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 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
Tables


Page

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

Page

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 10th
World 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 1213% 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
1


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
2


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, bidirectional, 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.
3


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.
4


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).

5


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 ( 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 ( />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
6


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
7


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).
8


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
9


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: 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
10


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

11


(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 (2025%), (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
12


ever seen a mental health professional. When we look at these prevalences for helpseeking behaviors among those with mental illness, we see a large gap between
rates of mental illness and rates of seeking treatment.
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
13


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 helpseeking 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 interrelationships 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 informalindigenous 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
14


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
15


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 teacherstudent relationships and more depression and anxiety symptoms than
common children. Parent-child contacts

helped
16

to

relieve

left-behind