Lived Experience of Adverse Childhood Experiences (ACEs) Among Adolescents and Young People in Pakistan: A Qualitative Evidence Synthesis

Abstract

Background: Adverse childhood experiences (ACEs), including abuse, neglect, household violence, peer violence, community violence, and family dysfunction, are associated with poorer mental, behavioral, social, and physical health. Although an expanding quantitative literature has documented the prevalence and cumulative health burden of ACEs, fewer studies have examined how adolescents and young adults in Pakistan experience, interpret, and respond to childhood adversity. Objective: To synthesize the available qualitative evidence concerning the lived experiences and perceived consequences of childhood adversity among adolescents and young people in Pakistan and to interpret these findings within the wider Pakistani and international ACE literature. Methods: A qualitative evidence synthesis was undertaken using published Pakistan-based qualitative studies involving adolescents or young adults who described childhood adversity, emotional crises, self-harm, or related psychosocial experiences. Because the direct qualitative evidence base was limited, Pakistan-specific cross-sectional studies and international systematic reviews and meta-analyses were used to contextualize, but not generate, the qualitative themes. Findings from the included qualitative studies were compared narratively, and related concepts were grouped into higher-order interpretive themes. Quantitative findings were reported separately and were not treated as qualitative evidence. Results: Two Pakistan-based qualitative studies directly contributed to the synthesis: a phenomenological study of 10 university students with elevated ACE exposure in Lahore and an interview study involving 16 adolescents aged 12–18 years presenting with self-harm. Five overarching themes were identified: persistent physical and psychological distress; emotional dysregulation and interpersonal conflict; distrust, social withdrawal, and impaired relationships; disruption of academic and everyday functioning; and reflection, coping, and prevention. Contextual Pakistani studies reported a high burden of ACE exposure and significant associations with poor mental well-being, depression, and anxiety. International evidence similarly demonstrated that cumulative ACE exposure is common and is associated with reduced resilience, substance misuse, justice involvement, and adverse physical health outcomes. Conclusion: The limited qualitative evidence from Pakistan suggests that childhood adversity is experienced through interconnected physical, emotional, relational, and educational difficulties. Interpersonal conflict, emotional crises, distrust, impaired functioning, and limited access to effective support recur across the available accounts. The findings should be interpreted cautiously because the evidence is based on small, geographically concentrated samples. Further direct qualitative research involving school-aged adolescents, rural communities, boys, marginalized populations, and young people outside formal education is required