diagnosed and to receive the proper
corresponding treatment.  In addition, many of the youth who qualified for
substance abuse treatment were not receiving such treatment.  In April 2010,
only 10.7% of Dozier youth were provided with substance abuse treatment
although 93% of them qualified for treatment.    

Finally, the NYFDC youth had insufficient exercise and structured
activities to contribute to their positive behaviors and medical and mental
wellbeing.  Exercise and recreational activities are vital components of a
youth’s rehabilitation.  See e.g. Mary Ellen O’Connell et al., Preventing Mental,
Emotional, and Behavioral Disorders Among Young People:  Progress and
Possibilities, National Research Council and Institute of Medicine of the
National Academies, 17 (2009) (“The prevention of [mental, emotional, and
behavioral] disorders and physical disorders and the promotion of mental
health and physical health are inseparable.”); National Commission on
Correctional Health Care Services in Juvenile Facilities, Standard YF 3,
(2004)(requires that juveniles receive at least one hour of large muscle exercise
per day, including walking, jogging, basketball, and other aerobic activities). At
NYFDC, youth spent a significant amount of time being idle.  Oftentimes, ROs
canceled outdoor exercise opportunities, claiming that the heat index was too
high, without replacing such activities by allowing the youth access to the
Dozier gymnasium.  Facilities for adequate exercise programs were available on
the Dozier campus.  The problem was that the facilities were not consistently
offered to the youth.  On the JJOC side, the boys were confined to their pods
and did not receive consistent opportunities for large muscle exercise.  On both
campuses, many of the youth were unable to engage in constructive
recreational activities because basic supplies, such as board games and
sporting equipment, were often unavailable.

The failure to address these concerns not only harms the youth, but has
a negative impact on public confidence and public safety.   The critical role of
the juvenile justice system to correct and rehabilitate is being abdicated, and
youth may well be leaving the system with additional physical and
psychological barriers to success.  FLA. STAT. § 985.01(b)(Stating that the
purpose of the juvenile code is to “provide for the care, safety, and protection of
children in an environment that fosters healthy social, emotional, intellectual,
and physical development; to ensure secure and safe custody; and to promote
the health and well-being of all children under the state's care”).
                                                                                                                                                                                   
      
(showing an hourly rate between $12.19 to $17.69) and
http://www.simplyhired.com/a/salary/search/q-juvenile+guard (showing an average
annual salary of $45,000).28
9. Unlawfully Unsanitary And Unsafe Conditions At Dozier
Confined youth are entitled to safe and sanitary living conditions.  
Youngberg, 457 U.S. at 316; Gary H., 831 F.2d at 1433 (approving consent
decree requirement of minimum sanitary conditions in a facility for juvenile
detainees).  We observed sanitation deficiencies in the living areas, dining area,
and educational areas of the Dozier campus.  First, there was no program in
place to address the cleanliness of the cottages.  As such, youth complained of
insects and rodents as an ongoing problem.  Our review also revealed dirty
living quarters, including evidence of insects and dirty toilets.  An inspection of
the kitchen revealed rodent droppings on the canned food.  Many of the youth
complained that they (and others) found insects and other foreign objects in
their food, a clearly problematic condition.  See e.g. Alexander S., 876 F.Supp.
at 787 (finding that “food containing cockroaches and other foreign matter falls
below what may be deemed minimally adequate.”).  Finally, the educational
areas were not cleaned regularly, sharp objects such as staples were not
securely stored in the classrooms, and basic provisions for cleanliness, such as
soap and spill kits were not readily available.  A number of the first aid kits
had broken seals and were not adequately stocked with supplies.  A simple
system could have been implemented to restock the supplies and avoid
unnecessary delays in emergency care.

IV. CONCLUSION
The constitutional violations outlined above are the result of the State’s
failed system of oversight and accountability.  To protect the youth in its
remaining facilities, the State must take immediate measures to assess the full
extent of its failed oversight with the assistance of consultants in juvenile
protection from harm issues.  The State must also strengthen its oversight
processes by implementing a more rigorous system of hiring, training, and accountability.