Last summer, Fabian Quintana spent 22 days isolated in a cell, often for 23 hours a day, at Spring Creek Youth Corrections Facility in Colorado Springs.
He was 14 years old.
"I was kind of losing my mind," Fabian said, using a 15-minute phone call from Lookout Mountain Youth Corrections Facility, where he is now committed. "I was just looking up at the ceiling, trying to focus my mind. I was doing everything just trying to keep my mind busy. I would sit there and read the Bible. Even when they brought me my tray of food, I would sit there and take an hour to eat, so I'm not just sitting there and doing nothing."
The punishment - carried out under a secretive program that violated state law - was common practice at all 10 state-run youth corrections facilities in Colorado.
The Gazette learned of the extent of the practice after a year-long battle to review facility incident reports.
The state's Division of Youth Corrections changed its policy regarding solitary confinement beginning Thursday and said it stopped using punitive isolation for juveniles on July 1, 2014, after Fabian and his mother contacted the American Civil Liberties Union of Colorado.
"The strides we've made in that area are impressive and I think comparable to other policies in other states," said Anders Jacobson, who has worked with DYC for 15 years and is now the associate director of institutions.
But the use of isolation is indicative of a deeper cultural problem illustrated in more than 1,600 documents The Gazette analyzed. The reports detail critical incidents occurring over 17 months beginning in January 2014.
Among The Gazette findings:
Taken together, the documents paint a picture of an out-of-control environment where harshness rules.
Video: Gazette investigation 'Trouble behind bars'
National experts say it's a self-perpetuating cycle. Juveniles act out in anger because of harsh treatment, and because juveniles are acting out guards respond harshly.
The U.S. Department of Justice and leaders in juvenile corrections across the nation are pushing to end the use of solitary confinement and focus on building constructive relationships between juveniles and staff.
The Division of Youth Corrections is working to rectify the situation too, and not just by moving away from solitary confinement. State security staff have backed off applying pressure to certain points on the body, such as the neck or shoulders, and are instead focusing on talking youth through the conflict, called verbal de-escalation.
"We continue to employ evidence-based practices, family engagement with a high emphasis on education and career tech," Jacobson said. "We have good clinical programs and therapy where needed. We know literally 100 percent of the youth that we serve are going back to the community and so we want to prepare them with the skills necessary. I think we've done a really nice job of building that level of program to position them to be successful."
But for some, the changes may have come too late.
"All this that he went through in these places that were supposed to help him just made him hard," said Quintana's mother, Antoinette Salas. "He actually really felt like he was nobody . . . He just wasn't Fabian anymore. He was just empty."
Salas doesn't sugar coat her son's behavior, but says the treatment he's received breaks her heart.
"He was my bad boy," she says, noting the 16-year-old is the second-youngest of eight siblings.
He has been in-and-out of corrections since he was 10.
The Division of Youth Corrections calls it administrative seclusion.
Despite the euphemism, the practice is as harsh as the isolation or solitary confinement in adult prisons.
Fabian said his days began with a guard removing the mat in his room so he couldn't sleep during the day. He could have one book - a Bible - and no writing materials.
Although he was supposed to get time to shower and exercise, there were days those privileges were revoked or Fabian refused to leave, according to records of his confinement obtained by the ACLU. He steadily declined and would yell or refuse to relinquish his mat to guards.
"It was really shocking to find out that DYC by its own policies sanctioned this practice of putting kids in solitary confinement for days, weeks and in some cases months at a time even when there was no emergency," said Rebecca Wallace, staff attorney with the ACLU. "Frankly, no emergency lasts for days, weeks or months at a time. If a child is banging his head against the wall or threatening to hurt himself or others for that long of period of time, they need mental health care, right? Not isolation."
Because of continued violent behavior, Fabian found himself on what DYC calls a Special Management Plan or SMP. Under this provision, isolation is clearly no longer used in response to an emergency but as a long-term form of punishment.
Juveniles on SMPs had to earn the right to leave isolation through good behavior, and slight infractions such as cussing or disobeying guards landed them back in the rooms for 23-hour days, according to the ACLU and critical incident reports.
Wallace wrote in June 2014 to division leadership and Reggie Bicha, head of the Department of Human Services that oversees DYC, outlining Fabian's case and other issues.
"We have found DYC leadership to be straightforward with us and to want to work collaboratively to solve this problem," Wallace said.
By July 1, 2014, DYC agreed to stop using solitary confinement in a punitive way.
"We moved away from traditional seclusion use to emergency only in July 2014," said Robert Werthwein, now the director of the Office of Children, Youth and Families overseeing DYC. "You should not see anything as a result of punishment. There should be no punishment related seclusion."
Incident records show DYC was slow to implement the change. Documents show that residents were placed in isolation at least 403 times between Jan. 1, 2014 and May 18, 2015. Of those instances, 299 - or 74 percent - happened after July 1, 2014.
Jacobson said management has been deliberate about how it introduced the change, working to sell the concept to guards.
"I think we've made that turn with our staff. We're a year into that and we continue to move forward," Jacobson said. "We have the ability to provide services and wrap around services for youth who are being very aggressive and help them continue in programming where they can be safe and others can be safe without locking them in a closed room."
But the issue didn't stop there.
Leadership began working on a new solitary policy, in consult with Wallace, that was released last month and took effect Thursday.
That policy allows for the use of seclusion only during an emergency "defined as a serious probable, imminent threat of bodily harm to self or others."
Seclusion is limited to four hours "except in the rare case where an emergency continues."
And seclusion is never to be used as a form of punishment.
Shift supervisors must be immediately notified and will determine if seclusion is appropriate. The facility director, behavioral health staff and parents will be notified if seclusion continues for several hours.
Violent offenders may be handcuffed or shackled more than other youth. Also, physical restraints, such as handcuffs, leg irons, wrist-to-waist shackles and chair wraps can be used when aggressive or disruptive behavior occurs.
Security guards in juvenile centers are not armed, said Charles "Chuck" Parkins, director of the Division of Youth Corrections. They also don't use pepper spray or other Department of Corrections tools.
"It's different than the adult Department of Corrections - we rely on law enforcement, if it gets to that level," he said.
As of August 2014, touch pressure techniques are used only in the worst circumstances, Jacobson said. For example, if a youth was biting an arm or hand and the staff was unable to stop him or her.
The focus now is talking through issues with the juveniles to let them work out their anger and helping them change direction so they can make good decisions about their behavior, Parkins said.
"You have to understand why kids do the things they do, what drives their behavior and we're responding to that," Parkins said. "It's outside-the-box thinking to engage kids and take a holistic look at the barriers to youth success - education, substance abuse, social dynamics."
It's unclear how the division's policies and practices moved so far beyond what state law requires, but it likely had to do with a culture creep.
Ned Loughran, executive director of the Council of Juvenile Correctional Administrators, said in the early to mid-90s lawmakers across the nation began cracking down on youth crime.
"The irony is a lot of the legislation was being passed as the juvenile crime wave was ending," Loughran said.
It happened in 1993 in Colorado - after the "Summer of Violence" - and was fueled by a few high-profile incidents, including where children were hit by stray bullets fired in gang violence. Former Colorado Gov. Roy Romer called a special session. Ten bills were passed, including ones that funded more jail space and allowed some juveniles to be tried as adults.
"There was a kind of hardening of the juvenile system, and that was one of the reasons that we founded my organization," said Loughran.
"That's the genesis of how a practice that is really an adult practice crept into a juvenile system," Loughran said. "People lull themselves into the idea that the place will be safer if we lock these kids down and lock them down for a good period of time."
But that's not the case. Loughran said states such as Oregon, Massachusetts and Indiana that move away from solitary confinement find that they become safer.
"Does it mean that they are incident free? No." Loughran said. "But incidents have been reduced."
Despite a policy change in Colorado, the number of critical incident reports from the first eight months of 2015 are virtually identical to the number in the first eight months of 2014.
Jerry Adamek was the director of Colorado's juvenile system from 1991 to 1998.
He remembers the system tightening down.
"Those of us that were involved in the system probably needed to hear the message that taxpayers have the right to expect us to protect them," Adamek said. "What happened is there was kind of a real extreme swing of the pendulum. It got pretty harsh, and then I think we lost the balance of what's in the best interest of the kid in tandem with public safety issues."
Adamek said they used solitary confinement when he was the director, although informally.
He now adamantly opposes the practice in the consulting work he does.
"I think that the use of seclusion is a very, very dangerous process," Adamek said. "I would say that of the incidents that I have seen happen over the years, particularly around suicide, suicide attempts, even assaults on staff, I think the use of seclusion is a totally counter productive practice."
Former state Rep. Maryanne "Mo" Keller sponsored the Protections of Persons from Restraint Act in 1999 after a disabled man died in a Colorado residential facility while in restraints. The bill, initially aimed at hospitals and psychiatric facilities, defined seclusion as a type of restraint. The law limits its use to emergencies and only when other less restrictive efforts have failed or are impossible.
Keller said the bill originally exempted both the Department of Corrections and the Division of Youth Corrections.
"The director of youth corrections at that time came before the committee and said, 'We will be in. We should be in. Something is wrong with us if we're not willing to measure the way we use seclusion and restraint,'" said Keller who served 16 years in the House and Senate.
That director was Betty Marler, who served from 1998 to 2001. She died in 2007, and the girls' juvenile facility in Lakewood is named for her.
"Even though we had these very violent kids, we did not want to be exempted from that," said Adamek, who was working for DYC on a contract at the time. He said Marler's approach to juvenile corrections was guided by her background as a social worker and teacher. "The values she brought into the system still exist today."
But Adamek said the youth population in the facilities has changed dramatically in recent years. Low-level offenders are less likely to be sentenced to a correctional facility in an acknowledgment that it often worsens their behavior. And courts are less likely to send serious offenders to adult systems.
"The kids that you are seeing in there are kind of the cream of the crop - or the bottom of the barrel," Adamek said. "These are pretty desperate kids. What you get into is a more disturbed kid, a more intense kid. The needs are greater."
It's unclear when DYC began using seclusion as punishment, but in 2012 the current behavior management policy was enacted.
John Gomez ran the division from 2001 until he retired in June 2014. Gomez could not be located.
Under him, the division adopted a policy to give juveniles hearings for their infractions and also punishments.
Time outs, loss of privileges, such as television or computer time, and other punishments are among the repercussions youth face for defiant behavior. The policy emphasizes restorative justice, which is the practice of allowing offenders to process their crimes with the victims.
Youth offenders have individual care plans that may include counseling for drug addictions or behaviors such as anger, academic and vocational education needs, mental health therapy, family counseling, spiritual care and community re-entry plans.
Records show some juvenile facilities are better at processing issues with juveniles than others.
Staff at Grand Mesa Youth Corrections Facility in Grand Junction assigned juveniles involved in a fight to write a six-verse song with a chorus after each verse about avoiding trouble with others. In the 17 months of records The Gazette reviewed, seclusion was used only twice at Grand Mesa.
And Grand Mesa was celebrated at the national level for going a year without any sexual misconduct incidents, which fall under the Prison Rape Elimination Act.
"Their population just geographically is different than maybe you might see in inner city Denver," Jacobson said. "There's not large-scale gang issues in Grand Junction. The retention of staff is I believe much better on the Western Region ... that helps to build a very steady culture and steady predictable cultures in our businesses are a benefit to youth."
Spring Creek has been anything but steady and predictable.
It has an interim director, Brent Nittmann. The previous facilities director, Dave Maynard, took over last July and then officials said he would move back to his previous job of overseeing five youth corrections' center. But apparently that didn't work out. Maynard is no longer with DYC.
And leadership has been volatile at the top since John Gomez retired in June 2014 after 18 years with the division.
Al Estrada, a long-time DYC employee, was promoted to director immediately after Gomez left. But he stepped down after a few months and is now associate director of strategic planning. Estrada was replaced by interim director Werthwein, while a national search was conducted. Werthwein is now the head of the entire Department of Human Services office that oversees DYC and other divisions. Werthwein replaced Julie Krow, who was moved during a February reorganization of DHS executives.
The department's new executive director, Charles "Chuck" Parkins, began in March. Parkins was superintendent of the Marion Superior Court Juvenile Detention Center in Indiana.
Loughran said that amount of turnover is common, and a problem.
"You have a void," Loughran said. "Staff can get back into old habits when there is a void."
Since Jan. 1, 2013, 42 directors have turned over in the nation in 41 states, he said. The average tenure across the nation of a director is 2.3 years.
"That to me explains, not just in terms of the use of isolation, but it does explain why cultures are hard to change, punitive cultures in the facilities because if leadership changes ... staff can just say we'll wait this one out."
The Gazette began hearing from teachers and guards in May 2014 that conditions at Spring Creek were dangerous.
Gomez initially denied problems at Spring Creek, but after he retired Krow and Estrada outlined a six-point plan for improvement in the facility, acknowledging to The Gazette that assaults there had peaked.
Part of the problem has been understaffing.
In Indiana, Parkins worked under an average 1-to-8 staff-to-juvenile ratio, which is the federal recommendation under the Prison Rape Elimination Act.
Colorado is closer to 1-to-14 during the day and 1-to-16 at night. The ratios vary by facility, however.
The state-run centers have 75 more security guards than last year; the Joint Budget Committee approved 53 in December and 22 for this fiscal year, which Jacobson said have been hired.
"I think we're spread a little thin, quite frankly," Parkins said. "I think you'll look at those incident reports and see that yourself. It's just a matter of numbers. When there's only one person providing supervision, it's hard to have eyes on every one in that room."
Werthwein said most of the 75 additional staff went to help cover night shifts.
"We learned a lot through looking at critical incidents that we needed a supervisor on the night shift and additional staff," Werthwein said.
He said the eight additional staff added to Zebulon Pike Youth Corrections Center led to a 30 percent reduction in fights and assaults.
"Every time we go there they are like, thank you so much," Werthwein said.
But Julie Rammer, a public defender with the Golden regional office who has spent five years working exclusively with juveniles, said she hasn't seen any improvement in the facilities she visits to check on her clients.
"I have not seen any differences, and quite frankly, often when I look at their written policies it astonishes me based on what I hear from my juveniles and see in practice," Rammer said. "They started putting kids in handcuffs wrist-to-waist, and instead of putting them in a small room they put them in a bigger open area and so that was not seclusion."
Rammer said she was horrified to hear juveniles are put in wrist-to-waist restraints day after day for months.
Two years ago she couldn't get people within DYC to admit they weren't taking a trauma-based approach to juveniles, but now she said officials tell her they are working in that direction.
A trauma-based approach takes into consideration that most of the youth in these facilities have faced trauma in their life, such as physical or emotional abuse, neglect, or witnessed or been a part of violence such as shootings and homicides.
Across the nation, there's a movement to develop programs that deal with those underlying issues, rather than to deal with the behavioral repercussions of the trauma.
Antoinette Salas said Fabian witnessed domestic abuse when he was a child and her divorce was hard on him too.
She spoke to The Gazette only on the condition that information about Fabian's convictions not be included in the article. Juveniles in Colorado have sealed records and can get those records expunged if they don't re-offend.
Asked what his plans are when he is released in May 2017, Fabian said he doesn't have a plan but was recently asked the same thing by staff at Lookout Mountain.
"I told them to be honest, right now, I'm not in the state of mind, that I just want to go back and do what I was doing where I left off, the gang thing."
Asked what staff could do to change his mind about returning to gang life, Fabian paused:
"They don't even try to do that. Really what they do is just do what they're supposed to do. Sit here and watch us and give us the basic rights. They just do what they have to do. I don't think they really care."