IACAPAP Textbook of Child and Adolescent Mental Health

MISCELLANEOUS

Chapter

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THE MENTAL HEALTH OF
CHILDREN FACING COLLECTIVE
ADVERSITY
POVERTY, HOMELESSNESS, WAR ANDDISPLACEMENT
Laura Pacione, Toby Measham, Rachel Kronick,Francesca Meloni, Alexandra Ricard-Guay, Cécile Rousseau &Monica Ruiz-Casares
Laura Pacione MD, MSc
Resident in Psychiatry, Équipede recherche et d’intervention
transculturelles; Divisionof Social and Transcultural
Psychiatry, McGill University,
Montreal, Quebec, Canada
Conflict of interest: nonereported

Toby Measham MD, MSc
Assistant Professor, Équipede recherche et d’intervention
transculturelles, Divisionof Social and Transcultural
Psychiatry, McGill University,
Montreal, Quebec, Canada

LondonStreetChildrenby Edward R.
King (1904)
UCL ArtMuseumConflict of interest: nonereported

Rachel Kronick MD

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Pacione L, Measham T, Kronick R, Meloni F, Ricard-Guay A, Rousseau C, Ruiz-Casares M. The mental healthof children facing collective adversity: Poverty, homelessness, war and displacement. In Rey JM (ed), IACAPAP e-Textbook of Childand Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

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1IACAPAP Textbook of Child and Adolescent Mental HealthAdversity can take multiple forms for children. It may stem fromconstitutional vulnerability, from parental and familial difficulties anddysfunction or from environmental stressors, all of which may jeopardize
children’s development and affect their mental health. Poverty, becoming
orphaned, homelessness child labor and war all expose children to potentiallyharmful environmental stress. This chapter will describe the effects of these kindsof collective adversities on the mental health and well being of children. The
experience of refugee children will be taken as an example to illustrate the approachto the mental health assessment and treatment of vulnerable children once they arein a situation of safety.

THE MENTAL HEALTH CONSEQUENCES OF
POVERTY FOR CHILDREN

Resident in Psychiatry, Équipede recherche et d’intervention
transculturelles, Divisionof Social and Transcultural
Psychiatry, McGill University,
Montreal, Quebec, Canada
Conflict of interest: nonereported

Francesca Meloni MA
PhD Candidate, Psychiatry,
Équipe de recherche etd’intervention transculturelles,
Division of Social andTranscultural Psychiatry, McGill
University School of Social
Work, Montreal, Quebec,
CanadaDefining poverty

Conflict of interest: nonereported

Poverty is a difficult concept to define because it overlaps with many different
cultural, social, and political dimensions. The "poverty line" is typically defined as
the cut-off point that separates the poor from those earning what is considered to
be an adequate level of income in a given country (Ravallion, 2010).

Alexandra Ricard-Guay MA

The World Bank defines the poverty line in two ways: A relative poverty line
is one that depends on the income distribution within a given country and varies
according to purchasing power. For example, the poverty line is often set at 50%
of a given country’s mean income. An absolute poverty line (also called extreme
poverty) is defined using different methods, but is often determined in relation to
the average cost of basic survival needs in the poorest 10 to 20 countries. In 2005,
the World Bank defined the absolute poverty line at a household income of lessthan $1.25 (US) per day (Chen & Ravallion, 2010). This new value is an increase
from the previous value of $1 (US) per day and is thought to better represent thecost of goods. Sometimes a household income of less than $2 (US) per day is used
as a cut-off to better describe the scope of poverty in a given country or region.
Using a cut-off of less than $1.25 (US) of household income per day, an estimated1.29 billion people, or about a quarter of the population of the developing world,
were living in absolute poverty in 2008 (World Bank, 2012). To put this in relative
terms, the number of people living in absolute poverty is over 4 times the size of
the US population as measured in the 2010 census.
A declaration and action plan developed at the UN World Summit on Social
Development in Copenhagen in 1995 defined absolute poverty as "a condition
characterised by severe deprivation of basic human needs, including food, safe
drinking water, sanitation facilities, health, shelter, education and information.
It depends not only on income but also on access to services." (Gordon, 2005).
Poverty can therefore be interpreted as the state of having insufficient access toresources needed for survival. Given the concept of relative poverty, poverty can also
be seen as a state of relative material and social disadvantage. These are obviously
overlapping definitions but each has unique consequences for children's physicaland mental health.

PhD Candidate, Social Work,
Équipe de recherche etd’intervention transculturelles,
Division of Social andTranscultural Psychiatry, McGill
University School of Social
Work, Montreal, Quebec,
CanadaConflict of interest: nonereported

Cécile Rousseau MD, MSc
Professor, Équipe derecherche et d’intervention
transculturelles, Divisionof Social and Transcultural
Psychiatry, McGill University,
Montreal, Quebec, Canada
Conflict of interest: nonereported

Monica Ruiz-Casares BLL,
MA, MSc, PhD
Assistant Professor, Équipede recherche et d’intervention
transculturelles, Divisionof Social and Transcultural
Psychiatry; McGill University,
Montreal, Quebec, Canada
Conflict of interest: nonereported
The section on child soldiers
is partly based on: Denov M,
Ricard-Guay A (in press). Girl
soldiers: towards a gendered
understanding of wartime
recruitment, participation anddemobilization. In Gender andWar: A Handbook. Edward
Elgar Publishers.

The multifaceted impact of poverty is captured by the United Nations (UN)
official definition of poverty that was ratified by the heads of all UN agencies in
1998: “Fundamentally, poverty is a denial of choices and opportunities, a violation

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2IACAPAP Textbook of Child and Adolescent Mental Healthof human dignity. It means lack of basic capacity to participate effectively in society.
It means not having enough to feed and clothe a family, not having a school orclinic to go to, not having the land on which to grow one’s food or a job to earn
one’s living, not having access to credit. It means insecurity, powerlessness andexclusion of individuals, households and communities. It means susceptibility toviolence, and it often implies living on marginal or fragile environments, without
access to clean water or sanitation” (Gordon, 2005). Indeed, Mahatma Gandhi has
described poverty as “the worst form of violence”.
Children are particularly affected by poverty because they are usuallydependent on their parents or other adults and in a powerless and vulnerablesocial position (Boyden & De Berry, 2004; Lansdown, 1994; Scheper-Hughes &Sargent, 1998). Poverty therefore has unique impacts on children.
Measuring child poverty
Given the vulnerable social position of children, The UN Children's Fund
(UNICEF) has urged that the conceptualization of child poverty be expanded
beyond the concept of income poverty. An operational definition of absolute
poverty for children has been defined as the severe deprivation of two or morebasic human needs for children, including severe deprivation in the following areas(Gordon & Nandy, 2008):•

Food deprivation leading to severe malnutrition•

Water deprivation with access limited to surface water or water sources
far from home•

No access to sanitation facilities (toilet or latrine)•

Health deprivation, including lack of immunization or medical
treatment•

Shelter deprivation (i.e., severe overcrowding with five or more people
per room, or dwellings with no flooring material)•

No access to professional education of any kind•

Information deprivation (i.e., children aged between 3 and 18 with noaccess to newspapers, radio, television, computers or phones at home)•

Deprivation of access to basic services (i.e., children living 20 kilometers
or more from any type of school or 50 kilometers or more from any
medical facility with doctors).

Mahatma Gandhi
described poverty as “theworst form of violence”

In 2006, the UN
General Assembly
adopted the firstinternationally agreed
upon definition of childpoverty:"Children living in poverty
are deprived of nutrition,water and sanitation
facilities, access to basic
health care services,shelter, education,
participation and protection,and that while a severelack of goods and services
hurts every human being,
it is most threatening andharmful to children, leaving
them unable to enjoy theirrights, to reach their fullpotential and to participate
as full members of thesociety” (Minujin & Nandy,
2012 p3).

Of these measures, severe deprivation of shelter, sanitation, information andwater are the most common worldwide, but the indices vary depending on theaffected region (Gordon & Nandy, 2008).
The scope of child poverty
Given the difficulties in measuring poverty using general data about income,access to resources and services can provide a clearer picture of poverty and social
inequality for children. Among the estimated 2.2 billion children in the world, one
billion are estimated to live on less than 1$ a day (UNICEF, 2005a). Furthermore,
for the 1.9 billion children who live south of the equator, there are:•Adversity

640 million without adequate shelter (one in three)

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3

IACAPAP Textbook of Child and Adolescent Mental HealthBrot! (Bread!) lithograph by
Käthe Kollwitz (1867-1945).

•

400 million with no access to safe water (one in five)•

270 million with no access to health services (one in seven) (UNICEF,
2005a).

Although rates of absolute poverty are striking in developing countries, highlevels of poverty in terms of relative economic and social deprivation are also foundin Western countries. In wealthy countries, the risk of poverty is significantly
affected by ethnicity, citizenship and immigration status. For example, in the US,
Black and Latino children are disproportionately poor, lacking health insurance,and having limited access to social services and education (Fass & Cauthen, 2008;
Guendelman et al, 2005). Citizenship may also influence a family's risk of poverty.
In Germany, the number of children in non-citizen families living in poverty
almost tripled from about 5% at the beginning of the 1990s to 15% in 2001, while
poverty levels for children of German citizens did not change (UNICEF, 2005b).
There is a strong relationship between poverty, health, social inequalityand denial of basic human rights (UNICEF, 2000; 2006a). Women are estimatedAdversity

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4IACAPAP Textbook of Child and Adolescent Mental Healthto make up 70% of the world's poor and are thought to be disproportionately
affected due to gender-based systematic discrimination that limits women's accessto education, health care, economic opportunities and control of assets (United
Nations Women, 2010). Consistently, female children are often disproportionallyaffected by poverty and under conditions of absolute poverty, they are more
likely than their male siblings to suffer malnutrition, have stunted growth and be
denied access to primary school education (Khuwaja et al, 2005; Baig-Ansari et al,
2006; United Nations, 2010). In some countries, gender biases in property andinheritance laws and restrictions on acquiring assets perpetuate the cycle of poverty
for women and girls (UNICEF, 2006a).
Poverty and armed conflict
Poverty also interacts with political instability, armed conflict, violence anddiscrimination in ways that specifically affect children. For instance, in cases ofarmed conflicts and dire poverty, family survival strategies may single out children
as expendable, through abandonment, trafficking, or militarization (Boyden & De
Berry, 2004; Einarsdóttir, 2006; Scheper-Hughes, 1987). Minors who are displacedby armed conflict, and who are often not recognized or protected by national
states are particularly affected by poverty (Boyden & Hart, 2007). In 2006, theUN High Commissioner for Refugees announced that 5.8 million people werestateless and 13.5 million internally displaced (Bhabha, 2009). For these children,
the entitlement to social rights that is, in principle, assured by a nation state, isoften denied or granted on compassionate grounds, if at all. Another example ofthe particularly vulnerable role of children is the case of citizen minors who lackaccess to education or health care because their parents do not have legal status
within their host country (Bernhard et al, 2007; Ruiz-Casares et al, 2010).
Developmental, emotional and behavioural consequences of poverty forchildren
The consequences of poverty for children can include long-lasting impacts
on psychological and physical development. In fact, the harm suffered due
to malnutrition and inadequate health care in early childhood often has severe
consequences on a child’s development and well-being (Brooks-Gunn & Duncan,
1997; Nandy et al, 2005; Seccombe, 2000; Simich, 2006). The higher prevalenceof neurodevelopmental disabilities and lower educational achievement amongchildren growing up in severe poverty may be explained by a number of factors,
including protein-energy malnutrition leading to structural brain abnormalities,
dietary micronutrient deficiencies, environmental toxins, lack of early sensory
stimulation, anemia secondary to parasitosis, and the sequelae of infectious disease(Bergen, 2008).
Much of the research on the impact of child poverty on mental health has
been conducted with children in developed countries who are exposed to relative
poverty and social deprivation. These data indicate that poverty increases the riskof behavioural and emotional symptoms in children and may also negatively affectmental health in adolescence and adulthood. In a study of 5000 low-income
families in 20 large US cities, homelessness or precarious housing status was
associated with more internalizing and externalizing problems among three-yearold children compared to their more stably housed counterparts (Park et al, 2011).

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5IACAPAP Textbook of Child and Adolescent Mental HealthIn a large longitudinal study done in Australia, exposure to poverty inutero and at six months, five years or 14 years were all associated with higher
rates of anxiety and depression in adolescence and early adulthood, and repeatedexperiences of poverty were associated with poorer mental health (Najman et al,2010). A study of poor rural US families who moved out of poverty because of an
income intervention demonstrated that among families who moved out of poverty,
their children exhibited fewer symptoms of conduct and oppositional defiant
disorders, but no change in symptoms of anxiety and depression (Costello et al,2003). This raises the possibility that the effects of poverty on internalizing andexternalizing symptoms in children may be moderated by different mechanisms. In
wealthy societies, on a population health level, child well-being is associated withgreater income equality and a lower percentage of children in relative poverty rather
than average household income alone (Pickett & Wilkinson, 2007). Therefore,
relative child poverty has been shown to have a lasting impact on both child andadult mental heath and may be related to both material and social deprivation andinequality. Reducing income inequality in wealthy countries may be an important
goal in order to improve child well-being across society as a whole.

Reducing income
inequality in wealthy
countries may be an
important goal in orderto improve child wellbeing across society as
a whole.

How child poverty leads to poorer mental health outcomes is not clearly
established, but some data suggest that the physical and psychological stresses ofpoverty have lasting consequences on the developing child. Poverty may mediate
its effect on mental health through alterations in the function of the sympathetic
nervous system, which increases release of adrenaline and noradrenaline, and the
hypothalamic-pituitary axis, which stimulates the production of the stress hormone
cortisol (Evans & Kim, 2007). Furthermore, excessive stress during childhood is

Nepalese Boy.

Photo: shashish
http://www.flickr.
com/photos/
shashish/3527873250/

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6

IACAPAP Textbook of Child and Adolescent Mental Healthassociated with architectural changes in different regions of the developing brain,including the amygdala, hippocampus, and prefrontal cortex, which are involved inemotional experience, stress regulation, learning and ability to cope with adversity(Shonkoff et al, 2012).
Resilience
Despite the harmful effects of poverty on children, it is important to take
into account the resilience and the coping strategies employed by these children.
Boyden (2004) remarked that factors such as gender, class and ethnicity play asignificant part in shaping children's experience and their capacity to deal withadversity. A longitudinal study on a multiracial cohort of children exposed
to chronic poverty has also shown the importance of children’s role within thecommunity, along with the presence of social networks and personal resources(Werner, 1993). Children are thus agents of their own development and, evenin situations of adversity and chronic poverty, they can consciously act upon andinfluence the environments in which they live.
Conclusion
In conclusion, we need to understand poverty as the result of the interactionof a multitude of factors, including labor markets, government policies, family
efforts, political conflicts, social discrimination, and personal strategies. For clinicalpractice, it is important to look at the influence of poverty and social inequality
not through a restricted focus on children’s deprivation, but within a much more
extensive framework which includes wider cultural, social, political, and individual
dimensions (Sen, 2008).

GROWING UP TOO FAST
ORPHANS, CHILD HEADED HOUSEHOLDS, STREETCHILDREN AND CHILD LABOR
In most middle and low income countries, the issue of poverty is clearly
related to other major risks to child health and well-being, including orphanhood,homelessness, displacement due to disasters and conflict, street children and childlabor. The most vulnerable children are those who do not have any adult caregivers.
These children often assume adult roles in order to survive under conditions ofsevere deprivation and adversity; however, they are typically denied the rights andprivileges afforded to adults in society.

ORPHANS AND CHILD HEADED HOUSEHOLDSThe number of orphans globally is estimated at 153 million (UNAIDS,
2010). This includes all children (0–17 years old) who have lost one or bothparents – single orphans and double orphans respectively – through death, separation
or abandonment. Of these 153 million, almost 12% have lost both parents and
11% of these have lost one or both parents to AIDS (UNAIDS, 2010). These
proportions, however, vary enormously by country; for example, 16% of allorphans in Namibia have lost both parents and 58% of these have lost one or bothparents to AIDS (UNAIDS, 2010). Diversity of definitions of what constitutes anorphan renders the comparative analysis of evidence difficult (Sherr et al, 2008). In

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Click on the picture to access“Introduction to Working withChildren and Psychosocial
Support Participant's
Manual”. The workshop is
designed to raise awarenessaround the issues thatchildren who are affectedby HIV are facing and how
to offer support and build
resilience(Hope Worldwide Africa,
2006)

7

IACAPAP Textbook of Child and Adolescent Mental Healththe last decade, based on existing research evidence on the situation of orphans andnon-orphans in many countries, UNICEF and most international organizations
have widened their focus to include a number of factors that make children andfamilies vulnerable other than orphanhood (e.g., household poverty, parental
education, child labor, homelessness etc). The expression “orphan and vulnerable
children” is therefore more commonly used.
To this day most orphans and other vulnerable children are still living
within their extended families, often with their grandparents (Monasch & Boerma,
2004; Nyangara, 2004). Multi-generational households and child fostering havea long tradition in many parts of the world as a means to strengthen relationships
and redistribute resources within families (Madhavan, 2004). While purposefulfostering of children within the extended family can reduce the impact oforphanhood, there is evidence that children from families with little regular contact
with relatives are at greater risk of being abandoned if their current caregiver dies
(Foster et al, 1997). Sometimes, relatives neglect, exploit or cast orphan relativesout (Foster et al, 1997). Relocation and housing insecurity frequently surroundparental death (Foster, 2000). As a result of war and displacement, millions ofchildren grow up in the absence of one or both parents, often separated fromsiblings and other family members.
As a result of abuse, poverty, and family separation in contexts of armed
conflict, natural disasters, and the AIDS pandemic, child- and youth-headedhouseholds have emerged (Luzze, 2002). In some cases, child- and youth-headedhouseholds are created in response to the last wishes of the deceased parent, or the
preference of children themselves (Foster et al, 1997). CHHs generally emerge
after the death of the mother. Since the first child- and youth-headed households
were recognized in Uganda and Tanzania in the late 1980s, this phenomenon
has been documented in many other countries in the region. There are also nonorphan, “functional” child- and youth-headed households which arise in order toallow children to complete their education (Ruiz-Casares, 2009).
The effects of parental separation due to a variety of causes have beenstudied in contexts of war, natural disasters and orphanhood. The loss of one orboth parents is often compounded by separation from siblings and other family
members, poverty, lack of access to basic services, stigma and exclusion (Cluver
et al, 2008). Sibling dispersion among relatives is a common coping mechanism
used in situations of orphan crisis, particularly when there are multiple infants andyoung children from the same family who require care (Foster, 2000). However,orphaned and separated children—particularly older ones − tend to try to stay
together as much as possible (Germann, 2005). By remaining together in theirparents’ home, children are able to help each other grieve; maintain sibling, family
and community ties; secure assets; avoid abuse by relatives and obtain assistanceand cultural guidance from elders in their communities (Germann, 2005).

Orphaned children try tostay together as much as
possible to help each othergrieve; maintain sibling,family and community ties;
secure assets; avoid abuseby relatives and obtainassistance and cultural
guidance from elders intheir communities.

Risks faced by orphaned children or child headed households
Orphaned children with no parents or adult guardians are especiallyvulnerable (Donald & Clacherty, 2005). Particularly disadvantaged are girls
because they are usually the first in the household to drop out of school, care foryounger siblings and take on many adult tasks (Francis-Chizororo, 2010). Some

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8IACAPAP Textbook of Child and Adolescent Mental Healthheads of child- and youth-headed households who are caring for multiple younger
siblings are as young as nine years old (Roalkvam, 2005). Orphaned children areoften forced into abusive situations and exploitative employment in an attempt tonegotiate their survival (Cluver et al, 2008). Many children are forced into sex work,
thereby exposing themselves to significant physical and psychological risks (Cluver
et al, 2011). School dropout, serious health deterioration and a consequent loss of
future are frequent consequences of orphanhood. Property grabbing by relatives
or other community members is common and children are often not consulted
about their preferred living arrangement after the death of their parent or othercaregiver (Ruiz-Casares, 2009). In a study of more than one thousand children in
Zimbabwe, orphans were found to suffer greater psychological distress compared
to non-orphans. This distress was mediated by trauma, being out-of-school, being
cared for by a non-parent, inadequate care, child labor, physical abuse, stigma anddiscrimination (Nyamukapa, 2010).
In the case of parental loss due to HIV/AIDS, not only are children often
alone in carrying the emotional burden of caring for and watching a loved one suffer
and die, but they may also experience stigma, discrimination, and a reduction insocial status and family economic power (Nyamukapa, 2010). Children orphaned
by HIV/AIDS often experience extreme or increased poverty because of expenses
related to caring for sick parents and the loss of parental financial support, andmany live in fear that they have the disease themselves (Bhargava, 2005; Cluver etal, 2008; Germann, 2005; Luzze, 2002). Many do (Hillis et al, 2012). A systematic
review of empirical studies on HIV/AIDS and orphans found that orphaned
children often have negative psychological and physical outcomes (Foster, 1998).
Researchers have found, for example, elevated levels of psychological distressin orphans, including anxiety, depressive symptoms, anger, loneliness, low selfesteem, social withdrawal, and sleep problems (Bhargava, 2005; Makame et al,
2002; Ruiz-Casares et al, 2009; Zhao et al, 2009).

Nermine, Street
Child in Cairo.
Photo: Linda
Forsell

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9IACAPAP Textbook of Child and Adolescent Mental HealthUnaccompanied minors
Unaccompanied minors who are asylum-seekers, refugees or internallydisplaced in their home countries are a special population of homeless children
who tend to face different challenges than non-migrant unaccompanied homelesschildren. They are often separated from their families in situations of armed
conflict, natural disasters and political violence. Unaccompanied minors aredefined by the UN Convention on the Rights of the Child as children less than
18 years of age “who have been separated from both parents and other relatives
and who are not being cared for by an adult who, by law or custom is responsiblefor doing so” (Touzines, 2007). Unaccompanied minors can therefore be thoughtof as a high-risk subset of orphaned children. They report high rates of personal
exposure to physical and sexual violence and have been shown to have high rates
of mental health problems, including depressive symptoms and post-traumaticstress, which persist even after resettlement in a new country (Seglem et al, 2011).
When compared to asylum-seeking children with families, unaccompanied minors
seeking asylum have higher rates of psychiatric symptoms and disorders (Wiese &Burhorst, 2007).

STREET CHILDREN
Children who are living on the streets, in poor urban slums or squattersettlements and those who are homeless because of armed conflict, natural disasters
or political violence are amongst the most vulnerable and disadvantaged. These
children suffer abuse, exploitation, sexual violence, and physical and mental
illnesses. The problem of street children can be viewed from human rights,
community mental health and economic development perspectives (McAlpine
et al, 2010). Despite living under extremely harsh circumstances, street children
display resilience and utilize effective coping strategies in their struggle for survival.
••

Africa Network forChildren Orphaned
and at Risk
Click on the picture toaccess briefing notes about
guidelines for programmes
aimed at providing support
to orphans and vulnerable
children(International HIV/AIDS
Alliance, 2003).

The term street children is used to refer to children who work or sleepin the streets. There is no universally agreed upon definition of street
children; UNICEF uses two definitions: Homeless street children, also
called “street-based children” or “children of the street”, who live andsleep on the streets in urban areas, often on their own, living with otherstreet children, homeless family members or other homeless adults, andNon-homeless street-involved children, also called “home-based children”
or “children on the street”, who spend much of the day on the street
but maintain contact with their families and typically return home atnight (UNICEF, 2001).

In Western countries, the terms homeless youth and street-involved youth
are used to refer to these two populations respectively. Street children therefore
comprise a heterogeneous group of children who may sleep on the streets, sleep
at home with their families or a mixture of the two; however, they tend to beunsupervised and unaccompanied for most of the day and are therefore at riskof abuse and exploitation. Based on these definitions, child laborers who work
most of the day on the street as vendors, garbage collectors, porters, shoe and car
cleaners, guards and street performers are also considered street children.
The number of street children cannot be accurately measured, but they are
estimated to be in the tens of millions with some estimates as high as 100 million

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10IACAPAP Textbook of Child and Adolescent Mental Health(UNICEF, 2006). With increasing global population and high migration to urban
areas, the number of street children is believed to be growing (UNICEF, 2006b).
Some studies use a capture-recapture method to estimate the number of street
children in a specific area. Studies using this method have demonstrated that the
majority of street children are male, maintain contact with their families, sleep athome at least once per week and are wage earners who help support their familiesof origin (Bezerra et al, 2011; McAlpine et al, 2010). An estimated 80% of street
children are boys, which may be the result of girls' perceived value as domestic
workers (Abdelgalil et al, 2004; Le Roux, 1996).
The primary reasons that street children report for becoming homelessinclude family poverty, abuse and family violence, being orphaned or becoming
separated from their parents during migration (Abdelgalil et al, 2004; McAlpine
et al., 2010). Homeless children are much more likely to report having fled abusein their families of origin compared to non-homeless street children (McAlpine etal, 2010). Unfortunately, once on the street, children are often exposed to moreabuse. Children who are homeless and sleeping on the streets without contact withfamily members or caregivers are estimated to comprise around 15% of all street
children (Bezerra et al, 2011). Street-involved children who sleep at home tend
to report different reasons for street-involvement, including family poverty, beingpressured by their parents to work or beg on the street and the desire to play orspend time with friends (Lalor, 1999).

Click on the picture to access“Guidelines for Working with
Street Children” by Judith
Ennew

The health of street children
Most studies on the health of street children are small and many focus on
drug use, infectious disease, especially HIV/AIDS, and abuse. However, being inthe streets exposes children to a multitude of health risks. Street children reporthigh levels of abuse and harassment by police and other street children, inability
to attend school, involvement in crime, and medical problems, including injuries
and skin and respiratory infections (Ali & Muynck, 2005; Huang et al, 2004).
In Brazil, thousands of street children have been murdered and the majority were
believed to have been killed by death squads, the police or other types of criminal
gangs (Inciardi & Surratt, 1998).
Both girls and boys living on the street report high rates of sexual assault by
strangers and engagement in “survival sex”, whereby children exchange sex for food,shelter or money, is common (Pagare et al, 2005; Sherman et al, 2005). In a studyof street children in Rwanda, more than three-quarters of girls, including 35%
under the age of 10 reported being sexually active and 93% reported having been
raped while over 60% of boys reported having perpetrated rape (Save the Children,2005). A high proportion of street youth are sexually active with multiple partners
and do not use any protection against pregnancy or sexually transmitted diseases(Nada & Sulima, 2010). Homeless street children who are also orphaned may haveeven greater health risks than non-orphaned homeless children, including a greaterrisk of HIV/AIDS (Hillis et al, 2012). Trauma, stigmatization and marginalization
limit street children's access to services for children affected by HIV/AIDS (Jones,
2009).
Rates of substance use are very high among street children and according to
the WHO, between 25% and 90% use psychoactive substances, including alcohol,
nicotine, stimulants, inhalants, cannabis and opioids (WHO, 2010). Among street
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Click on the picture to access
WHO’s “Working with Street
Children: A Training Package
on Substance Use, Sexualand Reproductive Health
Including HIV/AIDS” (WHO,
2002).

11

IACAPAP Textbook of Child and Adolescent Mental Healthchildren inhaling volatile substances including glues, nail polish remover, lighter
fluid, spray paint and other household products, perceived benefits included
increased physical strength, decreased shyness, promoting sleep, promoting a senseof well-being and numbing physical and psychological pain (Sharma & Lal, 2011).
Rates of mental illness among street youth, including substance use disorders,mood disorders, hyperkinetic disorders and anxiety disorders may be as high as
98%t (Scivoletto et al, 2011).

WORKING CHILDREN AND CHILD LABORChildren, whether living with their parents, in child- and youth-headedhouseholds or on the street, often contribute meaningfully to their households by
doing chores or other kinds of work. However, in the poorest regions of the world,children are often engaged in work that is hazardous or exploitative in order toensure their own survival and that of their families. Child labor is a complex issue,
and in addition to abuse and exploitation, the realities of child workers include
socialization, participation, learning and skills development, independence,
recognition, power, security and pride in their ability to contribute meaningfully
to their households (Liebel, 2004). However, the majority of children and youngadolescents in developing countries work out of financial necessity to support theirfamilies and many do not enjoy the work they do and would prefer to be in school(Mathews et al, 2003; Tabassum & Baig, 2002).
There is significant controversy around whether children should do economic
work at all, which kind of work may be beneficial or harmful, and the natureof work that may be considered appropriate for children and adolescents (Abebe& Bessell, 2011). Opinions on child labor are also informed by the meaning ofchildhood, which varies across cultures, and an understanding of children along acontinuum from vulnerable, passive entities in need of protection to competentactors who can contribute meaningfully to society and act as agents of their own
destinies (Abebe & Bessell, 2011).
Ennew, Myers and Plateau (2005) identified four key viewpoints on child

Click on the picture toaccess the “Child Labor
Incident Assessment Tool”.
Quick on-line resource thatallows you to check if aparticular incident is childlabor or not (Child Labour
Knowledge Sharing System;
Philippines).

labor:••••The labor market perspective, which views child labor as a sign of poverty
and underdevelopment that will be overcome as nations develop
The human capital perspective, which sees childhood as a protected
time in which scholastic education is paramount and in opposition toparticipation in labor
The social responsibility perspective that defines child labor as a cause
and consequence of social exclusion, where children's work is seen as
exploitative, alienating and oppressive and
The perspective that emphasizes the right of children to be protectedfrom exploitative labor.

Thus, while Western interests have often called for a complete ban on childlabor, working children's organizations in developing countries have called forequal rights and participation, including the right to be included as members on
the very labor advisory boards that aim to represent and protect them (Liebel,
2004 pp25-32).

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12IACAPAP Textbook of Child and Adolescent Mental Health

Current status and definitions
According to the International Labor Organization (ILO), founded by the
UN in 1919, there were an estimated 215 million children aged 5 to 14 years
involved in economic work in 2008, mainly in Asia, Africa and Latin America(ILO, 2010). This represents a decrease from the estimated 222 million children
who were employed in 2004, however, these estimates do not include children inmodern forms of slavery including forced or bonded labor and or other forms ofillicit work, including child soldering, sex work and drug trafficking. Furthermore,estimates do not include children, often girls, who do domestic work or raiseyounger siblings in their own households.
Based on definitions created by the ILO, children who do at least one hourof economic work per week are defined as being involved in the labor economy(Hagemann et al, 2006). These children are then divided into different groups
based on their age and the type of work they do:•

Economically active or working children refer to children aged 5 to 17
years

•

Child labor refers to working children aged 5 to 14 years•

Children in hazardous work refers to children aged 5 to 17 who workin dangerous occupations such as mining and construction, use heavymachinery, are exposed to toxins such as pesticides, or work more than
43 hours per week.

UNICEF uses a different definition that includes children who do excessive
hours of domestic chores in their own households (at least 28 hours per week forchildren aged 5 to 14 years or at least 42 hours of combined domestic chores andeconomic work for children aged 12 to 14). However, this definition of child laborexcludes children aged 12 to 14 who do less than 14 hours per week of economic
work and less than 42 hours of combined economic work and household chores per
week (Gibbons et al, 2005). When household chores are included, girls represent
38% of children involved in child labor worldwide (Gibbons et al, 2005).
In 1921 the ILO passed the first convention on child labor setting theminimum age for employment in industry at 14 years. More recently, increased
attention has focused on eradicating the worst forms of child labor that arelikely to harm "the child’s health or physical, mental, spiritual, moral or social
development” including child soldering, participation in the sex trade and otherwork that exposes children to the risk of physical or psychological harm. In 1992
the ILO ratified Convention 182 on the Worst Forms of Child Labor. However,many countries have not ratified these conventions, and as of 2008, 115 million
children worldwide were engaged in hazardous work (ILO, 2010). By far, themajority of child laborers are unpaid family workers and 60% work in agriculture(ILO, 2010). Only 20% of working children are wage earners, however, in somehouseholds, children earn a large proportion of the household income (ILO, 2010).
Even as unpaid family workers, children may work alongside their parents in small
industries, including artisan production, trades and services such as mechanic andrug weaving. While often viewed as less hazardous, the children working in theseAdversity

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IACAPAP Textbook of Child and Adolescent Mental Healthindustries are frequently exposed to physical strain, long hours of work, low wages,
and high exposure to noise, dust and chemicals without protective equipment(Nuwayhid et al, 2001).
Child labor as a risk to child healthChild labor has been
described as the largest
single cause of childabuse across the globe

Child labor has been described as "the largest single cause of child abuseacross the globe" (Scanlon et al, 2002). The harms associated with child labor
include risk of physical injury and illness, acute or chronic poisoning, risk of abuse,
ill treatment, exploitation and exposure to harsh working conditions. Working
children may also be unable to attend school. Both female and male children
involved in prostitution and work with armed groups risk exposure to physical,
emotional and sexual violence, infectious diseases including HIV/AIDS, low selfesteem and emotional and psychological harm.
Most studies that report the health risks of working children are small
and populations of child workers are often hard to access, particularly those who
are working in very hazardous or illicit industries, including forced labor andprostitution. Determining the impact of child labor on health is also made difficult
by the long latency period before disease onset, under-recognition of healthproblems, difficulties in measuring developmental changes and psychosocial
effects, and the "healthy worker effect" whereby the healthiest children are selected
for work and children who become ill or injured are excluded (Parker et al, 2010).
Consistently, studies that look at child workers in general often do not demonstrate
an overall negative impact of working on child health, however, studies that lookat specific populations of children doing hazardous work have demonstrated harm
(Understanding Children’s Work 2003a; 2003b).
The majority of the world's working children are employed in agriculture
and risk acute and chronic pesticide poisoning as a result of occupational
exposure (Corriols & Aragón, 2010). Certain agricultural industries, such ascocoa harvesting and tobacco production, have been shown to employ children
who work without protective clothing and are exposed to multiple health risks,
including risk of injury and exposure to toxins (McKnight & Spiller, 2005; Mull
& Kirkhorn, 2005; Otañez et al, 2006). Working children who are exposed tosolvents, such as those working in machine and artisan shops, perform worse on
most neurophysiological and neurobehavioral tests compared to both non-working
schoolchildren and to working children who are not exposed to solvents (Saddik,
2003; 2005). Unacceptably high blood levels of lead, a known neurotoxin that has
been shown to lower IQ and cause behavioral problems, have been demonstrated
in children working in ceramic-making, garbage scavenging and street vending(Ide & Parker, 2005). Children and adolescents exposed to dusty conditions inmining, stone polishing, pottery and brick making industries without protective
equipment are at increased risk of developing silicosis, a chronic debilitatinglung disease (Chiavegatto et al, 2010; Saiyed, 1995). Children and adolescents
employed in industry, especially those who work with powered wood cutters, risk
hand injury and amputation (Durusoy et al, 2011). The impacts of harmful work
on children therefore include acute and chronic health risks and developmental
insults that may limit children's cognitive potential.

Click on the picture toaccess briefing notes about
guidelines for programmes
aimed at providing support
to orphans and vulnerable
children (International HIV/AIDS Alliance, 2003)

One of the most frequent harmful consequences of child labor may be theinability or decreased ability to attend school. Clearly, child labor is intertwined

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IACAPAP Textbook of Child and Adolescent Mental Healthwith the issue of poverty because poverty itself may both preclude a child's ability
to attend school and force a child to work in order to help ensure family survival.
While many children successfully balance work and school, high rates of childlabor tend to be associated with poorer school attendance. For example, among
African countries in 2004, Swaziland had a child labor rate of 10% and a school
attendance rate of 78%, while Niger, at the other end of the spectrum, had a childlabor rate of 72% and a school attendance rate of 30% (Gibbons et al, 2005).
Child labor, and girls' involvement in particular, can be understood as contributing
to a cycle of limited educational attainment, inter-generational poverty and poor
health (Leinberger-Jabari et al, 2005). However, it should also be noted that forsome children whose families cannot afford to send them to school, children's
participation in the work force allows them to afford school fees, books and schoolsupplies (Woodhead, 2001). Despite the efforts of children to improve their own
situations, poverty and the need to work can interfere with their ability to attend
school, achieve academically and transcend the cycle of poverty.
Child labor as a risk to child mental health and well-being
There are relatively few studies that look at mental health outcomes of childlaborers. One study in Ethiopia that compared 528 child laborers 5-14 years of age
to their non-working counterparts found that working children had significantly
increased rates of behavioral and emotional disorders, including depression (Fekadu
et al, 2006). Among child laborers, starting work at a younger age and working
long hours are associated with poorer mental health (Caglayan et al, 2010). While
there is a paucity of data on mental health outcomes of child laborers, there is awell-established link between poor child and adult mental health and physical,
emotional, and sexual abuse and neglect in childhood (Gilbert et al, 2009). A highproportion of working children reports being emotionally, physically and sexually
abused by their employers (Gharaibeh & Hoeman, 2003; Mathews et al, 2003).
Furthermore, girls engaged in economic work may be at increased risk of sexual
violence. Among girls in Nigeria selling goods on the street, working in shops or
as domestic workers, 78% reported having been raped, the majority by customers,
and the risk was increased among girls who were younger than 12, worked formore than eight hours per day or had two or more jobs (Audu et al, 2009).
Unsurprisingly, girls who are employed as domestic servants are highly vulnerable
to physical, psychological and sexual abuse (Banerjee et al, 2008).

“Being poor is in itself ahealth hazard; worse,
however, is being
urban and poor. Much
worse is being poor,
urban, and a child. But
worst of all is being astreet child in an urban
environment.”

Ximena de la Barra, UNICEF(de la Barra, 1998)

Orphaned and vulnerable children, poverty, homelessness and child labor
There is a clear relationship between poverty and reliance on child laboras a family survival strategy. A national survey in Guatemala revealed that poor
households were more likely to use child labor and schooling reduction as strategies
to cope with socioeconomic hardship (Vásquez & Bohara, 2010). Among a sample
of poor families in Nigeria, thirty-nine per cent of parents indicated that they
thought their school-aged children should be working in order to supplement
family income, help with the family business and to allow children to gain work
experience (Omokhodion & Uchendu, 2010). Children who are poor, orphaned
and engaged in child labor have to cope with multiple interrelated challenges. For
orphaned children in Zimbabwe, being engaged in child labor and not being inschool are risk factors associated with greater psychological distress (Nyamukapa
et al, 2010).

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IACAPAP Textbook of Child and Adolescent Mental Health

When the number of children orphaned by HIV/AIDS overwhelms theability of families and communities to care for these children, orphaned children
are at high risk of becoming homeless. In Brazzaville, Congo, an estimated 50% of
street children are orphans (Nkouika-Dinghani-Nkita, 2000). Likewise, in Lusaka,
Zambia, 58% of street children were orphans: 22% had lost both parents, 26%
had lost their father, and 10% had lost their mother (Concern/UNICEF, 2002).
Impoverished families who take in orphaned relatives often have insufficient
resources to support these children, resulting in financial hardship and the needfor orphans to do economic work to help support the family (Balew et al, 2010).
However, while orphans are often viewed as a burden to families, they also
contribute meaningfully to family preservation through their work, for example,
by caring for sick relatives (Robson, 2004). For orphans in Uganda, identified
barriers to school attendance and academic success include hunger and being at
school all day without eating, heavy domestic workload including early morning
agricultural responsibilities causing late arrival at school, lack of school uniforms
and books, and limited options for education beyond the primary level due tofinancial constraints (Oleke et al, 2007). Furthermore, some orphaned adolescent
girls resort to engaging in sexual relationships with wealthy older males, commonlyreferred to as “sugar-daddies”, as a way of securing funds to pay for school tuitionand supplies (Oleke et al, 2007). Thus, under conditions of severe poverty anddeprivation, orphans engage in complex negotiations regarding their health,emotional well-being and the possibility for a better future for themselves andtheir families.
Vulnerable children, including poor, orphaned and homeless children are at
great risk of abuse and involvement in the most exploitative forms of child labor,
including debt bondage and other forms of slavery, association with armed groups,
begging, child prostitution and other forms of sexual exploitation.
Resilience
Despite the obvious dangers, severe adversity can lead children andadolescents to develop effective survival strategies that allow them to promote
their own growth and development (Ruiz-Casares, 2009). Children underdifficult circumstances can develop, among other things, practical survival
and management skills, independence, the ability to cope with stress, makeimportant decisions and develop a greater sense of self efficacy (Liebel, 2004).
In her study of child- and youth-headed households in Namibia, Ruiz-Casares(2010) documented how children of all ages demonstrated an ability to obtain
goods and services that they needed, and to maintain supportive community
ties. Children in child- and youth-headed households display resilience in theway that they are able to mobilize their social networks, including siblings,
friends and neighbors to provide emotional and academic support and material
goods (Donald & Clacherty, 2005). Nonetheless, few studies have exploredstrengths or positive outcomes. A study looking at homeless street children in
Kenya found that compared to non-street children, they displayed a high degreeof adaptability and flexibility in the face of adversity which allowed them toremain remarkably well adjusted (Ayuku et al, 2004; Luna 1991). Orphaned,poor, homeless and working children can also thus be seen as agents of theirown development who are trying to cope the best they can with the difficult

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IACAPAP Textbook of Child and Adolescent Mental HealthChild Soldier in Darfur. Outpost Magazine. Photo: Marie Frechon

circumstances in which they find themselves. Children should therefore not beseen solely as passive victims, but also as active participants in their families andcommunities who have a voice and are deserving of respect.

CHILD SOLDIERS
Issues of poverty, street children and child labor are intertwined with the
problem of minors being associated with armed forces or armed groups. Not only
do poverty, homelessness, forced child labor and, of course, the presence of war
and conflict constitute risk factors for recruitment of child soldiers, these issues
also represent challenges in the rehabilitation and reintegration of former childsoldiers back into civilian life.
Child soldiering is considered convenient and cheap (Wessels, 2006).
Children – boys and girls alike – are perceived as highly obedient and easily
manipulated (Denov, 2010; Wessels, 2006). According to the Coalition to Stop
the Use of Child Soldiers (CSUCS), this may partially explain why the use of childsoldiers is widespread in countries and regions affected by war (CSUCS, 2008).
Acknowledging the difficulty in getting accurate figures, the CSUCS (now called
Child Soldiers International) estimated in its 2004 report that 250,000 children
were part of fighting forces in both state and non-state armed groups (CCUCS,
2004). Since then, between 2004 and 2007, while the Coalition reported a decreasein the number of child soldiers following peace agreements and demobilization
programs in different countries, armed groups in 24 countries are known to haverecruited children under 18 years old (CSUCS, 2008).

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17IACAPAP Textbook of Child and Adolescent Mental HealthTerminology and definitions
The commonly used term of child soldier is contested in scholarship andconsidered problematic in many aspects (Denov, 2010; Wessells, 2006; McKay et
al, 2010). Like any other label, child soldier is applied to a wide range of children
and youth with highly diverse experiences. As highlighted by some authors (Denov,
2010; Wessells, 2006), the notion of “soldier” carries some archetypal image ofwell-trained combatants embodied mostly by a male figure in uniform. Yet thisimagery obscures the multiplicity of the roles and tasks they undertake. Childsoldiers are not only active combatants carrying guns, they also spy, cook, guard,
porter, messenger or are forced into sexual slavery.
In an attempt to acknowledge the varied tasks of child soldiers, the termchildren associated with armed forces or armed groups has been introduced, and has
been defined in the UN Paris Principle (2007) as: “Any person below 18 years of age
who is or who has been recruited or used by an armed force or armed group in any
capacity, including but not limited to children, boys and girls, used as fighters, cooks,
porters, messengers, spies or for sexual purposes. It does not only refer to a child who istaking or has taken a direct part in hostilities.” (United Nations, 2007, p7)
However, this definition is still problematic. The notion of “childhood”
itself is a highly contested concept. As a social construct mainly based on Westernviews and on biological age, the concept of children as being under the age of 18
years may disregard the varying meanings of childhood across cultures. Finally,
while the majority of child soldiers are adolescents, a large number of children
younger than ten years are associated with armed groups (Machel, 2001).
Experiences of child soldiersChild soldiers may become involved with armed groups through forced or
unforced recruitment (Denov, 2010; Wessells, 2006). Means of recruitment are
diverse, and while violent abduction and forced recruitment are pervasive in many
conflicts, the line between forced and unforced involvement is often unclear and thenotion of voluntary child recruits should be considered carefully (Wessells, 2006).
Based on testimonies, studies have shown that when not forcibly abducted, boys’
and girls’ decision to join armed groups are often made in contexts of deprivation,
hardship and maltreatment. Many reasons may drive girls and boys to join armed
groups (Wessells, 2006; Denov, 2010; Brett & Specht, 2004):•

Poverty and the opportunity to obtain food and shelter•

Lack of socio-economic opportunities•

To seek protection•

To flee abuses from their family of origin•

For religious or political beliefs•

To gain a sense of family or peer group•

To avenge the deaths of parents, other family members or friends•

Soldiering may also be attractive for the uniform or prestige.

Click on the picture to access“Psychosocial Adjustment
and Social Reintegrationof Children Associated with
Armed Groups: The Stateof The Field and Future
Directions” (Betancourt et al,2008).

Therefore, over-simplifying the dichotomy between forced and non-forced
recruitment methods can be problematic as it is often difficult to distinguishbetween unwilling victim and willing perpetrators of violence.

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IACAPAP Textbook of Child and Adolescent Mental Health

Recent studies have gone beyond narratives of victimization to explore
how, despite extreme violence and controlling environments, children do deploy
some forms of agency and resistance strategies (Denov, 2010; Denov & Maclure,
2007; Wessells, 2006). Testimonies from former child soldiers, boys and girls alike,
illustrate how experiences in armed groups are marked by an oscillation between
victimhood and resistance, or active participation in violence (Denov, 2010): "...
children’s experiences reveal that they continually drifted between committing acts ofviolence and simultaneously being victims of violence by others." (Denov, 2010, p129).
The process of militarization of boys and girls includes powerful indoctrination,harsh training, and the use of threats and violence to promote terror andcompliance (Denov & Maclure, 2007). Adjustments to a militarized and highly
violent environment entail shifts in behaviour, relationships, self-perception andsense of identity (Veale & Stravou, 2007; Denov & Maclure, 2007; Wessel, 2007).
Sometimes, obedience may become an imperative to survival (Denov, 2010).
These factors will have important consequences in the process of reintegration into
civilian life.
According to the Child Soldiers Initiative, an estimated 40% of childsoldiers are girls and they take on roles as varied as boys (Child Soldiers Initiative,2010). However, evidence shows that girls, because of their gender, will experience
armed conflict differently than boys (McKay & Mazurana, 2004). One dimensionof their gendered experiences is the pervasive sexual violence perpetrated against
girls. Testimonies from former girl soldiers in Northern Uganda, Sierra Leone andMozambique reported extensive sexual violence, including rape and gang rape
(McKay & Mazurana, 2004; Coulter, 2009). Girls also reported being forced into
sexual slavery by being ordered to marry males within the armed group and become
their sexual property, also known as being bush wives (Coulter, 2009; Denov,2010). This would allow protection from random sexual assaults from other malecombatants, while being obligated to be constantly sexually available for their“husbands” (Coulter, 2009). Forced marriage to powerful commandants can be asurvival strategy, and as such, both a source of protection and violence. In addition
to the psychological and social consequences, sexual violence also exposes girls tosexually transmitted infections, most notably HIV/AIDS, unwanted pregnancy,and severe injuries resulting from violent sexual assault (ACQUIRE Project,2005). Girls’ brutal experiences of violence are thus important to acknowledge. In
contrast, in some conflict settings there are strong prohibitions against the sexual
victimization of girl soldiers and girls report feeling protected (Keairns, 2002).
Girls' victimization is only one facet of their lived realities and much of the recent
literature has sought to challenge the unidimensional portrayals of girl soldiers as
victims (Coulter, 2009; McKay et al, 2010; Denov, 2010; Veale & Stavrou, 2007).
While often carrying out female roles and domestic work, such as cooking andsexual service, girls’ roles also include military duties and participation in combat
activities (Denov, 2010).

Click on the picture toaccess the Child Soldier
Treatment Centre database:organizations and centres
that specialize in thetreatment, rehabilitation,
education and rehabilitationof former child soldiers,
abductees or child victims ofwar, sorted by country.

The aftermath: psychosocial consequences
In the aftermath of participation in armed violence, whether the conflict
has ended or not, former child soldiers face critical transitions as they attempt toreintegrate into civilian life (Denov, 2010). The term reintegration is contested, as
it tends to assume that former child soldiers return to their family or community

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19IACAPAP Textbook of Child and Adolescent Mental Healthof origin and to their normal and previous lives’; however, this is rarely the case.
Moreover, former child soldiers may have been affected by war in very different
ways and thus may not require similar support. Some may be disabled, orphaned
or injured; some girls may be mothers or widows, or none of the above. They may
have been forced to commit atrocities – killing and raping – or may have carriedout domestic work. Some have been violently abducted, sometimes to the extent
of being forced to kill family members. This diversity needs to be acknowledged in
the understanding of their post-war lives (Wessells, 2006).
Given the profound psychosocial implications of exposure to violence,
the mental health and well-being of former child soldiers is key in the process of
reintegration to civilian life (Wessel, 2006). Acute war experiences and exposure
to extreme violence will affect former girl and boy soldiers in many ways, both
physically, such as through injuries, disabilities and infectious diseases, andpsychologically. A handful of studies examining mental health outcomes havereported symptoms of post-traumatic stress disorder (PTSD), anxiety anddepression among former child soldiers (Derluyn et al, 2004; Betancourt et al,2008). Among former child soldiers studied in northern Uganda, 97% reported
symptoms of PTSD (Derluyn et al, 2004). Importantly, it is not only girl soldiers
who report sexual violence. Male soldiers also report sexual violence and being
forced into sexual servitude, which is associated with higher rates of symptoms ofdepression and PTSD, social dysfunction and suicidal ideation compared to their
combatant peers who did not experience sexual violence (Johnson et al, 2008).
However, as pointed out by some scholars, the scarce literature on mental
health outcomes of former child soldiers almost exclusively focuses on the signs
and symptoms of PTSD. This trauma-focused Western medical approach has been
criticized for its emphasis on pathology and deficits (Wessells, 2006; Betancourt
et al, 2008; 2010; Klasen et al, 2010). Furthermore, PTSD may represent only
a fraction of the wide range of psychosocial implications of wartime violence(Betancourt et al, 2010; Wessells, 2006). Using a resilience frame, a few studies
have explored the positive adaptation, psychosocial adjustment and adaptive
capacities of former child soldiers (Klasen et al, 2010; Wessells, 2006). Girls – asmuch as boys – are not only victims of war trauma, they adjust to their new life andemploy creative coping strategies in the face of their many struggles (Betancourt etal, 2010; Klasen et al, 2010; Denov, 2010).

Mental health andpsychosocial support
in humanitarian
emergencies
The target group for WHO
work on mental healthand psychosocial support
in emergencies is any
population exposed to
extreme stressors, suchas refugees, internallydisplaced persons, disastersurvivors and terrorism,
war- or genocide-exposed
populations. Click here toaccess key documents
related to this field.

Disarmament, demobilization, reintegration and rehabilitation
Post-demobilization experiences are inevitably shaped and constrained bymany other factors apart from war-time experiences, including gender, ethnicity,socio-economic status, ability, position within the community and access to social
support. Poverty, displacement and loss of home following demobilization haveprofound psychosocial implications (Wessells, 2006). What stands out in recent
studies regarding reintegration and rehabilitation of former child soldiers is that
exposure to violence only represents part of the picture (Wessells, 2006), and does
not exclusively account for mental health problems or well-being (Betancourt etal, 2008; 2010; Kohrt et al, 2008; Klasen, 2010). Post-conflict factors may havepositive or adverse effects on the mental well-being of former child soldiers who

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IACAPAP Textbook of Child and Adolescent Mental Healthface diverse challenges, including social stigma and limited access to education,
health care, sustainable livelihoods and economic opportunities (Worthen et al,
2010; McKay et al, 2010; Wessells, 2006; Denov, 2010).
Social stigmatization and the discrimination experienced by former childsoldiers have been identified as key post-conflict factors contributing to adverse
mental health outcomes (Betancourt et al, 2008; 2010; Klasen et al, 2010). In thisregard, girls face particular and unique challenges affecting their post-conflict lives.
In addition to the physical and emotional scars resulting from sexual violence, many
former girl soldiers face greater risk of stigma following reintegration because they
are viewed as sexually impure or even unfit for marriage, which can have important
psychosocial consequences (Betancourt et al, 2008; McKay et al, 2010; McKay& Mazurana, 2004). On the other hand, community and family acceptance andsupport have been identified as critical factors for successful reintegration andenhanced psychosocial adjustment (Betancourt et al, 2010). Access to educationand socioeconomic opportunities are also important positive post-conflict factors.
The transition to civilian life – meaning abrupt shifts in relationships,
behavioural patterns, and expectations – entails a reshaping of identities, frommilitarized identities to civilian life (Veale & Stravou, 2007; Denov, 2010). In
fact, identity transformation and negotiation constitute a core challenge in thereintegration process (Veale & Stravou, 2007, p286). The process of making
child soldiers – through abduction, harsh training and indoctrination – meansthat complex identity negotiations are required to unmake child soldiers upon
demobilization (Denov, 2010; Denov & Maclure, 2007).

Click on the picture to access“Humantrafficking.org” a web
resource for combating humantrafficking (multiple countries).
Contains resources useful forchildren who are trafficked forlabor or sexual purposes

Disarmament, demobilization, reintegration and rehabilitation (DDRR)
is used to describe the process by which child soldiers are returned to civilian life.
This process is also used for adult combatants, but child-specific programs arecommon and take different forms in different regions. As previously discussed,
disarmament is not always necessary because children fulfill many non-combatantroles within armed groups. Despite being in widespread use, there is little dataon the success of DDRR programs. One study in Sierra Leone (Williamson,2006) identified nine areas of intervention contributing to successful family andcommunity reintegration:
•
•
•
•
•
•
•
•
•

Community sensitization to the returning children
Formal disarmament and demobilization
A period of transition in an “interim care center”
Family tracing and mediation
Family reunification
Traditional cleansing and healing ceremonies and religious support
School or skills training
Access to health care for those in school or training, andIndividual supportive counseling.

One study in Mozambique that followed former child soldiers for 16
years showed that long term reintegration and self-sufficiency was facilitated bycommunity acceptance and forgiveness, traditional cleansing and healing rituals,
livelihoods and apprenticeships (Boothby et al, 2006).

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IACAPAP Textbook of Child and Adolescent Mental HealthInterim or transitory care centers are typically the first places wheredemobilized children stay after returning from the armed groups with which they
were affiliated. In one such center, the Goma Transitory Care Centre in eastern
Democratic Republic of the Congo, 250 children are grouped into families ofaround 30 children, each with its own dormitory and staff counselors (Humphreys,2009). The children in each family group come from mixed ethnic backgrounds
and armed groups. In addition to limited individual counseling for children withspecific issues, the family groups are designed so that the children can listen to andsupport each other. The children spend three months at the center before being
reintegrated into the community.
Conclusion
In summary, within the context of reintegration, former child soldiers face
many other challenges in addition to coping with the scars of war experiences.
Indeed, access to education and employment, financial security, community
acceptance and many other factors related with their post-conflict life conditions
have psychosocial implications. An understanding of the impact of multiple
war-related and post-conflict factors is important for identifying appropriate
intervention targets. (Betancourt et al, 2010).

THE MENTAL HEALTH OF WAR-AFFECTED
CHILDREN
This section will limit itself to the effects of war on children who haveneeded to leave their home countries because of war and have migrated to a newhost country. Practical approaches to assessment and treatment planning will beoutlined to address these children’s mental health needs.
Research suggests that war trauma can affect children’s mental health. The
effects of this trauma are complex, given that experiences of war entail exposure
to multiple stressors including violence, displacement, family separation, loss andbereavement, disruption of education and the breaking of social ties.
Exposure to violence has been linked with psychological difficulties inchildren ranging from sleep difficulties and anxiety to post traumatic stress disorder(PTSD) (Fazel et al, 2011; Hjern et al, 1991, Rothe et al, 2002). It appears thatthe severity and quantity of violence exposure is important: children with multiple
exposures to violence over longer periods of time continue to exhibit mental healthdifficulties up to nine years after seeking asylum. In contrast, children who haveexperienced fewer adverse events tend to become asymptomatic more rapidly(Montgomery, 2010). The exposure of parents to violence also affects children’swell-being. Studies have demonstrated that children’s mental health is negatively
impacted if their parents have been tortured (Almqvist & Brandell-Forsberg,
1997; Cohn et al, 1985; Daud et al, 2008; Fazel et al, 2011). One study has also
noted that a child’s knowledge of a parent being detained is associated with thedevelopment of PTSD (Montgomery and Foldspang, 2006).
Children of war are sometimes separated from their families and forced toflee alone. Separation from family, itself, was associated with PTSD in one study(Geltman et al, 2005). Being unaccompanied when seeking asylum puts young
people at greater risk of mental health problems (Hjern et al, 1998). Children whose

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IACAPAP Textbook of Child and Adolescent Mental Health

HungerKäthe Kollwitz (1867-1945)(permanent loan by Gudrun& Martin Fritsch to the Käthe
Kollwitz Museum, Berlin)families are continuing to undergo adversity (for example, if a parent is detained or
still in a war-torn country) tend to have worse psychological functioning. On theother hand, children’s mental health appears to be protected when their families
remain cohesive and supportive (Fazel et al, 2011; Rousseau et al, 2004). Positive
school and peer experiences are also correlated with wellbeing in refugee children(Fazel et al, 2011; Geltman et al, 2005, Sujoldzic et al, 2006).
Experiences of migration
Families who have experienced organized violence prior to migration
can sometimes face difficulties in their welcoming countries including violence(Jaycox et al, 2002), racism (Gunew, 2003), poverty (Beiser, 2002), and uncertain
immigration status. Ongoing experiences of discrimination (Hassan & Rousseau,
2008; Rousseau et al, 2009), and barriers to securing care will influence children’s
psychological well-being as well as the trust and collaboration that can be fostered
within the care-provider relationship. One study of Somali adolescents who had

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IACAPAP Textbook of Child and Adolescent Mental Healthfled to the US demonstrated that depression and PTSD were associated with theyouth’s experiences of discrimination in the host country (Ellis et al, 2008).
It is important for clinicians to keep in mind that families fleeing war are
also often met with many barriers when trying to seek asylum. This too has an
impact on children’s psychological well-being. In fact, some longitudinal studies
suggest that post-migratory stressors are a stronger predictor of depression in
refugee children than are past conflict-related events (Sack et al, 1993). One such
stressor is immigration detention. Many industrialized countries have policies ofdetaining children and families who are seeking asylum. For children fleeing war,
detention is potentially re-traumatizing and correlates with high rates of psychiatricdifficulties.
Migrating families are in a period of adaptation that is sometimes very
stressful. The process of understanding difficulties and proposing solutions aretasks that need to be worked together with families, taking into account a family’s
strengths, their readiness and ability to cope with difficulties, their understandingsof the causes of their difficulties and their feelings about solutions proposed toaddress them.
Resilience
On the path to rebuilding a life there is a a new balance to be madebetween maintaining some continuity with the past and adopting new coping
strategies to deal with the unknown. In general, research suggests that the processof acculturation in asylum seeking children is complex, and that no one path ismore protective or harmful for all children (Fazel et al, 2011). Spirituality playsa central role for many families (Boehnlein, 2007), either in the form of personal
prayer or the support derived from attending religious rituals and celebrations.
These ethno-religious social networks may also give children a sense of belonging.
However, they may also act as a traumatic reminder when religion was associatedwith trauma. Artistic activities, sports, work, and study, if they establish continuity
with meaningful aspects of the life of a child before the experience of migrationand traumatic disruption, are important strengths. The same activities may also be
new to a child and, when given the appropriate support to learn these new roles,
they can represent positive dimensions of their adaptation.
It is important to acknowledge that all outcomes of war do not solely leadto loss and disability. Traumatic events can promote creative coping skills, and betransformed into a source of strength and resilience (Rousseau et al, 1999).
Dealing with the consequences of war: the assessment and treatment of waraffected children
Intervention for children affected by war as well as other humanitariandisasters has been considered along an intervention pyramid, where the base of
the pyramid represents advocating for basic services to ensure safety. The next layerof the pyramid involves strengthening community and family supports, followedby more focused non-specialized person to person supports. Specialized mental
health services form the top of the pyramid. It has been advocated that all of theseinterventions are ideally implemented concurrently. A practical guide to addressing
the provision of psychosocial and humanitarian support in humanitarian crises isAdversity

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IACAPAP Textbook of Child and Adolescent Mental Healthavailable in a number of languages from the Interagency Standing Committee(IASC, 2010)
Assessment
Accessing care: primary care, prevention and interpretation
A number of practical points can help support the assessment and treatmentof children who are experiencing mental health difficulties as a result of war, as wellas their families. Efforts to support schools, primary care workers and community
workers to help address the needs of these children and their families are important,as these children’s difficulties frequently present first to these persons. Children andfamilies have been offered help in community settings such as schools (Kataoka
et al, 2003; Ngo et al, 2008; Hodes 2008; Duncan & Kang, 1985) and primarycare clinics, where front-line professionals are supported by mental health teams.
This support at the front line level can also facilitate access to more specialized carewhen needed.
School and community-based prevention programs can also play a keyrole in promoting the mental health of children from migrant and ethno-culturalcommunities. Classroom-based activities can support children in assimilating pastand present experiences by presenting these as learning opportunities, facilitating
emotional expression with respect to their experiences and promoting thedevelopment of positive relationships within the classroom and society (Green et al2005). Some prevention programs use specific treatment modalities such as artistic
expression to support the transformation of past and present adversity throughcreativity and metaphorical representations and by fostering the developmentof solidarity among children (Rousseau & Guzder, 2008). Successful support offamilies and children at the community level also marks the beginning of a processof alliance building and service provision that supports the biopsychosocial needsof children who have experienced war and their families.
Finally, families who speak a language other than the dominant language ofthe health care system should be offered interpreters to help support the assessment
and treatment process. Interpreters facilitate the clinical encounter by providing
translation and, in some cases, may support assessment and treatment by acting
as cultural brokers and co-diagnosticians to help understand, reframe or transmit
cultural knowledge (Hsieh, 2007; Rousseau et al, 2011)
Self-reflexivity in the clinician
Exploring cultural references in clinical encounters requires a clinicalopenness to acknowledging the clinician’s own identity, a capacity to reflect on
how others see oneself, and an openness to perceiving oneself as a tool in thetherapeutic work (Kirmayer et al, 2003). This will facilitate the assessment andwill help the clinician to explore such areas as explanatory models of illness andapproaches to healing. Familiarity with ways of addressing cultural elements inmental health practice , such as the cultural formulation of the DSM-IV and work
providing guidance about how to adapt the cultural formulation to child mental
health care practice (see for example Ecklund & Johnson, 2007; Measham et al,2010) can help support an assessment that is attuned to cultural issues.

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Child mental healthrating scales in
war-affected andtraumatized children
Click on the picture to accessseveral rating scales (theChildren’s Revised Impact
of Event Scale, CRIES;
Depression Self-Rating
Scale for Children, DSRS;
Post-traumatic Cognitions
Inventory, cPTCI, the SelfReport for Childhood Anxiety
Related Disorders, SCARED
and others) (Children & War
Foundation)

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IACAPAP Textbook of Child and Adolescent Mental Health

The assessment process
The assessment of children and families who have experienced war includes
an exploration of several important themes:
•
•
•
•
•
•

The family’s experiences in their home and host country
The child’s symptoms
Symptoms experienced by other family members
Familial and individual strengths
Resources and previous help-seeking trajectories; andA negotiation of the complex reconstruction of the family and its social
network.

Attention to the therapeutic alliance is of great importance when addressing
the consequences of war on children. Families and children are often meetingwith unfamiliar persons and are guarded about who to trust and how much totrust. In addition, some family members may remain in situations of peril, so that
confidentiality of the therapeutic space is of paramount importance.
While it is important to explore children’s and families’ experiences of
war trauma, the timing of these inquiries, the ways in which this information issolicited and cultural values around disclosure need to be understood. Soliciting
disclosure in a Western way with respect to events that are culturally taboo canbe harmful, and addressing disclosure with children needs to take into accounttheir development and the effect of disclosure on parent-child relationships andtrauma transmission. Cultural brokers can help to understand what is at stakearound understanding traumatic experiences. In the case of children, approaching
disclosure in a modulated way, including an acknowledgment of the role ofparents as gatekeepers who can help their children understand their experiences is
helpful. Indirect methods to assess trauma through art, play, and metaphor may
also reveal important information for assessment, while not being experienced as
overly intrusive by family members (Measham & Rousseau, 2010).

Click on the picture to access“Working with DistressedChildren Toolkit”. Includes
information on identifying
and communicating with
distressed children andpsycho-social intervention
and cultural considerations(Action for the Rights ofChildren, Working withChildren, Revision version
01/01)

When family survival is at stake, attention needs to be paid to the family’spressing needs such as asylum, housing, security and education. Similarly, in a
refugee child mental health assessment, a systemic appraisal of the family’s
pathway to survival is needed. Therapeutic efforts directed at interrupting further
traumatic losses and the negative chain of consequences that can ensue fromthese are important (Miller & Rasmussen, 2010). Symptoms and the meaning of
diagnoses also need to be addressed. It is important to note that diagnoses can haveimportant ramifications outside the therapeutic space. In particular, a diagnosis
that does not recognize the post-traumatic aspects of symptoms can inadvertently
be unsupportive to people whose refugee status is in question as the PTSD
diagnosis is well accepted in legal circles, where it is often seen to lend credibility
to a traumatic story, and its absence is− falsely − considered proof that the person
alleging trauma is lying (Stein et al, 2007)). On the other hand, the victim identity
associated with the PTSD label, while encouraging empathic responses, may also
unduly medicalize problems and disempower the family and social network. Seeing
psychiatrists and receiving diagnoses may also be stigmatizing, and the effects ofreceiving a diagnosis on children needs to be addressed.

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IACAPAP Textbook of Child and Adolescent Mental Health

Refugee camp in Kenya, home to Somalis fleeing famine and conflict

Finally, the importance of identifying individual and family strengths andof reinterpreting family roles in the context of post traumatic adaptation will help
in the building of treatment plans. For example, children’s parentification toward
the nuclear or extended family is often negatively perceived as a burden, while thisrole may also be reassuring during the period of post-traumatic reconstruction.
Although parentified children may be suffering, their sense of having a purpose
and a mission is often simultaneously protective.
Treatment
Symptom reduction and reconstruction of the social world
Treatment involves a reconstruction of the personal, family and sociocultural
worlds with the aim of restoring a sense of normality for a child by allowing life
to go on (social integration) and overcoming the paralysis that terror and grief
can cause (symptom reduction). Gain in terms of reduction of impairment andimprovement in functioning need to be considered, and it is important to notethat their relation to symptom relief is not linear (Pynoos et al, 2009). The main
implication of this for treatment is that it is just as important to restore thecontinuity of life by facilitating a child and family’s social integration into the hostcountry as it is to reduce symptoms.
From precarious status to stability
Clinicians may feel uneasy when asked to help asylum claimants with theirimmigration papers. The support provided by a clinician to asylum-claiming
families through a letter supporting their immigration application is an explicit
testimony that the clinician acknowledges the authenticity of the family’s refugee
experience (Rousseau & Foxen, 2005). When such testimony enables asylum
seeking families to obtain secure immigration status, this relieves considerable
psychic suffering and symptomatology given that a precarious immigration status

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IACAPAP Textbook of Child and Adolescent Mental Healthis associated with poor mental health (Bean et al, 2007; Bodegard. 2005; Nielsen etal, 2008). Moreover, this support, even if families do not gain secure immigration
status with the clinicians efforts, can partially counteract the destructive impact ofa rejection of the asylum claim, which can be profoundly re-traumatizing.
Meeting basic needs
Solving everyday problems plays a key role in achieving a certain normalitythat allows the establishment of routine. Most refugee families will request some
type of practical help from community organizations, primary social and healthcare services, or even from schools, in resolving settlement problems. Sometimes,
reestablishing contact with families from the same homeland through community
organizations may facilitate the development of a social network. However, many
communities torn by organized violence are fragmented and remain in conflicteven when the community is in exile. Thus, the clinician needs to understandwhich social contacts can provide a social shield, and which can result in further
stressors.
Psychotherapeutic modalities: therapy, medication and traditional healing
Trauma-related anxiety disorders (mainly studied with respect to PTSD),
and depression, stemming from multiple losses in an exile setting, can be treatedthrough various forms of psychotherapy. Short-term therapy, either cognitive
behavioral therapy (CBT) or narrative exposure therapy , have been promoted forrefugee children and adolescents not because they provide a complete resolution of
trauma-related suffering, but because they are helpful in alleviating symptoms andcan realistically be implemented in settings including schools (Ehntholt & Yule
2006; Kataoka et al, 2003: Ngo et al, 2008).
While psychopharmacology is an option for these children, we recommend
caution given that there is little to no evidence of efficacy for refugee children
and adolescents, so that evidence for efficacy is extrapolated from studies with
non-refugee children with similar diagnoses. Therapies that integrate traditional
elements show promise in the medical literature. Creative arts based therapies, suchas art therapy, are sometimes preferred by refugee families, in part because these
therapies often emphasize nonverbal therapeutic methods, thus helping persons
who are reluctant to engage in verbal therapy. This may reflect either cultural
attitudes or the fact that verbal approaches may be seen as being disrespectfulof certain avoidance strategies. While Western treatment methods may favor a
more direct working-through of trauma by focusing therapeutic work on trauma,
other cultural traditions may prefer to work around trauma (Rousseau et al, 2005).
Finally, the unilateral imposition of either Western expertise or culturally sensitive
modalities may be experienced as coercive if the family’s or child’s choice of opting
in or out of their own culture at a particular time is not taken into account.
Drawing up an inventory of available resources in a particular community isessential for a realistic treatment plan. In many settings, specialized psychotherapy
may not be widely available, but committed community workers and primary care
professionals may provide excellent therapeutic support and a forum for empathic
listening that may begin to give relief to children and their families.
Conclusion
Addressing the consequences of war on refugee children whose families

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IACAPAP Textbook of Child and Adolescent Mental Healthhave experienced pre-migratory trauma requires a combination of cultural
knowledge and trauma therapy methods that encompass not only individuallyfocused psychotherapies and traditional therapeutic approaches, but alsosystemic interventions addressing the consequences of organized violence on thefamily’s social relationships. Primary care institutions, including clinics, schools
and community organizations, because they are very close to the family’s living
environment, may be particularly helpful in establishing a support network
around a refugee child and his or her family. They may however experience moredifficulties in providing specialized therapy. Efforts to strengthen preventive andcommunity-based supportive approaches to address the consequences of war on
children, while ensuring access to specialized mental health services as needed, will
help to address the multiple needs and strengths of refugee children and to provide
the right kind of support at the right place and the right time.

CONCLUSIONSChild mental health services need to address the adversity stemming fromsocial and environmental stressors. Although different forms of treatment may
help to alleviate symptoms and support the resiliency of a child and family, an
acknowledgment of the collective nature of social suffering and a validation of achild and family’s experience may be key. Mental health professionals in all countries
can play an important role through intersectorial forms of intervention that help
buffer this stress and even in some cases prevent it. Respecting the Convention
on the Rights of the Child (see Chapter J.7) is a long term goal. In high income
countries this could entail recognizing equal rights to health and education for
non-citizen children and other vulnerable children. In low and middle income
ones it could be linked to the implementation of protective measures to decreasechildren’s exposure to multiple adversities and improve their health and well-being.
Although these social changes are beyond the mental health professional’s
mandate, health professionals can have a critical role in advocating for the socialchanges that can improve the mental health and well-being of children.

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Click on the picture toaccess the UNICEF’s “Childand Youth Participation
Resource Guide”. This
guide has resources onchild and youth participationfrom Asia, Europe, North
America, Latin America,
Africa, Australia and thePacific. Most of the materials
are available in electronic
form. The main audiences
for this resource guide arepractitioners and managers
involved in promoting childand youth participation ingovernment, communitybased organizations, childled organizations, NGOs,
UN and donor agencies(UNICEF, 2006c).

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IACAPAP Textbook of Child and Adolescent Mental Health

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