The impact of attachment and depression symptoms on multiple risk behaviors in post-war adolescents in northern Uganda.

BACKGROUND: We have previously shown that depression symptoms are associated with multiple risk behaviors and that parental attachments are protective against depression symptoms in post-war adolescents. Accumulating literature indicates that low levels of attachment may sensitize individuals to increased multiple risk behaviors when depression symptoms exist. This investigation examined the interactive effects of attachment and depression symptoms on multiple risk behavior. METHODS: We conducted hierarchical logistic regression analyses to examine the impact of attachment and depression symptoms on multiple risk behavior in our post-war sample of 551 adolescents in Gulu district. RESULTS: Analyses revealed interactive effects for only maternal attachment-by-depression interaction. Interestingly, high levels of maternal attachment exacerbated the relationship between depression symptoms and multiple risk behaviors while low levels of maternal attachment attenuated this relationship. LIMITATIONS: It is possible that this analysis could be biased by a common underlying factor that influences self-reporting and therefore is correlated with each of self-reported attachment security, depressive symptoms, and multiple risk behaviors. CONCLUSIONS: These findings suggest that maternal attachment serves as a protective factor at low levels while serving as an additional risk factor at high levels. Findings support and expand current knowledge about the roles that attachment and depression symptoms play in the development of multiple risk behaviors and suggest a more complex etiology for post-war adolescents.

The mediating role of stigmatization in the mental health of adolescent victims of sexual violence in Eastern Congo.

This study aims to explore the factors that explain the mental sequelae of war-related sexual violence and focuses in particular on the role of stigmatization. Drawing on a large-scale quantitative survey undertaken in the war-affected region of eastern Democratic Republic of the Congo, we analyze how stigmatization mediates the mental health impact of sexual violence on adolescent girls who were victims of rape. Twenty-two secondary schools were randomly selected out of a stratified sample in Bunia, Eastern Congo. In a cross-sectional, population-based survey, 1,305 school-going adolescent girls aged 11-23 completed self-report measures assessing war-related traumatic events, experiences of sexual violence, stigmatization, and mental health symptoms. Of the 1,305 participants, 38.2% (n=499) reported experiences of sexual violence. Victims of sexual violence reported more war-related traumatic events and more stigmatization experiences. Several hierarchical regression analyses examined the mediating impact of stigmatization on the relationship between sexual violence and mental health outcomes, thereby controlling for sociodemographics (age, parental availability, and socioeconomic status) and war-related traumatic exposure. Our findings show that this stigmatization largely explains the mental health impact of sexual violence, in particular, on adolescent girls' reported symptoms of depression (full mediation) and posttraumatic stress (avoidance and total PTSD: full mediation; hyperarousal: partial (40%) mediation). No evidence of mediation by stigmatization was found for symptoms of anxiety and intrusion. Stigmatization plays thus an important role in shaping the mental sequelae of sexual violence, a finding with major consequences for clinical practice.

Parent-reported attention-deficit hyperactivity disorder and subtypes of conduct disorder as risk factor of recidivism in detained male adolescents.

OBJECTIVE: Parents are considered to be crucial informants in child psychiatry, particularly for disorders in which age of onset is included in the diagnostic criteria. In detained adolescents, however, parents all too often are difficult to reach or reluctant to cooperate. The clinical relevance of gathering parental information in this context should therefore be demonstrated. This study examines if parent reports of attention-deficit-hyperactivity disorder (ADHD) and age of onset subtypes of conduct disorder (CD) predict official criminal recidivism. METHOD: Participants were 110 detained male adolescents from all three Youth Detention Centers in Flanders. Between January 2005 and February 2007, both youth and a parent were interviewed with the Diagnostic Interview Schedule for Children Version IV. Two to 4 years later, information on criminal recidivism was retrieved. RESULTS: Youth self-reported ADHD and CD (subtypes) were not related with recidivism. Parent-reported ADHD, CD and childhood-onset CD predicted serious property recidivism, while parent-reported adolescent-onset CD predicted future violent arrests. In reverse, childhood-onset CD as reported by parents was negatively associated with violent recidivism. CONCLUSION: Obtaining parental diagnostic information in delinquent adolescents is crucial for predicting recidivism. This finding emphasizes the need of including parents when studying mental disorder in detained adolescents.

Exploratory study on domain-specific determinants of opiate-dependent individuals' quality of life.

BACKGROUND/AIMS: Studies on determinants of quality of life (QoL) among opiate-dependent individuals are scarce. Moreover, findings concerning the role of severity of drug use are inconsistent. This exploratory study investigates the association between domain-specific QoL and demographic, social, person, health and drug-related variables, and potential indirect effects of current heroin use on opiate-dependent individuals' QoL. METHODS: A cohort of opiate-dependent individuals who started outpatient methadone treatment at least 5 years previously (n = 159) were interviewed about their current QoL, psychological distress, satisfaction with methadone treatment and the severity of drug-related problems using the Lancashire Quality of Life Profile, the Brief Symptom Inventory, the Verona Service Satisfaction Scale for Methadone Treatment and the EuropASI. RESULTS: None of the QoL domains were defined by the same compilation of determinants. No direct effect of current heroin use on QoL was retained, but path analyses demonstrated its indirect effects on the domains of 'living situation', 'finances' and 'leisure and social participation'. CONCLUSION: These findings illustrate the particularity of each QoL domain and the need for a multidimensional approach to the concept. The relationship between current heroin use and various domains of opiate-dependent individuals' QoL is complex, indirect and mediated by psychosocial and treatment-related variables.

Social support in unaccompanied asylum-seeking boys: a case study.

BACKGROUND: The situation of unaccompanied asylum-seeking children (UASC) is characterized by a substantial disruption of the social network and loss of parental support, seriously jeopardizing their psychological well-being. However, little is known about the role of social support in the lives of UASC. METHODS: Twelve UASC completed a social support instrument and interview exploring perceived social support and what this implies for both buffering and main effects of social support. RESULTS: Asylum centre staff and the ethnic community were the most important resources of support. High importance was ascribed to social companionship as a way of coping. Despite pro-social efforts towards Belgian peers, this group provided hardly any social support. CONCLUSIONS: The provision of social support could enhance UASC's well-being through buffering effects (e.g. social companionship as avoidant/distractive coping) and main effects (acceptance by Belgian peers enhancing self-esteem). The asylum centre shows a great potential to stimulate UASC's psychological well-being by expanding the psychosocial function of staff members and community treatment.

Case management for persons with substance use disorders.

BACKGROUND: Patients with alcohol and other drug use disorders (AOD) frequently have multiple social, physical, and mental health treatment needs, yet have difficulty accessing community services, including drug abuse treatment. One strategy for linking patients with AOD with relevant services is case management, where a single case manager is responsible for linking patients with multiple relevant services. OBJECTIVES: To conduct a systematic review of all RCTs on the use of case management for helping drug abusers in or out of treatment. Outcome criteria included successful linkage with other services, illicit drug use outcomes, and a range of related outcomes. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2006), MEDLINE (1966 - 2006), EMBASE (1980 - 2006), LILACS (1982 - 2006), PsycINFO (1973 - 2006), Biological Abstracts (1982 t- 2000). Reference searching; personal communication; conference abstracts; book chapters on case management. SELECTION CRITERIA: Randomized controlled studies that compared a specific model of case management with either treatment as usual or another treatment model, included only patients with at least one alcohol or drug related problem. DATA COLLECTION AND ANALYSIS: Two groups of reviewers extracted the data independently . Standardized mean difference was estimated. MAIN RESULTS: In total, we could extract results from 15 studies. Outcome on illicit drug use was reported from 7 studies with 2391 patients. The effect size for illicit drug use was not significant, and small (standardized mean difference (SMD)=0.12, confidence interval=-0.09,0.29, p=0.20). Substantial heterogeneity was found (I(2)=69.9%). Linkage to other treatment services was reported in 10 studies with 3132 patients. The effect size for linkage was moderate (SMD=0.42, 95% confidence interval=0.21 to 0.62, p<0.001), but substantial heterogeneity was found (I(2)=85.2%). Moderator analyses suggested that a part of the heterogeneity found in linkage studies could be explained by the presence or absence of a treatment manual for case management. A single, large trial of case management with two arms, showed that case management was superior to psychoeducation and drug counselling in reducing drug use. AUTHORS' CONCLUSIONS: There is current evidence supporting that case management can enhance linkage with other services. However, evidence that case management reduces drug use or produce other beneficial outcome is not conclusive.

Comparison of single and multiple agency clients in substance abuse treatment services.

BACKGROUND: Frequent and multiple service utilization among substance abusers is a well-known problem. However, little statistical evidence exists about overlapping agency populations. METHODS: This phenomenon was studied in a clear-cut region in Belgium, based on intake information concerning all clients who addressed a drug treatment center within a 6-month period (n=1,139). RESULTS: Multiple service utilization was rather common but not omnipresent during this particular registration period. Almost 15% of the clients were registered in more than one substance abuse treatment agency. Compared to single agency attendees, multiple agency clients appeared to be more often poly-substance abusers with a longer previous treatment history and greater problem severity. CONCLUSION: A continuous care perspective, interagency collaboration and a common tracking and documentation system are recommended to better address the needs of this specific subgroup of substance abusers. More research is needed to clarify whether these multiple service utilization patterns are caused by client-related, agency-related or other factors.

Characteristics and profile of boys and girls with emotional and behavioural disorders in Flanders mental health institutes: a quantitative study.

BACKGROUND: In this article, we search for gender differences and outline a detailed gender profile for children and youngsters with emotional and behavioural disorders who are placed in Flemish residential care institutes. METHODS: Data were collected of all placements (517 children) in six residential and semi-residential mental health care centres for children and youngsters with emotional and behavioural disorders in East Flanders, Belgium. File data (gender, age, retention, current treatment, type of referral, education, intelligence, Diagnostic and Statistical Manual IV-diagnoses and medication use) were gathered. The Child Behaviour Check List (CBCL) was implemented and completed for each child. On the basis of the CBCL, a behaviour profile was developed by means of correlation tables (Pearson correlation coefficient) and cross tabulations. Finally, the profile was compared with the file data of the boys and the girls. RESULTS: Significant gender differences were found for type of referral, intelligence and diagnoses. The same profile was developed for both genders separately, based on variables Externalizing and Social Problems. The file data associated with the profile groups differ for boys and girls. CONCLUSIONS: The results of our study show the complexity and diversity of the needs of boys and girls with disruptive behaviour in Flemish residential care institutes. Flemish government has to be aware of the fact that the current referral system selects the children with outspoken externalizing and problematic behaviour towards special health care and special schools. They are relegated because the mainstream system is not equipped well enough to cope with their disruptive, aggressive behaviour. Even if governments are in favour of inclusive education, it seems that in practice a rest group is created, in which girls are selected through the same mechanisms as boys, in this case for the same reasons of negative externalizing behaviour and social problems. For this it seems appropriate that school and (semi)-residential institutes apply a specific and adapted methodology.

Retrospective study of similarities and relations between American drug-free and European therapeutic communities for children and adults.

This article focuses on the similarities and relations between the European therapeutic community for children and adults on the one hand and the American drug-free "concept" therapeutic community on the other. Both approaches are reviewed in a historical and comparative perspective with special attention to several critical issues: democracy versus hierarchy, self-help versus professionalism, psychoanalysis versus behaviorism and concept versus social learning. These two different TC-approaches can be considered as subdivisions of one modality, namely an environment for social learning in which living together in a group can be regarded as the primary agent of growth and human development. In recent years there has been a tendency towards further integration of these two approaches.

The design and effectiveness of therapeutic community research in Europe: an overview.

An overview of the state of the art of research on the treatment services of the therapeutic community for drug addicts in Europe is presented. This research tradition has largely been fragmented and local in its implementation. There has been a scientific gap concerning evaluation research and the treatment services offered by the therapeutic community. The American research antecedents to the European tradition are reviewed. The essential European groups, research designs and results are presented for each country with something greater than an ad hoc study experience. The strengths and weaknesses of the research designs, results and organizations are critically assessed. Recommendations for future research are presented and referenced to specific recommendations for therapeutic community research coming out of an American National Institute on Drug Abuse Technical Review. Among the conclusions of the overview is the need for more qualitative phenomenological research to complement the existing quantitative approach.

The "new" drug-free therapeutic community. Challenging encounter of classic and open therapeutic communities.

In view of a rapidly changing society, reflected in many changes within the drug-free Therapeutic Communities (TCs), the question has been raised: "What can and cannot be changed in this modality?" This question was addressed at a European conference of experienced therapeutic community workers, who concluded that many changes have occurred and will continue to occur, but some basic concepts should be preserved. The changes inherent in postmodern society are examined here in an effort to foresee their impact on the evolution of the TC. Necessary changes and additions are discussed.