Parental perceptions of child mental health symptoms, causes and responses among cambodian and its correlation with their children mental health

VIETNAM NATIONAL UNIVERSITY HA NOIUNIVERSITY OF EDUCATION PHAN RATHA “PARENTAL PERCEPTIONS OF CHILD MENTAL HEALTH: SYMPTOMS, CAUSES AND RESPONSES AMONG CAMBODIAN AND ITS CORRELATION WITH

VIETNAM NATIONAL UNIVERSITY HA NOI

UNIVERSITY OF EDUCATION

PHAN RATHA

“PARENTAL PERCEPTIONS OF CHILD MENTAL HEALTH: SYMPTOMS, CAUSES AND RESPONSES AMONG CAMBODIAN AND ITS CORRELATION WITH THEIR CHILDREN MENTAL HEALTH”

MASTER’S THESIS IN PSYCOLOGY

HANOI, VIETNAM: April, 2016

VIETNAM NATIONAL UNIVERSITY HA NOI

UNIVERSITY OF EDUCATION

PHAN RATHA

“PARENTAL PERCEPTIONS OF CHILD MENTAL HEALTH: SYMPTOMS, CAUSES AND RESPONSES AMONG CAMBODIAN AND ITS CORRELATION WITH THEIR CHILDREN MENTAL HEALTH”

MASTER’S THESIS IN PSYCOLOGY Major: Clinical psychology of children and adolescents

Code: Pilot

Supervisor: Dr Amie Pollack

Dr Dang Hoang Minh

HANOI, VIETNAM: April, 2016

SUPERVISOR’S RESEARCH SUPERVISION STATEMENT

TO WHOM IT MAY CONCERN

Name of program: Master’s degree of Art in ClinicalPsychology, specializing in Child and Adolescent Clinical Psychology.

Name of candidate: Phan Ratha

Title of research: ―PARENTAL PERCEPTIONS OF CHILD MENTAL HEALTH:SYMPTOMS, CAUSES AND RESPONSES AMONG CAMBODIANS AND ITSCORRELATION WITH THEIR CHILDREN MENTAL HEALTH‖

This is to certify that the research carried out for the above titled master‘s thesis wascompleted by the above named candidate under my direct supervision This thesismaterial has not been used for any other degree I played the following part in thepreparation of this thesis:

Supervisor (s)………

Date………

CANDIDATE’S STATEMENT

TO WHOM IT MAY CONCERN:

This is to certify that the thesis that I (Phan Ratha) am submitting, hereby entitled Parental Perception of Child Mental Health (Symptoms, Cause and Treatment Options) among Cambodians and its correlation with their children‘s mental health, for the degree of Master of Arts in Clinical Psychology at the University of Education, Vietnam National University-Hanoi is entirely my own work and, furthermore, that it has not been used to fulfill the requirements of any other qualification in whole or in part, at this or any other University or equivalent institution No reference to, or quotes from this document, may be made without the written approval of the author

Signed by: ………

Date: ………

Countersigned by the Chief Supervisor ………

Date: ………

Second supervisor (if any) ………

Date: ………

This thesis could not have been completed without the help of many peoplewho gave their support, advice, encouragement, and understanding I would like toshow my deepest gratitude to the following people whom I will never forget

First of all, I would like to give many thanks to my respectful mother, SousLon, and grandparents, who have always financially and emotionally supported me.Secondly, my appreciation is extended to Associate Professors Dr Bahr Weiss and

Dr Dang Hoang Minh for initiating and approving to release the first Englishclassesfor master‘s level psychology courses in Vietnam National University, Hanoi toCambodian students

Additionally, I would like to express my sincerest thanks to Dr Amie Pollackand Dr Cindy J Lahar, Dr Poch Bunnak and Dr Tran Thanh Namwho are my kindand intelligent supervisors for their advice, encouragement, and consultation so that

I would be able to successfully complete the thesis writing process from beginning

to end Without their technical support and professional guidance, constructing thethesis could not have been done properly

Furthermore, I would like to convey my thanks to lecturer Mr Sareth Khannand Mr Bunna Peoun who assisted me by frequently providing feedback to enhancethis report Moreover, my sincere thanks are delivered to all professors in themaster‘s program, who tried their best to provide me with valuable knowledge anduseful skills to conduct research and write the thesis

Finally, I cannot forget to say thanks to my classmates who provided warmlearning environment as well as Vietnamese and Cambodian friends who frequentlypushed me to focus on thesis tasks and provided a lot of feedback

TABLE OF CONTENTS

PART I - BACKGROUND 1

1.1 Background of the Study 1

1.2 Problem Statement 2

1.3 Importance of the study and policy implications 3

1.4 Purposes of the study / The Aim of Research (Research Questions): 4

1.5 Objectives of the study: 4

1.6 Hypotheses for the study: 5

1.7 Scope and Limitation 5

PART II - LITERATURE REVIEW 6

2.1 Introduction to mental health and mental disorders. 6

2.1.1 Worldwide epidemiological research regarding prevalence of mental disorders 6

2.1.2 Impact of mental health problems 8

2.1.3 Common causes of mental health problems 10

2.2 Mental Health Literacy 11

2.2.1 What is mental health literacy? 11

2.2.2 Mental health literacy regarding help-seeking behaviors 12

2.2.3 Factors influencing mental health literacy and help-seeking behavior 13

2.3 Parental influences on child mental health development and treatment 15

2.3.1 How parental factors put children at risk or help them recover from mental health problems 15

2.3.2 How parental mental health literacy affects identification, help seeking, and recovery from childhood mental health problems. 19

2.4 Cambodian Mental Health Perceptions 22

2.4.1 Rates of child and adult mental health in Cambodia 22

2.4.2 Cambodian mental health literacy and seeking-help behavior 23

PART III - RESEARCH METHODOLOGY 26

3.1 Participants 26

3.2 Sampling procedure 26

3.3 Data Collection and Procedures 27

3.4 Measurements (Scale) 27

3.5.Statistical Data Analysis 28

3.6 Ethical Considerations 29

PART IV – RESULTS AND DISCUSSION 30

4.1 Descriptive Results 30

4.2 Perceptions of the cause and consequences of specific child mental health problems 35

4.3 Health-seeking behavior for mental health issues in children 45

4.4 Analysis of parental perceptions 54

4.5 Exploratory Factor Analysis 57

4.6 Explore the factors may influence parental perceptions of child mental health 60 PART V - CONCLUSION AND FURTURE RECOMMENDATION 62

5.1 Conclusion 62

5.2 Recommendations 65

REFERENCES 67

LIST OF TABLES

Table 1 Demographics by location (percentages reported for urban versus rural) 31

Table 2 Responses to vignette of child with somatoform disorder 38

Table 3 Responses to vignette of child with separation anxiety disorder 39

Table 4 Responses to vignette of child with Attention Deficit Hyper-active Disorder (ADHD) 40 Table 5 Responses to vignette of child with tic disorder 41

Table 6 Responses to vignette of child with aggressive behavior 42

Table 7 Responses to vignette of child with depressive disorder 43

Table 8 Responses to vignette of child with Posttraumatic Stress Disorder (PTSD) 44

Table 9 Parental perception of causes of child mental health by demographic info 56

Table 10 Factorial analysis of cause of children mental health 58

Table 11.Correlations between parent perception factors, and demographic characteristics 61

LIST OF FIGURES

Figure 1 Level of education completed by mothers by residential area 33Figure 2: Level of education for fathers 34Figure 3 Household‘s income by location 35

PART I- BACKGROUND 1.1 Background of the Study

The healthy development of children is an important concern for families andsocieties around the world Given a nurturing environment, children have theopportunity to grow into successful and productive members of society Raisingchildren to be physically and mentally healthy requires much effort and serious carefrom parents or caregivers Mental health problems in children are a crucialinfluence on child development Understanding the symptoms and causes of mentalhealth problems will help parents effectively support their children and promotetheir cognitive, social and emotional development (MoH, 2005; TPO 2005)

―There is no health without mental health‖ said Ban Ki Moon on October 10thWorld Mental Health Day, 2011 This message encouraged public and privatesectors to take into account citizens‘ mental health care, children included.Improving people‘s quality of life and mental health is a priority for the WorldHealth Organization (WHO) Worldwide epidemiological data indicate that about20% of children and adolescents suffer from mental disorders with types ofdisorders varying by cultural context This finding is alarming and suggests thatearly intervention for mental health care is needed (Saxena, Thornicroft, Knapp;Whiteford, 2007) Another global study focused solely on children, conducted both

in developing and developed nations, and showed that 10% to 15% of childrensuffer from mental health disorders with 3% to 4% of children having significantdevelopmental delays or mental retardation (Dom Nokteok, 2010) This finding wasvery similar to a study (WHO, 2007) conducted by Seven Nation CollaborativeStudy on children aged 0-12 in the Philippines which found that 16% of children inthe Philippines had mental disorders

Regionally, a recent study (Weiss, Dang, & Nguyen, 2013) revealed that 13% of Vietnamese children (aged 6-16) suffer from mental health problems,indicating that 2.7 million of Vietnamese children need access to mental healthservices Studies have also looked at what factors place children at risk for mentalhealth problems Weiss and colleagues (2013) found that parental income andeducation play an important role as risk factors for Vietnamese child behavioral and

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emotional problems Another evidenced-based study of Spanish National HealthSurvey (SNHS) with Spanish representative found a strong correlation betweenparental education and child mental health among 4 to 10 year olds This findingwas not seen among children aged from 12 to 15 years olds Parental education was

a much greater risk factor for child mental health than family‘s income or socialstatus (Songego, Llacer, and Galan, 2013) Therefore, parental education appears to

be a strong risk factor for parent-reported child mental health

Parenting behavior appears to be an important factor in the development ofchild mental health disorders One study demonstrated that parenting style plays acrucial role in child mental health; parents with strong interpersonal relationshipswith their children had children with fewer mental health problems (Bolghan-Abadi,Kimiaee & Amie, 2011) Furthermore, research has shown that family interventionsthat use specific parenting skills are the most effective strategy to reduce childbehavioral problems (Hutching & Lane, 2005)

Research on child mental health is complicated by cultural variability inperceptions of mental health, parenting behaviors, and parent reporting styles Astudy of Vietnamese parents living in Australia indicates that these parents identifiedpsychotic symptoms, disorientation, and suicidal thoughts and behavior aspsychopathological for their child‘s mental illness Additionally, parents in the studybelieve that the most likely causes of child mental illnesses were metaphysical andsupernatural, biological/chemical unrest, and traumatic experiences (McKelvey,Baldassar, Sang, & Roberts 1999) Another study (Shanley, 2008)was conducted inNew Zealand to better understand multiple perspectives of parent‘s report of childmental health symptoms As a result, a parent-report measure was developed that isdesigned to be consistent with the cultural setting

1.2.Problem Statement

Professionals and experts have a deep understanding of the causal,developmental and maintaining factors of children's mental health problems.Research on psychopathology indicates the following: 1) the interaction betweenmultiple biological, psychological and social factors cause children's mental healthproblems (Shirk, Talmi, & Olds, 2000), 2) "One disorder can result from multiple

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pathways and one pathway can have multiple results" (Hudson, Kendall, Coles,Robin, & Webb, 2002), 3) child psychopathology can be also developed from theincrease of risk factors, especially exposure to risk factors during criticaldevelopmental periods which can accelerate the chance of developing mental healthdisorders (Shirk et al., 2000), and 4) risk and protective factors can be nonlinear, bi-directional, or reciprocal Children and their environments are not mutuallydisconnected; they constantly have reciprocal interactions and continually evolveover time (Shirk et al., 2000; Kazdin, Kraemer, Kessler, Kupfer, & Offord, 1997).

It is ambiguous whether Cambodian parents are able to understand thiscomplicated picture of the cause, development and maintaining factors of children'smental health problems The first mental health literacystudy in Australia (Jorm,Barney, Christensen; Highet, Kelly, 2006) (by using vignettes) on depression andschizophrenia indicated that many people cannot correctly describe psychiatricsymptomsfora disorder and various evidence also reveals that changing perceptionand beliefs about mental disorders will influence behavior Parents are more likely

to endorse a disease model when conceptualizing child mental health problems Adisease model, which first originated in medicine, describes maladaptivefunctioning as a syndrome that is either present or absent (Shirk et al., 2000; Sroufe,1997) For example, a parent who views their child's depression as either present orabsent would likely endorse the disease model, negating the notion that mentalhealth problems exist on a continuum of severity

Importantly, other literature shows that one key factor involved in parentalhelp-seeking for child mental health services is misperceptions of child mentalhealth symptoms or disagreement between parents regarding child mental health(Shanley, 2008) Although there is an emerging literature on perceptions of mentalhealth disorders in Cambodia (See Chapter 2.2), there is no current literature onreview of child mental health disorders yet in Cambodia Hence, scientific research

on Cambodian parental views of child mental disorders must be further explored

1.3 Importance of the study and policy implications

It is expected that this empirical study will generate many significant scientificfindings relevant to child mental health, family functioning and social development

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First, the study intends to further our understanding of parent‘s perceptions of childmental problem across a variety of demographic areas Additionally, it will informkey health and education professionals, including child psychotherapists, schoolcounselors, and child-focused government offices, NGOs and social organizationsworking to promote child health Finally, it will help improve efforts to educateparents about mental health problems and improve their ability to seek appropriateservices for children with mental health concerns.

1.4 Purposes of the study / The Aim of Research (Research Questions):

The purpose of this study is to explore parental perceptions of child mentaldisorders This research will address the following three main questions:

1. What are the common Cambodian parental perceptions of commonsymptoms, causes and effective responses to child psychopathologicalproblems?

2. What are the factors (education, socio-economic, demographic, familysituation, etc) that influence the Cambodian parental perceptions of childmental health?

3. Is there any existing association between parental perceptions of child mental disorders and their child‘s mental health?

1.5 Objectives of the study:

To specifically address the primary study research questions, the primary goals

of the study are the following:

1. Understand the general Cambodian parents‘ perceptions of symptoms andcauses of child‘s mental health problems and about howparents in Cambodiacommonly respond to children with mental health problems

2. Explore the factors that may influence Cambodian parents‘ perceptions of child mental health

3. To explore significant differences between Cambodian parents from urbanareas compared to parents from rural areas on their perceptions of childmental health

4. To explore how Cambodian parents‘ perceptions of child mental health problems may be associated with their own child‘s mental health symptoms

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1.6 Hypotheses for the study:

In response to above objectives, the author has pre-determinedly provided thefollowing hypotheses:

Hypothesis 1: A significant number of Cambodian parents will have inaccurate

beliefs regardingthe common symptoms, causes and effective responses to commonchild psychopathological problems

Hypothesis 2: Cambodian parental socio-demographic factors, including age,

education, andincome will be significantly correlated with their perceptions of childmental health symptoms, causes and appropriate parental responses

Hypothesis 3: There will be a significant difference between parents from urban

areas inCambodia compared to parents from rural areas on perceptions of childmental health

Hypothesis 4: Cambodian parents‘ reported responses to common mental health

problems andperception of causes of child mental health will be correlated withtheir own child‘s mental health

Hypothesis 5: High rates of mental health in children will be correlated

withCambodianparental demographic information

1.7 Scope and Limitation

The time frame for the study requires the author to strictly maintain a narrowfocus for the project Therefore, the study will mainly concentrate on parents‘perceptions of children‘s mental health and how these understandings correlate withtheir child‘s mental health status Additionally, the target group will be Cambodianparents of school age children who currently study in grades 1, and 2 The samplewill include parents from 2 schools in an urban area (Phnom Penh) and from 2schools in a rural area (Kampong Speu province, about 80 kms away from PhnomPenh)

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PART II-LITERATURE REVIEW 2.1 Introduction to mental health and mental disorders.

The World Health Organization (WHO) (1984) defined health to be

―complete physical, mental and social well-being and not merely the absence ofdisease or infirmity.‖ Hence, to be healthy people need not only physical stabilityand social well-being, but also mental well-being and positive functioning Mentalhealthrefers to a broad array of factors relevant to the promotion of well-being, theprevention of mental disorders, and the treatment and rehabilitation of peopleaffected by mental disorders (http://www.who int/topics/mental health/en/) Mentalhealth includes emotional, psychological, and social well-being which compriseslife satisfaction, self-confidence, and gives a sense of purpose and ability for dailylife functioning (MoH, 2005)

According to the DSM-V (APA, 2013),―mental disorder is a syndromecharacterized by clinically significant disturbance in an individual‘s cognition,emotion regulation, or behavior that reflects a dysfunction in the psychological,biological or developmental processes underlying mental functioning Mentaldisorders are usually associated with significant distress or disability in social,occupational, or other important activities.‖ The cause of psychological disorders isexplained by the diathesis-stress model which explains mental illness as the result of

a combination of biological (genetic) and environmental factors.The symptoms ofmental illness can range from mild to severe resulting in corresponding levels ofdistress and dysfunction Individuals with untreated conditions often are unable tocope well with life's daily routines and demands (http://www.medicinenet.com/mental _illness/ article htm) Untreated, mental illnesses may develop into chronic,debilitating disorders Factors such as a lack of effective services, economic stress,and stigma and discrimination, are all associated with lower rates of help-seeking(Stewart, Tsong & Phan Chan, 2010)

2.1.1 Worldwide epidemiological research regarding prevalence of mental disorders

Studies conducted in the US and Europe indicate that the most commonmental health disorders are anxiety, depression and substance abuse A study by

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Jordan, Hoge, Tobler, Wells, Dydek, & Egerton (2004) of 1837 Pentagon employees

in United State found high rates of PTSD (7.9%), depression (17.7%), panic attacks(23.1%), generalized anxiety (26.9%), and alcohol abuse (2.5%) A national mentalhealth survey in Australia and New Zealand (Slade, Johnston, Browne, Andrews &Whiteford, 2009) showed that mental disorders are common, and that comorbidity

of mental disorders is high The prevalence of any lifetime mental disorder wasfound to be 45.5% The prevalence of any current mental disorder (within past 12months) was 20.0%, with anxiety disorders (14.4%) the most common class ofmental disorder followed by affective disorders (6.2%) and substance use disorders(5.1%) Recently a study conducted in Portugal (Rabasquinho & Pereira, 2014),found prevalence rates ofmental disorders occurring between the years of 2000 and

2006 to be 32.15% The main disorders found in this sample included mooddisorders (42.6%), anxiety (13.8%), alcohol abuse or dependence (12.4%), mentalretardation (5.3%), dementia (4.7%) and schizophrenia (4.6%) Likewise, the SãoPaulo Megacity Mental Health Survey—a population-based epidemiological study

of psychiatric morbidity in São Paulo showed that mood, anxiety, impulse-controland substance use disorders, and suicide-related behavior were common disordersfor the population (Viana, Teixeira, Beraldi, & Andrade, 2009)

Mental health problems are also prevalent in Asia A study in China conducted

by Phillips, Zhang, Shi, Song, Ding, Pang & Wang (2009) examined a sample of63,004 adults and found that the prevalence of mood disorders was 6.1%, anxietydisorders was 5.6%, substance abuse disorders was 5.9%, and psychotic disorderswas 1% Mood disorders and anxiety disorders were more prevalent in women than

in men and in individuals 40 years and older than in those younger than 40 years.Alcohol use disorders were 48 times more prevalent in men than in women A studyconducted in India by Deswal & Pawar (2012) found that the overall lifetimeprevalence of mental disorders was 5.03% Among the diagnostic groups,depression (3.14%) was most prevalent followed by substance use disorder (1.39%)and panic disorder (0.86%) The prevalence of current mental disorders (past 12month prevalence rates) was found to be 3.18%, with depression (1.75%) found to

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be the most common current mental disorder, followed by substance use disorder(0.99%) and panic disorder (0.69%) An epidemiological study conducted in India‘sneighboring country; Nepal (Luitel, Jordans, Sapkota, Tol, Kohrt, Thapa & Sharma,2013) found that among 720 adults, 27.5 % met criteria for depression, 22.9 % foranxiety, and 9.6 % for PTSD.

Differences between findings from the various epidemiological studies (e.g.,high rates in the Nepal study vs low rates in the India study) may be attributable to

a number of factors Rates may be higher in low-resource countries or countriesexperiencing stress or trauma For example, in the study conducted in Nepal (Luitel

et al, 2013), the prevalence rates of depression and anxiety in the sample arecomparable to, or lower than, other studies conducted with populations affected byconflict and with refugees

Worldwide epidemiological statistics indicate prevalence rates for child andadolescent mental disorders are about 20% and the kinds of illness can varyacrosscultures It is important to suggest a very early start of psychological interventionand prevention for people About half of all lifetime mental disorders begin beforethe age of 14 years (Saxena, Thornicroft, Knapp & Whiteford, 2007) In 2009, theWorld Mental Health Survey (WMH), conducted by the WHO indicated that thetotal prevalence of child mental disorders is estimated to be 18.1-36.1% for anxiety,mood, externalizing, and substance abuse disorders Mental illnesses normallyhappen and often seriously impair individualsin every country throughout the world.Most mental disorders develop in childhood-adolescence and often significantly andnegatively impact subsequent role transitions (Kessler et al, 2009)

2.1.2 Impact of mental health problems

Mental health plays a significant role in one‘s life, family, vocational andrelationship success and impacts societal and national development Mental healthproblems impact people‘s development and life in many ways, including thoughts,mood, behavior and life functioning Mental health also helps determine how wehandle stress, relate to others, and make choices Mental health is important at everystage of life, from childhood and adolescence through adulthood (Kessler et al,2009)

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Mental health problems negatively impact on learning abilities and theeducation of individuals Aggarwal (2012) studied college students in London, andfound that mental health problems were a risk factor for poor academic performanceand social discrimination Another study looked at health and productivity instudents at Western Michigan University (Hysenbegasi, Hass & Rowland, 2005)and found that that depression was associated with a 0.49 point, or half a lettergrade, decrease in student GPA Depressed students reported a pattern of increasinginterference of depression symptoms with academic performance.

Mental health problems may also have a negative effect on parenting and lead thepatient‘s family to be dysfunctional Rutherford (2004) indicated that parents who arehighly anxious may have impaired ability to judge the situational demands and choosebehaviors that enhance their children's sense of mastery and self-confidence Theanxious parents exhibited different behaviors than non-anxious parents

Mental health plays an important role in physical health and health-relatedbehaviors Medical research has shown that anxiety and depression adversely affectasthma control and quality of life for asthma patients (Urrutia et al, 2012) Mentalhealth problems also influence individual‘s body weight and sleeping preferences; twofactors highly related to physical health A study looking at depressive and anxietysymptoms demonstrated a high association between mental health, physical health,body weight and sleeping preferences in adolescence (Pabst, Negriff, Dorn, Susman &Huang, 2009) In another study looking at the relationship between mental health andphysical health problems, social anxiety was shown to be related to poorer smokingcessation outcomes (Buckner, Zvolensky, Jeffries & Schmidt, 2014)

Mental health problems also have a negative impact on society and nationaldevelopment Mental health problems account for 3 to 4% of the Gross DomesticProduct(GDP) of developed countries Cost for low-income countries are muchhigher due to high cost, financial impact on family caretakers and losses inproductivity and it occurs in all countries in the world and cause immense suffering.The total costs of mental health disorders in the US have been estimated to beapproximately $ 1,250,000,000, 000 (one and a quarter trillion) per year (McDaid,Knapp & Raja, 2008) It additionally becomes important component of health as it

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is among the leading causes of disability and premature mortality (WHO, 2005;Mathers& Loncar, 2005; Murray & Lopez, 1997;Johnson, 2014) It is majorcontributors to illness and premature death rate, and is responsible for 13% of theglobal disease burden (Chinese Women's Research Network, 2011; Prince et al.,2007) In Nigeria, mental disorders have an enormous individual and societalfinancial burden; the annual individual impact of serious mental illness was US$463and the annual societal impact was US$ 166.2 million (Esan, Kola & Gureje, 2012).

2.1.3 Common causes of mental health problems

Many factors contribute to mental health problems, including (a) biologicalfactors, such as genes or brain chemistry, (b) life stressors and experiences, such astrauma or abuse, and (c) family history of mental health problems (US Dept ofHealth and Human Services: http://www.mentalhealth.gov/basics/what-is-mental-health) Mental illnesses sometimes run in families, as we know that individualswho have a family member with a mental illness may be somewhat more likely todevelop one‗s themselves Susceptibility may be passed on in families throughgenes Moreover, certain life stressors possibly trigger an illness in a person who issusceptible to mental illness, include, death or divorce, dysfunctional family life,feelings of inadequacy, low self-esteem, changing jobs or schools, social or culturalexpectations, substance abuse by the person or the person's parents These negativelife events and a passive coping style may increase the chance of developinganxiety, whereas protective factors such as social support and active coping mayhelp to protect against the development of anxiety symptoms (Lewis, Byrd, &Ollendick, 2011) Anxiety disorders may be caused by environmental factors such

as trauma from events such as abuse, victimization, the death of a loved one, stress

in a personal relationship, marriage, friendship, and divorce, stress at work, stressfrom school, stress about finances and money, stress from a natural disaster, or evenfrom lack of oxygen in high altitude areas Anxiety is also associated with medicalfactors such as anemia, asthma, infections, and several heart conditions (http://www.Medical newstoday.com)

Stress and trauma are among the most likely leads to the etiology of allpsychological disorders (Barlow & Durand, 2012) Studies have found a marked

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association between severe and traumatic life events and the start of depression(Mazure, 1998) Kendler, Karkowski, and Prescott (1999) reported that ―one third

of the relationship between stressful life events and depression is not the usualarrangement where stress triggers depression but rather individuals vulnerable todepression who are placing themselves in high-risk stressful environments, such asdifficult relationships or other risky situations where bad outcomes are common.‖Cognitive factors can also place people at risk for psychological disorders.People who consistently attribute negative events to their own qualities—called an

internal attributional style—are more likely to become depressed (Rosenberg &

Kosslyn, 2011) College students, who tended to blame themselves, rather thanexternal factors for negative events, were more likely than those who did not tobecome depressed after receiving a bad grade (Metalsky, Joiner, Hardin, &Abramson, 1993)

2.2 Mental Health Literacy

2.2.1 What is mental health literacy?

In order to be healthy, people have to be knowledgeable about health-relatedinformation Health literacy is defined as an individual‘s health–relatedunderstanding and ability to apply this understanding to their health care or that ofother individuals (Kuras, 2011) Understanding health problems helps people tounderstand linkages between symptoms, causes and treatments of chronic diseases.Mental health is an important aspect of overall health ―There is no Health withoutMental Health‖ said Ban Ki Moon on October 10th World Mental Health Day, 2011.This message encouraged public and private sectors to take into account citizen‘smental health care, children included Similarly to physical health understanding,mental health literacy refers to knowledge and perception about mental illness thatpeople appropriately recognize symptoms, manage and recommend suitableinterventions (Ganasen, Parker, Hugo, Stein, Emsley, & Seedat, 2008; Kuras, 2011).Mental health literacy (Jorm, 2011) has many components, including (a)understanding of mental disorder‘s prevention, (b) recognition of the developmentalprocess of disorders, (c) knowledge of help-seeking options and treatment servicesavailable, (d) knowledge of effective self-help strategies for milder problems, and

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(e) first aid skills to support others who are developing a mental disorder or are in a mentalhealth crisis.

Previous research (Jorm, 1999) found that many members of the public couldnot correctly recognize specific different type of mental disorders In general, laypeople normally differ from mental health professionals in their beliefs about thecauses of psychological disorders and the most effective interventions Generally,much of the mental health information accessible to the public is misunderstood.Many studies (Van, 2011;Jorm, 2011;Kermode, 2010) conducted in both developingand developed countries on mental health literacy have found that there is poorunderstanding of mental health by the public A study in Ethiopia (Mesfin &Samuel, 1999) found that people identified four main causes of mental healthproblems including, (a) psychosocial stressors, (b) supernatural retribution, (c)biological ―defects‖and (d) socio-environmental causes Among these,psychosocial stressors and supernatural retribution were considered to be the mostimportant causes Another study (Nan Zang, Teraza, & Hao, 2007) investigated theknowledge of Chinese and Vietnamese American immigrants in the US The resultsindicated a variety of beliefs about the causes of mental health problems, including(a) stressful circumstances in person‘s life (10-15%), (b) genetic or inheritedproblems (20-25%), (c) personality (e.g ―tendency to drill into things‖), (d) lifestyle (5-10%), and (e) consequences of misdeeds in one‘s previous lives (karma).However, there also are individuals who appropriately identify symptoms andcauses of mental health A study of adult community members in Vietnam (Van,2011) indicated that the most commonly identified symptoms of mental healthproblems were talking/laughing alone (90.5%), wandering (89.9%), loss of memory(82.5%) and imagining things (70.4%) The mostcommonly identified causes ofmental health problems included pressure/stress, studying/ thinking too much,environmental, brain injuries, and biological/genetic factors

2.2.2 Mental health literacy regarding help-seeking behaviors

A nationwide study in China (Phillips et al, 2009) showed that amongindividuals with a diagnosable mental illness, 24% were moderately or severelydisabled by their illness, 8% had ever sought professional help, and only 5% had

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ever seen a mental health professional When we look at these prevalences for seeking behaviors among those with mental illness, we see a large gap betweenrates of mental illness and rates of seeking treatment.

help-However, this treatment gap also exists in the US and Europe In Europeancountries, patients prefer seeking help from complementary and alternativemedicine therapists and religious advisers for psychological problems, while mentalhealth professionals are not frequently consulted In the European study of theEpidemiology of Mental Disorders (ESEMeD) (Sevilla-Dedieu, Kovess-Masféty,Haro, Fernández, Vilagut & Alonso, 2010) indicates that, among 2928 respondentswho already sought help in their lifetime for psychological problems (20.0%), 8.6%turned to complementary and alternative medicine providers, such as chiropractorsand herbalists, and a similar proportion (8.4%) to religious advisers such asministers, priests, or rabbis Only a small proportion (2.9%) consulted anymentalhealth professionals for their problems

2.2.3 Factors influencing mental health literacy and help-seeking behavior.

Social-cognitive theory explains that human action results from the interaction

of three variables – environment, behavior and cognition (Bandura, 1986) Thistheory emphasizes conscious thought over unconscious determinants of behavior.Social-Cognitive Theory (SCT) has demonstrated that beliefs have the power tosignificantly influence behavior More specifically, beliefs shape a person'sattitudes, attitudes lead an individual to create intentions, and these intentions oftendetermine an individual's behavior (Bandura, 2012) Supportively, Skogstad, Deane,

& Spicer (2006) found that inNew Zealand prisoners,social-cognitive factorspredicted intentions to seek help for prison-specific issues, such as relativereluctance to seek help when suicidal and reluctance to seek help from prisonpsychologists Theory of Plan Behavior variables predicted help-seeking intentionsfor suicidal and personal emotional problems Those with prior contact with prisonpsychologists had lower intentions to seek help for suicidal feelings than prisonerswithout such contact Moreover, lack of social cognitive understanding contributes

to the development of internalizing problems in some young children.Socialcognition is strongly associated with children's positive and negative

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behavioral outcomes in early childhood Thus, there is a need for the development

of early interventions focusing on social cognitive skills in the preschool period(LaBounty, 2009)

Knowledge of mental health and help seeking are influenced by numerousfactors, like one‘s lack of understanding of health issues, exposures to moretraditional or modern views of health, education and family income (Songego,Llacer, and Galan, 2013) In many cultures, the mentally ill are said to be possessed

by evil spirits as a punishment for misbehavior and seeking-help behavior varyacross cultures A study of depression among African American elders (Conner,2009) found that the stigma of having a mental problem can influence help-seekingperceptions and behavior, and that perceptions of help-seeking are related to help-seeking behaviors Negative attitudes towards treatment were associated withparticipants‘ treatment seeking attitudes and behaviors (Conner et al, 2010).Barksdale (2008) also found that African Americans do not seek psychological helpfrom formal sources, such as psychologists or psychiatrists

Help-seeking for mental health problems is also associated with culturalfactors Wynaden (2005) found that religion is an important factor influencingindividual and family health beliefs and that in the Taiwanese culture, many peopleturned to Buddhism and Taoism for folk healing Similarly, Wang (2011) reportsthat cultural factors, insight and stigmatization, have an indirect effect on the inter-relationships on the belief of seeking help for individuals with schizophrenia Otherresearch by Aloud (2004) found that Arab-Muslim‘s favorable or unfavorableattitudes toward seeking formal mental health services is most likely to be affected

by cultural and traditional beliefs about mental health problems, knowledge andfamiliarity with formal services, perceived societal stigma, and the use of informal-indigenous resources

Within each culture, factors such as community, family, and peer norms arealso related to psychological help-seeking Socio-demographic variables like age,education and residential area shape the process of help-seeking and service use forindividuals with mental health problems (Knipscheer & Kleber, 2005) A study inVietnam by Nguyen (2000) indicated that disclosure, help-seeking preferences, and

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problem prioritizing were significant predictors of attitudes Greater willingness todisclose, greater preference for professional resources over family/communityresources, and higher priority placed on mental/emotional health concerns overother concerns were each associated with more positive help-seeking attitudes.Stigma, traditional beliefs, and cultural commitment did not appear to be significantpredictors of attitudes Another study conducted by Van, Wright, Van, Doan &Broerse (2011) suggested that medical treatment options, often in combination withfamily care, are commonly preferred treatment options for Vietnamese Perceptions

of mental health and help-seeking behaviors were influenced by a lack ofknowledge and a mixture of traditional and modern views Lack of knowledge ofmental disorders and stigmatizing attitudes are important barriers to effective help-seeking (Jorm, Blewitt, Griffiths, Kitchener, & Parslow, 2005) Additionally, arecent study (Loo & Furnham, 2013) investigated depression literacy by using avignette-identification method in a sample of urban and rural Indians in Malaysia.The results showed that urban participants were more likely than rural participants

to identify depression as a disorder and trauma and stress were most frequentlyendorsed as causal factors by both residents

2.3 Parental influences on child mental health development and treatment

2.3.1 How parental factors put children at risk or help them recover from mental health problems

Child mental health is complicated by cultural variability in perceptions ofmental health, including symptom presentation and causation, parenting behaviors,and parent reporting styles Parents inherently have an intimate interpersonalrelationship with their children; they are one main factor and play an important role

in changing their children's quality of life and mental health Importantly, studiesindicate that parental factors, including parenting behaviors, appear to be important

in the development of child mental health disorders One study by Bolghan-Abadi,Kimiaee & Amie (2011) demonstrated that parenting style plays a crucial role inchild mental health They reported that parents with intimate interpersonalrelationships with their children had children with fewer mental health problems.The significant positive relation between the permissive style and the quality of life

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of children and also between authoritative styles and mental health wererevealed.There is also a significant negative relationship between the authoritarianstyle and the quality of life A study in Vietnam (Weiss, Dang, & Nguyen, 2013)demonstrates that parental income and education play an important role as riskfactors for Vietnamese child behavioral problems, particularly ADHD, and asprotective factors for Vietnamese child emotional problems, specificallyanxiety/depression Additionally, parental marriage also functions as a protectivefactor for Vietnamese children mental health; children living with married parents‘have significantly lower rates of mental health problems than children living withsingle parents This study also found that parents who spend time talking withchildren have lower rates of mental health problems in their children.

Studies show that children whose parents experience stress, hardships andmental health problems are at increased risk for developing mental health problemsthemselves Parental experiences of discrimination, traumatic experience orviolence and mental health may contribute to child mental health concerns, thushighlighting the role of family contexts in shaping child development (Hoven et al,2009;Tran, 2014;Hisle-Gorman, Harrington, Nylund, Tercyak, Anthony, & Gorman,2015) Moreover, Olfson, Marcus, Druss, Pincus & Weissman, (2003) demonstratethat children of parents with depression were approximately twice as likely aschildren of parents without depression to have a variety of mental health problems.Parents with substance abuse problems represent both a prenatal and a postnatal risk

to a child's development Children born to women who have substance abuseproblems are at great risk of problems affecting the development of the fetus and thecentral nervous system of the child These prenatal problems can continue to impactthe child‘s development through the stages of toddler, small child, and later inchildhood (Moe, Siqveland, & Slinning, 2011)

Child-parent separation may also impact child psychological development.Pan & Liu (2010) showed that parent-child separation is a significant risk factor forchild mental health; left-behind children demonstrated less harmonious teacher-student relationships and more depression and anxiety symptoms than commonchildren Parent-child contacts helped to relieve left-behind

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children'sdepression and anxiety symptoms indirectly through its effects onreducing the disharmony of left-behind children's relationships with teachers.Lucas,Nicholson& Erbas (2013) reported that children of separated parents consistentlyshowgreater likelihood of poor mental health than children of intact families;thisdifference appears to be explained by exposure to parental conflict,socioeconomic status and parent mental health, and to a lesser extent by parentingpractices Among children from separated families, the strongest predictor of childmental health is maternal parenting consistency.

Research by Daley (2006) investigated the mental health of second-generationCambodian refugee children in United States, and found that second-generationCambodian children face multiple risk factors for mental health problems, includinglow family socioeconomic and educational adjustment, strained parent-childcommunication, and a legacy of trauma from their parents' experiences of tortureduring the Khmer Rouge regime A recent study (Laezer, 2014) systematicallyinvestigated the cultural beliefs about parenting in Cambodia and found thattraditional parenting beliefs still plays an important role in childrearing inCambodia In the sample, 98% of the grandmothers and mothers agreed with thesaying ―Strike the steel while it is hot‖ for child‘s misbehavior (which suggests thatchildren should receive corporal punishment for misbehavior), and 34% reportedthat this saying involves corporal punishment With regards to the effect ofparenting practices on mental health adjustment of children, the study found higherlevels of emotional problems, conduct problems, hyperactivity-inattention and peerproblems among parents who used corporal punishment Supportively, scientificresearch has shown that family interventions using positive parenting skills (i.e.,non-corporal punishment strategies) are most effective in reducing child behavioralproblems (Hutching & Lane, 2005)

Child mental health is also influenced by parental academic achievement andfamily income Bøe, Sivertsen, Heiervang, Goodman, Lundervold & Hysing (2014)suggest that parental emotional well-being and parenting practices are two potentialmechanisms through which low socioeconomic status is associated with childmental health problems Family economy is associated with externalizing problems

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through parental emotional well-being and parenting practices, whereas maternaleducation level was associated with externalizing problems through negativediscipline Internalizing problems were directly associated with family economy andindirectly associated with parental emotional well-being and parenting Sonego,Llácer, Galán & Simón (2013) found a strong association between parentaleducation and parent-reported child mental health, among 4 to 11 years olds, andthat this relationship is stronger than the relationship between child mental healthand family income and social class Parental education was found to be the strongestrisk factor for parent-reported child mental health problems, for the lowesteducational level, but no association was found among 12- to 15-year-olds Malesex, immigrant status, activity limitation, parent‘s poor mental health, low socialsupport, poor family function, single-parent families, low family income and socialclass were associated with parent-reported child mental health problems in both agegroups An investigation of the mental health relationships between grandparents,parents and children (Moe, Siqveland, & Slinning, 2011) showed that mental healthhistories of both parents and grandparents play an important role in the social andemotional well-being of young children Children have greater mental healthdistress if their mother or father has a mental health problem For children aged 8–9years, a history of mental health problems in maternal grandmothers andgrandfathers was associated with higher SDQ scores in grandchildren, aftercontrolling for maternal and paternal mental health and other family characteristics.For children aged 4–5 years, only a mental health history in paternal grandfatherswas associated with higher SDQ scores.

Parental factors also serve as recovery and protective factors for child mentalhealth, which changes in mental health services, such as increased collaboration,lead to increased efficacy, mediates high expected treatment outcomes for child andfamily It predicts the opposite that training parents in efficacy and providing systeminformation will lead to increased parent-professional collaboration and othersystem factors (Norton, 1998) A study (Monsson, 2011) ofparents of children withautism spectrum disorder indicates that there are significant positive relationshipsbetween parents' hope for their child, and positive

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affect and satisfaction with support Significant negative associations between hopeand autism severity, chronic sorrow, anxiety, and depression werealso revealed.Additionally, results suggests that parents' hope for their child is an important factor

in positive coping in parents of children with autism

2.3.2 How parental mental health literacy affects identification, help seeking, and recovery from childhood mental health problems.

Parental knowledge of mental health significantly influences children‘s mentalhealth and may contribute to the development and recovery of internalizing andexternalizing problems in children Parenting programs are effective in increasingthe security of infant children‘s attachments, reducing conduct problems/antisocialbehavior in childhood, and they can be effective at a population level in preventingabuse (Scott, 2012) Understanding parent appraisals of child behavior problemsand parental help-seeking can reduce unmet mental health needs A literature review

by Jorm (1999) found that most people, including parents, are unable to recognizespecific different type of mental disorders and generally differ from mental healthprofessionals in their beliefs about causation of psychopathological disorders andthe most effective interventions In general, mental health information that isaccessed by the public is misunderstood Research (Van, 2011; Jorm, 2011;Kermode, 2010) in developing and developed countries on mental health literacyhas found that there is poor understanding of mental health by the general public.When we look at the prevalence of help-seeking behaviorsamong the mentally ill,there is a large gap between rates of disorder and rates of seeking appropriate careservices Godoy, Mian, Eisenhower, & Carter (2014) found that child emotional,behavioral, dysregulation problems, language delay, and parents‘ concerns aboutchild behavior depend on how the parent appraises the childbehavior.Stress anddepression in the parent are positively correlated with parent appraisal (and help-seeking) and significantly associated with parent thoughts about seeking help,which was significantly associated with service receipt Wilson (2000) suggests thatparental resources and perceptions of the stressor are significant predictors ofparental involvement Treatment acceptability is partially mediatedby parentalproblem perceptions and seeking mental health

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services In addition, parental characteristics also contribute to differential seeking decisions (Hankinson, 2011).

help-Macaluso (2006) found that educational level and attitudes about mental healthplay a potentially important role in how parents perceive mental health problems inchildren and their help-seeking patterns Positive attitudes

about mental health services predicted identification of mental health problems inchildren and seeking out mental health services for Major Depressive Disorder andADHD, but not for Oppositional Defiant Disorder (ODD) and Separation AnxietyDisorder (SAD) Higher levels of education are associated with the identification ofmental health problems in children and seeking out help for all the disorders, exceptfor MDD, but not preferring mental health specialists Pineda (2014) studied themental health literacy of Latino mothers and found that maternal acculturation is notlinked to identification of disorders, but to more symptoms recognize for childinternalizing and externalizing symptoms and project the use of formal source ofcare for child mental disorder A study of factors associated with child mental healthservice use in community (Verhulst &van, 1997) indicates that the factorsassociatedmostly strongly with service need and utilization are the child's problembehaviors (both internalizing and externalizing), academic problems, and familystress Parental psychopathology, life events, and family psychopathology lower theparents' threshold for evaluating the child's behavior as problematic, but do notincrease the likelihood of referral

Child‘s level of impairment, parental concern, and child's difficulty inperforming schoolwork are the three main predictors for use of mental healthservices In the classification models of sector of care, mental health versus schoolsetting was identified as a significant predictor for any disruptive disorder diagnosis.Helping parents link a child's impairment with a need for mental health care might

be a mechanism to reduce children's unmet need (Alegria et al, 2004) Sayal andcolleagues (2010) found that mental health care appointment systems were a keybarrier, as parents think that short appointments insufficiently address their child‘sdifficulties Continuity of care and trusting relationships with general practitionerswho validated their concerns are perceived to facilitate help-

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seeking Barriers to seeking help included embarrassment, stigma of mental healthproblems, and concerns about being labeled or receiving a diagnosis Some parentsare concerned about being judged a poor parent and their child being removed fromthe family should they seek help.

Selles and colleagues (2015) suggest that positive mental health attitudes (i.e.,low stigma, positive help-seeking attitudes and intentions), high approval for self-reliant methods of treating mental health problems (e.g., pull oneself together, physicalexercise, and relaxation), and perception of barriers to treatment are likely to be amoderate problem in attempts to obtain care Psychotherapy was also rated favorably;however, use of psychiatric medication was rated largely unfavorable along with otherinjective strategies (e.g., drinking alcohol, taking alternative medicine) Approval ofpsychotherapy was associated with past obtainment of such services, lower levels ofstigma, and more positive help-seeking attitudes Preston (2011) indicated that afterchildren receive clinical treatment for mental problems, parents report improvements inthe parent-child relationship, levels of support, satisfaction with parenting,involvement, positive communication, and limit setting in the parent-child relationship,compared to before the child participated in treatment

Ottaway (2001) found that parents of preschoolers with behavioral problemshave a high probability of seeking help, referring their children for mental healthservices and obtaining mental health treatment for their children more than parents

of preschoolers with internalizing problems However, parents of preschoolers withbehavior problems are also more likely to have perceived barriers to mental healthtreatment than parents of preschoolers without behavior problems, including thatthey feel they can solve the problem on their own, that the problem would go away

on its own, and that other family members do not believe the child has a problem

Parent-professional collaboration nor accessibility of information is found tosignificantly effect parents' expectations of treatment outcome, which changes inmental health services, such as increase collaboration, lead to increase efficacy,mediates high expected treatment outcomes for child and family Importantly,training parents in effective parenting practices and providing system information

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will lead to improved parent-professional collaboration and other system factors(Norton, 1998) Mak (2011) demonstrates that symptoms of child anxiety andparental efficacy are related to the amount of information parents received Thedevelopment of materials and decision aids to facilitate parents' informed decision-making will assist service providers in communicating with parents and familiesmore effectively, supporting informed decision-making, and strengthening family-centered care.

2.4 Cambodian Mental Health Perceptions

2.4.1 Rates of child and adult mental health in Cambodia

Cambodia is dealing with an exceptionally challenging and specific situationregarding mental health Countless psychosocial problems such as poverty, childabuse, sexual exploitation, domestic violence, trafficking, gambling, and alcoholdependence pose serious problems for Cambodia, including mental health(Somasundaram and van de Put, 1999; MoH, 2005) A study by Dubois, Tonglet,Hoyois, Sunbaunat, Roussaux & Hauff (2004) on prevalence of psychiatricsymptoms in the Kampong Cham province revealed that 42.4% of participants

reported symptoms that met the Diagnostic and Statistical Manual of Mental

Disorders, 4th edition criteria for depression, 53% displayed high anxiety symptoms

and 7.3% met posttraumatic stress disorder (PTSD) criteria Posttraumaticsymptoms of intrusion and avoidance were present in 47.8% and 45.4% of thesample, respectively When reviewing comorbidities, 29.2% have depression andanxiety symptoms, 16.5% anxiety symptoms, 6.1% depression and 7.1% have triplecomorbidity (PTSD, depression and anxiety) Regarding social functioning, 25.3%report being socially impaired Respondents with comorbid symptoms fordepression, anxiety and PTSD are associated with an increased risk for socialimpairment compare with others

Additionally, the Cambodia Mental Health Survey in Cambodia (Shunert et al,2012) studied a large sample ofover 2600 adults aged 21 and above and found ahigh prevalence of suicide attempts, PTSD, anxiety and depression in theCambodian population In this study, 27.4 and 16.7% of respondents reportedAnxiety and Depression respectively, and 2.7% experienced symptoms of PTSD

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In addition, probable schizophrenic disorders are estimated at 0.6% for males and0.2% for the female population The most common depressive symptoms areworrying, difficulty sleeping and low energy However, only 24.1% of therespondents seek help for their mental health problems Of those, 62.3% hadapproached a health center, 50.7% sought help within their family, and 34.1%sought help from local pharmacies Not surprisingly, many contacted traditional,spiritual and Buddhist resources (47.7%).

In regards to child psychopathology, there have been no nationwidepopulation-based epidemiological studies officially published on psychiatricproblems among children in Cambodia; most research has focused on adult mentalhealth, especially trauma-related problems A door-to-door survey conducted inrural 15 villages of Kandal province among 1741 school-going children, using theparent-report SDQ, found that on SDQ-parent version, primary caregivers report13% of their children having problems and the SDQ-teacher version shows 20% Inaddition, 21.8% of parents report that their child appears ―backward or slow tolearn‖ as compared with other children the same age (Center for Child andAdolescent Mental Health, 1999) In 2013, Chey Chumneas Refferal Hospital,Takhmau Town, offered 7227 consultations of which neuropsychiatric problems(mainly epilepsy) accounted for 11% of consultations and developmental disordersincluding autism accounted for 60% (Center for Child and Adolescent MentalHealth, 2013)

2.4.2 Cambodian mental health literacy and seeking-help behavior

The role of culture is a major factor in both the explanation and presentation ofmental disorders for Cambodians Khmer cultural explanations (traditional andmoral beliefs) for mental health is rooted in four basic traditional practices ratherthan a single ‗physical‘ model of health, including (a) Buddhist-Hindu beliefs such

as ―Dharma‖, (b) beliefs in spirits, (c) concept of luck (astrology + fortune tellers)and (d) somatic and physiological concepts (Jacobsen, 2006; Stewart et al., 2010;Hinton, Pich, Chhean & Pollack, 2005) A study by Bertrand(2005) demonstratedthat for Cambodian Buddhism, which reinforces power and credibility, spirits called

borameï, who possess a spiritual healer medium, can provide people with

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information about, and solutions to, the problems they are facing The medium'spractices allow the person to come into contact with these supernatural entities, and

as such the medium can be viewed as performing a role not unlike that whichpsychotherapists play in contemporary Western society Fuderich (2008) also foundthat family cohesion, positive childhood memories, supportive recoveryenvironment, stubborn determination to overcome obstacles, and Buddhist valuesare important factors that work together to produce resiliency The Buddhist values

of accepting suffering as fate allowspeople to better tolerate hardships and enablesthem to face adversity with optimism and confidence

The pattern of treatment seeking in Cambodia generally starts with reliance onindividual or family coping methods, including (a) recreational activities, (b)problem solving, (c) support from loved ones, (d) drinking only warm water(traditional), (e) ―coining‖ (rubbing a coin on the upper arm or on other parts of thebody), (f) ―cupping‖ (suction is created on the skin to mobilizes blood flow inorder to promote healing), (g) herbal remedies, (h) alcohol/drug use, and (i)gambling If these methods do not bring relief, Cambodians often seek theassistance of monks, traditional healers (kru khmer), or a medium or fortune teller

to alleviate their symptoms through meditative prayer, blessing ceremonies orcommunication with ancestral spirits (Bertrand, 2005; van de Put & van der Veer,2005; van de Put & Eisenbruch, 2002) Western medicines are used when traditionalapproaches do not alleviate the problem Neighbors often exchange medication theyhave been given; otherwise a pharmacist or physician is contacted for help(Pickwell, 1999) Hinton, Kredlow, Bui, Pollack & Hofmann (2012) also found thatpharmacological treatment for traumatized Cambodian refugees with PTSD wasassociated with improvement not only in PTSD symptoms, but also in culturallysalient somatic symptoms and cultural syndromes

Inhumane treatments of individuals suffering from schizoaffective orschizophrenic disorders have been reported in many rural areas of Cambodia(Stewart et al., 2010; Ministry of Health, 2003) These include putting the affectedindividual into cages or chaining them, sometimes for months or even years (PhnomPenh Post, 2014) A study on help-seeking behavior of schizophrenic patients in

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Cambodia (Coton, Poly,Hoyois,Sophal& Dubois, 2008) indicates that traditionaland religious medicine are the first pathway to mental healthcare when patient andcaregiver decide to seek help due to psychotic symptoms Lack of knowledgeregarding mental health and related services appears to be the main factor inschizophrenic patients' help-seeking behaviors and education is the only factor thatappears to significantly influence the help-seeking behavior of the schizophrenicpatient's family members Among 104 families studied, 56.7% seek help intraditional medicine, 22.1% with western medicine, psychiatry included, and 20.2%with religious medicine 77.3% do not initially seek help from psychiatry becausethey do not know that the symptoms reflect a mental health problem or because they

do not know mental health services exist

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PART III- RESEARCH METHODOLOGY

This research used a mix-method research design with both qualitative andquantitative methods applied in this study In the qualitative design, the researcherused open-ended questions in response to brief vignettes where parents gave theirgeneral viewpoint on some problems In the quantitative design, respondentsprovided responses to closed-ended and likert-scale style questions that aimed tolearn about parental understanding of mental health issues in children

3.1 Participants

Respondents were parents of children in grades 1 and 2 who attendedelementary schools in both urban and rural settings in Cambodia The two urbanschools were in the city of Phnom Penh and the 2 rural schools were in KampongSpeu province Fifty two participants were recruited from each of the four primaryschools Therefore; a total of 208 potential respondents were asked to voluntarilyparticipate in the study to describe their perception about children‘s mental healthproblems and report on their own child‘s recent behaviors related to mental health

A total of 200 parents completed the research, which is about 96% of thepotential sample; 8 respondents did not successfully complete questionnaires orasked to stop in the middle of the interview 100 respondents were parents ofchildren from 1st grade and 100 were parents of children from 2nd grade, and onehundred parents were from a rural area and one hundred were from the urban area.Sixty-four respondents were male (32%) and 136 respondents were female,equaling 68% of total respondents The average age of mothers were 33.41 years old(sd = 6.05), while the average age of fathers was 36.47 years old (sd=6.62) Theaverage years of mothers‘ education was 6.50 years (sd=4.86), while average years

of fathers‘ education was 8.28 years (sd=5.28) The average of number of children

in a family was 2.69

3.2 Sampling procedure

Convenience Sampling was used because of permission and access to

the four elementary schools in the study

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3.3 Data Collection and Procedures

The researcher recruited respondents at the 4 schools by sending a letter ofinformation home to their parents with all children in grades one and two of thoseschools Only parents with their children enrolled in 1st and 2nd grade (early primary

school years) received the letters Prior to sending the letters, permission was

received by the school principal of each of these schools asking for permission tosend information to parents.Parents who agree to participate were invited to theschool to complete the questionnaire and participate in a group interview.Completing the questionnaire took about 60 to 80 minutes If it was possible for theparents to stay longer, the researcher invited the parents to participate in a separatefocus group or short interview

3.4 Measurements (Scale)

The open-ended questions were developed by the study author and the questions were adapted from a parent-report measure developed by Dianne C.Shanley and her colleagues in New Zealand (Shanley, 2008) This set of questionswas translated into Khmer byEnglish-Khmer bilingual members of the psychologydepartment at the Royal University of Phnom Penh The scale was pilot tested inKhmer twice before being formally implemented The final part of the questionnairewas a quantitative parent-report measure of child mental health, the Strengths andDifficulties Questionnaire, SDQ (Goodman, 2005) The author received this scale in

closed-both English and Khmer as it has been used in previous research in Cambodia The

English and Khmer assessmets are attached in Appendix A and B.

Initially, parents completed a questionnaire that included socio-demographicitems to better understand the parents‘ and children‘s living situation (ages ofmother and father, total family‘s income, profession, education of mother and father,marital status, number of children, residential area of respondents and religion) Thesecond part of the questionnaire was a series of short vignettes describing commonchild mental health symptoms and asking parents why children may behave thisway and what parents should do in each situation

The third part of the questionnaire was adapted from Shanley‘s (2008)measure of parents‘ perceptions of cause of psychopathological disorder This scale

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has 58 items which describe 12 factors including biological, physical, motivational,emotional regulation, cognitive, social, stressful life event, trauma, parents, parent‘sthemselves and community factors The fourth part of the assessment is the parent-report Strength and Difficulty Questionnaire, SDQ (Goodman, 2005) for childrenaged 4-10 years old This measure is designed to assess child mental health; it iscomprised of 25 items where 5 items describe child strengths and 20 items concernchild mental health difficulties.

3.5.Statistical Data Analysis

The data for this research article were purely primary data which was directlycollected by the researcher from actual 200 parents of children enrolled in 1st and

2nd grade, aged from 4-12 years old during fieldwork Statistically, the investigatoranalyzed it by using SPSS/IBM version 20 To assess demographic information, thedescriptive statistics for data‘s characteristic was elaborated, including frequency(f), mean (X), variance, and standard deviations (sd) T-tests (Independent Sample t-test) and Analysis of Variance (One-way ANOVA) were used to see the significantdifferences between parental perceptions of child mental health and predictivefactors such as residing in rural vs urban areas, child gender, parental education,family income, number of children and parental and child age The groupings intorural and urban areas were done to assess the possibility of different perceptionstoward child mental health depending on geographic area Income and number ofchildren were used as a grouping variable as the author expected to find differentoutcomes for these factors Moreover, parental education was also included as agrouping variable as many studies have found that education played important role

in predicting their child‘s mental health T-test and ANOVA analyses can help theresearcher better understand how predictive factors influence parents‘ perceptions

of symptoms and what factors may prevent parents from seeking help formaladaptive children

Exploratory Factor Analysis was used to reduce the parental perceptionvariables Bivariate Correlational Analysis (Pearson r) was used to analyze therelationships among variables such as the association (including direction andstrength) between parents‘ perceptions of child mental health symptoms and causes

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with the demographic profile and current child mental health, and the SDQ report which divided into five subscales (hyperactive, behavioral, emotional, socialand peer problem) Moreover, the statistical significantly levels were also integratedinto analysis‘s examination.

parent-3.6 Ethical Considerations

In order to conduct this project in an ethical and responsible manner, theresearcher (author) first wrote a letter of information to briefly inform parents aboutthe project which was sent home from the school to their children The parents whoattended the data collection session were then provided with detailed informationabout the project prior to data collection and provided voluntary consent toparticipate Parents were clearly told that they have a choice to participate and thatchoosing not to participate will not have any negative impact on themselves or theirchildren Importantly, the data and the name of all participants in the study were notused for any other purposes, besides the study‘s objectives, and will never bedisclosed to anyone outside of the study

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PART IV – RESULTS AND DISCUSSION

This chapter presents descriptive results, including participants‘ backgroundcharacteristics of gender, age, marital status, education, occupation, family position,and economic situation, number of children, location, and region Additionally,analyses investigated how factors such as residing in rural vs urban areas, childgender, parental education, family‘s income, number of children and parental andchild age impact parental perceptions of child mental health T-test and ANOVAanalyses were conducted to understand how predictive factors influence parents‘perceptions of symptoms and what factors may prevent parents from seeking helpfor children with mental health problems.Bivariate analysis of association were alsoconducted in order to more clearly understand the nature of the relationship betweenparents‘ perceptions of child mental health, and demographic and child mentalhealth factors

4.1 Descriptive Results

Analyses of participants‘ background characteristics examined characteristicssuch as age, gender, number of children in family, marital status, education,occupation, landholding status and economic status, by residential location (urban/rural) Table 1 includes many of the background characteristics of the samplegrouped by residential location

4.1.1 Demographic Profile of Respondents

Sixty-eight percent of the 200 respondents were female (the female proportionwas higher in the both locations) Regarding marital status, Table 1 shows that88.5% of respondents were married (90% of urban versus 87% of rural population),4.5% (3% of urban versus 6% of rural respondents) were widows or widower, and 7

% of all respondents were divorced (7% of urban versus 7% of rural population).88.5% of respondents were married (the married proportion was higher in the bothlocations) Finally, results also revealed that in this sample, an overwhelmingmajority of the respondents were Buddhist (97.5% of the urban sample and 100% ofthe rural sample)

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Table1 Demographics by location (percentages reported for urban versus rural) Variables