There were no lights, air conditioning or working toilets when Natalia Merced returned to her dorm room at the University of Puerto Rico in late October, a month after Hurricane Maria struck the island. Classes had resumed at the university’s Rio Piedras campus, but most of the island was still in the middle of the disaster. Earning her degree was too important to her to give up on her senior year, so she left home and went back to classes, too.

The school she found was a shell of what it once was. Laptops were useless without power. The water supply was gone, so showers, faucets and fountains didn’t work. Some students commuted two hours from home to attend a single class. Merced ate military-style packaged meals, cereal and canned chicken with her three roommates in the stifling heat.

It wasn’t what Merced, 21, had envisioned for her senior year. She battled anger, sadness and exhaustion daily after the storm. Eventually, she left campus and decided to commute from home, where she had family for support. She graduated on time, with a degree in public relations and advertising, but many classmates were not able to do the same. Several dropped out, she said, fraying under the strain of a historic natural disaster, a slow — many would say fumbled — recovery by the government and the toll it all had taken on their mental health.

There were few places to turn to for help. When her roommate sought help for her post-Maria anxiety from a campus psychiatrist, Merced said the woman was handed a stack of Internet articles and a prescription for antidepressants; she filled it.

“People don’t care about us. That gets you angry, but also makes you want to cry. We’ve got to save ourselves.”

That pervasive sense of sadness and loss has been compounded in recent weeks, as the Puerto Rican government for the first time acknowledged a death toll 46 times higher than its previous estimate (something President Donald Trump subsequently and publicly disputed). Reports revealed that federal officials allowed millions of bottles of water to go to waste on an airport runway while people still struggle to secure safe drinking water.

“We’re tired,” Merced said. “People don’t care about us. That gets you angry, but also makes you want to cry,” she said this week. “We’ve got to save ourselves.”

A year later, Maria’s legacy of destruction can be witnessed in the wrecked infrastructure and staggering 2,975 deaths, but perhaps most starkly in the increase in suicide. Six months after the storm, the Puerto Rican Department of Health released a preliminary estimate of 253 suicides in 2017, representing a 29-percent increase compared to the previous year.

Before the storm, 7 percent of Puerto Ricans reported at least one mental health issue, according to Suzanne Roig Fuertes, the head of Puerto Rico’s Administración de Servicios de Salud Mental y Contra la Adicción. A year later, she said, federal, territorial and local officials in Puerto Rico are still figuring out how long a shadow Hurricane Maria cast over mental health and how that percentage has changed. Her staff has noticed an uptick in anxiety disorder, but she did not say by how much. Without comprehensive government data, it’s hard to capture the scope of mental health issues after the storm or how they will access needed treatment.

In the hierarchy of basic needs, mental health often falls to the bottom. But teachers, residents and child development experts interviewed by the PBS NewsHour say they’re worried about the long-term mental health effects on a generation of Puerto Rican children growing up after Hurricane Maria and what that means for the island’s future.

A new storm of troubles

Long before Hurricane Maria, uncertainty shaped the lives of many Puerto Rican children and families. For years, the island had endured a spiraling debt crisis, and it wasn’t unusual for a parent to leave family behind for work on the mainland, earning money to send home. The tourism industry, which fuels the Puerto Rican economy, had taken a hit after the Zika virus emerged and spread widely, infecting more than 1 million people. In June 2017, the island declared the outbreak over (although it still advised pregnant women against traveling there). Three months later, Hurricanes Irma and Maria happened.

Merced headed to her family’s home in Mayaguez when college officials canceled classes, anticipating Maria’s arrival. For days, her father, Jacobo, monitored weather forecasts and storm projection models, which can be notoriously inconsistent and easy to dismiss. A system engineer for Hewlett Packard, Jacobo was struck by how every model showed the hurricane catching his lifelong home in its crosshairs. He bought canned food, batteries, gasoline, 20 cases of drinking water, and a 35-gallon barrel to hold water for bathing and washing clothes. He secured his windows with plywood and then waited, playing Monopoly, UNO and dominoes with his wife, Natalia and his other daughter, who was 16.

Intergenerational family norms and nuclear families are “breaking down completely.”

Nearly 120 miles east and further inland in Canóvanas, Raiza Parilla moved her 5-year-old daughter and 2-year-old son at 2 a.m. away from a loose tormentera after the mounting winds threatened to yank it from the wall and shatter the window underneath. In her brother’s concrete house, Parilla, a nutritionist at Caribbean Medical Center, and her husband had decided to wait out the storm with 10 family members. With her children now wide awake, Parilla handed them coloring books and told them the hurricane would bring howling wind and pouring rain. She couldn’t bring herself to talk about the floodwaters, snapped trees or broken homes she feared would greet them after the storm passed. She thought they understood.

Then the island went dark.

After the storm, Cynthia Garcia Coll walked out of her north coastal home, located 20 miles west of San Juan, in a daze. “Like a network of bees and ants,” her neighbors soon went to work trying to rebuild their lives. For hours, they stood in lines for water, for cash. ATM machines and credit cards were worthless on an island without electricity and where less than 12 percent of the population could make a phone call. Garcia Coll, a pediatric psychologist who taught for 30 years at Brown University before moving back home to Puerto Rico in 2011, said she was stunned that society did not break down.

Different parts of Puerto Rico recovered faster and had better access to resources than others, creating two distinct recovery tracks, said pediatrician Irwin Redlener, who has studied the role disasters like Maria, Hurricane Katrina and the Sept. 11 attacks play in child resilience and mental health.

In easier-to-reach places like San Juan, people got back on their feet quickly. Many households received generators, and some version of routines resumed, making it easier for children and families to get the help they needed as soon as possible, Redlener said. But in more remote parts of the island those resources were slow to show or never came.

Juan Carlos Rivera, an educator in San Juan, said his hometown of Aguas Buenas lost power on Sept. 6 and wasn’t restored until June. When he went to check on his sister’s family, he said his 11-year-old niece remained stoic while her 10-year-old sister wailed, “Uncle, we lost everything.”

Though his sister applied for FEMA aid to rebuild a week later, she is still living in a single room with her husband and two daughters, as their home has undergone a series of appraisals, Rivera said. For months, his nieces did not sleep well.

Traumatic events can mold how children sees themselves and the world around them, even if it’s not immediately clear exactly how, Redlener said. As part of the 2010 National Commission on Children and Disasters, Redlener found that children who lived in the path of Hurricane Katrina were 4.5 times more likely to develop an emotional disturbance than children outside the hurricane’s path.

“Puerto Rico is in the process of recovery in every way, and mental health is no exception.”

Garcia Coll observed that the endless disruption to routine and relationships was difficult for children who lived near her, as well as the college students she taught at Carlos Albizu University. Parents and extended family left the island to find work on the mainland. Intergenerational family norms and nuclear families are “breaking down completely,” she said.

Most people briefly present symptoms, such as nightmares, but then process the fear and anxiety and move on, said Megan Gunnar, who studies toxic stress — intense, repetitive or prolonged adversity without a caregiver’s support — and child development at the University of Minnesota. But between 10 and 20 percent of children develop post-traumatic stress disorder after a disaster, she said, marked by symptoms like a return to bedwetting, nightmares or emotional volatility — going from being easy-going to angry or sobbing.

Child psychiatrist Daniel Cardona saw this play out. For 14 years, he has operated in the town of Caguas, and saw an average of 14 patients a day, aged 2 to 19, who were seeking treatment for autism, attention deficit and hyperactivity disorder or behavior issues. After Hurricane Maria, his caseload dropped to as few as two patients a day. Many missed appointments. Some patients lost loved ones during or after the storm. Some who lost their homes stayed on the island, shuffling from one relative to the next, but others moved to Wisconsin, Chicago or New York City. Everyone was too busy surviving to pursue treatment, Cardona said. On top of that, many physicians and specialists left the island after the storm, Cardona said, further straining an overwhelmed health care system.

Facing the destruction

“Not only are you going through the aftermath, but when you finally start looking for your provider, your provider is not there,” he said.

To reach patients who were otherwise stranded, Cardona joined brigades of health care providers who traveled from town to town across the island. Cardiologists, internists and others would drive treacherous mountain roads to deliver food, water and prescriptions, if needed, but Cardona said the need “was out of proportion, out of our hands. We were not able to help everyone.”

Neuroscientist Kenira Thompson was among those trying to help, traveling from the Ponce Medical School Foundation on the island’s southern coast up into the mountains days after the storm to assess mental health needs. These efforts were largely funded by private dollars, Thompson said, including help from Americares and Direct Relief.

One day she found a family of four adults and seven children living in a one-bedroom shack without power or running water, where they slept on the floor after the hurricane blew away their home. The children, ages 11 to 18, stared back at her with blank expressions and never smiled. After five months, the children returned to school, but Thompson said it’s important to monitor children and families exposed to such high — and potentially transformative — levels of toxic stress, especially during early and adolescent child development. And it could take months or even years for these effects to fully manifest.

“What shapes our brains are our experiences,” she said. “Any negative experience or positive experience can affect how those brain connections are formed.”

How mental health fits into disaster recovery

It’s not clear how the government is monitoring children’s mental health on the island.

A spokesman from the Substance Abuse and Mental Health Services Administration deferred any official statement on government oversight of storm-related mental health issues to the Federal Emergency Management Agency, which led the nation’s hurricane response in Puerto Rico.

“Anyone who is dealing with the mental and emotional effects of a disaster or act of mass violence can call SAMHSA’s Disaster Distress Helpline at 1-800-985-5990,” the spokesman said in a July 3 statement to the PBS NewsHour.

FEMA declined to comment on how many children and adolescents had at least one mental health issue after Hurricane Maria and instead deferred to Puerto Rico’s Administración de Servicios de Salud Mental y Contra la Adicción, which manages mental health and substance use issues. Agency administrator Suzanne Roig Fuertes said, “Puerto Rico is in the process of recovery in every way, and mental health is no exception.”

Roig Fuertes praised the work of Gov. Ricardo Rossello, but she would not comment on the Trump administration’s response to the storm. The president has described “incredibly successful” work on the island after Maria.

In Orocovis, high in Puerto Rico’s Cordillera Central range, Eugenio Soto’s students returned to school in November 2017, about two months after the storm, he said. In a school of 201 students, a dozen didn’t come back after the hurricane.

During that first month, grades slipped. Tempers flashed. Fights broke out, and fourth and fifth graders burst into tears. Classrooms had no electricity, so Soto taught math outside on the playground. He transformed the curriculum, teaching the children to count how many seeds they planted or how many meters of soil they needed to sow. There, on the playground, they shared jokes. He worked to create a routine for the children, at least when they were at school. The advocacy group Save the Children developed group therapy sessions for students in his school to talk through issues as they arose. He learned not to judge the children for poor grades or behavior.

“We don’t know all the damage they have endured, all the stress those kids carry,” Soto said.

“We don’t know all the damage they have endured, all the stress those kids carry,” Soto said.

Without action, more children could suffer post-traumatic stress disorder and pass along intergenerational trauma for years to come, Redlener said — enduring psychological behavior problems, missing school, or losing academic and developmental progress.

“How do you make that up? That’s a real big challenge, and we don’t have a lot of good answers,” he said. “A lot of children are going to be affected in ways that we’re all going to regret.”

Redlener developed a list of best practices following a disaster that includes things like basic psychological first aid, figuring out where children and their families can go for shelter, food, water and reassurance. Then it is essential to restore routine for people and especially children, in order to protect their mental recovery, Redlener said. Part of that process involves the business of rebuilding — applying for FEMA aid and enrolling in the nearest school. But, it also included best practices for tending to a child’s mental health, such as having a trusted adult to buffer the shocks of life after a disaster and re-establish routine as soon as possible. And months or years later, if families and children still struggle with stress, Redlener said they need mental health services to monitor and possibly treat depression.

Roig Fuertes’ staff has noticed an uptick in anxiety disorder, but did not say by how much. On Nov. 1, she deployed 350 staff to schools and offices in 78 municipalities to offer services and coordinate follow-up mental health care. This project is ongoing and is scheduled to wrap up in a year, Roig Fuertes said. They also promote an existing 24-7 crisis helpline, Linea PAS, for minors to call in order to connect with mental health service providers. This resource is more helpful now than a month after the storm, when 39 percent of cellphones remained out of service; FEMA says mobile phone service has been almost entirely restored.

In its response to Puerto Rico’s crisis, Redlener said the United States remained woefully behind longstanding best practices and under-resourced. Representatives from several agencies — from the Department of Education to Puerto’s mental health agency to the health care system — said the island’s infrastructure was quickly overwhelmed.

In disaster-prone coastal areas like Puerto Rico, having more buildings that can be reinforced to withstand a hurricane is vital to restoring health, education and other vital services as quickly as possible. “No reason we can’t have backup generators available for every school in Puerto Rico or anywhere else,” said Redlener.

Just as, educators, police officers, firefighters, physicians and others who serve their communities need to talk to each other to develop response plans before a hurricane hits

so do families, teachers and other caregivers, he said. What can one do? Explain how to prepare for the next hurricane, to give a sense of control during post-disaster recovery. Reassure children their family and home will be safe if it should ever happen again. The child needs to know what the plan is the next time a hurricane blows through and where to go if the family is separated.

At first, Raiza Parilla said her children viewed the natural disaster as an adventure. They cleaned up leaves and debris from the street. They lived without electricity for a month and slept in the living room. Their school lessons moved outside. Now, as the weather is changing, Parilla’s children don’t act scared, but she said they ask more questions than they once did.

“Kids are at the bottom of the totem pole,” Garcia Coll said. “We don’t think of their needs systemically.”

‘There’s no opportunity for young people like me here’

For three weeks, Jacobo Merced’s home had no electricity, and five weeks passed before the water was restored. But his planning paid off — his family ate three meals a day, drank enough water and kept themselves and their clothes clean. His employer shipped him a gas-powered generator that he bought — an incredibly valuable item when it became clear the electrical grid’s issues would take time to solve. They fared better than many others on the island.

But his daughters have had enough. “‘We don’t want to stay here. When we can, we’ll leave and study any other place but not here,’” he said they told him.

His younger daughter will graduate high school next spring and wants to be an architect or interior designer. Natalia, now 22, lives with her parents and younger sister and works at an advertising agency in Mayaguez, saving money and making plans to leave the island forever. Three times a week, the electricity still blacks out in her home, she said — each time a reminder of Hurricane Maria.

The storm and everything it brought has worn down Natalia and her peers, despite the reserves her father stockpiled ahead of the hurricane

“There’s no opportunity for young people like me here,” she said.

Her father has no plans to leave Puerto Rico, but he knows he must let his children decide if their island can sustain their dreams and ambition. After Maria, he predicts the same economic and political forces that sent millions of Puerto Ricans to the mainland before the storm will soon compel his own daughters to leave.

“We’re destined to lose most of the minds of the future to contribute to the development of the island,” Merced said. “That’s a very big problem.”

Four months ago, electricity returned to Orocovis, the mountain town where Soto teaches, lifting the children’s spirits, he said. Yet Soto worries as this year’s hurricane season presses on. Since Hurricane Maria, he has installed solar panels on his concrete-block home. But he sees neighbors who still have wooden homes topped with blue tarpaulins. He knows if another record-breaking storm hits Puerto Rico, they will suffer.

And he worries about his students. To help them, he has talked about how to prepare for the next storm — what they should do, where they should go, how they should pack. Like his nephews, the children he teaches worry about another Hurricane Maria.

“Children in general are not and will never be prepared,” he said. “No matter what we tell them, the fear will always be there, but we will always be prepared to support them anyway.”

Spanish translation provided by PBS NewsHour’s Michael Rios and Patty Gorena Morales.