Mental health disorders constitute 16% of the global burden of disease and injury in adolescents (WHO, 2019). Statistics depict that each year one out of every five adolescents, start experiencing at least one form of mental illness (WHO, 2017). Individuals in the adolescence phase are emotionally, physically, socially and mentally vulnerable as it is a very crucial phase due to the initiation of transition from childhood to adulthood. This vulnerability leads to the development of many mental illnesses that might persist in adulthood ultimately affecting the overall health-related quality of life of an individual (UNICEF, 2019). The most common mental illnesses encountered by adolescents include anxiety disorder (mainly generalized anxiety disorder), depression, attention deficit disorders, conduct and eating disorders (Michaud & Fombonne, 2005).
Generalized anxiety disorder (GAD), defined as “excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities”, is a type of anxiety disorder that is characterized by continuous worry and anxiety along with several other symptoms like restlessness, functional impairment, sleep disturbance, gastrointestinal symptoms, chronic headaches and muscular cramps(Association., 2013). Symptoms of GAD is fairly common and impairing condition in adolescents with a lifetime prevalence of 3% globally. If the time period is restricted to 3 months than the prevalence increases to 5% worldwide (Gale & Millichamp, 2016).
Estimates of GAD based on symptomatology and may vary worldwide; the reported prevalence of GAD in adolescents in the USA lies between 3-9% whereas in the United Kingdom it is 0.7% (Green, McGinnity, Meltzer, Ford, & Goodman, 2005). Danish children and adolescents have a prevalance of 1.5% of symptoms related to GAD (Esbjørn, Hoeyer, Dyrborg, Leth, & Kendall, 2010) while Nigerian adolescents have a 3.5% of overall burden of GAD symptoms (Adewuya, Ola, & Adewumi, 2007). Regionally quite a few studies depicted the burden of GAD related symptoms in children and adolescents. A study conducted in Urban India reported a 20.9% occurrence of GAD related symptoms in children and adolescents (Jayashree, Mithra, Nair, Unnikrishnan, & Pai, 2018) whereas Iran reported a 0.54-20.18% burden among adolescents (Zarafshan, Mohammadi, & Salmanian, 2015). Chinese school going adolescents have a reported burden of 1.77% (Shen et al., 2018). This vast range of prevalence reported by many studies might be due to the different cultural settings, different predefined diagnostic thresholds, availability of different tools to assess GAD based on symptomataology or due to underreporting of symptoms because of the fear of stigmatization (Burstein, Beesdo-Baum, He, & Merikangas, 2014).
In Pakistani settings, there were very limited studies which exhibited a definite burden of GAD related symptoms in adolescent population. One study conducted in Lahore, Pakistan indicated that 52% of adolescents have at least one symptom of GAD whereas approximately 8% of adolescents have more than 4 GAD persistent symptoms (Afzal, Sarfraz, & Hassan, 2014).
Previous literature has highlighted multiple risk factors and predictors which could lead to the development of symptoms of GAD in adolescents. The most common factors includes parent-to-child conflicts, parent-child relationship, parental control, hormonal changes that occur during adolescence, genetic predisposition, stress, family conflicts, communication gap with parents, traumatic life experiences, academic stresses, physical changes, socioeconomic burden, conflicts in friendships and interpersonal relationships, succumbing to parental pressure, cultural norms and religious obligations (Afzal et al., 2014; Brown, Chorpita, & Barlow, 1998; Newman, Shin, & Zuellig, 2016; Wittchen, 2002). Moreover age was also indicated as one of the prime risk factors of increasing risk of GAD symptoms, early adolescence was linked to a greater risk as compared to late adolescence(Carter, Silverman, & Jaccard, 2011). Among all these significant risk factors, traumatic childhood experience due to parent-to-child maltreatment of any sort including physical, emotional, mental as well as neglect, was found to be one of the most reported risk factor leading to occurance of GAD symptoms (Safren, Gershuny, Marzol, Otto, & Pollack, 2002). Adults who experience any variant of parent-to-child mistreatment, the burden is reported to be 30 – 40 % , with up to 30% of all maltreated children fulfilling DSM-IV criteria for psychological morbidity in their late 20s (Dannlowski et al., 2012). Statistics reveal that every year, about 4–16% of children are maltreated by parents and one in ten is neglected or psychologically mistreated (Gilbert et al., 2009). 13% is the reported prevalence of parent-to-child maltreatment in developing countries (Kim, Wildeman, Jonson-Reid, & Drake, 2017; Runyan, 2018). According to a previous study, 43% of children in Pakistan self-reported parent-to-child maltreatment and amongst these, 57% were neglected, 49% were physically maltreated and 50% suffered from emotional maltreatment (M. Lakhdir et al., 2016). Another study indicated a 25.5% of physical abuse and a 17.9% of emotional abuse by parents among Pakistani Children (Ali & Khuwaja, 2014). Literature indicated that continuous and frequent exposure to child maltreatment interrupts hypothalamic pituitary adrenxal axis functioning and leads to neurobiochemical changes in brain including an increase in thalamic grey matter volumes of subcortical region of the brain which can result in development of GAD symptoms (Calhoun, Ridenour, & Fishbein, 2019; Liao et al., 2013). Moreover, constant maltreatment by parents can disrupt the safety blanket of an adolescent resulting in various fears, apprehensions, cognitive deficit and emotional vulnerability which could lead to anxiety disorders (Berzenski, Madden, & Yates, 2019).
GAD and related symptoms has major public health implications predominantly in adolescents. It is considered as a prodrome of chronic depression (Masi, Favilla, Mucci, & Millepiedi, 2000). Moreover, it is also considered as the route to the development of sleep disorders, eating disorders and other psychological comorbidities (Varchol & Cooper, 2009). The long term effect of GAD symptoms personally, socially and economically is quite damaging and therefore needs to be addressed especially in developing population where reporting mental illness is still considered as a stigma. Given the escalating burden of anxiety disorders in adolescents, it is the need of the hour to identify the predictors associated with GAD symptoms so that it can be addressed and treated accordingly. Furthermore, in Pakistani cultural settings where harsh disciplinary meaures are considered as a norm (M. Lakhdir et al., 2016; M. P. A. Lakhdir et al., 2017), parent-to-child maltreatment is extremely prevalent and may lead to various anxiety disorders including GAD. Adolescents constitute a large chunk of the Pakistani population and their psychosocial issues must be adequately and timely catered to prevent further detrimental consequences. There is a wide gap in research that identifies the potential risk factors including parent-to-child maltreatment which leads to the development of anxiety disorders in adolescents in our settings. Furthermore, the definite burden of GAD symptoms and its assciation with parent-to-child maltretament in adolescents is also not yet established in our settings. Thus the aim of this study is to determine the occurance of GAD symptoms in association with parent-to-child maltreatment and other risk factors among adolescents aged 11-17-year-old in Karachi, Pakistan.