The Hanging

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.

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Amy Silverman is a two-time winner of the Arizona Press Club’s Journalist of the Year award. Her work has appeared on the radio show This American Life and in the New York Times, the Washington Post, Lenny Letter, and Brain, Child. She’s the co-curator of the live reading series Bar Flies, and a commentator for KJZZ, the NPR affiliate in Phoenix. Silverman is the author of the book My Heart Can’t Even Believe It: A Story of Science, Love, and Down Syndrome (Woodbine House 2016). Follow her on Instagram (@amysilverman), Twitter (@amysilvermanaz), and at amy-silverman.com.