I have to confess I have had to struggle a little bit with myself to write this article. For someone who has devoted a career to studying the consequences of trauma on health in general and mental health in specific, this should have been a run of the mill article for me to describe in elaborate detail the consequences of child abuse not only for the child but for the well-being of the society. However, there was an innate fear, that just like everything else that has been reported so far in the wake of Zainab’s brutal rape and murder, this would become yet another article. One more article that will fall on deaf ears and nothing will change, just like after Kasur’s child pornography scandal, or when the World cried for our children after watching ‘Pakistan’s Hidden Shame’ documentary about the sexual abuse of our youth but we as a nation remained obtuse to any sort of reforms, and I would have to grapple with the reality that Pakistan is too stubborn to change. So much has been already written covering every aspect of the heinous crime, be it in a political context or a purely sympathetic context that I would rather limit my role today to just presenting to the public, a brief overview of why crimes like the murder of Zainab happen, why these can’t be stopped and why the system will require unprecedented reforms to prevent this from happening in the future. While everyone has been talking about the recent sexual abuse cases, which certainly is the highest imaginable crime against a child’s dignity, there is no one explicitly talking about the basic definition of child abuse, which according to WHO, “includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity”. There were reports a few days ago about how a 9 year old madrasah student, Hussain was beaten to death by a maulvi but it’s not just these blatant crimes of sexual and physical abuse leading to death that we should be holding the perpetrators accountable for. The harsh reality is that child abuse and neglect is an ominously pervasive problem of our society and most of the times it’s the parents who are to be blamed. While the rapist and murderer of Zainab is awaiting his fate behind bars, how many families in Pakistan can say with authority that they have not willingly subjected their children to any of the above mentioned forms of child abuse. When we say that we need to teach our kids to grow up as better human beings, it will have to start with us, as parents first. By age 3, a baby’s brain has reached almost 90 percent of its adult size. The growth in each region of the brain largely depends on receiving stimulation. This stimulation provides the foundation for learning. That being said, the figure here shows the brains of two three year old children, one of which suffered extreme neglect due to institutionalization and lack of necessary caregiving. This lack of development in key areas of child’s brain predisposes him to high risk of mental as well as physical problems later in life. Although, physically functioning but this child will be more likely to become addicted to drugs, be involved in violent crimes, and much more as compared to his normal counterpart shown here. Similarly, this figure is showing the brain power in a child who developed around positive parenting and one who suffered neglect. The red area shows increased activity, measured through quantitative EEG studies, while green means decreased activity. Unfortunately, the regions which are shown as green in the neglected brain in comparison to the red in healthy brain, constitute key regions such as prefrontal cortex, which is the centre for executive functioning and orbitofrontal cortex which plays a key role in regulating emotions. As a consequence, children who have been neglected have a difficulty in regulating emotions, lack of cause-effect thinking, inability to regulate emotions in others, incoherent sense of self and a lack of conscience. While everyone has been talking about the recent sexual abuse cases, which certainly is the highest imaginable crime against a child’s dignity, there is no one explicitly talking about the basic definition of child abuse, which according to WHO, ‘includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity’ While some might argue that I have presented an extreme example here, it is worth pointing out that there is global consensus that children who have experienced abuse and neglect, be it physical or emotional, are at increased risk for a number of problematic developmental, health and mental health outcomes, including learning problems, problems relating to their peers, internalizing problems such as depression and anxiety and what seems most pertinent to our society, externalizing problems ie, conduct disorder, aggression, anti-social personality disorder and even psychopathy. Studies dating back to 1980s have provided evidence time and time again that convicted male felons, particularly who had committed sexual offenses, reported much higher rates of childhood physical abuse. In one such study, it was revealed that homicidal depressed male patients reported higher rates of childhood physical abuse than did a non-homicidal, depressed sample. There have been talks about how Zainab’s killer should be hanged in public and made an example for others because he is a psychopath and doesn’t belong in this society but no one has mentioned that studies have provided strong evidence that violent offenders with antisocial personality+psychopathic traits have a history of more severe childhood physical abuse as compared to offenders with antisocial personality without psychopathic traits. There are also studies which have provided evidence that some of the brain anomalies distinguishing violent offenders with psychopathy may result from physical abuse in childhood. Furthermore, there is ample evidence that the severity of psychopathy is associated with the severity of overall childhood abuse. Our kids have to endure through multiple levels of abusive environments. If the parents are understanding, more aware and don’t resort to physical maltreatment, there is always the school where the teachers are waiting for them and if they escape that, there is always the madrasah. Have we ever taken a step back and thought why aggression is so rampant in our streets? The level of aggression towards the two brothers brutally murdered in broad daylight in Sialkot back in 2010, or more recently towards Mashal Khan has been mind-numbing. Can a case be made here why in Pakistan it’s so easy to kill in the name of a religion which is known for promoting peace and tolerance? I am well aware that many of the readers would be sceptical that by this definition everyone in Pakistan should be a psychopath or at least a violent aggressor which doesn’t seem to be the case, thankfully. In order to understand this link we have to think about the development of a child in the context of Gene x Environment. While we know that the genetic makeup of an individual plays a certain role, for instance abused kids who had high levels of a specific gene ‘MAOA’ expressed in their genotype, were less likely to develop antisocial personality as compared to the ones who had low levels of expression but these genes can get triggered by environmental factors such as abusive experiences through epigenetic modification. Therefore, while most of our children don’t end up being psychopaths as adults, some of them do. What we know for certain is that there is a scientific consensus that the origins of these problems are frequently found among developmental and biological disturbances that occur in early years of life. As shown in this figure, abusive experiences which could be as blatantly traumatic as sexual abuse by a perpetrator or as subtle as a parental figure not being emotionally available, set our children on the path to a life of distress and suffering. Simply put, if we could get rid of childhood abuse from the society, we can get rid of 54 percent of current depression, and 67 percent of suicide attempts. We could also reduce substance abuse by 73 percent. And it’s a very simple metric, the more abuse a child has to endure; the more severe will be the outcome, be it mental or physical. Over the past twenty years, childhood abuse has been scientifically associated with not only mental disorders but also with poor school performance, joblessness, disability due to poor health, ischemic heart disease, stroke, and even cancer. In fact according to one study, a nearly 20 year reduction in lifespan was found among individuals who had experienced more than 6 forms of abusive experiences in their childhood. While we blame lower life expectancy in South Asia on poverty, weaker health systems, lack of resources, infectious diseases etc, we never talk about the role of abusive experiences that set our children on the path to an unhealthy life. Unfortunately, child abuse is not only the problem of Pakistan, it’s a global problem. In fact according to recent reports, half of the world’s children – one billion children experience violence in one form or another. The reason it has become so critical for Pakistan is what this problem has done to our society. It’s not just about Zainab, it’s about saving millions of our children who will never achieve their full potential if we don’t break this cycle. Figures from Aga Khan University Hospital in 2016 suggested that 1 in 4 Pakistanis i-e., around 50 million people were suffering from common mental disorders. Approximately 20 million children in our country needed attention from mental health practitioners. This is why it becomes so critical to raise awareness and take significant steps to address this problem because child abuse is the most important preventable risk factor for developing mental disorders as a child, as an adult and even in old age. So where do we start? Which unit of the society should be targeted first and foremost to prevent this from happening? Let’s talk about the mothers because a mother is the very first and most critical object of affection for a child. Unfortunately, mothers who experience abuse as children have increased odds of developing antenatal and postnatal depression and are more likely to abuse their own children. One can see why antenatal depression which has a prevalence of 15-20 percent in developed countries has been reported to be as high as 80 percent in recently published two studies in Pakistan, conducted in KP. At the same time, 31 percent prevalence of postpartum depression in Pakistan is the highest in South Asia. It’s important to note that young girls who experience abuse are more likely to experience further re-victimisation in adulthood and pregnant women who are victims of intimate partner violence have been shown to have 5.8 fold increased risk for developing severe depression. Unfortunately, not only will this increase the chances of maltreating their children by four times, but actually the children who will be exposed to maternal depression as well as abuse from mothers will have a 12 times greater risk of developing mental disorders. In fact the effects of childhood abuse can be so long-lasting that in a recent study it was shown that in mothers who were abused as children, their newborns had lower brain volumes as compared to newborns of the mothers with no abuse history. Now, my message here is not to just paint a dark and bleak picture of our society but actually to present to the public the real problem and what could be done to address this problem. Hanging Zainab’s killer is only a temporary fix, may be for us to feel less guilty as a society. Yes, he should be punished, if proven guilty for what he has done, but that’s not the solution to this problem. We will have to grow and develop ourselves, not only to prevent crimes like this from happening but for the sake of providing our children with the future they truly deserve. Child abuse is not just limited to sexual abuse or being beaten to death by a psychopathic and ignorant madrasah mullah, it’s actually a much deeper problem and starts with the parents. We will have to start by respecting our wives, so that we can serve as role models for our children as they develop their own individual personality. According to a report by UNICEF, 53 percent of girls aged 15-19 and 34 percent of boys aged 15-19 think that a husband/partner is justified in hitting or beating his wife or partner under certain circumstances. No wonder according to Human Rights Watch, almost 90 percent women in Pakistan experience domestic violence during their lifetime. While it might not be acknowledged in Pakistan but witnessing inter-parental violence is a known form of child abuse and has been shown to result in physical alteration of fibre tracts in the brains of children who have witnessed inter-parental violence. As I have made the case earlier, it affects the child on multiple levels. Not only does it directly affect the offspring even during pregnancy but also indirectly as the mother develops depression and becomes emotionally negligent and/or physically abusive towards the child. The emotional toll of just being a witness to violence against his/her mother can be overwhelming for a developing child’s brain. Furthermore, as these children grow and watch their fathers disrespecting and beating their mothers, the boundaries start getting blurred and eventually they find themselves beating their wives because it becomes the norm. The cycle keeps repeating itself. We will also need to have a system in place that holds teachers accountable. School teachers can prove as effective role models for children who come from disadvantaged households where the home environment is not ideal due to lack of education, awareness and socioeconomic conditions. However, our teachers are often found partaking in these crimes against our children. Clinicians and health care workers will need to be informed and trained accordingly. Recent neuroscientific findings suggest that people presenting with mental disorders along with histories of childhood abuse need to be diagnosed and treated differently than people presenting with mental disorders without histories of childhood abuse. One such study showed that only 18 percent of depressed people who were abused between the age window of 4-7 showed positive response to antidepressant medication. In comparison 82 percent of the group that was depressed but not abused showed a positive response to medication. We will also need to have effective screening strategies implemented nationwide both within the healthcare system and in the community through the lady health worker network. There is a lack of formalized programs for screening and managing for child abuse, non-accidental injuries etc., across Pakistan. Unfortunately, injury overall is the third leading cause of death in children aged 1-4, however because of a lack of adequate screening, there is high likelihood that abuse is being overlooked. Similarly, the government will need to step up its efforts significantly to address the mental health gap. The lack of awareness is such that up to 85 percent of the people affected by mental disorders don’t seek treatment for their mental disorders. It’s rather unrealistic and quite difficult to expect a father or mother to take care of their child’s needs if they lack the cognitive capacity and skills needed for adequate parenting due to disorders like depression. To summarise, child abuse is a national problem. It’s not confined to a single city, a single perpetrator or a gang exploiting young children. We will need to take ownership of the fact that we have failed as a nation to protect our children, instead of using occasional high profile crimes for political gains and slights against each other. We will need to recognize that on a daily basis our children experience abuse not only in the form of brutal physical and sexual abuse, but also in the form of neglect and emotional and physical abuse by their parents, by their teachers and even by their peers. Acknowledging the problem will pave the way for future reforms. The Government will have to take this not only as a top moral obligation but also as a critical public health priority rather than setting up hotlines and creating taskforces which never convene due to lack of interested team members. Zainab cannot be brought back, her perpetrator will soon meet his fate but we as a nation should take this opportunity to introduce reforms that could save millions of Zainabs and help promote a morally healthy and developed society where every child is safe. The writer is instructor in Psychiatry, McLean Hospital, Harvard Medical School, Developmental Biopsychiatry Research Program Published in Daily Times, February 5th 2018.