Mental health in cambodian adolescents relationship among cultural specific syndromes, depression, anxiety, ptsd, and functional impairment

Mental health in cambodian adolescents relationship among cultural specific syndromes, depression, anxiety, ptsd, and functional impairment

Background of the study

Cambodia's long history of civil war and oppressive political regimes has created a complex mental health crisis among its citizens This legacy of violence has contributed to significant social issues, including domestic violence, poverty, child abuse, human trafficking, and substance abuse (Schunert et al., 2012) Alarmingly, 36% of ever-partnered women have reported experiencing physical, sexual, or emotional violence from their partners (MoWA, 2015) Additionally, incidents of rape and sexual assault are on the rise, both within families and in the broader community (MoWA, 2008) Despite the passage of time since the Khmer Rouge era, these troubling patterns of violence and crime persist.

(2011) found a high level of violence experienced by second generation

A study conducted in Cambodia after the Khmer Rouge regime revealed alarming statistics about child abuse: 47% of children faced significant physical punishment from parents, 14% experienced sexual abuse, 22% witnessed the rape of another child, and 48% were aware of child trafficking cases Furthermore, it highlighted that traumatized parents often failed to protect their children from violence and did not meet their emotional and physical needs, largely due to their own traumatic experiences (Field, 2011).

Cambodians face significant daily stress due to poverty, low quality of life, and inadequate social support (Sonis et al., 2009) A national survey by Schunert et al (2012) revealed that higher poverty levels correlated with increased depressive symptoms, anxiety, trauma exposure, and higher rates of suicide and suicidal thoughts Additionally, a study by Seponski et al (2018) reported that 16.7% of Cambodian respondents experienced significant depression, 27.4% had anxiety disorders, and 7.6% met the criteria for posttraumatic stress disorder.

Only 24 percent of Cambodians with significant mental health issues receive the necessary support, with most seeking help from general health centers or family rather than trained mental health professionals Additionally, 20-27 percent of those seeking assistance turn to traditional spiritual services, such as monks and healers, who lack the training to effectively address mental health concerns.

According to Schunert et al (2012), only 19 percent of the Cambodian population is aware of psychology and mental health, which significantly hinders their ability to seek necessary assistance for mental health issues.

Despite high rates of emotional disorders such as anxiety, depression, PTSD, and substance abuse among Cambodians, mental health issues receive minimal attention from the government and policymakers This neglect is largely due to the stigma surrounding mental health, which makes these problems less visible compared to physical health issues Additionally, Cambodia faces a significant shortage of mental health legislation and psychiatric facilities, with less than 1% of the total annual health budget allocated to mental health services, further hindering support and resources for those in need.

Cambodians to receive effective treatment for their mental health problems

Statement of the problem

Mental health issues are a significant concern in Cambodia, with high rates of psychopathology observed among both adults and adolescents Common challenges include aggressive behavior, bullying, attentional problems, depression, and anxiety, which hinder students' academic performance Consequently, Cambodian youth face the highest risk for suicidal behavior in the country To address these pressing mental health problems, it is essential to conduct a thorough examination and implement appropriate assessment methods However, the cross-cultural challenges in diagnosing mental health issues highlight the need for valid and effective assessment tools that consider local contexts.

Mental health issues in Cambodia have historically been overlooked by the government and key stakeholders such as parents, teachers, and healthcare professionals Despite growing concerns raised by foreign NGOs regarding the prevalence of mental health disorders, policymakers and health practitioners have largely neglected this critical area Recently, however, the Cambodian government has started to show interest in developing and integrating mental health services within existing healthcare facilities to tackle these pressing challenges.

In Cambodia, knowledge about mental health services and help-seeking behaviors is limited, with stigma and social discrimination significantly impacting those with mental health issues Many individuals conceal their symptoms due to fear of rejection, leading to low rates of seeking help and hindering effective treatment (Saxena et al., 2007) Particularly in rural areas, there is a prevalent belief that mental illness stems from ancestral spirits' anger or other traditional views, rather than being understood as psychosocial or biological conditions (Chhim, 2017; Kim & Peeters, 2017; Ka, Ka, & Savin, 2014).

Research on mental health among Cambodian youth is scarce compared to the extensive studies conducted on adults, such as the 2011 Cambodian Mental Health Survey While organizations like the Royal University of Phnom Penh and the Transcultural Psychosocial Organization have focused on adult mental health, understanding culturally specific mental health issues in youth is crucial for valid assessments A significant gap in current research is the emphasis on adults when exploring the relationship between culturally specific psychopathology and Western mental health disorders like PTSD With a rapidly growing youth population and significant socio-economic changes, it is imperative to investigate youth mental health, as issues such as depression, anxiety, and substance abuse often emerge early in life Thus, developing valid and culturally appropriate assessment methods for this demographic is essential.

This study addresses a significant gap in understanding mental health among Cambodian adolescents by exploring the connections between the Cambodian Symptom and Syndrome Inventory and common Western syndromes such as depression and anxiety It also examines the impact of these mental health issues on functional impairment and quality of life, as well as adolescents' attitudes towards mental health and their help-seeking behaviors.

Aims of the study

This dissertation evaluates the construct validity of culturally-specific psychopathology syndromes in Cambodia through the Cambodian Somatic Symptoms and Syndrome Inventory (CSSI) The study examines the relationships between the CSSI, standard Western psychopathology syndromes such as depression and anxiety, and various pathology indicators, including functional impairment, mental health treatment-seeking behavior, and quality of life Mental illness and psychopathology are characterized by their association with dysfunction in individuals Therefore, the construct validity of the CSSI is defined by its statistically unique relationships to these indicators of psychopathology, independent of Western anxiety and depression.

Research Questions and Hypotheses

The current study has four primary main research questions that it seeks to address and answer:

1 Are the CSSI cultural syndromes subscale and CSSI somatic symptoms subscale significantly correlated with the standard Western (i.e., which are part of DSM and ICD) depression and anxiety syndromes?

2 Are the standard Western syndromes of depression and anxiety significantly associated with the indicators of psychopathology, including (a) functional impairment, (b) help-seeking, and (c) quality of life?

3 Are CSSI cultural syndromes subscale and CSSI somatic symptoms subscale significantly associated with the indicators of psychopathology, including (a) functional impairment, (b) help-seeking, and (c) quality of life?

The CSSI cultural syndromes subscale and CSSI somatic symptom scale exhibit statistically unique associations with functional impairment, help seeking, and quality of life, even when controlling for standard Western syndromes such as anxiety and depression.

1 H1 The CSSI cultural syndromes subscale and CSSI somatic symptoms subscale will significantly correlate with the standard Western (i.e., which are part of DSM and ICD) depression and anxiety syndromes

2 H2 The standard Western syndromes of depression and anxiety will significantly correlate with the indicators of psychopathology, including (a) functional impairment, (b) help-seeking, and (c) quality of life

3 H3 The CSSI cultural syndromes subscale and CSSI somatic symptoms subscale will be significantly associated with the indicators of psychopathology, including (a) functional impairment, (b) help-seeking, and (c) quality of life

The CSSI cultural syndromes subscale and CSSI somatic symptom scale demonstrate distinct associations with functional impairment, help-seeking behaviors, and quality of life These correlations remain significant even when controlling for standard Western syndromes of anxiety and depression, highlighting the unique impact of cultural and somatic factors on these outcomes.

Significance of the study

Cambodia faces high rates of mental health issues among both adults and youth, largely due to its history of war and trauma Currently, the mental health support system in Cambodia is underdeveloped, highlighting the need for culturally appropriate assessment and diagnosis to enhance prevention, intervention, and treatment programs Early intervention is crucial, particularly for youth, as many mental health problems emerge in childhood, affecting individuals' ability to contribute to society This study aims to evaluate the construct validity of the Cambodian Somatic Symptoms and Syndrome Inventory (CSSI) among adolescents, exploring the relationship between culturally-specific psychopathology syndromes and traditional syndromes like depression and anxiety By identifying unique variances associated with culturally-specific syndromes in relation to functional impairment and treatment needs, the findings will emphasize the importance of incorporating these syndromes into mental health assessments and treatments Additionally, the results will provide valuable insights for institutions and NGOs to strategize improvements in mental health care in Cambodia.

Literature review

Cultural psychology posits two primary perspectives on psychopathology: the "etic" and "emic" approaches The etic perspective seeks to identify universal elements of mental illness that transcend cultural boundaries, while the emic perspective emphasizes the unique syndromes and influences of psychopathology within specific cultures Proponents of the emic approach argue that mental health issues are shaped by cultural values and demands, suggesting that understanding these culture-bound elements can enhance insights into psychological problems and lead to the development of tailored, effective therapeutic interventions.

1.1.1 Culturally specific psychopathology syndromes (culture-bound syndromes)

The DSM-5 defines cultural perceptions of distress as the unique ways different cultural groups experience and communicate emotional and psychological suffering These perceptions encompass three main concepts: (1) cultural syndromes, which are symptom clusters specific to certain cultural groups; (2) cultural idioms of distress, which refer to culturally specific expressions of emotional suffering that may not align with clinical symptoms; and (3) cultural explanations, which are the culturally influenced views on the causes of mental health issues Understanding these cultural concepts is essential for clinical practice, as they provide insight into the realities faced by individuals and groups in diverse societies.

The following are some examples of specific cultural concepts of distress that have been identified as occurring in Cambodia:

"Wind attack" (khyâl) is a panic attack characterized by neck tension and induced by orthostatic hypotension, which occurs when a person suddenly stands or sits up, leading to low blood pressure This phenomenon is a key aspect of the Khmer response to trauma and traumatic experiences (Hinton et al., 2010) From a Western medical viewpoint, orthostatic hypotension can cause symptoms such as lightheadedness, dizziness, and even fainting due to the drop in blood pressure.

Khyâl attacks, prevalent among Cambodians, are often triggered or worsened by anxiety and traumatic memories, mirroring the symptoms of panic attacks During these episodes, individuals experience intense fear of dying due to bodily dysfunctions, akin to panic attacks observed in Western cultures Research indicates that khyâl attacks represent a culturally specific manifestation of anxiety and trauma-related symptoms, often accompanied by various somatic complaints such as muscle soreness, dizziness, tinnitus, and even loss of consciousness Additionally, studies reveal a significant co-occurrence of khyâl attacks and posttraumatic stress disorder (PTSD) in affected individuals.

The "Wind Mutes" (kyol goeu) syndrome is a severe manifestation of 'kyol cap,' characterized by an overwhelming sensation of inner wind originating within the body This excessive wind becomes trapped due to the body's internal structures, particularly the bone joints, preventing its release As a result, individuals experiencing kyol goeu often suffer from intense dizziness, excessive sweating, and a pervasive coldness throughout their body The term "kyol goeu" in Khmer combines 'kyol,' meaning wind, and 'goeu,' meaning mute, reflecting the condition's essence of internalized wind.

The phenomenon known as 'kyol goeu' can cause individuals to faint, become unconscious, and appear mute or lifeless In Cambodian culture, this muteness and fainting are believed to result from an accumulation of bodily wind, which incapacitates those affected by kyol goeu.

The term "the wind mutes" aptly describes a syndrome characterized primarily by mutism Another name for this condition, "kyol goeu," translates to "unable to speak" in Cambodian, highlighting its core symptom (Hinton, Um & Ba, 2001b).

Sleep Paralysis, known as khmaoch sângkât` in Cambodia, is a culturally specific syndrome where individuals experience the sensation of a malevolent spirit pressing down on their chest during the transition between sleep and wakefulness This phenomenon is characterized by an inability to move, accompanied by feelings of chest tightness and shortness of breath, which are interpreted as omens of bad luck and potential death (Hinton et al., 2005a) During these episodes, Cambodians often perceive a shadowy figure, believed to be an evil spirit, exerting pressure on their body, leading to heightened anxiety and fear This figure is thought to be the ghost of someone who has died in the household or a person whom the individual or their family may have wronged, including those who suffered traumatic deaths (Hinton et al., 2013) The belief is that these spirits may return repeatedly to inflict the experience of khmaoch sangot, reinforcing the cultural significance of this phenomenon in Cambodian society.

The "Weak Heart" syndrome (khsaoy beh daung) is a Cambodian belief that attributes heart dysfunction to "excessive bodily wind" (kyol goeu) This condition can lead to heart palpitations (dysrhythmia) triggered by minimal physical activities, such as suddenly standing up, exposure to strong odors, being startled, or engaging in exercise, whether for work or recreation.

Hinton et al., 2010) Lambert (1986) has described the "weak heart" syndrome in detail as a culturally-specific manifestation of the PTSD mental illness symptoms

Hinton et al (2002) argue that the Cambodian syndrome is most similar to Panic Disorder in Western diagnoses due to the resemblance of symptoms and the quick onset and resolution of these symptoms.

The 'weak heart' syndrome, known as khsaoy beh daung, manifests through symptoms like bodily and mental fatigue, shortness of breath, and dizziness due to low blood pressure These symptoms resemble those of Western DSM and ICD disorders, particularly panic attacks and PTSD Research by Hinton et al (2002) revealed that 60% of respondents believed they suffered from this syndrome, with Khmer refugees in the U.S frequently identifying with it The syndrome is often attributed to severe trauma, leading researchers to view it as a culturally specific interpretation of PTSD and panic disorder During the Khmer Rouge regime, the combination of starvation and excessive labor contributed to heart palpitations and even fatalities, with many Khmer people associating deaths from this period with heart attacks, termed keang beh daung Additionally, the Khmer translation for 'heart attack' aligns with the term for death from palpitations, reinforcing the perception of 'weak heart' as a potentially fatal condition linked to PTSD, panic disorder, and poor physical health (Hinton et al., 2002).

Kut caraeun, a Cambodian mental health syndrome, describes a state of heightened anxiety where individuals are preoccupied with stressful personal issues, particularly related to family finances and health Those affected often ruminate on past traumas, including experiences of physical abuse, serious accidents, and significant losses, such as the death of a parent or a child's prolonged illness Their worries typically center around finances, health, and the well-being of family members, leading to symptoms akin to Western anxiety, including dizziness, fatigue, and discomfort, particularly in areas like the knees, elbows, and neck (Hinton et al., 2010).

While much research on culture-specific syndromes has centered on Cambodia due to its history of trauma, similar syndromes have also been studied in other cultures One notable example is the Obeah illness found among Jamaicans, which is rooted in the belief that spirits or ghosts significantly influence mental health and can lead to either sanity or mental illness.

―insanity‖ The Agahinda Kenshi syndrome has been identified in Rwanda

(Betancourt et al., 2011) Agahinda Kenshi appears to be a culture-specific syndrome, similar in some ways to depression but with more of an emphasis on overt anger than sadness

1.1.2 Western-based depression, anxiety, Posttraumatic Stress Disorder (PTSD) Major Depressive Disorder (MDD)

Major Depressive Disorder (MDD) is a common and debilitating mental health condition in the Western world, characterized by persistent feelings of sadness, emptiness, or irritability, particularly in children and adolescents Accompanying these emotional symptoms are significant somatic and cognitive changes that hinder the individual's ability to function effectively, leading to functional impairment MDD exemplifies the quintessential disorder within the classifications of DSM and ICD.

Major Depressive Disorder (MDD) is characterized by core symptoms of sadness or anhedonia, accompanied by at least five additional symptoms persisting for a minimum of two weeks These symptoms must cause significant distress or functional impairment in social, occupational, or other critical areas of life Common symptoms include a depressed mood for most of the day, a marked decrease in interest or pleasure in activities, significant changes in weight or appetite, and sleep disturbances such as insomnia or hypersomnia.

Study Conceptual Framework

This study aims to evaluate the construct validity of the CSSI scales and the broader concept of culturally specific mental health syndromes by examining their unique relationships with indicators of psychopathology, such as functional impairment The research hypothesizes that life stress is a primary contributor to mental health issues, while cultural and social factors also play a significant role in how individuals express and experience symptoms, distinguishing between DSM and CSSI syndromes Both types of symptoms are anticipated to negatively affect functional impairment, hindering daily activities and increasing the risk of distressing experiences like intrusive thoughts, avoidance, and hyper-arousal (Rona et al., 2009).

Help-seeking behavior is influenced by CSSI and DSM symptoms, with functional impairment serving as a mediator While psychological impairment often leads individuals to conceal their struggles due to ignorance, stigma, and social pressures, daily functional impairment can directly motivate individuals to seek help This necessity arises from their limited capacity to engage in daily activities, prompting encouragement from their environment to pursue assistance.

Figure 1 Study conceptual process framework

SUMMARY

Mental health issues are a significant concern in Cambodia, especially among adolescents, influenced by the country's history of war and trauma The understanding of mental health in Cambodia may differ from Western definitions, highlighting the need for culturally appropriate resources Cultural factors contributing to psychological distress can be categorized into three types: cultural syndromes, cultural idioms of distress, and cultural explanations for these issues Notably, various cultural syndromes, such as "Wind attacks" (khyâl), have been identified in the Cambodian context.

Wind Mutes‖ (kyol goeu) The Cambodian Somatic Symptom and Syndrome

The Cultural Syndromes and Symptoms Inventory (CSSI) was created to evaluate cultural syndromes, yet research on its validity, especially among Cambodian adolescents, remains limited This study aims to assess the construct validity of the CSSI specifically within this demographic.

Overview of Research Design

A cross-sectional, correlational design was employed to evaluate the hypotheses, collecting data from 391 high school students aged 15 to 19 in Phnom Penh and the rural Prey Veang province of Cambodia The study included a diverse range of conditions and received approval from the National Ethics Committee for Health Research under the Ministry of Health, Cambodia.

Sampling

This study gathered data from high school students in grades 10 and 11 across two high schools in Phnom Penh, an urban area, and two high schools in Prey Veng province, a rural area The selection process for high school respondents involved multiple steps, including the selection of schools, classrooms, and students, with separate procedures implemented for both Prey Veng and Phnom Penh.

The study employed a strategic selection of high schools, choosing both urban and rural institutions through convenience sampling Within each selected school, two classrooms from Grade 10 and two from Grade 11 were randomly chosen using probability sampling, totaling eight classrooms per location A systematic quota sampling technique was then applied to select 25 students from each classroom, culminating in a sample of 197 students in Prey Veng and 194 students in Phnom Penh This research specifically targets high school students in grades 10 and 11, as late adolescence is a critical period marked by an increased risk of developing mental health issues.

10 and 11; the age range of participants thus was from ages 15 to 19 years.

Procedure

To prepare for data collection, the research questionnaires, including The Brief Impairment Scale (BIS) and the General Health Seeking Questionnaire (GHSQ), were translated and back translated.

The researcher translated the scales into Khmer and conducted a pilot test with first-year undergraduate students to assess their understanding of the scales and gather feedback for further refinement and adaptation.

Second, the researcher prepared research documents, including research protocol and questionnaires, to submit to the Ministry of Education, Sport and

The researcher obtained fieldwork permission from the Ministry of Education, Youth and Sport (MoEYS) through the Rector of the Royal University of Phnom Penh (RUPP) to conduct research in selected high schools Following this, a research ethics approval application was submitted to the National Ethics Committee for Health Research (NECHR) due to the health-related nature of the study This application included a cover letter, application form, support letters from RUPP and MoEYS, the main research protocol, questionnaires, and consent forms, all provided in both English and Khmer.

After obtaining approval from the NECHR, the researcher prepared the necessary documents, including two letters, to request permission from the Department of Education, Sports and Youth in Prey Veng province and Phnom Penh City to work with high school students Once permission was granted, the researcher met with school principals and teachers to secure their consent for the study involving grades 10 and 11 Following agreements with the schools, the researcher introduced the study to the students, addressing their questions and encouraging them to discuss participation with their parents Students who obtained parental consent signed informed consent forms, after which the researcher distributed questionnaires and provided study instructions Finally, the researcher emphasized the importance of completing the questionnaires and informed students about available mental health services if needed.

Instruments

Questionnaires included in the study were:

The study utilized a Demographic Background Questionnaire designed to collect essential information about respondents' characteristics, encompassing gender, age, living conditions, urban or rural residence, and socioeconomic status (SES), which includes parental family status and parents' occupations.

 (II) Cambodian Somatic Symptom and Syndrome Inventory (CSSI), developed by Hinton and his colleagues (2013) Dr Hinton is fluent in

Dr Hinton, who conducted doctoral research in Southeast Asia and has over twelve years of experience working with traumatized Cambodian refugees in the U.S., collaborated with colleagues to develop the Cambodian Somatic Symptom and Syndrome Inventory (CSSI) This tool includes two subscales: the CSSI somatic symptoms subscale, featuring 18 items, and the CSSI cultural syndromes subscale, consisting of 19 items across five categories The CSSI was piloted in Cambodian mental health clinics, refined based on clinician and patient feedback, and is now recognized as a standard assessment tool that effectively distinguishes mental health patients from non-patients Over three years of use have shown that CSSI symptoms are more relevant to patients than many PTSD symptoms, with items rated on a 5-point scale demonstrating strong internal consistency (α = 88 for both subscales) The CSSI’s cultural relevance and clarity make it an essential resource for guiding mental health treatment in Cambodia.

The Patient Health Questionnaire (PHQ-9), developed by Spitzer et al in 1999, is an internationally recognized tool for screening and assessing depression severity Comprising nine items based on DSM-IV criteria, such as "little interest or pleasure in doing things," it has been translated and validated in over 40 languages, including various Asian languages (Sawaya et al., 2016) Each item is rated on a 4-point scale, with scores ranging from 0 (not at all) to 3 (nearly every day) The cut-off scores indicate minimal symptoms at 5-9 and higher severity at 10 and above.

14=minor depression; 15-19= major depression, moderate; and >20=major depression, severe The items demonstrated good internal consistency for the current sample (α = 82)

The Generalized Anxiety Disorder Assessment (GAD-7), developed by Spitzer et al in 2006, is a self-report tool specifically designed to assess generalized anxiety disorder (GAD) Comprising seven items, such as "feeling nervous, anxious, or on edge," it aligns with DSM-IV criteria The GAD-7 has been translated and adapted into over 40 languages and has received international validation, making it a widely recognized measure for evaluating anxiety levels.

The GAD-7 scale, as outlined by Sawaya et al (2016), utilizes a 4-point rating system where responses range from 0 (not at all) to 3 (nearly every day) The cut-off scores indicate levels of anxiety: 5-9 signifies mild anxiety, 10-14 indicates moderate anxiety, and 15-21 reflects severe anxiety The scale exhibits strong internal consistency, with a reliability coefficient of α = 87 for the current sample.

The Brief Impairment Scale (BIS), developed by Bird et al in 2005, consists of 23 items that evaluate global functioning across three key domains: interpersonal functioning, school/work performance, and self-care For instance, it assesses interpersonal issues by asking about a child's relationship with their mother, school/work attendance by inquiring about missed days in the past year, and self-care by comparing a child's health maintenance to peers Each item is rated on a 4-point scale ranging from 0 (no problem) to 3 (serious problem) The scale has shown adequate internal consistency in recent studies, with a reliability coefficient of α = 69.

The Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) is a tool developed by Endicott et al in 1993 to evaluate individuals' quality of life enjoyment and satisfaction This questionnaire consists of 14 items that gauge life satisfaction over the previous week, asking respondents to reflect on various aspects, such as their physical health Each item is rated on a 5-point scale, ranging from 1 (not at all) to 5 (very much), allowing for a nuanced assessment of overall well-being.

2= a little; 3= moderately; 4= very much; 5=extremely) The items demonstrated good internal consistency for the current sample (α =.85)

The General Help Seeking Questionnaire (GHSQ) is designed to evaluate individuals' utilization of various mental health support sources over the past six months It prompts respondents to identify help sources, frequency of help received, and the perceived usefulness of that help The GHSQ has shown satisfactory reliability and validity, making it a versatile tool for assessing help-seeking behaviors across different contexts (Wilson et al., 2005) Comprising 13 items, the questionnaire rates help-seeking on a 5-point scale, measuring both the frequency and effectiveness of assistance received, with an internal consistency of α = 72 for the current sample.

For each of these questionnaires, the Total Score was calculated and then the questionnaire‘s standard instructions for calculating the cut-off score were followed to determine participant clinical caseness.

Ethical issues

The study was reviewed and approved by Cambodian National Ethics

On January 1, 2018, the Committee for Health Research (NECHR) approved a study involving high school students, determining that it posed minimal risk to participants While minor inconveniences, such as potential disruption of schedules and the possibility of emotional discomfort from certain questions, were acknowledged, participation was entirely voluntary Students had the right to decline or withdraw from the study at any time without facing penalties Personal identification information was not collected, except for a consent form that was stored separately from the data All participant information was kept confidential and would not be shared with parents, teachers, or school staff.

Data collection commenced only after obtaining voluntary informed consent from participants, which included signed assent forms from students and parental consent for children involved in the research.

The research team ensured that parents were fully informed and consented to their children's participation in the study They provided a comprehensive list of available services, along with brief descriptions and contact information for mental health support, should the students wish to access it.

Data analysis

The analysis was conducted in SPSS (IBM SPSS statistics for Windows,

2013) The analysis included descriptive and inferential analyses among specified concepts generated from the above questionnaires

A one-way analysis of variance (ANOVA) was conducted to compare the CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life, and help-seeking behavior between urban and rural respondents.

A one-way analysis of variance (ANOVA) was conducted to examine the differences in cultural syndromes subscale scores, anxiety, depression, functional impairment, quality of life, and help-seeking behavior between genders.

The one-way analysis of variance (ANOVA) was employed to assess the differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life, and help-seeking behavior across various grade levels.

The one-way analysis of variance (ANOVA) was conducted to examine age-related differences in various factors, including CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life, and help-seeking behavior.

A one-way analysis of variance (ANOVA) was conducted to examine the differences in CSSI cultural syndromes subscales, anxiety, depression, functional impairment, quality of life, and help-seeking behavior based on the marital status of parents.

A one-way analysis of variance (ANOVA) was conducted to examine the differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life, and help-seeking behavior based on living conditions.

A one-way analysis of variance (ANOVA) was conducted to examine the differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life, and help-seeking behavior based on parents' occupation.

 Pearson Chi-Square statistical test was used to compare differences in rates of differences sources of help (from the general help seeking behavior) by sex and by residence

 Bivariate correlation statistical test was used to analyze the correlation of CSSI cultural syndromes subscale, CSSI somatic symptoms subscale, anxiety, depression, functional impairment and help seeking behavior

The study employed a General Linear Model (GLM) approach for data analysis due to its versatility, encompassing various statistical models such as ANOVA, ANCOVA, Multiple Regression, and t-tests GLM was chosen for its ability to assess total and unique effects, particularly focusing on Type III Sums of Squares to determine unique influences while controlling for other variables This method facilitated the examination of relationships between the CSSI cultural syndromes subscale and CSSI somatic symptoms subscale with standard DSM and ICD syndromes, including depression and anxiety, while accounting for demographic background and socioeconomic status (SES) Additionally, GLM was utilized to analyze the associations of these syndromes with functional impairment, help-seeking behavior, and quality of life, again controlling for demographic and SES factors, as well as to explore the unique relationships of CSSI measures with these outcomes while considering anxiety and depression symptoms.

The Kolmogorov–Smirnov D test was utilized to evaluate the normality of the distributions for the dependent variables in the dissertation According to Berger & Zhou (2005), a D value greater than 045 indicates a significant deviation from normality However, the results for all three dependent variables revealed D statistics below this threshold, with values of D[BIS] = 031, D[QLES] = 0.039, and D[GHS] = 0.014, suggesting that the distributions do not significantly deviate from normality.

Results

This chapter presents the background information of respondents, including sex, residence (urban/rural), grade, age, and socioeconomic status (SES), which encompasses parental marital status, occupation, and living conditions It details the findings from a one-way ANOVA statistical test that examines the relationships between CSSI cultural syndromes subscale, anxiety, depression, quality of life, functional impairment, and help-seeking behavior in relation to respondents' background and SES factors Additionally, it includes results from the Pearson Chi-Square test, comparing the use of various help sources by sex and residence, as well as bivariate correlation analyses of CSSI, psychopathology syndromes, and pathology indicators Finally, the chapter presents the General Linear Model (GLM) results for CSSI cultural syndromes subscale, somatic symptoms, anxiety, depression, quality of life, functional impairment, and help-seeking behavior, while controlling for demographic and SES factors.

3.1.1 Background characteristics of respondents and Socio-Economic Status

This article presents summary statistics on respondents' background characteristics, including age, sex, grade, and socioeconomic status (SES), which encompasses parental marital status, occupation, and living conditions in urban or rural settings It further analyzes the CSSI cultural syndromes subscale, along with metrics for anxiety, depression, functional impairment, and quality of life, all segmented by demographic background and SES factors Additionally, the article explores help-seeking behaviors in relation to personal and emotional challenges.

The total sample comprised of 391 high school student participants from two residences: Phnom Penh city (urban) and Prey Veang province (rural) There were

194 students (boys0, girls) from Phnom Penh city and 197 students

In Prey Veang province, a study involving grade 10 and 11 students revealed that the average age of participants was 16.62 years (SD=1.091) Notably, 85% of the respondents reported living with intact families, with a higher percentage in rural areas (90.36%) compared to urban areas (78.87%) Conversely, 15% of the students lived with non-intact families, with urban respondents at 21.13% and rural respondents at 9.64%.

Table 1 Respondents’ Background Characteristics and SES

A survey revealed that 46% of respondents had fathers working as farmers, with a stark contrast between urban (13.92%) and rural (77.66%) areas Additionally, 22.3% identified their fathers as sellers or workers, while 21.5% were employed in government or non-government organizations Mothers' occupations showed that 44% were farmers, predominantly in rural areas (77.66%), while 29.2% were housewives, mostly in urban settings (52.58%) Other occupations included 17.1% as sellers or workers and 5.9% in government or NGO roles, with a small percentage (3.8%) reporting varied professions.

A survey assessing living conditions asked respondents to evaluate their family's situation in comparison to their neighbors within the village Participants classified their living conditions into three categories: poor, medium, and rich The findings revealed that 89.5% of respondents rated their living conditions as medium, with 88.66% from urban areas and 90.36% from rural areas Additionally, 7.7% identified as poor, consisting of 8.76% urban and 6.60% rural respondents, while only 2.8% were classified as rich, with 2.58% from urban settings and 3.05% from rural ones.

3.1.2 CSSI and psychopathology syndromes and pathology indicators

The ANOVA test was conducted to analyze the differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life, and help-seeking behavior based on various factors, including residence, sex, grade, age, parents' marital status, living conditions, and parents' occupations.

This section also presents the rates and levels of help seeking behavior when they experienced the personal and emotional issues

3.1.2.1 CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior by residence

The analysis reveals that respondents residing in rural areas reported significantly higher scores on the CSSI cultural syndromes subscale and quality of life compared to their urban counterparts, with rural participants averaging 1.74 and urban participants averaging 1.37 (p = 004).

A study on Cambodian syndromes revealed that the quality of life scores were significantly higher in rural areas (0.48) compared to urban areas (0.44), with a p-value of 000 Conversely, the mean functional impairment among urban respondents was notably higher than that of their rural counterparts, with scores of 0.09 and 0.08, respectively.

The study found no significant differences in the mean levels of anxiety, depression, and help-seeking behavior between respondents living in urban areas and those in rural areas.

Figure 2 Urban vs Rural differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

CSSI cultural syndromes subscale (F=8.421, p=.004); anxiety (F=1.700, p=.193); depression (F=1.941, p=.164); functional impairment (F.399, p= .001); quality of life (F&.569, p= 000) and help seeking behavior (F=2.553, p=.111)

3.1.2.2 Sex Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

The study found no significant differences in anxiety, functional impairment, and quality of life between male and female respondents However, notable disparities were observed in the CSSI cultural syndromes subscale, depression levels, and help-seeking behavior, with males scoring 1.42 and females 1.70 (p = 026) for cultural syndromes, males at 0.07 and females at 0.18 (p = 000) for depression, and males at 0.24 compared to females at 0.20 (p = 010) for help-seeking behavior.

Figure 3 Sex Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

CSSI cultural syndromes subscale (F=4.983, p=.026); anxiety (F=.530, p=.467); depression (F.377, p=.000); functional impairment (F=.590, p= 443); quality of life (F=.588, p= 444) and help seeking behavior (F=6.704, p=.010)

3.1.2.3 Grade Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

A comparison of cultural syndromes subscale scores revealed that grade 10 respondents (mean = 1.38) exhibited lower scores than grade 11 respondents (mean = 1.73), with a statistically significant difference (p = 005) However, there were no significant differences in mean scores for anxiety, depression, functional impairment, quality of life, or help-seeking behavior between students in grade 10 and those in grade 11.

Figure 4 Grade Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life enjoyment and satisfaction and help seeking behavior

CSSI cultural syndromes subscale (F=8.007, p=.005); anxiety (F=1.980, p=.160); depression (F=1.366, p=.243); functional impairment (F=3.075, p= .080); quality of life (F=2.060, p= 152) and help seeking behavior (F=2.669, p=.103)

3.1.2.4 Age Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

The ages of respondents were grouped into two groups (15-17 years and 18-

A study examining cultural syndromes, anxiety, depression, functional impairment, quality of life, and help-seeking behavior revealed no statistically significant differences between the age groups of 15-17 years and 18-19 years.

Figure 5 Age Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life enjoyment and satisfaction and help seeking behavior

CSSI cultural syndromes subscale (F=2.846, p=.092); anxiety (F=1.097, p=.296); depression (F=.169, p=.681); functional impairment (F=.003, p= 954); quality of life (F=.210, p= 647) and help seeking behavior (F=1.745, p=.187)

3.1.2.5 Parent Marital Status Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

A study revealed that individuals from non-intact families experience significantly higher levels of anxiety (0.41 vs 0.28, p = 006) and depression (0.19 vs 0.11, p = 048) compared to those from intact families, along with greater functional impairment (0.12 vs 0.08, p = 000) Conversely, respondents from intact families reported a higher quality of life (0.46 vs 0.43, p = 018) However, there were no significant differences in cultural syndromes or help-seeking behaviors between the two groups.

Figure 6 Parent Marital Status Differences CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

CSSI cultural syndromes subscale (F=.909, p=.341); anxiety (F=7.630, p=.006); depression (F=3.926, p=.048); functional impairment (FI.030, p= 000); quality of life (F=5.682, p= 018) and help seeking behavior (F=1.891, p=.170)

3.1.2.6 Living Condition Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

A study indicated that respondents from poor families reported significantly higher levels of CSSI cultural syndromes, anxiety, depression, and functional impairment compared to those from medium and rich families, with p-values indicating strong statistical significance (CSSI: poor= 2.51, medium= 1.48, rich= 1.47, p = 000; anxiety: poor= 0.59, medium= 0.27, rich= 0.34, p = 000; depression: poor= 0.32, medium= 0.11, rich= 0.10, p = 000; functional impairment: poor= 0.11, medium= 0.09, rich= 0.07, p = 016) Conversely, individuals from rich families reported a significantly higher quality of life than those from medium and poor families (rich= 0.51, medium= 0.46, poor= 0.42, p = 006) However, there were no significant differences in seeking behavior among respondents across different socioeconomic statuses.

Figure 7 Living Condition Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

CSSI cultural syndromes subscale (F=9.806, p=.000); anxiety (F.165, p=.000); depression (F=8.086, p=.000); functional impairment (F=4.171, p= .016); quality of life (F=5.250, p= 006) and help seeking behavior (F=.299, p=.742)

3.1.2.7 Father Occupation Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

The study categorized respondents' fathers' occupations into four groups: "farmer," "office staff," "seller or worker," and "others." While there were no significant differences in the CSSI cultural syndromes subscale, anxiety, and health-seeking behavior across these categories, notable differences emerged in depression, functional impairment, and quality of life Specifically, respondents whose fathers were "sellers or workers" exhibited a significantly higher mean depression score (P = 004), while those categorized as "others" showed the highest mean functional impairment (P = 000) Additionally, respondents with fathers in the "farmer" category reported a higher mean quality of life compared to other occupations (P = 003).

Table 2 Father Occupation Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior by father occupation

Variables Total Farmer Office staff

3.1.2.8 Mother Occupation Differences in CSSI cultural syndromes subscale, anxiety, depression, functional impairment, quality of life and help seeking behavior

Occupation of respondents‘ mother occupation was classified into 5 categories such as ―farmer‖, ―office staff‖, ―seller or worker‖, ―housewife‖ and

Discussion

The current study aimed to explore the relationships between the CSSI cultural syndromes subscale, the CSSI somatic symptoms subscale, and standard Western mental health syndromes, specifically depression and anxiety It also examined how these factors relate to functional impairment, help-seeking behaviors, and quality of life The findings revealed significant positive associations between the CSSI subscales and depression, anxiety, functional impairment, and overall health-seeking behaviors, suggesting that these cultural syndromes reflect psychopathology Additionally, the study indicated that anxiety and depression are also significantly linked to these indicators of pathology in the Cambodian context This research highlights the need for clinicians to understand how mental health issues are conceptualized in Cambodia, potentially enhancing communication and treatment engagement with patients.

The CSSI cultural syndromes and somatic symptoms subscales did not show unique associations with functional impairment, quality of life, or help-seeking behavior, suggesting they lack additional insights into psychopathology in this sample In contrast, anxiety and depression demonstrated distinct relationships with functional impairment, with anxiety specifically linked to help-seeking behavior, indicating that Western syndromes offer valuable information regarding psychological pathology.

Culturally-specific psychopathology syndromes consist of three key components: cultural syndromes, which are symptom clusters that primarily occur within specific cultural groups due to unique causal processes; cultural idioms of distress, where psychological pain is expressed in ways that are distinct to a culture despite having cross-cultural origins; and cultural explanations of distress, which provide culturally specific interpretations of psychological symptoms Understanding these components is essential for effective mental health treatment across diverse populations.

Wind attack (khyâl) is a culturally specific syndrome that encompasses cognitive, emotional, and physical experiences, often attributed to unique explanations such as possession by ghosts (Lewis-Fernández & Aggarwal, 2013) Understanding and assessing these culturally-specific syndromes is crucial for enhancing the effectiveness of mental health assessment tools and interventions, ultimately improving treatment outcomes.

Culturally specific psychopathology syndromes may reflect unique forms of mental health issues tied to distinct cultural contexts This study found that while these syndromes are correlated with indicators of pathology, they do not exhibit unique relationships with these indicators The significant overlap between culturally specific syndromes and Western syndromes, particularly their strong correlations with anxiety (r = 691) and depression (r = 708), indicates that the cultural syndromes are more about social and cultural interpretations of symptoms rather than unique causal processes If unique underlying causes existed, one would expect distinct relationships between syndromes and impairment in functioning, but the absence of such unique relations suggests that these culturally specific syndromes do not arise from unique causal factors.

Understanding culturally-specific syndromes is crucial as they embody significant beliefs about mental health that are often overlooked by standard Western diagnoses For example, the Cambodian concept of khyaˆl attacks, recognized in the Cultural Syndromes and Symptoms Inventory (CSSI), highlights a vital form of distress for Cambodian individuals, which is absent in Western assessment tools like the PHQ and GAD By incorporating these culturally relevant syndromes into assessments, clinicians can foster clearer communication with mental health clients, enhancing their engagement in both the assessment and treatment processes This approach allows clients to articulate their distress in their own terms, leading to more effective assessments and interventions (Belsiyal, Sasirekha, 2017).

The findings of the current study highlight the importance of culturally specific psychopathology syndromes, as assessed by the CSSI, for clinicians and psychologists in Cambodia These syndromes provide valuable insights into understanding mental health within the cultural context, enabling professionals to offer more effective and relevant care to patients.

Clinicians and psychologists can enhance their understanding of clients' issues within the Cambodian context by utilizing local idioms of distress, particularly through CSSI syndromes This approach enables clients to better comprehend their own symptoms, facilitating clearer communication in their own terms According to DSM-5, discussing mental health issues in familiar language improves communication, which aids in treatment negotiation and engagement, ultimately leading to better treatment adherence Moreover, this culturally sensitive method fosters a stronger clinician-client relationship, as patients feel more at ease discussing their symptoms when viewed through their cultural lens.

Utilizing the Cambodian idioms of distress through the CSSI can enhance the willingness of individuals to seek and engage in treatment for psychological disorders By helping clients better understand their problems and symptoms, this approach fosters a stronger therapeutic alliance and empathetic rapport Understanding both the linguistic and conceptual language of patients improves communication, facilitating negotiations that ultimately lead to increased treatment retention and adherence.

The findings of this study suggest that using Western measures like the PHQ and GAD may suffice for assessing psychopathology, potentially reducing the need for culturally-specific measures such as the CSSI However, this does not diminish the clinical value of culturally specific syndromes, which play a crucial role in assessment and treatment Incorporating culturally relevant terms and explanations can enhance understanding for clients who may struggle with Western diagnostic labels, ultimately fostering greater engagement in the assessment process (Karthick & Sangita, 2017).

The integration of Western syndromes into non-Western cultures can offer significant advantages Firstly, these syndromes may carry less stigma, as traditional symptoms of distress are often associated with moral weakness or failure in social roles, leading to feelings of shame and anxiety In contrast, Western syndromes, which lack a deep-rooted cultural association with negative outcomes, may be perceived more neutrally Secondly, Western mental health syndromes are grounded in objective scientific research, providing a more empirical basis for understanding and treatment This connection to scientifically identified causal processes means that conditions like anxiety and depression can be linked to effective treatment programs Ultimately, a hybrid approach that combines elements from both Western and traditional systems may prove to be the most beneficial.

The study has several limitations that warrant consideration Firstly, by utilizing an adolescent sample, the research may overlook culturally specific causal processes that could emerge later in development, which could yield significant insights into psychopathology Secondly, the focus on Cambodia, while revealing culturally unique psychopathology syndromes, may not capture similar syndromes present in other nations that relate differently to factors like functional impairment and help-seeking behaviors Thirdly, the analysis of PTSD was hindered due to only 10% of participants experiencing a traumatic event, limiting our ability to explore its unique relationships Additionally, many assessment measures used lack formal validation in Cambodia, despite being developed with cultural sensitivity and expert approval This limitation is echoed in similar studies, such as one conducted in Vietnam, which, although lacking formal validation, still provides valuable insights into culturally relevant psychological complaints.

The GAD-7 was designed specifically to evaluate Generalized Anxiety Disorder, which raises concerns that it may not effectively assess other anxiety disorders, including panic disorder and PTSD, in current research.

Research indicates that the GAD-7 not only assesses generalized anxiety disorder but also effectively identifies other anxiety disorders such as PTSD, social anxiety disorder, and panic disorder (Spitzer et al., 2007; Spoont et al., 2013).

The GAD-7 scale primarily evaluates generalized anxiety disorder; however, incorporating a wider range of Western anxiety syndromes could enhance the unique variance of the CSSI While measures such as the PHQ-9, GAD-7, BIS, Q-LES-Q-SF, and GHSQ scales are validated and commonly used in various countries, including those in Southeast Asia, they have yet to undergo formal validation in these specific regions.

CONCLUSIONS

The study revealed a significant positive correlation between the CSSI cultural syndromes subscale and standard Western depression and anxiety syndromes Additionally, both the CSSI cultural syndromes and Western syndromes were associated with functional impairment, quality of life, and health-seeking behaviors However, the findings suggest that the CSSI cultural syndromes and Western-based psychopathology share conceptual and empirical similarities, indicating that CSSI syndromes may not offer distinct insights into psychological pathology.

RECOMMENDATIONS

The following recommendations are made:

1 Researchers determine whether culturally specific psychopathology syndromes among adults have unique relations to psychopathology indicators, in order to determine whether culturally unique casual processes may occur later in humand development

2 Conduct similar research among other ethnic groups in Cambodia such as the Cham, in order to determine if there are unique effects for CSSI syndromes among cultural minorities in Cambodia

3 Future research should develop cut off scores for the CSSI in order that it can be used for clinical purposes (e.g., to make treatment decisions) within

4 Further study should be conducted to asses the predictive ability of CSSI in clinical evaluations

5 Future research should assess other forms of validity of the CSSI, such as predictive validity

6 To more fully understand the relative utility and value of the CSSI vs

When evaluating Western assessment tools like the PHQ-9 and GAD-7, it's essential to consider factors such as difficulty level and time investment This analysis will enhance our understanding of the relative utility of these measures, highlighting their advantages and disadvantages for future research.

7 Use these findings regardings the CSSI in training of clinical psychology master‘s students at the Royal University of Phnom Penh to encourage the new psychologists in the understanding of Khmer psychometric and psychopathology assessment

1 Predictors of mental health help seeking among Cambodian adolescents

VNU Journal of Science: Education Research, Vol 35, No 3 (2019) 115-

2 The Unique relations of Cambodian somatic symptom and syndrome inventory (CSSI) items with functional impairment among adolescents in Cambodia The Fifth International Conference on Child Mental Health in

Vietnam: Mental Health Literacy in the Schools and Community in Hanoi,

3 Hinton, D.E., Seponski, D.M., Khann, S., Armes, S.E, Lahar, C.J., Kao, S.,

& Schunert, T (2019) Culturally sensitive assessment of anxious-depressive distress in Cambodia: Avoiding category truncation Transcultural

American Psychiatric Association (2013) Diagnostic and statistical manual of mental health disorders (5th ed.) Washington, DC: American Psychiatric

Armes, S., Somo, C M., Khann, S., Seponski, D M., Lahar, C., Kao, S &

Schunert, T (2018) Mental Health Indicators of Suicide in Cambodian Women

Asia Journal of Public Health https://journals.sagepub.com/home/aph

Arnault, D S., Sakamoto, S., & Moriwaki, A (2006) Somatic and depressive symptoms in female Japanese and American students: A preliminary investigation Transcultal Psychiatry, 43(2):275-86

Belsiyal, C X., & Sasirekha (2017) Culture bound syndrome - an unprecedented inclusion Int J Health Sci Res, 7(10):256-261

The study by Betancourt et al (2011) explores the mental health challenges faced by Rwandan children and adolescents affected by HIV/AIDS, emphasizing the importance of understanding these issues within their local, cultural, and contextual frameworks The research highlights the need for culturally relevant interventions to address the unique psychological impacts of the HIV/AIDS epidemic on this vulnerable population By focusing on the specific experiences and needs of affected youth, the study contributes valuable insights into improving mental health care strategies in Rwanda.

Bossola, M., Stasio, E D., Antocicco, M., Pepe, G., Tazza, L., Zuccalà, G., &

Laudisio, A (2016).Functional impairment is associated with an increased risk of mortality in patients on chronic hemodialysis BMC Nephrology, 17:72 DOI 10.1186/s12882-016-0302-y

Bhugra, D (2006) Severe mental illness across cultures Acta Psychiatr Scand, 113 (429): 17–23

Bhui, K (2010) Culture, religion and health care International Journal of

Integrated Care – V (10) – ISSN 1568-4156 – http://www.ijic.org/

Bird, H R., Canino, G J., Davies, M., Ramírez, R., Chávez, L., Duarte, C., & Shen,

S (2005) The Brief Impairment Scale (BIS): A Multidimensional Scale of Functional Impairment for Children and Adolescents Journal of the American

Academy of Child & Adolescent Psychiatry, 44(7), 699-707 http://dx.doi.org/10.1097/01.chi.0000163281.41383.94

Bitsika, V., Sharpley, C F., & Melhem, T C (2010) Gender differences in factor scores of anxiety and depression among Australian university students:

Implications for counseling Interventions Canadian Journal of

Counseling/Revue Canadienne de Counseling 51, ISSN 0826-3893, 44(1)

Bohman H., Jonsson U., Paaren A., Knorring L V., Olsson, G., & Knorring, A.V

(2012) Prognostic significance of functional somatic symptoms in adolescence:

A 15-year community based follow-up study of adolescents with depression compared with healthy peers BMC Psychiatry, 12:90

Byaruhanga, E., Cantor-Graae, E., Maling, S., & Kabakyenga, J (2008) Pioneering work in mental health outreach in rural southwestern Uganda in intervention

International Journal of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict, 6, 117–131

Campinha-Bacote, J (1988) Cultural assessment: An important factor in psychiatric consultation-liaison nursing Archives of Psychiatric Nursing, 2, 244-250

Cornally, N., & McCarthy, G (2011) Help-seeking behavior: A concept analysis

International Journal of Nursing Practice, 17, 280-288

Chhabra V., Bhatia M.S., & Gupta, R (2008) Cultural bound syndromes in India

Chhim, S (2012) Baksbat (Broken Courage): The development and validation of the inventory to measure baksbat, a Cambodian trauma-based cultural syndrome of distress Culture Medicine and Psychiatry, 36:640-659 DOI 10.1007/s11013- 012-9279-6

Chhim S (2017) Mental Health in Cambodia In: Minas H., Lewis M (eds) Mental Health in Asia and the Pacific International and Cultural Psychology Springer, Boston, MA

Desai, G., & Chaturvedi, S K (2017) Idioms of Distress Journal of neurosciences in rural practice, 8(Suppl 1), S94-S97

Desiree, M S., Cindy J L., Sareth, K., Sovandara, K., & Tanja, S (2018) Four decades following the Khmer rouge: sociodemographic factors impacting depression, anxiety and PTSD in Cambodia, Journal of Mental Health, DOI: 10.1080/09638237.2018.1466039

Drapeau, A., Boyer, R., & Lesage, A (2009) The influence of social anchorage on the gender difference in the use of mental health services Journal of Behavioral

Drukker, M., Kaplan, C., Feron, F., & Van Os, J.( 2003) Children‘s health-related quality of life, neighbourhood socio-economic deprivation and social capital A contextual analysis Soc Sci Med, 57(5):825-841

Elliott, I ( 2016) Poverty and Mental Health: A review to inform the Joseph

Rowntree Foundation’s Anti-Poverty Strategy London: Mental Health

Ellis, H A (2015) Obeah-illness versus psychiatric entities among jamaican immigrants: cultural and clinical perspectives for psychiatric mental health professionals Archives of Psychiatric Nursing, 29(2), 83-89 DOI:

Endicott, J., Nee, J., Harrison, W., & Blumenthal, R (1993) Quality of Life enjoyment and satisfaction questionnaire: a new measure Psychopharmacol

The article by Field (2011) explores the intergenerational transmission of trauma resulting from the Khmer Rouge regime, emphasizing an attachment perspective It is featured in the edited volume "Cambodia's Hidden Scars: Trauma Psychology in the Wake of the Khmer Rouge," which highlights the lasting psychological impacts on survivors and their descendants The work discusses how traumatic experiences can affect familial bonds and mental health across generations, providing insight into the profound effects of historical trauma in Cambodia.

In their study, Field and Chhim (2008) explore the complex relationship between the desire for revenge and attitudes toward the Khmer Rouge tribunal among Cambodians, highlighting the psychological impacts of historical trauma Meanwhile, Fletcher and Jason (2008) examine adolescent depression, focusing on its diagnosis, treatment, and the implications for educational attainment, emphasizing the importance of addressing mental health issues to improve academic outcomes.

Fried, E.I., & Nesse, R.M (2014) The impact of individual depressive symptoms on impairment of psychosocial functioning PLoS ONE, 9(2): e90311 doi:10.1371/journal.pone.0090311

Genizi, J., Srugo, I., & Kerem, N C (2013) The cross- ethnic variations in the prevalence of headache and other somatic complaints among adolescents in Northern Israel The Journal of Headache and Pain, 14:21

Goldston, D B., Walsh, A., Arnold, E M., Reboussin, B., Daniel, S S., Erkanli, A., Nutter, D., Hicman, E., Palmes, G., Snider, E., & Wood, F B (2007)

Reading problems, psychiatric disorders, and functional impairment from mid- to late adolescence J AM Acad Child Adolesc Psychiatry, 46:1 DOI:

Green, G., Hayes, C., Dickinson, D., Whittaker, A., & Gilheany, B (2003) A mental health services users perspective to stigmatization Journal of Mental

Green, H., McGinnity, A., Meltzer, H., Ford, T., & Goodman, R.(2005) Mental health of children and young people in Great Britain (1st) New York, NY:

Patients with somatic complaints in general practice often experience high rates of depression, anxiety, and somatoform disorders These mental health issues are frequently linked to psychosocial stressors, highlighting the importance of addressing psychological factors in primary care settings This study by Haftgoli et al emphasizes the need for healthcare providers to recognize and manage these interconnected conditions to improve patient outcomes.

Henning, E R., Turk, C L., Mennin, D S., Fresco, D M., & Heimberg, R G

(2006) Impairment and quality of live in individuals with generalized anxiety disorder Depression and Anxiety DOI 10.1002/da

Hinton, D E., Seponski, D M., Khann, S., Armes, S E., Lahar, C J., Kao, S., & Schunert, T (2019) Culturally sensitive assessment of anxious- depressive distress in the Cambodian population: Avoiding category truncation Transcult Psychiatry, 56(4), 643-666 doi:

Hinton, D E., & Lewis-Ferna´ndez, R (2010) Idioms of Distress among Trauma Survivors: Subtypes and Clinical Utility Cult Med Psychiatry, 34:209–218 DOI 10.1007/s11013-010-9175-x

Hinton, D E., Pich, V., Marques, L., Nickerson, A., & Pollack, M.H (2010) Khyâl attacks: a key idiom of distress among traumatized Cambodia refugees Cult

Hinton, D E., Um, K., & Ba, P (2001b): Kyol Goeu ('Wind Overload') Part I: A cultural syndrome of orthostatic panic among Khmer refugees Transcultural

Hinton, D E., Hinton, S., Um, K., Chea, A., & Sak, S (2002) The Khmer ‗weak heart‘ syndrome: Fear of death from palpitations Transcultural Psychiatry, 39(3): 323–344 doi:10.1177/136346150203900303

Hinton, D E., Chhean, D., Pich, V., Pollack, M H., Orr, S.P., & Pitman, R K

(2006) Assessment of posttraumatic stress disorder in Cambodian refugees using the clinician-administered PTSD Scale: Psychometric properties and symptom severity Journal of Traumatic Stress, 19(3) 405 DOI:

Hinton, D E., Pich, V., & Chhean, D (2005a): 'The ghost pushes you down': Sleep paralysis-type panic attacks in a Khmer refugee population Transcultural

In their 2013 study, Hinton et al explored the connection between PTSD and significant somatic complaints among Cambodian refugees in a psychiatric clinic They introduced the Cambodian Somatic Symptom and Syndrome Inventory (CSSI) to assess these relationships, highlighting the impact of cultural syndromes on mental health The findings emphasize the importance of considering cultural context in understanding somatic symptoms related to PTSD in refugee populations.

Hofmann, S G., & Hinton, D E (2014) Cross-Cultural Aspects of Anxiety

Disorders Current Psychiatry Reports, 16(6), 450 http://doi.org/10.1007/s11920-014-0450-3

Huang, V., Beshai, S & Yu, M (2016) The effects of the gender-culture interaction on self-reports of depressive symptoms: Cross-cultural study among Egyptians and Canadians Peer-Reviewed Journal, DOI 10.7717/peerj.2783

Hudson, C G (2005) Socioeconomic status and mental illness: Tests of the social causation and selection hypotheses American Journal of Orthopsychiatry,

IBM Corp (2013) IBM SPSS Statistics for Windows (Verson 22) Armonk, NY

Jegannathan B., & Kullgren G (2011): Gender differences in suicidal expressions and their determinants among young people in Cambodia, a post-conflict country BMC Psychiatry, 11:47 11 (47)

Jimenez, D E., Bartels, S J., Cardenas, V., Daliwal, S S., & Alegría, M (2012) Cultural Beliefs and Mental Health Treatment Preferences of Ethnically Diverse Older Adult Consumers in Primary Care The American Journal of Geriatric

Kadzikowska-Wrzosek, R (2012) Perceived stress, emotional ill-being and psychosomatic symptoms in high school students: The moderating effect of self- regulation competences Archives of Psychiatry and Psychotherapy, 2012; 3: 25–33

Ka, S., Ka, M., & Savin, D (2014) Depression: A case study from Cambodia

Karkhanis, D G., & Winsler, A (2016) Somatization in children and adolescents: Practical implications J Indian Assoc Child Adolesc Ment Health, 12(1):79-

The study by Kessler et al (2005) in the Archive of General Psychiatry explores the lifetime prevalence and age-of-onset distributions of DSM-IV disorders through the National Comorbidity Survey Replication This comprehensive research highlights the significant patterns of mental health disorders, providing valuable insights into their occurrence and timing in the population Additionally, Kohrt et al contribute to the understanding of mental health by examining various factors influencing these disorders, emphasizing the importance of addressing mental health issues in public health initiatives.

Mutamba, B B., de Jong, J T., Hinton, D E (2013) Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology International journal of epidemiology, 43(2), 365-406

Lawrence, D., Johnson, S., Hafekost, J., Boterhoven De Haan, K., Sawyer, M., Ainley, J., & Zubrick, S.R (2015) The Mental Health of Children and

Adolescents Report on the second Australian Child and Adolescent Survey of

Mental Health and Wellbeing Department of Health, Canberra

Lee, Y M (2015) Somatic symptoms and depressive symptoms among older adult Korean immigrants Journal of Gerontological Nursing, 41(1)

Lee, J., Wachholtz, A., & Choi, K H (2014) A Review of the Korean Cultural Syndrome Hwa-Byung: Suggestions for Theory and Intervention Asia

T'aep'yongyang sangdam yon'gu, 4(1), 49

Letvak, S (2002) The importance of social support for rural mental health Issues in Mental Health Nursing, 23(3), 249-261

McCauley, E., Katon, W., Russo, J., Richardson, L., & Lozano, P (2007) Impact of anxiety and depression on functional impairment in adolescents with asthma General Hospital Psychiatry, 29(3), 214–222 http://doi.org/10.1016/j.genhosppsych.2007.02.003

McLaughlin, K A., Costello, E J., Leblanc, W., Sampson, N A., & Kessler, R C

(2012) Socioeconomic status and adolescent mental disorders American journal of public health, 102(9), 1742-50

A study by Meng et al (2013) investigates the relationship between rural/urban backgrounds and mental health issues, specifically depression and suicidal ideation, among Chinese college students The research highlights significant findings on how geographical upbringing influences psychological well-being Additionally, Mickelson (2001) explores the impact of perceived stigma and social support on depression, emphasizing the importance of social networks in mental health outcomes Together, these studies underscore the critical role of environmental and social factors in understanding mental health challenges in young adults.

Personality and Social Psychology Bulletin, 27, 1046–1056

Ministry of Health (2016): Mental Health and Substance Misuse Strategic Plan 2011-2015 National Program for Mental Health, World Health Organization Phnom Penh, Cambodia

Ministry of Women‘s Affairs (2008) A fair share for women: Cambodia gender assessment 2008 Phnom Penh: Cambodia

Ministry of Women's Affairs (2015) National Survey on Women's Health and Life

Experiences in Cambodia Phnom Penh: Cambodia

Mueser, K T., & Taub, J (2008) Trauma and PTSD among adolescents with severe emotional disorders involved in multiple service systems Psychiatric

Nakao, M., & Yano, E (2006) Somatic symptoms for predicting depression: One- year follow-up study in annual health examinations Psychiatry and Clinical

Stress plays a significant role as a pathophysiological factor in functional somatic syndromes, highlighting the complex relationship between mental health and physical symptoms (Natert, Fischer, & Ehlert, 2011) Additionally, gender differences influence the impact of adolescent depressive symptoms on educational attainment in young adults, suggesting that these factors must be considered in educational and mental health interventions (Needham & Belinda, 2009).

Neighbors, H.W., Caldwell, C., Williams, D R., Nesse, R., Taylor, R J., Bullard, K.M., Torres, M., & Jackson, J S (2007) Race, ethnicity, and the use of services for mental health disorders: Results from the national survey of

American life Archives of General Psychiatry, 64, 485-494

Nooner, K.B., Linares, L O., Batinjane, J., Kramer, R A., Silva, R., & Cloitre, M

(2012) Factors related to posttraumatic stress disorder in adolescence Trauma,

Oliver, M I., Pearson, N., Coe, N., & Gunnell, D (2005) Help-seeking behavior in men and women with common mental health problems: cross-sectional study

Overton, S.L., & Medina, S L (2008) The stigma of mental illness Journal of

Pappa, V S (2013) Relations between Parents‘ Marital Status and the

Psychological Well-being of Adolescents in Greece Journal of Psychology and

Parker, G., Cheah, Y C., & Roy, K (2001) Do the Chinese somatize depression? A cross cultural study Social Psychiatry and Psychiatric Epidemiology, 36, 287–

Paritala, C B G., Nallapaneni, N R., & Chennamsetty, S K (2014) A cross- sectional study to assess the prevalence of somatisation and associated socio demographic factors in depression The Andhra Pradesh Journal of Psychological Medicine, 15 (1) January-June 2014

Patel, V., & Sumathipala, A (2006) Psychological approaches to somatization in developing countries Advances in Psychiatric Treatment, 12, 54–62

Perry, C T., Oum P., & Gray, S H (2007).The body remembers: Somatic symptoms in traumatized Khmer Journal of the American Academy of

Paruk, S., & Karim, E (2016) Update on adolescent mental health South African

Quinn, N., & Knifton, L (2014) Beliefs, stigma and discrimination associated with mental health problems in Uganda: Implications for theory and practice

International Journal of Social Psychiatry, 60(6) 554–561

Raval, V.V., & Martini, T S (2009) Maternal socialization of children's anger, sadness, and physical pain in two communities in Gujarat, India The

International Journal of Behavioral Development; 33: 215-229 doi:

A systematic review by Reiss (2013) highlights the significant impact of socioeconomic inequalities on mental health issues among children and adolescents, emphasizing the need for targeted interventions Additionally, research by Rickwood et al (2005) explores the help-seeking behaviors of young people facing mental health challenges, revealing barriers they encounter and the importance of accessible support systems Together, these studies underscore the critical intersection of socioeconomic factors and mental health support in youth, advocating for comprehensive strategies to address these disparities.

Romero-Acosta, K., Canals, J., Hernandez-Martinez, H., Penelo, E., Zolog, T C., & Domenech-Llaberia, E.(2013) Age and gender differences of somatic symptoms in children and adolescents Journal of Mental Health, 22(1): 33–41 DOI:

Rona, R J., Jones, M., Iversen, A., Hull, L., Greenberg, N., Fear, N T., Hotopf, M.,

& Wessely, S (2009) The impact of posttraumatic stress disorder on impairment in the UK military at the time of the Iraq war Journal of Psychiatric

Ryder, A G., Yang, J., Zhu, X., Yao, S., Yi, J., Heine, S J., & Bagby, R M (2008) The cultural shaping of depression: Somatic symptoms in China, psychological symptoms in North America? Journal of Abnormal Psychology, 117, 300–313, doi:10.1037/0021-843X.117.2.300

Santiago, C D., Wadsworth, M E., & Stump J.(2011) Socioeconomic status, neighborhood disadvantage, and poverty-related stress: Prospective effects on psychological syndromes among diverse low-income families Journal of

Sayar, K., & Ak, I (2001).The predictors of somatization: A review Bulletin of

Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H (2007): Resources for mental health: Scarcity, inequity, and inefficiency The Lancet 370 (9590), 878–

Sawant, N S., & Nath, A.(2012) Cultural misconceptions and associated depression in Dhat syndrome SL J Psychiatry; 3 (1):17-20

In a study conducted by Sawaya et al (2016), the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) were adapted and initially validated for Arabic-speaking Lebanese psychiatric outpatients This research, published in Psychiatry Research, highlights the importance of culturally relevant mental health assessment tools in improving the accuracy of diagnosing depression and anxiety disorders in this population The findings underscore the effectiveness of the PHQ-9 and GAD-7 in clinical settings, contributing to better mental health care for Arabic-speaking individuals.

Schunert, T., Khann, S., Kao, S., Pot, C., Saupe, L B., Sek, S., & Nhong, H (2012)

Cambodian Mental Health Survey Report Phnom Penh, Cambodia:

Department of Psychology, Royal University of Phnom Penh

Segal, D L., Coolidge, F L., Mincic, M S., & O'Riley, A (2005) Beliefs about mental illness and willingness to seek help: A cross-sectional study Aging & Mental Health, 9(4), 363-367, DOI: 10.1080/13607860500131047

Seponski, D M., Lahar, C., Khann, S., Kao, S., & Schunert, T (2018) Four decades following the Khmer Rouge: Sociodemographic factors impacting rates of depression, anxiety, and PTSD in Cambodia Journal of Mental Health Impact factor (1.941)

Shakoor, A., Shafqat, F., Mehmud, T H., Akram, M., Riaz, S., Iqbal, Z., & Khan,

A (2010) Frequency of depression and somatic symptoms in patients on interferon Alpha/Ribavirin for chronic hepatitis J Ayub Med Coll Abbottabad, 22(4)

Smith, K L W., Matheson, F.I., Moineddin, R., Dunn, J.R., Lu, H., Cairney, J., & Glazier, R H (2013) Gender differences in mental health service utilization among respondents reporting depression in a national health survey Health, 5, 1561-1571

Sonis, J., Gibson J.L., de Jong, J.T.V.M., Field, N.P., Hean, S., & Komproe, I

(2009) Probable Postraumatic Stress Disorder and Disability in Cambodia Associations with perceived Justice, Desire for Revenge and Attitudes towards the khmer rouge trials The Journal of the American Medical Association, 302

Sotheara, C (2017): A qualitative and quantitative investigation into ethno-cultural framing of trauma in Cambodia: baksbat (broken courage), a Cambodian trauma syndrome akin to PTSD https://doi.org/10.4225/03/58ae54da3dabf

Spitzer, R L., Kroenke, K., Williams, J B W., Lowe, B (2006) A brief measure for assessing generalized anxiety disorder Archives of Internal Medicine, 166, 1092-1097

Spuij, M., Reitz, E., Prinzie, P., Stikkelbroek, Y., de Roos, C., & Boelen, P.A

(2012) Distinctiveness of symptoms of prolonged grief, depression, and post- traumatic stress in bereaved children and adolescents Eur Child Adolesc

Sulaiman, S.O.Y., Bhugra, D., & Silva, P (2001) Perceptions of depression in a community sample in Dubai Transcultural Psychiatry, 38, 201-218 http://dx.doi.org/10.1177/136346150103800204

Thesen, J (2001) Being a psychiatric patient in the community—Reclassified as the stigmatized ―other.‖ Scandinavian Journal of Pubic Health, 29, 248–255

The ASEAN Secretariat (2016) ASEAN Mental Health Systems Jakarta:

Thida, K & Amaury, P (2017) Pattern of Treatment-seeking for Mental Health

Problem in Cambodia Rural Community Paper presented at the First Southeast

Asia Regional Conference of Psychology: Human well-being and Sustainable Development (pp.154) Hanoi: Vietnam

Trivedi, M H (2004) The link between depression and physical symptoms Primary Care Companion to The Journal of Clinical

Ustun, B., Chatterji, S., & Editorial ( 1997) Measuring functioning and disability common framework International Journal of Methods in Psychiatric Research, 7:79–83

VandenBos, G R., & American Psychological Association (2007) APA dictionary of psychology Washington, DC: American Psychological Association

Vidourek, R A., King, K A., Nabors, L A., & Merianos, A L (2014) Students‘ benefits and barriers to mental health help-seeking Health Psychology &

Behavioural Medicine, 2(1), 1009–1022, http://dx.doi.org/10.1080/21642850.2014.963586

Vogel, D L., Wester, S R., & Larson, L M ( 2007) Avoidance of counseling: psychological factors that inhibit seeking help Journal of Counseling &

Wagenaar, H B., Kohrt, B A., Hagaman A K., Mclan K.E., & Kaiser, B N

(2013) Determinants of care seeking for mental health problems in rural Haiti: culture, cost, or competency Psychiatric Services, 64, 366–372, 2013; doi: 10.1176/appi.ps.201200272

Ward, E., Wiltshire, J C., Detry, M A., & Brown, R L (2013) African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors Nurs Res, 62(3), 185–194 doi:10.1097/NNR.0b013e31827bf533

Weiss, B., Tram, J M., Weisz, J R., & Rescorla, L (2009) Differential symptom expression and somatization in Thai versus U.S children Journal of Consulting and Clinical Psychology, 77( 5), 987–992

Westphal, M., Olfson, M., Gameroff, M J., Wickramaratne, Priya., Pilowsky, D J., Neugebauer, R., Lantigua, R., Shea, S., & Neria, Y (2011) Functional impairment in adults with past posttraumatic stress disorder: Finding from primary care Depression and Anxiety, 28, 686–695

Wilson, C J., Deane, F P., Ciarrochi, J., and Rickwood, D (2005) Measuring Help-Seeking Intentions: Properties of the General Help-Seeking Questionnaire

Canadian Journal of Counselling / Revue canadienne de counseling, 39(1)

Wolport, L (2001) Stigma of depression— a personal view British Medical

Zahn-Waxler, C., Shirtcliff, E, A., & Marceau, K (2008) Disorders of childhood and adolescence: gender and psychopathology Annual Review of Clinical

APPENDICES QUESTIONNAIRE IN KHMER VERSION លិខិតជូនចំព ោះឪពុកម្តាយ និងទម្រង់ជូនដំណឹងពីការយល់ម្ពរ របស់ឪពុកម្តាយ កាលបរិច្ចឆទ ……… ជូនចំច្ ោះអាណាពាបាលសិសស ខញុំច្្មោះ ខាន់ សាច្រ៉េត ជានិសសិតថ្ននក់បណ្ឍិតច្ៅសាកលវិទាល័យជាតិ ច្វៀតណាម និងជាសាស្ត្សាាចារយច្ៅច្ដបា៉េតឺមង់ចិតាវិទា សាកលវិទាល័យភូមិនទភនំ ច្ពញ។ ខញុំកំពុងច្ធវើការសិកាស្រសាវរជាវសាីពី“សុខភាពផលូវចិតាជំទង់ច្ៅកមពុជា: ទំនាក់ ទំនងរវាង បណ្ាុំច្ោគសញ្ញដវបបធម៌ជាក់លាក់ ការធ្លលក់ទឹកចិតា ថប់បារមភ និងការធ្លលក់ ចុោះនន ការបំច្ពញមុខងាររបចាំនថង” សរាប់សរច្សរនិច្កេបបទបញ្ចប់ថ្ននក់បណ្ឍិត។ ខញុំានបំណ្ងអច្ញ្ជើញកូនរបស់ច្លាកអនក ឲ្យចូលរួមកនុងការស្រសាវរជាវច្នោះដដល នឹងសួរអំពី: ពត៌ានផ្ទទល់ខលួននិងសាានភាពជីវភាពរគួសារ បញ្ញាសុខភាពផលូវចិតា ការធ្លលក់ចុោះការបំច្ពញមុខងារ និងអាកបបកិរិយាដសវងរកការពាបាល។ ការច្ឆលើយ សំណ្ួរនឹងចំណាយច្ពលរបដែលជា៦០នាទី។ ការច្ឆលើយសំណ្ួរ គឺជាការសម័រគចិតា ច្ែើយកូនរបស់ច្លាកអនកានសិទធិកនុង ការបញ្ចប់ការច្ឆលើយសំណ្ួរទំងច្នោះ ច្ៅច្ពលណាក៍បាន ច្ោយច្ែតុផលអវីក៍ បាន។ ចច្មលើយកូនរបស់អនក នឹងរតូវរកាជាការសាងត់។ របាយការណ្៍ស្រសាវរជាវ នឹងមិនបងាាញអតាសញ្ញដណ្របស់អនកច្ឆលើយសំណ្ួរ ឬចំច្ ើយជាលកេណ្:បុគគល របស់ពួកច្គ។ របសិនច្បើច្លាកអនក ានសំណ្ួរឬការរពួយបារមភណាមួយ សូមទក់ទង មកខញុំ តាមរយ:ទូរស័ពទច្លខ ០12 986 837 ឬតាមរយ:អុីដមល: khannsareth@gmail.com ។ ខញុំទនទឹងរង់ចាំការចូលរួមរបស់កូនច្លាកអនក។ អរគុណ្ ខាន់ សាច្រ៉េត ទម្រង់ជូនដំណឹងពីការយល់ម្ពររបស់ឪពុកម្តាយ សម្ម្តប់ការចូលរួររបស់កុម្តរកនុងការម្ាវម្ាវពនោះ តាមរយ:ការចុោះែតាច្លខាខាងច្រកាម នាងខញុំ/ខញុំបាទអនុញ្ញដតឲ្យកូនរបស់ខញុំ (ច្្មោះ)……… ចូលរួមកនុងការសិកាស្រសាវរជាវសាីពី “សុខភាពផលូវ ចិតាជំទង់ ច្ៅកមពុជា: ទំនាក់ទំនងរវាងបណ្ាុំច្ោគសញ្ញដវបបធម៌ជាក់លាក់ ការធ្លលក់ ទឹកចិតា ថប់បារមភ និងការធ្លលក់ចុោះននការបំច្ពញមុខងាររបចាំនថង” ដដលកំពុងច្ធវើ ច្ោយច្លាក ខាន់ សាច្រ៉េត សាស្ត្សាាចារយច្ដបា៉េតឺម៉េង់ចិតាវិទា សាកលវិទាល័យ ភូមិនទភនំច្ពញ។ ខញុំដឹងថ្ន:

QUESTIONNAIRE IN ENGLISH VERSON Letter to Parent and Parent’s Informed Consent Form

Khann Sareth, a PhD student at Vietnam National University and a lecturer in the Department of Psychology at the Royal University of Phnom Penh, is researching mental health in Cambodian adolescents His dissertation focuses on the relationship among culturally specific syndromes, depression, anxiety, PTSD, and functional impairment He invites your child to participate in a survey that gathers information on background and socio-economic status, mental health issues, functional impairment, and treatment-seeking behaviors.