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SHOOTING AT SANDY HOOK ELEMENTARY SCHOOL

REPORT OF THE OFFICE OF THE CHILD ADVOCATE

November 21, 2014

DEDICATION

The authors of this report submit this work with acknowledgement of the 27 individuals murdered on December 14, 2012, and the terrible and incalculable loss suffered by all victims. Authors convey condolences for these losses and the grief that continues to be felt by the victims, families, and the community. We acknowledge and honor the lives of the twenty first graders who died at Sandy Hook Elementary School; they have been the sole reason for this report.

Avielle Ana

Allison Benjamin Caroline Catherine Charlotte

Chase Daniel Dylan Emilie Grace Jack Jesse Josephine Jessica James Madeleine Noah Olivia

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STATEMENT FROM THE AUTHORS

In January, 2013, the Office of the Child Advocate was directed by the Connecticut Child Fatality Review Panel to prepare a report that would focus on Adam Lanza (hereinafter referred to as AL), and include a review of the circumstances that pre-dated his commission of mass murder at Sandy Hook Elementary School. The charge was to develop any recommendations for public health system improvement that emanated from the review. Authors of this report focused on AL's developmental, educational, and mental health profile over time, the services he received from various community providers, and ultimately his condition prior to his actions on December 14, 2012.

Authors looked for any warning signs, red flags, or other lessons that could be learned from a review of AL's life. It was not the primary purpose of this investigation to explicitly examine the role of guns in the Sandy Hook shootings. However, 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. Our emphasis on AL's developmental trajectory and issues of mental illness should not be understood to mean that these issues were considered more important than access to these weapons or that we do not consider such access to be a critical public health issue.

It is important to state at the outset that this report is crafted with recognition of the lives lost on December 14, and authors have a deep sense of compassion for the families of the children and adults who were murdered by AL. To honor the terrible loss of life, authors strove to create a comprehensive and candid report that we hope will inform approaches to making other children, families, and communities safer in the future.

This report will identify missed opportunities in the life of AL. Authors underscore however that only AL was responsible for his murderous actions at Sandy Hook. There can be no direct line drawn between one entity or person's actions and a mass murder. This report cannot and does not answer the question of "why" AL committed murder. This report focuses on how to identify and assess youth from a very young age, the importance of effective mental health and educational service delivery, and the necessity of cross-system communication amongst professionals charged with the care of children.

Additionally, because the work of this report tracks AL from birth to the mass shooting the authors described AL in what appear to be human terms. Authors acknowledge that the telling of AL's story may be painful for some readers, especially those irrevocably harmed by his terrible actions. However, the report required a review of AL's life to address interventions and services that could have and should have been delivered over the course of his life. This report does not seek to draw any link between mental illness and violence, or between persons with autism and violence. As stated later in the report, there are millions of individuals with mental illness or developmental challenges in this country and worldwide, and a very small percentage of these individuals will engage in any act of violence, much less violence on a horrific scale. AL was an individual with mental illness and he was an individual who was diagnosed as having Autism Spectrum Disorder. This report outlines this story and makes recommendations accordingly. It is vital to note that AL was completely untreated in the years before the shooting and did not receive sustained, effective services during critical periods of his life, and it is this story that the report seeks to tell. .

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Table of Contents

ACKNOWLEDGEMENTS ..........................................................................5

EXECUTIVE SUMMARY ..........................................................................6

INTRODUCTION

........................................................................12

ADAM LANZA'S EDUCATION, MENTAL HEALTH, AND DEVELOPMENT

Early Years ..............................................................................................15

Summary and Recommendations ......................................................................21

Elementary School.......................................................................................24

Summary and Recommendations......................................................................31

Middle School.............................................................................................36

Summary and Recommendations.......................................................................44

High School ..............................................................................................48

Summary and Recommendations.......................................................................80

2010 to 2012..............................................................................................96

FINAL STATEMENT................................................................................106

APPENDIX............................................................................................109

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ACKNOWLEDGEMENTS Many individuals contributed to the development of this report.

Primary Authors Include Sarah Healy Eagan, J.D., Child Advocate State of Connecticut, Office of the Child Advocate Faith VosWinkel, M.S.W., Assistant Child Advocate, Office of the Child Advocate Julian D. Ford, Ph.D, Dept. of Psychiatry, Center for Trauma Recovery and Juvenile Justice University of Connecticut Health Center Christopher Lyddy, L.C.S.W., C.O.O., Advanced Trauma Solutions, Inc. Harold I. Schwartz, M.D., Psychiatrist-in-chief, Institute of Living, Hartford Hospital, Connecticut Andrea Spencer, Ph.D., Dean, School of Education, Pace University

Additional Contributors Include Kirsten Bechtel, M.D., Yale New Haven Hospital Kathleen Costello, MSW Candidate, University of Connecticut School of Social Work Jeffrey Goldberg, Copy Editor James W. Loomis, Ph.D., The Center for Children with Special Needs, Glastonbury, CT Felicia McGinniss, Law Student, University of Connecticut School of Law Michael D. Powers, Psy.D., Director, CCSN: The Center for Children with Special Needs & The Center for Independence, Glastonbury, CT Colleen Shaddox, Communications consultant Paul Weigle, M.D., Child and Adolescent Psychiatrist, Natchaug Hospital

Additional Acknowledgements The Office of the Child Advocate would also like to extend thanks to the following individuals and organizations for assisting with the development of this report: Connecticut State Police Federal Bureau of Investigation Members of the State Child Fatality Review Panel Nina Rovinelli Heller, Ph.D., Professor, University of Connecticut School of Social Work Patricia Llodra, First Selectwoman, Town of Newtown State's Attorney's Office, Judicial District of Danbury U.S. Attorney's Office, District of Connecticut

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