The emotional welfare of children follows predicatable patterns. In the fall, when school begins, beds at psychiatric treatment centers fill up. They empty again during summer break and the winter holidays.
In recent years, doctors and psychologists have detected a new pattern: Children's crisis centers brim with new patients in the aftermath of a school shooting.
In the week following the Valentine's Day shooting spree on the Parkland campus of Marjory Stoneman Douglas High, admissions of children to mental health treatment centers in Florida have spiked, professionals say.
"Children do not feel safe," said Patricia Ares-Romero, the chief medical officer of Jackson Behavioral Health Hospital in Miami. "Children are supposed to be happy — maybe a little concerned about whether they're getting good grades, or if they are going to get grounded. Right now, they're scared.
"Even when you have a dysfunctional family, when you do not have a good home life, there is one place where children always feel safe: in school," said Ares-Romero. "And now, that has been ripped away from them. This creates anxiety and fear, and they are coming into the hospital because they are not able to deal with that sense of uncertainty."
Jackson Memorial's 40-bed children's and adolescent psychiatric unit has been operating at or near capacity since the shootings, Ares-Romero said. Two-thirds of those beds typically are empty.
The lion's share of admissions to Jackson involve middle schoolers aged 12 to 13, Ares-Romero said, and the majority of the youngsters are experiencing acute anxiety, depression and fear.
Marcia Monroe, the chief clinical officer for the Central Florida Behavioral Health Network, said the nine children's crisis units within her authority also have seen an increase in admissions — though many of them were not voluntary.
"Given what regretfully happened in Broward, it's not only parents and caregivers, but people's co-workers, brothers, sisters are looking at social media — Facebook, Instagram, Snapchat — they're looking at what's being said, looking at photographs and taking to heart "if you see something, say something."
Martha Lenderman, a retired state mental health administrator who oversees Baker Act training statewide for USF, also said the tragedy likely prompted parents or other caregivers to seek help for their children after procrastinating in the past.
"They've seen behavior in the past that concerns them, but they've been putting it off.''
While previous school violence has brought an uptick in admissions, the effect following the Parkland shooting has been more pronounced, experts say. The pattern has been repeated throughout Florida.
"We are certainly seeing a higher level of visits than we usually see this time of year," said Kerting Baldwin, a spokeswoman for Memorial Regional Hospital in Hollywood, which is 35 miles south and east from where Nikolas Cruz opened fire with an AR-15 assault rifle, killing 14 teens and three educators — and wounding 15 others.
Memorial's pediatric emergency room typically sees between zero and six psychiatric patients on an average day, Baldwin said. Since the shootings on Feb. 14, such visits to the ER have about doubled, to 10 or 12.
Keep up with Tampa Bay’s top headlines
Subscribe to our free DayStarter newsletter
You’re all signed up!
Want more of our free, weekly newsletters in your inbox? Let’s get started.Explore all your options
Manny Llano, the CEO of Fort Lauderdale Hospital, said Friday he has "for sure seen an increase" in involuntary commitments for both children and adults.
"We've been full in the last few days," Llano said. "We've had to go so far as to turn them away and refer them to other facilities."
"I understand that there is lower attendance in the schools right now. People are at home, scared and concerned," Llano said. "Parents are paying attention to things they may have not before. The shooting is on their minds, and they are thinking about it and taking steps to bring it to someone's attention."
Llano said he didn't have data readily available but said his beds were "overflowing."
Near St. Petersburg, at the Personal Enrichment through Mental Health Services, or PEMHS, facility, the average census of the program's crisis stabilization unit for children is about eight kids. In the shooting's immediate aftermath, PEMHS had filled all 14 of its pediatric beds, and was sending some patients elsewhere for treatment, said Jerry Wennlund, the program's CEO.
For budget year 2016 (the most recent data available), 32,000 children were involuntarily committed to a psychiatric facililty under what is called the Baker Act, the state's mental health law. That represented a per capita increase of about 44 percent since 2011. Miami-Dade had the second-most such petitions, with 2,359; Hillsborough County, which includes Tampa, recorded 2,918. Broward reported an even 2,000, according to a database maintained by the University of South Florida.
Among children who are involuntarily committed, about 22 percent of the petitions are initiated at school.
On Friday, Gov. Rick Scott proposed a wide-ranging initiative to bolster security at Florida's schools.
The "action plan" includes $50 million in new funding for children's mental health and a proposal to "embed" in the sheriff's offices of all 67 counties a Department of Children & Families "crisis welfare worker for repeat cases in the community."
"We must expand mental health service teams statewide to serve youth and young adults with early or serious mental illness by providing counseling, crisis management and other critical mental health services," Scott said at a news conference.
Cruz, 19, has been charged with 17 counts of first-degree murder. His attorneys in the Broward County Public Defenders' Office have said they would allow Cruz to plead guilty if prosecutors agree to forgo the death penalty — though such a move is seen as extremely unlikely.
Cruz arrived at the school in an Uber, wearing a dark hat and carrying a black bag that contained an AR-15 semiautomatic rifle that he had bought one year earlier from a Sunrise "tactical supply" store. He prowled the school's interior, firing at students and teachers. Then he left on foot, blending in with panicked students. Spotted by a deputy after leaving a nearby Walmart, he was detained and cuffed.
Previous incidents of school violence also prompted an uptick in mental health admissions among children, even hundreds of miles away. Monroe, whose mental health network spans 14 counties in Central Florida, said children and youth in her catchment area sought assistance in coping with emotional trauma near the end of 2012, when 20-year-old Adam Lanza slaughtered 20 children — mostly 6- and 7-year-olds —at Sandy Hook Elementary in Newtown, Connecticut.
"After Sandy Hook there was a bit of a blip," Monroe said. "This is closer to home."
Ares-Romero, at Jackson, said Miami's psychiatric hospital also has seen swings in admission tied to cataclysmic events such as school killings, but few had the kind of consequences as the rampage at Stoneman Douglas. "There was so much more impact, because it was so much more close to home."
At PEMHS near St. Petersburg, demand for treatment beds spiked in the immediate aftermath of the Douglas shooting, then began to decline. Many of the admissions, Wennlund said, were involuntary, and involved parents and guardians for whom the Parkland tragedy appeared to be a wake-up call.
"People were being very cautious," Wennlund said. "This has people nervous and concerned. They want to make sure that they err on the side of caution."
When a child enters the door via the Baker Act, it's particularly traumatizing, Wennlund said. "If you have been Baker Acted, it's not your best day. It is alarming, and scary and frightening and upsetting. And it's not necessarily the best way to be introduced to services. But it may be the only way to get help for someone who is a danger to themselves or others."