On a sweet, sunny spring Tuesday, children across the state were preparing for summer break, feeling that giddy rush that comes to kids in those last, loose days of the school year when unstructured hours of summer fun spool out before them.
Then came a dispatch from a small city in South Texas on May 24 that would devastate and disorient the entire country — again.
"At approximately 11:32 a.m. this morning, there was a mass casualty incident at Robb Elementary School in Uvalde, Texas. This school has children that are in second, third and fourth grade. I can confirm right now that we have several injuries, adults and students, and we do have some deaths," said the now disgraced former Uvalde CISD Police Chief Pete Arredondo.
He was later fired after scrutiny of the law enforcement response to the shooting revealed a delayed and disorganized response for which he bears the blame.
In the hours after the shooting, Arredondo explained that 19 children and two adults — fourth graders and teachers — were targeted, trapped in their classrooms and massacred by a young man who had once walked those very halls as a fourth grader himself.
"The suspect is deceased at this point. DPS is assisting with the investigation,” he said. "And at this point, the investigation is leading to tell us that the suspect did act alone during this heinous crime."
Salvador Ramos acted alone. The 18-year old was a former Uvalde student who started in kindergarten with this year’s graduating class of seniors, but was involuntarily withdrawn from the district in 2021 for poor grades and attendance. Despite being 17 at the time of the withdrawal, he had only completed ninth grade.
"Evil swept across Uvalde yesterday," said Gov. Greg Abbott the day after the massacre.
"Before coming out here, we had a long discussion with law enforcement at all levels. We had a discussion with community leaders, elected officials. And I asked the sheriff and others an open-ended question and got the same answer from the sheriff as well as from the mayor of Uvalde," Abbott said.
"The question was,” Abbott continued, “what is the problem here? And they were straightforward and emphatic. They said, ‘we have a problem with mental health illness in this community.’ And then they elaborated on the magnitude of the mental health challenges that they are facing in the community and the need for more mental health support in this region."
That was a polarizing statement, for many reasons.
In spite of his call of the need for mental health support, Abbott himself cut $211 million from the department that oversees mental health programs in the state in April 2022.
Uvalde is a city of 15,000 people about 80 miles from the Texas border with Mexico. It is a mostly rural area, and one-fifth of the population of 24,456 Latino residents live in poverty. In recent years, Uvalde County received budgeted funds of $2.8 million to $3.8 million for health and welfare.
Additionally, Texas is a state that has more guns per capita than any other state.
In the nearly two months between May 14 and July 4 of this year, three young men took high capacity, magazine fed, semi-automatic, high velocity firearms — assault rifles — and shot them into crowds of innocent people, killing 38 people in total.
These men weren’t driven by mental illness in the way experts typically think of it.
They weren’t experiencing the types of hallucinations or delusions one might associate with schizophrenia. They weren’t driven by depression or an anxiety attack. They weren’t in the grip of a manic episode one might associate with bipolar disorder. They had planned their attacks meticulously. They weren’t having psychotic breaks.
People with these types of mental health challenges are far more likely to be victims of violent crime than to commit one. Research shows that less than 10% of shootings involved a perpetrator with mental health issues.
So what role does mental health play in these shootings, and does the lack of access to mental health care across the country make future mass shootings more likely?
Learning from the school shooting database
In the days after the massacre in Uvalde, the Texas legislature created a three-member legislative committee to investigate the Uvalde shooting.
On July 17, the committee gathered in Uvalde to share their conclusions.
State Rep. Dustin Burrows, the chairperson of the committee, pointed first to “multiple systemic failures."
At nearly 80 pages, the hefty report attempted to account for everything — from which doors at Robb Elementary were locked to details of the law enforcement response.
Related: Texas House report blames local, state and federal officers for 'systemic failure' in Uvalde
"I think some of the same systems that we found here that failed that day are across the entire state and country,” Burrows added. “I do not want to say because of one thing or one person here, it could not happen elsewhere. I think that's a disservice and not the respectful thing to do."
At the center of the report were ten pages examining the life of the shooter — his childhood, family, schooling, and his ultimate deterioration into a man who fit nowhere and whose rage influenced his actions.
Burrows and the committee surmised that the killer fit the profile. The broken home and dysfunction of an estranged father, the struggles in school, the social isolation from peers were the hallmarks of that profile, but also of Ramos’ life.
However, he networked with peers the way so many kids do today — online — through social media and violent video games. Burrows said that he “ultimately had a fixation on school shootings and even developed the nickname ‘School Shooter.’ "
Burrows’ brief summation depicted a staggering series of missed opportunities for intervention that began for Ramos very early on in the fourth grade.
The fourth grade classrooms were where Ramos focused his killing spree.
Burrows said Ramos fit the profile of many others who have plotted and executed plans to murder others in schools, churches, synagogues, grocery stores and other places where many unsuspecting people gather. If these profiles are part of a pattern, what interventions can society impose to keep the next troubled child from becoming a school shooter?
David Riedman is the founder of and a researcher for the K-12 School Shooting Database. He established the database in 2018 after the shooting in Parkland, Florida.
At the time, he was in a think tank program at the Naval Postgraduate School. The program worked to create solutions for emerging homeland security issues.
“When the Parkland shooting occurred, it was evident that there were a lot of warning signs that were missed, and they were missed because people didn't have the tools to recognize them and know which actions to take,” Riedman said.
The K-12 School Shooting Database tracks a variety of factors, from what time active shootings most commonly begin to where they most commonly take place. Reidman also works with the Violence Project, which explores the shooters’ backgrounds, their guns and their motivations.
"Uvalde follows a pattern that unfortunately is very similar to other school shootings and mass shootings in general," he explained.
Riedman outlined the pattern: "Somebody has a standard life course where you go through an expected evolution of events. And as you move from one step to the next, you're raised in early childhood by a nurturing family.”
Going to school moves the person to connections with others outside the home. “At school, you learn to make friends,” he said.
After a student graduates, they might go to college or else find a job. “There's a very linear evolution,” Riedman explained. “And when things break down, it creates unresolved conflicts and then people go down a path of deviance."
What about the person who goes down a path of deviance early on — in the school stage? "What we see, looking at the life histories of these mass shooters and especially Uvalde,” he said, is that “their life course goes wrong from the very start.”
He also believed the Uvalde shooter had unresolved childhood trauma. Reports indicated that the gunman's mother was abusive, that she used illegal substances, that she had a boyfriend who may have sexually abused the shooter at a very young age.
“He had told his mother about that and she didn't believe him," Riedman added.
The state’s report explained all of this. Reidman said, for some people, similarly unresolved trauma can lead to a crisis, and at that crisis point, a person with Ramos’ history might start blaming others.
"And it appears that the blame he was directing was at his fourth grade class, in his fourth grade classroom,” Riedman explained.
The gunman experienced bullying during that grade. He developed a speech impediment. Learning disabilities became evident. He fell behind. He began isolating from his peers. The state report said his fourth grade year at Robb Elementary School was indeed significant to him. It explained that he discussed bad memories of fourth grade with an acquaintance just weeks before the shooting.
Riedman believed that Ramos fixed blame on his fourth grade classroom. “Then they fixate on that, and they fixate on it, (saying,) ‘I have to do something about this. I'm going to commit an attack there.’ And they begin kind of planning towards this attack. And they think the only way to resolve all of these problems and all of these issues that derailed the life force is this public attack."
The shooter’s challenges were not the fault of his fourth grade teachers or classmates or anyone at the school. They were certainly not the fault of those children and teachers he so mercilessly murdered.
But understanding how he came to have this violent fixation is essential to stopping the next massacre and the next one, Riedman said. "Unfortunately, it's that same pattern of trauma crisis, blame, fixation, eventually leading to violence because nobody intervenes. That plays out over and over."
How and when to intervene?
According to the state’s investigation, the gunman's pre-K teacher found him to be “a pleasure to have … a wonderful student … always ready to learn.” She described his “hard work and positive attitude in the classroom.”
But by third grade, the school had already identified him as “at-risk” due to consistently poor test results.
And in fourth grade, the state’s report detailed his experience with bullying over his stutter, his clothes and his haircut. His fourth grade teacher testified that she thought she’d handled the situation effectively and that he’d made friends. His family reported that he didn’t.
And there was no record of Ramos receiving academic or any other kind of services, even though he was clearly in need of educational and emotional support by the time he was in the fourth grade.
Ramos had started sliding off the expected life course — that pattern Riedman described — and was careening toward a terrible conclusion.
By 2018, Ramos had accumulated more than 100 absences in one school year. The state is required to intervene when a child has missed that number of days of school, but the report said it was unclear whether any school resource officers ever visited Ramos’ home.
How did Ramos fall through the cracks? Dr. Barbara Robles-Ramamurthy, a psychiatrist at UT Health San Antonio, said this sort of precipitous descent happens all too often.
She explained that "50% of mental illness begins by age 14. Only about 50% of kids who need mental health treatment are getting it. And this number likely is worse in rural communities with more limited resources."
She added that when kids do have access to treatment, it doesn’t always come from specialized providers trained to treat children and families.
Another issue emerges when the child and family fail to complete treatment. “Even if they come to us as specialized providers, we know that most of them are only going to stick around for one or two or three visits,” Robles-Ramamurthy added.
She admitted that she did not work on this particular case, but she works with kids in the juvenile justice system, and she grew up in South Texas, in a town similar to Uvalde.
Robles-Ramamurthy explained that kids who end up in the justice system, or end up hurting themselves or others, don’t just wake up one day and decide to be violent, and they weren’t born evil either.
Every child she works with has a history of adverse childhood experiences. The idea of “adverse childhood experiences” encompasses physical, emotion, and sexual abuse, as well as neglect of all kinds.
For example, she said, "it can be physical or emotional neglect. It can be having a parent with a severe mental illness that cannot provide that parenting and support that a child needs. It can be parents having substance use issues. They can be experiencing intimate partner violence or family violence and other forms of community violence."
Some people may counter that a lot of kids are bullied. A lot of kids have adverse childhood experiences. They don’t all necessarily buy an assault rifle and kill people.
"Most kids are not going to pick up a gun and go and shoot multiple people at a school or another public place,” Robles-Ramamurthy admitted. But a lot of kids are picking up guns, too, unfortunately, and a lot of adults are picking up guns. … But gun violence is a public health concern in our country that cannot be ignored."
Kids who are in these situations often have nowhere to turn. The mental health system is part of a health care system that can be really hard to navigate, especially in communities that don't have appropriate support and resources.
The mental health field is trying to expand its reach to increase the mental health competency of people who are in frequent contact with children, according to Robles-Ramamurthy. That means primary care doctors, pediatricians, and even teachers.
This is especially important in rural areas like Uvalde, where mental health professionals have been few and far between, and someone may have to drive for hours to see one.
According to the Texas Department of Health and Human Services rankings for 2022, Uvalde had one mental health care provider for every 1,780 people. The best performing counties in the United States have one provider for every 250 people.
Rural areas across the country have numbers similar to Uvalde’s 2022 numbers. They’re what’s known as “mental health deserts,” and troubled kids may have to suffer for months or a year or longer before getting in to see a mental health professional.
Uvalde’s numbers will certainly improve in next year's HHS survey, because resources have flooded the county since May 24.
But what about everywhere else?
"It’s something that needs to be addressed in rural communities, not just in Texas, but in other states, too. We don't have the services that we need," said Uvalde Mayor Don McLaughlin.
Mental health deserts
McLaughlin has been a lightning rod for controversy. He’s a conservative partisan who’s appeared on Tucker Carlson’s show on the Fox news network and tried to shout down Beto O'Rourke, the former El Paso congressman and current Democratic gubernatorial candidate, when he interrupted Abbott’s news conference the day after the massacre.
On the sweltering, late summer day he spoke to TPR, he prepared to announce plans for the construction of a community center for kids that would give them a place to go and participate in all kinds of activities.
The mayor believes building community can be a key component to improving mental health.
When asked about what the governor said at that news conference about the town's mental health needs, McLaughlin added that “the governor said, the day after the shooting, that officials involved said this occurred because there were unmet mental health needs. Still is. Mental health has been a problem everywhere. Mental health is not 100% of the problem, but it's a problem. And it's a problem up until before the shooting.”
He added that prior to the Uvalde shooting, there were only two mental health counselors to cover five counties. “So these people get missed," he explained. "They don't have the services they need. They don't have the help they need."
Texas ranks last in the United States when it comes to access to mental health care.
"Right now,” McLaughlin said, “if we have somebody that we have to take to a bed, we may have to go as far as Texarkana, Texas, to find a bed available. You know, that's a 13-hour drive from Uvalde. (Abbott) said he hopes this tragedy 'will bring awareness both to the gun side of it and to the mental health side of it.' "
Texas is also last in the country in the number of people insured. Furthermore, 14% of Texas children with health insurance have no coverage for treatment of mental or emotional problems. That puts Texas in 48th place in national rankings. The state moves to 50th when it comes to the ratio of mental health providers to people -- with 830 people for every one mental health care provider, according to Mental Health America.
The numbers are even more grim in rural areas. Seventy-five percent of rural counties across the United States have no mental health providers, and Texas has the highest number of counties with no mental health care providers, according to an ABC News analysis of Centers for Medicare and Medicaid Services data.
They’re called “mental health care deserts.”
According to Keith Herman, a professor at the University of Missouri and co-director of the Rural School Mental Health Center, “people in rural settings are more dependent on their schools for identifying mental health needs and then providing services in schools. And we know that creates challenges for schools because a lot of educators aren't prepared to provide that type of support.”
The idea of improving the mental health competency of the people who see kids every day is difficult, because teachers are already overworked and overwhelmed, especially as they deal with the ongoing impact of the COVID-19 pandemic.
Teachers in both rural and urban settings are stressed. A lot of that stress is related to the daily workload. So to address supporting children with mental health issues is a matter of feasibility and what can be reasonably expected of teachers.
Which is why, Herman said, he stresses the importance of preventative work with kids in elementary school and providing “safe, effective environments at school where all kids get access to more positive interactions with adults.”
Herman also promotes training teachers to look for certain signs in elementary school kids that may be indications that a child is starting to slide off a healthy path and may need some support. Mental health concerns common in youth include anxiety or depressive disorders.
Herman added that warning signs are readily identifiable by behaviors that teachers and other school personnel can be alert to. He said one observable sign comes when the student begins to struggle academically.
"That can set kids up on a trajectory not only for academic failure,” Herman explained, “but for enduring behavior problems, enduring emotional problems and regulation problems."
So if a teacher notices a child is starting to struggle, what is the next step?
“That is one of the challenges," Herman admitted. "If you're going to do screening, you need a plan for when kids emerge in fourth grade, fifth grade, sixth grade.”
There need to be effective protocols in place then, he explained. “Are you going to be able to service them in your own building? Or what's your network of support that you're going to provide by perhaps contracting with … agencies outside your region who might be able to provide telehealth services or other types of support?"
Other barriers to mental health care that exist everywhere but are more keenly felt in rural areas are the lack of insurance, lower income than in urban areas, lack of trust in the health care industry, and stigma.
The stigma
Herman lives in Missouri. The state has mental health access centers that are one-stop shops, essentially, for diverse mental health care needs. One of the centers is in an urban area. Rural clients had to drive some distance to get there, so satellite offices were built in the rural areas.
But once this easier access was provided, the families from the rural areas did not want to access services in the satellite offices closer to them. They preferred to go into the city. Herman said they preferred the anonymity despite having to travel a longer distance.
“Even though stigma can be a fairly universal experience,” he explained. “There's unique aspects of stigma that someone in a rural setting might have because of people getting in their business.” He added that “rather than being more open to doing it as a resource, it becomes more as a burden” because of the stigma.
And in places like Uvalde, specifically, which is more than 80% Latino, Robles-Ramamurthy said there may be cultural reasons for the sense of stigma.
She said, “Latinos do have some cultural barriers that impact the way that we access care or stay in treatment. But I want to preempt that by saying that our nation has a problem with stigma.”
In many Latino households, she added, there is shame in what she called “putting your family’s problems out there.”
"In Spanish we say, 'los problemas de la familia se quedan en casa.' The family's problems stay at home," she said.
And then there’s the sense of guilt that all parents get when they feel like they’re failing their child. It is the idea, she said “that as families, as parents, we should be able to deal with our children's behavior.”
But even if a person from a Latino household was to overcome their shame, their guilt, the stigma, another issue that hampers support for Latinos is racism and experiences of discrimination in health care.
Robles-Ramamurthy pointed to research that showed that 20% of Latinos reported experiencing discrimination in health care appointments and in clinical settings.
This treatment can deter an already vulnerable population from following up for support and care.
How do these factors affect boys, since most mass shooters are male? "We know that the stigma is severe for boys and men to access and receive mental health care,” Robles-Ramamurthy explained, citing generational systems of oppression.
"We cannot isolate boys’ and men's mental health from other systems of oppression,” she said. She added that notions of “sexism and misogyny” influence their world view and that these systems place a “burden on men to act a certain way to behave in certain ways.”
Vulnerability plays a role in their ability to say, ‘I need help, this is not working.’” Robles-Ramamurthy explained. “We have to expand their ability to see their options in the world as more than just what they have been told is possible."
Back to school
Related: This teacher survived the Uvalde shooting. Here's why she is returning to the job
Nicole Ogburn was in her fourth grade class at Robb Elementary School on May 24. She saved her students and herself by escaping through their classroom window.
“So we had to open a window with bullet holes and glass everywhere to get out,” she recalled. “And when we opened it, there were just, I don't know how many officers outside pulling us out the window. We put a chair, we jumped, we were just filing kids out the window as fast as we could.”
She spoke with Juana Summers with NPR’s All Things Considered just before the school year started. She was preparing her new fourth grade classroom in a new building called Uvalde Elementary. She thought with trepidation about the year ahead.
“Am I gonna still be able to keep my composure when those kids come in and have an anxiety attack over being here at school and feeling scared?" Ogburn asked. "Am I gonna be able to handle that? And I hope I am, but I'm not sure.”
And despite the resources that have come to Uvalde since the May shooting, she’s not the only one fighting extreme fear. Mental health is on everybody’s mind there.
“Every day,” she said, “you kind of want to know … how your kids are feeling, because sometimes that can gear how your lessons are gonna go or how that child may just need to be by themselves that day. …”
Ogburn showed NPR her classroom, which included a piece of black poster board bordered with bright, confetti-like polka dots and plastic pockets for little gingerbread people, one for each student.
Related: Uvalde students return to school for the first time since May’s deadly shooting
The children are able to select a gingerbread person with an expression that conveys their feeling for that day or that moment. “So this is just kind of our way of seeing how they're feeling for that day," she explained. "So maybe if we just need to take that moment, we can, with them.”
Social-emotional learning helps kids identify what they’re feeling and teaches them the language that will help them express themselves throughout their lives. This includes their needs, worries, hopes, and fears.
“I know the first few weeks, I'm sure they're all gonna be pretty scared and anxious,” Ogburn said, but then throughout the year there will be other emotions and “everyday family life things happening.”
This is akin to the screening Herman described. Teachers can take their students’ emotional temperatures. It’s also something Josh Knutson has tried to replicate with the RHITHM app, which will also be available to students in Uvalde.
“RHITHM is a wellness check-in tool,” he explained. It’s an app that can check students' emotional wellness across several categories — mental, emotional, physical, social — and it's all emoji based.
It takes 30 seconds to a minute to complete it. The system is set up to launch in-the-moment individualized, adaptive care, and elements of content that actually help students develop some of those soft skills and prepare to engage in class — all under two minutes.
“Because in order to really sit down and learn, the thinking parts of my brain need to be turned on,” Knutson said. "And the way the brain works, the way my body works, the way the nervous system works, is that if I'm not regulated, if I'm angry, if I'm anxious, if I'm hungry, if I'm just excited … the activation of my brain shifts to different emotion centers, and it reduces activation in the thinking and learning sense.”
In the context of learning, this sort of emotional regulation becomes fundamentally important for a student.
RHITHM also shares check-in information with teachers so they can track who might be feeling sad or angry. “Being able to identify students as human people that are experiencing challenges earlier up the chain,” Knutson said, “I think it can be a major preventative mechanism.”
But what can be done for a child identified as needing a little more help, particularly in areas where mental health resources are limited, in those mental health care deserts?
In Texas, some school districts have a program called TCHATT — Texas Child Health Access Through Telemedicine.
Laurel Williams, a professor of child and adolescent psychiatry at Baylor College of Medicine and part of the Texas Child Mental Health Care Consortium, oversees the implementation of TCHATT across the state.
She explained that “whenever a young person is identified who has needs that are beyond what a counselor could assist them with, they can, with the parents’ permission, make a referral for our health care team to talk to the parent, get a consent, and then provide an assessment for the for the family.”
It sounds like telemedicine — like a Zoom meeting with a doctor — so distance would not be a factor in this option for care.
TCHATT health care professionals go into the schools. In this way, families don't have to have their young person leave for lengthy periods of time to go to a health care visit. They can step out of a class, walk down the hall, have their private, secure visit, and then go back to class.
TCHATT has been around since 2019. It was developed in response to the 2018 school shooting at the high school in Santa Fe, Texas, in which eight students and two teachers died.
After the massacre in Uvalde, Abbott and the legislature decided that access to TCHATT should be rapidly expanded, and the tele-mental-health program should be made available in every Texas school district that wants it by next fall.
Williams said some rural school districts have been a little slower to get on board, despite the obvious benefits. She recognized that the population of Texas is diverse. “There's no one Texas,” she said, “and we're definitely a composite state.” Her teams in rural areas of Texas said that school districts and providers want to obtain a level of familiarity and trust first.
“We're not here to tell you what to do at a school,” she said. “We're here to be a support. And I think sometimes they're a little bit hesitant to believe us.”
But, she added, “We're only ever going to partner with you. And if you say you really need this and this campus is the one you need the most help with, that's the campus we're going to help you with. So I think that that trust just has to build. And you don't build trust overnight.”
The Uvalde school district is among those that will use TCHATT services this year. The district did not have TCHATT when Ramos was in school.
If it had been available then, could it have prevented the horror that was to come? Williams didn’t know. “But I do think that we can help prevent people committing suicide,” she said. “We can help prevent people from being so depressed they drop out of school. ... We can prevent people from maybe starting substance misuse and having additional problems.
“And obviously," Williams added, "we all hope that we can come together to prevent another school shooting.”
Related: Can telehealth solve America's mental health crisis in schools?
There are some actionable ways to improve mental health care access to children no matter how much money they have or where they live. These programs will need funding, and parents, residents and voters must support school board members, town council members, and state and federal lawmakers that are willing to fund them and to improve mental health care access in other innovative ways.
Uvalde may be a model for how to better reach kids in rural areas but there are thousands of other towns where kids are suffering with no one to help them. Struggling families also need support, particularly parents who are dealing with their own unmet mental health needs. They can't be the fully present parents their children need as they navigate and endure the dangers of their online worlds, like bullying and revenge porn, misogyny and racism.
Parents are the grownups. They must be strong enough to guide their children safely through their modern, digital lives. The community they inhabit must be the source of that strength. Uvalde is the cautionary example of what can happen when those communal obligations are broken. Then lives are broken, and bodies are broken, and hearts are shattered ... forever.
Texas Public Radio is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering challenges and solutions to accessing mental health care in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity, and newsrooms in Arizona, California, Georgia, Illinois, Pennsylvania, and Texas.
