October 2014 October 2015

Transcription

1 A Cooperation Research Project of the Department of Psychology, Royal University of Phnom Penh (RUPP), Cambodia and the Sigmund-Freud-Institute (SFI), Frankfurt/Main, Germany Principal Investigator: October 2014 October 2015 Dr. Katrin Luise Laezer (Sigmund-Freud-Institut, Frankfurt/Main, Germany, Telephone: , , Beethovenplatz 1-3, D Frankfurt/Main) Co-investigator: M.A. Elizabeth Högger Klaus (GIZ Development Advisor of the Department of Psychology, Royal University Phnom Penh, Cambodia, Telephone: , Heads of the Cooperating Institutions: M.A. Sek Sisokhom (Head of the Department of Psychology, Royal University Phnom Penh, Cambodia, Russian Federation Boulevard, Toul Kork, Phnom Penh, Cambodia) Prof. Dr. Marianne Leuzinger-Bohleber (Director of the Sigmund-Freud-Institut, Frankfurt/Main, Germany, Telephone: , Fax: , Beethovenplatz 1-3, D Frankfurt/Main) 1

2 1. Background During and after the Khmer Rouge (KR) regime, during which an estimated two million people out of a population of seven million were killed, a largely traumatized first generation now merges with a rapidly growing second and third generation. These second and third generation is affected by the first through the problems of a post-conflict society as well as directly through the problems of their own parents: poverty, non-functioning governments, lack of human rights as well as widely spread domestic violence including corporal punishment of children, sexual abuse, trafficking, substance abuse, gambling, and psychiatric conditions in parents (Van de Put & Eisenbruch, 2002, p.10; Gourley, 2009; Sonis et al., 2009; McLaughlin & Wickeri, 2011). A national sample study found a relatively high prevalence rate for current PTSD among survivors of the Khmer Rouge regime of 14.2% (Sonis et al., 2009; Van de Put & Eisenbruch, 2002). A sizable minority of offspring of Khmer Rouge survivors will have grown up with parents who continue to suffer psychologically from the effects of the Khmer Rouge regime. Therefore, evidence for secondary traumatization in the offspring linked to parent s Khmer Rouge trauma would have broader societal implications (Field, Muong & Sochanvimean 2013). In order to meet the needs of the new generations born after the Khmer Rouge regime that constitute almost 50% of the population, detailed knowledge about the current situations of parents and their children in regard to the experienced trauma and to their parenting style is inevitably required. Attachment researchers showed a strong association between disorganized attachment patterns and the quality of parenting caused by the parent s unresolved trauma or loss (George & Solomon, 2009). One consequence of exposure to trauma in childhood on later parenting is the development of rolereversing parenting in which the parent turns to the child to have his or her emotional needs met (George & Solomon, 2009). A research group from Geneva showed that mothers who have been diagnosed with Posttraumatic Syndrome Disorder (PTSD) have difficulties in reading the emotions and responding to their children s social bids. PTSD mothers capacity to respond to their children s distress is often likely compromised (Schechter & Serpa, 2014). In Cambodia, there are just very few studies on parental practices in Cambodia, most of them nonscientifically based (Smith-Hefner, 1990; Lenart et al., 1991; Kelley, 1996; Keo, 2004; Ovensen et al., 1996; Rodier 1999; Simcox, 2014). Only two studies focus on the impact of traumatized parents in Cambodia on their parenting styles and on the mental health adjustment of their children (Field, Om, Kim and Vorn, 2011; Field, Muong and Sochanvimean (2013). Further fundamental research on parenting in Cambodia is needed. Insight into how these problems of parenting and child rearing are now interpreted and dealt with in the families enables tailored intervention and prevention programs in the future. The PPCIC study will investigate the relationships between trauma exposure during and after the Khmer Rouge regime, current trauma symptoms of the first and second generation, their parenting styles and the psychological adjustment of children in the third generation. This research project contributes to a better understanding of the current situation of parents and children and their needs in Cambodia. 2. State of the art Two scientific studies on parental styles in the second generation after the Khmer Rouge regime have been conducted recently by Field, Om, Kim and Vorn (2011) and by Field, Muong and Sochanvimean (2013). In both studies the researchers looked at the relationship between a) trauma exposure during the Khmer Rouge regime and current trauma symptoms in the parents in generation 1 (G1), b) the children s adjustment of the child in generation 2 (G2) measured as symptoms of depression and anxiety and c) the parenting style including role-reversal parenting, overprotecting parenting and 2

3 rejecting parenting as a possible mediator (see figure 1). Figure 1. Research topics and questions of Field, Om, Kim and Vorn (2011) The two studies differed in the samples. The first study (Field, Om, Kim & Vorn, 2011) investigated 200 Cambodian high school students (female students = 100; mean age = 16.99, mother s mean age = 42.34, mean family monthly income in USD = , SD = ). The 200 students retrospectively assessed their parents trauma exposure, their current trauma symptoms and parenting styles. Further, the students evaluated their own symptoms of depression and anxiety. The results can be summarized as following: First of all, they found a considerable variation in the extent of trauma exposure, because the students had limited knowledge of their parents trauma exposure. The father s and mother s perceived trauma symptoms were positively correlated with child s depression and anxiety. The father s perceived trauma symptoms score was correlated with role-reversing parenting style, while the mother s perceived trauma symptoms score was correlated with an overprotecting parenting style. Neither father s nor mother s trauma exposure was related to the parenting style. Interestingly, the father s and mother s role-reversing parenting style was significantly positively related to the child s depression and anxiety. Mother s overprotecting parenting style was also significantly positively correlated with the child s depression. Calculating a path analysis meditational model, Field, Om, Kim and Vorn (2011) found an indirect effect of parents perceived trauma symptoms on the child s depression, fully mediated by their role reversing parental style (Sobel statistic = 1.94, p <.05, one-tailed). Further, the data supported the hypothesis that parental styles mediate the impact of parent s perceived trauma symptoms on the child s anxiety. A significant indirect effect of parent s perceived trauma symptoms on the child s anxiety was mediated via their role reversing parental style and via the mother s overprotectiveness (Sobel test = 1.70, p <.05, one-tailed). The second study (Field, Muong & Sochanvimean, 2013) included two sub-samples of mother-child dyads. The first sub-sample investigated 46 Cambodian female students, aged and their mothers who were survivors of the Khmer Rouge regime (Mother s mean age = 44.78, mother s education: no or primary school = 45.6%, secondary school = 52.2%). The second sub-sample comprised 15 clinical mother-child pairs and 17 nonclinical mother-child pairs in the Khmer community in San Francisco (USA) (child s mean age in both groups 16, mother s mean age in both groups 47). Within the sub-sample of female students and their mothers, they found the same positive correlations as in the first study. Regarding the mediating effect of parental styles, they discovered a statistically significant indirect effect of the mother s PTSD total symptoms on daughter s anxiety, as mediated by her role-reversing parental style. A statistically significant indirect effect of the mother s PTSD hyperarousal symptoms on daughter s anxiety, as mediated by her role-reversing parental style, was 3

4 also identified. These findings were replicated in the clinical sample showing a significant indirect effect of the mother s PTSD total symptoms score and other subscales: PTSD reexperiencing, PTSD avoidance, PTSD hyperarousal on her child s anxiety symptoms, mediated by role-reversal parenting. The significant direct effect of PTSD total symptoms (and other subscales: PTSD reexperiencing and PTSD avoidance) on her child s anxiety revealed that the role-reversal parenting does not fully explain the impact of mother s PTSD symptoms on her child s anxiety. Neither role-reversing parenting nor rejecting parenting mediated the relationship between mother s PTSD symptoms and her child s depression. Summary of the state of art: The studies of Field, Om, Kim and Vorn (2011) and Field, Muong and Sochanvimean (2013) found: A positive association between parents trauma PTSD symptoms and children s adjustment in terms of anxiety and depression. A positive association between parent s trauma PTSD symptoms and their parenting particular their role-reversal parenting. A positive association between role-reversal parenting and children s anxiety and depression. Parents PTSD symptoms on children s anxiety and depression are mediated by their rolereversal parenting style. 3. Objectives and hypotheses The PPCIC project focuses on the impact of the intergenerational transmission of trauma stemming from the Khmer Rouge regime on parenting and mental health adjustment. We are going to do a replication study of Field, Om, Kim and Vorn (2011) and Field, Muong and Sochanvimean (2013), but adding four more new dimensions: We look at cultural beliefs of parenting in Cambodia: o We hypothesize that role-reversal parenting is not only linked to trauma exposure and trauma symptoms. It might be that the role-reversal parenting is as well imbedded in and supported by the Cambodian culture in which children have to take care of their parents. o We also hypothesize that grandmothers and older siblings might play a significant role as secondary or even primary caregivers for children in Cambodia. o A questionnaire for parenting beliefs in Cambodia will be developed. We extend the study to one more generation: o G3 (children, 14 and 15 years old, enrolled in grade 8 and 9 and a younger sibling aged 6-8 years) o G2 (mother; she was a child during KR regime or born shortly after KR regime) o G1 (grandmother; she was an adolescent or a young adult during KR regime) o We would like to assure that the PPCIC project covers the broader family history (before, during and after the Khmer Rouge regime) and captures information on all relevant caregivers of each child. Therefore, we extend the study to the generation of the grandmother. o We assume to find positive correlations between trauma exposure, current trauma symptoms as well as parenting styles in generation 1 and 2 and attachment and mental health problems in generation 3. 4

5 o We will investigate mothers and grandmothers because they are described as the main primary caregivers in Cambodian culture and for practical reasons. The fathers and grandfathers perspective could be investigated in a follow-up study. We extend the measures of children s adjustment: o Child Psychosocial Distress; Daily Functioning; Trauma Short Form; Stressful Live Events; Substance Use; Strengths and Difficulties Questionnaire; Mood and Feelings Questionnaire (derived from the nationwide survey Youth Distress Screening ) o It is important to assure a multi-dimensional perspective on mental health problems in generation 3. These measures enable us to draw a differentiated picture on current problems of children in generation 3 in Cambodia. We look at attachment patterns of children: o For the first time, a standardized attachment measure for children aged 4 to 8 years will be introduced to Cambodia using the internationally well-validated Manchester Child Attachment Story Task (MCAST) (Green, Stanley, Smith & Goldwyn, 2000). o We assume that in contrast to a normal population distribution we find a higher proportion of insecure disorganized children among those families who experienced trauma exposure during the Khmer Rouge regime and who are still struggling with severe trauma symptoms. As the PPCIC study is an ambitious project, we are going to build synergistic effects by: Using the sample of the RUPP Nationwide Survey Youth Distress Screening for the recruitment of the PPCIC sample and By using questionnaires that were already applied in the recently conducted RUPP Cambodian Mental Health Survey (Schunert, Khann, Kao, Pot, Saupe, Sek & Nhong, 2012) and the RUPP adaptation and validation study Child Psychosocial Distress Screener, done in 2013 (Domburgh, Kao, Tim, Pot & Sao, 2014). The PPCIC project further aims to improve the scientific research skills of the future generation of Cambodian researchers and clinical psychologists. Therefore, 22 students of the Master Program of the Department of Psychology (RUPP) and one school psychologist from Caritas-CCAMH, Chey Chumneas Referral Hospital will be trained in the research methods used in the PPCIC project. The RUPP students will participate in the research and will be given the opportunity to write their Master thesis within the PPCIC project. Eleven topics for Master Theses related to the data of the PPCIC project are listed in the Annex 1. The research methods will be taught within a 45-hours course of the Master Program on Child Therapy. We also would like to express our wish to support young researchers from Cambodia and Germany to improve their research skills and methods on an international level. Therefore, an international exchange of young researchers is planned. One outstanding student and two young scientists from RUPP will be offered a four-week scholarship at the Sigmund-Freud-Institut (SFI) in Frankfurt am Main, Germany. On the other hand, two young scientists from the Sigmund-Freud-Institut will be offered a four-week scholarship at the Department of Psychology of the Royal University Phnom Penh (RUPP). 5

6 4. Design and sampling procedure The study is performed as a cross-sectional survey recruiting the sample from the RUPP Cambodian Nationwide Survey Youth Distress Screening that will start in November Figure 2 summarizes the study design and the sampling procedure. Figure 2. Design and sampling procedure of the PPCIC study 5. Participants and ethical issues Two hundred students (100 male and 100 female) enrolled in grade 8 and 9 (aged 14 and 15 years) and their mothers and their grandmothers from the mother s side as well as 100 of their siblings aged 6 to 8 will participate in the study. Written informed consent will be obtained before the interview from every participant. Interviews will be conducted in strict privacy and respondents names will not appear on the interview forms, ensuring absolute anonymity. Regarding the assessment of the children in the PPCIC study, it will take place as part of the RUPP Cambodian Nationwide Survey Youth Distress Screening starting in November The National Ethics Committee of the Ministry of Education has approved the study protocol and the version of the written informed consent form for this Nationwide Survey. The PPCIC study consists solely of verbal questions. There will be no blood tests or other invasive procedures and no drugs administered. Hence there is no risk of adverse effects. If nevertheless the 6

7 questioning itself should cause any psychological problems for the participant he or she will be referred to the field supervisor for counseling who will arrange contact to a counselor (a M.A. clinical psychologist of RUPP) if the problem cannot be solved in one session. 6. Measures The PPCIC project includes the following measures. Almost all of them (except for the APQ, PI and MCAST) were already used in scientific studies in Khmer in Cambodia either by the RUPP Cambodian Mental Health Survey (Schunert, Khann, Kao, Pot, Saupe, Sek & Nhong, 2012) or by Like Domburgh and colleagues during the adaptation and validation study of the Child Psychosocial Distress Screener done in 2013 (Domburgh, Kao, Tim, Pot & Sao, 2014) or by Nigel Field and colleagues (Field, Om, Kim & Vorn, 2011 and Field, Muong & Sochanvimean, 2013). The superscripts G1, G2 and G3 right after the name of the measure gives the information about the PPCIC participants who will apply the measure (G1 grandmothers, G2 mothers, G3 children). Sociodemographic data Questionnaire G1-G3 (Schunert, Khann, Kao, Pot, Saupe, Sek & Nhong, 2012), contains information on education, monthly household income, ownership of land, ownership of life stocks & household appliances. Screening Questionnaire G1, G2 (Schunert, Khann, Kao, Pot, Saupe, Sek & Nhong, 2012) for mothers and grandmothers to screen whether they or a family member experienced problems, abuse, addictions, suicide attempts, financial problems, gambling. Domestic Violence Questionnaire G1, G2 (Schunert, Khann, Kao, Pot, Saupe, Sek & Nhong, 2012; National Institute for Public Health and ORC Macro, 2006) for mothers and grandmothers looks at 13 different behaviors of domestic violence and the frequency committed by the spouse or another member of the family. Alabama Parenting Questionnaire Short Form (APQ-9) G1-G3 (Elgar, Waschbusch, Dadds & Sigvaldasan, 2007) is a 9-item-questionnaire for children (aged 6-18) and for parents of children aged 6-18 that assesses positive parenting, inconsistent parenting and poor supervision. Additionally, the subscale of corporal punishment and 5 items on other discipline practices, providing information on an item-to-item basis, will be applied (Frick, 1991). Parentification Inventory (PI) G1-G3 (Hooper, 2013, 2009) is a 18-item retrospective self-report measure that assesses caregiving and parental roles, responsibilities, and relationships usually reserved for adults but carried out by children leading to 3 subscales: parent-focused parentification, siblingfocused parentification and perceived benefits of parentification. Parental Bonding Instrument (PBI) G1-G3 (Parker, Tupling &Brown, 1979; Parker, 1983). Two scales termed care and overprotection or control, measure fundamental parental styles as perceived by the child. The measure is retrospective, meaning that adults (over 16 years) complete the measure for how they remember their parents during their first 16 years. Relationship with Parents Scale (RPS) G1-G3 (Alexander, 2003) is a retrospective measure of parentchild role reversal. Harvard Trauma Questionnaire (HTQ) G1, G2 (Mollica, Caspi-Yaspin, Lavelle, Tor, Yang, Chan, 1996; Schunert, Khann, Kao, Pot, Saupe, Sek & Nhong, 2012) captures experienced and witnessed 7

8 trauma exposure during and since Khmer Rouge regime as well as current trauma symptoms. Hopkins Symptom Checklist 25 (HSCL-25) G1-G3 (Mollica, Wyshak, de Marneffe, Khuon & Lavelle, 1987; Schunert, Khann, Kao, Pot, Saupe, Sek & Nhong, 2012) is a widely used screening instrument that was adapted to the Indochinese context and first developed for refugees. Two scores are calculated: one for anxiety symptoms and one for depression symptoms. Cambodian Somatic Symptoms and Syndrome Inventory (C-SSI) G1, G2 (Hinton, Hinton, Eng & Choung, 2012; Schunert, Khann, Kao, Pot, Saupe, Sek & Nhong, 2012) is a culturally sensitive 15- item assessment tool for traumatized Cambodians and their somatic and psychosomatic symptoms. Cultural Beliefs of parenting in Cambodia Questionnaire (PPCIC) G1, G2. This 10-item questionnaire will be developed within the PPCIC project together with the RUPP Master students during the course. The items, rated with a 5-point Likert-scale, will consist of Cambodian proverbs, popular sayings and statements. The Manchester Child Attachment Story Task (MCAST) G3 (Green, Stanley, Smith & Goldwyn, 2000), a narrative story stem task that involves playing with dolls, is a well-validated, standardized measure that evaluates young children s attachment representations through the use of play scenarios allowing for differentiation between four overall attachment classifications: secure attachment, insecure-ambivalent attachment, insecure-avoidant attachment and insecure-disorganized attachment representations. Child Psychosocial Distress Screener (CPDS) G3 (Domburgh, Kao, Tim, Pot & Sao, 2014). This 15- item screening questionnaire is a tool to identify Cambodian youth at risk of mental health problems focusing on daily functioning and on psychosocial distress. Strength and Difficulties Questionnaire (SDQ) G3 (Goodman, 1997) is an internationally widely used 25-items screening instrument that allows to differentiate between four subscales: prosocial behavior, emotional symptoms, hyperactivity, peer relationship and conduct problems. Trauma Short Form and Stressful Life Events G3 (Domburgh, Kao, Tim, Pot & Sao, 2014) is a 45- item questionnaire that explores traumatic situations of children at home with their family and community. Substance Use G3 (Domburgh, Kao, Tim, Pot & Sao, 2014) screens the substance use of children and family members. Mood and Feelings Questionnaire G3 (Domburgh, Kao, Tim, Pot & Sao, 2014) covers symptoms of anxiety and depression in children in Cambodia. 7. References Alexander, P. C. (2003). Parent-child role reversal: Development of a measure and test of an attachment theory model. Journal of Systemic Therapies, 22(2), Domburgh, L, Kao, S., Tim, P., Pot, C. & Sao, S. (2014). Preliminary Findings on the Validation of the Child Psychosocial Distress Screener. Conference organized by the Psychology Department, Royal University Phnom Penh (RUPP), 29 th May 2014, Phnom Penh. 8

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