This chapter delineates areas of concern in international child and adolescent mental health and focuses on issues of particular clinical import to child and adolescent psychiatrists and other child mental health clinicians. Many of the topics that are addressed are now relevant to domestic practice given widespread global immigration patterns.

International child and adolescent mental health embraces the world view on the place of children in society, the appreciation of diverse behavioral styles, the identification of psychopathology, and the setting of priorities for the use of scarce resources. As noted in the seminal articles on child psychiatry in developing countries (1,2,3), child and adolescent mental health is influenced by the economics of countries and societies within countries, by the internal and external displacement of children and adolescents through war and catastrophe, by the role of the child in the family, and by the place of women in society. New knowledge and greater recognition of the impact on children of exposure to trauma, sexual and physical abuse, inhumane living and working situations, inadequate health care, and drug abuse have heightened interest in approaches to ameliorating the impact on child and adolescent health and mental health of these potentially pathogenic influences. It is a challenge to child and adolescent psychiatrists and allied professionals to be active participants in understanding the nature of the problems faced and in being a part of the solution (4).

The overall health and wellbeing of children are international concerns. All countries with the exception of the United States of America have ratified the 1989 United Nations Convention on the Rights of the Child (5,6). It commits countries to “ensure that all children have the right to develop physically and mentally to their full potential, to express their opinions freely, and to be protected against all forms of abuse and exploitation.” The concern among some countries was the perception that ratification of the treaty would intrude on sovereign rights and/or traditional views of the child in a dependent position in society. In the end these concerns did not impede ratification but do impact implementation. In some countries that are party to the treaty, the affirmation of the rights of children has not resulted in benign policies toward the protection of children from harm or the fostering of positive development.

In the international arena, and increasingly in multicultural societies, child mental health and child psychopathology cannot be gauged solely from a Western perspective. It is simplistic to state, but meaningful to understand, that what may appear pathologic in one country or society, or to one cultural or subcultural group within a country, may be deemed normative or adaptive in another. This does not imply that it may not be helpful to have a consensus about a frame of reference regarding psychopathologic conditions, but the interested party must keep an open mind in attributing cause to behaviors, interpreting responses to events, or judging parental or familial interactions with children. The complexity of understanding children and adolescents embraces anthropologic, social, psychological, political, and rights dimensions. For the domestic practitioner, understanding the culture of the individual is important. For example, Murthy (7) reports that studies have found that suicide rates among immigrants are more closely aligned to the rates in the country of origin than to the rates in the country of adoption. Generally, suicide rates of immigrant populations are higher than in the country of origin. The methods of suicide are those used traditionally in the culture of origin. Canino et al. (8) also documented the persistence of the importance of culture-bound syndromes.

In many resource-poor countries, educational institutions represent the most coherent system embracing children and adolescents. As never before, the value placed on education in societies is being emphasized as agrarian pursuits have become commercialized or made nonviable. In resource-poor countries, the impact of technology is differentially affecting parts of society. On the one hand, technologic advance offers an unprecedented opportunity to the educated, but on the other, it accelerates inequality with the less educated. Urbanization combines with the technology revolution further to challenge accustomed ways that may stress individuals and families (9). Children and adolescents, as students or as part of a family, experience new stresses that convey either advantage or disadvantage, depending on access, intelligence, and resources. In response to these changes in society, resilience-building programs in schools, along with primary care health programs in communities, have evolved. While the emphasis on education may be profound in urban settings in resource-poor countries, the role of traditional healing for child mental health disorders, especially in rural settings, remains powerful (10,11,12,13,14,15). For instance, in Cambodia, the taxonomies and explanatory models of childhood illnesses are embedded in powerful beliefs about the role of ancestral spirits and the preceding mother from the child’s previous incarnation (16).

The role and responsibilities of child and adolescent psychiatrists and other child mental health professionals vary in resource-poor countries. The competencies of the child and adolescent psychiatrist must fit the needs of the society in which they exist. For example, epilepsy and mental retardation clearly fall within the expected clinical competencies of child and adolescent psychiatrists in resource-poor countries but not in resource-rich countries. The infrastructure in some countries post conflict may have decimated the child mental health workforce. In Cambodia, for example, where the country’s entire infrastructure, including the health system, was destroyed

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