





Restraints were ingrained in the company’s culture, but there was more than that at work, added Glen Gandy, who worked with residents at Carlton Palms for several years. High turnover meant workers often didn’t know residents well enough to calm them, and they would turn to restraints instead, Gandy said. He was fired in 2012 after an incident in which he and other workers attempted to wrestle a thrashing resident into a wrap mat. As Gandy held the resident’s head, the man bit down on Gandy’s finger. Gandy broke the man’s jaw—accidentally, he says—getting his finger out of the man’s mouth.

Hiram Henriquez for ProPublica

AdvoServ said in a statement that the company’s turnover is “higher than we’d like” but lower than the industry average. Officials also said they have only used triple shifts “in the case of a natural disaster,” and that the company has always met staffing and training requirements.

Kennedy-Shields had little way of knowing about the abuse complaints involving Carlton Palms. Such allegations usually aren’t publicized or available to parents, especially if their child is not involved. Right after the no-contact period ended, she went to see Adam, who appeared to be doing well. “When I saw him,” she says, “he was so happy to see me.” She says she visited at least once a month and called at least once a week. She’d pack her car up with new clothes, candy, and toys and leave the bustle of Tampa, passing rolling hills and grazing cattle on the way to Mount Dora. She always called or emailed ahead, alerting staff when she planned to arrive on campus.

Employees would bring Adam to her at the main administration building, and they would visit in a conference room. If it was a weekend, when administrators weren’t there, they would go into a classroom or hang out at the swings. They’d sing to each other and have simple conversations, with Adam signaling his preferences with a word or gesture. Each fall in the first few years Adam was there, she and her family attended Carlton Palms’s family day—a festival featuring pony rides and barbecue dinners. She never saw anything that gave her pause. She later realized she didn’t see all that much—staff members usually asked her to stay in designated areas and only let her see her son’s bedroom once in seven years.

Kennedy-Shields participated in phone meetings with Carlton Palms and school district officials about Adam’s special education plan. He seemed to be making progress—at least toward the narrowly constructed targets set for him. The school told her he was completing more tasks successfully. But Kennedy-Shields had no way to check. His lack of speech and the fact that he was so far from home made it impossible for her to verify what Carlton Palms told her. And though it was paying the bill, the school district didn’t independently evaluate Adam’s academic growth.

Adam aged out of the school system in 2007 when he turned 22. But Medicaid—the government insurance program for the poor and disabled—paid for him to continue his stay at Carlton Palms as an adult.

Staffers said they would keep working to help Adam meet his goals. Yet Kennedy-Shields found herself enmeshed in a series of conflicts with Shea. The tensest interactions were over her son’s health.

Adam started taking an antipsychotic drug a few years into his stay, after Carlton Palms staff told Kennedy-Shields that her son was agitated. She balked at first, but relented, hoping it would help Adam relax. The program’s doctor would change drugs and adjust doses regularly, depending on how well the medicine seemed to be working.

Then, in 2006, she got a letter from a Medicaid psychiatrist suggesting the antipsychotic Adam was on should be monitored closely because of potentially dangerous side effects. A psychiatrist working for Carlton Palms responded that all the necessary lab work had been done, writing, “Thank you, so much, for this incredibly intrusive waste of my time.” But Kennedy-Shields began to ask more questions. Her son hadn’t been diagnosed as psychotic or bipolar. “They were always pushing it with me, and I was like, ‘I don’t think he needs this,’” Kennedy-Shields says. “There is no drug for autism.”

In 2007, she said, Shea threatened to discharge Adam if Carlton Palms couldn’t put him on Abilify—a potent antipsychotic that is sometimes prescribed for autistic patients who are irritable or lash out. As with all antipsychotics, the potential side effects were frightening—they could include diabetes, significant weight gain, and involuntary facial tics. Kennedy-Shields had grown worried that Adam’s caretakers weren’t paying close enough attention to his reactions to drugs. Once, she’d found him gasping for breath after a medication change, but staff hadn’t seemed to notice. So this time, Kennedy-Shields refused to give her consent.

A bigger blowup came soon after, when she learned that a blood test had shown that Adam was anemic, a diagnosis he had never received before. She asked the doctor who worked at Carlton Palms to find out why. Shea told her never to call the doctor again and denied the anemia, Kennedy-Shields says—though a nurse had read the full test results to her. (She says she never got an explanation, though she later surmised he simply wasn’t getting enough food.)

Noah, Adam’s brother, remembers visiting Adam and seeing his face torn up from itching and scratching after an apparent allergic reaction that had gone untreated. “It looked like a raccoon had attacked him,” Noah says. Another time, Adam took off running during a visit—and fought workers when they grabbed him—something Noah says he wishes the family had viewed as a warning sign.

By early 2008, Kennedy-Shields was fed up. She asked Adam’s support coordinator—who assisted families with Medicaid in arranging for services—what she needed to do to move Adam. A few weeks later, Kennedy-Shields discovered the raw wound on Adam’s wrist. Shea responded to her questions with rage, she says.

“Every day it was something else,” Kennedy-Shields says. “I would pick up that something was wrong, something was wrong, something was wrong.”

“I don’t have to take this shit from you,” Shea told her during their February 2008 confrontation, Kennedy-Shields says. They sat around a table in a small conference room with faux-wood paneling. Shea grabbed her son’s chair in his hands and pushed it roughly, she says, as he squeezed past and headed for the door. She jumped to her son’s defense. “Get the fuck out of my way,” he told her, she says. He is going to hit me, she thought. She stepped aside.

In court proceedings related to Kennedy-Shields’s lawsuit, Shea has denied making those comments.

Kennedy-Shields wanted to put Adam in the Suburban and take him home right away. The support coordinator urged her not to act rashly—paperwork had to be filled out, and she’d first need to set up a bedroom in her house for Adam and line up a new behavior analyst. After what had happened, they wouldn’t lay a hand on Adam, he said. He told Noah to lead Kennedy-Shields out. “I’m sure they were very scared driving home with me,” she says. “I was hysterically crying the whole way.” No one spoke during the ride.

Shea wrote a letter of dismissal for Adam, calling Kennedy-Shields uncooperative and saying she was unwilling to work with staff.

Kennedy-Shields told legal advocates for the disabled about the confrontation. Someone complained to the state about Adam’s treatment. Carlton Palms reported that it was discharging Adam “due to verbal attacks against staff, doctors etc by” an unnamed person who made “all kinds of accusations against the staff,” state records show. (The names are blacked out, but it is clearly referring to Kennedy-Shields.) Nothing came of the complaint.

After her confrontation with Shea, Kennedy-Shields spent weeks in a frenzy, rearranging her home and life to prepare for Adam’s return.

He no longer had a bedroom in her house, so the family had to redecorate his old room. They made sure big pieces of furniture, like bookcases and dressers, were bolted to the wall so he couldn’t accidentally pull them over. They fixed the locks so he couldn’t work them. They moved electronics and remote controls up high, because Adam liked to turn up the sound so loud he’d blow the speakers. They put plexiglass on the window so he wouldn’t break one with a slap, as he had before.

Kennedy-Shields called the state Agency for Persons with Disabilities, too. The agency wanted to put Adam in a group home for people with “intensive behaviors.” She refused and fought to arrange for aides and a behavior analyst to work with her son at home. Distracted one day outside the agency’s building after a heated encounter, she got into a minor car wreck after failing to look before changing lanes.

As the weeks ticked by, Kennedy-Shields worried about Adam “every minute of the day,” her husband, Tom Shields, says. “I don’t think she slept for two weeks. You could see the distress on her face worrying about it.” She’d wonder what was happening that day. She’d say over and over, “He needs to be out of there.”

Finally, one day in April, Adam arrived home in a Carlton Palms van that carried all his possessions. A bit hesitant when he first walked in the door, he soon happily roamed a house he knew well, visiting his bedroom and rummaging through kitchen cabinets like he’d never left. His brother and sister—who had been nine and five when he had left—were now 16 and 12. Kennedy-Shields hovered over Adam like she hadn’t in years, making him his favorite sandwich—a “fluffer-nutter”—and attending to his every need.

But any comfort Kennedy-Shields felt in Adam’s seemingly easy transition quickly dissipated. She began to discover clues that revealed what his years at Carlton Palms had been like.

He still needed constant supervision, and when he took off his clothes, she saw round circular spots where the hair was missing on his upper body and arms, and a white scar across his upper chest, below the shoulder. “What’s going on here?” she wondered, grabbing a camera to photograph them. She was shocked, too, at his protruding rib cage and hollow cheek bones. He was down to 153 pounds on his 6-foot, 5-inch frame.

When Adam finally got home, a few months after this picture was taken, his mother realized how much thinner he’d become. Courtesy of Lori Kennedy-Shields

She soon found he had acquired strange new habits, too. He’d grab food as soon as it was put in front of him and stuff it in his cheeks, like a chipmunk. “He’d say, ‘Go to your room, no Pizza Hut,’” Kennedy-Shields recalls. Her family never ordered from Pizza Hut, and she had certainly never punished Adam by withholding food. Besides, he had a milk allergy and was not supposed to eat dairy. He also said things like, “you motherfucking little bitch” that he hadn’t heard at home. Sometimes, he changed the pitch of his voice—as if mimicking someone who wasn’t there—when doing it.

“Every day it was something else,” Kennedy-Shields says. “I would pick up that something was wrong, something was wrong, something was wrong.”

Then one day, shortly after he came home, he walked out of the bathroom and began screaming and shaking his head back and forth. He started hitting himself with a ferocity Kennedy-Shields had never witnessed. He was slapping his head and trying to bang it into his knee. “He was making himself bleed,” she says. “He was beating himself.” She had no idea what had set him off or how to stop him. She and Noah grabbed Adam’s arms and tried to talk to him, but it was as if he didn’t see them. His hands shook uncontrollably.

“It was very scary,” says Noah. He realized his brother—so long a benign presence—had come home a different person.

Adam grew agitated when someone stood in front of him or moved too quickly toward him. He’d stare blankly and tremble. He seemed to be in a trance when upset—he didn’t even appear to recognize his own mother. He refused to swim in the family pool and frequently grew upset while in the bathroom. He would punch holes in walls, shred clothes. A few times, he woke up at night and smeared feces on himself. Kennedy-Shields was wary of taking him out in public. At home, the family used a helmet, mitts, pillows, and padding to protect Adam from himself. She began to build a list of things that seemed to spark his episodes—triggers she says he developed while at Carlton Palms.

“I started to put everything together,” Kennedy-Shields says. “And that’s when I hired the attorney.”

After two years at home, Adam moved to a group home, then to an apartment, and finally to a rental house to live on his own with the help of round-the-clock aides. He gained 90 pounds in the six months after leaving Carlton Palms and grew more stable—without restraints—though he still had episodes when what seemed like a “fight or flight” instinct kicked into high gear. Kennedy-Shields now had a plan for how to handle Adam’s meltdowns. Still, every time one occurred, she found herself struggling to function.

Her outrage over the dramatic changes in her son continued to simmer. She believed Carlton Palms was responsible. But she still didn’t know exactly how.

The school had maintained detailed records of Adam’s care. But, she says, it had never allowed her to see them. Shortly after Adam left, she received an odd letter from Carlton Palms’s lawyer, saying that portions of Adam’s file had been stolen out of an employee’s car.

Kennedy-Shields’ lawyer put in requests—in 2008, 2009, and 2010—for records on the use of restraints on Adam and about other incidents involving him, to no avail.

She wanted to send a message and hold the program accountable. In late 2011, she filed a lawsuit in federal court, alleging Adam had suffered permanent injuries and seeking unspecified damages. A judge kicked the suit to state court.

As the case dragged on, Kennedy-Shields watched closely for news about Carlton Palms. The media carried accounts of complaints filed by the state against the facility. The accusations were staggering: When a boy at Carlton Palms refused to lie face down for a restraint, a staffer had kicked him in the head and choked him. Residents had been beaten, dragged across the floor, and struck with a plastic container that caused an open head wound, the state alleged. In 2013, a 14-year-old girl with autism died there after a night in which she projectile-vomited while being tied to a bed and a chair.

Then one day in the summer of 2014, an envelope from Kennedy-Shields’s Tampa personal injury attorney arrived in her mailbox. It contained a flash drive holding documents that Carlton Palms had finally released about Adam’s time there.

Hunched over her son Noah’s laptop computer, Kennedy-Shields clicked on files containing the narrative of her son’s days that she’d both yearned for and feared. She learned that staffers had given Adam meals like macaroni and cheese, despite his dairy allergy. He’d once climbed over a fence and splashed in a lagoon where she remembered seeing alligators sunning themselves during her visits. He had hurt himself falling off a swing. A staff member was fired after hitting him.

But it was the restraints that took her breath away.

She had steeled herself before she looked at the files, expecting to read that in his final months at Carlton Palms, Adam had been shackled in restraints, as the wound she had spotted suggested. Then she saw the date.

Carlton Palms reported that a restraint had occurred at 10:20 a.m. on June 17, 2001—roughly seven months after Adam arrived at the school, when Kennedy-Shields had thought everything was fine. She felt her heart quicken as she realized that Adam had been tied up and pinned down for years without her knowledge.

After a few minutes, she shut the files and called her attorney, furious. She couldn’t bear to see more.

Weeks passed. Depositions were scheduled for her and Tom Shea. Bracing herself, she knew she had to read on.

There were more than 750 pages of records. In dispassionate terms, the records revealed repeated incidents of Adam refusing to follow directions, escalating his behavior as workers intervened, and ending up forced into a wrap mat, or with his ankles shackled or with his wrists cuffed against a waist belt. Shea was notified directly of some incidents, records said. Interspersed were reports of injuries Adam suffered in and out of restraints.

Hiram Henriquez for ProPublica

Some restraints occurred in response to what sounded like dangerous behavior, such as his hitting himself or banging his head. But others hardly screamed emergency at all. One time, Adam refused to clean up Legos and ended up in mechanical restraints. He was put in them, too, for an incident that began with his smiling and throwing a toy across the room. His ankles were bound after he tossed a dinner bowl and broke it, and after he launched couch cushions across the room.

Some episodes seemed more punitive than safety-related—he was placed in a wrap mat “because he hit Matt in the head,” a staffer wrote, for instance—or even for convenience: “It was in the best interest of the great room to put mechanical restraints and use the protective wrap mat.”

Kennedy-Shields stopped reading so she could run and vomit, then she sat down on her kitchen floor and sobbed, knowing she finally had the answer to the question she had asked Shea nearly seven years earlier. Noah came over and kept reading, stopping at one point to throw something across the living room in anger. They pressed on through the night. Together, they finally learned the secrets Adam had never been able to tell.

In the spring of 2015, more documents arrived from Carlton Palms. Adam’s “behavior plans” laid out the habits that were causing him problems and described what the facility was doing to address them. Parents were supposed to consent to treatment options and sign forms when new plans were written. But despite yearly updates that showed Adam’s behavior getting worse—not better—as Carlton Palms used progressively more forceful means to control him, Kennedy-Shields only recognized the first plans as ones she had seen and approved.

The plans told a heartbreaking tale. A “handsome young man” who enjoyed music and being outdoors arrived at Carlton Palms in November 2000, seeking help with his speech and a decrease in socially disruptive, but typically not life-threatening, behaviors like hand-biting and slapping. His aggression, an admissions document said, was “not very frequent” and “not very sophisticated.” He slept well and had a good appetite. He was not on any medication.

The years ticked by, and his behavior worsened. He started hitting himself and scratching until he bled. His behavior got more intense when he was ill—and he was often ill—as he endured chronic sinus congestion, headaches, and ear infections. The plans recognized that medical problems triggered his outbursts, but also attributed them to his desire to “escape from demands”—or, essentially, to ignore instructions.

Clinicians responded by upping the ante: At first, he was given a sort of “time out” away from others. By 2003, the plan called for the use of the wrap mat for five minutes plus one minute of calm—though records show Adam had been subjected to it before. Later, a “range of motion” device was added to the plan—a waist belt with wrist cuffs that can be clipped to it to force users’ hands to their sides.

By 2005, the description of Adam had changed dramatically from the original admissions forms Carlton Palms staffers had filled out. The new plan said he was admitted to the program because he had “attacked his younger siblings and has eloped from the house into dangerous situations” and that “within the home they could not offer the kind of 24-hour supervision that he required ensuring safety.” It said that, “While living at home his family would have to take turns staying up at night to ensure that Adam did not run away or self-injure.” None of that was mentioned in the intake forms. And it hadn’t happened while Adam was with Kennedy-Shields, who says she took care of Adam for all but a few hours a month.

The 2005 plan raised the possibility of finding a placement closer to Tampa for Adam. But Carlton Palms behavioral specialists asserted that any place would need the same strong measures—mechanical restraints like a wrap mat, 24-hour supervision, locked premises, and a well-staffed facility—to control him. Those parameters suggested few, if any, other homes would work.

By 2008, Adam’s plan said that if he wouldn’t stop his aggression or self-injury, workers should bind him in the wrap mat until he was quiet for one minute, then secure him in the “range-of-motion” device until he was calm for an hour.

“They,” she says, pausing, “tortured him.”

The last year Kennedy-Shields’s signature appeared on a plan was 2002, documents from Carlton Palms showed. Forms attached to a few other plans were signed by Fields, Adam’s now-estranged adoptive father, who did not have custody but visited him a few times. Kennedy-Shields, in contrast, says she talked with Carlton Palms staff several times a week, visited regularly, and had a fax machine at home. She was Adam’s legal guardian. Neither Adam’s father, nor the facility, told her what was in those plans, she says.

In 2004, clinicians had Adam sign the parent consent line himself, though he can’t write. In 2006, the signature—presumably his—is wavy scribbles that don’t resemble letters. On another plan, a clinician who drew up the plan signed her own name on the parent consent line, adding, “conv. with mom.” (Kennedy-Shields says no such conversation took place.)

The plans aimed to justify Carlton Palms’s hands-on approach with Adam. Top administrators at the center—including Shea signed off on them. A peer review committee that considered them sometimes included state officials alongside Carlton Palms representatives.

There were other revelations in the records Kennedy-Shields received. At one point in 2007, a physician authorized workers to pin down Adam with a bed net a blanket of woven mesh that is fastened to the bed frame and stretched across patients so they can’t sit up or fully move their arms or legs. The records don’t say how often it was used, if ever. Another document revealed that Adam wasn’t the only resident who was underweight—a 2005 letter from a nurse listed a dozen residents whose weight was dwindling to the point of concern.

It turned out the support coordinator was wrong when he insisted Adam would not be touched at Carlton Palms after Kennedy-Shields’s confrontation with Shea. Workers tied Adam down at least 44 times in the roughly two months before he arrived home. Some occurred in the middle of the night.

It is hard to visualize what happened in some of the incidents, or to know why staff felt the danger was significant enough to warrant restraints. In one instance, a staffer wrote, “Begin scratching his legs and back, while sitting in a Fetal position.” There was no mention of why he might be itching, or whether something less drastic—treating dry skin or allergies, clipping his nails or putting mitts on him—would have quelled his urge to scratch.

Adam was also getting hurt a lot. Roughly six weeks before leaving Carlton Palms, he was sitting listening to headphones, then took them off and began scratching and slapping himself. He was put in a wrap mat. While he was in it, another resident walked over and kicked him in the face. Then, barely two weeks later, workers noted that he had a black eye—offering no explanation in the documents for the swollen and discolored eyelid. A day after that, “staff found client Adam bleeding from the head” because of an unexplained half-inch cut.

The plans and restraint forms revealed that Adam was getting unmistakably worse during his time at Carlton Palms. By his final year there, he no longer slept through the night, had been on and off antipsychotic medication, and sometimes tried to seriously hurt himself.

After spending hours poring through the paper trail on her son’s care, Kennedy-Shields reached her own conclusion about what Carlton Palms had done to Adam: “They,” she says, pausing, “tortured him.”

One bright, cool morning this spring, I visited Adam. Six months earlier, Kennedy-Shields had moved him into his own small rental house, with a brick front walkway and a screened-in back porch. It is utilitarian, not fancy, with a huge flat-screen television that is turned up too loud. Warm sunlight streams through ceiling-level windows, and Adam is snuggled under a blanket on a soft leather couch.

He says good morning in muffled tones, his gaze shifting around the room. He is excited to go to lunch with his mom. “Van ride!” he says, working on sewing shoe laces through holes in a bunny-shaped card.

Adam, now 31, spends his day playing with toys, such as Mega Bloks, and doing simple chores, guided by round-the-clock aides who are paid for by Medicaid. His brother Noah, who is studying to become a behavior analyst, works with him daily. Adam can easily visit his family’s house a quarter-mile away, but if he gets overwhelmed, he has his own space to return to.

Shredding paper is one of the tasks Adam likes to do in the small rental home where he lives with help from his family and 24-hour aides. He is no longer restrained. Heather Vogell/ProPublica

Kennedy-Shields gives Adam a candy cane for doing something she asked. He crunches through it, holding it in his enormous hands and taking giant bites as if it’s a carrot stick. He moves on to a turtle lacing card.

He starts to whine and squeal, which can be a precursor to agitation. “Hey, excuse me,” Kennedy-Shields says, trying to quiet him. “Who loves you, baby?”

Adam settles down to play again. “This is my kid,” she says, “He should have stayed this way.”

He can fold laundry and do easy tasks like shredding paper. “He could have had supported employment,” she says. “What they did is they ruined his life. In every way, every way. They ruined mine,” she says, tears collecting in her eyes. “Because he should be like this all the time. This is what he’s like.”

Kennedy-Shields is girding herself for a trial in her case against Carlton Palms, which she expects will take place in 2016. She still doesn’t think she has seen all of Adam’s records, and her lawyers are trying to get Carlton Palms to turn over the rest.

She monitors Adam’s care closely now. Video cameras are mounted in full sight throughout his house. Rigged to her cellphone, she checks the feed several times an hour. “Any time, any day. In the middle of the night, I’ll just get up and look,” she says.

I ask Kennedy-Shields if Adam has ever hurt her.

When he first came back and went wild, she tried to hold his hands like she used to, to calm him. “His hands are so much bigger,” she says, remembering. He squeezed her finger too tightly, digging his nails in until it stung. He has hit her, too, while flailing his arms. But at those times he had that vacant stare, like the one she first saw at Carlton Palms. “When he hits me,” she says, “he has no idea who I am.”

He is not on antipsychotics. When he gets upset, his caregivers put a pillow in his lap—to keep him from banging his head on his knee—and back off.

He is not restrained, with one exception: His brother Noah sometimes grabs hold of Adam’s hands to stop him from harming himself. Noah is the only one who’s allowed to do that. Scars on Noah’s forearms serve as reminders of the desperate place where his older brother’s mind still goes.

“No one’s hurting him again,” Kennedy-Shields says. “Ever.”

Annie Waldman provided data analysis for this story