Saturday, November 22, 2014

Who Failed Adam Lanza?

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.

And also,

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.


Ignatius Acton Chesterton OCD said...

I wonder how much of this sad storyline was fueled by the threat of a lawsuits? Or, at very least, a fear of one. Between our litigious culture and all the mental health activists, we live in a paralyzed society, subject to the "Rule of Nobody" -- a vast bureaucracy and catalog of laws that protect no one and enable the worst and most clever among us (see Jonathan Gruber, et al).

What we have is a citizenry hamstrung, unable to respond effectively. We can't do what we need to do beacuse we don't have the time, nor expertise, required to go through the maze of legal wranglings, and the lobbying by single-issue activists. We hear "Careful, you might get sued," and we stop in our tracks. As a result, we are left vulnerable to the Adam Lanzas of the world, and powerless in facing down the Nancy Lanzas of the world. We assume "the system" we pay for has our back. It doesn't. It can't. It's a bureaucracy, and bureaucracies are rarely held accountable for failure. Instead, they just grow... more expensive, more unaccountable, more ineffective. And they produce reports, like this one.

Lanza's mother bought those guns. We cannot stop delusionsal parents from being sentimental about how "normal" their disturbed children are, or may become. Does anyone seriously believe that the average school counselor would stand up to Nancy Lanza's intransigence? No way. Adam's school performance masked his deep issues, and counselors have a couple hundred other students to manage. I do not say this to diminish the school counselor -- we all face a nameless, faceless "they," and come to the conclusion that resistance is futile. It is easier to do nothing. The alternative is to look at everyone as a psychotic risk, bringing on a different kind of bureaucratic paralysis.

We cannot possibly prevent these kinds of atrocities when parents are in denial, enabling their children, plying them with firearms. No "system" can stop that, no school, no mental health professional. The remedies (taking away parental prerogatives, enacting blanket gun control laws, passing more toothless legislation) are worse than the problem, and unfair to citizens who have their $#%& together. Sad as it may seem, this is part of humanity, and bad things happen. I'm sure the families of the Sandy Hook victims are going through another cold, sad holiday season, again asking "Why?" There's no satisfactory answer.

Who failed Adam Lanza? His mother. He killed her, too. But the bigger question is what allowed Nancy Lanza to resist efforts to support Adam for so long? I suspect it is the legalistic, bureaucratic system we've enslaved ourselves to. Who's accountable? In today's America, no one.

Anonymous said...

Laurie Dann. N.IL. in the 80s.

Psychotic, tried to kill her husband. an acknowledged threat to the community.

Her wealthy influential dad thwarted every attempt to deal with the danger.

Laurie shot several schoolchildren, then herself.

Dad lived on, unrepentant. -- Rich Lara

Ares Olympus said...

I hadn't thought about anorexia nervosa, assumed that was a girl's disease, and concern for appearances or control over one's body.

I imagined Adam's case was self-neglect, hours on the computer and video games, but here it sayshe was also addicted to some sort of dance (video?) game.

Part of me would prefer to limit second-guessing of his support. Or at least I imagine if you imagined a path of forced treatment, only justified after the fact, knowing what eventually happened, you'd end up with either identifying millions of other children with behavioral problems who will never participate in such shootings, and perhaps that's good, except for the fact that each of these millions will have their own special conditions and ideal treatment, so either you have to accept a need to spend hundreds of billions of dollars training more therapists and 24-hour life coaches to help these kids, OR assume a large fraction of them are dangerous and keep them confined in mental hospitals for the rest of their lives.

Its just hard to see what middle approach exists. My own approach of course would be to keep guns away from people who express feelings of rage, but who gets to decide? The smallest step would assume 99% of of gun wielding maniacs do NOT result in deaths, so if you're willing to allow the 1%, then you could say anyone threatening another person with a gun, whether fired or not, can be brought under the law, and be judged unstable, and barred from owning a gun.

But again, Adam is the 1% this won't work. He's like the suicide bombers, a rebel with a cause who's willing to die.

So if we can't get rid of the guns, then we just have to accept there's going to be maniacs out there who will kill others, and themselves, and that's unavoidable.

But a last question for me is how society should face mass murders. It seems possible and reasonable to categorically REFUSE publicizing ANYTHING about such killers.

I mean maybe like the way Israel dealt with the suicide bombers in years past, you pretend it was a natural disaster, people died, and you can morn the victims, and ignore the killer completely.

At least sucidal killers, it seems easier to ignore them, but harder if the killer lives, but even the court hearings perhaps could keep the killer's motives or narrative private, doing whatever it takes to dispossess the illusion that there can be any justification for mass murder.

I know, we all want to know why, and professionals need some second-guessing, and somewhere there is a middle ground, where you can catch 10% of the killers before they act, at the cost of liberty for 90% of those who feel rage but never express it in mass murder, or whatever proper hypothetical ratio we select.

It certainly is a lot of responsibility, and whatever authorities do, it will be judged wrong by someone.

Anonymous said...

Your analysis of the evidence is fine, but the evidence itself is very, very flawed.

Let me show you why.