Children with developmental disabilities were held under brutal conditions at a notorious New York facility. Decades later, they still face abuse and neglect.
By Benjamin Weiser
[Watch a Times investigation of abuse at state-run group homes on “The Weekly,” on FX and Hulu.]
When the abuse began, Migdalia could not call for help.
She was 57 but with the mind of a child. She had never spoken and could not form words. She lived in a Bronx group home with two dozen other adults who also were mostly nonverbal and helpless.
Bruises started appearing on her arms and legs. What looked like a shoe print on her belly.
A state investigation later concluded that she and other residents had been beaten by some of the home’s employees, the people who had been entrusted with her care. In Migdalia’s case, the abuse represented an especially deep betrayal.
Migdalia and thousands like her had grown up in the Willowbrook State School, a notorious institution on Staten Island. For decades, the state used the facility as a warehouse for children and adults with developmental disabilities. They were left unattended, naked or in rags. Some were strapped in beds or chairs; others were left to rock endlessly on filthy, locked wards.
Exposure of these conditions led to a landmark 1975 federal court settlement in which New York agreed to move Willowbrook’s residents into small group homes. The state pledged that each individual had a “constitutional right to protection from harm.”
But that vow has been broken: Many of the institution’s 2,300 alumni who are alive today still suffer from mistreatment, a New York Times investigation found.
Last year alone, there were 97 reported allegations of physical abuse by group home workers against Willowbrook alumni, according to internal state data obtained by The Times.
There also were 34 allegations of psychological abuse and hundreds more of neglect and other mistreatment, like improper use of restraints or seclusion, medication errors and theft, the data shows.
Negligence may have contributed to the death of one disabled woman in Brooklyn and the loss of another woman’s finger in a Long Island group home, interviews showed. One man placed in a scalding bath or shower went to the hospital with second-degree burns.
Even critics agree that large numbers of the surviving alumni are in a better situation today than they were in the harrowing conditions at Willowbrook, but they say the homes are still short-staffed and the employees do not have sufficient training and oversight.
“The system is floundering,” said Antonia Ferguson, executive director of the Consumer Advisory Board, an independent agency created under the court settlement that advocates on behalf of former Willowbrook residents, particularly those who do not have family available.
The Bronx group home where Migdalia lived, on Union Avenue, offered a clear example of the problem. Of more than a dozen residents found to have been abused or neglected in the state-run facility, at least five of the victims were Willowbrook alumni.
“Now we have small Willowbrooks,” said Ida Rios, 86, a retired teacher whose late son Anthony was at Willowbrook and who now runs an association for Bronx families with relatives in group homes. “As much as things have changed,” she said, “they don’t change.”
In 1964, when Migdalia’s parents placed her at Willowbrook at the age of 7, the overcrowded, understaffed wards were chaotic and violent. In a visit the following year, then-Senator Robert F. Kennedy said the facility “borders on a snake pit.”
“The sadness of the place was overwhelming,” said William Bronston, 80, a former Willowbrook staff physician who had helped organize parents to demand reforms.
Willowbrook exploded in the national consciousness in early 1972, when the television reporter Geraldo Rivera aired graphic footage from inside a children’s ward.
That March, the New York Civil Liberties Union and the Legal Aid Society filed class-action lawsuits over the conditions, leading to the landmark 1975 court settlement in which the state said it would protect Willowbrook’s residents from harm.
“It was better than a promise — it was an order,” said Chris Hansen, one of the early civil liberties lawyers on the case.
But moving the so-called Willowbrook class members dragged on for more than a decade, while conditions inside remained deplorable, recalled another of the lawyers, Robert M. Levy, who visited Willowbrook in the early 1980s and is now a U.S. magistrate judge.
“People would be naked on the wards,” he said. “They would have shoelaces tying their pants up instead of belts. In many ways, it was still like a concentration camp.”
Finally, in 1993, with the institution closed, a judge approved a settlement in which New York agreed that the Willowbrook class members were to receive high-quality services for the rest of their lives.
Helpless and vulnerable
As infants, Migdalia and an older sister both received a diagnosis of developmental disability — “mental retardation,” their medical records said.
Their parents tried to care for them in their modest Bronx apartment, but as the family expanded to 14 children, the girls’ needs became too great. They were incontinent and unable to dress or feed themselves and could not respond to simple directions, according to state records.
“It was hard for my mom,” said Sandra Romero, the oldest child. Her mother later explained that a social worker had suggested sending the girls to Willowbrook, where things would be better, she said.
The girls’ 1964 admission forms used the harsh terminology of the time. Under “Mental Status,” for example, the staff had checked the same box for each girl: “idiot.”
Migdalia spent 16 years at Willowbrook; by the time she was moved out in 1980, she was in her early 20s. Migdalia’s sister, who had lost her eyesight while at Willowbrook, also was moved and ultimately placed in a state-run group home on Prospect Avenue in the Bronx.
But Migdalia went home, where she thrived. Her mother took her to the park and to visit relatives and included her when she entertained family and friends, according to Ms. Romero and another sister, Hilda Youssef.
Migdalia was friendly, cooperative and responded to people who were familiar to her, records show. She could smile, feed herself and drink from a cup. She liked to hold a stuffed animal.
In 2004, when Migdalia was 47, her mother died suddenly. Ms. Romero, who worked full-time, placed Migdalia at Union Avenue, a three-story facility with eight residents to a floor.
Ms. Romero remembered touring the building and meeting the staff. “I was comfortable,” she said. “I trusted them.”
The Willowbrook mentality
The investigation at Union Avenue began after an employee turned whistle-blower sent letters in the summer of 2014 to a state official and to relatives of three residents who were found with unexplained black eyes and other bruises.
In the letters, the employee accused staff members of pervasive abuse and claimed that some supervisors had helped to cover it up.
A state agency, the Justice Center for the Protection of People with Special Needs, substantiated numerous allegations of abuse and neglect against 13 employees, according to records, transcripts of employee interrogations and legal depositions obtained by The Times.
Five of the Union Avenue abuse victims had already endured the hardships at Willowbrook, including one who was hit so hard in the head he needed stitches and another who was struck repeatedly by the same Union Avenue worker as he ate, the records show.
“He is afraid of her and hunches over his plate,” investigators wrote.
Willowbrook continued to cast a shadow as the Justice Center’s inquiry moved forward. Employees told the investigators of a “Willowbrook attitude” among some workers who, disrespectful of the residents, would line them up in their underwear for “assembly line” showers.
Tara Ganni, a Justice Center investigator, almost seemed astonished when questioning another employee to learn that former Willowbrook residents had gone through additional suffering at Union Avenue, a transcript shows.
“That’s kind of sad, isn’t it?” Ms. Ganni said. “You have to live through that — and then do it again.”
In Migdalia’s case, the Justice Center collected evidence that she suffered repeated trauma over at least six months in 2014. Workers told of seeing her with a “big purple blotch” resembling a shoe imprint below her navel, as if someone had kicked her, and of “big red circles” on her stomach, chest and legs.
She had received no medical attention. “Staff is under the impression that as long as a bruise was documented on the body check form,” they did not have to tell anybody about it, the investigators wrote.
The state Office for People With Developmental Disabilities, which oversees group homes, tried to fire the workers, but none lost their jobs. Strong union protections allowed them to block their dismissals in arbitration. Ultimately, allegations that had been substantiated were dropped entirely for some employees, records show.
“It’s a fair process,” said Denise Berkley, an official with the union, the Civil Service Employees Association. “Sometimes we like what the arbitrator says, sometimes we don’t.”
The union never condones abuse, she added.
The Bronx district attorney, Darcel D. Clark, said her office investigated for more than a year at Union Avenue, but there was insufficient evidence to prosecute the allegations of abuse. Victims could not speak for themselves, she said, and her office could not obtain cooperation from witnesses. “It’s not whether or not it happened,” she said. “It’s what could we prove.”
The state office for people with disabilities declined to comment on specific cases but said any abuse was unacceptable. It said disciplinary action was taken against workers with substantiated allegations, and employees received retraining and enhanced supervision after the arbitration process. Nine of the employees still work for the agency, and seven of those continue to work in group homes, though none returned to Union Avenue, the state said.
The office said it takes its commitment to quality services and safety very seriously, and offers oversight, protection and corrective actions when abuse or neglect is reported.
The Justice Center said it could not comment on individual cases or its own confidential appeals process, which it said reversed the findings against two employees. One worker who was found to have beaten Migdalia also had that finding reversed, according to a person familiar with the ruling.
The center said various factors can lead to a reversal, like a witness’s unwillingness or inability to testify and the available evidence at the time of the appeal. A reversal does not necessarily mean abuse or neglect did not happen, the center said.
The most effective action against the Union Avenue employees accused of abuse turned out to be a 2016 lawsuit filed on behalf of three residents — none of them Willowbrook class members.
The state, in settling the lawsuit this fall, agreed to pay $6 million to the three families and to transfer control of the facility to a nonprofit provider, the Institutes of Applied Human Dynamics, which took over in December.
Omayra Andino, the chief executive of Applied Human Dynamics, said her organization has brought on all new staff.
Burns, an amputation and death
One day last spring, two staff members from the Consumer Advisory Board, the independent agency that advocates for former Willowbrook residents, visited a class member — a woman in her 50s — living in an upstate group home.
The woman, in addition to her mental impairment, had difficulty walking and maintaining her balance, and she wore a soft helmet because of falls, including one tumble backward down the cellar stairs.
The advisory board, a kind of front line for accountability for Willowbrook class members, already had concerns about her care and wanted her moved to a different home. On this visit, the staff members were horrified to see items strewn across the woman’s floor that she was allowed to keep as “toys” — marbles; batteries; a toilet-bowl brush holder; Lego pieces; plastic dog dishes; and a filthy industrial mop bucket atop a broken wooden toy chest that had exposed nails and screws.
Beneath the chest was an infestation of ants.
Photos were shared with the group’s board, which included parents and siblings of class members. One parent told the other board members that the mop bucket resonated with her: She remembered that when she visited her son at Willowbrook, she often saw children playing with mop buckets because of the lack of appropriate toys and activities.
Antonia Ferguson, the advisory board’s executive director, emailed state officials.
“It is 2019,” Ms. Ferguson wrote. “Nobody should be reliving their horrors of Willowbrook — whether it be class members or their family members.”
As the Willowbrook alumni age and their relatives die or move away, it has fallen to the advisory board as well as two legal groups appointed by the court to watch over the class members’ personal and legal interests.
The New York Civil Liberties Union, one of those groups, described recent incidents in which an employee’s negligence, even inattention, had disastrous consequences for class members.
Last spring, a 56-year-old woman in a Long Island group home had to have part of her finger amputated after it became caught in a wheelchair wheel. An employee had failed to ensure the woman’s hands were in her lap.
In December, a 58-year-old woman with seizures and asthma was found dead in her bed in a Brooklyn group home after an employee failed to check on her every 15 minutes, as medical orders required.
And in 2017, a Manhattan man, 69, ended up in a hospital burn unit with second-degree burns over his entire back, groin, calves and feet; he had been placed in a scalding tub or shower.
The group home’s staff had to be retrained in how to measure water temperatures.
In the park
Migdalia, now 63, still lives at the Union Avenue home. On a day of brilliant sunshine in September, she sat on a bench in a nearby playground next to her younger sister, Ms. Youssef, and Ms. Youssef’s son.
Migdalia gave no indication that she recognized Ms. Youssef, but she held her hand. “She knows that I’m family,” Ms. Youssef said.
But Migdalia seemed agitated. She looked left and right, making humming sounds and sucking her thumb. Her curly black hair was unwashed and mussed.
Ms. Youssef said that Migdalia’s sister, who lives at the nearby group home, is groomed and dressed neatly and appears to be happy and to have devoted caretakers.
Ms. Youssef began singing “Mary Had a Little Lamb” and tried a round of patty-cake. Migdalia seemed uninterested.
Soon, Ms. Youssef and her son led Migdalia back to her group home. Later, Ms. Youssef choked back tears as she described trying to hug her sister, who kept pushing her away. It seemed as if Migdalia was always watching her back, Ms. Youssef said. As if she was trying to say something, but could not.
Susan C. Beachy, Alain Delaquérière and Tiff Fehr contributed research.
Full Article & Source:
Beatings, Burns and Betrayal: The Willowbrook Scandal’s Legacy