14-year-old girl from a close, supportive family came to a hospital feeling that she was “going mad” with worry. She had no significant medical or psychiatric history. She complained of feeling stressed all the time and constantly worried about “anything and everything.” The problem had started when she was studying for her 9^th grade examinations. She reported being incapacitated with anxiety. Despite wanting to study medicine as per her parents’ wishes, she felt that she would be unable to cope with the pressure and fear, upsetting and disappointing her parents. When worried, she felt tension in her shoulders, stomach and legs; her heart raced and sometimes, she found it difficult to breathe. She slept poorly and felt tired and irritable most of the time.

This is a typical presentation of anxiety disorder in children and adolescents. It is thought to occur in about 10 percent of children before puberty. Clinicians around the globe have witnessed soaring rates of mental health challenges among children and adolescents, especially higher anxiety and depression presentations over the course of time. Following Covid-19 pandemic, children and families have experienced enormous adversity and disruption.

Children represent the most important asset and wealth of a nation as healthy children alone can make a healthy nation. It is estimated that more than 40 percent of Pakistan’s population is under the age of 18; 22.7 percent of the citizens are adolescents, aged 10-19 years. This huge young population is particularly susceptible to multiple co-occurring risk factors such as natural and man-made disasters; rapid, unplanned urbanisation; violence; social and economic inequalities; stigma; poor educational facilities and educational environment; bullying; an absence of caregivers; chronic poverty; and armed conflicts etc that risk development of mental health problems. Increasing screentime and unmonitored technology use add another challenge, making children vulnerable to online predators, cyberbullying and potentially harmful content.

Mental health among children and adolescents remains a significant public health concern. The World Health Organisation estimates that about 20 percent of young people face psychiatric difficulties. A considerable proportion (50 percent) of psychiatric morbidity in adults manifests in the formative years. Suicide is the third leading cause of death among adolescents. Depression often has an onset in adolescence and is associated with substantial psychosocial impairment and risk of suicide. Despite the high burden of mental illnesses originating at a young age and associated disability, evidence suggests that most children at risk of psychiatric illness remain undetected and untreated. In Pakistani society, parents are often held accountable for their child’s mental illness. Frequently, conditions reported in later years are traced back to formative years. Despite a huge burden of mental illnesses, less than 1 percent of the health budget is allocated to mental health and there is no dedicated budget for child mental health. There are limited dedicated child and adolescent psychiatric services in the country and none in rural areas. Child and adolescent psychiatry/ psychology training programmes are still in their infancy and there are less than 10 quali ed child and adolescent psychiatrists in the country.

Limited resources and services in mental health have led to the advocacy of public health approach and use of more innovative avenues to improve mental health status of children and adolescents in Pakistan. Capacity building of family physicians and paediatricians working collaboratively with parents, teachers and social workers and under the supervision of specialists, can be a useful human resource tool in providing holistic care to young people with mental health problems in community settings. Enhancing parenting skills, helping parents to improve their communication patterns with their children and adolescents means that they can guide, educate and protect their children more effectively and efficiently.

Stable, supportive and nurturing relationships with caregivers give children trust, positive social-emotional development and the capacity to form secure and strong relationships in the future. Health education programmes, including social media campaigns, can address stigma around child and adolescent mental illness and suicide. Schools offer a unique platform to integrate promotion, prevention and early identification of mental health issues as well as consistent support for children with psychological difficulties with access to specialist care where needed. Schools may also prove to be turning points for children with poor support systems and unsuitable home environments and for those hailing from disadvantaged neighbourhoods by building their resilience and abilities to cope with adverse life experiences. Focus on mental health literacy and life skills trainings for adolescents can make a big difference. Future initiatives should include incorporating mental health into the school curriculum, sharing stories from people with lived experiences and encouraging student-led initiatives focusing on mental health advocacy. There is also a need for setting up confidential helplines and access to professional expertise for early intervention and treatment of mental illnesses in young people.

Children’s mental health is crucial for their active social and economic participation. As unmet mental health needs are linked with vast health, social and economic costs globally, there is a real need to bring child mental health further up the healthcare agenda. It’s important for all stakeholders to work together to improve the mental health of children and adolescents in Pakistan.

The writer is a professor and head of Child and Family Psychiatry Department at King Edward Medical University/ Mayo Hospital, Lahore. She can be reached at nazishimrandr@gmail.com