The global problem of displacement from family, home, community, and country are of enormous importance to the mental health of populations. Displacement by war resulted in approximately 21.5 million refugees in 1999. An additional 30 million, 80% of whom are children and women, were displaced internally. Fullilove (19) emphasizes the importance of “place” in the healthy development of individuals. Sampson et al. (20) specifically address the importance of the community as a mediator and contributor to the impact of violence on children and adolescents. The delineation of the importance of “collective efficacy” in communities is an important concept when one considers the impact of imposed poverty, housing disruption, and displacement in ethnic conflicts affecting previously closely aligned groups. In resource-poor countries, the notion of “place” and community are of equal or greater importance. The disruption of traditional communities by war, famine, and natural disaster leave children and adolescents in vulnerable situations that affect mental health. Internal displacement by war and famine leads to the breakup of families, months and years of uncertainty, disruption of education, and physical illness. Forced emigration and the loss of parents and relatives in war often mean abandonment or orphaning of children and adolescents. Although these stressors may serve to demonstrate the enormous resiliency of youth, they often lead to depression, suicide, and a range of stress responses.

The problems of displacement from homes, families, communities, and countries affect children in a host of ways. Zivic (21), in a study of Croatian children during war, found significantly higher depressive and phobic symptoms in displaced refugee children than in local children in stable social conditions. Laor et al. (22), in a developmental study of Israeli children exposed to Scud missile attacks, found higher externalizing and stress symptoms in displaced children as opposed to those able to maintain family and community connections. Children in these circumstances may find themselves without the protection and support of parents at critical junctures in their lives. Children are forced to act in more mature ways far earlier than normal development would dictate or allow. Displaced children are faced with exposure to war and violence that may have included seeing family members murdered. Less often, but even more horrific, some children have been forced into being the murderers of their family or conscripted to serve as child soldiers. Others find themselves either displaced to other countries or internally displaced and left to fend for themselves. Street children engage in survival tactics that include criminal activity and prostitution. In an effort to find a context for survival, the formation of youth gangs is increasingly evident, especially in societies where there is a lapse in government organization and control. More often than not, the children are the victims rather than the perpetrators.

Eisenbruch et al. note that one out of every 275 persons on Earth is “of concern” to the United Nations High Commissioner for Refugees (23). More than 21 million are displaced within their own country, a 25 percent increase from the year before. Eighty per cent of refugees are women and children (24). Families face the added stress of high infant mortality rates, and resort where possible to culturally familiar coping strategies (15). War brings in its wake many unaccompanied minors who face life without their parents (25).

Many refugees live in camps that have become “total institutions” with the attendant “process of mortification” (26). Dependency is a feature in many camps and especially in those that reproduce the authoritarian regimes from which the refugees escaped (27). Others are suffering from the multiple traumatic effects of torture. An outbreak of peace may mean fewer violent deaths, but entering the repatriation and resettlement phase of the cycle is yet another challenge for the disempowered (28,29).

The priority concern of international child and adolescent mental health is often the acute and continuing tragedies that involve youth in armed conflict or its aftermath. Eighty percent of the victims of war are reported to be children and women (30). The result of armed conflict is often displacement externally as refugees or asylum seekers or internally within settings of civil war. Thabet and Vostanis (31) investigated anxiety symptoms and disorders in children living in the Gaza strip and their relation to social adversities. Children completed the revised manifest anxiety scale (a questionnaire with yes/no answers for 28 anxiety items and nine lie items), and teachers completed the Rutter scale (a questionnaire of 26 items of child mental health problems rated on a scale of 0–2: “certainly applies,” “applies somewhat,” “doesn’t apply”). Children reported high rates of significant anxiety problems and teachers reported high rates of mental health problems that would justify clinical assessment. Anxiety problems, particularly negative cognitions, increased with age and were significantly higher among girls. Low socioeconomic status (father unemployed or unskilled worker) was the strongest predictor of general mental health problems. Living in inner city areas or camps, both common among refugees, was strongly associated with anxiety problems.

Thabet et al. (32) examined the mental health profile among 322 Arab children living in the Gaza strip. Western categories of mental health problems did not clearly emerge from the factor analysis, the main difference appearing to operate in parents’ perceptions of emotional problems in preschool children. The authors warn of the need to establish
indigenously meaningful constructs within this population and culture, and subsequently revise measures of child mental health problems

More attention is needed to culturally appropriate trauma therapy for children. Culture mediates the possible range of child responses (33). More than half of children exposed to war meet the criteria of PTSD (34), levels of stress were related to war exposure (35), the Impact of Event Scale (IES) persists after the war (36), and those who do are at higher risk of comorbid psychiatric diagnosis (37).

In the turmoil of some resource-poor countries, children are now being forced to become child soldiers, and others are drawn into the conflict as sexual slaves. Child soldiers reportedly suffer posttraumatic stress disorder (38,39,40,41,42,43). Somasundaram states that to prevent children becoming soldiers we need first to understand why children choose to fight due to push factors (traumatization, brutalization, deprivation, institutionalized violence, and sociocultural factors) and pull factors (military drill from early childhood), as well as society’s complicity (44).

These horrific experiences place an as yet undefined burden on the psychological development of the victim. Understanding these experiences may shed additional light on the extremes to which resiliency may allow future healthy development, but perhaps more likely it will demonstrate the more permanent scarring evidenced in disturbed interpersonal relationships, distorted defenses, heightened aggression, reduced empathy, and self-destructive behavior. The data are not yet available to ascertain whether these young people evidence posttraumatic stress disorder (PTSD) in the classic sense or whether, because of the early age of induction into the culture of war, they develop in a different way as a survival response. Huge challenges face child mental health clinicians in helping to reclaim the lives of former child soldiers (45,46).

As for trafficking in children, worldwide, an estimated 1 million children are forced into prostitution every year and the total number of prostituted children could be as high as 10 million (47). Children are trafficked worldwide (48,49,50,51,52,53,54,55,56). The most urgent attention is paid to combating the trafficking (57), but the management of the psychological sequelae for the children will need to be given further attention. Nongovernmental organizations have been taking a lead in developing programs for children and adolescents freed from trafficking. Another issue of concern is the trafficking of children for child labor and other forms of exploitation. The International Labor Organization has taken this up as a major concern (58). The psychological consequences of child labor are complex, involving distorted relationships of children to their families and the assumption of adult roles prematurely.

In sub-Saharan Africa, Russia, and parts of Asia, acquired immunodeficiency syndrome (AIDS) is now a pandemic. Special attention needs to be given to the consequences of AIDS on children and youth. The direct impact on children and adolescents is evident in India, other parts of Asia, and Africa, where sexual exploitation has led to a high incidence of youth infected, with the inevitable outcome of death as a result of lack of available treatment. An estimated 1.5 million children under 15 years old are living with human immunodeficiency virus (HIV) infection or AIDS (59). More than one-fourth of the young population in sub-Saharan Africa is infected. Among the ten most affected countries all in sub-Saharan Africa, approximately 6 million children younger than 15 lost their mother or both parents to AIDS.

As documented by Carlson and Earls (61), whether through social policy as evidenced in the Leagane children of Romania, or as the consequence of the pandemic of AIDS, the rearing of children in orphanages or in other situations that deprive children of appropriate stimulation and nurturance has potentially long-lasting consequences for societies. Those infected but struggling with the illness face the prospect of having to adjust to declining physical and mental functioning and often living isolated lives. Thus, the mental health consequences of AIDS as a chronic and pervasive illness must be considered. There is the obvious concern with the direct effect of AIDS on the youth with manifestations of neuropsychological dysfunction including dementia, depression, and other disorders, which go largely untreated. These children and adolescents living as orphans or in stigmatized environments are vulnerable because of the loss of parent figures, malnutrition, and disenfranchisement from societies that have a stigmatized view of AIDS-affected and HIV-infected persons.

The mental health consequences are similar in the international arena and are well documented in U.S. studies (60). The caution in developing countries is that recognition of the neuropsychological consequences will be overshadowed by the totality of the devastation. This lack of recognition of depression, dementing illness, and other consequences of HIV infection may contribute to the continuing spread of the epidemic.

Substance abuse in children and adolescents is a worldwide problem (62). In resource-poor countries, the problem is of no less importance than in Western countries and exacts a tremendous toll in terms of morbidity and mortality. Illicit drugs and psychoactive substances not defined as drugs of abuse (such as khat, inhalants, and alcohol) are used by youth regardless of economic circumstance or religious prohibition. Remarkably, in some Muslim countries, alcohol use and abuse are significant contributors to psychological morbidity. Khat or miraa (Catha edulis) is used extensively in East Africa and the Middle East. In Somalia, Ethiopia, and Kenya, the leaves of khat are chewed at all levels of society from about the age of ten (63). Khat may induce a mild euphoria and excitement that can progress to hypomania. In youth, khat use, especially if it is combined with the use of other psychoactive substances, may lead to psychosis.

Homeless street children are now found worldwide and appear particularly vulnerable to substance abuse and other high-risk behavior (64). Senayayake et al. (65) studied the background, life styles, health, and prevalence of abuse of street children in Colombo. Family disintegration was mentioned as the cause for life on the streets by 36%; child labor was reported in 38%; 16% admitted to being sexually abused; 20% were tobacco smokers. Homeless children also are prominent among those groups using inhalants and who are caught in cycles of physical and sexual abuse, often under the influence of drugs. Road accidents among those using drugs are also high.

Solvent and inhalant use is associated with poor economies. In South America, inhalant use is a dominant factor in the presentation of youth affected by psychoactive substances. In São Paolo, Brazil it is reported that up to 25% of children age 9 to 18 years abuse solvents (66). In the Sudan, gasoline is the inhalant of choice, whereas in Mexico, Brazil, and elsewhere in Latin America, paint thinner, plastic cement, shoe dye, and industrial glue are often used. Solvent use is also found among the aboriginal groups in Australia and on Native Canadian reservations (67). In Mexico, three of
every 1,000 people between the ages of 14 and 24 years use inhalants on a regular basis (68). These figures do not include two high-risk groups, the homeless population and those less than 14 years old, whose rates of inhalant abuse are much greater. Several community studies carried out in different parts of Mexico show that starting ages are as young as five or six years (68). Data suggest that the percentage of young people using inhalants decreases with age, as other substances such as alcohol and marijuana are substituted. Inhalant use decreases as educational level increases (69).

Wittig et al. (70) examine the hypothesis that drug use among Honduran street children is a function of developmental social isolation from cultural and structural influences. Data from 1,244 children working and/or living on the streets of Tegucigalpa are described, separating “market” from “street” children. The latter group is then divided into those who sniff glue and those who do not to identify salient distinguishing factors. Family relations, length of time on the street, and delinquency are the most important factors.

Forster et al. (71) studied the self-reported activities engaged in by children found wandering on the streets of Porto Alegre, Brazil, aiming to describe their drug abuse habits and practice of thefts or mendicancy. Regular abuse of inhalants was reported much more frequently by the street subgroup of children, reaching a prevalence of 40%. The practice of theft was self-reported mainly by the children from the street group and only by the ones who used illicit drugs. These results show that very poor children might spend many hours of the day by themselves in the streets of a big city accompanied by children who are never under adult supervision. In spite of being alone for some hours a day and making friends with others who might use drugs, having a family and regularly attending school decreases the risk of delinquent acts and drug use.

Violence to and by children and adolescents now appears to be all too prevalent worldwide (72). Bullying, corporal punishment, victimization of parents by children and adolescents has now been reported worldwide. It is beyond the scope of this chapter to address all forms of violence; it will focus on specifics related to child abuse. Understanding child abuse requires understanding the vast cultural diversity in which children and adolescents live, and there is a need for greater attention to be given to possible country-specific interventions (73). What is termed abuse varies between cultures.

There are differences in cross-cultural definitions, incidence in developed and developing countries across continents, and measures that have been instituted to prevent and manage child maltreatment (74). The literature suggests that child maltreatment is less likely in countries in which children are highly valued for their economic utility, for perpetuating family lines, and as sources of emotional pleasure and satisfaction. However, even in societies that value children, some children are valued more than others (75). Ethnicity has been found to play a role in the epidemiology of pediatric injury (76). There is a diverse culture-specific literature on abuse (77,78,79).

There are reports of structural models of the determinants of harsh parenting, for example, among Mexican mothers, where cultural beliefs play a major role in parenting within the framework of Mexican family relations (80). Changing cultural norms and attitudes in a given setting (e.g., Korea) can lead to children being at risk of abuse in the name of discipline or other seemingly appropriate parental or authority responses (81,82,83). Child abuse might increase in certain cultural groups as a result of cultural change rather than emerging from their traditions (84). Child psychiatrists with insufficient awareness about normative practices by parents, for example, dermabrasion or cao gao in Vietnam (85), may jump to the conclusion that hematomas around the child’s head, neck, or chest signals that the parents may have been wrongdoers who abused their child. A culturally competent child psychiatrist, while not dismissing abuse out of hand, would also evaluate the alternative possibility, that the parents, with the best interests of the child in mind, submitted him/her to ritual treatment, for which the bruising acts as a public signal to the community that the child has been unwell.

Shalhoub-Kevorkian (86) reported a survey of victims of sexual abuse among Palestinian Israeli girls aged 14 to 16 years. Data revealed that the girls’ attitudes not only conformed to general findings on disclosure of sexual abuse but also reflected sociopolitical fears and stressors. Helpers struggled between their beliefs that they should abide by the state’s formal legal policies and their consideration of the victim’s context. The study reveals how decontextualizing child protection laws and policies can keep sexually abused girls from seeking help.

The legal implications of child abuse are affected by practices which may be normative in certain cultural settings, for example, female genital mutilation (87). Some ethnic groups may carry out procedures on their children as a sign of caring rather than as a punitive measure. For instance in Cambodian and Vietnam there are cases with facial burns associated with what was termed “innocent cultural belief” (88). Thus, factors that lead to underreporting by physicians have included ethnic and cultural issues (89). Ethnographic data point to the importance of the social fabric in accounting for differences in child maltreatment report rates by predominant neighborhood ethnicity (90). There can be mismatches between the definition of child abuse between the culture of the professional and the culture of the families (91). There is much to be learned about the use of cultural evidence in child maltreatment law (92).

There has been a growing recognition in child psychiatry in Western settings to consider cultural context in the assessment of psychopathology (8). A culturally competent framework for assessment in resource-poor countries, while sorely needed, has not been developed. A simplistic attribution to culture of seemingly bizarre symptoms that in fact represent treatable mental illness would deflect energy from the development of effective treatment and prevention efforts. At the same time, an understanding of the cultural construction of major psychiatric disorders (including culture-bound disorders affecting young people) would minimize inaccurate diagnoses. This view has to be balanced with the understanding of less severe psychopathology, in which the observation of Neki (98) holds true, that ethnodynamics determine psychodynamics. In India, where the cultural ideal of an independent adult is not an autonomous adult, dependency is inculcated from childhood through a prolonged dependency relationship between mother and child. Dependency has a negative, pejorative connotation in Western thought, which is not so in the Indian context. The fostering of dependency is coupled with a high degree of control, low autonomy, and strict discipline, enforced within the broad framework of the family system. When this is identified by clinicians as representing a degree of pathology, decreased emphasis on the expression of thoughts and emotions in children could explain the greater preponderance of neurotic, psychosomatic, and somatization disorders (99). Thus, cultural context influences the definition of normalcy or disorder. It proscribes the values and ideals for the behavior of individuals, it determines the threshold of acceptance of pathology, and it provides guidelines for the handling of pathology and its correction (100).

Cultural issues also affect assessment because of problems with cultural validation of instruments. A German study showed problems in applying the United States factor structure of the Conners Parent Rating Scale (CPRS), with lack of correspondence of the impulsiveness/hyperactivity scale (101). A Greek study of the Conners-28 teacher questionnaire in a Greek community sample of primary schoolchildren found that the factor structure was similar to that originally reported by the United States, with a high level of discrimination between the referred and nonreferred sample, especially for the inattentive-passive scale (102).

Rey et al. (103) noted the lack of simple, reliable measures of the quality of the environment in which a child was reared which could be used in clinical research and practice. They developed a global scale to appraise retrospectively the quality of that environment and found good interrater reliability with clinicians from Australia, Hong Kong, and the People’s Republic of China. Goodman et al. (104) developed a computerized algorithm to predict child psychiatric diagnoses on the basis of the symptom and impact scores derived from Strengths and Difficulties Questionnaires (SDQs) completed by parents, teachers, and young people. The predictive algorithm generates ratings for conduct disorders, emotional disorders, hyperactivity disorders, and any psychiatric disorder. The algorithm was applied to patients attending child mental health clinics in Britain and Bangladesh. SDQ prediction for any given disorder correctly identified 81–91% of the children who had that diagnosis.

Determining the epidemiology of childhood mental disorders in Western society is a challenge. On the international scene, the ability to determine the precise magnitude of mental disorders is even more complex. Reporting systems are inadequate, the definition or recognition of disorders varies or has variable interpretations, and the cultural component of what constitutes a disorder is only now being more fully appreciated by epidemiologists and researchers. Of significance in resource-poor countries is that any measure of mental disorder takes place against a background of child and adolescent mortality and morbidity that makes the epidemiology of psychiatric disorder not only inaccurate, but often of a lower priority. Thus, in studying the epidemiology of psychiatric disorder in children and adolescents in resource-poor countries, it is important to define not only the prevalence and incidence of the disorders, but also the degree of impairment and burden of disease. No single study or consistent set of independent studies on the epidemiology of child and adolescent disorders since 1980 can be identified as definitive or relevant across societies. Those studies carried out in the 1980s reflect the deficiencies noted earlier and certainly do not reflect the current realities of the countries from which the data were reported (105,106). Weiss has defined a new epidemiological approach combining qualitative study with classic epidemiologic methods (107,108,109). This new “cultural epidemiologic” approach has not yet been applied to child and adolescent mental disorders but holds the promise of gaining a more satisfactory understanding of the nature and extent of child and adolescent mental disorders worldwide.

Until now, when one has been faced with the realities of resource-poor countries, as noted, there is the danger of becoming a diagnostic nihilist in attempting to understand mental disorders in youth. However, for example, responsible investigators in Western Ethiopia clearly identified disordered mental functioning that meets a set of defined criteria (110). There is clear evidence that depression, psychosis, and mania can be defined and treated. The problem arises when one considers the context for the presentation of child and adolescent mental disorders. Is a hallucination during a ritual a disturbance in need of treatment? If the hallucination persists, should it be treated? What diagnostic label is appropriate? Giel and Van Lujik (111) found, in the pre-HIV/AIDS era, and counter to prevailing belief, that mental disorders were diagnosed more frequently than infectious diseases in the health centers in Africa that they studied. Until reporting is adequate and accurate, it cannot be assumed that the current state of mental health in the developing world actually supports the too prevalent minimalist and optimistic view. This sense is supported by the finding from WHO studies of primary care clinicians that showed that many patients seeking care had mental disorders, and their communities were aware of the problem (112). In the current era, Omigbodun (113) documented the psychosocial problems in a child and adolescent psychiatric clinic population
in Nigeria: 62.2% of new referrals to the clinic had significant psychosocial stressors in the year preceding presentation. Problems with primary support, such as separation from parents to live with relatives, disruption of the family, abandonment by the mother, psychiatric illness in a parent, and sexual/physical abuse occurred in 39.4%. Significantly more children and adolescents with disruptive behavior disorders and disorders like enuresis, separation anxiety, and suicidal behavior had psychosocial stressors when compared to children with psychotic conditions, autistic disorder, and epilepsy.