The story hit like a punch to the gut. Montana Lance, a 9-year-old with a toothy grin and a love of anything mechanical, had apparently committed suicide in a restroom at his elementary school in The Colony, Texas.
And people wondered how that could even be possible. Why would a 9-year-old take his own life? How would a child that age even know about suicide?
Much of the shock comes from the rarity of such an act.
The numbers of suicides involving children 5 to 9 years old are extremely low -- a total of 33 nationally in the eight-year period of 1999 through 2006, with just two in Texas, according to the Centers for Disease Control and Prevention.
The numbers are so small as to be statistically insignificant, the CDC says -- a rate of .02 deaths per 100,000 children, compared with much higher rates of 10- to 14-year-olds (1.25 per 100,000), 15- to 19-year-olds (7.74 per 100,000) and 20- to 24-year-olds (12.35 per 100,000).
For children up to age 9, suicide isn't even in the top 10 causes of death. It ranks third for 10- to 14-year-olds and second for those 15 to 24.
But those 33 deaths of young children are "completed suicides," said Dr. Gregory Fritz, academic director at Bradley Children's Hospital, a psychiatric hospital for children in East Providence, R.I., and a professor at Alpert Medical School at Brown University.
"It's hard to know what the number of attempted suicides are compared with completed suicides," Dr. Fritz said, "but there are probably several hundred times more attempted suicides.
"We have an in-patient ward for children under 12, and every day there are children there who have attempted to kill themselves. And we're not an unusual psychiatric ward."
Fortunately, young children typically aren't left alone. Parents or other caregivers are nearby, able to intervene.
"Attempts are not as rare as people might think, but deaths are rare, thank goodness," Dr. Fritz said.
Thirty years ago, even professionals rejected the idea of child suicides. Cases that seem clear in retrospect were often described as "accidental."
"It used to be thought that children 5 to 9 years old couldn't be depressed, and that because they didn't have the capacity to think of time in the same way as adults they couldn't be hopeless," Dr. Fritz said.
"But kids that age can have profound sadness and want to kill themselves."
Those who knew Montana Lance didn't see him that way.
Robby Wright, a friend who served as spokesman for the Lance family, told The Dallas Morning News that Montana's death on Jan. 21 seemed to stem from "a sudden idea he had."
"If the building had fallen in on us, we couldn't be any more shocked," he said.
Brian Bradford, pastor of Horizons Church in The Colony, said the Lances are "a very giving family. Naturally, they're just numb."
"What makes this such a tough tragedy is there's nothing I know of that contributes to the 'why' of this," Bradford said. Montana's dad, Jason, works part-time as sound and media director at the church.
Over the past few decades, a growing base of knowledge about the way kids think, and what they think about, has changed the way psychiatrists and psychologists consider child suicide.
"It wasn't until the early '80s that this became much more of a topic," said Dr. Cynthia Pfeffer, a child and adolescent psychiatrist and a professor at Weill Cornell Medical College, part of Cornell University, in New York City.
"Kids always have pressures -- peer issues, academic issues -- and if a child has a tendency to be anxious, that's difficult also," she said. "This group has lower rates (of suicide), but that doesn't mean that a particular child might not be more at risk."
Anxiety, trauma, peer interaction and various conditions like bipolar disorder can be factors, Dr. Pfeffer said.
"Bullying is often a big issue," she said. "Hopelessness can be a risk factor."
And the motivation that leads to suicide can be very different from child to child.
"For some kids, it can be because they feel bad. They have a strong conscience and feel guilty and worthless and (as if they) don't deserve to live," Dr. Fritz said. "Sometimes kids do it because they're in an environment where their pain isn't recognized, or no one sees how unhappy they are. It can be a product of desperation."
But unlike teenagers, younger children are more "contextually dependent" -- reacting impulsively to things that happen.
Even then, though, there probably are warning signs.
Both Dr. Pfeffer and Dr. Fritz say parents need to be watchful for indications their child is troubled or unhappy.
"It isn't out of the blue that they decide to kill themselves," Dr. Fritz said. "If a parent sees their child withdrawing or being unhappy a lot of the time, being depressed, changing the way they act with friends, they should be concerned about that.
"Now, every kid will be moody, sad, mad at the world," he said. "But usually those feelings are more transient. If it lasts for several weeks, that's much worse than being mad for the day."
None of those signs necessarily point to suicide. But parents should consult a professional if the moods persist, the doctors said.
And if a child mentions suicide, take it seriously.
"I don't think most kids talk about suicide," Dr. Fritz said. "They don't say, 'I wish I was dead,' or 'I want to die' at any age. But if parents hear something like that, they should be worried.
"No parent wants to admit that a child is so unhappy that they mention suicide," he said. "They'll say, 'Oh, you don't mean that.'
"Well, they might."
Explore further: Early exposure to antidepressants affects adult anxiety and serotonin transmission