When Adam Lanza gunned down children and teachers at the Sandy Hook Elementary School we asked why he had never received any help for his very obvious mental illness.
Some blamed it on the gun culture. For my part I asked why he and some of the other apparently psychotic mass murderers were not committed involuntarily to psychiatric institutions.
Now, a new report commissioned by the state of Connecticut suggests that the issues were more complicated. If we assume that this report is definitive it corrects some of my views. Thus, it is worth reporting.
The story has been covered in numerous newspapers. The story in The Hartford Courant seems to be the most comprehensive.
Where I and others assumed that Lanza was suffering from a psychosis, the study suggest other diagnoses, among them depression, obsessive-compulsive disorder and anorexia.
In truth, these descriptive diagnoses do not preclude a more important problem, something on the order of a brain disease or psychosis. Sometimes people suffering from a brain disease adopt certain symptoms in order to try to self-medicate or even to draw attention to their illness.
Clearly, Adam Lanza was anorexic. Clearly, anorexia affects brain function. And yet, anorexia has never, to my knowledge been associated with mass murder.
And, while Adam certainly demonstrated obsessive-compulsive symptoms, that condition has never, to my knowledge been associated with homicidal mania.
Most striking is the fact that while the mental health professionals who evaluated Adam recommended an aggressive course of treatment, his mother consistently refused to follow their advice, preferring to appease and mollify her increasingly violent son.
The Hartford Courant summarizes the findings:
A report released Friday by the Office of the Child Advocate pointed to the Yale episode as one of dozens of red flags, squandered opportunities, blatant family denial and disturbing failures by pediatricians, educators and mental health professionals to see a complete picture of Adam Lanza's "crippling" social and emotional disabilities.
The study paints a picture of a grossly irresponsible mother who colluded with school officials to ensure that her son’s illness not be treated. One might believe that mental health professionals have a vested interest in shifting the blame, but there is little evidence that Adam’s mother understood the nature of his problem or the need for treatment. Apparently, she ignored the advice of professionals.
Yet, when Adam did take the medication prescribed by one physician his condition did not improve; it deteriorated. Thus, his mother’s decision to reject psychiatric advice might have had some basis in fact.
Also, while some professionals were reasonably alarmed by Adam’s deteriorating mental health, others were willing to take his mother’s side, ignoring the problems or assuming that they would go away.
The newspaper report explains:
Nancy relied heavily on the advice of a psychiatrist who, in contrast with other clinicians, said that Adam would benefit from being away from school. It was the psychiatrist who said that Adam was a candidate for the homebound program, in which students who are medically or emotionally unable to attend school are tutored at home.
The report was highly critical of this move, stating that there was no evidence that the school had a treatment or education plan for Adam, and that there was no record that he even received the 10 hours a week of tutoring required.
"In the face of disabilities that were so significant as to apparently justify [Adam's] lack of attendance for the entire school year it does not appear that anyone questioned why, if he was so debilitated, he was never hospitalized or referred for specialized educational placement," the report said. "On a number of levels and on numerous occasions, the district did not follow appropriate procedures, monitor [Adam's] individual education plan … for goals and objectives, or document attempts to follow up with providers or the family regarding psychiatric or pediatric care."
Even if Nancy Lanza could not make her way through a thicket of differing expert opinions, she ought to have exercised far more caution and not allowed her son free access to an arsenal of guns.
The Hartford Courant continues:
February 2007, Yale clinicians identified in Adam Lanza what they believed were profound emotional disabilities and offered him treatment that they said could give him relief for the first time in his troubled life.
But Adam was angry and anxious, and he didn't want to go. His mother, Nancy Lanza, constantly placating her son, was inclined to pull away from the treatment, prompting a psychiatric nurse to reach out to his father, Peter Lanza, in an urgent email.
"I told Adam he has a biological disorder that can be helped with medication. I told him what the medicines are and why they can work. I told him he's living in a box right now and the box will only get smaller over time if he doesn't get some treatment."
Let us emphasize that the nurse insisted that Adam had a biological disorder and that the disorder needed to be treated. One wonders why the clinic had a nurse communicate with the boy’s father. Surely, a psychiatrist’s word would have carried more weight.
When, in middle school, Lanza went to see a pediatrician, the result was as follows:
For example, at the apex of Adam's increasing phobias and problems coping with middle school, he went to a pediatrician and was repeatedly prescribed a lotion to soothe hands rubbed raw by excessive washing and a laxative to ease constipation brought on by a dangerous loss of weight. Yet, the authors note, there was no effort during these visits to address the underlying causes. A visit to a hospital emergency room was cut short before there was a chance for clinicians to explore Adam's problems at greater depth and schedule him for long-term treatment because Nancy Lanza said that being at the hospital was making Adam anxious.
Do we really want pediatricians making psychiatric evaluations?
School officials did not do their job either:
At times, the report said, school officials in Newtown failed to comply with legal requirements in their handling of Adam. They also point to a chronic lack of communication and coordination among the various players involved with Adam's education and treatment, inside and outside of Newtown.
"The lack of sustained, expert-driven and well-coordinated mental health treatment, and medical and educational planning, ultimately enabled his progressive deterioration," the report said.
Today, the psychiatric profession believes that psychoses are brain diseases, not mental illnesses. Why was it that no one recommended a neurological exam?
Among the troubling omissions cited in the report, the authors reveal that Adam never underwent a neurological examination despite reported seizures and a diagnosis of obsessive-compulsive disorder and depression. Adam was repeatedly pulled from special education programs, therapy and schools at various times and was in the state's little-known homebound program with minimal oversight by school officials.
Early on, in what would become a recurring theme throughout much of his schooling, Adam's ability to perform well academically led to the perception that he did not need special education or additional therapy.
The report said that "neither the parents nor the educational system persevered to ensure that he received neurological follow-up, a comprehensive psychological evaluation or evaluation of his behavioral and sensory processing challenges." Such follow-up early on "might have clarified and deepened the understanding of his needs," the report said.
Responsibility does not only fall on Adam’s mother. School authorities should have seen that something was radically wrong and should have taken charge of the situation.
If Adam had been subjected to child abuse, school authorities would have been obliged to report the case to the proper authorities. In that case the child would have been treated without his mother’s consent.
The report suggests that authorities did not pursue the case more aggressively because Adam was being brought up in relative affluence. If he had been a poor child he might have been removed from his home. It is easier to accuse a poor parent of neglect than it is to do the same with an upper middle class parent.
The report also describes what happened on the two occasions when Adam could have received psychiatric treatment. In both cases his mother prevented it:
In Adam's two most significant opportunities for meaningful psychiatric treatment — an evaluation at the Danbury Hospital emergency room in September 2005, and a complete work-up by clinicians at the Yale Child Study Center in New Haven the following year — Nancy rejected expert advice in both cases and further isolated her son by keeping him at home and away from school.
At Danbury Hospital, she declined an extensive medical evaluation and psychiatric examination for Adam, who was suffering from overwhelming anxiety. Instead, she asked for a note excusing him from school indefinitely. When she didn't get her wish, she took Adam home.
At Yale in October 2006, a psychiatrist examined Adam at Peter Lanza's urging. The doctor noted Adam's "accelerating" social withdrawal and concluded that Adam suffered from obsessive-compulsive disorder and severe social disabilities and would benefit from intensive therapy. The psychiatric nurse at the center reached similar conclusions about what the clinicians were calling an "increasingly constricted social and educational world."
But Nancy pulled Adam out of treatment at the Yale center, saying that the diagnosis "didn't fit" and that her son didn't want to go to the sessions. The authors noted that a clinical report by the Yale team apparently never made it to Newtown High School and that Adam's educational planning at the school lacked any connection to the Yale findings.
A story of missed opportunities, with some fault lying with psychiatry, some lying with the school system, but a great deal lying with a mother who refused to accept that her son was ill.