The recently released report, Shooting at Sandy Hook Elementary School, from Connecticut’s Office of the Child Advocate offers a searing in-depth account of the holes in our mental health care system. The report is careful to point out that no causative link exists between their findings and the events at Sandy Hook. However, this in-depth investigation offers an opportunity, if we are able to hear and take action on its recommendations, to begin to fix a system that without significant attention may lead to an ever growing epidemic of serious mental illness.

I highlight 4 key points addressed in the 114-page report:

1. Early means early. When significant problems in social-emotional development are identified, the greatest investment of resources ideally should come well before age three. In this time period, when the brain is rapidly growing and changing,  opportunity exists to set development on a healthier path. The report states:

A review of information regarding AL’s early years with his family does not reveal any profound tragedies or traumas. However, records clearly indicate the presence of developmental challenges and opportunities to maximize therapeutic and intensive early intervention. These observations underscore the importance of parental and pediatric vigilance regarding children’s developmental well-being. AL was referred for early intervention late in his toddler years, when he was almost three. By this time, he presented with several developmental challenges, including significant speech and language delays, sensory integration challenges, motor difficulties, and perseverative behaviors.

I would also like to highlight the report’s important statement: “Research-based intervention to support improved sensory processing through occupational therapy is a critical service for these children.”

2. The problem is located not exclusively in the child, but in parent-child relationships. The report describes significant ongoing marital conflict, with Adam’s father described as a “weekend father” who was not involved in the emotional lives of his children. There is evidence that Adam’s mother might have had significant emotional illness. She was preoccupied with her own health and mortality despite the fact that her doctors reports do not show signs of physical illness.  While these findings do not represent “profound tragedies or traumas,” the story is one of a biologically vulnerable child with two parents preoccupied and emotionally unavailable.

When a problem is placed squarely in a child,  the relational nature of these problems may be missed. Perhaps by addressing the issues in the marriage and the mother’s mental health, room could have been made in their minds for thinking about the meaning of Adam’s increasingly disturbed behavior.

3. Need for collaborative care with adequate reimbursement. The report states:

Pediatricians’ offices must have resources to conduct comprehensive and ongoing developmental and behavioral health screening for youth, with appropriate reimbursement strategies to support this work.

 Children and their families should have access to quality care coordination, often reserved only for children with complex medical needs, but beneficial for children with developmental challenges and mental health concerns. Care coordination should facilitate more effective information-sharing between medical, community, and educational providers.

When people are stressed and vulnerable, they will share what is important only when they feel safe. Parents may experience terrible shame in the face of a child who is struggling and a marriage that is collapsing. Clinicians need to be reimbursed for time spent listening to parents. Time spent in coordination of care, a critical part of comprehensive treatment, also should be reimbursed.

4. Listening, not placing blame, will lead to meaningful change. The report concludes by emphasizing that it “in no way blames parents, educators or mental health professionals for AL’s heinous acts.” I remain hopeful that blame can stay out of the conversation. Already media coverage has focused on the one adversarial aspect of the report that suggests the school “appeased” his mother, perhaps because she was white and wealthy.

All the accumulated evidence points to extreme suffering in the Lanza home over many years; suffering that went unheard and unrecognized. Blaming the school or the mother is not only unhelpful but also diverts attention from the critically important recommendations in this report.

We are in the midst of an epidemic of violence and mental illness. The recommendations, particularly those I have outlined above, may offer a way off that path. I hope that those in a position to effect these changes will be open to listening. If this comprehensive report can be used to make substantive changes in the education, health care and mental health care systems, then some meaning may be found in the senseless, tragic loss of life at Sandy Hook.

Claudia M. Gold is a pediatrician who blogs at Child in Mind and is the author of Keeping Your Child in Mind.