SAN FRANCISCO — Jason Lance thought Jan. 21, 2010, was a day like any other until the call came.
He had dropped off his 9-year-old son, Montana, at Stewart's Creek Elementary School in The Colony, Texas, that morning.
"There were no problems at home. He was smart. He wore his heart on his sleeve and he talked and talked and talked," said Lance. It was "the same old, same old normal day. There were kisses and goodbyes and he said, 'I love you, Daddy.'"
A few hours later, school officials called to say Montana had died by suicide while locked in the nurse's bathroom.
"I knew he had some issues going on in school, but I never seen it coming," said Lance. His shock and grief were complicated by the realization that there may have been more signs his son was struggling.
As children across the country step back into school routines this fall, it is important to pay attention to their mental health as well as their academics. Suicide ranks as either the seventh- or eighth-leading cause of death among children ages 5 to 11, according to the Centers for Disease Control and Prevention and recent studies. And numbers show the rates among younger kids appear to have increased in the past decade, especially among Black boys.
A growing body of research shows that "historically we thought that suicide is a problem of teens and adults, but younger children are expressing similar thoughts that may have been ignored before," said Paul Lipkin, a pediatrician at the Kennedy Krieger Institute in Baltimore and a specialist in developmental disabilities such as autism.
This has many experts calling for lowering the screening age for suicide ideation in children and moving to develop more effective early suicide risk detection and targeted prevention strategies. The broad approach includes pediatricians, teachers, and parents working with children at a young age to build their resilience and identify and manage their stress.
Studies have found that young children gain an understanding about death and killing oneself from TV or other media, discussions with other children, or exposure to death from a family or community loss.
"Pediatric suicide wasn't on our radar decades ago and maybe was underreported," said Holly Wilcox, president of the International Academy of Suicide Research and a professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore. "The truth is that now we can do stuff about it."
It is quite likely the 136 reported suicides from 2001 to 2021 among 5- to 9-year-olds were an undercount.
"Counts are often incomplete, and causes of death may be pending investigation resulting in an underestimate relative to final counts," said Margaret Warner, a senior epidemiologist at the CDC.
The problems with those numbers are important because, Warner said, "if we are missing deaths, or don't have all the information leading to them, we can't properly develop programs to prevent future deaths."
That's why there's also an ongoing national effort by coroners and medical examiners to improve the quality and consistency of pediatric death investigations.
Leaders in suicide prevention hope this wide spotlight on pediatric suicide will also help curtail the rising suicide rate among people ages 10 to 24 in the U.S. since suicide is the second-leading cause of death in that age group, according to the CDC.
Some of the increase in mental health issues among children has been attributed to the isolation and lack of school structure during the pandemic. Beginning in April 2020, pediatric emergency room visits for children 5 to 11 increased approximately 24%, according to a CDC report from November 2020.
Other factors, such as being neurodivergent or having a psychiatric disorder, can make a child more vulnerable to suicide.
A study published in February in Frontiers in Public Health also found that being the victim or perpetrator of bullying is a risk factor for suicide, even when researchers controlled for other risk factors.
Montana Lance was diagnosed with attention-deficit/hyperactivity disorder, as well as dyslexia, and often was the target of bullying at school.
Officials at the Lewisville Independent School District declined to comment on Montana's death. His parents filed a lawsuit against the school district, but it was dismissed, and the district was found not liable for his death.
Suicide is complex, but recent studies have found that there are things parents, teachers, pediatricians, and caregivers can do to help protect children from it.
Lisa Horowitz, a pediatric psychologist and staff scientist at the National Institute of Mental Health, said, "It's never too early to start a conversation with kids about recognizing mental health distress and doing what we can do to help them have better coping strategies and foster resilience."
Building resilience in children can help buffer them in times of stress, according to a study published in 2022 in Frontiers of Psychiatry.
"I don't want people to panic but just want them to be vigilant about their children," said Horowitz.
Sometimes that vigilance can be "tricky" because depression may look different in younger kids. They may act out, be more irritable, and not manifest their symptoms in the same way as teens and adults, Wilcox said.
"We don't have enough studies on how best to identify preteens and children at risk for suicide. Oftentimes you just have to trust your gut about these things," she said.
If a child is upset, parents should ask them questions about what they're experiencing, said Tami D. Benton, psychiatrist-in-chief, executive director, and chair of the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children's Hospital of Philadelphia.
"Parents shouldn't talk kids out of their feelings or give them examples of when it happened to them, or minimize their feelings. It puts them down," she said.
Parents and children should come up with a plan together, but also teach their children that they can master these situations, said Benton.
When parents get stuck about what to do in difficult situations, they should consult with their child's pediatrician.
In March, the American Academy of Pediatrics recommended universal screening for suicide risk in all children 12 and older and when clinically indicated for kids 8 to 11. There aren't any screening tools validated for use in children under 8. But Horowitz said younger children can still be assessed and evaluated for suicide risk.
Schools can also play an important role in suicide prevention.
Meghan Feby, a school counselor in the Colonial School District in New Castle, Delaware, said, "I am the sole school counselor in my building. It is a daunting task. That's why there are supports in place that have eyes where I can't have eyes … on school computers. Employing software strategies like GoGuardian Beacon can really help fill in gaps and supports."
The software captures keywords and phrases that might indicate a child is thinking about suicide and has already been used to intervene when children using district computers displayed concerning behavior. It is monitoring activities on school computers used by more than 6.7 million public school students in kindergarten through 12th grade.
Some schools said they are having problems implementing software like this because some parents find it intrusive.
Many schools use the Good Behavior Game, a decades-old behavior management intervention for kids in first and second grades, and it has been used in higher grades. The team-oriented classroom curriculum uses peer pressure to stimulate students to be attentive and engaged and work together. Researchers such as Wilcox have studied the extensive participation of thousands of students and found it reduced suicidal thoughts and behaviors.
Children who have played the game were half as likely as young adults to report suicidal thoughts and about a third less likely to report a suicide attempt.
Lance said that the day Montana died by suicide changed his life forever.
"You're not supposed to bury your children. They're supposed to bury you," he said. "All this attention on the mental health status of children these days is not going to bring my child back, but it can stop another family from suffering."