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By most accounts, the Uvalde school gunman was the type of person a fledgling $290 million Texas youth mental health program was designed to reach — before his apparent distress and instability could escalate to mass violence.
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But it hadn’t reached Salvador Ramos by the time the 18-year-old high school dropout — whose adolescent years were reportedly beset by truancy, cruelty to animals and violence at home and at school — walked into Robb Elementary with an assault rifle last week and killed 19 kids and two teachers, health officials said.
Created by state lawmakers in 2019 and already in more than 300 school districts comprising some 40% of the state’s school population, the Texas Child Mental Health Care Consortium of experts operating from a dozen universities across the state has treated more than 6,000 students identified by school staff, doctors and others — including those at high risk for hurting themselves or others.
Ramos’ school district was on the list to be offered entry into the program, but it has not been formally included yet because the program is still ramping up, said Dr. Steven R. Pliszka, chair of psychiatry and behavioral sciences at UT Health San Antonio and administrator of the university’s consortium-funded program.
The gap was simply a matter of timing and resources available to a brand-new program still trying to build partnerships with school districts across the state, he said.
“We kind of reached a limit to our staffing in the first round of funding and we were planning to reach out to more rural districts, and Uvalde was obviously on our list,” he said. “Sadly, this happened before we could make that connection.”
The teen gunman, many in the mental health community say, might have been identified early and perhaps even diverted from that devastating path had more resources been available to him and those around him as he grew up in an underserved area.
But it’s a matter of speculation among politicians, mental health advocates and even consortium members whether an early intervention for Ramos would have saved the lives of the Uvalde schoolchildren in the absence of any other actions.
“I think the work the consortium does is part of the answer, but it isn’t necessarily the whole answer,” said Dr. David Lakey, head of the Texas Child Mental Health Care Consortium and vice chancellor for health affairs at the University of Texas System.
Few would disagree that Texas needs more resources to address a mounting mental health crisis. A recent report by Mental Health America found that Texas ranked last in the nation for access to mental care. The Texas chapter of the National Alliance on Mental Illness estimates that some 3.3 million Texans suffer from some form of mental illness.
Texas also has the highest number of uninsured residents in the nation. Among the measures gauged by the mental health report were the number of children and adults who didn’t receive treatment or whose treatments were not covered by insurance.
In Uvalde, about 1 in 5 residents is uninsured.
Many argue that the shooting is more appropriately blamed on lax school security, easy access to weapons or the simple fact that he was, as Texas Gov. Greg Abbott said, “the face of pure evil” than on the lack of early intervention.
Abbott, a pro-gun Republican who pushed for the creation of the consortium after the deadly 2018 mass shootings in El Paso and Odessa, insisted in the hours after the Uvalde massacre that the problem was rooted in the dearth of mental health services in that rural area, not lax Texas gun laws.
The governor’s comments after the Uvalde shooting mirrored those made after the last mass shooting: The problem is mental illness, not guns.
"We as a state, we as a society need to do a better job with mental health," Abbott said a day after the shootings. "Anybody who shoots somebody else has a mental health challenge. Period. We as a government need to find a way to target that mental health challenge and to do something about it.”
Gun-control advocates, weary of school shootings that have plagued the nation, and especially Texas in the last decade, argue that the Uvalde children were endangered because Texas had made it too easy for mentally unstable people like the gunman in Uvalde to get weapons.
Still, mental health advocates bristle at most suggestions that Ramos had a mental illness that caused him to shoot the children, which they say reinforce an unfair perception that all mentally ill individuals are violent, a stigma that they’ve been fighting for decades. They point to Abbott’s own statements that Ramos wasn’t even in the mental health system as evidence that he could not have been failed by it.
“Is it likely that a person who goes into a school and commits such violence is having some level of psychiatric issues? I would say yes, but there is no diagnosable mental health condition that leads a person to commit such atrocities,” said Greg Hansch, executive director of the Texas chapter of the National Alliance on Mental Illness. “This person wasn’t part of the mental health system. This doesn't appear to be a failure of the mental health system.”
But clinicians who work with at-risk youth say that system — the counselors, hospitals, psychiatrists and other health care professionals who respond to people in crises — can’t work if a student who needs services falls through the cracks and never gets help.
They also say it’s hard to argue that a mentally stable person would go into a school and slaughter children, experts say.
“When we look at mass shootings, it’s not normal behavior. There is something pathologic that’s happening when someone carries out a mass shooting. So in my opinion, mental health is always a part of the conversation to be having,” said Dr. Sarah Wakefield, chair of psychiatry at Texas Tech University Health Sciences Center in Lubbock and medical director of that university’s consortium-funded school-based mental health program.
Early intervention, actually getting people like Ramos into the mental health system he reportedly was not in, can be key to averting tragedy, Pliszka said.
“I’ve been a psychiatrist for 40 years, and I’ve had a lot of patients that showed very dangerous signs, and none have ever gone on to do this,” Pliszka said. “And I attribute some of that to the fact that they remained in treatment. People who tend to do these things are either never identified or have abandoned treatment, as a general rule.”
That certainly was at least part of the stated reasoning behind the state’s creation of the child mental health consortium, which first appeared in 2018 in a School Safety Action Plan pushed by Abbott to avoid more mass shootings, particularly in schools — in a section called “Preventing Threats in Advance.”
“As long as mental health challenges trouble our children, there will never be enough safety barriers we can build to protect our students,” Abbott said at the time.
If the program had existed and been available in Uvalde schools years ago, Lakey said, the training that would have been given to teachers as part of the program may have triggered a referral for Ramos when he started showing signs of a potential mental crisis, such as bullying or violent tendencies.
“People may have picked up that things aren’t going right with this student right now and could have referred him, got him counseling and services that would make it less likely that this type of horrific event would have occurred,” Lakey said. “But it’s a new program and we are trying to run as fast as we can to get it stood up.”
The plan
In that Abbott-endorsed 43-page School Safety Action plan from 2018, a wide variety of proposals were outlined. How to “harden” schools against physical breaches and create intelligence networks to monitor social media and identify threats. There was also a list of mental health initiatives designed to prevent attacks before they happen. There were no substantial gun control proposals.
Also tucked inside the plan were proposals on how to provide threat assessment programs, character-building curricula to schools and the creation of the consortium to get treatment, therapy and other crisis services to students in underserved areas.
“This plan provides dozens of strategies that can be used before the next school year begins to keep our students safe when they return to school,” Abbott wrote on the August 2018 plan. “The strategy I most strongly encourage the Legislature to consider is greater investment in mental health – especially crisis intervention counselors.”
A year later, the Texas House implemented some 25 of his recommendations, including 17 new laws he described as supporting school safety, and appropriated $339 million toward the initiative, according to an update Abbott released after the 2019 session.
In that session, the state allocated $99 million to the creation of the Texas Child Mental Health Care Consortium — the most expensive of the mental health initiatives Abbott proposed. The consortium was able to spend just under half of that on all its programs in the first year, officials said.
Through their Texas Child Health Access Through Telemedicine program, also known as TCHATT, the consortium funnels resources and expertise into a network of doctors, counselors and other professionals at universities in 12 regions across the state to respond to children identified in schools as showing signs of distress.
Last year, lawmakers budgeted an additional $230 million over two years in both state and federal funds to expand the network’s reach. The group also trains and places mental health professionals in community health centers and runs other programs to reach children and teens, whether they are in school or not.
In its first two years, the consortium spent about $56 million on starting their programs and hiring staff, officials said. Just under half the agency’s budget is for the TCHATT school district partnerships, which provide telemedicine or telehealth programs to students.
Some 6,023 students have been referred to the TCHATT program and its partnering institutions by schools for problems ranging from depression, anxiety and anger to substance abuse and more, Lakey said. Those programs are available to children in 336 of the state’s more than 1,000 school districts with about 2.2 million students eligible to be offered the services, Lakey said.
The system typically works like this. Once a child shows signs of distress at school — truancy, bullying, lashing out or even less obvious signs like sleeping or never being able to turn in homework — a school counselor may be notified. At that point, the counselor may ask the student’s parent for permission to refer the child to the consortium for services if it’s an appropriate next step.
If permission is granted, the student and a parent is contacted by either a member of the consortium, a counselor or a psychologist or another health officer for an initial review of the case. That review is typically conducted through an online appointment. After that, the child’s case is reviewed by that clinician in consultation with other members of the TCHATT program overseeing that child’s region. Finally, a treatment plan is created, if needed, that may include family counseling, psychologist visits, behavior therapy or other interventions.
Wakefield called the creation of the consortium “the boldest step I’ve ever seen any state do in trying to address these issues.”
Despite the pandemic, the program’s reach has grown in the two years it’s been taking referrals. But the shooting in Uvalde has brought even more urgency to bring it into as many districts as possible, Lakey said.
“We’re going to have that discussion this upcoming legislative session about additional resources we need in order to take the next logical step of moving this to a more statewide program,” Lakey said. “It’s going to take a little bit of time, it’s going to take some more resources, but the health-related institutions really are trying to work together to learn from each other and work with the schools and state agencies to provide the service as quickly as we can.”
Slipping through the cracks
The worst school shooting in Texas history was committed by a teenager, one now believed to have been troubled for years before he walked into Robb Elementary, gunned down a classroom of kids and then was killed by the police.
A day after the shootings, Abbott said authorities were unaware of any criminal or mental illness history of 18-year-old Ramos that could have identified him as a potential threat.
But he also said mental illness was described by the sheriff and other local officials as “the problem here.”
“They were straightforward and emphatic,” Abbott said last week. “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 they are facing in the community and the need for more mental health support in this region.”
According to media interviews with Ramos’ friends, family and others who knew him, the teenager was about to be denied graduation from his high school in Uvalde because of excessive truancy.
In both middle school and high school, he was characterized as a bully who had at one point been teased about a stutter and a lisp. Social media posts he made `were threatening and by classmates’ accounts, he had a hard time making and keeping friends.
His father didn’t have a lot of contact with him and his mother, who has been characterized by family members as a drug user. The house the teen once shared with her was visited by police several times during arguments between the two, with Ramos accusing his mother of trying to kick him out.
Although officials don’t believe the gunman made any specific threats on the school until the hours and minutes before he carried out his plan, many who are familiar with the reports of his past say that the red flags were there, if only there had been someone to see them or, perhaps more importantly, someone available to respond to them.
“I am always leery of drawing conclusions without having the most complete data set possible. I think there is much left to know in the case of this tragedy,” Wakefield said. “However, there seem to have been many warning signs that could have led to referral and intervention if there was access to such, and providing that access is exactly what these programs are designed to do.”
But when it comes to services for Uvalde’s troubled youth and mentally ill, there is little debate about how much access they have there.
“It’s a fairly underserved area,” Pliszka said.
Texas Sen. Roland Gutierrez, a Democrat whose district includes Uvalde, said the rural community has no psychiatrists and its state-funded community health clinic needs more resources. More clinics and services, he said, are what is needed to address mental challenges.
“What’s happened here is just a disaster and [Abbott] does nothing about it but speak of evil and mental health,” Gutierrez said. “A mental health system which, by the way, he refuses to fund.”
Abbott was also criticized on social media in the wake of the Uvalde shootings for a transfer in April of $211 million from Texas Health and Human Services, the state agency which manages Texas’ health programs, the state child welfare system and other related services including Medicaid, along with about $250 million moved from other state agencies.
But the transfer of money, which went into the governor’s border operations, did not affect the agencies’ budgets because the state applied federal funds obtained for those agencies through the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), agency officials said.
The agency was required to lapse state funding as part of that legislative budget move and it did not result in any reduction in services, said Christine Mann, spokesperson for the health and human services commission.
State Sen. Jane Nelson, the Flower Mound Republican who was behind the creation of the consortium, said lawmakers continue to fund it with the goal of increasing the program’s reach.
“The purpose of the consortium is to identify students at high risk of suicide or becoming a danger to others and get them into treatment,” Nelson said in a statement to The Texas Tribune on Tuesday. “We added funding in the current budget to expand the program’s reach, and the goal is to make these services available across the state.”
Lakey said finding and training more mental health professionals to meet the needs of not only the students in the program but of the state as a whole, is a major challenge. The consortium seeks to address this by trying to recruit and train new professionals, but it’s a constant struggle, he said.
“Currently, throughout the state of Texas, we have a shortage of mental health providers,” he said.
The Uvalde Consolidated Independent School District falls into a region covered by the consortium’s program run out of the UT Health Sciences Center San Antonio, which has brought 1,344 at-risk students into services since it launched in late 2020, Pliszka said.
So far, the program has partnered with 37 districts out of 136 in its region, he said, including several districts in Bexar County, an urban area experiencing its own struggle with mental health access. The plan is to eventually extend the offer to every district in the region, he said. The San Antonio program already staffs clinicians at Hill Country Mental Health and Developmental Disabilities Centers, a group that is based in Kerrville and offers services in 19 counties, including Uvalde County.
Because the shooting both highlighted the more urgent need for services there and likely created the need for them for those left behind, Uvalde schools are now being offered access to those services immediately, Pliszka said.
While Texas is doing a “phenomenal” amount of collaboration and resource-leveraging to try and help children in mental distress in recent years, particularly with the consortium, there is much more that needs to be done — “it takes time,” Wakefield said.
“In the last few years, [Texas has] started to focus on this conversation, but we are still so far behind the curve, still, not as a state but as a world,” she said. “We started, just like everyone has, from way behind.”
Disclosure: Texas Tech University, Texas Tech University Health Sciences Center and University of Texas System have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.