Care improves self-reported daily functioning of adolescents with emotional and behavioural problems

European Child & Adolescent Psychiatry - Emotional and behavioural problems (EBP) have a negative impact on various life domains of adolescents. Receiving care for EBP may improve the...     

Differences in psychological symptoms and self-competencies in non-suicidal self-injurious Flemish adolescents

The aim of the present study was to examine differences in psychological symptoms and sense of self-competence between adolescents with and without non-suicidal self-injurious behavior. We collected data in a sample of 281 Flemish adolescents. Psychological symptoms and self-competencies were assessed by means of the Youth Self-Report (YSR) and NSSI was assessed using the Self-Harm Inventory (SHI-22). Results showed significant differences between adolescents with and without NSSI on all psychopathological subscales. Furthermore, adolescents engaging in NSSI reported significantly lower scores on social competence, but equal levels on other competencies. Results revealed that externalizing problems and attention/thought/social problems are significantly associated with NSSI. Results also showed that having a higher score on aggressive behavior or thought problems increases the chance of belonging to the NSSI group; whereas a higher score on the social competence scale decreases the chance of belonging to the NSSI group. Clinical implications of these findings are discussed.     

Doctors and Vampires in Sub-Saharan Africa: Ethical Challenges in Clinical Trial Research

Collecting blood samples from individuals recruited into clinical research projects in sub-Saharan Africa can be challenging. Strikingly, one of the reasons for participant reticence is the occurrence of local rumors surrounding “blood stealing” or “blood selling.” Such fears can potentially have dire effects on the success of research projects—for example, high dropout rates that would invalidate the trial''s results—and have ethical implications related to cultural sensitivity and informed consent. Though commonly considered as a manifestation of the local population''s ignorance, these rumors represent a social diagnosis and a logical attempt to make sense of sickness and health. Born from historical antecedents, they reflect implicit contemporary structural inequalities and the social distance between communities and public health institutions. We aim at illustrating the underlying logic governing patients'' fear and argue that the management of these beliefs should become an intrinsic component of clinical research.Collecting blood samples from individuals recruited into clinical research projects in sub-Saharan Africa can be challenging. Strikingly, one of the reasons for participant reticence is the occurrence of local rumors surrounding “blood stealing” or “blood selling”^1–5; such fears can potentially have dire effects on the success of research projects—for example, high dropout rates that would invalidate the trial''s results—and ethical implications related to cultural sensitivity and informed consent. Though commonly considered as a manifestation of the local population''s ignorance and/or disconnection from modern society, these rumors often represent an attempt to make sense of sickness and health. As such, the currently adopted solution to address such concerns—namely, including additional information on the medical procedures in the informed consent process—is inadequate to prevent or dispel existing doubts or distrust toward clinical research and fails to circumvent the associated pitfalls for trial implementation and the related ethical hazards. We aim at illustrating the underlying logic governing patients'' fear of providing blood samples in Gabon, while showing its applicability in other settings in sub-Saharan Africa by drawing from ethnographic data collected in Gabon between 2007 and 2009 and a general literature review.The fear of giving blood has been reported across sub-Saharan Africa and has been associated with conceptions of blood as a lifeforce,^4–6 with beliefs that a lack of blood is a sign of diminished strength and inherent disease^7–10 and with notions of blood being a tradable good, requiring remuneration.⁴ In still other settings, such as in Gabon and certain other African countries, these fears are often linked to mystical realms of reality. To understand the logic guiding accusations of blood stealing and selling here we must first understand how and why sudden and unexpected illness/death is frequently attributed to sorcery. In Gabon, disruptions of social order and/or health, such as inexplicable good or bad fortune or sudden illness and death are ascribed to evou, a mystical agent of the invisible world, translated in French as le vampire, though unrelated to the Western concept of the “living-dead.” The vampire is passively available in most people, but is an active force in sorcerers (who use it to inflict illness) and in healers (who with it offer recovery of health).When sorcery is identified as the cause of an inexplicable event, the question of who is responsible soon follows. In various contexts throughout Africa, Gabon included,^11–18 these accusations are frequently directed at those who are “unnaturally” successful. Such people of influence are suspected of having acquired their power through the consumption of the souls of mystically killed innocents (i.e., “eating people,” “drinking their blood”)^19–22; notably, the agent needed to acquire such unnatural wealth is precisely what clinical trials require from their participants: blood. Alleged evou users are believed to acquire power through blood sacrifices, consisting of the mystical forfeit of family members, children, and unknown innocents who, as a result, will become ill and die.^19–21,23 Consequently, institutions where blood is regularly collected—namely hospitals and research centers—are considered highly suspect.In the Gabonese context, it is believed that blood drawn from hospital patients or research participants is sold by medical staff to the Rosicrucian Order,^19–21 a semi-secret society affiliated with the Free Masons of Western Europe and the United States. The Rosicrucian order has been strongly linked to colonial²⁴ and postcolonial governments,²⁵ and boasts numerous highly visible and influential members, reportedly even in government circles. Most importantly, its affiliates are believed to secure their stations through sorcery, whereby members use the acquired blood in sacrificial rites to secure or enhance their positions of influence.²⁶Notably, such perceptions are not a new phenomenon. Rumors of blood theft, including specific references to the medical field, date back to colonial Africa where blood thieves were often described as white people, or their black collaborators, operating at night using European technology, such as medicines and syringes, to extract local people''s blood, which they then either sold or transformed into other commodities, such as medicine.^27–30 Among many examples recorded by historians across sub-Saharan Africa, the following are quite illustrative of populations'' interpretations of the medical field: in the mid-1940s it was said that Medical Department trucks patrolled the streets in Lamu, Kenya, and, were they to come upon a straggler, would draw out all of his blood with a rubber pump, leaving the body in the gutter.²⁹ Over a decade later, “motor vehicles painted red” were said to drain the blood from lone pedestrians captured along the Kisumu highway to Busia; the blood was then reportedly taken to blood banks in hospitals.²⁹Apart from these historical antecedents, various factors continue to foster an association between rumors of blood stealing/selling and medical research in sub-Saharan Africa. Unavoidably, clinical research involves blood sampling from patients. Study participants'' poor understanding of the reasons for blood collection and of general trial goals in general increases the ambiguity required for blood taking to be linked to blood theft and inexplicable illness. Furthermore, limited community participation, the social distance between communities and medical institutions, the association of hospitals—and research centers in particular—with authoritarian and elitist state and foreign institutions, and palpable social class divisions further nurture these suspicions. Pre-existing patients'' fears within any of these domains may be aggravated by poor comprehension during the informed consent process,³⁰ potentially caused, among other factors, by poor communication between the patient and the researcher, power unbalance, lack of time, or by insufficient consideration for the local cultural features in the informed consent process.Blood stealing/selling, however, is not the only rumor associated with clinical research. Rumors of purposive sterilization of women associated with clinical trials have been reported since 1920 throughout Africa. Furthermore, anti-malarials, vaccinations, condoms, micronutrients, vitamins, and other public health interventions continue to be suspected of causing sterility or of containing hidden contraceptives.^30–39 These rumors continue to be reinterpreted or generated in contemporary African societies and are frequently linked to magical realms of power.^13–18 These beliefs paint a grim historical picture on how local populations perceive medical expertise and therapeutic power, with the underlying concerns likely preceding the advent of clinical research. In this context, health education campaigns or consent forms, meant to inform local communities on the use of collected blood may have little impact as perceptions of blood extraction date back to colonialism, to the introduction of western medicine and persist in modern forms of sorcery accusations. Rumors, such as these, are a reflection of social injustice and asymmetric power relations,³² historical threats to the collective survival of particular groups, and a way to interpret society.³¹ As such, though the Gabonese concept of “evou” is local, it is founded upon a universal rational search for causality in the face of inexplicable events such as illness and death. Not very different from attributing the inexplicable to the will of God (in monotheist religions), to transgressions or good deeds in a previous life (reincarnation), to the intervention of ancestors (ancestor worship), to spirits (animism), to good luck, faith, or sorcery,^22,40 such universal beliefs represent a social diagnosis or a rational attempt to make sense of a chaotic, unjust and an often incomprehensible world.Concerns such as these, further present an important bottleneck for the ethical conduct of research and for routine surveillance. The ethical principle of respect for persons, widely recognized as a pillar of medical research,⁴¹ implies the specific duty of being sensitive to other cultural perspectives.⁴² Researchers should, therefore, develop culturally appropriate ways to communicate with research participants^42–44 and address concerns such as those mentioned previously. Being part of the sociocultural context, similar beliefs are also shared to a large extent by local medical staff within international research teams, making the need for cultural sensitivity all the more pressing. Unfortunately, there is a gap between principles and practices as the adequate expertise and resources needed to address culturally based concerns are still largely absent and remain a non-priority in biomedical and clinical research.There have been noteworthy—but anecdotal—efforts of researchers trying to counter blood-selling rumors by increasing the information provided to communities or through some form of community participation (e.g., inviting patients to visit the laboratories) and sensitization or even by avoiding the color red in symbols and products related to the intervention. Additional measures such as community consent and participation aiming at reducing the distance between trial teams and communities could have a positive impact. However, no in-depth research on how to avoid or tackle these rumors has been carried out thus far; therefore, making recommendations at this point remains an exercise in futility.In conclusion, accusations or rumors on blood stealing and blood selling cannot simply be labeled as participants'' ignorance. Born from historical antecedents, reflecting implicit contemporary social and structural inequalities, and the social distance between communities and public health institutions, these rumors or accusations represent a social diagnosis and a logical attempt to make sense of the clinical trial in today''s world. As such, these beliefs should be acknowledged and their management become an intrinsic component of clinical research.     

Attachment Narratives in Refugee Children: Interrater Reliability and Qualitative Analysis in Pilot Findings From a Two‐Site Study

Although forced migration research on refugee family functioning clearly points to the potential breakdown of parental availability and responsiveness in the context of cumulative migration stressors, studies exploring attachment security in refugee children are surprisingly lacking so far. The authors report their findings from a 2‐site, small‐scale administration of an attachment measure, adapted for use with refugee children aged between 4 and 9 years from a reliable and validated doll‐play procedure. We evaluated interrater reliability and conducted a qualitative analysis of refugee children's narrative response to identify migration‐specific representational markers of attachment quality. The level of agreement among 3 independent coders ranged between .54 to 1.00 for both study samples, providing initial psychometric evidence of the measure's value in assessing child attachment security in this population. The exploratory analysis of migration‐related narrative markers pointed to specific parameters to be used in parent–child observational assessments in future validation of the attachment measure, such as parental withdrawal or trauma‐communication within the parent–child dyad.     

The effects of early prevention programs for families with young children at risk for physical child abuse and neglect: a meta-analysis

In this article, a meta-analysis is presented on 40 evaluation studies of early prevention programs for families with young children at risk for physical child abuse and neglect with mostly nonrandomized designs. The main aim of all programs was to prevent physical child abuse and neglect by providing early family support. For the meta-analysis, a multilevel approach was used. A significant overall positive effect was found, pointing to the potential usefulness of these programs. The study demonstrated a significant decrease in the manifestation of abusive and neglectful acts and a significant risk reduction in factors such as child functioning, parent-child interaction, parent functioning, family functioning, and context characteristics.     

Participation in medical research as a resource‐seeking strategy in socio‐economically vulnerable communities: call for research and action

The freedom to consent to participate in medical research is a complex subject, particularly in socio‐economically vulnerable communities, where numerous factors may limit the efficacy of the informed consent process. Informal consultation among members of the Switching the Poles Clinical Research Network coming from various sub‐Saharan African countries, that is Burkina Faso, The Gambia, Rwanda, Ethiopia, the Democratic Republic of Congo (DRC) and Benin, seems to support the hypothesis that in socio‐economical vulnerable communities with inadequate access to health care, the decision to participate in research is often taken irrespectively of the contents of the informed consent interview, and it is largely driven by the opportunity to access free or better quality care and other indirect benefits. Populations' vulnerability due to poverty and/or social exclusion should obviously not lead to exclusion from medical research, which is most often crucially needed to address their health problems. Nonetheless, to reduce the possibility of exploitation, there is the need to further investigate the complex links between socio‐economical vulnerability, access to health care and individual freedom to decide on participation in medical research. This needs bringing together clinical researchers, social scientists and bioethicists in transdisciplinary collaborative research efforts that require the collective input from researchers, research sponsors and funders.     

Salivary cortisol: a possible biomarker in evaluating stress and effects of interventions in young foster children?

Young foster children undergo an early separation from their caregiver(s) and often experience severe stress before placement. However, a considerable part of the children do not show apparent signs of distress, making it difficult for the foster carer to be aware of the amount of stress in their foster child. Potential evidence for using salivary cortisol levels as a dimension to evaluate the amount of stress in young foster children is reviewed. Moreover, the applicability of salivary cortisol in the evaluation of stress-reducing interventions for young foster children is discussed. A systematic review was performed using the databases Medline, Psychinfo, Embase, Ebscohost, and Academic Search Premier. Nine studies were traced in which salivary cortisol was used to measure stress in children placed in family foster care or in adoptive families. Stress in general but also neglect, early loss of a caregiver, a younger age at first placement, and a higher number of placements were associated with an altered hypothalamic–pituitary–adrenal (HPA) axis function in foster children. Moreover, four studies on the effect of stress-reducing interventions on HPA-axis functioning of young foster children were found. These studies suggest that caregiver-based interventions can actually help to normalize the HPA-axis function in foster children, and that such changes co-occur with improved behavioral functioning. Although the results from the papers discussed in this review suggest that diurnal cortisol with a wake up and a bedtime measurement may be a relevant tool to evaluate stress in young foster children, this cannot yet be concluded from the present studies, because statistical data from the studies on foster care and adoption in this review were not robust and researchers used different methods to collect the salivary cortisol. Still, it is noteworthy that all studies did find the same pattern of reduced levels in relation to chronic stress (caused by maltreatment and neglect of the child).     

Stroke versus primary CNS lymphoma in the immunocompromised patient.

Primary central nervous system (CNS) lymphomas are an uncommon form of brain neoplasm that should be considered in the immunocompromised patient with neurological changes. It can be difficult to distinguish primary CNS lymphoma from stroke on initial radiographic images. Neuroscience nurses who are involved in the care of these patients should be prepared to assist the patient and family in coping with an evolving diagnosis and in explaining the related diagnostic procedures, treatment options, and eventual discharge plan.     

Refining the COPES to Measure Social Climate in Therapeutic Residential Youth Care

Background

Previous studies have shown that social climate in therapeutic residential youth care (TRC) is important to the welfare of residents, staff, and assessing treatment outcomes. The most influential theory on social climate in residential settings is the theory of Moos. The measurement of the concepts and aspects of this theory using the Community Oriented Programs Environment Scale (COPES) has repeatedly been criticized regarding usability, validity, and reliability, especially for TRC.

Objective

To improve the usability and psychometric quality of the COPES by shortening and refining the original subscale structure for usage in TRC.

Methods

Four-hundred adolescents living in Norwegian TRC participated. We supplemented confirmatory factor analysis (CFA) with item response theory (IRT) to evaluate model fit, investigate factor loadings, and shorten scales to improve their psychometric qualities and usability in describing social climate in TRC.

Results

The original subscales were not acceptable as evaluated by the criteria for CFA and IRT. By removing psychometrically weak items, the instrument was shortened to 40 items within the original ten subscales. This short version showed acceptable psychometric qualities based on both CFA and IRT criteria and the instrument retained its content validity. Finally, the original three higher-order dimensions was not supported.

Conclusions

Compared to the original instrument, the refined 40-item version of the COPES represents a more usable instrument for measuring social climate in TRC. Future studies are needed to confirm the multifaceted refined short version in comparable samples of youth and staff to further investigate predictive value and construct validity.