(Luận văn thạc sĩ) parental perceptions of child mental health symptoms, causes and responses among cambodian and its correlation with their children mental health

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 W

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

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 ITS CORRELATION WITH THEIR CHILDREN MENTAL HEALTH‖

This is to certify that the research carried out for the above titled master‘s thesis was completed by the above named candidate under my direct supervision This thesis material has not been used for any other degree I played the following part in the preparation 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: ………

ACKNOWLEDGEMENTS

This thesis could not have been completed without the help of many people who gave their support, advice, encouragement, and understanding I would like to show 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, Sous Lon, 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 Englishclasses for master‘s level psychology courses in Vietnam National University, Hanoi to Cambodian students

Additionally, I would like to express my sincerest thanks to Dr Amie Pollack and Dr Cindy J Lahar, Dr Poch Bunnak and Dr Tran Thanh Namwho are

my kind and 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 the thesis could not have been done properly

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

Finally, I cannot forget to say thanks to my classmates who provided warm learning environment as well as Vietnamese and Cambodian friends who frequently pushed 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 33 Figure 2: Level of education for fathers 34 Figure 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 and societies around the world Given a nurturing environment, children have the opportunity to grow into successful and productive members of society Raising children to be physically and mentally healthy requires much effort and serious care from parents or caregivers Mental health problems in children are a crucial influence on child development Understanding the symptoms and causes of mental health problems will help parents effectively support their children and promote

their 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 private sectors to take into account citizens‘ mental health care, children included Improving people‘s quality of life and mental health is a priority for the World Health Organization (WHO) Worldwide epidemiological data indicate that about 20% of children and adolescents suffer from mental disorders with types of disorders varying by cultural context This finding is alarming and suggests that early 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 children suffer from mental health disorders with 3% to 4% of children having significant developmental delays or mental retardation (Dom Nokteok, 2010) This finding was very similar to a study (WHO, 2007) conducted by Seven Nation Collaborative Study on children aged 0-12 in the Philippines which found that 16% of children in

the 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 health services Studies have also looked at what factors place children at risk for mental health problems Weiss and colleagues (2013) found that parental income and education play an important role as risk factors for Vietnamese child behavioral and

12-emotional problems Another evidenced-based study of Spanish National Health Survey (SNHS) with Spanish representative found a strong correlation between parental education and child mental health among 4 to 10 year olds This finding was 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 social status (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 of child mental health disorders One study demonstrated that parenting style plays a crucial role in child mental health; parents with strong interpersonal relationships with their children had children with fewer mental health problems (Bolghan-Abadi, Kimiaee & Amie, 2011) Furthermore, research has shown that family interventions that use specific parenting skills are the most effective strategy to reduce child behavioral problems (Hutching & Lane, 2005)

Research on child mental health is complicated by cultural variability in perceptions of mental health, parenting behaviors, and parent reporting styles A study of Vietnamese parents living in Australia indicates that these parents identified psychotic symptoms, disorientation, and suicidal thoughts and behavior as psychopathological for their child‘s mental illness Additionally, parents in the study believe that the most likely causes of child mental illnesses were metaphysical and supernatural, biological/chemical unrest, and traumatic experiences (McKelvey, Baldassar, Sang, & Roberts 1999) Another study (Shanley, 2008)was conducted in New Zealand to better understand multiple perspectives of parent‘s report of child mental health symptoms As a result, a parent-report measure was developed that is designed 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 between multiple biological, psychological and social factors cause children's mental health problems (Shirk, Talmi, & Olds, 2000), 2) "One disorder can result from multiple

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

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

to endorse a disease model when conceptualizing child mental health problems A disease model, which first originated in medicine, describes maladaptive functioning 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 or absent would likely endorse the disease model, negating the notion that mental health problems exist on a continuum of severity

Importantly, other literature shows that one key factor involved in parental help-seeking for child mental health services is misperceptions of child mental health symptoms or disagreement between parents regarding child mental health (Shanley, 2008) Although there is an emerging literature on perceptions of mental health disorders in Cambodia (See Chapter 2.2), there is no current literature on review 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 scientific findings relevant to child mental health, family functioning and social development

First, the study intends to further our understanding of parent‘s perceptions of child mental problem across a variety of demographic areas Additionally, it will inform key health and education professionals, including child psychotherapists, school counselors, and child-focused government offices, NGOs and social organizations working to promote child health Finally, it will help improve efforts to educate parents about mental health problems and improve their ability to seek appropriate services 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 mental

disorders This research will address the following three main questions:

1 What are the common Cambodian parental perceptions of common symptoms, causes and effective responses to child psychopathological problems?

2 What are the factors (education, socio-economic, demographic, family situation, etc) that influence the Cambodian parental perceptions of child mental 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 and

causes of child‘s mental health problems and about howparents in Cambodia commonly 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 urban

areas compared to parents from rural areas on their perceptions of child mental health

4 To explore how Cambodian parents‘ perceptions of child mental health

problems may be associated with their own child‘s mental health symptoms

1.6 Hypotheses for the study:

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

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

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

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

education, andincome will be significantly correlated with their perceptions of child mental 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 child mental health

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

problems andperception of causes of child mental health will be correlated with their 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 narrow focus for the project Therefore, the study will mainly concentrate on parents‘ perceptions of children‘s mental health and how these understandings correlate with their child‘s mental health status Additionally, the target group will be Cambodian parents of school age children who currently study in grades 1, and 2 The sample will include parents from 2 schools in an urban area (Phnom Penh) and from 2 schools in a rural area (Kampong Speu province, about 80 kms away from Phnom Penh)

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 of disease or infirmity.‖ Hence, to be healthy people need not only physical stability and social well-being, but also mental well-being and positive functioning Mental health refers to a broad array of factors relevant to the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by mental disorders (http://www.who int/topics/mental health/en/) Mental health includes emotional, psychological, and social well-being which comprises life satisfaction, self-confidence, and gives a sense of purpose and ability for daily life functioning (MoH, 2005)

According to the DSM-V (APA, 2013),―mental disorder is a syndrome characterized 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 Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.‖ The cause of psychological disorders is explained by the diathesis-stress model which explains mental illness as the result

of a combination of biological (genetic) and environmental factors.The symptoms

of mental illness can range from mild to severe resulting in corresponding levels of distress and dysfunction Individuals with untreated conditions often are unable to cope 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 common mental health disorders are anxiety, depression and substance abuse A study by

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 mental health 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 was found to be 45.5% The prevalence of any current mental disorder (within past 12 months) was 20.0%, with anxiety disorders (14.4%) the most common class of mental 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 mood disorders (42.6%), anxiety (13.8%), alcohol abuse or dependence (12.4%), mental retardation (5.3%), dementia (4.7%) and schizophrenia (4.6%) Likewise, the São Paulo Megacity Mental Health Survey—a population-based epidemiological study of psychiatric morbidity in São Paulo showed that mood, anxiety, impulse-control and substance use disorders, and suicide-related behavior were common disorders for 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 of 63,004 adults and found that the prevalence of mood disorders was 6.1%, anxiety disorders was 5.6%, substance abuse disorders was 5.9%, and psychotic disorders was 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 study conducted in India by Deswal & Pawar (2012) found that the overall lifetime prevalence 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 12 month prevalence rates) was found to be 3.18%, with depression (1.75%) found to

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‘s neighboring country; Nepal (Luitel, Jordans, Sapkota, Tol, Kohrt, Thapa & Sharma, 2013) found that among 720 adults, 27.5 % met criteria for depression, 22.9 % for anxiety, 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 countries experiencing 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 are comparable to, or lower than, other studies conducted with populations affected by conflict and with refugees

Worldwide epidemiological statistics indicate prevalence rates for child and adolescent mental disorders are about 20% and the kinds of illness can varyacross cultures It is important to suggest a very early start of psychological intervention and prevention for people About half of all lifetime mental disorders begin before the age of 14 years (Saxena, Thornicroft, Knapp & Whiteford, 2007) In 2009, the World Mental Health Survey (WMH), conducted by the WHO indicated that the total prevalence of child mental disorders is estimated to be 18.1-36.1% for anxiety, mood, externalizing, and substance abuse disorders Mental illnesses normally happen and often seriously impair individualsin every country throughout the world Most mental disorders develop in childhood-adolescence and often significantly and negatively 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 and relationship success and impacts societal and national development Mental health problems impact people‘s development and life in many ways, including thoughts, mood, behavior and life functioning Mental health also helps determine how we handle stress, relate to others, and make choices Mental health is important at every stage of life, from childhood and adolescence through adulthood (Kessler et al, 2009)

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

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

Mental health plays an important role in physical health and health-related behaviors Medical research has shown that anxiety and depression adversely affect asthma control and quality of life for asthma patients (Urrutia et al, 2012) Mental health problems also influence individual‘s body weight and sleeping preferences; two factors highly related to physical health A study looking at depressive and anxiety symptoms 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 and physical health problems, social anxiety was shown to be related to poorer smoking cessation outcomes (Buckner, Zvolensky, Jeffries & Schmidt, 2014)

Mental health problems also have a negative impact on society and national development Mental health problems account for 3 to 4% of the Gross Domestic Product(GDP) of developed countries Cost for low-income countries are much higher due to high cost, financial impact on family caretakers and losses in productivity 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 be approximately $ 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

is among the leading causes of disability and premature mortality (WHO, 2005; Mathers& Loncar, 2005; Murray & Lopez, 1997;Johnson, 2014) It is major contributors to illness and premature death rate, and is responsible for 13% of the global disease burden (Chinese Women's Research Network, 2011; Prince et al., 2007) In Nigeria, mental disorders have an enormous individual and societal financial burden; the annual individual impact of serious mental illness was US$463 and the annual societal impact was US$ 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) biological factors, such as genes or brain chemistry, (b) life stressors and experiences, such as trauma or abuse, and (c) family history of mental health problems (US Dept of Health and Human Services: http://www.mentalhealth.gov/basics/what-is-mental-health) Mental illnesses sometimes run in families, as we know that individuals who have a family member with a mental illness may be somewhat more likely to develop one‗s themselves Susceptibility may be passed on in families through genes Moreover, certain life stressors possibly trigger an illness in a person who is susceptible to mental illness, include, death or divorce, dysfunctional family life, feelings of inadequacy, low self-esteem, changing jobs or schools, social or cultural expectations, substance abuse by the person or the person's parents These negative life events and a passive coping style may increase the chance of developing anxiety, whereas protective factors such as social support and active coping may help 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, stress from school, stress about finances and money, stress from a natural disaster, or even from lack of oxygen in high altitude areas Anxiety is also associated with medical factors 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 all psychological disorders (Barlow & Durand, 2012) Studies have found a marked

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 usual arrangement where stress triggers depression but rather individuals vulnerable to depression who are placing themselves in high-risk stressful environments, such as difficult 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 than external factors for negative events, were more likely than those who did not to become 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-related information Health literacy is defined as an individual‘s health–related understanding and ability to apply this understanding to their health care or that of other individuals (Kuras, 2011) Understanding health problems helps people to understand linkages between symptoms, causes and treatments of chronic diseases Mental health is an important aspect of overall health ―There is no Health without Mental 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‘s mental health care, children included Similarly to physical health understanding, mental health literacy refers to knowledge and perception about mental illness that people appropriately recognize symptoms, manage and recommend suitable interventions (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 developmental process of disorders, (c) knowledge of help-seeking options and treatment services available, (d) knowledge of effective self-help strategies for milder problems, and

(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 could not correctly recognize specific different type of mental disorders In general, lay people normally differ from mental health professionals in their beliefs about the causes 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 developing and developed countries on mental health literacy have found that there

is poor understanding of mental health by the public A study in Ethiopia (Mesfin & Samuel, 1999) found that people identified four main causes of mental health problems 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 most important causes Another study (Nan Zang, Teraza, & Hao, 2007) investigated the knowledge

of Chinese and Vietnamese American immigrants in the US The results indicated a variety of beliefs about the causes of mental health problems, including (a) stressful circumstances in person‘s life (10-15%), (b) genetic or inherited problems (20-25%), (c) personality (e.g ―tendency to drill into things‖), (d) life style (5-10%), and (e) consequences of misdeeds in one‘s previous lives (karma)

However, there also are individuals who appropriately identify symptoms and causes of mental health A study of adult community members in Vietnam (Van, 2011) indicated that the most commonly identified symptoms of mental health problems were talking/laughing alone (90.5%), wandering (89.9%), loss of memory (82.5%) and imagining things (70.4%) The mostcommonly identified causes of mental 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 among individuals with a diagnosable mental illness, 24% were moderately or severely disabled by their illness, 8% had ever sought professional help, and only 5% had

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 between rates of mental illness and rates of seeking treatment

help-However, this treatment gap also exists in the US and Europe In European countries, patients prefer seeking help from complementary and alternative medicine therapists and religious advisers for psychological problems, while mental health professionals are not frequently consulted In the European study of the Epidemiology of Mental Disorders (ESEMeD) (Sevilla-Dedieu, Kovess-Masféty, Haro, Fernández, Vilagut & Alonso, 2010) indicates that, among 2928 respondents who already sought help in their lifetime for psychological problems (20.0%), 8.6% turned to complementary and alternative medicine providers, such as chiropractors and herbalists, and a similar proportion (8.4%) to religious advisers such as ministers, priests, or rabbis Only a small proportion (2.9%) consulted anymental health 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) This theory emphasizes conscious thought over unconscious determinants of behavior Social-Cognitive Theory (SCT) has demonstrated that beliefs have the power to significantly influence behavior More specifically, beliefs shape a person's attitudes, attitudes lead an individual to create intentions, and these intentions often determine an individual's behavior (Bandura, 2012) Supportively, Skogstad, Deane,

& Spicer (2006) found that inNew Zealand prisoners,social-cognitive factors predicted intentions to seek help for prison-specific issues, such as relative reluctance to seek help when suicidal and reluctance to seek help from prison psychologists Theory of Plan Behavior variables predicted help-seeking intentions for suicidal and personal emotional problems Those with prior contact with prison psychologists had lower intentions to seek help for suicidal feelings than prisoners without such contact Moreover, lack of social cognitive understanding contributes

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

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 numerous factors, like one‘s lack of understanding of health issues, exposures to more traditional 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 vary across cultures A study of depression among African American elders (Conner, 2009) found that the stigma of having a mental problem can influence help-seeking perceptions and behavior, and that perceptions of help-seeking are related to help-seeking behaviors Negative attitudes towards treatment were associated with participants‘ treatment seeking attitudes and behaviors (Conner et al, 2010) Barksdale (2008) also found that African Americans do not seek psychological help from formal sources, such as psychologists or psychiatrists

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

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

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

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

of mental health and help-seeking behaviors were influenced by a lack of knowledge and a mixture of traditional and modern views Lack of knowledge

of mental disorders and stigmatizing attitudes are important barriers to effective help-seeking (Jorm, Blewitt, Griffiths, Kitchener, & Parslow, 2005) Additionally, a recent study (Loo & Furnham, 2013) investigated depression literacy by using a vignette-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 frequently endorsed 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 of mental health, including symptom presentation and causation, parenting behaviors, and parent reporting styles Parents inherently have an intimate interpersonal relationship 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, studies indicate 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 in child mental health They reported that parents with intimate interpersonal relationships with their children had children with fewer mental health problems The significant positive relation between the permissive style and the quality of life

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

Studies show that children whose parents experience stress, hardships and mental health problems are at increased risk for developing mental health problems themselves Parental experiences of discrimination, traumatic experience or violence and mental health may contribute to child mental health concerns, thus highlighting 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) demonstrate that children of parents with depression were approximately twice as likely as children 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 abuse problems are at great risk of problems affecting the development of the fetus and the central nervous system of the child These prenatal problems can continue to impact the child‘s development through the stages of toddler, small child, and later in childhood (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 for child mental health; left-behind children demonstrated less harmonious teacher-student relationships and more depression and anxiety symptoms than common children Parent-child contacts helped to relieve left-behind

children'sdepression and anxiety symptoms indirectly through its effects on reducing the disharmony of left-behind children's relationships with teachers.Lucas, Nicholson& Erbas (2013) reported that children of separated parents consistently showgreater 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 parenting practices Among children from separated families, the strongest predictor of child mental health is maternal parenting consistency

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

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

through parental emotional well-being and parenting practices, whereas maternal education level was associated with externalizing problems through negative discipline Internalizing problems were directly associated with family economy and indirectly associated with parental emotional well-being and parenting Sonego, Llácer, Galán & Simón (2013) found a strong association between parental education and parent-reported child mental health, among 4 to 11 years olds, and that this relationship is stronger than the relationship between child mental health and family income and social class Parental education was found to be the strongest risk factor for parent-reported child mental health problems, for the lowest educational level, but no association was found among 12- to 15-year-olds Male sex, immigrant status, activity limitation, parent‘s poor mental health, low social support, poor family function, single-parent families, low family income and social class were associated with parent-reported child mental health problems in both age groups An investigation of the mental health relationships between grandparents, parents and children (Moe, Siqveland, & Slinning, 2011) showed that mental health histories of both parents and grandparents play an important role in the social and emotional well-being of young children Children have greater mental health distress if their mother or father has a mental health problem For children aged 8–9 years, a history of mental health problems in maternal grandmothers and grandfathers was associated with higher SDQ scores in grandchildren, after controlling for maternal and paternal mental health and other family characteristics For children aged 4–5 years, only a mental health history in paternal grandfathers was associated with higher SDQ scores

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

affect and satisfaction with support Significant negative associations between hope and 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 mental health and may contribute to the development and recovery of internalizing and externalizing problems in children Parenting programs are effective in increasing the security of infant children‘s attachments, reducing conduct problems/antisocial behavior in childhood, and they can be effective at a population level in preventing abuse (Scott, 2012) Understanding parent appraisals of child behavior problems and parental help-seeking can reduce unmet mental health needs A literature review by Jorm (1999) found that most people, including parents, are unable to recognize specific different type of mental disorders and generally differ from mental health professionals in their beliefs about causation of psychopathological disorders and the most effective interventions In general, mental health information that is accessed by the public is misunderstood Research (Van, 2011; Jorm, 2011; Kermode, 2010) in developing and developed countries on mental health literacy has 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 care services Godoy, Mian, Eisenhower, & Carter (2014) found that child emotional, behavioral, dysregulation problems, language delay, and parents‘ concerns about child behavior depend on how the parent appraises the childbehavior.Stress and depression 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 that parental resources and perceptions of the stressor are significant predictors of parental involvement Treatment acceptability

is partially mediatedby parental problem perceptions and seeking mental health

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

help-Macaluso (2006) found that educational level and attitudes about mental health play a potentially important role in how parents perceive mental health problems in children and their help-seeking patterns Positive attitudes about mental health services predicted identification of mental health problems in children and seeking out mental health services for Major Depressive Disorder and ADHD, but not for Oppositional Defiant Disorder (ODD) and Separation Anxiety Disorder (SAD) Higher levels of education are associated with the identification

of mental health problems in children and seeking out help for all the disorders, except for MDD, but not preferring mental health specialists Pineda (2014) studied the mental health literacy of Latino mothers and found that maternal acculturation is not linked to identification of disorders, but to more symptoms recognize for child internalizing and externalizing symptoms and project the use of formal source of care for child mental disorder A study of factors associated with child mental health service use in community (Verhulst &van, 1997) indicates that the factors associatedmostly strongly with service need and utilization are the child's problem behaviors (both internalizing and externalizing), academic problems, and family stress Parental psychopathology, life events, and family psychopathology lower the parents' threshold for evaluating the child's behavior as problematic, but

do not increase the likelihood of referral

Child‘s level of impairment, parental concern, and child's difficulty in performing schoolwork are the three main predictors for use of mental health services In the classification models of sector of care, mental health versus school setting 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 and colleagues (2010) found that mental health care appointment systems were a key barrier, as parents think that short appointments insufficiently address their child‘s difficulties Continuity of care and trusting relationships with general practitioners who validated their concerns are perceived to facilitate help-

seeking Barriers to seeking help included embarrassment, stigma of mental health problems, and concerns about being labeled or receiving a diagnosis Some parents are concerned about being judged a poor parent and their child being removed from the 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, physical exercise, and relaxation), and perception of barriers to treatment are likely to

be a moderate problem in attempts to obtain care Psychotherapy was also rated favorably; however, use of psychiatric medication was rated largely unfavorable along with other injective strategies (e.g., drinking alcohol, taking alternative medicine) Approval of psychotherapy was associated with past obtainment of such services, lower levels of stigma, and more positive help-seeking attitudes Preston (2011) indicated that after children receive clinical treatment for mental problems, parents report improvements in the 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 problems have a high probability of seeking help, referring their children for mental health services and obtaining mental health treatment for their children more than parents of preschoolers with internalizing problems However, parents of preschoolers with behavior problems are also more likely to have perceived barriers

to mental health treatment than parents of preschoolers without behavior problems, including that they 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 to significantly effect parents' expectations of treatment outcome, which changes

in mental 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

will lead to improved parent-professional collaboration and other system factors (Norton, 1998) Mak (2011) demonstrates that symptoms of child anxiety and parental efficacy are related to the amount of information parents received The development of materials and decision aids to facilitate parents' informed decision-making will assist service providers in communicating with parents and families more 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 situation regarding mental health Countless psychosocial problems such as poverty, child abuse, sexual exploitation, domestic violence, trafficking, gambling, and alcohol dependence 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 psychiatric symptoms 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 Posttraumatic symptoms of intrusion and avoidance were present in 47.8% and 45.4% of the sample, respectively When reviewing comorbidities, 29.2% have depression and anxiety symptoms, 16.5% anxiety symptoms, 6.1% depression and 7.1% have triple comorbidity (PTSD, depression and anxiety) Regarding social functioning, 25.3% report being socially impaired Respondents with comorbid symptoms for depression, anxiety and PTSD are associated with an increased risk for social impairment 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 a high prevalence of suicide attempts, PTSD, anxiety and depression in the Cambodian population In this study, 27.4 and 16.7% of respondents reported Anxiety and Depression respectively, and 2.7% experienced symptoms of PTSD

In addition, probable schizophrenic disorders are estimated at 0.6% for males and 0.2% for the female population The most common depressive symptoms are worrying, difficulty sleeping and low energy However, only 24.1% of the respondents seek help for their mental health problems Of those, 62.3% had approached 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 nationwide population-based epidemiological studies officially published on psychiatric problems among children in Cambodia; most research has focused on adult mental health, especially trauma-related problems A door-to-door survey conducted in rural 15 villages of Kandal province among 1741 school-going children, using the parent-report SDQ, found that on SDQ-parent version, primary caregivers report 13% of their children having problems and the SDQ-teacher version shows 20% In addition, 21.8% of parents report that their child appears ―backward or slow to learn‖ as compared with other children the same age (Center for Child and Adolescent 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 disorders including autism accounted for 60% (Center for Child and Adolescent Mental Health, 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 of mental disorders for Cambodians Khmer cultural explanations (traditional and moral beliefs) for mental health is rooted in four basic traditional practices rather than 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) demonstrated that for Cambodian Buddhism, which reinforces power and credibility, spirits

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

information about, and solutions to, the problems they are facing The medium's practices 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 which psychotherapists play in contemporary Western society Fuderich (2008) also found that family cohesion, positive childhood memories, supportive recovery environment, stubborn determination to overcome obstacles, and Buddhist values are important factors that work together to produce resiliency The Buddhist values

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

The pattern of treatment seeking in Cambodia generally starts with reliance on individual 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 the body), (f) ―cupping‖ (suction is created on the skin to mobilizes blood flow in order

to promote healing), (g) herbal remedies, (h) alcohol/drug use, and (i) gambling If these methods do not bring relief, Cambodians often seek the assistance of monks, traditional healers (kru khmer), or a medium or fortune teller to alleviate their symptoms through meditative prayer, blessing ceremonies or communication with ancestral spirits (Bertrand, 2005; van de Put & van der Veer, 2005; van de Put & Eisenbruch, 2002) Western medicines are used when traditional approaches do not alleviate the problem Neighbors often exchange medication they have been given; otherwise a pharmacist or physician is contacted for help (Pickwell, 1999) Hinton, Kredlow, Bui, Pollack & Hofmann (2012) also found that pharmacological treatment for traumatized Cambodian refugees with PTSD was associated with improvement not only in PTSD symptoms, but also in culturally salient somatic symptoms and cultural syndromes

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

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

do not know mental health services exist

PART III- RESEARCH METHODOLOGY

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

3.1 Participants

Respondents were parents of children in grades 1 and 2 who attended elementary schools in both urban and rural settings in Cambodia The two urban schools were in the city of Phnom Penh and the 2 rural schools were in Kampong Speu province Fifty two participants were recruited from each of the four primary schools Therefore; a total of 208 potential respondents were asked to voluntarily participate in the study to describe their perception about children‘s mental health problems 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 the potential sample; 8 respondents did not successfully complete questionnaires or asked to stop in the middle of the interview 100 respondents were parents of children from 1st grade and 100 were parents of children from 2nd grade, and one hundred 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) The average 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

3.3 Data Collection and Procedures

The researcher recruited respondents at the 4 schools by sending a letter of information home to their parents with all children in grades one and two of those schools 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 to send information to parents.Parents who agree to participate were invited to the school to complete the questionnaire and participate in a group interview Completing the questionnaire took about 60 to 80 minutes If it was possible for the parents to stay longer, the researcher invited the parents to participate in a separate focus 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 questions was translated into Khmer byEnglish-Khmer bilingual members of the psychology department at the Royal University of Phnom Penh The scale was pilot tested in Khmer twice before being formally implemented The final part of the questionnaire was a quantitative parent-report measure of child mental health, the Strengths and Difficulties 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-demographic items to better understand the parents‘ and children‘s living situation (ages of mother and father, total family‘s income, profession, education of mother and father, marital status, number of children, residential area of respondents and religion) The second part of the questionnaire was a series of short vignettes describing common child mental health symptoms and asking parents why children may behave this way 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

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

3.5.Statistical Data Analysis

The data for this research article were purely primary data which was directly collected 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 investigator analyzed it by using SPSS/IBM version 20 To assess demographic information, the descriptive 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 significant differences between parental perceptions of child mental health and predictive factors such as residing in rural vs urban areas, child gender, parental education, family income, number of children and parental and child age The groupings into rural and urban areas were done to assess the possibility of different perceptions toward child mental health depending on geographic area Income and number of children were used as a grouping variable as the author expected to find different outcomes for these factors Moreover, parental education was also included as a grouping 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 the researcher better understand how predictive factors influence parents‘ perceptions

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

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

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

parent-3.6 Ethical Considerations

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

PART IV – RESULTS AND DISCUSSION

This chapter presents descriptive results, including participants‘ background characteristics 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, child gender, parental education, family‘s income, number of children and parental and child age impact parental perceptions of child mental health T-test and ANOVA analyses were conducted to understand how predictive factors influence parents‘ perceptions of symptoms and what factors may prevent parents from seeking help for children with mental health problems.Bivariate analysis of association were also conducted in order to more clearly understand the nature of the relationship between parents‘ perceptions of child mental health, and demographic and child mental health factors

4.1 Descriptive Results

Analyses of participants‘ background characteristics examined characteristics such 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 sample grouped by residential location

4.1.1 Demographic Profile of Respondents

Sixty-eight percent of the 200 respondents were female (the female proportion was higher in the both locations) Regarding marital status, Table 1 shows that 88.5% 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 both locations) Finally, results also revealed that in this sample, an overwhelming majority of the respondents were Buddhist (97.5% of the urban sample and 100% of the rural sample)

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

(N=100)

Rural (N=100)