Review Article

A Review of Intersection of Social Determinants and Child and Adolescent

Mental Health Services: A Case for Social Psychiatry in Pakistan

Abstract Aisha Sanober

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Pakistan faces the accelerated growth of a young population each year. The country’s many Chachar1,
structural challenges include an unstable economy, poverty, gender inequality, health disparities, and Ayesha I. Mian2
vulnerable systems (especially sectors serving education and justice). The advent of the 21st century 1
Founder & CEO, Synapse
has witnessed rapid societal change globally. This societal evolution has inevitably shaped the
Pakistan Neuroscience Institute,
sociocultural landscape for Pakistan’s children, families, and childrearing practices as well, yet the
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2
Consultant Child, Adolescent,
social determinants remain stacked against them. Although children make up one‑third of the Pakistan and Adult Psychiatrist, Karachi,
population, they remain the most physically, economically, and socially vulnerable group. For Pakistan
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

Introduction child and adolescent mental health (CAMH)

population.[3] Social determinants of health
According to the World Health
impact a child’s mental health, well‑being,
Organization (WHO), social determinants
and quality of life. Examples of four social
of health are “the circumstances under
determinants demonstrate CAMH‑based
which people are born, grow, live, work,
inequities and health outcomes among
and age.”[1] It is difficult to definitively
people transitioning into adulthood; these
prove, but many links between earlier social
include (1) socioeconomic status, i.e., low
experiences and later health outcomes
education and family income; (2) childhood
are causal, with potential psychological
adversities, i.e., maltreatment and domestic
and physiological explanations explaining Address for correspondence:
violence; (3) family configuration across Dr. Ayesha I. Mian,
the connections.[2] Reaching health equity
development, i.e., single, motherhood, 4th Floor, 13 GPC, Rojhan
requires valuing everybody equally with
the role of fathers, early childbearing, Street, Block 5, Clifton,
focused and enduring efforts to address Karachi 75600, Pakistan.
divorce, and paternal attitudes; and (4)
avoidable inequalities and historical and E‑mail: ayesha.mian@synapse.
neighborhood‑related factors, i.e., org.pk
ongoing injustices and eliminate health
residential arrangement, stability, and
and health‑care disparities. Clarifying
community involvement. The concept of
how equity has been conceptualized and
social determinants attempts to uncover the Access this article online
measured is an essential first step for the
factors associated with the community’s Website:
Submission: 29‑06‑22 Decision: 29-06-22 profoundly ingrained health inequities. It www.worldsocpsychiatry.org
Acceptance: 30‑06‑22 Web Publication: 22-08-22 is worth noting that social determinants DOI: 10.4103/wsp.wsp_23_22

This is an open access journal, and articles are of health are the same as health inequity Quick Response Code:
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, How to cite this article: Chachar AS, Mian AI. A
as long as appropriate credit is given and the new creations are Review of Intersection of Social Determinants and
licensed under the identical terms. Child and Adolescent Mental Health Services: A
Case for Social Psychiatry in Pakistan. World Soc
For reprints contact: [email protected] Psychiatry 2022;4:69-77.

© 2022 World Social Psychiatry | Published by Wolters Kluwer - Medknow 69

 Chachar and Mian: Social determinants and child and adolescent mental health services in Pakistan

determinants.[4] The most striking example of health is major variability in this pattern, primarily because of the
inequity is the discrepancy of CAMH services in low‑  and absence of mental health awareness and stigma attached to
middle‑income countries (LAMIcs). Children’s rights, mental and emotional disorders.[11] Nonpsychiatric physicians,
social justice, human capital investment, and health equity including pediatricians, are also a significant referral source,
ethics are the four components of child health equity. These showing the need to enhance more work to examine the existing
components can be used to promote children’s health by pathways to psychiatric care.[12] A survey in Lahore found a
eliminating health inequities through equity‑based clinical prevalence of 9.3% emotional and behavioral problems, with
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treatment, child advocacy, and policy formulation. ‘anti‑social’ problems as a common issue. Since the school
systems do not have mental health services; teachers are not
The fundamental feature of health sector reform in Pakistan trained to identify children with problems.[13] As a result, most
is health as a right. Literacy, income, access to safe children with mental health illnesses or learning difficulties are
drinking water, housing, and family size are essential health
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ignored and labeled as “slow,” “disobedient,” or “naughty.”

determinants. These are also known as traditional health
determinants. However, considering conventional health Another reason for underresource is the shortage of CAMH
determinants is insufficient for a country like Pakistan. Given professionals. Children with CAMH issues go undiagnosed
the current state of inequity, evaluating the variables underlying and mistreated since there are <10 trained child and
the social determinants, known as structural determinants,[5] adolescent psychiatrists in the country. Faith healers and
is critical. The governing process and economic and social religious leaders are the first approaches for most mentally
policies affecting income, working conditions, lodging, and ill patients. Also, pediatricians, who are also often the first
education are structural determinants. Structural determinants gatekeepers, are not trained in recognizing, diagnosing, and
influence whether health‑care resources are distributed equally treating common CAMH diseases.
in society or unequally based on race, gender, social class, This highlights the need for intervention in the integrated
geography, sexual orientation, or other factors. These structural path to mental care. Heuristics, misleading endorsement
determinants must be prioritized in policies and programs. of symptoms by teachers, parents, and physicians, or
Unfortunately, most analyses miss this reality.[6] This article clinicians’ differential interpretation of diagnostic criteria
also discusses the intersectionality of social causes of CAMH can lead to unintended overdiagnosis, misdiagnosing, or
in Pakistan. polypharmacy.[14] In addition, parental lack of knowledge,
lack of information, and the stigma associated with specific
Child and Adolescent Mental Health Services conditions such as epilepsy and CAMH disorders may
in Pakistan be grounds for avoiding seeking guidance or treatment.
As a nation of 229 million[7] and 60% of people under 30,[8] Current professionals in the field have an unbalanced
Pakistan has one of the world’s largest youth populations; understanding of CAMH problems due to several
despite accounting for one‑third of Pakistan’s population, misconceptions regarding many of the salient features of
children remain the most physically, economically, and developmental, cognitive, and emotional features.[15]
socially vulnerable demographic. With rapidly growing In addition, there is a substantial dearth of child mental
young people, the country is confronted with several health data, reflecting an unmet need for representative
structural issues, including the pressures of a stressed statistics on children’s primary mental health problems.
economy, poverty, health inequities, and unstable systems, Although the United Nations strongly emphasizes
particularly in the education and justice sectors.[9] Child prevalence of pathology in LAMICs,[16] most of the
mental health services in Pakistan are still in their literature is based on high‑income countries’ suggestions.
infancy, and there are only a handful of dedicated child Given the large vacuum in published data on LMICs, such
psychiatry teams, mainly in the provinces of Punjab an approach may only be partially applicable in LAMICs.
and Sindh, where services are located primarily in the The scarcity of child mental health services in Pakistan
urban sector. These services are almost nonexistent in mirrors the dearth of epidemiological studies. There is a
the remaining two provinces, Baluchistan and Khyber lack of mental health services for children, partly reflecting
Pakhtunkhwa.[10] The focus of the child health‑care system a lack of adequate information about the magnitude of the
has been on communicable diseases that have almost needs that should be met.[17]
ignored the CAMH needs. The accessibility and availability
of the practice, referral mechanisms, and connections with Country Situational Analysis
physicians and pediatricians influence the usage of services Economic factors
in Pakistan. As per WHO data, 21 million child and
Pakistan is the South Asian country with the lowest Human
adolescents experience some mental health problem.
Development Index (HDI). Given the high annual rate of
As stated above, CAMH services are limited to a few tertiary youth population growth, the country faces a relative risk of
areas of the country. It is conventionally believed that referrals poverty.[18] It is worth noting that Pakistan’s primary health‑care
to these services are usually from the schools. However, there provider is the private sector, with a limited to nonexistent

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 Chachar and Mian: Social determinants and child and adolescent mental health services in Pakistan

health‑care insurance system and an inadequate public health including diarrhea and pneumonia, and a lack of access
system. This is understandably linked to out‑of‑pocket costs to drinking water, health care, and sanitation contribute
and restricts access to health treatments. The average life to this worrying scenario.[28,29] One out of every fourteen
expectancy at birth is 65 years. As a LAMIC, Pakistan has Pakistani children dies before age one. One of every
significant socioeconomic disparities between rural and eleven children do not live to see their fifth birthday.[30]
urban areas, as poverty is higher in rural areas (55%) than in Despite efforts and progress, there are significant inequities
urban areas (9%), and health outcomes reflect this disparity. and barriers to receiving safe childbirth delivery services
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For example, children in rural areas have more respiratory during prenatal, natal, and postnatal periods. It has been
infection symptoms than children in urban areas, and roughly established that the mother’s nutritional status affects the
half of rural young people are not adequately immunized. child in utero, and early breastfeeding is associated with
Furthermore, stunting, wasting, and being underweight are protection against childhood infections. However, early
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more common in rural areas, affecting children’s educational breastfeeding initiation is low in Pakistan, i.e., within 1‑h
prospects ‑  for example, only 60% of children aged ten and of birth. Early recognition and treatment of mothers’ mental
up attend school.[19] Research has established that children who health problems may help reduce children’s morbidity and
grow up in an area with a high population and a low HDI are mortality rates.[15]
likely to lack resources for optimal growth, especially in the
Sociodemographic factors
early years.[20] However, in Pakistan, child poverty is measured
using resources that do not explicitly show child poverty Countries with higher levels of education demonstrate
estimates. better health equity. Pakistan has the world’s second‑highest
proportion of out‑of‑school children.[31] Girls face a worse
Children in rural Pakistan face visible disparities between
situation as they attend school at a lower rate than boys.
rural and urban areas as most urban populations fall below
However, school enrollment is much lower in rural areas
the national poverty line.[16] A lack of urban planning for
due to poverty, distance from schools with no transportation,
physical and social infrastructure is a significant barrier to
school inaccessibility, and a lack of awareness of education
employment opportunities. This never‑ending struggle to
needs.[32] The movement restrictions, school closures, and
meet basic needs denies children’s fundamental rights to
stay‑at‑home during the COVID-19 pandemic will likely
education, development, good health, and safety, directly and
lead to a rise in the rates of domestic violence, loneliness,
indirectly.[21] For example, the disparity between household
depression, fear, panic and anxiety, and substance use
needs and parents’ ability to meet those expectations,
among school students.[33] The potential fallout of an
where children are forced to work.[22] According to the
economic downturn on physical and mental health is likely
International Labor Organization, Pakistan’s child labor
to be profound, but they are not inevitable. Government
population has surpassed 12 million.[14] Many children
measures will be crucial in mitigating widening inequalities
work as domestic laborers in factories, agricultural fields,
and public health consequences by identifying and ensuring
textile, and domestic industries. Widespread risk factors
that the most at risk are protected. This area required a
such as poverty, insufficient legal protections, illiteracy, big
discussion of a specific budgetary analysis focused on
family size, or unemployment create situations conducive
child health, education, and social protection and practical
to child abuse.[23] On the other hand, parenting stress and
measures taken by various agencies and organizations
factors mediating parental depression are influenced by the
within civil society.[34]
social gradient as seen as more common in lower‑income
communities.[24] Children with disabilities and special needs are among
Pakistan’s most vulnerable and neglected citizens. WHO
Health‑care system
estimates that 10% of the population in developing nations
Pakistan is one of the signers of the Sustainable live with disabilities, including 10% of the people in
Development Goals, which seek to improve maternal and Pakistan. The propensity of individuals with disabilities to
child health and reduce poverty.[25] Their target is to end all live in poverty is a cyclical issue. Poverty and disability
forms of malnutrition by 2030, attaining the internationally are linked in two ways: Disability increases the chance
agreed targets on stunting and wasting in preschoolers by of poverty, and poverty increases the risk of persons with
2030.[26] However, children’s nutritional status is far from disabilities.[35] This situation is evident as 66% of the
optimal, with 35% underweight, more than half stunted population with disabilities live in rural areas, and 23% of
growth, and roughly 9% emaciated.[26] The most important this cohort is school‑aged children. However, integrating
indicator of social development is a child and maternal special needs students into the regular school system is a
health, indicating a country’s level of nutrition, learning, and relatively recent phenomenon. Although Special Education
access to health care. Compared to surrounding countries, Departments run centers for disabled students and provide
Pakistan has a high newborn death rate.[27] Most children in free transportation, hearing aids, and other auxiliary
Pakistan do not get the fair opportunity to attain full health services, only 2% of students have access to special
potential (health equity). Malnutrition, the rise of infections education.

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 Chachar and Mian: Social determinants and child and adolescent mental health services in Pakistan

Child rights 47,000 individuals have perished due to terrorism‑related

violence.[42] Estimates of common mental disorders in
Children’s rights can be defined as “the rights, which
an IDP population have been found, with 60% affected
are concerned both with the protection of the individual
before displacement. The displaced face adversity due to
child and with the creation of the conditions in which all
security restrictions for which the government has made
children can develop to their full potential.”[36] The larger
provisions; however, the increase in number from original
domains in which these rights are usurped are those related
estimations has overwhelmed government facilities.[43] The
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to education, health, neglect, abuse (physical, emotional,

lack of capacity of overburdened countries to respond to
and sexual), corporal punishment, and child labor.[34] For
conflict‑related, displaced populations’ mental health needs
the child and adolescent population, the government of
is like anywhere else.[44]
Pakistan signed up for the Convention on the Rights of the
Child on September 20, 1990. It was ratified on November Nevertheless, the government has established temporary
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12, 1990, by the United Nations High Commissioner for shelters, such as government schools.[45] Child protection
Human Rights.[16] By signing this treaty, the government is also an issue; poverty, lack of education, and insufficient
agreed that every child has the right to survival; maximum access to essential services are shared among Afghan
development; Protection from harmful influences, abuse, children (International Rescue Committee, 2017). Moreover,
and exploitation; and full participation in family, cultural, they face bodily injuries, death, and forced recruitment into
and social life. However, in periodic reports, suggestions the armed forces directly from the fight against terror. In
were not adequately addressed.[37] addition, displacement, loss of family, and trauma connected
with witnessing acts of violence impact them indirectly.
Another critical question is Who is a child under Pakistani
law? In legal cases involving children. The juvenile justice At‑risk population
system is overwhelmed by insufficient infrastructure According to the Pakistan Demographic Health
and resources, overcrowded jails, and a lack of focus on Survey (PDHS) 2012‑2013, fertility is considerably
reform.[38] Although there are rules concerning children, higher in rural communities than in urban areas. On
their implementation leaves a lot needed. Despite a average, most rural women have 4.2 children. However,
legislative obligation, Pakistan does not have separate the contraceptive prevalence rate remains low, and most
courts for minors. Gaps in the current legal framework people are not using birth control methods. This is despite
have resulted in countless abuses of children’s rights, 96% of married Pakistani women being aware of at least
making them vulnerable. one modern contraceptive method. Adolescents and young
Geopolitical factors people frequently face barriers in accessing sexual and
reproductive health information and services, cascading
After religious and ethnic strife in the Indo‑Pak area, impactson their lives and opportunities. The Pakistan
Pakistan became an independent state in 1947. It has a Demographic and Health Survey (2006‑2007) revealed
distinguished history as an ancient civilization.[39] Despite that nearly half of the girls aged 15–18 were pregnant or
having a wealth of historical and natural resources, caring for a child.[46] UNFPA has piloted four adolescent
the country’s economic and social growth has lagged. counseling centers in collaboration with the Department
Pakistan is also prone to natural hazards, which have of Population Welfare and Pathfinder. More than 9,000
caused numerous internal displacement and migration adolescents and young people accessed services in the past
movements. Despite the government’s sparse help, the 2 years. Despite these efforts, many factors contribute to
affected zone remains one of the country’s least developed early or child marriages, including weak legislation, a lack
places, with underlying poverty jeopardizing children’s of enforcement of existing laws, public awareness about
rights to survival, education, health, and protection. The the harmful lifelong and intergenerational effects of child
country’s political and military crises have exacerbated the marriages, internal trafficking, poverty, and an ineffective
problem. On the other hand, Internal migration streams birth registration system.[47] Birth registration for children,
are often linked to the development disparity between particularly girls, has not been prioritized, allowing the
urban and rural areas. People move for better employment child’s age (especially for girls) to be manipulated at
opportunities and to overcome poverty.[40] marriage. Most children under‑five in rural areas are not
Internally‑displaced Pakistani (IDP) children belong to registered at birth. As a result, rural areas have a higher
families who fled a military operation fighting against rate of young marriages than urban areas.
terror.[41] Since 1990, Pakistan has hosted one of the five South Asia stands at the second‑highest, with 30.7%
largest refugee populations worldwide (IOM Migration of its population living in slums as of 2014 (U.N.,
Data Portal, 2018). As a result, Afghan refugees, especially 2015). Pakistan holds one of the world’s largest slum
undocumented migrants, are at risk of abuse. Children regions, Orangi Town Karachi. Regarding disparities,
make up around 42% of the IDP population, given the PDHS coverage data for 2018 does not explicitly
the geopolitical circumstances. In addition, more than highlight the child health discrepancies in the slum areas.

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 Chachar and Mian: Social determinants and child and adolescent mental health services in Pakistan

Nevertheless, marginalization, ethnic and economic, low methods in Pakistan have been impacted by global trends
awareness levels, caregivers’ neglect, and inaccessibility of digitalization, industrial development, urbanization,
to the health‑care centers have been identified as the and ecological transitions in the family structure.[51] These
significant barriers to health‑care access in the slums.[48] adjustments in context are ecological transitions, such as
Similarly, neglect by nuclear and extended families from starting school, getting a sibling, getting married, getting
impoverished communities and family conflicts might cause divorced, a new teacher, single parenthood, unmarried
children to seek sanctuary on the streets. As a result, these partnerships, same‑sex marriages, and remarried families
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street children are at a higher risk of being denied crucial have grown to favor viable living arrangements. In the
developmental support and exposed to numerous dangers. bigger picture, some regions view globalization as a forced
They are also more vulnerable to sexual exploitation.[49] westernization. The reaction to this notion is sometimes
These street children are at a higher risk of deprivation reverting to fundamentalist leanings. People return to what
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from support essential for development and various they feel are their societies’ original practices and cultural
forms of danger. They are also at a higher risk of sexual ideas to maintain “traditional” values and convictions.[58]
exploitation. Around 90% of the 170,000 street children in
Religion, or the culture of religion, is a fundamental pillar of
Pakistan are subjected to the sex trade, and it is estimated
Pakistani society.[2] It is the foundation of their daily lives,
that only 20% of sexual abuse cases are reported. However,
and religious precepts are strictly adhered to and constitute
60% of young victims accuse the authority of being the
an integral component of everyday life. In some cases, it
perpetrators.[50]
becomes the basis of developing children’s sentiments
Cultural and familial factors toward the opposing gender and sect shaped primarily by
parental prejudices and religious inclination.[59] The great
The family structure and dynamics of the home environment
majority of Pakistani adolescents identify with religiously
are the primary site for vitality, early schooling, and the
oriented value systems. This deep identification may serve
stabilization of adult personality development. Pakistan has
as a source of identity and feeling of self for many of
traditionally maintained a combined family system. However,
them. Some children may be at risk of being radicalized
the balance has moved toward the nuclear family system
due to this predisposition. Families prefer madrassas in
with time, as in other Asian countries.[51] There has been a
difficult economic situations with limited access to formal
slight shift in the dominant role of parents in metropolitan
education. Certain madrassas have long been regarded as
regions. However, life in rural areas is mostly unchanged.
essential in developing radicalization in the country, with a
Traditionally, the oldest male family member heads the
reputation for influencing young minds.[60]
family, and male members are regarded as the financial
providers, though this is changing. Families have an average Individual factors
of seven people and mixed family compositions.[52] As a
Individual factors such as the child’s gender, age, and
result, extended family members and substantial childrearing
birth order should be considered. A child’s gender can
tasks may shape parenting.[53] Mothers are often unemployed
influence health‑care services, the risk of maltreatment,
and are expected to stay at home and care for the extended
education priorities, and intergenerational biases.[61] For
family.[54] Endogamous weddings are widely practiced, with
example, stricter disciplinary techniques for female
cousin marriages occurring in most of Pakistan’s urban and
children may reflect parental attitudes and practices
rural communities.[55] Grandparents and extended families
than for male children. Similarly, girls are less likely
play a vital role in the care and wellbeing of children,
to receive overall health care and less likely to receive
influencing essential milestones in the future, such as
treatment for CAMH problems, particularly behavioral
career and marital decisions.[56] As a daily societal norm,
issues such as ADHD.[62] One possible explanation for
harsh disciplinary measures are commonly considered
gender differences is that parents may regard behavioral
acceptable corrective parenting strategies.[57] As families
problems as culturally acceptable, especially for boys, and
migrate to urban centers in hopes for better opportunities
thus are unaware of the need for treatment for some girls.
and therefore improving their socioeconomic status, some
Unfortunately, this gender disparity is not being addressed.
of these traditional support structures are disrupted. Nuclear
A child’s age and familial characteristics may influence
parents may report additional parenting stress and challenges
how a family treats a child. For example, an increase in
in raising children which may increase the risk of adverse
a child’s age determines the lowest risk of maltreatment.
developmental processes.
Bullying by an older sibling, verbal abuse, family quarrels,
Every child endures changes from one ecological physical fighting, and the child’s academic standing, on
milieu to the next, and families act as a buffer between the other hand, are examples of familial influences. Birth
globalizing influences and children’s daily decisions and order also influences how a child is treated in the family,
challenges ‑ the same is true for Pakistan. Children’s as middle children are likelier to be abused than the first
developmental trajectory, mental health and rights, the and last children. In addition, the firstborn is considered a
sociocultural landscape for families, and childrearing valuable asset to the family. As a result, they become role

World Social Psychiatry | Volume 4 | Issue 2 | May-August 2022 73

 Chachar and Mian: Social determinants and child and adolescent mental health services in Pakistan

models for their siblings as time passes. In contrast, the last dropout, marital instability, and economic insecurity;
born is usually too young. It is subjected to less discipline the bidirectional relationship between mental health
and rules due to family pampering.[61] As a result, children disorders and social determinants can exacerbate personal
in the middle of the birth order are less likely than the choices, affect living conditions that limit opportunities,
oldest to receive CAMH treatment overall. This aspect is and influence how one navigates societal norms and
consistent with the literature, which shows that investment structures affecting educational performance, employment
in children’s health, education, and nutrition varies by birth capacity, and involvement with the justice system.[69,70]
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order. Concurrently, the interaction of familial factors with However, this is less commonly explored than the reverse
individual variables is significant in elucidating the social pathway.[71] Baranne and Falissard[72] have highlighted
determinants of CAMH. For example, parental factors for how health determinants have evolved from mortality to
child maltreatment include a history of childhood abuse, disability. It was only recently that CAMH has received
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parental academic level, socioeconomic wealth index, consideration in this construct.[73] They have specifically
mother’s age, and the connection between physical fighting highlighted the phenomenon of Epidemiological Transition
in the family.[61] in the burden of CAMH disorders among 5–14 years.
Health seeking factors E.T. is the complex change in patterns of health and
disease and the interactions between these patterns and
Decisions related to CAMH disorders treatment occur their demographic, economic and sociologic determinants
in a unique context, distinct from other health‑care and consequences.[74] CAMH disorder account for 15%–
decisions and even adult mental health treatment 30% of the disability‑adjusted life years (DALYs) lost
decisions. CAMH problems may emerge gradually and during the first three decades of life.[75] The prevalence
are challenging to differentiate from ordinary ‑  albeit of mental health disorders in children and adolescents
challenging ‑ developmental behaviors.[63] Although it is has been estimated to be between 15%[73] and 20%[76]
uncertain if the father’s presence increases the child’s globally, with studies indicating the median age for onset
likelihood of receiving mental health treatment when being 14 years. Higher rates of CAMH problems tend to
required, in terms of gender, there is a likelihood of occur in poorer countries. Although the government has
active effort while pursuing better health‑care services for not been established as a substantive factor in prevalence
a male child than a female child.[61] One‑parent families estimates within multivariate models,[75] the unequal
are more likely to use services but not less likely to have distribution of resources causes disparities in social
unmet needs.[64] Research suggests that grandmothers may determinants.[77] Government responds to the hierarchy of
be just as effective as husbands at ensuring children get needs with increased resource allocation to health issues
needed treatment. Indeed, the father’s presence may inhibit like malnutrition and infectious disease. Only when these
children from getting treatment in general and for CAMH health factors with higher DALYs are better addressed, and
disorders. One possible clarification for this result may be communities become more complicated with technology
that fathers are more opposed to the treatment for mental and societal advancement, then the implications of MH and
health and favor an approach of “toughing it out.” Likewise, CAMH disorders become more explicit.
the number of adults in the home might influence the
probability of treatment, especially if there are considerable Social gradient affects both risk factors for disorder and
time constraints in seeking special treatment. Nevertheless, barriers to services, affecting mental health outcomes.
this applies to Pakistan, with extended family members For example, individuals already at risk of experiencing
being the key stakeholders in childhood development. In social, mental, and physical health issues, minimal
addition, while birth order has been found to influence family income becomes a barrier to seeking treatment,
other forms of investment in children, such as education, it alone or with symptom intensity.[78,79] Mood disorders,
has not been studied in children’s mental health‑care use.[65] neurodevelopmental disorders, and other CAMH problems
interfere with children’s wellbeing, educational attainment,
Implications and future job performance. Thus, undiagnosed and
untreated CAMH problems impact future psychosocial and
Child development is a complex interrelationship of
economic wellbeing.[80]
biological, social, psychological, and economic factors.[66]
Isolated variables and their intricate interactions between Developing countries like Pakistan face challenges in
risk and protective factors and environmental features promoting and implementing child mental health care,
within different systems can change the lives of children including stigma, illiteracy, lack of adequate statistical
and their families.[67] In childhood, optimal mental health data, and a severe shortage of pediatric psychiatrists.[81]
is a powerful predictor of adult mental wellbeing and is Despite the challenges discussed above, in recent years,
linked to various positive outcomes later in life, including Pakistan has taken positive strides to start the conversations
enhanced social interactions, higher educational attainment, about MH leadership and the professional landscape,
employment, and financial security.[68] CAMH disorders a trend that is likely to continue. However, the various
can impact social factors such as homelessness, school components of public and private health‑care systems

74 World Social Psychiatry | Volume 4 | Issue 2 | May-August 2022

 Chachar and Mian: Social determinants and child and adolescent mental health services in Pakistan

have remained inadequate in reducing this treatment gap. preventive approaches. Similar approaches may be tried in
To create and maintain the momentum, support in terms Pakistan to address this large gap between prevalence of
of capital resources, human resources, infrastructure, and pathology and service delivery.
need for advocacy at governmental and nongovernmental
levels is necessarily required.[9] Interventions and policies Conclusion
directly targeting CAMH exist in two main areas: Mental There are various commonalities of challenges faced by
health, led by the health sector, and early childhood, Pakistan and many L MIC nations. It would be wise to
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led by the education sector. Improving child health, investigate the possibility of cross‑learning across LMIC
nutrition, and education can be considered the first line nations on feasible and viable approaches to growing
of intervention and prevention for CAMH conditions. CAMH services and supports. We know that it is impossible
CAMH services can be conceptualized and developed to segregate social factors from CAMH outcomes for
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 11/29/2024

through intersectoral activities, including stakeholders from Pakistani youth. Achieving health equity in Pakistan
the health and education sectors, social welfare, gender has been difficult due to multiple factors that include
equality, juvenile justice, civic society, and humanitarian poverty, geographical location, large household size, high
aid. This approach emphasizes a child’s life quality, dependency ratio, illiteracy, unemployment, lack of access
potential and talents, contributions, and future growth to essential utilities, poor food choices, or high‑priced
that influence developmentally sensitive stages.[46] While nutritious food. Furthermore, the limited CAMH services
most successful CAMH initiatives have relied on regular are to blame for the significant disease burden among
interaction between young children and highly trained children and adolescents. Financial inequality, educational
workers, teachers and caregivers in Pakistan have not achievements, and other social disadvantage indications
obtained enough early childhood development training. To must be discerned. The extent to which inequalities
bridge this gap, a multitiered, transdiagnostic, task‑shifting persist in adolescence and whether they lessen or expand
strategy‑based model for Pakistan’s CAMH services has over time are critical issues. Finding health disparities
been proposed.[82] connected to all social variables may be difficult, especially
in Pakistan, when fewer data are relevant to children and
Clinicians can be essential in diagnosing disparities in their
adolescents. However, some links are more significant for
community and practice. Integrated care between pediatric
specific outcomes while others are weaker. Identifying
and primary care providers and psychiatric services
social factors can investigate the bidirectional relationship
can strengthen access to mental health care.[83] Clinical
between mental health disorders and social determinants.
approaches to addressing social determinants of health and
Health‑care systems must invest in research and locally
breaking the intergenerational cycle of disadvantage include
contextualized interventions to promote equity.
screening for CAMH early signs, connecting families to
local resources, improving service comprehensiveness Financial support and sponsorship
by integrating existing cultural resources, addressing Nil.
family health in pediatric encounters, and moving
care out of the clinics and into the community with Conflicts of interest
life‑course approach across all levels of a multilevel social There are no conflicts of interest.
determinants framework.[55] Health literacy is essential for
patient‑centered, equitable, and safe care because it allows References
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