Mental Health of Pakistani Children

and Associated Socio Cultural

Factors

EHSAN U.SYEDASSOCIATE PROFESSORAGA KHAN UNIVERSITY

KARACHI,PAKSITAN

GEOGRAPHY

164,741,924….. (July 2007 est.)

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.)

SCHOOL ENROLLMENT

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

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.

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

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

Child Psychiatric disorders estimates in Pakistan A recent study concluding in 2006 using Parent rated SDQ

•34.4% of children as falling under the' abnormal category on

SDQ . •Among males 40.1% and among females 27.9% were rated as abnormal.On the individual behavioral subsets scores

•42.3% on conduct problems, •37.3% on emotional subset, •18.8% on hyperactivity, and•37.8% on peer problems subset

•This study found male gender and poor school environment/quality of education associated with higher rating on SDQ•Poor maternal education was also weakly associated. Syed E , Abdul Hussien S, Mahmud S.Screening for emotional and behavioural problems amongst 5–11-year-old school children in Karachi, Pakistan Social Psychiatry and Psychiatric Epidemiology (2007) 42:421–427

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

•Another study conducted at a university out patient clinic showed that mothers of children with psychopathology were more likely to be depressed then the mothers of children who had medical illnesses.

•35.8% of mothers of child psychiatric clinic attendees scored above the cutoff on SRQ compared to 18.2% in the mothers of general pediatric outpatients group. •This difference was highly significant( p = 0.002). Odds ratio for scores above 10 was 2.51 (95% CI= 1.38 – 4.55) which meant that women bringing their children to child psychiatric clinic, were at much greater risk of mental distress compared to the other group. Syed EU & Zuberi SI (2006). Mental distress in mothers of child psychiatric patients Journal of College of Physicians and surgeons of Pakistan 16(6): 416-9.

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

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)

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.

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

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

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

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

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

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.

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