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Table of Contents
Year : 2022  |  Volume : 4  |  Issue : 2  |  Page : 69-77

A Review of Intersection of Social Determinants and Child and Adolescent Mental Health Services: A Case for Social Psychiatry in Pakistan

1 Founder & CEO, Synapse Pakistan Neuroscience Institute, Karachi, Pakistan
2 Consultant Child, Adolescent, and Adult Psychiatrist, Karachi, Pakistan

Date of Submission29-Jun-2022
Date of Decision29-Jun-2022
Date of Acceptance30-Jun-2022
Date of Web Publication22-Aug-2022

Correspondence Address:
Dr. Ayesha I Mian
4th Floor, 13 GPC, Rojhan Street, Block 5, Clifton, Karachi 75600
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_23_22

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Pakistan faces the accelerated growth of a young population each year. The country's many structural challenges include an unstable economy, poverty, gender inequality, health disparities, and vulnerable systems (especially sectors serving education and justice). The advent of the 21st century has witnessed rapid societal change globally. This societal evolution has inevitably shaped the sociocultural landscape for Pakistan's children, families, and childrearing practices as well, yet the social determinants remain stacked against them. Although children make up one-third of the Pakistan population, they remain the most physically, economically, and socially vulnerable group. For children growing up in low-income families, which are the majority, these challenges are magnified to a greater degree. These children are more likely to experience multiple family transitions, frequent moves, and change of schools. The schools they attend are poorly funded, and their neighborhoods more disadvantaged. The parents of these children have fewer resources to invest in them. Thus, the home environment becomes less cognitively stimulating, and parents invest less in education. Living in poverty and struggling to meet daily needs can also impair parenting. Socioeconomic deprivation during childhood and adolescence can have a lasting effect, making it difficult for children to escape the cycle of poverty as adults because the adverse effects of deprivation on human development accumulate. Health services for children are also underresourced. This state is evident by the extreme shortage of child and adolescent mental health (CAMH) services in a country with a significantly high disease burden among children and adolescents experiencing mental health disorders. The article examines the social determinants of CAMH in Pakistan and their implications for the orientation and effectiveness of child mental health services.

Keywords: Child mental health, low- and middle-income countries, Pakistan, public health, social determinants, social determinants

How to cite this article:
Chachar AS, Mian AI. A Review of Intersection of Social Determinants and Child and Adolescent Mental Health Services: A Case for Social Psychiatry in Pakistan. World Soc Psychiatry 2022;4:69-77

How to cite this URL:
Chachar AS, Mian AI. A Review of Intersection of Social Determinants and Child and Adolescent Mental Health Services: A Case for Social Psychiatry in Pakistan. World Soc Psychiatry [serial online] 2022 [cited 2023 May 31];4:69-77. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/2/69/354181

  Introduction Top

According to the World Health Organization (WHO), social determinants of health are “the circumstances under which people are born, grow, live, work, and age.”[1] It is difficult to definitively prove, but many links between earlier social experiences and later health outcomes are causal, with potential psychological and physiological explanations explaining the connections.[2] Reaching health equity requires valuing everybody equally with focused and enduring efforts to address avoidable inequalities and historical and ongoing injustices and eliminate health and health-care disparities. Clarifying how equity has been conceptualized and measured is an essential first step for the child and adolescent mental health (CAMH) population.[3] Social determinants of health impact a child's mental health, well-being, and quality of life. Examples of four social determinants demonstrate CAMH-based inequities and health outcomes among people transitioning into adulthood; these include (1) socioeconomic status, i.e., low education and family income; (2) childhood adversities, i.e., maltreatment and domestic violence; (3) family configuration across development, i.e., single, motherhood, the role of fathers, early childbearing, divorce, and paternal attitudes; and (4) neighborhood-related factors, i.e., residential arrangement, stability, and community involvement. The concept of social determinants attempts to uncover the factors associated with the community's profoundly ingrained health inequities. It is worth noting that social determinants of health are the same as health inequity determinants.[4] The most striking example of health inequity is the discrepancy of CAMH services in low- and middle-income countries (LAMIcs). Children's rights, social justice, human capital investment, and health equity ethics are the four components of child health equity. These components can be used to promote children's health by eliminating health inequities through equity-based clinical treatment, child advocacy, and policy formulation.

The fundamental feature of health sector reform in Pakistan is health as a right. Literacy, income, access to safe drinking water, housing, and family size are essential health determinants. These are also known as traditional health determinants. However, considering conventional health determinants is insufficient for a country like Pakistan. Given the current state of inequity, evaluating the variables underlying the social determinants, known as structural determinants,[5] is critical. The governing process and economic and social policies affecting income, working conditions, lodging, and education are structural determinants. Structural determinants influence whether health-care resources are distributed equally in society or unequally based on race, gender, social class, geography, sexual orientation, or other factors. These structural determinants must be prioritized in policies and programs. Unfortunately, most analyses miss this reality.[6] This article also discusses the intersectionality of social causes of CAMH in Pakistan.

  Child and Adolescent Mental Health Services in Pakistan Top

As a nation of 229 million[7] and 60% of people under 30,[8] Pakistan has one of the world's largest youth populations; despite accounting for one-third of Pakistan's population, children remain the most physically, economically, and socially vulnerable demographic. With rapidly growing young people, the country is confronted with several structural issues, including the pressures of a stressed economy, poverty, health inequities, and unstable systems, particularly in the education and justice sectors.[9] Child mental health services in Pakistan are still in their infancy, and there are only a handful of dedicated child psychiatry teams, mainly in the provinces of Punjab and Sindh, where services are located primarily in the urban sector. These services are almost nonexistent in the remaining two provinces, Baluchistan and Khyber Pakhtunkhwa.[10] The focus of the child health-care system has been on communicable diseases that have almost ignored the CAMH needs. The accessibility and availability of the practice, referral mechanisms, and connections with physicians and pediatricians influence the usage of services in Pakistan. As per WHO data, 21 million child and adolescents experience some mental health problem.

As stated above, CAMH services are limited to a few tertiary areas of the country. It is conventionally believed that referrals to these services are usually from the schools. However, there is major variability in this pattern, primarily because of the absence of mental health awareness and stigma attached to mental and emotional disorders.[11] Nonpsychiatric physicians, including pediatricians, are also a significant referral source, showing the need to enhance more work to examine the existing pathways to psychiatric care.[12] A survey in Lahore found a prevalence of 9.3% emotional and behavioral problems, with 'anti-social' problems as a common issue. Since the school systems do not have mental health services; teachers are not trained to identify children with problems.[13] As a result, most children with mental health illnesses or learning difficulties are ignored and labeled as “slow,” “disobedient,” or “naughty.”

Another reason for underresource is the shortage of CAMH professionals. Children with CAMH issues go undiagnosed and mistreated since there are <10 trained child and adolescent psychiatrists in the country. Faith healers and religious leaders are the first approaches for most mentally ill patients. Also, pediatricians, who are also often the first gatekeepers, are not trained in recognizing, diagnosing, and treating common CAMH diseases.

This highlights the need for intervention in the integrated path to mental care. Heuristics, misleading endorsement of symptoms by teachers, parents, and physicians, or clinicians' differential interpretation of diagnostic criteria can lead to unintended overdiagnosis, misdiagnosing, or polypharmacy.[14] In addition, parental lack of knowledge, lack of information, and the stigma associated with specific conditions such as epilepsy and CAMH disorders may be grounds for avoiding seeking guidance or treatment. Current professionals in the field have an unbalanced understanding of CAMH problems due to several misconceptions regarding many of the salient features of developmental, cognitive, and emotional features.[15]

In addition, there is a substantial dearth of child mental health data, reflecting an unmet need for representative statistics on children's primary mental health problems. Although the United Nations strongly emphasizes prevalence of pathology in LAMICs,[16] most of the literature is based on high-income countries' suggestions. Given the large vacuum in published data on LMICs, such an approach may only be partially applicable in LAMICs. The scarcity of child mental health services in Pakistan mirrors the dearth of epidemiological studies. There is a lack of mental health services for children, partly reflecting a lack of adequate information about the magnitude of the needs that should be met.[17]

  Country Situational Analysis Top

Economic factors

Pakistan is the South Asian country with the lowest Human Development Index (HDI). Given the high annual rate of youth population growth, the country faces a relative risk of poverty.[18] It is worth noting that Pakistan's primary health-care provider is the private sector, with a limited to nonexistent health-care insurance system and an inadequate public health system. This is understandably linked to out-of-pocket costs and restricts access to health treatments. The average life expectancy at birth is 65 years. As a LAMIC, Pakistan has significant socioeconomic disparities between rural and urban areas, as poverty is higher in rural areas (55%) than in urban areas (9%), and health outcomes reflect this disparity. For example, children in rural areas have more respiratory infection symptoms than children in urban areas, and roughly half of rural young people are not adequately immunized. Furthermore, stunting, wasting, and being underweight are more common in rural areas, affecting children's educational prospects - for example, only 60% of children aged ten and up attend school.[19] Research has established that children who grow up in an area with a high population and a low HDI are likely to lack resources for optimal growth, especially in the early years.[20] However, in Pakistan, child poverty is measured using resources that do not explicitly show child poverty estimates.

Children in rural Pakistan face visible disparities between rural and urban areas as most urban populations fall below the national poverty line.[16] A lack of urban planning for physical and social infrastructure is a significant barrier to employment opportunities. This never-ending struggle to meet basic needs denies children's fundamental rights to education, development, good health, and safety, directly and indirectly.[21] For example, the disparity between household needs and parents' ability to meet those expectations, where children are forced to work.[22] According to the International Labor Organization, Pakistan's child labor population has surpassed 12 million.[14] Many children work as domestic laborers in factories, agricultural fields, textile, and domestic industries. Widespread risk factors such as poverty, insufficient legal protections, illiteracy, big family size, or unemployment create situations conducive to child abuse.[23] On the other hand, parenting stress and factors mediating parental depression are influenced by the social gradient as seen as more common in lower-income communities.[24]

Health-care system

Pakistan is one of the signers of the Sustainable Development Goals, which seek to improve maternal and child health and reduce poverty.[25] Their target is to end all forms of malnutrition by 2030, attaining the internationally agreed targets on stunting and wasting in preschoolers by 2030.[26] However, children's nutritional status is far from optimal, with 35% underweight, more than half stunted growth, and roughly 9% emaciated.[26] The most important indicator of social development is a child and maternal health, indicating a country's level of nutrition, learning, and access to health care. Compared to surrounding countries, Pakistan has a high newborn death rate.[27] Most children in Pakistan do not get the fair opportunity to attain full health potential (health equity). Malnutrition, the rise of infections including diarrhea and pneumonia, and a lack of access to drinking water, health care, and sanitation contribute to this worrying scenario.[28],[29] One out of every fourteen Pakistani children dies before age one. One of every eleven children do not live to see their fifth birthday.[30] Despite efforts and progress, there are significant inequities and barriers to receiving safe childbirth delivery services during prenatal, natal, and postnatal periods. It has been established that the mother's nutritional status affects the child in utero, and early breastfeeding is associated with protection against childhood infections. However, early breastfeeding initiation is low in Pakistan, i.e., within 1-h of birth. Early recognition and treatment of mothers' mental health problems may help reduce children's morbidity and mortality rates.[15]

Sociodemographic factors

Countries with higher levels of education demonstrate better health equity. Pakistan has the world's second-highest proportion of out-of-school children.[31] Girls face a worse situation as they attend school at a lower rate than boys. However, school enrollment is much lower in rural areas due to poverty, distance from schools with no transportation, school inaccessibility, and a lack of awareness of education needs.[32] The movement restrictions, school closures, and stay-at-home during the COVID-19 pandemic will likely lead to a rise in the rates of domestic violence, loneliness, depression, fear, panic and anxiety, and substance use among school students.[33] The potential fallout of an economic downturn on physical and mental health is likely to be profound, but they are not inevitable. Government measures will be crucial in mitigating widening inequalities and public health consequences by identifying and ensuring that the most at risk are protected. This area required a discussion of a specific budgetary analysis focused on child health, education, and social protection and practical measures taken by various agencies and organizations within civil society.[34]

Children with disabilities and special needs are among Pakistan's most vulnerable and neglected citizens. WHO estimates that 10% of the population in developing nations live with disabilities, including 10% of the people in Pakistan. The propensity of individuals with disabilities to live in poverty is a cyclical issue. Poverty and disability are linked in two ways: Disability increases the chance of poverty, and poverty increases the risk of persons with disabilities.[35] This situation is evident as 66% of the population with disabilities live in rural areas, and 23% of this cohort is school-aged children. However, integrating special needs students into the regular school system is a relatively recent phenomenon. Although Special Education Departments run centers for disabled students and provide free transportation, hearing aids, and other auxiliary services, only 2% of students have access to special education.

Child rights

Children's rights can be defined as “the rights, which are concerned both with the protection of the individual child and with the creation of the conditions in which all children can develop to their full potential.”[36] The larger domains in which these rights are usurped are those related to education, health, neglect, abuse (physical, emotional, and sexual), corporal punishment, and child labor.[34] For the child and adolescent population, the government of Pakistan signed up for the Convention on the Rights of the Child on September 20, 1990. It was ratified on November 12, 1990, by the United Nations High Commissioner for Human Rights.[16] By signing this treaty, the government agreed that every child has the right to survival; maximum development; Protection from harmful influences, abuse, and exploitation; and full participation in family, cultural, and social life. However, in periodic reports, suggestions were not adequately addressed.[37]

Another critical question is Who is a child under Pakistani law? In legal cases involving children. The juvenile justice system is overwhelmed by insufficient infrastructure and resources, overcrowded jails, and a lack of focus on reform.[38] Although there are rules concerning children, their implementation leaves a lot needed. Despite a legislative obligation, Pakistan does not have separate courts for minors. Gaps in the current legal framework have resulted in countless abuses of children's rights, making them vulnerable.

Geopolitical factors

After religious and ethnic strife in the Indo-Pak area, Pakistan became an independent state in 1947. It has a distinguished history as an ancient civilization.[39] Despite having a wealth of historical and natural resources, the country's economic and social growth has lagged. Pakistan is also prone to natural hazards, which have caused numerous internal displacement and migration movements. Despite the government's sparse help, the affected zone remains one of the country's least developed places, with underlying poverty jeopardizing children's rights to survival, education, health, and protection. The country's political and military crises have exacerbated the problem. On the other hand, Internal migration streams are often linked to the development disparity between urban and rural areas. People move for better employment opportunities and to overcome poverty.[40]

Internally-displaced Pakistani (IDP) children belong to families who fled a military operation fighting against terror.[41] Since 1990, Pakistan has hosted one of the five largest refugee populations worldwide (IOM Migration Data Portal, 2018). As a result, Afghan refugees, especially undocumented migrants, are at risk of abuse. Children make up around 42% of the IDP population, given the geopolitical circumstances. In addition, more than 47,000 individuals have perished due to terrorism-related violence.[42] Estimates of common mental disorders in an IDP population have been found, with 60% affected before displacement. The displaced face adversity due to security restrictions for which the government has made provisions; however, the increase in number from original estimations has overwhelmed government facilities.[43] The lack of capacity of overburdened countries to respond to conflict-related, displaced populations' mental health needs is like anywhere else.[44]

Nevertheless, the government has established temporary shelters, such as government schools.[45] Child protection is also an issue; poverty, lack of education, and insufficient access to essential services are shared among Afghan children (International Rescue Committee, 2017). Moreover, they face bodily injuries, death, and forced recruitment into the armed forces directly from the fight against terror. In addition, displacement, loss of family, and trauma connected with witnessing acts of violence impact them indirectly.

At-risk population

According to the Pakistan Demographic Health Survey (PDHS) 2012-2013, fertility is considerably higher in rural communities than in urban areas. On average, most rural women have 4.2 children. However, the contraceptive prevalence rate remains low, and most people are not using birth control methods. This is despite 96% of married Pakistani women being aware of at least one modern contraceptive method. Adolescents and young people frequently face barriers in accessing sexual and reproductive health information and services, cascading impactson their lives and opportunities. The Pakistan Demographic and Health Survey (2006-2007) revealed that nearly half of the girls aged 15–18 were pregnant or caring for a child.[46] UNFPA has piloted four adolescent counseling centers in collaboration with the Department of Population Welfare and Pathfinder. More than 9,000 adolescents and young people accessed services in the past 2 years. Despite these efforts, many factors contribute to early or child marriages, including weak legislation, a lack of enforcement of existing laws, public awareness about the harmful lifelong and intergenerational effects of child marriages, internal trafficking, poverty, and an ineffective birth registration system.[47] Birth registration for children, particularly girls, has not been prioritized, allowing the child's age (especially for girls) to be manipulated at marriage. Most children under-five in rural areas are not registered at birth. As a result, rural areas have a higher rate of young marriages than urban areas.

South Asia stands at the second-highest, with 30.7% of its population living in slums as of 2014 (U.N., 2015). Pakistan holds one of the world's largest slum regions, Orangi Town Karachi. Regarding disparities, the PDHS coverage data for 2018 does not explicitly highlight the child health discrepancies in the slum areas. Nevertheless, marginalization, ethnic and economic, low awareness levels, caregivers' neglect, and inaccessibility to the health-care centers have been identified as the significant barriers to health-care access in the slums.[48] Similarly, neglect by nuclear and extended families from impoverished communities and family conflicts might cause children to seek sanctuary on the streets. As a result, these street children are at a higher risk of being denied crucial developmental support and exposed to numerous dangers. They are also more vulnerable to sexual exploitation.[49] These street children are at a higher risk of deprivation from support essential for development and various forms of danger. They are also at a higher risk of sexual exploitation. Around 90% of the 170,000 street children in Pakistan are subjected to the sex trade, and it is estimated that only 20% of sexual abuse cases are reported. However, 60% of young victims accuse the authority of being the perpetrators.[50]

Cultural and familial factors

The family structure and dynamics of the home environment are the primary site for vitality, early schooling, and the stabilization of adult personality development. Pakistan has traditionally maintained a combined family system. However, the balance has moved toward the nuclear family system with time, as in other Asian countries.[51] There has been a slight shift in the dominant role of parents in metropolitan regions. However, life in rural areas is mostly unchanged. Traditionally, the oldest male family member heads the family, and male members are regarded as the financial providers, though this is changing. Families have an average of seven people and mixed family compositions.[52] As a result, extended family members and substantial childrearing tasks may shape parenting.[53] Mothers are often unemployed and are expected to stay at home and care for the extended family.[54] Endogamous weddings are widely practiced, with cousin marriages occurring in most of Pakistan's urban and rural communities.[55] Grandparents and extended families play a vital role in the care and wellbeing of children, influencing essential milestones in the future, such as career and marital decisions.[56] As a daily societal norm, harsh disciplinary measures are commonly considered acceptable corrective parenting strategies.[57] As families migrate to urban centers in hopes for better opportunities and therefore improving their socioeconomic status, some of these traditional support structures are disrupted. Nuclear parents may report additional parenting stress and challenges in raising children which may increase the risk of adverse developmental processes.

Every child endures changes from one ecological milieu to the next, and families act as a buffer between globalizing influences and children's daily decisions and challenges - the same is true for Pakistan. Children's developmental trajectory, mental health and rights, the sociocultural landscape for families, and childrearing methods in Pakistan have been impacted by global trends of digitalization, industrial development, urbanization, and ecological transitions in the family structure.[51] These adjustments in context are ecological transitions, such as starting school, getting a sibling, getting married, getting divorced, a new teacher, single parenthood, unmarried partnerships, same-sex marriages, and remarried families have grown to favor viable living arrangements. In the bigger picture, some regions view globalization as a forced westernization. The reaction to this notion is sometimes reverting to fundamentalist leanings. People return to what they feel are their societies' original practices and cultural ideas to maintain “traditional” values and convictions.[58]

Religion, or the culture of religion, is a fundamental pillar of Pakistani society.[2] It is the foundation of their daily lives, and religious precepts are strictly adhered to and constitute an integral component of everyday life. In some cases, it becomes the basis of developing children's sentiments toward the opposing gender and sect shaped primarily by parental prejudices and religious inclination.[59] The great majority of Pakistani adolescents identify with religiously oriented value systems. This deep identification may serve as a source of identity and feeling of self for many of them. Some children may be at risk of being radicalized due to this predisposition. Families prefer madrassas in difficult economic situations with limited access to formal education. Certain madrassas have long been regarded as essential in developing radicalization in the country, with a reputation for influencing young minds.[60]

Individual factors

Individual factors such as the child's gender, age, and birth order should be considered. A child's gender can influence health-care services, the risk of maltreatment, education priorities, and intergenerational biases.[61] For example, stricter disciplinary techniques for female children may reflect parental attitudes and practices than for male children. Similarly, girls are less likely to receive overall health care and less likely to receive treatment for CAMH problems, particularly behavioral issues such as ADHD.[62] One possible explanation for gender differences is that parents may regard behavioral problems as culturally acceptable, especially for boys, and thus are unaware of the need for treatment for some girls. Unfortunately, this gender disparity is not being addressed. A child's age and familial characteristics may influence how a family treats a child. For example, an increase in a child's age determines the lowest risk of maltreatment. Bullying by an older sibling, verbal abuse, family quarrels, physical fighting, and the child's academic standing, on the other hand, are examples of familial influences. Birth order also influences how a child is treated in the family, as middle children are likelier to be abused than the first and last children. In addition, the firstborn is considered a valuable asset to the family. As a result, they become role models for their siblings as time passes. In contrast, the last born is usually too young. It is subjected to less discipline and rules due to family pampering.[61] As a result, children in the middle of the birth order are less likely than the oldest to receive CAMH treatment overall. This aspect is consistent with the literature, which shows that investment in children's health, education, and nutrition varies by birth order. Concurrently, the interaction of familial factors with individual variables is significant in elucidating the social determinants of CAMH. For example, parental factors for child maltreatment include a history of childhood abuse, parental academic level, socioeconomic wealth index, mother's age, and the connection between physical fighting in the family.[61]

Health seeking factors

Decisions related to CAMH disorders treatment occur in a unique context, distinct from other health-care decisions and even adult mental health treatment decisions. CAMH problems may emerge gradually and are challenging to differentiate from ordinary - albeit challenging - developmental behaviors.[63] Although it is uncertain if the father's presence increases the child's likelihood of receiving mental health treatment when required, in terms of gender, there is a likelihood of active effort while pursuing better health-care services for a male child than a female child.[61] One-parent families are more likely to use services but not less likely to have unmet needs.[64] Research suggests that grandmothers may be just as effective as husbands at ensuring children get needed treatment. Indeed, the father's presence may inhibit children from getting treatment in general and for CAMH disorders. One possible clarification for this result may be that fathers are more opposed to the treatment for mental health and favor an approach of “toughing it out.” Likewise, the number of adults in the home might influence the probability of treatment, especially if there are considerable time constraints in seeking special treatment. Nevertheless, this applies to Pakistan, with extended family members being the key stakeholders in childhood development. In addition, while birth order has been found to influence other forms of investment in children, such as education, it has not been studied in children's mental health-care use.[65]

  Implications Top

Child development is a complex interrelationship of biological, social, psychological, and economic factors.[66] Isolated variables and their intricate interactions between risk and protective factors and environmental features within different systems can change the lives of children and their families.[67] In childhood, optimal mental health is a powerful predictor of adult mental wellbeing and is linked to various positive outcomes later in life, including enhanced social interactions, higher educational attainment, employment, and financial security.[68] CAMH disorders can impact social factors such as homelessness, school dropout, marital instability, and economic insecurity; the bidirectional relationship between mental health disorders and social determinants can exacerbate personal choices, affect living conditions that limit opportunities, and influence how one navigates societal norms and structures affecting educational performance, employment capacity, and involvement with the justice system.[69],[70] However, this is less commonly explored than the reverse pathway.[71] Baranne and Falissard[72] have highlighted how health determinants have evolved from mortality to disability. It was only recently that CAMH has received consideration in this construct.[73] They have specifically highlighted the phenomenon of Epidemiological Transition in the burden of CAMH disorders among 5–14 years. E.T. is the complex change in patterns of health and disease and the interactions between these patterns and their demographic, economic and sociologic determinants and consequences.[74] CAMH disorder account for 15%–30% of the disability-adjusted life years (DALYs) lost during the first three decades of life.[75] The prevalence of mental health disorders in children and adolescents has been estimated to be between 15%[73] and 20%[76] globally, with studies indicating the median age for onset being 14 years. Higher rates of CAMH problems tend to occur in poorer countries. Although the government has not been established as a substantive factor in prevalence estimates within multivariate models,[75] the unequal distribution of resources causes disparities in social determinants.[77] Government responds to the hierarchy of needs with increased resource allocation to health issues like malnutrition and infectious disease. Only when these health factors with higher DALYs are better addressed, and communities become more complicated with technology and societal advancement, then the implications of MH and CAMH disorders become more explicit.

Social gradient affects both risk factors for disorder and barriers to services, affecting mental health outcomes. For example, individuals already at risk of experiencing social, mental, and physical health issues, minimal family income becomes a barrier to seeking treatment, alone or with symptom intensity.[78],[79] Mood disorders, neurodevelopmental disorders, and other CAMH problems interfere with children's wellbeing, educational attainment, and future job performance. Thus, undiagnosed and untreated CAMH problems impact future psychosocial and economic wellbeing.[80]

Developing countries like Pakistan face challenges in promoting and implementing child mental health care, including stigma, illiteracy, lack of adequate statistical data, and a severe shortage of pediatric psychiatrists.[81] Despite the challenges discussed above, in recent years, Pakistan has taken positive strides to start the conversations about MH leadership and the professional landscape, a trend that is likely to continue. However, the various components of public and private health-care systems have remained inadequate in reducing this treatment gap. To create and maintain the momentum, support in terms of capital resources, human resources, infrastructure, and need for advocacy at governmental and nongovernmental levels is necessarily required.[9] Interventions and policies directly targeting CAMH exist in two main areas: Mental health, led by the health sector, and early childhood, led by the education sector. Improving child health, nutrition, and education can be considered the first line of intervention and prevention for CAMH conditions. CAMH services can be conceptualized and developed through intersectoral activities, including stakeholders from the health and education sectors, social welfare, gender equality, juvenile justice, civic society, and humanitarian aid. This approach emphasizes a child's life quality, potential and talents, contributions, and future growth that influence developmentally sensitive stages.[46] While most successful CAMH initiatives have relied on regular interaction between young children and highly trained workers, teachers and caregivers in Pakistan have not obtained enough early childhood development training. To bridge this gap, a multitiered, transdiagnostic, task-shifting strategy-based model for Pakistan's CAMH services has been proposed.[82]

Clinicians can be essential in diagnosing disparities in their community and practice. Integrated care between pediatric and primary care providers and psychiatric services can strengthen access to mental health care.[83] Clinical approaches to addressing social determinants of health and breaking the intergenerational cycle of disadvantage include screening for CAMH early signs, connecting families to local resources, improving service comprehensiveness by integrating existing cultural resources, addressing family health in pediatric encounters, and moving care out of the clinics and into the community with life-course approach across all levels of a multilevel social determinants framework.[55] Health literacy is essential for patient-centered, equitable, and safe care because it allows a physician to connect with the socioeconomic determinants of child health and act as a change agent.[84] Health literacy is the ability of individuals to receive, process, and comprehend essential health information and services required to make sound health decisions. Public stigma and discrimination must be addressed by an ant stigma approach such as protests or social activity, public education, and contact with people with mental illnesses. Interventions for adolescents using digital tools and literacy has been more efficacious.[85] There have been various initiatives in resource limited environments around the globe that have shown promise. These include pediatric behavioral health collaborative care with PCPs as extenders, development of community health workers, parenting education by public health nurses or neighborhood volunteers, community system of care principles in the US, and collaboration with the faith sector to support CAMH and educate families on preventive approaches. Similar approaches may be tried in Pakistan to address this large gap between prevalence of pathology and service delivery.

  Conclusion Top

There are various commonalities of challenges faced by Pakistan and many L MIC nations. It would be wise to investigate the possibility of cross-learning across LMIC nations on feasible and viable approaches to growing CAMH services and supports. We know that it is impossible to segregate social factors from CAMH outcomes for Pakistani youth. Achieving health equity in Pakistan has been difficult due to multiple factors that include poverty, geographical location, large household size, high dependency ratio, illiteracy, unemployment, lack of access to essential utilities, poor food choices, or high-priced nutritious food. Furthermore, the limited CAMH services are to blame for the significant disease burden among children and adolescents. Financial inequality, educational achievements, and other social disadvantage indications must be discerned. The extent to which inequalities persist in adolescence and whether they lessen or expand over time are critical issues. Finding health disparities connected to all social variables may be difficult, especially in Pakistan, when fewer data are relevant to children and adolescents. However, some links are more significant for specific outcomes while others are weaker. Identifying social factors can investigate the bidirectional relationship between mental health disorders and social determinants. Health-care systems must invest in research and locally contextualized interventions to promote equity.

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Conflicts of interest

There are no conflicts of interest.

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