Although exact figures are difficult to determine, what numbers we have paint a grim picture. In 1970 there were approximately 2.5 million refugees. By 1995, that number had increased to 17 million. These figures do not include "internal refugees," i.e., those who are displaced but have not crossed internationally accepted borders. Estimates of this group run from 25 to 40 million. Refugees now number 1 in every 135 alive human beings! Of that count, children and adolescents represent nearly one-half. Ironically, countries with the highest standard of living host the fewest refugees. There have been recent attempts to return refugees to their home countries, despite a recognition that many of these countries remain dangerous places. For refugees today, the world is every bit as dangerous and brutal a place as it was during the cold war. Here is a brief description of Pol Pot's reign of terror that brought refugees to our shores almost twenty years ago.

The Pol Pot Era: 1975 to 1979
Cambodia had become politically unstable as the result of the U.S. bombing during the Vietnam War. In 1975 this beleaguered country came under the fanatical control of Pol Pot and the Khmer Rouge who launched a bizarre attempt to eradicate all "Western influence" and convert the entire nation to an agrarian form of Maoist communism. This task was undertaken mercilessly with complete disregard for humanitarian considerations, or indeed for human life. During these four years of horror, between 1 and 2 million of the country's 7 million people died. David Hawk, a scholar of this era described the Pol Pot regime as a three-tiered structure of murder by government. At the top of this metamorphic pyramid of death was the prison system that systematically tortured and executed so-called political prisoners. Only 9 out of over 45,000 such prisoners escaped execution in these prisons. The second tier of this pyramid was a series of massacres directed at particular social, political, economic and ethnic groups. Buddhist monks, civil servants, soldiers, businessmen and anyone with a Western connection or background was a target. Children were often bribed with food to spy on their adult family members and relatives and to report what they said to the Khmer Rouge. Those showing "subversive"ideas could be summarily executed. Children over the age of six were often separated from their parents and forced to work in camps, with little food. Children were to be raised by the state, not by their parents. The Pol Pot regime fractured all of the normal social networks among its people: familial, religious, and commercial. Finally, the bottom and largest layer of this pyramid of death were those who died from a combination of exhaustion, starvation, and disease as a result of the forced marches into the countryside and/or the relentless work with no proper food or medical care and the constant threats of death. In early 1979 the Khmer Rouge were finally driven from power by the communist Vietnamese regime, but only in the last year have the Khmer Rouge lost all political power, first with the death of Pol Pot and more recently with the surrender of some major leaders.

As a result of this upheaval in 1979 when many Khmer people fled to refugee camps in Thailand, the United States and several other countries announced their willingness to resettle Cambodians who had claimed some connection to this country. Under this sponsored resettlement movement, the bulk of the Cambodian refugees came between 1981 and 1985, mostly from refugee camps in Thailand.

The Initial Portland Study: 1983-1984
In this initial study, we were able to interview in a relatively standard fashion, and with the able interpretive assistance of Mr. Rath Ben, 46 of the 52 available Khmer students at this Portland public school. We elicited their recounts of their concentration camp experiences, the atrocities they had witnessed, the separations from loved ones, and the malnutrition they endured. We also probed for current symptoms of Post-Traumatic Stress Disorder (PTSD), such as intrusive thoughts of war, nightmares, hypervigilence, poor sleep, as well as various symptoms of depression and the stresses of resettlement in a new land with a new culture. We did worry that our inquiries might have adverse repercussions, setting off a flood of decompensating war memories. We were relieved to learn that most students were pleased that someone in the United States was interested in what they had experienced. Half of these students said they had never discussed the Pol Pot times with anyone, even their own family members. Asian people place a high premium on smooth interpersonal relationships and are taught not to burden others with internal pain or distress. The movie The Killing Fields aided our cause by legitimizing for the refugees a now public portrayal of what they had endured.

One student told us that at age nine she was tied to a tree in the morning, being accused of taking food that did not belong to her, and told she would be executed that evening when the soldiers returned. She lived in abject terror that day, feeling her young life was over. When the soldiers returned they cut her loose with the admonition that she would be killed the next time that she "stole food." Another told us she saw an infant thrown up in the air and caught on the end of a bayonet. We heard with horror many such stories. (I still cannot bring myself to see The Killing Fields.)

The Epidemiologic Research
Having learned that half of our original sample of Khmer refugee adolescents were suffering from PTSD and some form of depression, we wanted to learn how generally prevalent these problems were in a larger group of such adolescents and their parents. With the able assistance of Shirley McSharry, a social worker in Salt Lake city (now deceased), and working hard to finally obtain a federal research grant from the National Institutes of Mental Health, we were able to further standardize our research interview protocol, check the instruments for reliability and validity, and interview 209 Khmer adolescents randomly in two communities, Portland, Oregon and Salt Lake city, Utah. This research took three years to collect.

We learned that PTSD was comparable at a prevalence rate of twenty percent in the youth of both communities, but that the rates of PTSD were much higher in their parents. Moreover, the parents seemed more functionally incapacitated by their symptoms than did their offspring. These students with PTSD symptoms were attending school, were not becoming antisocial, were not using drugs or alcohol, and were making a relatively good adjustment to life in the United States. All were relatively fluent in English. In contrast, the parents had a much more difficult time mastering language skills, and their functional abilities were less when they suffered from PTSD.

We also attempted to study the kinds of resettlement stressors these refugee families faced when they arrived on our shores. We found that once a refugee suffered from PTSD, that person was more vulnerable to the subsequent stresses of resettlement. For instance a parent whose paycheck did not arrive on time might again experience the fear of starving to death from lack of food. As we tried to make sense of the experiences this group of refugees had, we found that their stresses could be divided roughly into three main categories: war trauma stress, the stresses of resettlement per se (new schools, language barriers, food, climate, etc.), and finally the everyday stresses of living together. As we examined our rates of PTSD across generations (i.e. from parent to child), we noted that if a parent had PTSD, one of their offspring was more likely also to be suffering from PTSD. Whether this was due to a genetic susceptibility, or perhaps having suffered the same extent of war trauma, we were never able to differentiate.

The Longitudinal Study 1983-1996
Because of the devoted commitment of our research staff, particularly Chanrithy Him, a Pol Pot survivor who was mainly responsible for persuading these subjects to undertake the interview survey, and who did many of the interviews herself, we were able to again reinterview the original 46 subjects three years later (1985-87), six years later (1990), and twelve years later (1996). This was important because it gave us a longitudinal portrait of how war trauma might influence development as the refugee youth moved from adolescence into adulthood. We learned several important things: Even though PTSD tended to persist in our Khmer youth, it didn't seem to greatly impair their ability to function. Most all were pursuing employment or attending school. Most all had made a successful transition to American culture and felt the United States was now their home. When in 1996 we asked these youth what they still remembered of the war, those with current PTSD remembered a specific traumatic event that had been life threatening. Those without current PTSD remembered the war during their childhood (now almost twenty years ago) as an experience primarily of loss and upheaval, without a conscious memory of a specific trauma. So early childhood trauma seemed closely linked to the PTSD diagnosis over this period of time. While PTSD tended to be persistent and chronic, depressive symptoms had largely disappeared by the time we reinterviewed them in 1990 at the 6-year follow-up. Our analysis showed that depressive symptoms were strongly related to current stressors over the past six months and not to the trauma of war itself. Thus PTSD was persisting while depression was much more transient and short-lived. Over a period of time, almost fifty percent of the parents had sought some form of mental health treatment while the Khmer youth sought help at a much lower rate, around twenty percent. These youth were no different than their American counterparts; they felt rather stigmatized by having to see a psychiatrist! Only a small minority of our subjects wanted to return to Cambodia to live, most wanted to return only to visit.

Conclusions
Our finding that PTSD in children is chronic and persistent is consistent with a growing body of research literature on adult subjects who have suffered trauma: combat veterans, prisoners of war, accident and rape victims, etc. All these studies show that PTSD, once it occurs (and it often comes years after a trauma), does not easily disappear. War trauma, however, because of its relentless impact of multiple traumas, seems the most devastating form of trauma to experience, and leaves its imprint for the longest period of time. Such a tragedy for the war survivor means that even though the actual war is over, for the PTSD subject it recurs and must be reexperienced in dreams, flashbacks, and intrusive memories, time and time again. Thus, for these individuals, the war is never truly over.

Yet, despite the persistence of PTSD symptoms and war memories, our Khmer youth have not been functionally crippled by their childhood war experiences. Only a very small minority have had problems with alcohol, and an even smaller number have been involved in antisocial activities. This could change with the passage of more time. Moreover, the refugee youth we studied do not represent all such youth in this country. Other studies from different locales could reach different conclusions. But to date, these findings are encouraging. We have been amazed at the resiliency of these Khmer youth, and their capacity to overcome the tragedy of their experiences in Cambodia. Now, they are making constructive contributions to American society. Moreover, they have enriched the lives of our research team as we have had an opportunity to watch their developmental achievements unfold as they rebuild their lives in a new land.