Discussion

Recent analysis of suicides throughout the world has indicated a shift in the magnitude of the problem from eastern Europe to Asia. ^{Reference Värnik7} Further, a study of the effects of the 2008 global economic crisis revealed a strong impact on suicides in Europe and the Americas. ^{Reference Chang, Stuckler, Yip and Gunnell8} Our analysis of suicides in children aged 10-14 years in 81 countries over two decades showed a minor decline in the overall suicide rate for boys, from 1.61 to 1.52 per 100 000, and a slight increase for girls, from 0.85 to 0.94. Overall the problem seems to be shifting to South America (with rates highest in Guyana and Suriname), with a significant increase in 9 out of 11 South American countries for boys and in 6 countries for girls. Yet suicide rates remain critical in some former USSR republics such as Kazakhstan, Kyrgyzstan and Russia, where the rates are especially high for boys. Both regions have experienced significant economic and financial problems in recent decades. Factors such as unfavourable economic conditions, poor environment and parental unemployment are also contributors to suicide in children. ^{Reference Kõlves9} However, as shown recently, governments have an important role in implementing strategies to minimise the adverse effects of a country’s economic recession. ^{Reference Stuckler and Basu10} As concluded by Hawton & Haw:

Although suicidal behaviours are often linked to mental disorders (especially mood disorders) at the individual level, prevalence of mental disorders in a given country or region may not be reflective of suicide rates at a national or regional level. A systematic review and meta-analysis of 116 epidemiological studies on the prevalence of major depressive disorder showed that point prevalence in the world was 4.7%, being lowest in North America (3.7%), east and south-east Asia (4.0%) and South America (4.0%), and highest in south Asia (8.6%) and in Africa and the Middle East (6.6%). ^{Reference Ferrari, Somerville, Baxter, Norman, Patten and Vos12} The authors detected a time trend, suggesting an overall increase with the time of major depression. However, children aged 10-14 years have a lower prevalence of mental health problems associated with suicide compared with the age group 15-19 years. ^{Reference Soole, Kõlves and De Leo13}

It is important to note that the countries with the world’s highest suicide rates for girls aged 10-14 years, Guyana and Suriname, are the non-Latin countries of South America, both with high proportions of south Asian (mainly Indian) population. Analysis of the Nickerie, the region with the highest suicide rates in Suriname, showed that the problem is concentrated in the younger Hindustani population. ^{Reference Graafsma, Kerkhof, Gibson, Badloe and van de Beek14} High suicide rates have been shown in other Indian diaspora groups. ^{Reference McKenzie, Serfaty and Crawford15} Another important factor contributing to increasing suicide rates in Central and South America is the high prevalence of different suicide risk factors in native ethnic groups. More specifically, there have been indications of changes in suicide rates of indigenous young people. ^{Reference Botega, D'Oliveira, Bertolote, Wasserman and Wasserman16,Reference Quinlan-Davidson, Sanhueza, Espinosa, Escamilla-Cejudo and Maddaleno17} Analysis of groups in Australia showed that Aboriginal and Torres Strait Islander populations had a 2.2 times higher suicide risk, which was even more pronounced in children aged 5-14 years, with indigenous children having a 9.6 times higher suicide risk than non-indigenous children. ^{Reference De Leo, Sveticic and Milner18} Pettersen & Vasques suggested a role for the high demands of academic performance, lack of family support and strict parental style, as well as sexual and psychological abuse of children and adolescents and wide-spread substance misuse in South America. ^{Reference Pettersen, Vasques, Wasserman and Wasserman19} Substance misuse (mainly heavy alcohol consumption in the society) has been related to the suicide mortality of youth in Russia, ^{Reference Chang, Stuckler, Yip and Gunnell8} and in addition social media and overall media reporting have been blamed for recent clusters of teenage suicides in Russia. ^{Reference Kaylen and Pridemore20}

There is no systematic information about the causes of child suicide in Kazakhstan, which has the world’s highest rate for boys aged 10-14 years and has shown an increase for both girls and boys. ^{Reference Haarr22} Recent reports by the United Nations Children’s Fund (UNICEF) consultant Robin Haarr gave some insight into the violence and suicidal behaviours of children in Kazakhstan. ^{Reference Haarr23,Reference Haarr24} The assessment of children’s vulnerabilities to risk behaviours, sexual exploitation and trafficking showed that factors related to suicidal behaviours vary. ^{Reference Haarr23} Often they are related to the multiple forms of violence, abuse, neglect and exploitation children experience in their lives, further complicated by stigmatisation and discrimination. A recent analysis of violence in schools in Kazakhstan revealed that children engaging in self-harming and suicidal behaviours were significantly more likely to witness and be the victims of school violence and discrimination by their peers, and they were also more frequently perpetrators of school violence. ^{Reference Haarr24} In addition, they experienced discrimination from school directors and teachers more frequently. Children engaging in self-harming and suicidal behaviours were also exposed to other factors such as family domestic violence and running away from home. ^{Reference Haarr24}

The prevalence of suicide in children is likely to be underestimated owing to underreporting and/or misclassification of suicide deaths as accidental or undetermined. Research suggests that suicide may be more underreported among children than in adolescents and adults. ^{Reference Pritchard and Hansen25} This might be due to social stigma and shame around suicide, coroners’ reluctance to determine a verdict of suicide in a child or the misconception that children are precluded from engaging in suicidal acts owing to their cognitive immaturity.