The kid had slashed himself with a razor-sharp rock up and down his arm, at least 20 times. Maybe 30. Horizontal cuts on the inside of his wrist, like you make when you are trying to kill yourself.
No one reported the mutilation. That's disturbing, since the boy is in the custody of the state. He's institutionalized at Eagle Point, the Arizona Department of Juvenile Corrections' detention facility in Buckeye. The boy's one-on-one counselor had not done anything about it, nor had the security guards. On-site teachers ignored the slashings.
The boy was not sent to the health unit. Not a single, responsible adult filled out the required Incident Report that would document his behavior in case it happened again or escalated.
In fact, without an Incident Report, it's unlikely a kid who mutilates himself will get counseling and psychiatric treatment at all.
According to the official who monitored the agency's compliance with government regulations, the lapse was more than simple negligence. It was an unwritten policy.
Margaret Leon charges that ADJC administrators instructed staff not to note suicidal behavior in their reports because the agency feared a documented trail would lead to large insurance claims by the victim's families as well as bad press.
Two weeks ago, Leon anguished when she heard that another boy in ADJC's care had hanged himself the second such incident in three months. So she resolved to step forward and reveal for the first time what she learned inside the agency.
As ADJC's quality assurance specialist, it's been her job for the past year to talk to youth and staff and find out what's really going on at the agency responsible for approximately 1,000 children at five detention facilities around the state. After interviewing more than 600 people, Margaret Leon is the leading authority on what is really going on at ADJC.
And what's really going on, she says, is that ADJC is ignoring suicidal behavior among the kids the agency is charged with rehabilitating.
The two recent suicides beg the question: If ADJC is doctoring the record, how will they identify those children most in danger?
Leon has a gentle manner, with dark glossy hair, a warm smile and her own 19-year-old son, which might be why the kids she interviews open up to her. But more likely, it's simply that she'll listen.
She sat with the boy who slashed himself with the sharp rock for more than half an hour. It had been a week since the cutting, and he was still depressed. He was stressed out, the boy told Leon. He didn't get along with his roommate. Leon made sure he got someone else to talk to. And he got his room changed. Kids who cut say it's addictive, describing it as a way to have control in a world where they feel powerless. They say the physical pain momentarily masks emotional pain. Experts say that any act of self-injury is considered suicidal behavior, although cutting is not always accompanied by suicidal thoughts. The only way to know for sure is to get the child immediate counseling.
And that certainly didn't happen with this boy. "I don't know how he could have hid this. They were straight up and down his arm from his wrist to elbow," Leon says. She detailed the event in a memo, noting that it never was formally documented in an Incident Report.
That troubled Leon. A big part of her job, along with kid and staff interviews, was gathering Incident Reports on everything that went on at ADJC from the use of force by staff to drug smuggling to injuries. The information is reported as part of a national program that tracks standards at juvenile corrections facilities, including ADJC. Since the agency began participating in 1999, the paperwork reflected well upon the administration so well, in fact, that last year ADJC Director David Gaspar was elected president of the Council of Juvenile Correctional Administrators, which oversees the program in conjunction with a branch of the U.S. Department of Justice.
Leon says the agency's part in the program is a sham, and that Gaspar and other ADJC administrators know it, because she's told them to their faces and documented it in memos, which she provided to New Times.
"They're walking around saying, Oh, yeah, we've addressed all these problems, our kids are not showing suicidal behaviors,'" Leon says. "But in fact that data they were reporting was incorrect."
ADJC officials declined to respond to specific questions regarding charges made by Leon and the ADJC ombudsman, who also recently resigned. ADJC officials say they are looking into the assertions. New Times also sent the questions to Governor Jane Hull's office, which did not respond.
Now Leon is concerned that ADJC may be preparing to release its performance-based standards reports to the Justice Department which is investigating conditions at Arizona's juvenile facilities as proof of ADJC's high performance. As Leon was preparing to leave the agency, staff was busily preparing the past three years of reports. She reminded administrators that the 2001 reports are full of errors and warned that the other years could be as well.
"If they use those numbers to report to the Justice Department, they're wrong," says Leon, adding that she asked ADJC officials to take her name off the reports. "I don't want anybody investigating me."
Material from Incident Reports accounts for about 30 percent of the data used to determine performance. But often, Incident Reports aren't written at all, Leon says. She has audited those reports that do exist, and says that many times pertinent information is left out, such as an injury sustained by a kid pushed to the ground by a corrections officer. Sometimes information is misreported when the data is computerized, and until her, Leon says, no one was double-checking; she estimates that about 70 percent of the Incident Reports contain errors.
Leon's findings went well beyond documenting lapses in recordkeeping. In fact, her most disturbing data questions the physical safety of the kids ADJC oversees.
Leon also found that between October 2001 and March 2002, hundreds of injuries including assaults, accidents and self-injury were not reported in Incident Reports at all.
She is most bothered by ADJC's attitude toward the reporting of self-injuries, or suicidal behavior.
The standards clearly state that all self-abuse, with the exception of tattoos and scarification, is to be reported, because "Even if a youth's true intent was to 'get attention,' the behavior must be treated as bona fide because (a) a suicidal gesture might inadvertently become a suicide and (b) normal youth in health environments do not seek attention by engaging in self-destructive behavior."
And yet, Leon says, she has been told repeatedly that self-abuse should not necessarily be reported.
She recalls a conversation in February of this year with Jim Hillyard, ADJC's assistant director.
"We were discussing the errors that were being made on the Incident Reports, and one of the errors was that people were not marking . . . danger to self' or suicidal behavior with or without injury,'" Leon recalls. She told Hillyard that an ADJC health professional had informed her that staff was being told not to write Incident Reports on self-injuries, including cutting. Leon insisted that cutting should be marked as a self-injury, telling Hillyard that "normal, healthy youth" don't do that.
"His response was, Well, I don't know that I agree with that because if we marked every one of those as suicidal behavior, the department would then be liable if in fact one of these kids was actually successful in committing suicide. It would look like we didn't do enough to prevent them.'"
Leon was appalled.
She was even more upset a month later, when Christopher Camacho, 15, was found hanging from a bed sheet, dead, in his cell at Adobe Mountain, the north Phoenix detention facility for boys.
Another ADJC staffer who has since quit in frustration has reason to believe that Camacho asked for help on the day of his death, but was turned away.
And when 14-year-old David Horvath hanged himself earlier this month, also at Adobe Mountain, Leon put in her resignation even before she learned that the boy had been taken off life support and died.
David Horvath had threatened suicide in the past, usually when a judge would talk about sending him to Adobe Mountain. But the first sign Barbara Horvath had that her son might truly mean it was when she noticed that he had cut himself. It was earlier this year. David had ditched school that day and skipped a meeting with his probation officer, and when he unzipped his green sweat shirt Barbara saw cuts up and down his arm.
"Like this," his sister Christina says, motioning back and forth in long diagonal strokes, along the inside of her forearm.
Family and neighbors fill the Horvaths' Mesa home this summer afternoon, several days before David's funeral. While she's sitting at the kitchen table, telling her son's story yet again, the phone rings and Barbara learns that the state will pay for his funeral. Small consolation for a mother who says she warned authorities repeatedly that her son might kill himself.
Barbara still speaks of David in the present. Her pale blue eyes are dry. She agrees that she might be in shock. But she doesn't seem at all surprised.
A single mom, she moved her family to Mesa from Staten Island, New York, 13 years ago. Christina is 18, Elena 10. David was a happy child sometimes, Barbara says, but always suffered from anger and low self-esteem. His first brush with the law came when he was 11. He and Christina were fighting. She pushed him and he grabbed a knife. Christina slammed her bedroom door and David stabbed the door. Barbara called the police. She says the first court psychiatric evaluation of David and several others that followed listed him as a danger to himself, others and the community.
Several incidents followed in the next three years, all similar, Barbara says. One time, David locked himself in his room with his BB gun, after a fight with Christina. Last year, he slapped his mother's hand after she "backhanded" him for swearing in line at Fry's. David was in and out of the county detention facility and last year he was in a residential treatment program for three months. Everything worked for a while. And then David was back in trouble again.
After she noticed the cutting this spring, Barbara called a suicide treatment center and got David counseling and medication. That helped temporarily, too, she says.
The final incident the one that got David sent to Adobe Mountain took place May 2. David was playing chess online. It was bedtime. Elena sleeps in the living room, and she needed to get up the next day for school. Barbara gave David 10 minutes to wrap up the game. He got angry. She offered to let him stay up; Elena could sleep in his room. He got angrier and threw the phone. "He's just out of control and it scares me," Barbara says.
She called the police, who took David to the county detention facility in Mesa.
"I said, Make sure you put him on suicide watch.'"
Barbara begged the judge to send David to a locked residential treatment facility, but there was no money. The judge rejected the alternative, an outpatient program Barbara had found, and sent David to Adobe Mountain for six months.
David was there for just two weeks. The family says his first letter reported that the place was "pretty tight" (that's a good thing, his sister confirms) although he complained about the 90-second showers.
The first Saturday, which is visiting day, Barbara brought Elena and pizza. The second, Christina and Chinese food. Both days, David appeared to be happy. He said he liked his roommate. He was delighted to be allowed a pencil. He sent Barbara some drawings, asking her to leave them for him on his bedroom dresser.
On the second Saturday five days before he hanged himself David did mention that his medication was being changed, but he didn't mention whether he would be getting a different drug or a different dose. He had been taking aderol, which is commonly used to treat attention deficit disorder and hyperactivity.
Barbara says she never spoke to anyone at Adobe Mountain, never had the opportunity to tell them that David was suicidal. But, she says, "if anybody opened up my son's file, it clearly states that in there."
The only clue the family has about what happened next is in a letter David's father received in the mail the day after David died. Christina says the letter related "that he wishes that his Dad was there to play ball with him" and to fish. She says David wanted to show his father his new skateboard tricks.
According to Christina, David also wrote to his father that his roommate was starting to make him mad because he told David he shouldn't have a relationship with his father, since he hadn't been there for him in the past.
"That's not a reason to go kill yourself," Barbara says, adding that David also wrote that he disagreed with the roommate and that father and son would have many years together.
ADJC officials haven't said much about the events surrounding David Horvath's death.
David still hadn't been placed in permanent housing at Adobe Mountain. He was living in an assessment unit. According to ADJC spokesman Steve Meissner, on Thursday, July 11, at 1:25 p.m., David and another youth got into an argument. (Meissner didn't say whether it was the roommate David spoke of to his mother, and ADJC officials haven't told her if it was.) The boys were placed in separate rooms for a "conflict resolution."
David was found with a sheet tied around his neck. He did have a pulse. His family took him off life support four days later.
Meissner says David was alone for just eight minutes. Barbara Horvath doesn't believe that. She says it would have taken him longer to construct such a strong, effective noose.
Fewer details are available about Christopher Camacho's death. ADJC hasn't even officially labeled it a suicide.
Camacho, 15, was found dead with a sheet tied around his neck at about 8:40 p.m. April 11, in a cottage at Adobe Mountain called Freedom. His family has turned down interview requests.
The boy was sent to Adobe after repeated parole violations. His other offenses: conspiracy to commit burglary and possession of drug paraphernalia.
What is known is that Christopher Camacho apparently did not have optimum living conditions under ADJC's care. He and other Freedom residents had been locked down in their cells for days at a time just prior to his death, forced to eat, study and exercise in the tiny cinderblock rooms. Also, a youth rights advocate would later learn, Camacho had repeatedly complained to kids and other staff that a staff member was touching boys inappropriately.
Meissner refuses to discuss anything related to Camacho, pending the results of an investigation. Three months later, Meissner says the investigation is complete but the materials must be redacted by ADJC attorneys before they can be released. He doesn't know when that may be. Meissner has also refused to discuss Michael Cowie, the staff member who allegedly touched boys.
Terri Capozzi remembers Michael Cowie well. For three and a half years, Capozzi served as ADJC's youth rights administrator, or ombudsman. Last month, she quit in disgust. Capozzi recalls the Cowie situation because her staff had pointed out to her that several boys were complaining about Cowie, but that no one at Adobe Mountain had written an Incident Report about it, or initiated an investigation into his behavior. Capozzi instructed her staff to put it all in writing.
It was not uncommon, Capozzi says, for incidents to be only spoken about and never recorded, for liability purposes.
Capozzi says she was told by an ADJC sergeant that Christopher Camacho asked to go to separation the unit where he might have received counseling the day he died, and was denied.
Meissner says there is no evidence that Camacho made such a request, but says the agency will look into it.
Capozzi knows all about Margaret Leon's challenges, trying to accurately report self-injuries and other events at ADJC.
"I was extremely disturbed by that, but it's not new. It's not a new practice in the agency," Capozzi says. "All these people do what they have to do to keep their jobs."
Margaret Leon was a stickler from her first days at Adobe Mountain, where she started off as an English as a Second Language (ESL) coordinator. After many years as a teacher in public schools in Colorado and Arizona, and some time in administration at the Arizona Department of Education, Leon was eager to work with a challenging group of kids.
But she didn't know just how challenging it would be. While other teachers took their chances in classrooms without security (it's required that a corrections officer be present in or near each classroom, but that rarely happens, teachers say), Leon insisted she at least have a radio so she could call for help in an emergency.
Her colleagues didn't bother to document threats or fights between kids or problems with other staff, but Leon dutifully noted everything in Incident Reports, per department policy. Leon was surprised that no one seemed to care if anyone wrote anything down.
But it wasn't until she was transferred to "quality assurance" that Leon realized just how lax the department really is and often, she charges, by design. From April 2001 until last week, when she resigned, Leon spent much of her time at ADJC finding mistakes and omissions in the department's reporting. She hounded administrators about owning up to the real problems at the agency instead of glossing over them with cooked numbers.
In essence, she says, the department is in denial.
"Their whole thing is to make whatever numbers they need work. And if they don't work, then they quash them."
Leon was most concerned that suicidal behavior and contributing factors that lead to suicide were not being reported and thus ignored. She estimates that as many as 30 percent of the cuttings go completely unreported, mainly because the agency is so short-staffed that no one notices.
And just because someone notices doesn't mean they'll do anything. Leon explains that when a child is discovered cutting or displaying other suicidal behavior, ADJC protocol calls for him to be removed to a secure facility called the "separation unit." There he will receive a psychological assessment and counseling, as well as medical treatment. There's a catch: Every referral to the separation unit must be accompanied by an Incident Report. So if staff is being discouraged from writing Incident Reports on cuttings and other self-inflicted wounds, less treatment will be available. (Leon adds that there's the possibility of counseling later in the process, which doesn't require a report, but that's done on an ad hoc basis.)
Capozzi confirms that Incident Reports often weren't written, and kids often weren't sent to separation.
"If a kid goes to separation, then there are other staff who are looking at this kid's issues, questioning or having a hand in his treatment, and increasing the chance that the info will go up the chain and out of the institution to, God forbid, [the] Central Office," she says. "Some units do not want to air' their dirty laundry by sending kids to separation, and they think handling things in-house makes them look good.
"It also keeps them in total control of this kid's environment. When I saw a unit where kids didn't grieve and didn't go to separation, I was scared about what was happening in that unit. No IR, it didn't happen. Plus, no IR and our stats look good. No IR and no smoking gun during an investigation because who believes delinquent kids in the absence of corroborating evidence? I mean, the advantages to the agency for people to forget or overlook documentation are unending."
Leon examined every injury report at each ADJC facility between October 2001 and March 2002. There were 957 injuries reported during that time, including 203 self-injuries, or suicidal behavior. Leon found that only 497, or a little more than half of the total number of injury reports, had been documented in Incident Reports.
Even since the first suicide in April, Leon found that reporting has been lax. There are fewer than 400 juveniles housed at Adobe Mountain School, where both Christopher Camacho and David Horvath died. For May 2002, Leon found three cases of suicidal behavior with no Incident Report.
Last month, she says, there were eight incidents of suicidal behavior listed on Adobe Mountain's injury reports. (Remember, the number could be much higher that's the number who got medical treatment.) Of the eight injury reports, there were only three Incident Reports. And of those three, two were reported inaccurately. So the official record reflects just one instance of suicidal behavior at Adobe Mountain for June 2002.
And it wasn't just cutting, Leon adds. One child swallowed cleaning chemicals, she says; another punched a wall repeatedly.
Not offering counseling immediately in such a situation could be dangerous, says Patricia Kempker, manager of suicide prevention services at EMPACT Suicide Prevention Center in Tempe and a member of the Arizona Suicide Prevention Coalition.
"Suicidal behavior could easily be defined as any self-inflicted wounds," Kempker says, although she adds that not all cutting is accompanied by suicidal thoughts. The only way to know is to have professionals talk to the kid.
"I would say cutting should never be ignored, and if a child is cutting, yes, they should be getting counseling. I think even logic would dictate that if somebody is inflicting wounds on themselves, then something is wrong," she says. "Any child who's cutting should be assessed for suicidal risks."
Leon found that even when Incident Reports about suicidal behavior were completed, they were mysteriously not showing up on official ADJC reports created as part of the performance-based standards reviews. During one month in 2001, she says, there were more than 20 such incidents at Adobe Mountain, yet the total turned up as 0. She found that the information had been coded incorrectly and caught it five months later. She says administrators were not willing to go back and fix more errors.
She also audited ADJC facilities and found that the agency was lying about the number of idle hours a kid has each day.
In October 2001, Leon interviewed staff, who said the kids had four idle hours each day. The kids reported 4.3 hours. The "unit logs," where staffers record idle hours, said only three hours.
Leon says Joe Taylor, an ADJC assistant director, instructed her to report only the "unit log" numbers, which reflected more favorably on the agency.
But ultimately, Leon says, the agency tossed all that aside and reported that juveniles at Adobe Mountain had just one idle hour each day.
In May 2002, she says, her audit revealed that kids at Adobe Mountain had 4.2 idle hours a day.
And Leon was concerned that there was debate among ADJC officials over whether to report contraband kids were turning up with.
Leon says contraband is important to note, not merely because the performance standards require such documentation, but because rocks and metal and other items kids get ahold of can be used for self-injury. And it's vital to recognize how many hours a kid is idle and minimize them because idle time is widely acknowledged to lead to suicidal behavior amongst those who are disturbed.
And Leon says she heard Gaspar brag at national conferences about how all of the kids at ADJC get group counseling every day. It's not true, she says, and he knows it. ADJC kids are supposed to be assigned a "primary" counselor, for one-on-one treatment. Many kids she's interviewed don't know who their "primary" is, Leon says.
ADJC is short-staffed, and the staff they do have is often undertrained and overworked, Leon and Capozzi agree.
The kids are begging for time, the women say. "These staff do not have the time that it takes to just sit and talk to these children," Capozzi says.
Leon sees suicidal behavior as an obvious result. "If I as a kid want attention and I'm not getting it, one of the things I might do is cut myself. . . . Then I'm going to get attention, right?"
Both agree that while there are bad seeds, there are many fine people working as corrections officers, teachers and counselors who are just completely overwhelmed. Like Capozzi and Leon, many leave. Three weeks after she left the agency, Capozzi returned to pick up her retirement paperwork. She saw at least 40 packets for people who had left the agency since her departure.
Leon believes that she was passed over for a promotion this year because she was constantly pointing out errors in the system, and she figures ADJC officials will brush off her charges as the grousing of a disgruntled employee.
"I am disgruntled. I am very disgruntled. I am appalled and disgusted that these people don't ask for action immediately [in the wake of the Camacho and Horvath suicides]," she says.
Before she resigned, Leon met with Gaspar one last time, to try to explain to him that the numbers he was using to report on ADJC's progress were wrong.
"He told me that we should not be policing and looking for problems, that we should be focusing on successes," Leon says. "And that's when I realized that our discussion is over."
Capozzi adds, "I really feel quite honestly that sometimes staff feel as hopeless as kids. There's an aura of hopelessness."
Although Christopher Camacho's death marked the first time in 14 years that a child had died in a state detention facility, the Arizona Department of Juvenile Corrections is no stranger to strife.
In the late 1980s, the agency was sued in federal court over poor conditions including solitary confinement and substandard education, and until 1998 ADJC was under a federal court order, monitored for compliance with standards established through the court.
After the court order was lifted, the agency operated in almost complete autonomy. The "performance-based standards" program was introduced and celebrated by David Gaspar as a way to prove that conditions were continuing to improve.
But that just wasn't true.
A series of articles ("Slammed," July 5, 2001) in New Times over the past year revealed that ADJC was violating its own policies and in some cases the court order by routinely putting children in solitary confinement in specialized "separation units" for days or weeks, sometimes even months, without adequate education or other services; locking children in their cells for days at a time; failing to meet staff-to-youth ratios. In addition, staff members were using violence to control kids and were not always disciplined for these physical outbursts. There were staff members having sex with kids. Corrections officers and teachers were at risk because department policies weren't followed to ensure their safety.
And mental health services were found to be inadequate. Unqualified staff were counseling kids, and there were not enough spaces in the special mental health unit to accommodate boys in need of extra mental health services.
A subsequent story ("Learning Disorder," December 13, 2001) revealed that while ADJC runs state schools, it does not meet the standards all other Arizona schools are held to, particularly with regard to special education.
After the initial "Slammed" article appeared, officials from the U.S. Department of Justice began an informal inquiry into conditions at ADJC, and several months later announced a formal investigation, into areas including educational services and the use of force by staff against kids. Also following "Slammed," a group of more than 30 community leaders asked Governor Jane Hull to create a task force to look into conditions at ADJC. She never responded to the request.
Following David Horvath's suicide, Jan Christian, the former executive director of the Governor's Select Commission and Task Force on Juvenile Corrections, who headed the letter-writing group, confirmed she has yet to hear from Hull. "The governor refused to listen to the pleas of citizens," Christian says. "I wish she would at least listen to the cries of desperate children."
Margaret Leon's admissions do much to explain why the individual reports of abuse and other disturbing activities leaked by ADJC employees and the glowing descriptions of the agency's performance released by spokesman Steve Meissner never matched up.
But now Leon is gone. She'll start a new job soon, working on dropout prevention for the Paradise Valley Unified School District. And she leaves behind almost 1,000 kids. The National Association of State Mental Health Program Directors reported last year that 50 percent to 75 percent of youth in public and private corrections programs have at least one diagnosable mental health disorder. That's a lot of mentally ill kids.
Following the Camacho and Horvath suicides, there's been a lot of talk about a lack of funds, that if only there had been money for David Horvath to go to a residential treatment facility, he would be alive.
That may well be, Terri Capozzi says, but she believes kids could be treated just as well at ADJC as they are in those outside facilities. It's not merely about a lack of funds, she says, but rather, "It's about stewardship of funds." Instead of firing line-staff, ADJC could have closed institutions and consolidated populations, or stopped hiring more administrators, Capozzi says.
Further, she adds, ADJC officials have long known that their population was changing, and even though Gaspar has a background in mental health, they did little to respond.
"We knew that the population changed. We talked about it all the time. All the numbers reflect it. The kids are getting younger. Their offenses are getting smaller. And they're sicker. They're mentally ill. . . . We lock them up. We don't give them the treatment they need. We don't give them stimulation. We don't give them programs.
"And yet on paper we look terrific. We know what to say."
Editor's note: Suicide prevention counseling is available through EMPACT at 480-784-1500 or 1-800-SUICIDE.
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