Mental Health of Pakistani Children and Associated Socio Cultural Factors

1. Mental Health of Pakistani Children and Associated Socio Cultural Factors EHSAN U.SYED ASSOCIATE PROFESSOR AGA KHAN UNIVERSITY KARACHI,PAKSITAN

2. GEOGRAPHY Pakistan is very strategically located on the cross roads between central Asia, the middle east and southeast Asia. It has over 1000 km of cost line with two major ports i.e. Karachi, which is the business hub and newly constructed and yet to be functional Gwadar (pronounced gu awder) port � to be connected by road to china and central Asia.Pakistan is very strategically located on the cross roads between central Asia, the middle east and southeast Asia. It has over 1000 km of cost line with two major ports i.e. Karachi, which is the business hub and newly constructed and yet to be functional Gwadar (pronounced gu awder) port � to be connected by road to china and central Asia.

3. 164,741,924�.. (July 2007 est.) This makes Pakistan the 6th most populous country in the world. And as you can see we are still counting. The male to female ratio is 1.5 to 1 to 1.05 to 1 in different parts of the country. Although there was a major population growth in the 6th and 7th decade corresponding with industrial and economic growth but since he 90s there has been a plateau This makes Pakistan the 6th most populous country in the world. And as you can see we are still counting. The male to female ratio is 1.5 to 1 to 1.05 to 1 in different parts of the country. Although there was a major population growth in the 6th and 7th decade corresponding with industrial and economic growth but since he 90s there has been a plateau

4. POPULATION BY AGE 0-14 years: 36.9% (male 31,264,576/female 29,507,174) 15-64 years: 58.8% (male 49,592,033/female 47,327,161) 65 years and over: 4.3% (male 3,342,650/female 3,708,330) (2007 est.) Median age 20.9 years Fertility 3.71 children born/woman (2007 est.) IMR 68.84 deaths/1,000 live births Life Expectancy 63.75 years Adult Literacy: 49.9% male: 63% female: 36% (2005 est.) The child and adolescent population is almost 37% and if we include those up to 21 it will be close to 50%. So is a young nation. The IMR is one of the worst in the region and fertility one of the highest. Major discrepancy b/w male and female literacy mirroring cultural attitudes and discriminatory behavior. Traditional village families avoid co ed schools and rather give informal education to girls which is hard to quantify assess or document � yet some other families simply prioritize son�s education over their daughter�s on account of meager resources and need for helping hands at home.The child and adolescent population is almost 37% and if we include those up to 21 it will be close to 50%. So is a young nation. The IMR is one of the worst in the region and fertility one of the highest. Major discrepancy b/w male and female literacy mirroring cultural attitudes and discriminatory behavior. Traditional village families avoid co ed schools and rather give informal education to girls which is hard to quantify assess or document � yet some other families simply prioritize son�s education over their daughter�s on account of meager resources and need for helping hands at home.

5. SCHOOL ENROLLMENT In the last 10 years there has been an increase in over all school enrollment however this rise is more marked for primary schools ( grade 1 thru 5) this graph may also represent high dropout rate after 5th grade.In the last 10 years there has been an increase in over all school enrollment however this rise is more marked for primary schools ( grade 1 thru 5) this graph may also represent high dropout rate after 5th grade.

6. CHILD MENTAL HEALTH Psychiatrists � 400 Child & Adolescent Psychiatrists � 05 Child Psychologists � 01 Speech Therapists - 10 � 15 Occupational Therapists- < 10 Remedial Teachers- <20 * All numbers are approximate and keep changing Most of these professionals have joined the work force in the last 10 years so you can see the change is only at its beginning stageMost of these professionals have joined the work force in the last 10 years so you can see the change is only at its beginning stage

7. MENTAL HEALTH DATA Population-based epidemiological studies among adults show the prevalence of common mental disorders in Pakistan to be one of the highest in the developing world � higher even than developing countries with similar socio-economic indicators. These figures range from as low of 25% (urban areas) to a high of 72% (rural areas) for women between 10% (urban) and 44% (rural) for men. Mumford, D. B.,Minhas, F., Akhter, F., et al (2000) Stress and psychiatric disorder in urban Rawalpindi. British Journal of Psychiatry, 177, 557-562. This research was done in various settings and has consistently reported high rates of depression / anxiety assessed by using screening instruments e.g. Bradford Somatic Inventory.This research was done in various settings and has consistently reported high rates of depression / anxiety assessed by using screening instruments e.g. Bradford Somatic Inventory.

8. Child Psychiatric disorders estimates in Pakistan First study carried out in Lahore(1992) To establish the prevalence of emotional and behavioural problems in school children. Rutter�s children behavioural questionnaire. Result :The prevalence rate was found out to be 9.3% with antisocial disorders being the commonest. Javad, A.M., Kundi, M.Z., & Khan, A.P. (1992) Emotional and behavioural problems among school children in Pakistan. Journal of Pakistan Medical Association, 42, 181-184 Rutter scale in this study was not validated for Pakistani population and there are issues about sampling.Rutter scale in this study was not validated for Pakistani population and there are issues about sampling.

9. Child Psychiatric disorders estimates in Pakistan Estimates of the prevalence of mental retardation were 19.0/1,000 children (95% Cl= 13.5-24.4) for serious retardation and 65.3/1,000 children (95% Cl= 48.9-81.8) for mild retardation Both estimates were considerably higher than industrialized countries and in selected less developed countries. Lack of maternal education was strongly associated with the prevalence of both serious (odds ratio = 3.26, 95% Cl 1.26-8.43) and mild retardation (odds ratio = 3.08, 95% Cl 1.85-5.14) Durkin M. S., Hasan, Z. M. Hasan K. Z.(1997) American Journal of Epidemiology Vol. 147, No. 3 Methodology of this study is technically sound and their results are quite accurate.Methodology of this study is technically sound and their results are quite accurate.

10. Child Psychiatric disorders estimates in Pakistan SDQ is validated in Pakistani population and this population is reasonably representative. However this is a single informant ( parent version) other part of the study which reports on both parent and teacher version with equally high numbers. CBCL was used on the same population ( manuscript being prepared ) which validated the Achenbach�s tool as well as show concurrence with SDQ but significantly lower rates.SDQ is validated in Pakistani population and this population is reasonably representative. However this is a single informant ( parent version) other part of the study which reports on both parent and teacher version with equally high numbers. CBCL was used on the same population ( manuscript being prepared ) which validated the Achenbach�s tool as well as show concurrence with SDQ but significantly lower rates.

11. MATERNAL MENTAL HEALTH In Pakistan maternal mental health is strongly associated with psychopathology in offspring, just as every where else. A case control study done at a maternal and child health center showed that malnutrition in children was strongly associated with mother�s mental distress. 57% of mothers of underweight cases had poor mental health as measured by the SRQ, compared to only 25% of controls: OR = 3.9 (95% CI = 1.9�7.8). A. Rahman, H. Lovel, J. Bunn, Z. Iqbal and R. Harrington (2004) Mothers� mental health and infant growth:a case�control study from Rawalpindi,Pakistan Child: Care, Health & Development, 30, 21�27 Maternal mental health has become a recent area of interest for researchers and policy makers. Women�s health status is quite questionable in our country.Maternal mental health has become a recent area of interest for researchers and policy makers. Women�s health status is quite questionable in our country.

12. MATERNAL MENTAL HEALTH This corroborated the findings from Rehman et al.This corroborated the findings from Rehman et al.

13. MATERNAL MENTAL HEALTH DOMESTIC VIOLENCE Only 7 (3.2%) out of the 216 women did not report enduring any type of domestic violence ever Shaikh M.A. Is domestic violence endemic in Pakistan: perspective from Pakistani Wives Pakistan Journal of Medical Sciences. 2003, 19(1) 23 - 28 Probability of a girl dying underage 5 years =115/1000 A girl between her first and fifth birthday in India or Pakistan has a 30-50% higher chance of dying than a boy This neglect may take the form of poor nutrition, lack of preventive care (specifically immunisation), and delays in seeking health care for disease. Early marriage and pregnancy, anemia, sexual violence, Fikree F., Pasha O. Role of gender in health disparity: the South Asian context British Medical Journal 328: 3 April 2004

14. CHALLENGES FACED Scarcity of data Under developed services in public sector Cost of professional services in private sector Limited Human resource in child mental health Lack of awareness and stigma �For professionals in developing countries the term child mental health therefore covers a broad range of problems, including neurological and developmental disorders, mental retardation, educational difficulties, and psychiatric disorders� (Graham,1981) So the little research that is presented may represent all that has been done so far in this area. This has a direct consequence that child mental health remains under recognized and under served So the traditional western model of care may be a pie on the sky and we may have to take on a role for which we find ourselves ill equipped after training in US or in some cases UK.So the little research that is presented may represent all that has been done so far in this area. This has a direct consequence that child mental health remains under recognized and under served So the traditional western model of care may be a pie on the sky and we may have to take on a role for which we find ourselves ill equipped after training in US or in some cases UK.

15. CHALLENGES FACED Most referrals to child/adult psychiatrists are through GPs, Pediatricians Minimal referrals from schools. No school mental health. Teachers have no training in behavioral issues. Parents and Teachers often blame each other for child�s problems. Schools do not pick problems until it�s a major issue and are reluctant to talk to parents about mental health fearing negative reactions. Most GPs and pediatricians them selves have not had any exposure to child psychiatry during their education and they often delay treatment by either not recognizing the problem or some times resorting to indiscrete pharmacological interventions.Schools do not pick problems until it�s a major issue and are reluctant to talk to parents about mental health fearing negative reactions. Most GPs and pediatricians them selves have not had any exposure to child psychiatry during their education and they often delay treatment by either not recognizing the problem or some times resorting to indiscrete pharmacological interventions.

16. CHALLENGES FACED Precious time lost between onset of symptoms and 1st psychiatric contact Parents often reluctant to start medications and put low value to psychotherapy Unprofessional, pseudo-scientific advise Extended families interfere and discourage ongoing treatment This makes our job even more difficult since parents are now expecting miracles! The bad news that no one had bothered to break to them becomes our challenge to face/ responsibility as if we are pulled to a primary care level for e.g. telling parents 1st time that their 10 year old is actually MR and not just disinterested in studies as they would have it.This makes our job even more difficult since parents are now expecting miracles! The bad news that no one had bothered to break to them becomes our challenge to face/ responsibility as if we are pulled to a primary care level for e.g. telling parents 1st time that their 10 year old is actually MR and not just disinterested in studies as they would have it.

17. CHALLENGES FACED Extended and Joint family setup Paternal grandparents in the house Paternal grandparents and paternal uncles with families Paternal grandparents and paternal uncles with families and paternal aunts Two or more brothers with families sharing the house Two or more brothers with families sharing the house but in different portions or floors � semi independent Divorced or widowed moms living with their parents family sometimes sharing with their brothers� families Mothers have limited say in child rearing � families make decisions. Many young parents seek help for their children without the knowledge of the extended family in the house. Sometimes Moms bring children even without telling their spouses Fathers are more likely to downplay the problem and less likely to come for follow ups Families can be a great source of encouragement and motivation however many times we find extended family to be counter productive in our line of work � difficult to build consensus between multiple care givers and cut through the hierarchy of the family system. Not unusual to see an irate mother in law coming along in one of the follow up appointments with her grand child and daughter in law, blaming later for exaggerating the situation to get the psychiatrist to prescribe Ritalin ( a potential poison!!!) instead of doing a better job in child rearing � I raised 5 boys ,one of them happens to be your spouse, all quite hyperactive but I never took them to anyone and handled everything myself and see how good they have turned out� Families can be a great source of encouragement and motivation however many times we find extended family to be counter productive in our line of work � difficult to build consensus between multiple care givers and cut through the hierarchy of the family system. Not unusual to see an irate mother in law coming along in one of the follow up appointments with her grand child and daughter in law, blaming later for exaggerating the situation to get the psychiatrist to prescribe Ritalin ( a potential poison!!!) instead of doing a better job in child rearing � I raised 5 boys ,one of them happens to be your spouse, all quite hyperactive but I never took them to anyone and handled everything myself and see how good they have turned out�

18. CHALLENGES FACED School environment Public/Government schools grossly under funded and understaffed Community schools inadequate in numbers Private schools charge heavy tuitions ALL ARE OVERCROWDED Very little interaction between teachers and parents Teachers often miss emotional and behavioral issues and see �misbehavior" and academic decline School culture is largely insensitive to child's mental health needs and very goal oriented towards high academic achievement � everything else is the parents� jobSchool culture is largely insensitive to child's mental health needs and very goal oriented towards high academic achievement � everything else is the parents� job

19. CHALLENGES FACED School Mental Health Assessment for LD and IQ very rare Classroom interventions and resource rooms almost non existent School counselors, extremely rare Schools often unable to follow the recommendations made Teachers get frustrated with behavioral issues and recommend measures such as holding the child back OR suggest school change without a road map for parents Some resourceful schools are beginning to realize the need for such services and organizing themselves along those lines but this is limited to elite schools and only a tiny minority benefits from this.Some resourceful schools are beginning to realize the need for such services and organizing themselves along those lines but this is limited to elite schools and only a tiny minority benefits from this.

20. CHALLENGES FACED ENIVRONMENTAL ISSUES Pollution and lack of road safety in cities Poverty and filth in villages LEAD Heavy metals in drinking water Nutritionally deficient food Urban centers have one of the highest pollution rates (ppm) in the region with vehicle emissions, industrial fumes and burning garbage � a common practice (although illegal) to reduce the bulk for its removal. Petroleum is unleaded however some paint manufacturers have not phased out lead and old houses still have lead in water supply pipes. No data. But suspect the lead effect will be considerable. Shanty towns around industrial towns are recipients of drinking water laced with arsenic, mercury etc.Urban centers have one of the highest pollution rates (ppm) in the region with vehicle emissions, industrial fumes and burning garbage � a common practice (although illegal) to reduce the bulk for its removal. Petroleum is unleaded however some paint manufacturers have not phased out lead and old houses still have lead in water supply pipes. No data. But suspect the lead effect will be considerable. Shanty towns around industrial towns are recipients of drinking water laced with arsenic, mercury etc.

21. CHALLENGES FACED GLOBAL ISSUES CHILD LABOR �worst forms of child labor� described in HRW report on bonded child laborers in India and Pakistan. (Human rights watch) www.hrw.org STREET CHILDREN Pakistan is seen to be a receiving country for children coming from India and Nepal to work in farming, fishing, and sex industry. (Child workers in Asia) www.cwa.tnet.co.th TERRORISM CHILDREN AS VICTIMS ADOLESCENT SUICIDE BOMBER � average age of the suicide bomber has decreased over the years Christoph Reuter In: My Life Is a Weapon: A Modern History of Suicide Bombing By Princeton University Press(2004) CHILDREN EXPOSED VIA MEDIA � graphic portrayal of mutilated bodies and debris. Children in villages work on farms and tend cattle and in cities slum area kids do jobs ranging from errand boy (gofers) at households to waiting on tables to factory workers. Once at work seldom continue school because of long working hours. Some carpet weavers are tied to their machines for the duration of their working day which can be any where form 8 to 12 hrs. Street kids are runaway children who have mostly escaped physical abuse in villages and opt for an impoverished but free life in cities, they wash car windows sell flowers and bouquets on traffic lights. Subject to a great deal of sexual abuse either by adults on the street or their own older peers. A younger runaway kid is often sodomised by an older street child/adolescent as an initiation rite into the street world, this way a hierarchy is also established � exclusively boys � girls disappear as soon as they appear!? The recent rise in global terrorism has hit the region in a very profound manner which will lead to long term repercussions which are to be expected in the future. Pakistan is a victim of suicide bombing. Many children have been injured or killed as a result of bombings although most of the casualties have been adults so far. The worst development is use of younger adolescents in such activities , it is becoming a norm rather then an exception to use someone as young as 16 to blow himself up along with a perceived enemy target. These boys are often not integrated in their society and often poor performers at school and could even be intellectually limited. Come form large families living on the fringes of the society with a lot of pathology at an individual and systems levelChildren in villages work on farms and tend cattle and in cities slum area kids do jobs ranging from errand boy (gofers) at households to waiting on tables to factory workers. Once at work seldom continue school because of long working hours. Some carpet weavers are tied to their machines for the duration of their working day which can be any where form 8 to 12 hrs. Street kids are runaway children who have mostly escaped physical abuse in villages and opt for an impoverished but free life in cities, they wash car windows sell flowers and bouquets on traffic lights. Subject to a great deal of sexual abuse either by adults on the street or their own older peers. A younger runaway kid is often sodomised by an older street child/adolescent as an initiation rite into the street world, this way a hierarchy is also established � exclusively boys � girls disappear as soon as they appear!? The recent rise in global terrorism has hit the region in a very profound manner which will lead to long term repercussions which are to be expected in the future. Pakistan is a victim of suicide bombing. Many children have been injured or killed as a result of bombings although most of the casualties have been adults so far. The worst development is use of younger adolescents in such activities , it is becoming a norm rather then an exception to use someone as young as 16 to blow himself up along with a perceived enemy target. These boys are often not integrated in their society and often poor performers at school and could even be intellectually limited. Come form large families living on the fringes of the society with a lot of pathology at an individual and systems level

22. OPPORTUNITIES SCHOOLS MAY BE THE STARTING POINT TEACHERS TRAINING IN MENTAL HEALTH INCORPORATING CHILD PSYCHIATRY IN MEDICAL SCHOOL CURRICULM GENERAL PSYCHIATRISTS AND PEDIATRICIANS RECEIVE TRAINING Atleast in the cities schools are showing interest in developing services, obtaining training and have liaison with mental health professionals. We recently conducted training workshops for a few schools which are run by a trust and cater for middle and lower middle income groups. The training revolved mainly around ADHD and was directed towards teachers helping them recognize normal developmental variants as well as major disruptive disorders. Some class room based interventions as well as assessment tools e.g. Conner's were also discussed. Yet to see if it results in any increase in identification of ADHD. None of the medical schools have recognized child psychiatry as a rotation or a subject requiring didactic teaching Some efforts being made to train family doctors and pediatricians in recognizing atleast major syndromes and appropriate and timely referrals. Psychiatric training has now incorporated child psychiatry as a mandatory rotation but shortage of child psychiatrists will impact all such efforts for a long time.Atleast in the cities schools are showing interest in developing services, obtaining training and have liaison with mental health professionals. We recently conducted training workshops for a few schools which are run by a trust and cater for middle and lower middle income groups. The training revolved mainly around ADHD and was directed towards teachers helping them recognize normal developmental variants as well as major disruptive disorders. Some class room based interventions as well as assessment tools e.g. Conner's were also discussed. Yet to see if it results in any increase in identification of ADHD. None of the medical schools have recognized child psychiatry as a rotation or a subject requiring didactic teaching Some efforts being made to train family doctors and pediatricians in recognizing atleast major syndromes and appropriate and timely referrals. Psychiatric training has now incorporated child psychiatry as a mandatory rotation but shortage of child psychiatrists will impact all such efforts for a long time.