IMMIGRATION LAW - PATIENTS OR PRISONERS? COURT CLARIFIES STANDARD FOR EVALUATING MENTAL HEALTH CARE PROVIDED TO UNACCOMPANIED ALIEN CHILDREN - DOE V. SHENANDOAH VALLEY JUVENILE CTR. COMM'N.

• Date: 22 June 2021
• Author: Callahan, Kathleen

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Under federal law, children under the age of 18 years old with no legal immigration status and no parent or legal guardian in the United States to provide for them are qualified as "unaccompanied alien children" (UACs). (1) Once the children arrive in the United States, the Department of Health and Human Service's Office of Refugee Resettlement (ORR) coordinates the children's care with qualified individuals and facilities based on their individualized needs. (2) In Doe v. Shenandoah Valley Juvenile [*460] Ctr. Comm'n, (3) the Fourth Circuit decided the appropriate standard for determining whether a state juvenile detention facility has provided a constitutionally adequate level of mental health care to UACs. (4) The Court held that the correct standard to evaluate a facility's mental health care services is whether the care provider's actions represent a "substantial departure from the relevant standard of professional judgment" and not [*461] whether there is a "deliberate indifference to the children's injuries" as the lower court held. (5)

The Appellants are part of a class action of UACs who escaped the violence and turmoil of their home countries and fled to the United States for safety. (6) The class representative, John Doe 4 (Doe), left his native country of Honduras after he was attacked by local gang members and feared for his life after watching the murder of his friends. (7) Upon crossing over the [*462] border into the United States, Doe was apprehended by U.S. Customs and Border Protection (CBP) officers and turned over to the custody of ORR. (8) He was placed in detention centers in Arizona and New York before ultimately being transferred to the Shenandoah Valley Juvenile Center (SVJC), a secure juvenile detention facility in Virginia designated to care for immigrant children who present behavioral concerns. (9)

In October 2017, Appellants filed a class action complaint on behalf of the UACs currently detained at SVJC.

(10) The children alleged that SVJC engaged in unlawful patterns of conduct through: "(1) excessive use of force, physical restraints, and solitary confinement; (2) failing to provide a constitutionally adequate level of care for plaintiffs' serious mental health needs; and (3) discrimination on the basis of race and national origin." (11)

[*463] The Appellants ultimately withdrew their discrimination claim, and the lower court issued summary judgment in favor of SVJC on the excessive force and inadequate mental health care claims. (12) Although the Appellants abandoned the excessive force claim, they appealed the lower court's decision regarding the appropriate standard of medical care. (13) The Fourth Circuit Court of Appeals reversed and remanded the lower [*464] court's decision after holding that the Court used an improper standard to evaluate the adequacy of mental health care provided to the Appellants at SVJC. (14)

Detained immigrant children represent an important intersection of two historically vulnerable groups. (15) These vulnerabilities were the focus of the seminal 1993 case Reno v. Flores, where the Supreme Court addressed the substantive and procedural due process rights of minors in the custody of Immigration and Naturalization Services (INS). (16) The Court ultimately rejected the plaintiffs' constitutional claims, but the parties reached a historical settlement agreement mandating the standard of care the federal government must afford immigrant children [*465] in its care. (17) Since Flores, the federal government has passed a number of legislative acts to define the proper standard of care UACs are entitled to while in government custody. (18)

While the Flores agreement and federal legislation have clarified the government's duties to UACs in many ways, the legal standard used to evaluate mental health care owed to detained immigrant children has been less clear.

(19) In recent [*466] decades, courts have developed two main standards of care concerning involuntarily detained groups: "deliberate indifference" and "professional judgment." (20) In Farmer v. Brennan, the Supreme Court defined the deliberate indifference standard and held that a facility may be held liable if they subjectively know a detainee faces a substantial risk of serious harm, but fails to take reasonable measures to mitigate it. (21) Conversely, the professional judgment standard was set forth in the 1982 Supreme [*467] Court case

Youngberg v. Romeo. (22) A less rigorous standard for a detainee to meet than deliberate indifference, the professional judgment standard holds that liability may be imposed when the facility's decision represents a "substantial departure from accepted professional judgment." (23)

In Patten v. Nichols, the Fourth Circuit Court of Appeals analyzed both standards of care in a case concerning the adequacy of medical care provided by a state hospital to an involuntarily committed psychiatric patient. (24) In doing so, the Court differentiated pre-trial detainees from involuntarily committed patients and established a three factor test to determine when the professional judgment standard should apply over the deliberate [*468] indifference standard. (25) For the first factor, the purpose of the detention, the Court held that the professional judgment standard is appropriate when an individual is in custody for rehabilitative treatment as opposed to security concerns. (26) The second factor examines the nature of the confining facility, and emphasizes that involuntarily committed patients are often placed in hospitals, whereas pre-trial detainees are held in criminal detention centers such as prisons or jails. (27) Lastly, the third factor in Patten highlights the length of an individual's detention and notes that involuntarily committed patients usually face a lengthy confinement, whereas pre-trial detainees are held for a short period of time. (28) Based on these substantial differences between pre-trial detainees and involuntarily committed patients, the Court concluded that the level of care a hospital provides an involuntarily committed patient should be evaluated [*469] under the more rigorous professional judgment standard set forth in Youngberg. (29)

In Shenandoah Valley Juvenile Ctr. Comm'n, the Fourth Circuit Court of Appeals examined whether professional judgment or deliberate indifference was the appropriate standard to evaluate the adequacy of mental health care provided to UACs at SVJC. (30) Relying on Patten's distinction between pre-trial detainees and involuntarily committed patients, the Court held that Youngberg's standard of professional judgment governs cases of detained immigrant children. (31) The Court reasoned that similar to cases of involuntarily committed patients, ORR places UACs at SVJC for the dual purposes of security and treatment. (32) While the Court acknowledged that the nature of a [*470] juvenile detention center is not a hospital or therapeutic setting, as was the case in Youngberg and Patten, it reasoned that the "facility is secondary to the reason a person is confined in it." (33) Lastly, because SVJC considers a child's level of care when releasing [*471] them from custody, the Court held that mental health is a primary objective at SVJC and the adequacy of the facility's care should therefore be governed by the professional judgment standard. (34) The Court concluded its decision by holding that traumainformed care represents the relevant standard of professional judgment for juvenile detention centers and remanded the case for further proceedings consistent with its opinion. (35)

In an impassioned dissent, Circuit Judge Wilkinson critiqued the majority's holding and argued that the lower court was correct to apply the deliberate indifference standard. (36) Judge [*472] Wilkinson applied the same

Patten factors as the majority, but argued that the juvenile immigrant detainees at SVJC are more akin to pre-trial detainees than involuntarily committed patients. (37) He reasoned that because the purpose of SVJC is not rehabilitative, the nature of the facility is for security, and the duration of the children's stay is temporary, the majority was incorrect to apply Youngberg's professional judgment standard. (38) Aside from doctrinal problems, Judge Wilkinson also argued that the majority "needlessly creates a circuit split" and tasks judges with making decisions about mental health care that they are "utterly unqualified" to do. (39)

[*473] The Fourth Circuit Court of Appeals' decision to apply the professional judgment standard in Shenandoah Valley Juvenile Ctr. Comm'n is appropriate given the Court's precedent in Patten and the current statutory scheme regulating UACs. (40) The Court thoroughly analyzed ORR regulations regarding the care of UACs, SVJC's mission and protocols, and the unique vulnerabilities of detained immigrant children when applying Patten's threefactor test. (41) In likening UACs to involuntarily committed patients as opposed to pre-trial detainees, the Court relinquished UACs from bearing the burden of proving a facility's subjective intent to disregard their care and instead implemented [*474] an objective test guided by professional opinions on trauma informed care. (42)

Not only does Judge Wilkinson's dissent incorrectly point out that the Fourth Circuit Court of Appeal's decision creates a circuit split, it would hardly be "needless." (43) Given the continued influx of UACs to the United States and reports of inhumane conditions at government detention facilities, Shenandoah Valley Juvenile Ctr. Comm'n presented an important opportunity [*475] for the Court to clarify the level of mental health services facilities are legally mandated to provide detained immigrant children. (44) Based on the harrowing experiences most UACs flee from and the severe and long-lasting impact these events have on children's mental health, the Fourth Circuit Court of Appeals took a much needed...