By John D. Sutter, CNN
Puerto Rico (CNN)Her son cried out for help via text message on the morning of October 17, a month after Hurricane Maria wrecked this Caribbean island.
“Where are you??” the 18-year-old wrote at 11:32 a.m.
“Mami call me it’s important.”
Cellular networks in Puerto Rico were still damaged after the Category 4 hurricane, and the messages from her son didn’t go through, the boy’s mother said.
When his frantic words finally appeared on her phone, she panicked.
She knew her son suffered from depression, which had worsened severely in the aftermath of Maria, she told CNN in an interview this summer. The 2017 storm had left the family, like more than a million others on this US territory, without electricity or running water for what would become months, sowing despair, uncertainty, illness and contributing to deaths.
Before the hurricane, her teenage boy had made remarkable progress in recovering from another tragedy — his father’s death from cancer one year before. The death had inspired him to become a nurse, according to relatives. The teenager had just started classes at a university, giving him a new sense of purpose — clarity about his future.
Then came Hurricane Maria, shuttering his school.
His mother received his texts about 90 minutes after they were written.
She wrote back.
Again, and again.
There was no answer.
She rushed home to find her son dead on the back patio.
Medical professionals labeled his death a suicide.
He was an opinionated and sensitive young man who felt his island’s suffering deeply, his mother said. He was one of six teenagers who took their lives after Maria, according to mortality records. CNN does not typically identify suicide victims who are not public figures. For this story, the teen will be called Alejandro, and his mother Isabel.
An additional seven suicide victims were 25 or younger, according to the database, which CNN and the Centro de Periodismo Investigativo (CPI) sued the Puerto Rico government to obtain. It covers deaths that occurred for about nine months after the storm and may not include all deaths. Between that day — September 20, 2017 — and the end of the year, there were 82 deaths labeled suicides by forensics experts, according to Puerto Rico’s Commission on Suicide Prevention, which is more than the 47 suicides during the same dates the previous year.
More research is needed in order to say whether the suicide rate increased because of Maria, said Nayda I. Román-Vázquez, a clinical psychologist at the commission.
CNN investigated five of the six teen suicides, including Alejandro’s. In four, families believed the hurricane played a role in the deaths of their loved ones. The youth suicide deaths CNN researched have not been publicly ascribed to the hurricane by Puerto Rican authorities, who have come under criticism for their handling of the Maria death toll.
In August, officials said that nearly 3,000 people died directly or indirectly from the storm, based on a George Washington University statistical analysis of deaths that occurred from September 2017 to February 2018. But that is just an estimate — a number. Local officials have released details on only 64 people who died in the aftermath of Maria. At least two of those are suicides, which is in line with federal guidance that says deaths can be attributable to a storm because of “loss/disruption” of mental health care or “psychosocial stress or anxiety.”
Mental health experts caution that it is often difficult, if not impossible, to say why a person takes their own life. Typically, multiple factors play a role.
Asking for help
The suicide rate in the United States has seen sharp increases in recent years. Studies have shown that the risk of suicide declines sharply when people call the national suicide hotline: 1-800-273-TALK.
There is also a crisis text line. For crisis support in Spanish, call 1-888-628-9454.
The lines are staffed by a mix of paid professionals and unpaid volunteers trained in crisis and suicide intervention. The confidential environment, the 24-hour accessibility, a caller’s ability to hang up at any time and the person-centered care have helped its success, advocates say.
The International Association for Suicide Prevention and Befrienders Worldwide also provide contact information for crisis centers around the world.
Still, the longer chaos persists, psychologists and disaster experts said, the more damaging a disaster like Hurricane Maria becomes for vulnerable kids. Children in Puerto Rico have watched as their homes were torn apart, their friends moved to the mainland, their government struggled to restore water and power service and their parents lost jobs. Before the storm, their island was bankrupt and hemorrhaging its 3.3 million US citizens. Now, there are serious questions about how many young people will be left when the “exodus” slows.
“It’s just tragic,” Dr. James D. Norcross, a professor of child and adolescent psychiatry at the University of Texas Southwestern Medical Center, said of the overall situation. The slow federal recovery efforts in Puerto Rico, he said, helped create these dire circumstances for kids.
“Hopelessness develops over time.”
The results of the stressors run a spectrum — from boredom to despair. But Puerto Rico’s children are united by their experiences of the past year.
One researcher called them “The Maria Generation.”
A recognition that they may be forever shaped by the storm.
CNN spent more than three weeks this summer interviewing young people and their families to try to understand the lasting consequences for youth — both physical and psychological.
Some children made it through Maria virtually unscathed. Their homes were repaired, power was restored, eventually, and life has started to return to normal.
Others, however, have been pushed toward despair.
Among the circumstances CNN found: siblings, 9 and 10, who stopped eating because of anxiety caused by the destruction of their home and months without electricity, and were diagnosed with malnutrition, according to relatives; a 14-year-old girl who attempted suicide in part because her parents lost their jobs after the storm; a boy whose mother left for the mainland in search of work, leaving him unsure how long she’ll be gone and how long he’ll live without her; an infant, born after Maria, who was hospitalized repeatedly with breathing problems while living in a moldy home with a damaged, leaky roof; elementary school kids in Loiza who pinned their clothes and handwritten notes (“Here are my tennis shoes with the sand from my last day of playing in the schoolyard”) to the gate of their school, which closed this summer and would not reopen; 10- and 13-year-old sisters who were doing homework by candlelight in May because they still lacked electricity nearly nine months after Maria; a 5-year-old boy in suburban San Juan whose teachers say his reading and writing skills are delayed because schools were closed for so long; and a 13-year-old girl in the interior who, according to federal court records, was coerced into “sexual conduct” by a neighbor who met her in the storm’s aftermath and, according to investigators, offered her an Internet connection.
In July, the neighbor pleaded guilty in that case to sexual coercion and enticement of a minor, which carries a sentence of at least 10 years in prison, records show.
The suffering is not confined to a few.
CNN exclusively obtained the results of a survey of more than 60,000 public school students in Puerto Rico, which was conducted earlier this year by the Puerto Rico Department of Education in consultation with the Medical University of South Carolina.
Nearly half of surveyed students — who were in fourth grade through high school — reported their homes were “destroyed or greatly damaged” by the storm, researchers said. About a third reported their families “struggled to find food or water.” Twelve percent saw fights or violence in their homes or neighborhoods. And about 30% of the public school students thought they “could have died” during Maria.
These are hardships that can lead to hopelessness and suicide, said Rosaura Orengo-Aguayo, an assistant professor at the Medical University of South Carolina who was involved in the report. (Researchers did not specifically ask about child suicide because of the sensitivities involved, she said.)
More than 7% of students surveyed showed signs of post-traumatic stress disorder, or PTSD; and more than 8% of students showed symptoms that suggest depression, researchers found. The rate of depression symptoms, in particular, is “definitely much higher than what you’d expect” — about twice as high as kids in non-disaster settings, Orengo-Aguayo said.
Calls to a Puerto Rico crisis hotline in which people — of all ages — reported attempting to kill themselves or having suicidal thoughts were up 78% in October 2017, after the storm, compared to October 2016 — from 2,233 to 3,969 calls, according to Puerto Rico’s Commission on Suicide Prevention.
In all of 2017, the hotline received 7,456 calls in which a person reported a suicide attempt. That’s a 50% increase in reported suicide attempts compared to the year before, when 4,958 such calls were made, said Román-Vázquez, the psychologist and education coordinator at the Commission on Suicide Prevention.
“Never underestimate what someone can do when they feel hopeless,” she said.
It’s possible suicide calls were up in part because the Puerto Rico Health Department was trying to spread the word about the existence of the hotline after Maria, she said.
Adults generally want to believe that children are “resilent” little superheroes — that they don’t feel tragedy as deeply as adults and can shake it off quickly, said Dr. Myron Belfer, a professor of psychiatry at Harvard Medical School and Boston Children’s Hospital.
But “that’s old thinking,” he said. “It’s very soothing to think that kids are so resilient or that kids don’t get depressed and they don’t get anxious and they don’t experience trauma. But there’s ample evidence to suggest that the idea that kids are resilient is overplayed. We know in these situations where kids are traumatized that it can actually affect their brains.
“Living in a toxic environment — I don’t mean toxic in terms of chemicals but toxic in the sense of stress — can impact brain development and have longer-term impacts.”
Young children develop “models of the world” — core assumptions about how they can expect things to operate, said Ryan Kilmer, a professor of psychology at The University of North Carolina at Charlotte who studied mental health in children after Hurricane Katrina hit the Gulf Coast in 2005. Some of these assumptions, he said, are things like “mom and dad keep me safe” and “the world is fair.” “Something like Maria comes,” he said, “and no matter what mom and dad do they can’t stop it, and they couldn’t necessarily keep everyone safe.”
Adults can recover from almost any kind of trauma that’s disaster-related — even being forced to live in a shelter for months or a year. They have the life experience to start over and rebuild. But “children are much more highly sensitive to interruption of services and support,” said Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University in New York, and “the consequences can be and often are lifelong.”
Their sense of fairness — of future — can be shaken, he said.
Kids can start to wonder: Will this ever be normal?
Alejandro was the type of kid who liked to ask big questions.
Why are we here? Why is there war? Why do children suffer?
His mother started fielding them when he was in elementary school, if not before.
“I didn’t have answers to some of the questions he had about God, about poverty, about hunger — all of that,” Isabel said. She liked that her son asked her these questions, though. Alejandro was the type of kid who observed the world in detail, who cared about the people and ideas in his orbit. He didn’t accept things as they were, she said.
In 2016, though, his questions became more personal — harder to answer.
Alejandro’s father was hospitalized with cancer. Alejandro visited him often, relatives said, massaging his father’s legs and trying to assist the nurses.
Still, his father died in September 2016.
If there were a God, why did this happen?
Alejandro sank into depression, withdrawing from the family. At one point he expressed suicidal thoughts to his mother: “I don’t feel good, Mami. I want to die,” he told her.
But in the spring of 2017, before Maria, things changed, Isabel said.
Alejandro’s mood improved. He decided to turn tragedy into opportunity; the time he spent with his dad in the hospital motivated him to become a nurse. He enrolled at a university in a nearby town. His mom recalls him telling a school counselor that he felt needed and loved.
The comments floored her.
“I love this college,” she recalls him saying. “This college brings out the best in me.”
Power was out indefinitely. So was water.
Alejandro’s family lives near the island’s western coast, almost two hours from the capital of San Juan and the center of aid distribution. His college had closed temporarily, forcing the teen to move out of the dorm and back home amid the turmoil. He found purpose, relatives said, volunteering at a nearby hospital, caring for older patients who needed assistance after the hurricane. Purpose he’d so desperately needed after his dad’s death from cancer.
As the weeks wore on, his depression plunged to entirely new levels, they said.
“He was upset. He became aggressive,” said his mother. “He was in denial about the situation. He’d talk about the government — how the government always has been stealing from the people and the power grid has always been a disaster, even before the hurricane.”
Those big questions he loved to ask about how the world works and why?
Alejandro started answering them.
“This is going to last forever,” he told his mom.
It was a statement. Not a question.
“The situation after the hurricane,” Isabel said, “was a ticking time bomb for him.”
Answers go with them to the grave.
Experts in child suicide say it is often impossible to know what led a person to take his or her life. Sometimes there is no single identifiable reason. Almost always, there are many.
“It’s rarely going to be a direct cause-and-effect,” said Redlener, the pediatrician and disaster-response expert at Columbia University. “A storm would not cause a well-balanced kid to kill themselves. But this is mostly worrisome for the vulnerable children — that is, (children) who have had some preexisting challenges like depression … Kids who tend to be loners and not very communicative. Kids with other types of mental health conditions … This is the last straw.
“The storm pushes them over the edge and puts them in a very dark place.”
In Caguas, a sprawling metropolis nestled in a valley of eastern Puerto Rico, two teenage sisters, ages 14 and 17, worried after Maria that they’d become a financial burden on their parents, both of whom had at least temporarily lost their jobs after the storm.
The teenagers heard mom and dad fretting. When communication systems returned to their part of the island after outages, they overheard their parents calling creditors, asking for time. They didn’t have enough money for food, much less rent and bills.
The elder sister recalled thinking that “my sister would get two-times the food” if she were no longer around. She considered killing herself, she told CNN.
For her younger sibling, it was worse.
The younger girl attempted to kill herself in late October.
She was hospitalized but survived.
“It stressed me out,” the 14-year-old said of the storm.
She said she attempted suicide “to search for an escape” from Maria’s aftermath.
Outside of San Juan, a mother’s skin was still puffy and raw where she had the word “Mah!” tattooed on her left forearm. That’s what her 13-year-old daughter called her before the tragedy that the mother still can refer to only as “the incident.”
After Maria, the teenage girl slept on an air mattress on the front patio, mosquitoes gnawing at her body — “just waiting for things to happen, waiting for light to come, waiting for time to pass,” her mother said. The family was having financial trouble after the storm, and she was the type of girl who internalized problems — who wanted to help but couldn’t.
“She was always worried, thinking ‘What are we going to do?'” said her mother. “She was so humble and so caring. She was always trying not to stress out others.”
In undated notebooks, the daughter drew a girl wearing an oversized sweater with the words “Hug me, pls” on it. In another journal, she wrote: “Depression feels like drowning.”
The mother said her daughter suffered from depression and had attempted suicide once before the storm. The teenager was coming to terms with her sexual orientation in an unaccepting world, she said. But the prolonged aftermath of Maria was her “detonation point.”
Her daughter killed herself on December 15.
My daughter “was light,” she said. “She was life, all around.”
The population of young people has declined in Puerto Rico. In the 1990s, about a third of all people living on the island were children. In 2016, children accounted for only about one in five.
The population of young people has declined in Puerto Rico. In the 1990s, about a third of all people living on the island were children. In 2016, children accounted for only about one in five.
In eastern Puerto Rico, a 19-year-old and his family moved into his grandmother’s home because their own residence had its roof partially torn off by Maria. Eleven people crowded inside. The teen slept in the living room. He took the situation the hardest, according to his mother. As months passed, the buzz of people, the lack of privacy, lack of cell phone service, lack of power, lack of anything to do, made him anxious and violent, she said.
He didn’t have access to his usual counseling services, she said.
(The Federal Emergency Management Agency says it spent $6.7 million on a “crisis counseling” program that ended in March; Puerto Rico authorities sent 300 staff to provide therapy at disaster centers and door-to-door in homes, FEMA told CNN in an email).
On December 3, the mother found her son dead outside the house; he had apparently taken his own life.
“These deaths could have been avoided,” she told CNN. “People with depression don’t know how to express their feelings or deal with them — especially in these months.”
In northern Puerto Rico, a 14-year-old girl also had been struggling with depression after years of sexual abuse, according to her mother. In the weeks after Maria, the mother called police to try to enforce a restraining order against the alleged abuser, she said, but could not reach authorities because cellular networks didn’t work. Court proceedings and therapy related to the sexual abuse case stalled after the storm, too, she said, causing new anxieties.
“All of these delays were because of the hurricane,” she said.
The 14-year-old killed herself on February 10.
Puerto Rico officials did not respond a request for comment on whether the deaths had been investigated or were determined privately to be hurricane related.
‘This is the last straw’
On October 17, when the delayed pleas for help finally arrived on her phone, Alejandro’s mother already suspected the worst. The “ticking time bomb” had gone off.
She didn’t expect help after the storm to come immediately.
But she certainly could not have prepared for this.
The US and Puerto Rican governments’ response to Maria has widely been criticized as slow and insufficient — and in a July report FEMA admitted it was inadequately prepared for the “unprecedented” 2017 disaster season, which included several major storms and wildfires, events climate scientists say will become more frequent as humans continue to warm the planet.
Puerto Ricans were left to live in the wind and rain, without roofs, for months because of delays in federal contracts and programs. Power was restored far more slowly on the island than in recent hurricanes in Florida and Texas.
Federal officials — who have authority in Puerto Rico because it is a US commonwealth, home to American citizens who don’t elect voting members of Congress and who can’t vote in the general election for US president — have said repeatedly that the government responded to the crisis in Puerto Rico as it would to a storm in a US state. The island’s remoteness and the poor state of its power and water systems before the storm made it more difficult to repair, officials have said.
President Donald Trump, meanwhile, said earlier this month that federal recovery efforts were “an incredible, unsung success,” baffling Puerto Rico’s governor and others on the island.
“This was the worst natural disaster in our modern history,” Puerto Rico Gov. Ricardo Rosselló said in response to Trump’s comments on September 11. “Our basic infrastructure was devastated, thousands of our people lost their lives and many others still struggle.”
On September 13, Trump falsely claimed that “3,000 people did not die” in the hurricanes that hit Puerto Rico, dismissing the hardships of thousands of people — like Alejandro and Isabel.
When Isabel arrived home on that harrowing day in October, she called her son’s name.
There was no answer.
She only wishes that the phones had been working, and that she had been there to reason with her son, to tell him all the reasons he had to continue living.
“The conversation, if we could have had it, would have been a really important one,” she said. “He listens to me. I could calm him down. Maybe he could have regained some hope.”
Would it have saved him?
She thinks so.
The stressors are beyond their control and they are many.
Among them: More than half — 56% — of this island’s kids lived in poverty before the storm, with some storm-hit interior municipalities seeing rates of child poverty nearing 80%, according to the Youth Development Institute of Puerto Rico, a research and advocacy group.
And: Their peers are leaving.
Last fall, 346,000 kids started public school here. This year, it’s almost 39,000 fewer.
Some 277 schools — one in four — closed permanently in the year after the storm.
These shifts partly occur because of longstanding issues — hundreds of thousands of people fled Puerto Rico’s failing economy in the last decade — but also because of a sad fact: Some families don’t see a future in Puerto Rico, with its government about $120 billion in bond and pension debt, its staggering rates of poverty and, now, the myriad hardships that have followed Maria.
The problem for kids post-Maria is “not just that the families that stay are going to be in dire situations, and that kids are going to go through traumatic stress,” said Amanda Rivera-Flores, executive director of the Youth Development Institute. “There are people who just leave — and we further the pattern of an aging population. We keep losing children and young people. And that undermines the economic ability of Puerto Rico to survive. We don’t have people.
“What does that mean in 10 years? How many kids are we going to have here?”
When Rivera was growing up, in the 1990s, about a third of all the people living in Puerto Rico were children. In 2016, children accounted for only about one in five people, according to data from the Kids Count project from the Annie E. Casey Foundation.
“That piece of data blows my mind,” Rivera said.
She expects the outmigration to continue.
And for “The Maria Generation” to continue to face an uncertain future.
In the mountains of Caguas, at the top of a hill so steep cars have to floor the gas to make it up, 16-year-old Katielie Flores is sure that she’ll stay in Puerto Rico and that things will work out.
For months after the storm, she was living in a home without a functional roof. Her aunt died about a month after the storm from complications related to chronic asthma and other breathing conditions. She couldn’t operate a breathing machine that required electricity.
The teenager suffers from the same lung condition.
For weeks, she said, she couldn’t sleep because her lungs were strained and her mind raced.
“My God, what if I’m next?” she thought, sitting up in bed. “What if I can’t make it? I was just scared. I told myself, ‘Don’t think about this because it’s just going to get worse.'”
In July, Flores was hospitalized with acute breathing problems, according to her grandmother, Jackeline Carrasco. The family has moved to an apartment in town in hopes it will help.
Flores at times has the weary look of someone who’s lived well beyond her years.
In other moments, though, she chases siblings around the house and laughs with abandon.
Ask her about the future and she tells you it’ll be fine.
She loves this island, wants to be a nurse. She doesn’t know how, but everything will work out.
Her grandma, though, isn’t always so sure.
What will be left of this place, she wonders.
Isabel is left with questions of her own.
Front of mind: Why?
“With the help of the United States and so many organizations, why did it take so long to recover?” she told CNN, tears running down her face.
She wonders what will become of her family, and of Puerto Rico. So many families have left the island. So many homes remain covered in flimsy blue tarps.
Normalcy has yet to return.
She has started to answer some of her own questions.
Isabel believes strongly that Alejandro should be counted among the victims of Maria.
Isabel said she told FEMA and Puerto Rico’s Bureau of Forensic Sciences, which conducted an autopsy, about the circumstances of her son’s death. She assumed, based on their conversations, that Alejandro’s death was tallied. (FEMA said it is not able to comment on individual claims for assistance for privacy reasons).
“I thought that he was on the list,” she said this summer after CNN showed her the list of the 64 people that Puerto Rico says died in the storm and its prolonged aftermath. Her son was not there.
“It’s important that all the world knows the real toll — so that everyone knows how badly the government was managing this situation … This is like a third-world country disguised as a first-world country.”
Officials in Puerto Rico, and some psychologists, emphasize the importance of hope — of trust that the future will be brighter, that Puerto Rico will reemerge stronger from this catastrophe.
“We are here, we believe in them, we’re not giving up,” Julia B. Keleher, Puerto Rico’s secretary of education, told CNN when asked what she would tell students who are giving up hope. “Little by little and day by day, we promise that there will be some indicators of positive.”
But CNN also asked Isabel what she makes of the future.
What will become of Puerto Rico and its children?
For that, she had an answer.
A statement, not a question.
“I don’t see hope.”