# <mark>Introduction</mark>

Fragile, conflict and violence-affected (FCV) settings present complex challenges for societies, families and children by contributing to greater mental health burdens. FCV areas are characterized by low levels of per capita income, high levels of food insecurity, vulnerability to climate hazards, and increasing intersections with internally displaced and refugee populations (The World Bank, 2024). This can create a vicious cycle wherein people who are least equipped with the resources to manage stressful environments will be most likely to live in areas defined by reduced access to services and greater risks. Young children often bear the heaviest health burdens in the wake of fragility and conflict (Murthi & van der Heijden, 2024), and the compounding effects of various facets of maternal mental health concerns found at high rates in FCV contexts may be especially detrimental to early childhood development (ECD). In areas of conflict and forced displacement, there is evidence of high rates of depression and stress-related disorders (80% and 88%, respectively) (Bogic et al., 2015; Morina et al., 2018), and multi-generational impacts of conflict on child development outcomes and beyond (Chatterjee et al., 2023).

Parents in Khyber Pakhtunkhwa, Pakistan, confront a multitude of risks to child development that have worsened in the last decade. Longstanding challenges include high rates of poverty, low access to high-quality education (including preprimary education), and incomplete and inadequate coverage of social assistance cash transfers (Alam et al., 2022; Cheema et al., 2020; Shah et al., 2022). Added to these risks are maternal depression, anxiety and parenting stress, which have been found to be consistently negatively impacted by fragility, conflict and violence (Al-Abri et al., 2023; Chen et al., 2017). Yet little is known about the prevalence of maternal mental health concerns in Khyber Pakhtunkhwa and how recent events may have exacerbated them.

Various studies confirm that higher levels of parental depression, anxiety, and parenting stress respectively predict higher levels of children’s internalizing behaviors (e.g., withdrawal, anxiety), higher levels of externalizing behaviors (e.g., anger, aggression), and reduced social-emotional competence (e.g., ability to self-regulate, follow instructions, get along with peers) (De Oliveira et al., 2019; Fang et al., 2022; Mäntymaa et al., 2012). When multiple parental mental health problems co-occur, early childhood functioning is at increased risk (Watkeys et al., 2022). In Pakistan, rates of comorbidity of anxiety and depression have been found to range between 25% to 34% and higher rates are seen in women than men (Farooq et al., 2019; Mirza & Jenkins, 2004). While these risks occur across the socioeconomic spectrum, women in low-income households experience disproportionate levels of mental health concerns, such as depression, and display fewer characteristics that foster favorable ECD, such as maternal supportiveness and cognitive stimulation (Reeves & Krause, 2019). For instance, exposure to community-level stressors such as flooding or other natural disasters, and community-level crime have been shown to increase stress and anxiety (Kerker et al., 2023; Maselko et al., 2018; Sitwat et al., 2015; Yousuf et al., 2023). Risks and stressors at the household and individual levels, including poverty, food insecurity, discrimination, exposure to intimate partner and other domestic violence, and fear, related to safety in the home or community, are also correlated with depression and anxiety (Adamu & Adinew, 2018; Iqbal & Ali, 2021; Wei et al., 2024). In addition, research on chronic depression shows correlations with impaired social-emotional functioning among young children in Pakistan (De Oliveira et al., 2019). Nationally representative studies in Pakistan also show a decline in the likelihood of developing on track as exposure to risk factors increases in number (Hentschel et al., 2024; Tomlinson et al., 2023). Further, evidence suggests that living with parents 2