On Monday, November 24, Dr Joseph V. Erardi, Jr, superintendent of the Newtown school district, responded to the report from the Office of the Child Advocate (OCA), released Friday, November 21, saying that his first thoughts go directly to the victims’ families.

“How can I offer any kind of assistance to families?” he asked.

The report was prepared in response to a directive from the Connecticut Child Fatality Review Panel to review Adam Lanza’s life prior to the commission of mass murder, and develop recommendations for public health system improvements. Failure of the Newtown schools to follow established guidelines and multiple examples of lack of coordination for services are among the many findings in the report.

The district practices referred to in the OCA report, Dr Erardi said, were from 5 to 15 years ago.

“That report was crying for communication at multiple levels, at multiple times, at multiple stages throughout the perpetrator’s school years,” he said.

 “I take full ownership for everything from April 2014 [when he took over as superintendent] for the recovery of this school district,” he said. “We have surviving children and staff on a variety of levels.”

The lesson from the OCA report must be better identification of student needs based on the chronology presented of the Sandy Hook perpetrator, according to Dr Erardi, Decision makers must be “proactive rather than reactive,” he said, “well in advance of what played forward in this community on 12/14.”

One reason he was interested in assuming the position of superintendent of Newtown Schools, Dr Erardi said, was his belief in the important elements of leading a district: all around partnership and communication.

“We have worked very hard for seven to eight months in allowing the voices of parents and partners to be heard, respected, valued, and weighed,” said Dr Erardi. “That is what is best for every youngster, not just those with special needs. Accessibility has been at a premium in my administration. We are available, accessible, and listening.”

Referring back to the OCA report, Dr Erardi said that he had felt very strongly that the authors of the report be given whatever was needed, as the investigation was underway. Indeed, the authors said that the schools had been completely accommodating, and even “humble,” during the investigation.

Dedicated to the 20 children who were killed on 12/14 at Sandy Hook Elementary School (SHS), and written primarily by Sarah Healy Eagan, JD, child advocate State of Connecticut, Office of the Child Advocate; Faith VosWinkel, MSW, assistant child advocate, Office of the Child Advocate; Julian D. Ford, PhD, Department of Psychiatry, Center for Trauma Recovery and Juvenile Justice University of Connecticut Health Center; Christopher Lyddy, LCS, COO Advanced Trauma Solutions, Inc; Harold I. Schwartz, MD, psychiatrist-in-chief, Institute of Living, Hartford Hospital; and Andrea Spencer, PhD, dean, School of Education, Pace University, the report from OCA on the shooting at SHS examines the life of shooter Adam Lanza from birth to his death, also 12/14, by his own hand.

On Friday, November 21, members of the media and other guests were invited to take part in a webinar/phone conference with the authors of the report. The Newtown Bee and staff from The Hartford Courant were also selected to take part in an additional pull-in telephone conference.

The authors of the report responded to questions from media, most of which focused on the initial summary of the report, key points, and key recommendations. Ms Eagan stressed that the purpose of the report was not to assign blame or causation for the events of 12/14, but to follow Adam Lanza’s developmental trajectory, “and what we can learn from this review.”

Throughout the 100-plus page report, the authors paint a picture of a lack of integration and coordination of services by the school, family, medical, and mental health providers, from the time Adam Lanza was very young until 12/14. Beginning with recommendations of early intervention while a toddler, at which time he “presented with several developmental challenges, including significant speech and language delays, sensory integration challenges, motor difficulties, and perserverative behaviors,” to his early adolescence and young adulthood when diagnoses of obsessive compulsive disorder (OCD) and extreme anxiety, as well as a suspicions of an autism spectrum disorder were repeatedly noted by experts, Adam Lanza’s life is portrayed as one in which educational focus was placed on curriculum, and professional mental health expertise  — most notably a Yale Child Study Center evaluation — was disregarded, with a profound lack of other services that may have contributed to a continued deterioration of Adam Lanza’s health. The picture is of an unbalanced relationship with his mother, and an increasingly distant relationship with is father and older brother over the years.

An Opportunity Missed

Adam Lanza’s was a life filled with constant movement in and out of schools and home settings for educational purposes, and one in which his mother, Nancy Lanza, appeared to fluctuate between seeking counsel and disregarding recommendations. Increasingly choosing to seclude her son from aspects of the real world that he found upsetting, the report suggests that Mrs Lanza, while having best of intentions, may have unwittingly drawn her son into a reclusive setting that the psychiatrist at Yale particularly warned against.

The 2006 Yale Child Study Center evaluation was done at the behest of Nancy and her then-husband, Peter Lanza, but indications that both medication and intensive therapy were advised to offset future adverse consequences were found unacceptable by Adam Lanza and his mother. It was an opportunity missed, said Dr Ford, who added, “Parents need to think of the mental health system as providing help for the whole family.”

“Beyond the impact of OCD symptoms on himself and his mother, we are very concerned about AL’s increasingly constricted social and educational world… We believe it is very important to reframe the discussion with school from issues of curricular content to much more urgent issues of how to accommodate Adam Lanza’s severe social disabilities…” the Yale psychiatrist writes in the report.

The authors of the OCA report, however, found no evidence that this psychiatric study, despite a signed release from his parents, ever found its way into Adam Lanza’s school files. Special accommodations continued to prioritize only Adam Lanza’s curriculum needs. In the November 21 conference call, Ms Eagan said “There was a effort by Mr Lanza to try to coordinate information sharing … some information was shared.” Authors found that a phone call between Adam’s school and Yale did take place, although the substance of that conversation is unknown.

Ms Eagan was quick to point out that the authors were sensitive about not linking autism and violence.

“This individual did have that diagnosis,” she said, but the authors found no support that his profile meant it would lead to “horrific acts.”

Numerous indications of “no documentation,” “no record” and “no evidence” of various communications or coordination of care between caregivers and schools throughout Adam Lanza’s school career pepper the report. An acquiescence by the school to recommendations by Nancy Lanza and a community psychiatrist for homebound schooling in his eighth grade year, considered to be the most restrictive of all school adaptations, does not follow protocol for review and monitoring.

The state must consider assertive review of considerations of removal [of children from the school setting} and better mentoring, said Dr Spencer. Ms Eagan added that the state should be auditing “who are the children on homebound, and what are the needs our system is not meeting.”

Aside from the seriousness of putting a child into homebound, said Ms VosWinkel, critical social interaction is lost for that child.

While engaged and seemingly interested in improving his future, the Lanzas appeared to not be aware of the magnitude of their son’s problems, said Dr Ford, and pulling Adam Lanza further away from the world was “a tragic mistake.”

“We have a lot of best practice guidelines,” Ms Eagan said, that offer up to date guidance for schools. There is a great deal of variability among schools, so far as how those guidelines are adhered to, she said, but not due to a lack of interest, care, or willingness on the part of staff and teachers. Special education is a hidden system issue, she said, with a high cost to implement properly.

It is essential to eliminate barriers to financial support, said Ms Eagan, and that providers have more flexibility to provide care to families, not just the child. She also recommended that better care can be provided children if schools can import mental or related services into the school setting. Services must support and respond to children and families, said Ms Eagan, efforts that seem time and again to have failed throughout Adam Lanza’s life.

The Stigma Of Mental Illness

The authors expressed concerns that classification of a student puts a child into a “slot,” with special education services then not addressing overlaying problems. The stigma of mental illness is such that families will overcompensate in order not to be labeled as such, said Ms VosWinkel. Ms Eagan noted that for a parent of a child like Adam Lanza, who was“profoundly debilitated by anxiety and OCD, that can by itself be a very isolating dynamic.”

Dr Schwartz agreed, saying “Stigma is one of the reasons people do not seek help and why families collude with individuals needing help. They don’t want to be recognized as having a disorder in the family,” he said. Internalization of stigmas by people with difficulties leads to feelings of shame and moral failure.

“Stigma is an enormous obstacle to recognition, assessment, and appropriate care,” he added.

In responding to questions surrounding Adam Lanza’s co-authoring of a “book” for a school assignment while a student at Reed Intermediate School, a story that reflected “a level of horrific violence” beyond what is considered normal for that age group, Dr Schwartz noted that there was no evidence of how the staff responded to that violence nor if the parents knew about the book. The report noted that “The Big Book of Granny” shows a child “deeply troubled by feelings of rage, hate, and (at least unconscious) murderous impulses.” 

The report asserts, however, that “No direct line can be drawn between a disturbing artistic representation at age 10 and a act of mass violence at age 20.”

Thinking About Guns

However, if addressing the safety of children, “How can we not be thinking about guns?” Dr Schwartz brought into the conversation. “In another country, without the ubiquitous presence of assault weapons, our kids would be safe,” he said. Easy access to firearms is a direct risk for use of those firearms, he stressed, and the single common denominator to mass shootings in the United States.

His comments repeated the authors’ statement early in the report. While not charged with examining the role of guns in the shootings at SHS, “The conclusion cannot be avoided that access to guns is relevant to an examination of ways to improve the public health. Access to assault weapons with high capacity magazines did play a major role in this and other mass shootings in recent history,” they wrote.

Dr Schwartz emphasized, though, that while severe mental illnesses are distributed uniformly across populations, few commit acts of horrific violence.

“The rate of gun violence varies according to access to guns,” he said, and the presence of assault weapons and high capacity ammunition is a public health concern.

A Theme Of Disconnection

Although repeatedly pointing out deficiencies in coordination and follow-through for Adam Lanza’s education, the report did note that school staff felt they were doing what was best for Lanza’s educational outcome, and that it is clear that more training and support is essential for teachers and staff to recognize and address mental health issues in young people.

What stood out for Mr Lyddy with this case, was that the Lanzas communicated often with the school system, but a positive outcome for their son was not within the understanding or reach of either party.

“The real learners here,” said Mr Lyddy, “are the systems.”

Dr Ford acknowledged that one take-home message from this report is the consistent theme of disconnection.

“Adam Lanza and his family disconnected from himself and services, and service providers, including the schools, also disconnected,” Dr Ford said.

“There were not perfect services for [Adam Lanza] in this world. There was a significant lack of developmental services in the community for developmental challenges,” Ms Eagan concluded.

Newtown’s Superintendent of Schools hopes readers of the report will take away from it is how vitally important it is that every school district has mechanisms and partnerships in place to know the most complex students, staff, and community members.

Dr Erardi acknowledged how painful the release of the report is for those affected by the tragedy.

“My heart and my help continues to be front and forward to anyone who is recovering from this incident,” he said.