The Office of the Child Advocate (OCA) of the State of Connecticut released a report Friday, November 21, focusing on Sandy Hook Elementary School (SHS) mass murderer Adam Lanza. The report defines lapses in integration of education and health care, and how untreated mental illness contributed to Adam Lanza’s overall decline.

Directed by the State Child Fatality Review Panel (CFRP), in late January 2013, the OCA was asked to investigate “the circumstances leading to the death of the children at Sandy Hook, with a focus on any public health recommendations that may emanate from a review of the shooter’s personal history.”

CFRP reviews unexpected deaths of children in the state.

The report is an in-depth review of records relating to Adam Lanza’s life, from early childhood through early adulthood, when he killed himself after shooting his way into SHS on December 14, 2012, and taking the lives of 20 children and six educators there.

“OCA reviewed thousands of pages of documents, consulted with law enforcement and members of the Child Fatality Review Panel, conducted interviews, and incorporated extensive research to develop the report’s findings and recommendations,” according to the report.

Key findings of the report include that Adam Lanza presented with significant developmental challenges from earliest childhood, including communication and sensory difficulties, socialization delays, and repetitive behaviors, while living with his mother, father, and older brother in New Hampshire.

After moving to Connecticut, Newtown’s school district provided special education services to Adam Lanza while a student at SHS and Reed Intermediate School, “but services were limited and providers did not identify any communication or social-emotional deficits.”

“Social-emotional challenges” increased for him after fourth grade, although the report notes as well that Adam Lanza’s school records indicate he was “well-liked” by his peers in fifth grade. The report also includes a letter from Nancy Lanza, his mother, to SHS at the end of grade four. Adam Lanza had been exited from special education at this point, but Mrs Lanza asked that the school continue to consider his educational plan going forward and consider the selection of a “nurturing” teacher for him in fifth grade.

Key points also include indication of early preoccupation with violence, most notably in a comic book-style assignment he co-authored in fifth grade, “The Big Book of Granny.” The “graphic writing appeared to have been largely unaddressed by schools and possibly by parents.”

In eighth grade, Adam Lanza was placed in homebound educational status at his mother’s request, due to increasing anxiety he was experiencing. The report indicates that the “district provided little surveillance of [Adam Lanza’s] homebound status, which lasted an entire school year.”

“Recommendations from the Yale Child Study Center, where [Adam Lanza] was evaluated at age 14 (his 9th grade year), offered prescient observations that withdrawal from school and a strategy of accommodating [Adam Lanza], rather than addressing his underlying needs, would lead to a deteriorating life of dysfunction and isolation,” is yet another key point brought out in this report.

“Medical and education records reflect repeated reference to [Adam Lanza’s] diagnosis of Autism Spectrum Disorder, Anxiety, and Obsessive Compulsive Disorder,” the report states.

Further special education and therapeutic support, as well as taking prescribed medications, were recommendations that were not implemented.

A plan to return Adam Lanza to the school setting in tenth grade was not successful. He eventually finished school through independent study, tutoring, and classes at a local college.

“Records indicate that the school system cared about [Adam Lanza’s] success but also unwittingly enabled Mrs Lanza’s preference to accommodate and appease him through the educational plan’s lack of attention to social-emotional support, failure to provide related services, and agreement to his plan of independent study and early graduation at age 17,” is a key point emphasized in the report.

While Adam Lanza exhibited symptoms of Autism Spectrum Disorder and was diagnosed as such, “The likelihood of an individual with Autism Spectrum Disorder or severe problems with anxiety and obsessive-compulsive tendencies committing an act of pre-meditated violence, much less one of [Adam Lanza’s] magnitude, is rare,” according to the authors of this report.

Medical records do not show a need for mental health treatment, and his adult medical records “do not reflect awareness or diagnosis of ongoing mental health issues.” The report indicates a deterioration of his social, physical, and mental health in the last years of Adam Lanza’s life.

He ceased communication with his father, in 2010, and became “increasingly preoccupied with mass murder…”

He was involved with both parents (separated since 2002 and divorced since 2009) in recreational shooting, and had access to firearms and high capacity ammunition magazines in the home.

Mrs Lanza’s plan to move from Sandy Hook in 2012 may have exacerbated Adam Lanza’s fears of leaving the comfort zone of the home where he had isolated himself, following which Adam Lanza planned and executed the massacre at SHS.

The key points of the OCA report conclude: “In the course of [Adam Lanza’s] entire life, minimal mental health evaluation and treatment (in relation to his apparent need) was obtained. Of the couple of providers that saw Adam Lanza, only one — the Yale Child Study Center — seemed to appreciate the gravity of [Adam Lanza’s] presentation, his need for extensive mental health and special education supports, and the critical need for medication to ease his obsessive-compulsive symptoms.

“This report suggests the role that weaknesses and lapses in the educational and healthcare systems’ response and untreated mental illness played in Adam Lanza’s deterioration.” The report stresses that “No direct line of causation can be drawn from these to the horrific mass murder at Sandy Hook.”

Recommendations include improved screening and evaluation of children from very young ages, with outside expert evaluations “available to inform clinical and educational decision-making.”

Care coordination and information sharing among medical, community, and health providers; improved training of teachers, administrators, related service personnel, pediatricians, and parents concerning mental health issues; family focused support systems put into place; the integration of schools and mental health providers; less focus on “primary disabilities” and “more holistic approach to identification for special education eligibility”; and a need to increase expertise and services for children with developmental and mental health issues are further recommendations elaborated upon in the OAC report.

The full report can be viewed here.