To the best of our knowledge, this is the first study to evaluate the previous substance use, strenghts and difficulties, self-esteem and SWB of intitucionalized adolescents in a portuguese TC. The 2019 European School Survey Project on Alcohol and Other Drugs (ESPAD) data collection is useful to compare the substance use and other forms of risk behaviour between our sample and 15- to 16-year-old european students included in ESPAD [36]. The 2019 ECATD-CAD, a cross-sectional study carried out among portuguese public school students aged between 13 and 18 years old, is also referenced [37, 38]. In ESPAD countries 41% of students had smoked cigarettes at least once in their lifetime, and one fifth of the sample (20%) were considered current smokers, with similar proportions in the ECATD-CAD [36, 38]. Meanwhile all of our participants had previously consumed tobacco. In almost all ESPAD countries, over half of the students reported having consumed alcohol at least once during their lifetime. The ESPAD average was 79% and, in Portugal, was 68% [36, 37]. The reported alcohol use on our sample was superior to both of those proportions. The average prevalence of lifetime use of illicit drugs was 17%, with considerable variation across ESPAD countries [36]. It should be noted that this mainly relates to cannabis use (average lifetime prevalence of 16%). In Portugal 15% of students had already used some illicit drug, with slightly fewer of those who did so in the last year (13%) and far fewer in the month prior to the survey (6%) [37]. Cannabis was the most commonly used illicit substance (13%, 12% and 6% in the lifetime, last 12 months and last 30 days, respectively). The percentage of students with daily or almost daily cannabis use was residual (1%), although, when considering only the group of current users, the percentage was higher (14%) [37, 38]. The use of illicit drugs other than cannabis had some expression in terms of experimentation (5%) and recent use (3%), with a residual percentage of use in the last month (<1%) – in descending order of prevalence, ecstasy, amphetamine, cocaine and LSD or other hallucinogens [36–38]. Our participants reported previous substance use (cannabis or others) in line with the results found in ESPAD and ECATD-CAD, although with higher proportions as expected in a TC.
In our sample, the prevalence of previous psychological contact was 83.6%, with a lower percentage for previous psychiatric contact (43.3%). Both percentages are superior to those observed in studies about general residential care [11, 39]. Sainero and colleagues found that 27% of the children aged between 6 and 18 in residential care in south-western Spain were receiving psychological treatment [39]. However, the percentage of children having a clinical score on Child Behavior Checklist or on the Youth Self Report rose to 45%, meaning that many of these children had not been diagnosed or received treatment [39]. Indeed, in our study, there is also evidence of psychological problems and psychosocial difficulties which may indicate a high frequency of psychopathology. The sum of the percentages above the cut-off points for the borderline and abnormal scores in the SDQ total of difficulties was 53.8%. Similar values were found in studies with adolescents in residential care [40, 41]. Regarding SDQ subscales, the ones with a higher number of participants with a borderline or abnormal score were, in descending order, hiperactivity (46.3%), conduct problems (46.2%), peer problems (38.9%), emotional symptoms (25.4%) and prosocial behavior (9%). This seems to suggest that our youth self-reported more externalizing problems than internalizing. While it is true that other studies observed the same trend and our participants were young people in a TC due to high-risk behaviors, we wonder if it could be influenced by the youth self-perception as well as an internalised stigma about emotionality [41, 42].
Our participants had self-esteem levels within normal range (20.2±4.84). In fact their self-esteem levels were higher than the total RSES mean score obtained by Pechorro et al. for 15-17 year olds of a forensic sample (15.9±0.80) and a school sample (15.8±0.75) [28, 29]. We found average mean levels of SWB in our youth (78.6±12.39), which is in the normative range for Western populations. Indeed the adolescents intitucionalized in ART scored above 75 points out of 100 on the PWI total scale and above 6 points out of 10 on the OLS, which are in line with results obtained by researchers in adolescent in-care populations in Catalonia and Portugal [11, 43, 44]. On the other side, our results were superior to those observed on another national study both in general population (70.9±11.83) and youth in generalist residential care (68.7±16.39), although the difference is not of statistical signifance [45]. While some other works identified higher levels of self-esteem and SWB in males, in our sample the only gender difference observed was in SDQ total score [11, 45–47]. Out of all PWI’s domains, our participants scored higher on Personal Health and Personal Safety (both above 8 points out of 10). We hypothesized that living in ART is associated with structure and stability, both identified as important factors for well-being in studies about residential care [48]. We were aware that many of the participants came from situations of severe vulnerability (social, economic and environmental). As highlighted by other works, a stable and positive relationship of the adolescent at risk with educators is a key factor of resilience, self-esteem, and SWB, and that may be a protective factor in our sample [49–51]. Studies with a very specific population, namely adolescent prisoners, suggest that they frequently adopt passive coping styles during the initial phase of incarceration, but during the process of adaptation the use of these coping strategies declines, favoring active coping techniques [52–55]. Among incarcerated adolescents, the use of passive coping was associated with a poorer well-being and increased psychological stress, and active coping was associated with a decrease in psychological distress and a positive adjustment to incarceration, although the effects were modest [53–55]. Some works suggest that self-esteem might deteriorate due to negative processes associated with any type of institutionalization, like stigmatization, but others indicate that self-esteem remains stable or even increases during imprisonment depending on the ability of adolescents to adjust and cope with the new circumstances [56, 57]. Our participants share several similarities with them, including multiple life stressors, disadvantaged backgrounds, and present or past personal history of legal issues. It is possible that the coping styles of our adolescents are another significant factor for the normal range of their self-esteem and SWB levels.
We found correlations between cannabis use and externalizing behavioral difficulties (conduct problems), SDQ total difficulties and low prosocial behavior. Our results are consistent with those found in other works suggesting that early-onset persistent conduct problems were associated strongly with problem cannabis use and that cannabis use can be viewed as an indicator of risk for mental health problems in adolescence [58, 59]. We also found a positive correlation between other substances (sedatives and hallucinogens) and internalizing behavioral difficulties (peer problems), which could indicate a different psychological profile with the use of less common substances as possible coping strategies for internalizing problems [60, 61].
Limitations
One of the measures introduced during the first wave of COVID-19 cases in Portugal (from March 19 to May 2, 2020) was a social lockdown, including temporary school lockdowns, and afterwards a generalised move to online teaching. The following school year resumed with some “normality” until Portugal entered a second nationwide lockdown, from January 15 to March 15, 2021, with the need to go back to online teaching. During those months of lockdowns and uncertainty, the youth living in ART were deprived of face-to-face contact with their families, friends, school peers and teachers, with a potential deleterious effect on young people's well-being and other parameters. Although both periods of data collection shared similarities and did not include the months of lockdowns, the national panorama was complex and very particular, which could bring bias to our results since predictors of life satisfaction include stressful events and social support network [62]. On the other side, it is important to reflect that, given the impossibility of other types of activities and social contacts, both lockdowns contributed to the deepening of the relationships between adolescents and ART educators. Based on our results and taking into account what was observed in other works, it is possible to theorize that the strengthened relationships were protective and contributed positively to self-esteem and SWB levels observed in our sample. Regarding the temporal order, is not conclusive whether substance use affects quality of life and behavior, or whether it is the other way around. Another limitation is that the data are entirely based on self-reported information provided by the adolescents.