Barriers to implementation of treatment guidelines for ADHD in adults with substance use disorder.

OBJECTIVE: Attention deficit hyperactivity disorder (ADHD) is common among adult patients with a substance use disorder, yet often goes undetected. This is a qualitative study to explore implementation barriers to a guideline developed in Belgium for the recognition and treatment of ADHD in adult patients with substance use disorder and to gain a better understanding of the strategies to overcome these barriers. METHODS: Focus groups were conducted with caregivers and patients to explore experiences with comorbid substance use disorder and ADHD. The barriers reported in these focus groups became the subject of further study in focus groups with addiction professionals (physicians, psychiatrists, and psychologists) who had tried the guideline and with psychiatrists specializing in addiction but without experience with ADHD. RESULTS: Our analysis revealed a number of barriers to the implementation of this guideline, including lack of information from the family, pressure from patients and caregivers to make an ADHD diagnosis, and the potential for abuse of ADHD medication. Furthermore, diagnostic instruments for ADHD have not been validated in people with substance use disorder. Although patients with ADHD are usually treated in an outpatient setting, patients with ADHD comorbid with substance use disorder are difficult to identify in an outpatient setting for various reasons. Finally, there is a lack of specific ADHD expertise in substance use treatment organizations. CONCLUSIONS: Despite the availability of an approved guideline for recognizing and treating adult ADHD in patients with a substance use disorder, underdiagnosis and inadequate treatment still persist. As in general substance use treatment, medication only plays a supportive role in the treatment of substance use disorder with comorbid ADHD. An integrated approach and further improvements in the competence of practitioners may help to reduce the resistance to diagnosing ADHD in substance use treatment centers. Practitioners who specialize in addiction medicine and therapists without medical education view the problem from different perspectives and therefore each group needs specific information and training. Targeted interventions need to be developed to keep these patients in treatment.

The Effectivity of a School-Based Early Intervention Targeting Psychological Complaints and Non-Suicidal Self-Injury in Adolescents.

Background: Recent research suggests a concerning trend of non-suicidal self-injury (NSSI) and suicidal behaviors emerging at younger ages (as early as age 12). Early onset of NSSI is linked to more severe outcomes. While universal school-based prevention programs have shown promise in addressing suicidal behaviors, there is limited research on their effectiveness in preventing NSSI onset among adolescents. This study aims to evaluate the efficacy of a universal prevention program in schools for NSSI and mental complaints while enhancing resilience and mental health in 11-14-year-old adolescents. Methods: In total, 329 Flemish secondary school students (55.6% female), aged 11 to 14 years, participated in a 4 h classroom universal prevention, with a focus on emotion regulation, mental health, and specific strategies to prevent NSSI and reduce stigma. For both the intervention and control group (N = 124), a pre-, post-, and one-month follow-up questionnaire was administered, containing reliable and valid measures for NSSI and suicidality, emotion regulation, help-seeking behaviors, well-being, and psychological distress. Results: The prevention program effectively reduced NSSI and psychological distress, particularly for adolescents with a history of NSSI. Conclusions: These findings support previous research on the effectiveness of school-based programs in reducing mental complaints and suggest promising outcomes for NSSI prevention.

Strengthening Mental Health and Resilience Through Schools: Protocol for a Participatory Design Project.

BACKGROUND: Mental health problems are a main contributor to the global burden of disease in children and young people within urban environments. In response, the potential of both school- and sport-based mental health promotion interventions has been advocated. However, there exists limited insights into how sport-based interventions can be integrated within school environment. Moreover, there is a need to consider children and young people's specific needs, challenges, and motivations when designing novel mental health promotion interventions. OBJECTIVE: The Strengthening Mental Health and Resilience Through Schools (SMARTS) project aims to co-design an evidence-informed school-sport-based mental health promotion program. Specific objectives include (1) co-designing a multicomponent program, integrating sport sessions with class-based sessions, and complementing with educational modules for teachers and parents; (2) exploring how the mental health program can be implemented most effectively within the Brussels school system; and (3) conducting preliminary process and outcome testing of the program. METHODS: A participatory design framework will be adopted to develop the program. This framework involves end users throughout the entire study process, from problem identification to intervention delivery and evaluation, while at the same time ensuring program development remains directly informed by the available scientific evidence. RESULTS: Participant recruitment will commence in September 2023. The full project will be completed by March 2027. CONCLUSIONS: With this intervention, we aim to provide a direct contribution to the promotion of children and young people's mental health within the Brussels school context. At a broader level, conducting and documenting this large participatory design project can, hopefully, inspire other researchers to tailor their mental health programs to specific populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/49670.

Risky Sexual Behaviour and Sexual Victimization among Young People with Risky Substance Use in Europe-Perspectives from Belgium, Sweden, the Czech Republic, and Germany.

BACKGROUND: Research indicates that among the risks associated with young people's alcohol and illicit drug use are sexual risks. However, insights into co-occurrence of substance use and sexual risks in adolescent samples and possible differences across countries are limited. METHODS: A sample of 1449 adolescents from Belgium, Sweden, the Czech Republic, and Germany screened positive for risky alcohol/illicit drug use in a web-based intervention against alcohol and illicit drug use. They also reported incidents of sex while being drunk and/or high on drugs, condomless sex on these occasions, and sexualized touching and sexual victimization while being drunk or high on drugs. RESULTS: In the sample, 21.5% of the participants reported sexualized touching, 9.9% being victim to sexual assault, and 49.8% having had sex while being drunk and/or high on drugs; of the latter, 48.3% had condomless sex. Reports on having had sex while being drunk and/or high on drugs were associated with higher levels of past 30-day binge drinking. Being a victim of sexual assault was associated with past 30-day binge drinking only in young men. CONCLUSION: When devising preventive interventions against risky substance use in adolescents, an additional focus should be set on integrating steps against sexual risks.

Subjective wellbeing and psychological symptoms of university students during the COVID-19 pandemic: Results of a structured telephone interview in a large sample of university students.

University students are at elevated risk for psychological distress, especially during the COVID-19 pandemic. The aim of this study was to warmly contact our students and investigate the psychological impact of the COVID-19 pandemic on the subjective wellbeing (SWB) and levels of psychological symptoms (such as depressive and anxious feelings) of university students in Belgium. All bachelor and master students of the Vrije Universiteit Brussels (N = 15,475) were invited for a brief structured telephone interview in March, 2021. In total, 7,154 students were assessed by a structured interview, based on the Kessler Psychological Distress Scale (K6) and the Anamnestic Comparative Self-Assessment (ACSA). Compared to a representative sample, students considered their life during the pandemic as less satisfying compared to their life before the pandemic. Overall, all students have suffered from COVID-19 and the measures taken to contain the pandemic. Twenty percent of our sample of 7,154 VUB students scored above the K6 cutoff, indicating a heightened risk for having a diagnosable mental illness severe enough to cause functional limitations and to require treatment. This study highlights the need for psychological support for all students, during the COVID-19 pandemic.

Essential elements of treatment: a comparative study between European and American therapeutic communities for addiction.

The purpose of this study was to investigate whether European and American therapeutic communities (TCs) for addiction, both traditional and modified, share a common perspective on what is essential in treatment using the Survey of Essential Elements Questionnaire (SEEQ). The European sample (N = 19) was gathered in 2009. For the American sample (N = 19), we used previously published research data. Despite comparable perspectives, European traditional TCs (N = 11) scored significantly higher than their American predecessors (N = 11) on four SEEQ domains. Cluster differences were more pronounced in Europe than in America.

The impact of a social network intervention on retention in Belgian therapeutic communities: a quasi-experimental study.

BACKGROUND: Although numerous studies recognize the importance of social network support in engaging substance abusers into treatment, there is only limited knowledge of the impact of network involvement and support during treatment. The primary objective of this research was to enhance retention in Therapeutic Community treatment utilizing a social network intervention. AIMS: The specific goals of this study were (1) to determine whether different pre-treatment factors predicted treatment retention in a Therapeutic Community; and (2) to determine whether participation of significant others in a social network intervention predicted treatment retention. DESIGN, SETTING AND PARTICIPANTS: Consecutive admissions to four long-term residential Therapeutic Communities were assessed at intake (n = 207); the study comprised a mainly male (84.9%) sample of polydrug (41.1%) and opiate (20.8%) abusers, of whom 64.4% had ever injected drugs. Assessment involved the European version of the Addiction Severity Index (EuropASI), the Circumstances, Motivation, Readiness scales (CMR), the Dutch version of the family environment scale (GKS/FES) and an in-depth interview on social network structure and perceived social support. Network members of different cohorts were assigned to a social network intervention, which consisted of three elements (a video, participation at an induction day and participation in a discussion session). FINDINGS: Hierarchical regression analyses showed that client-perceived social support (F1,198 = 10.9, P = 0.001) and treatment motivation and readiness (F1,198 = 8.8; P = 0.003) explained a significant proportion of the variance in treatment retention (model fit: F7,197 = 4.4; P = 0.000). By including the variable 'significant others' participation in network intervention' (network involvement) in the model, the fit clearly improved (F1,197 = 6.2; P = 0.013). At the same time, the impact of perceived social support decreased (F1,197 = 2.9; P = 0.091). CONCLUSIONS: Participation in the social network intervention was associated with improved treatment retention controlling for other client characteristics. This suggests that the intervention may be of benefit in the treatment of addicted individuals.

Motivation and readiness for therapeutic community treatment: psychometric evaluation of the Dutch translation of the Circumstances, Motivation, Readiness, and Suitability scales.

There is empirical evidence that treatment motivation and readiness are closely linked to retention. Several instruments have been developed to measure these concepts; such instruments can reliably assess the stages of motivation and readiness, and predict treatment retention and outcome. However, limited efforts have been undertaken in Europe to translate those instruments and to determine their reliability and validity. In this study, the psychometric properties of a Dutch translation of the Circumstances, Motivation, Readiness, and Suitability (CMRS) scales by De Leon and Jainchill and the shortened CMR Intake Version are illustrated in a Flemish sample of therapeutic community residents (n = 207). Exploratory factor analyses confirm three CMR subscales, although confirmatory factor analysis reveals only a moderate fit for both the CMRS and the CMR. In contrast, the predictive power of the instrument is strong, specifically for 1-year retention. Significant correlations were found between CMRS measures and age, drug severity, legal referral, and social problems. It is concluded that the Dutch translation of the CMRS and the CMR can be employed as a valid indicator of treatment motivation and readiness, although additional research concerning factorial structures is needed.

Problem severity profiles of substance abusing women in European Therapeutic Communities: influence of psychiatric problems.

This article aims to search for a specific female, psychiatric profile based on a large European sample of substance dependent clients (828) entering therapeutic communities. First, all six areas of functioning of the EuropASI were included, using the composite scores to search for gender differences. Next, the 'psychiatric' status section was selected for further study. A binary logistic regression was performed with gender as the dependent variable, and nine individual psychiatric items, country, and age as predictors. According to this model a number of problem variables could be identified as being reported more often by women than by men in therapeutic community treatment. Women are more likely to report serious depression, problems in understanding, concentrating or remembering, being prescribed medication, and serious thoughts about suicide; they have also attempted suicide more often than men. Women find treatment for these psychological problems more important than their male counterparts. They also have a more severe history of abuse. Women in therapeutic communities may need specific treatment interventions for their more severe psychiatric needs.

Mentally ill offenders in prison: the Belgian case.

According to the EUPRIS-study on mental health in prisons (2007), available data on mental disorders in prison are scarce. Therefore, this study aims at summarizing and discussing the available knowledge on incarcerated mentally ill offenders concerning: (1) the screening and assessment for detecting mental health; (2) the psychiatric expertise in order to evaluate the mental status; and (3) the development and provision of forensic psychiatric treatment and care. These findings will be applied to the current situation in Belgium, which is a particularly interesting case. Belgium is currently facing difficulties concerning a large population of interned mentally ill offenders residing in correctional establishments. Implications with regard to the penal code, general or mental health legislation, screening, assessment, and treatment could deliver interesting viewpoints on how this problem could be tackled more effectively. Therefore, the findings will be discussed with reference to the international scientific and policy debate, focusing on ethical implications.

Informant agreement in the assessment of disruptive behavior disorders in detained minors in Belgium: a diagnosis-level and symptom-level examination.

OBJECTIVE: Because diagnostic assessment of children emphasizes information from multiple informants, the reliability of findings in detained and incarcerated samples may be hampered. The objective of the current study was to examine parent-child agreement with regard to disruptive behavior disorders (with or without impairment) and disorder-related symptoms in detained male youths. METHOD: Between January 2005 and February 2007, a representative sample of 150 detainees, 12 to 17 years old, from the 3 Youth Detention Centers for boys in Flanders, Belgium, and 1 parent of each were interviewed with the Diagnostic Interview Schedule for Children, Version IV (DISC-IV). Interviewees were selected consecutively on the basis of Belgian origin for practical, financial, and time-related reasons. Of the 150 participants, 9 were excluded and the parents of 26 could not be included for various reasons, and thus full data were obtained for 115 parents. RESULTS: Overall poor parent-child agreement at the disorder and symptom level was found, which is consistent with previous studies. Parents reported significantly more unique information on attention-deficit/hyperactivity disorder (ADHD) (p < .001) and oppositional defiant disorder (ODD) (p < .001), while youths reported significantly more unique conduct disorder (CD)-related information (p = .01). CONCLUSION: The large proportion of parents uniquely reporting ADHD and ODD supports previous concerns about the reliability of self-reported ADHD and ODD and suggests an essential contribution by parents to the accurate assessment of these disorders in adolescent detainees. With regard to CD, it may be appropriate to rely on youth self-report.

The role of gender differences and other client characteristics in the prevalence of DSM-IV affective disorders among a European therapeutic community population.

There is a lack of research illustrating the extent of psychiatric problems in European TCs. Furthermore, there is a need to obtain more insight into gender differences concerning comorbidity in the TC population. In an attempt to respond to previous shortcomings, three specific goals were formulated for the current study. The primary aim was to explore the lifetime prevalence of affective disorders in European TC clients. The second aim was to focus on related gender differences. And finally, client characteristics measured by the EuropASI were related to mood and anxiety disorders measured by the SCID-I. Nine out of ten substance abusers treated in a European TC program have an affective disorder. Gender differences are noted for two anxiety disorders: men have more obsessive-compulsive disorders; women have more post-traumatic stress disorders. The study illustrates that not only gender but also other client characteristics should be taken into account when organizing treatment.

The third generation of therapeutic communities: the early development of the TC for addictions in Europe.

AIMS: It is the goal of this study to investigate the first development of the drug-free therapeutic community (TC) in Europe. The paper aims at systemizing information, scattered all over Europe and is the first stage in an ongoing study to record the development of the European TC movement and its influences. DESIGN: After a study of the grey (hidden) literature, TC pioneers and experts per country were contacted to further elaborate the first findings. Subsequently, a preliminary summary of our findings was published in the Newsletter of the European Federation of Therapeutic Communities (EFTC), inviting additional information and corrections. The authors completed the results for this article with relevant first-hand information, obtained through interviews with European pioneers. FINDINGS: The findings are summarized under three topics: chronology, interconnections and European identity. It was found that from 1968 until 1989, a new therapeutic approach arose all over Europe, modeled after Synanon, Daytop and Phoenix House, New York, through Phoenix House, London and Emiliehoeve in the Netherlands. Therapeutic communities were established in Belgium, Finland, Germany, Greece, Ireland, Italy, Norway, Spain, Sweden and Switzerland as well. These communities were closely-knit and interconnected in their reaction against psychiatric and methadone treatment. The European TCs developed an own identity compared to the American ones. CONCLUSIONS: The European TCs adapted the model of their American predecessors to their own culture, influenced more by milieu-therapy and social learning. Instead of harsh behaviorism, more emphasis was placed on dialogue and understanding. Professionals occupied a more pivotal role and took over the dominant position of ex-addicts. Research, executed by TC professionals gradually entered the TC. A generic network of TC connections, through which the development evolved, was uncovered, and clear regional trends can be observed.

Two decades of "research-practice" encounters in the development of European therapeutic communities for substance abusers.

In 1981, a "research-practice" breakthrough was realized through the foundation of the European Federation of Therapeutic Communities (EFTC). Since its foundation EFTC regularly organized conferences and symposia. A few years later (in 1983), the European Workshop On Drug policy Oriented Research (EWODOR) was established at the Erasmus University in Rotterdam, including a special section devoted to the therapeutic community (TC). The authors examined the proceedings of all meetings organized by EFTC and EWODOR. The major topics presented throughout the last 20 years are highlighted in a chronological selection and these presentations largely focus on the challenges of the TC and the state of the art regarding scientific knowledge. In this overview only those authors who published articles in scientific journals indexed in the "Web of Science" (Institute for Scientific Information-ISI) were retained. Although research has never been the primary consideration in TCs, it played a far from negligible role in its development. Research findings prompted innovations and thus often provoked resistance, but on the other hand they functioned as a catalyst between the necessity of a belief system and the reality of society. The role of "grey" literature and the availability of information through the Internet will become more and more important in the communication between researchers and practitioners.