Local clinician perspectives on cause,impact,and treatment of key expressions of distress in Cambodian children

Abstract

Child trauma and posttraumatic stress in Cambodia is highly prevalent, perpetuated within a postwar sociocultural context. The examination of locally meaningful expressions of distress is needed to provide culturally sensitive assessment and treatment of trauma-affected Cambodian children. The acceptable, feasible, and sustainable incorporation of expressions of distress into assessment and intervention development relies on key mental health professionals operating in Cambodia, who can provide invaluable perspectives on child trauma experiences in this particular sociocultural context. In this study, qualitative interviews were conducted with 15 Cambodian mental health professionals (MHPs) who work directly with trauma-affected Cambodian children. MHPs were presented with seven key posttraumatic problems derived from previous qualitative interviews with Cambodian children and caregivers, and discussed 1) the causes of these problems, 2) the impact of the problem on the child or those around them, 3) the current treatment for the problem in Cambodia, and 4) recommended treatment. MHPs provided unique insights and perspectives of trauma-affected children in the Cambodian context regarding key target problems, including palpitations, difficulties in school, headache, and thinking too much, and highlighted future directions for assessment and intervention. Recommendations are discussed in regard to programming design and organizational training development to promote culturally salient, feasible, and sustainable mental health service provision in Cambodia.

Keywords

Cambodia children clinicians posttraumatic stress trauma

Introduction

The Cambodian experience during and after the Khmer Rouge regime from 1975 to 1979 resulted in multiple severe risk factors for poor mental health outcomes. War, genocide, poverty, displacement, famine, torture, gender-based violence, and severance of families and social networks set the stage for pervasive physical and mental health problems across Cambodia. Studies of posttraumatic stress indicate high rates across generations. In a longitudinal national probability sample of 1,017 Cambodians, Sonis and colleagues (2009) found that 11.2% of adult Cambodians had current probable PTSD; for those who were at least three years old during the Khmer Rouge epoch, the rate of PTSD was 14.2%. Other studies indicate rates as high as 28.4% for PTSD among Khmer Rouge survivors (de Jong et al., 2001). In a comparative community survey, Mollica and colleagues (2014) noted the Cambodian population continued to suffer “psychiatric morbidity and poor health” 25 years after the Khmer Rouge regime.

Thus, Cambodia’s current youth population is being raised by generations with primary or secondary genocide experience, which urges the consideration of caregiver trauma “residue” as a contributing factor to increased exposure to potentially traumatic experiences, elevations in symptomatology, and other vulnerabilities for offspring of trauma survivors (Lambert et al., 2014). As such, Cambodian youth directly experience significant trauma, with estimates of over half of Cambodian children experiencing abuse, and over 70% a traumatic experience by age 18 (Ministry of Women’s Affairs, 2014; Schunert, 2012). Over 25% of women have reported domestic violence from their partners, which is likely an underestimate (McCue, 2008). Community violence is also prevalent; in the late 1990s, Cambodia’s homicide rate of 11.6 in every 100,000 persons was the highest rate in the region, and second worldwide only to the Philippines (Broadhurst, 2002). Direct victimization in this population is likely compounded by intergenerational trauma transmission (Lambert et al., 2014), family dynamics such as parenting practices (Field et al., 2011), poverty (Peters et al., 2008), and limited access to health and education systems (De Walque, 2006). Accordingly, Cambodian children continue to display abnormally elevated rates of posttraumatic stress, even as compared to children from neighboring countries involved in war conflicts (e.g., Thailand and Vietnam; Kinseth, 2009).

Despite the substantial impact mental health problems have on social, political, and economic systems in Cambodia, little attention and funding is provided for mental health care (it is estimated about 0.02% of Cambodia’s national health budget is allocated for mental health services; McLaughlin & Wickeri, 2012). In the mid-2000s, the Ministry of Health in Cambodia initiated the National Program for Mental Health in collaboration with health development partners, non-governmental organizations (NGOs), local authorities, and communities to address mental health and substance abuse. By 2010, there were 35 psychiatrists, 45 psychiatric nurses, 170 basic mental physicians, and 233 basic mental nurses appointed at national and provincial hospitals, and training programs implemented throughout Cambodia have increased the number of social workers and counselors at the community level (Schunert, 2012). Although a drastic improvement, the number of mental health staff remains inadequate for Cambodia’s population of approximately 16 million people. This is particularly true for rural Cambodian populations (85% of the total population), as most health providers are centralized in urban settings (Olofsson et al., 2018). Illustratively, only 10 of the 35 psychiatrists work outside of Cambodia’s capital, Phnom Penh (McLaughlin & Wickeri, 2012). Additionally, health care provision in Cambodia is often managed and implemented by private health care institutions, such as NGOs. In 2010, private health care institutions outnumbered government health care facilities by about five to one (Schunert, 2012).

Private institutions typically rely on foreign aid for funding and program development, which often leads to non-Cambodian professionals providing training, diagnostic tools, and intervention recommendations (Suárez & Marshall, 2014). In combination with a relative lack of research regarding culturally specific symptom presentations in Cambodia, many of the mental health assessments and interventions utilized with Cambodian populations were designed and validated with predominantly Western populations. Cross-cultural studies consistently indicate trauma and posttraumatic distress criteria validated in Western contexts may not accurately and comprehensively measure distress in international populations (Chhim, 2012; Cunningham & Cunningham, 1997; de Jong et al., 2001, 2005; Hinton & Good, 2016; Hinton & Lewis-Fernandez, 2011; Kohrt & Hruschka, 2010; Lewis-Fernández et al., 2010; Marsella et al., 1996; Michalopoulos et al., 2015).

Socioculturally specific expressions of distress, including linguistically marked idioms, represent culturally meaningful, shared experiences, rooted in local concepts of health and illness, that express distress in locally intelligible terms (Hinton & Lewis-Fernández, 2010; Keys et al., 2012; Kirmayer & Young, 1998). Prior idioms of distress studies conducted with Cambodians suggest somatic symptoms are an important sequalae of distress expression in this population (Hinton et al., 2013). For example, symptom presentations often attribute the experiences of arousal-reactive symptoms in anxiety-related psychological distress (e.g., heart palpitations, sweating, dizziness) to a “weak heart” (khsaoy beh doung; Hinton et al., 2002). Other examples of somatic symptom expression in Cambodian populations include dizziness, headaches, and muscle soreness among an array of other physical ailments (Hinton et al., 2013; Mollica et al., 1993).

Affective and emotional experiences associated with posttraumatic stress may lead to and perpetuate somatic symptomatology. For Southeast Asian populations, anger expression is indicated as playing a particularly important role in posttraumatic stress presentations (Abe et al., 1994; Hauff & Vaglum, 1994; Hinton et al., 2003), and is considered central to the sociocultural course of trauma-related disorders in Cambodians (Hinton, Rasmussen et al., 2009). Illustratively, in a sample of 193 Cambodian refugees in the United States, Hinton, Rasmussen et al. (2009) found that anger expression episodes resulted in multiple somatic symptoms (71% of participants experienced four or more DSM-IV panic attack somatic symptoms), catastrophic cognitions of heart arrest and neck-vessel rupture (84% and 81%, respectively), and trauma flashbacks (68%), with those with anger episodes in the previous month being about four times more likely to meet criteria for PTSD. Other idioms of distress in Cambodian populations both in Cambodia and in the United States include “thinking too much” (kit chraern; Hinton et al., 2015, 2016) and “broken courage” (baksbat; Chhim, 2012, 2013).

The examination of idioms of distress helps illuminate barriers to accurate prevalence assessments and effective client–provider communication (Hinton & Lewis-Fernandez, 2010; Keys et al., 2012), and thus hold significant clinical relevance. However, the majority of research targeting Cambodian distress expression and treatment has been conducted in adult refugee populations, and may not always directly inform mental health professionals implementing interventions in Cambodia, particularly for those working with child populations. In order to integrate local expressions of distress into assessment and treatment design in acceptable, feasible, and sustainable ways in Cambodia, it is crucial to engage local providers implementing community programs and interventions. Cambodian mental health professionals, and their key insights, are vital to the meaningful incorporation of expressions of distress research findings into practice. The importance of clinician perspectives is three-fold: (1) Cambodian clinicians provide an in-the-field view of how those assessing and implementing mental health services conceptualize the causes and impact of child problems following adverse life experiences; (2) Cambodian clinicians are in a unique position to provide recommendations for mental health treatment in Cambodia that are acceptable, feasible, and sustainable; and (3) Cambodian clinicians are particularly able to nest experiences and expressions of adverse life experiences in the Cambodian social, political, and cultural context. Clinician perspectives in prior studies have been incorporated into treatment design and adaptation by enriching conceptualizations of trauma experience and expression (e.g., Rettmann et al., 2009), identifying barriers to trauma treatment implementation and adherence (e.g., Back et al., 2009; Salyers et al., 2004), and improving navigation of contextual mental health care systems (e.g., Frueh et al., 2006).

The current study aims to investigate key distress presentations among trauma-affected children. We interviewed mental health professionals working with trauma-affected child populations in Cambodia to enrich and extend previous findings of expressions of distress in Cambodian children, according to the Design, Implementation, Monitoring, and Evaluation of mental health and psychosocial assistance programs for trauma survivors in low resource countries—Module 1 (DIME; Applied Mental Health Research (AMHR) Group, 2013). The DIME procedure was designed specifically for trauma and posttraumatic stress assessment in low-resource countries, and has been conducted in contexts comparable to Cambodia, including Haiti (Bolton et al., 2012), Aceh (Poudyal et al., 2009), and Uganda (Betancourt et al., 2009), and in other post-genocide contexts (e.g., Rwanda; Bolton, 2001).

The DIME procedure is rooted in a grounded theory approach to qualitative data collection, which aims to develop response-driven concepts that both explain and describe a social phenomenon (Morse et al., 2016). This is accomplished through the following tenets of the DIME process: (1) data collection and analyses functioning as concomitant and interrelated processes, (2) concepts reported across participants are the basic unit of analysis, (3) responses are constantly compared to each other to formulate categories, and (4) broader conditions that impact the phenomenon are integrated into the explanations of the study’s microscopic aims (Corbin & Strauss, 2015). Clinicians in the current study are in a unique position to provide key insight into the causes and impact of child-level problems, and trauma treatment recommendations. Response themes can inform assessment and intervention design and implementation in organizations in Cambodia targeting child mental health.

Methods

Participants

In collaboration with three community organizations, interviews were conducted with 15 key informants (in this case, mental health professionals working with trauma-affected children). It was important key informants were local members of the community in which the target population lives and works, not outsiders who visit the community or are living there temporarily (AMHR Group, 2013). Thus, to participate in the interviews, participants needed to be (1) a native Cambodian and (2) working in the field of mental health care of trauma-affected Cambodian children. Although held to this inclusion criteria, key informants in the current study had a range of educational and occupational experiences. Participants were recruited from the three following organizations.

The Transcultural Psychosocial Organization (TPO) Cambodia is a not-for-profit non-governmental organization (NGO) run and staffed entirely by Cambodians. Through a range of grass-roots projects, community-based structured programs, a mental health treatment center in Cambodia’s capitol city Phnom Penh, consultancy, research, and initiatives to increase mental health awareness, TPO Cambodia aims to improve the mental health of Cambodians with traumatic experiences and promote positive health policy change. Since opening in 1995, TPO Cambodia has provided mental health care and support to more than 200,000 Cambodians.

Cambodia Children’s Trust (CCT) is a community development organization with a holistic model of programs and services that enable vulnerable children in the Battambang province of Cambodia to break free from the intergenerational cycle of poverty, while promoting family preservation and reintegration. Battambang province is the fifth most populous province in Cambodia, with a population of just under one million. The province includes Battambang City, the third largest city in Cambodia, with a population of about 200,000 compared to 2.2 million in Phnom Penh (NIS, 2019). Battambang is a largely agricultural province of rice and fruit farms, known as “the rice bowl” of Cambodia.

Komar Rikreay Cambodia (KMR) provides social services to vulnerable children and their families in the Battambang province of Cambodia, including temporary transitional home and alternative care facilities, health, education, economic development support, mental health support, and advocacy for the children’s safe and sustainable community reintegration.

Interview protocol

Interview questions for the current study were in direct reference to responses from a study conducted just prior (Figge et al., in press), in which in-person interviews were conducted with 30 children with adverse life experiences and their 30 caregivers (n = 60) in the Battambang province of northwest Cambodia. Participants were caregivers of children and children who were receiving mental health services at TPO at the time of the interview to address exposure to domestic violence and other adverse events. Both caregivers and children were asked to report the most common and most severe problems in Cambodian children following adverse life experiences.

For the interviews in the current study, the two most prevalent and two most severe child-reported and caregiver-reported problems were selected, which resulted in eight reported problems. Both children and caregivers reported the same problem (easily angered, or mour mao) as most frequent, resulting in a total of seven problems presented individually to each Key Informant:

Easily angered (mour mao)—Child- and caregiver-report, frequent

Headaches (chheur kobal)—Child-report, frequent

Crying (yom)—Caregiver-report, frequent

Fearfulness (phay klach)—Caregiver-report, severe

Rapid heart rate (beh-dong doeu nyaob)—Caregiver-report, severe

Difficulties with comprehension/learning in school (rien men ches)—Child-report, severe

Poor sleep (Dek men sov lok)—Child-report, severe

For each problem listed above, the following four questions were asked to Key Informants (for a total of 28 questions to each participant):

“What are the causes of [problem x]?”

“What are the effects of [problem x] on the individual and those around them?”

“How is [problem x] usually treated in Cambodia?”

“What should be done to treat [problem x]?”

Responses were elicited with minimal follow-up questions to allow for participant-driven, in-depth explorations of these domains. Following administration of interview questions, participants completed a brief demographic questionnaire.

All interviews were conducted by the principal investigator with an on-the-spot translator to allow for all participant responses to be in Khmer. The same interviewer and translator were used for all interviews, and the translator underwent a two-day training procedure according to the DIME procedure, Institutional Review Board (IRB) Human Subjects training, and qualitative interviewing techniques, and conducted two pilot training interviews prior to data collection. Interviews lasted approximately one hour. All study materials and procedures were approved by DePaul University’s Institutional Review Board. Informed consent was obtained for all participants.

Data analysis

All mental health professional (MHP) interviews interviews were audio recorded and saved across two encrypted memory drives. The English translation portions of the interviews were transcribed by the interviewer and undergraduate research assistants. Interviews were open-coded to create a framework based on themes outlined in the DIME procedure and subthemes within and across interviews (Morse & Field, 1995). Theme analyses of MHP interviews consisted of organizing response themes into the following categories, according to DIME:

– Perceived causes of the reported problem

– Effects on the person with the problem and on others close to them

– What people currently do about it

– What should be done about it (if the resources are available)

The final result is a summary sheet for each problem, with common responses listed under each of the four subheadings listed above. Findings were presented to the research staff at TPO Cambodia to reflect, validate, and modify themes, and to increase credibility and acceptability of findings.

Results

Interviews were conducted with 15 Cambodian mental health professionals (MHP) who work with Cambodian children with adverse life experiences across three organizations. Providers were eligible if they reported experience working directly with trauma-affected youth. Participants included five males and 10 females whose ages ranged from 27–55 years (M = 37.47 years). For highest education completed: less than high school (n = 1), high school (n = 2), some college (n = 1), a bachelor’s degree (n = 6), and a postbachelor’s degree (n = 5). All participants worked clinically with trauma-affected child populations (11 identified as counselors, four as social workers) exposed to the following trauma types: emotional abuse (n = 14), domestic violence (n = 13), physical abuse (n = 12), sexual abuse (n = 12), neglect (n = 12), illness and disease (n = 10), malnutrition (n = 10), and community violence (n = 8). The current sample represents a range of educational and training experiences, characteristic of the larger body of professionals working in mental health in Cambodia (McLaughlin and Wickeri, 2012).

Problems rated as most frequent and most severe by children and caregivers are presented below, with corresponding key informant responses organized by (1) causes of the problem, (2) effects on the individual and those around them, (3) current treatment, and (4) what treatment should be for the problem. The total number of key informants reporting each response is listed alongside the description. In each of the following sections we discuss the results, organized as emotional, somatic, cognitive, and sleep problems. No response trends or patterns were identified dependent on the participant’s organizational affiliation. Given the range of MHP professional roles, trainings, and experiences across geographical regions, child trauma experiences and presentations, and occupational responsibilities, results are considered a glimpse of local clinician perspectives and recommendations regarding the experiences and treatment of trauma-affected children in Cambodia, not an epidemiological evaluation of child trauma and posttraumatic stress.

Table 1.

Mental Health Professional (MHP) perspectives on child- and caregiver-reported posttraumatic problems.

Posttraumatic problem (Caregiver & Child Report)	Causes (n = frequencies, MHP Report)	Effects (n = frequencies, MHP Report)	Current treatment (n = frequencies, MHP Report)	Treatment Recommendations (n = frequencies, MHP Report)
Easily Angered (Mour Mao)	Parent Discipline (9)	Physical Aggression (8)	Talk Therapy (7)	Family Therapy (9)
	Labor Demands (6)	School Success (7)	Relaxation (7)	Coordination of Care (6)
	Poverty (5)	Family Relationships (6)	Psychoeducation (6)	Psychoeducation (5)
	Family Violence (5)	Communication (4)	Family Therapy (3)	Relaxation (5)
	Dissatisfaction (5)	Peer Relationships (4)	Play Therapy (3)	Consult Spiritual Leaders (2)
	Trauma (4)	Alcohol/Drug Use (4)	Rapport/Empathy/Proximity (3)	Art Therapy (2)
	Can’t Solve Problems/Can’t Think Properly (3)	Withdrawal (3)	Art Therapy (2)
	Peer Conflict (3)	Loss of Societal Resource (3)	Behavioral Therapy (2)
	Innate Disability (2)	Teacher Relationships (3)	Coping Strategies/Thought Shifting (2)
		Criminality (3)
		Increase Family Violence (2)
		Suicide/Self-Harm (2)
Crying (Yom)	Physical Illness (6)	Physical Health (8)	Rapport/Proximity/Allow for Emotional Expression (9)	Rapport/Proximity/Allow for Emotional Expression (5)
	Trauma (5)	Family Relationships (7)	Talk Therapy (6)	Psychoeducation (4)
	For Attention (4)	Releases Tension/Chest Tightness (6)	Family Therapy (4)	Talk Therapy (3)
	Expression of Inner State (4)	Peer Relationships (6)	Art Therapy (3)	Family Therapy (3)
	Trauma Flashbacks (3)	Increases Risk for Family Violence (4)	Psychoeducation (3)	Art Therapy (2)
	Fearfulness (3)	Communication (2)	Encourage Exercise (2)	Coordination of Care (2)
	Dissatisfaction (2)	School Success (2)
	Anger (2)	Child Gets What They Want/Reinforcement (2)
	Sadness (2)
	Parent Discipline (2)
Fearfulness (Phay Klach)	Trauma (11)	Family Relationships (11)	Relaxation (8)	Coordination of Care (6)
	Family Violence (10)	Physical Health (8)	Talk Therapy (7)	Exposure/Desensitization Therapy (6)
	Community Violence (8)	School Success (6)	Exposure/Desensitization Therapy (6)	Family Therapy (3)
	Ghosts/Spirits (4)	Withdrawal (6)	Rapport/Proximity/Allow for Emotional Expression (3)	More Formal Assessments (3)
	Parent Discipline (4)	Peer Relationships (6)	Psychoeducation (3)	Psychoeducation (2)
	Sexual Abuse (2)	Low Self-Worth/Low Confidence (5)	Family Therapy (2)
		Loss of Societal Resource (4)	Medication/Medical Treatment (2)
		Increased Risk for Later Psychopathology (4)	Coping Strategies (2)
		Poor Sleep (2)	Group Therapy (2)
		Communication (2)
		Nightmares (2)
Headache (Chheur (Kbal) Kobal)	Thinking Too Much (7)	School Success (12)	Medication/Medical Treatment (8)	Coordinate Care Across Ecology (7)
	Poor Nutrition (6)	Family Relationships (6)	Relaxation Techniques (7)	Family Therapy (5)
	School Difficulties (5)	Physical Aggression (4)	Traditional Remedies (4)	Find Etiological Causes (4)
	Trauma (5)	Low Self-Worth/Low Confidence (4)	Exercise (3)	Art Therapy (3)
	Physical Illness (4)	Communication (3)	Art Therapy (3)	Exercise (2)
	General Stress (4)	Physical Health (3)	Talk Therapy (2)	Nutrition Education (2)
	Parent Discipline (3)	Withdrawal (2)	Psychoeducation (2)
	Expression of Inner State (3)	Poor Sleep (2)	Play Therapy (2)
	General Mental Problem (3)	Criminality (2)	Case Management (2)
	Family Violence (3)	Won’t Eat (2)	Coordinate Care with Medical Providers (2)
	Anger (3)	Financial Problems in Family (2)
	Labor Demands (2)
	Peer Conflict (2)
Rapid Heart Rate (Beh-Dong Doeu Nyaob)	Trauma (6)	Physical Health (9)	Relaxation Strategies (10)	Coordinate Care with Medical Providers (7)
	Fearfulness (6)	Peer Relationships (5)	Medication/Medical Treatment (7)	Talk Therapy (5)
	Physical Illness (5)	School Success (4)	I Don’t Know (3)	Relaxation Strategies (4)
	Trauma Flashbacks (3)	Fearfulness (4)	Family Therapy (2)	Assessements (3)
	Sadness/Depression (2)	Communication (4)	Psychoeducation (2)	Family Therapy (2)
	Thinking Too Much (2)	Family Relationships (4)
	Anger (2)	Thinking Too Much (3)
	I Don’t Know (2)	Withdrawal (3)
		Medical Treatment (3)
		Financial Problems for Family (3)
		Loss of Societal Resource (2)
		Low Self-Worth/Low Confidence (2)
School Difficulties in Learning/Comprehension (e.g., Rien Men Ches)	Problems with Teacher (7)	Family Relationships and Stress (7)	Coordination of Care with Teachers (6)	Coordination of Care with Teachers (9)
	Trauma (7)	Impairs Career Prospects (6)	Case Management/Link Family to Resources (4)	Family Therapy (7)
	Family Violence (5)	Discrimination (6)	Psychoeducation on the Importance of School (4)	More School Counselors (2)
	Parent Discipline Regarding Schooling (5)	Physical Aggression (5)	Talk Therapy (3)	More Formal Learning Assessments (2)
	Learning Disability (4)	Financial Problems for Family (4)	I Don’t Know (3)	Skills/Vocational Training (2)
	Memory Functioning Impacted by Trauma (2)	Peer Relationships (4)	Family Therapy (3)
	Thinking Too Much (2)	Intergenerational Effects on Schooling Perspectives (3)	Learning Assessments (2)
	Poor Nutrition (2)	Alcohol/Drug Use (3)	Skills/Vocational Training (2)
	Trauma Flashbacks (2)	Loss of Societal Resource (2)
	Peer Conflict (2)	Low Self-Worth/Low Confidence (2)
	Poverty (2)
Poor Sleep (Dek Men Sov Lok)	Thinking Too Much (8)	School Difficulties (13)	Relaxation (11)	Relaxation (9)
	Trauma Flashbacks (6)	Physical Health (11)	Family Therapy (6)	Talk Therapy (5)
	Poor Nutrition (4)	Easily Angered (8)	Nutrition Education (5)	Coordination of Care (3)
	Physical Illness (4)	Family Relationships (7)	Sleep Hygiene (5)	Psychoeducation (3)
	Screen Time/TV (4)	Peer Relationships (5)	Medication/Medical Treatment (4)	I Don’t Know (3)
	Trauma (3)	Exhaustion (3)	Psychoeducation (4)	Sleep Hygiene (3)
	Family Violence (3)	Physical Aggression (2)	Find Etiological Causes (2)	Family Therapy (2)
	Labor Demands (2)	Loss of Societal Resource (2)
	Sadness/Depression (2)	Headache (2)
	Nightmares (2)

Emotional problems: Easily angered (mour mao), crying (yom), and fearfulness (phay klach)

The most frequently MHP-reported causes were harsh or unfair parent discipline for easily angered (mour mao), physical illness for crying (yom), and trauma (ka pas tong kej plov jit; directly, something particularly emotionally distressing) for fearfulness (phay klach). Fearfulness was also reportedly caused by family and community violence, and concern of ghosts and spirits, often as a result of stories from adults attempting to dissuade certain behaviors deemed unsafe.

Children run around sometimes in some community or some rural area. If the kids run around or they try to see things, to experiment with the environment around them, the parents try to ban them by saying “don’t go over there, there are witches or there are ghosts.” It creates fearfulness inside them. (Counselor, female, age 32)

The most frequently reported effects of crying (yom) and fearfulness (phay klach) were congruent: physical health and family relationships. Easily angered (mour mao), however, was most frequently reported to lead to physical aggression and interfere with school success. Fearfulness was reported to beget other internalizing-type problems, including withdrawal and low self-worth/low confidence, whereas anger was reported to beget other internalizing (withdrawal and suicide/self-harm ideation) and externalizing-like symptoms (aggression, and later drug/alcohol use and criminality). All emotional problems were reported to impact school success, family relationships, peer relationships, and ability to effectively communicate thoughts and needs.

The impact of anger on the kids is that it is easy for them to lose opportunity for communication and it will also affect their education. (…) If that kid has anger, it would lead him/her to physical violence, like he or she would destroy all the properties in the house and that would affect people around them and bother them. So if anger is not solved for kids, it would lead the kid to be not a very nice person for society in the future. (Social worker, female, age 42)

Overall, mental health professionals (MHPs) in this sample most frequently reported the following treatments as currently employed in Cambodia to address reported affective/emotional problems: talk therapy, family therapy, psychoeducation, building rapport/being an empathic listener, and relaxation strategies (namely, breathing exercises, meditation, and progressive muscle relaxation). MHPs highlighted incorporating Buddhist ideology into meditation practices and recommending religious-based healing practices to children and families.

According to my experience we usually do meditation based on practices in Buddhism and we also let the person talk, to express their feeling to another person that they have trust in them. But culturally we sometimes tell people go to pagoda to have water blessing in order to feel nice or to feel better. (Counselor, female, age 38)

Specific to fearfulness, over a third of the mental health professionals reported they employ exposure therapy techniques. Recommendations for future treatment highlighted increased coordination of care across the child’s social ecological levels, as MHPs noted teachers, family members, psychiatrists, medical doctors, spiritual leaders, close friends, and others who live near the child as critical to care provision:

I think the best intervention is not looking at the child, it is looking at the person in the environment. If teachers are not a part of the intervention, then what we could offer is education to normalize the phase, to educate the peers, the family, so they don’t put more pressure on the child. (Counselor, male, age 43)

Somatic symptoms: Headache (chheur kbal) and rapid heart rate (beh-dong doeu nyaob)

The four most frequently reported causes of headache (chheur kbal) highlight the variety of perceived etiologies of this problem: thinking too much (cognitive), poor nutrition (physical health), school difficulties (functional impairment), and trauma (experiential). Rapid heart rate (beh-dong doeu nyaob), on the other hand, was largely considered a result of trauma and fear-based posttraumatic stress (fearfulness and flashbacks). Somatic symptoms shared the following perceived causes: thinking too much, trauma, anger, and physical illness. In many cases, MHPs noted somatic symptoms were an expression of psychological distress, often modeled through parenting:

In Cambodia, expressing through physical symptoms is very common. (…) Instead of saying, “I am sad,” or “I hate someone,” this is not the feeling the community, or the environment accepts for the person to express. (…) Through the parenting of Cambodians, they learn that when they act distressed, they express physical. In children, I see it as an expression of mourning from an adult. (Counselor, female, age 38)

The frequently reported effects of headache are as diverse as the causes, including school difficulties, family relationships, physical aggression, and low self-worth/low confidence. Rapid heart rate was most frequently reported to impact the child’s physical health, including later high blood pressure and heart problems, such as increased risk for cardiac arrest. Both somatic symptoms were reported to impact school success, family relationships/stress, low self-worth/low confidence, ability to communicate their thoughts and needs, risk for later physical health problems, withdrawal, and an increase in financial burden for families.

Both somatic symptoms were reported to be most commonly treated by relaxation strategies and medication/medical treatment:

Particularly with a chest problem, they consult a medical doctor first. (…) For me, this [case] was clearly trauma-related, and there was one physician giving her injections for a heart problem, and we just didn’t know what this injection was. And then the whole community believed this was a heart problem. They treated her like they didn’t want her to have a heart attack. (Counselor, female, age 38)

However, no MHPs reported medical treatment as a recommendation for future treatment. Instead, increased coordination of care with psychiatrists and primary care physicians was the most frequent response for both somatic symptoms. Across symptoms, six MHPs noted increased time and effort should be spent delineating whether the cause of headaches and rapid heart rate is physical, psychological, or both, through increases in coordinated care, more in-depth screening, and/or utilization of more formal assessment tools:

As a result of trauma, a complete assessment should be done. And actually in assessment we don’t have any formal questionnaires. We use very simple questions, like giving us a guess. I think we should have more formal assessment tools. (Social worker, male, age 29)

Cognitive problems: Difficulties with learning and comprehension in school (e.g., rien men ches)

The most frequently reported cause of school difficulties was problems with teachers, including low teacher skill and contentious teacher-child relationships. Next, MHPs attributed school difficulties to trauma, family violence, and parent discipline surrounding schooling expectations. The effects of school difficulties also included impaired family/peer relationships (including discrimination from others) and externalizing behaviors (i.e., physical aggression) but were otherwise largely occupational and future-oriented, including intergenerational effects of children becoming parents that teach their children that education holds little value, impaired career prospects, and future drug/alcohol use: “The child would have no self-esteem. Evokes anger, evokes aggression, dropping out of school. Leading to other dangerous behaviors like smoking, trying alcohol early. They go out with friends and try dangerous behaviors” (counselor, male, age 47);

They don’t want to study because they think that the study has no value for them, so it would affect the family development because it’s kind of creating a cultural thing in that family. It would affect one generation to another generation and that perspective will stay in that family. (Social worker, female, age 36)

MHPs reported school difficulties also lead to a loss of a societal resource, an important aspect for a postwar country in rehabilitation:

So not just this problem, but also the previous problems we have talked about, it would affect to the society as well because kids are the younger generation that need to be educated so they can have knowledge to develop the country. So if they are having a problem and they can’t really concentrate or they can’t study, it affects the society. (Counselor, female, age 27)

Reported current treatment for school difficulties aligns closely with recommended treatments, including coordinated care with teachers, family therapy, and skills/vocational training for students struggling academically. Additionally, MHPs recommended increasing access to/utilizing more formal learning assessments for treatment/academic planning and increasing the number of counselors working within Cambodian schools:

I think the best way to treat this problem is to have a counselor in school. We need to work cooperatively with the youth, education setting, sport department, and family in order to provide counseling in school so that the kids are helped. (Counselor, male, age 37)

Sleep problems: Poor sleep (dek men sov lok)

Key causes of poor sleep included thinking too much, trauma flashbacks, poor nutrition, and physical illness:

The kids think too much and they can’t really get out of that problem or that feeling. And that feeling keeps haunting them and that’s why they can’t sleep well. The other problem is that the problems they have experienced in the past keeps haunting them, like flashbacks to the experiences they had before. (Counselor, female, age 27)

These causes are most closely aligned with those reported for headaches (thinking too much, poor nutrition, trauma), suggesting MHPs consider headaches and poor sleep as interrelated by common causes and effects, as headaches were listed as an effect of poor sleep, and vice versa. The most common effect of poor sleep was school difficulties, followed by physical health, easily angered (mour mao), and impaired family/peer relationships.

Current and recommended treatment for poor sleep also had considerable overlap, including relaxation strategies, family therapy, psychoeducation, and improving sleep hygiene. However, similar to somatic symptoms, current treatment included medication/medical treatment, whereas recommended treatment included increased coordination of care, primarily with families and medical providers: “Looking at the child as a whole, at the biological and psychological aspects, and their environment as well. So the intervention is always for the child's needs, physical and psychological, and how the environment interacts with them” (counselor, female, age 38).

Discussion

Children and caregivers associate a range of affective, emotional, cognitive, and somatic problems with exposure to adverse experiences. MHPs indicated several causes and effects for problems that align with etiological and symptomatic conceptualizations found across cultural contexts, such as trauma and violence exposure leading to anger, fearfulness, and functional impairment. This may indicate a subset of shared conceptualizations between Cambodian and Western providers, or may be an artifact of being trained largely by Western institutions and professionals. In addition, MHP responses provide information notable for the Cambodian context, such as insights into somatic symptoms like headaches and palpitations, causes such as thinking too much, ghosts/spirits, poor nutrition, child labor demands, and Cambodian family dynamics (parenting norms and family hierarchy structures), and effects such as thinking too much and symptom expression as a release of physical tension.

Similarly, current interventions in place and recommended directions for treatment shared some common methods with international contexts. Further, MHPs offered other contextually sensitive methods for Cambodian populations. Cambodian MHPs in the current sample conduct individual, family, and group therapy targeting trauma experiences, family violence, and substance use, and many MHPs use exposure therapy as a front-line treatment for fearfulness. However, some MHPs in Cambodia also integrate Buddhist ideology into meditation and relaxation practices and tailor parent training and family therapy to Cambodian family dynamic contexts—and somatic symptoms with reportedly psychological causes are often treated by medical providers. Taken together, recommended future directions for intervention according to MHPs indicated consultation with spiritual leaders, increasing mental health services as part of multidisciplinary, coordinated care (alongside teachers, medical providers, families, friends, spiritual leaders, and close others), and access to more formal assessment tools.

The interrelationships between problems reported in this study highlight the complexity of how symptoms are expressed, perpetuated, and reinforced, often in multidirectional ways. For example, school difficulties were a problem listed by children and caregivers, and were identified by the MHPs as a cause of headaches and as an area negatively impacted by all problems examined in this study. School difficulties were also one of the most severe problems as reported by children, highlighting the salience of this problem across patients and providers. From cross-cutting problems such as school difficulties, examples of interrelationship networks can be outlined, such as in Figure 1, which shows how, according to children, caregivers, and MHPs, school difficulties may be caused and perpetuated by other problems, including increased risk for victimization due to family stress.

Another frequent response that crosscuts several problems was thinking too much (TTM; kit chraern), a cultural idiom with robust extant support as an important expression of distress across non-Western contexts (Hinton et al., 2015, 2016; Kaiser et al., 2015). In the current study, TTM was a reported cause of headaches, poor sleep, rapid heart rate, and school difficulties, and an effect of rapid heart rate. See Figure 2.

Hinton and colleagues (2015, 2016) have likewise found that “thinking a lot” is a key complaint that frequently triggers poor sleep and headache, as well as multiple somatic symptoms; it also often triggers poor concentration, which might also contribute to difficulties in school, another key complaint in the current study.

Somatic symptoms explored in the current study align with extant findings that indicate panic and palpitations are prominent among Cambodian victims (Hinton et al., 2006, 2008); further, emerging literature indicates the importance of headache as a key complaint (Hinton et al., 2015, 2016, 2018). Other key complaints identified here, such as poor sleep and emotional problems, should also be evaluated and treated.

Current findings provide local perspectives of child mental health following adverse life experiences and recommended treatment for several key problems that present in trauma-affected Cambodian children, and can inform international organizations that aim to work collaboratively within the Cambodian context. For example, many MHPs noted family therapy and parent training as recommended directions for treatment, which is fitting given the highly frequent reporting of harsh parent discipline and family violence as causes of these problems. Parent training models of intervention have strong empirical support in Western populations, such as Parent-Child Interaction Therapy (PCIT; e.g., Eyberg, 2005), which has also shown promising treatment outcomes in trials in Asia, such as Taiwan, Hong Kong, and mainland China with minor cultural adaptations (Chen, & Fortson, 2015; Leung et al., 2009, 2015). Adapting parent training interventions for the Cambodian family context may be a future direction of treatment that aligns with MHP recommendations.

As palpitations were indicated as a particularly severe problem by caregivers, and as an interrelated, multidirectional symptom by MHPs, Cambodian youth may benefit from culturally adapted treatment models that target somatic symptomatology and demonstrate reductions in posttraumatic stress symptoms to be concomitant with reductions in somatic symptoms, including Culturally Adapted-Cognitive Behavioral Therapy (CA-CBT) and somatic-focused therapy for traumatized refugees (Hinton et al., 2006, 2008; Hinton, Rivera et al., 2012). However, these treatment models were not designed for child populations and have not been implemented in Cambodian populations still residing in Cambodia.

Other intervention strategies recommended by MHPs in this study for further development include coordination of care and more formal assessment tools. In regard to posttraumatic stress assessment, Hinton and colleagues (2013) developed the Cambodian Symptom and Syndrome Inventory (C-SSI) to better capture Cambodian-specific expressions of distress, including “thinking too much.” Scores on the C-SSI increased significantly across levels of posttraumatic stress severity, illustrating that a Cambodian who meets criteria for PTSD also has several other culturally salient somatic symptoms. This measure highlights the integration of DSM criteria found across cultural contexts with expressions of distress salient to Cambodian populations to provide a more comprehensive and accurate representation of distress in this population. However, the C-SSI was designed for Cambodian adult refugee populations, and may require adaptation to Cambodian child populations still residing in Cambodia.

Trauma-oriented trainings conducted with local organizations should include findings specific to the Cambodian context as much as possible to maximize cultural applicability. Such trainings may benefit from incorporating the current findings in the following ways: (1) to highlight key expressions of distress and associated domains of functioning salient to Cambodian caregivers and children, (2) to increase knowledge of the role of adverse life experience and posttraumatic stress in child symptoms and functioning in Cambodia, (3) to provide language-specific symptom and problem indicators for screeners and assessment to better capture trauma-affected Cambodian children, (4) to facilitate collaborative development of treatments across Cambodian mental health providers/organizations, and (5) to demonstrate an emphasis on cultural sensitivity and the importance of local context in organizational collaboration. The current study is one of several that can contribute to culturally sensitive training development in Cambodia (see Minas & Lewis, 2017; Figge et al., in press; Hinton, Hofmann et al., 2009; Hinton, Hinton et al., 2012); Nickerson & Hinton, 2011; Saraceno et al., 2007; Stammel et al., 2013; Stockwell et al., 2005).

Several limitations should be acknowledged. First, the majority of participants (11 of 15) were recruited via a single organization, TPO Cambodia. Thus, these MHPs often underwent similar trainings; organization-level perspectives on service provision may somewhat be a reflection of which trainings were offered. Further, the MHPs in the current study employed by Komar Rikreay and the Cambodian Children’s Trust may have also received TPO-led trainings, as TPO is one of the few NGOs in Cambodia primarily focused on mental health and many social work and support service personnel in other organizations around Cambodia travel to TPO for mental health trainings. Also, MHP responses were likely impacted by their unique educational and professional experiences, which limits generalization of current responses across types and severity of trauma in Cambodian children. Study design, data collection, coding, analysis, and manuscript preparation were completed in close collaboration with bilingual Cambodian clinical and research personnel at TPO in attempts to ensure linguistic and conceptual consistency with terms and definitions translated from Khmer.

To conclude, Cambodian MHPs offer unique perspectives on the current state of posttraumatic problem conceptualization, treatment, and future directions. MHPs in the current study highlighted key domains salient to the Cambodian context, such as somatic symptoms like headache and palpitations, causes such as thinking too much, ghosts/spirits, poor nutrition, child labor demands, and effects such as thinking too much and symptom expression as a release of physical tension. Further, MHPs recommended several future directions for trauma assessment and intervention in Cambodia, including increased consultation of spiritual leaders, coordination of care across the child’s social ecological levels, including family, peers, teachers, spiritual leaders, and medical providers, and access to more formal assessment tools. Foreign and local organizations operating within Cambodia may benefit from current findings to inform training development, assessment and intervention design, and sustainable mental health service provision.

Footnotes

Acknowledgments

The authors wish to express their sincere gratitude to Mr. Lun Lao, Ms. Phan Chanveasna, Ms. Mark Savy, Mr. Chandarey Vong, and all TPO staff for their support and guidance. Also, many thanks to the clinicians of TPO, Komar Rikreay, and the Cambodian Children’s Trust for their invaluable perspective and their work with Cambodian families.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded in-part by a DePaul University internal research grant.

ORCID iD

Caleb J. Figge

Caleb J. Figge, PhD, is a clinical child psychologist and a Fogarty global health research fellow at the Harvard TH Chan School of Public Health and Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania. Broadly, his research focuses on biopsychosocial outcomes of childhood adversity. His research aims to integrate local expressions of distress and health-seeking behaviors into assessment, intervention, and community program design in low- and middle-income countries.

Cecilia Martinez-Torteya, PhD, is a clinical psychologist and faculty member at University of Monterrey and DePaul University. She studies the effects of early exposure to violence and risk and protective mechanisms that shape children's biopsychosocial outcomes in the face of traumatic stress.

Sopheap Taing, BA, is the Research, Monitoring, and Evaluation Coordinator for the Transcultural Psychosocial Organization (TPO) Cambodia. She is also actively involved in TPO’s fundraising activities, and supervises its Community Mental Health programs in the Siem Reap, Battambang, and Kampong Thom provinces. She obtained her BA in Psychology from the Royal University of Phnom Penh.

Sotheara Chhim, MD, PhD, MPM, is a Senior Consultant Psychiatrist and Executive Director of the Transcultural Psychosocial Organization (TPO) Cambodia. Dr. Chhim has been providing mental health services to Cambodian people for the past 24 years, with a special interest in trauma, transcultural psychiatry, and community mental health. He testified twice as a trauma expert for Khmer Rouge survivors at the Extraordinary Chambers in the Court of Cambodia.

Devon E. Hinton, MD, PhD, is an anthropologist and psychiatrist, and an Associate Professor of Psychiatry at Massachusetts General Hospital and in the Department of Global Health and Social Medicine, Harvard Medical School. He has researched in cross-cultural perspective idioms of distress, somatic symptoms, sleep paralysis, panic attacks, panic disorder, and PTSD, with a focus on Southeast Asian populations, particularly Cambodian and Vietnamese refugees, as well as Latino populations. He has written extensively on culturally sensitive CBT. He is fluent in several languages, including Cambodian, Spanish, and Thai.

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