Mental health problems among children and youths are common and have numerous negative consequences for young people and their social network. Therewith, these problems pose a social issue. GPs... Show moreMental health problems among children and youths are common and have numerous negative consequences for young people and their social network. Therewith, these problems pose a social issue. GPs play an important role in early detection and management of these problems. Insight into their clinical decision- making and, as a result, way of working would be helpful to develop methods for providing children and youths with the help they need. Previous literature suggest many doctors(-to-be), of whom some are or will become GPs, have (lived) experience related to mental health problems themselves. Previous studies also suggest having (lived) experience influences GPs’ clinical decision-making, and consequently their way of working. It would have clinical benefits for GPs and patients to explore this process. This thesis is constructed of four different articles, each contributing to answering the main question: ‘How do GPs decide on child and youth mental health problems and what is the influence of their(lived) experience regarding these problems on this decision?’ Article 1: How do GPs make decisions regarding mental health problems in children and youths? For answering this subquestion, a mixed methods design was used: interviews among 14 and an online survey among 15 GPs. GPs were asked about their clinical decision-making process on children and youths with mental health problems using three vignettes describing children and youths with mental health problems representative of clinical practice. The findings suggest GPs differ with regards to their decision- making regarding child and youth mental health problems, and that their decision-making is influenced by factors related to 1) the GP, for example if the GP approaches the problem somatically or psychosocially, if the GP considers themself competent enough to solve the problem with regards to their interest in and knowledge about youth mental health care, 2) the child and its social context, for example if the child or youth has psychiatric (co)morbidity, if the problem is likely to solve itself and if the problem could be assessed as being complex and 3) the GPs’ collaboration with other youth care providers, for example if GPs have existing collaboration agreements with these youth care providers and how they view their collaboration. Article 2: Can GPs’ decisions on child and youth mental health problems be supported by means of a decision-support method?For answering this subquestion, a literature search was conducted to retrieve studies that involved clinical decision support methods for GPs’ clinical decision-making related to mental health problems among children and youths. This systematic review yielded 25 studies on 18 clinical decision-support methods, divided into computer-based methods (such as MyGRaCE), telecommunication methods (such as CAP PC) and methods with a combination of components related to computer-based methods and telecommunication methods (such as Collaborative care for depression intervention). The article provides insight into (possible) beneficial clinical implications of clinical decision-support methods. These methods could give more insight into possible mental health problems, they could provide structured information which can be used by the GP and/or parents during their next consultation with the child or youth, and they could also decrease time and costs spent by the primary care practice and the GP. There are also less beneficial clinical implications, such as an inability for some computer-based methods to be used in emergency situations, when time is short, problems for children and youths when using computer-based methods because of their mental status, and impediment to discuss certain topics freely because the decision-support method gives too much direction to the consultation. The article describes certain considerations for GPs when choosing a decision-support method, which may indirectly have a positive impact on the implementation of such methods into general practice. For example, the GP can take into account their way of working, user flexibility of the method for the GP, the child/youth and their parent(s) with regards to understandability and ease of use, if the GP already uses a clinical decision-support method, if the GP already has collaboration agreements with youth care providers, as well as their own attitude and knowledge regarding mental health problems among children and youths.Article 3: Do doctors-to-be, among whom future GPs, have (lived) experience regarding mental health problems? Study focused on preclinical medical students.For answering this subquestion, self-report questionnaires were sent to 1311 preclinical medical students of Leiden University Medical Center to measure burnout-, depression- and anxiety-related symptoms. The article concludes that symptoms related to mental health problems are common among preclinical medical students. Burnout-related symptoms were found in 46%, depression-related symptoms in 27% and anxiety- related symptoms in 29% of preclinical medical students. Burnout-related symptoms among preclinical medical students were correlated with a sleep duration of less than 6 hours per night, low happiness and a high need for recovery after a day of study. Depression- and anxiety-related symptoms were mainly correlated with low optimism, low happiness, and a high need for recovery after a day of study. These findings suggest preclinical medical students are at risk to develop mental health problems, which can inspire universities to come up with preventive interventions.Article 4: Do doctors-to-be, among whom future GPs, have (lived) experience regarding mental health problems? Study focused on medical interns.For answering this subquestion, self-report questionnaires were sent to 709 medical interns of the same institution mentioned in article 3 to measure burnout-related symptoms. Burnout-related symptoms were found in 30% of medical interns. Burnout-related symptoms among medical interns were related to low dedication with regards to work, a high work pace and quantity, a high need for recovery after a day of work and low optimism. These correlates could be used to prevent mental health problems among medical interns by making adjustments to the medical curriculum. The articles of this thesis suggest GPs’ decision-making on mental health problems in children and youths is multifactorial and consists of objective and subjective components. Furthermore, decision-making seems to differ between GPs, which may be an explanation why there are a variety of clinical decision support methods. Some clinical decision support methods have been implemented in the context of research into general practice, like MyGRaCE, CHICA, Mobiletype, Youth StepCare, consultation-liason method(between GPs and psychiatrists), telepsychiatry consultation practice and the MC3 Program. A clinical implication is GPs can choose a decision-support method which match their personal style of clinical decision-making. However, the validity, trustworthiness and usability of available methods need to be further explored. A clinical implication with regards to medical students’ mental health comprises universities provide accessible proactive mental support to preclinical medical interns and medical interns, because many do not seek help themselves. Furthermore, universities could stimulate a stigma-reducing educational environment, for example in collaboration with the department of (Child- and Adolescent) Psychiatry. Therefore, medical students could be equipped with effective strategies to cope with mental health problems. Also, they might be made aware of their vulnerability, so that they may know their subjectivity and use their personal experiences in practice. The results of this thesis invite more (longitudinal) research on the diagnostic precision, predictive value and cost-efficiency of clinical decision-support methods. Furthermore, more research is needed on the prevalence of mental health problems among graduated doctors, like GPs, and possible effects of these problems on their way of working, their decision-making and their contacts with patients. Strengths of this thesis include exploration of a relatively unknown research area, namely GPs’ clinical decision-making regarding mental health problems among children and youths. Therefore, this thesis used multiple research methodologies and it used a practical scope. This thesis also contains several limitations, such as inclusion of a small GP population, as well as self-selection bias in the studies on preclinical medical students, medical interns and GPs. Finally, interpretation of the results of this thesis was impeded because the research has been conducted in one university, because cause and effect of results could not always be disentangled and because of low statistical power. Because having mental health problems may influence GPs’ clinical decision-making, one could explore how (future) doctors work, study and relax. Therefore, it is recommended to strive for educating balanced doctors: persons who, in collaboration with their colleagues, are – through reflection – aware of their needs and wants between professional boundaries. Show less
The societal toll and human misery associated with mental health disorders is well established. Nonetheless, only about one in five minors with mental health difficulties access adequate... Show moreThe societal toll and human misery associated with mental health disorders is well established. Nonetheless, only about one in five minors with mental health difficulties access adequate professional support. Care pathways and procedures have to facilitate timely recognition and adequate evaluation of patients’ needs to navigate those who can benefit towards ‘the right service in the right place, at the right time, and delivered by the right person’ - a meaningful Chinese proverb often used by authors from the field of healthcare. To reach this meaningful goal, professionals should be able to ‘look’ at a patient and ‘see’ patients’ needs. This by relying on their sufficient knowledge to recognize a probable mental health need, their skills and experience to enquire further, known methods to reliably assess strengths and weaknesses, and readily available resources to translate what they see into an adequate support or management plan. In this PhD thesis we present a series of studies aimed to fill gaps in empirical knowledge on this topic of recognition, assessment, and referral of youth with mental health problems at the interface of primary care and mental healthcare. The results of the studies could inform clinicians on the status quo considering recognition and referral of minors with mental health problems. Moreover, the findings could serve policy and curriculum makers, thereby improving effective practices in child and adolescent mental healthcare. Show less
Both prosociality in group context and morality are important aspects of social life and living together with others in society. In both situations, understanding the cognitive processes underlying... Show moreBoth prosociality in group context and morality are important aspects of social life and living together with others in society. In both situations, understanding the cognitive processes underlying the decisions is argued to be a crucial step in designing evidence-based interventions addressing not only choice outcomes, but the driving forces of the choices as well. Using fine-grained and unobtrusive measure of cognitive processes in the decision process, eye tracking is applied in the investigation of cognitive processes in this dissertation. Chapter 2 investigated active ignorance to others’ group membership. Chapter 3 presented two eye tracking studies, in which the cognitive processes of prosociality in intergroup contexts were investigated. Chapter 4 reported a study investigating the cognitive processes underlying moral decisions, speaking to the theoretical debate in moral decision making, advocating a choice discriminability perspective over the dual process theory of moral judgment. The work demonstrates the merit of further illuminating the inner workings of the “black box” of decision making, by using process-tracking techniques to gain insights about decision processes that would have been difficult to achieve when only using choices. Moreover, the work presented here makes a methodological contribution by developing a standardizable and incentivized moral dilemma task Show less
What influences decision-makers to attack another country when on the brink of war? The main aim of this study is to detect a causal mechanism underlying the decision to attack another country when... Show moreWhat influences decision-makers to attack another country when on the brink of war? The main aim of this study is to detect a causal mechanism underlying the decision to attack another country when on the brink of war, and whether or not this mechanism differs between regime-types. It investigates whether or not regime-type, the nature of the conflict, the power used, and hawkish beliefs of decision-makers matter in this decision. By addressing this question from a political psychological and comparative perspective, this dissertation tests the microfoundations of democratic peace theory simultaneously with alternative theories of decision-making during conflict resolution.The core analytical instrument is a decision-making experiment, executed in the US, Russia, and China. The experimental results are triangulated with a large N-study, and a case study. The overall results show that although the democratic peace as an empirical regularity might still be valid, the theoretical arguments to explain why democracies do not fight with each other turn out to be built on empirically unsupported foundations. This study argues that an actor-based approach towards decision-making processes within international relations offers important insights to the more structured-based theories of international relations. It thereby convincingly shows that the individual matters, also in IR. Show less
This thesis presents a series of translational research studies to explore topics of importance to a patient stakeholder community--Duchenne and Becker muscular dystrophy. The overarching objective... Show moreThis thesis presents a series of translational research studies to explore topics of importance to a patient stakeholder community--Duchenne and Becker muscular dystrophy. The overarching objective was to inform a patient/family foundation's interventions and policy and advocacy approaches. Results from a longitudinal study on mothers__ wellbeing support the need for systematic exploration of caregivers__ unmet support needs, especially those related to coping with DMD-related uncertainty and fear. Efforts to improve mothers__ adaptation should focus on fostering resilience and enhancing benefit finding. A study on treatment preferences and disease impact that used Best-Worst Scaling found that caregivers were willing to accept a serious or fatal risk when balanced with a non-curative treatment, even absent lifespan improvement. Parents__ most pressing worries were about symptom progression and access to medical care. The final qualitative studies highlight the complexity of clinical trial decision making, especially for rare, progressive pediatric disorders, where participants equated doing __nothing__ with doing harm. Parents developed intentions to participate in trials before the informed consent process. Parents__ decisions were strongly influenced by the anticipation of individual benefit. The adaptive optimism engendered by the availability of trial was highly valued by both parents and clinicians on trial teams. Show less
In the Netherlands, information provision about fertility preservation (FP) for young women with breast cancer is not sufficient. Since an increasing number of Dutch breast cancer patients will... Show moreIn the Netherlands, information provision about fertility preservation (FP) for young women with breast cancer is not sufficient. Since an increasing number of Dutch breast cancer patients will face this preference-sensitive decision each year, there is a clear need for improvement of information provision about FP. The overall aim of this thesis was therefore to (a) develop and (b) evaluate a Decision Aid (DA) about FP that is targeted to improve information provision and decision making about FP for young women with breast cancer. This thesis describes consecutively the development and evaluation of such a DA with values clarification exercise (VCE) Show less
The referendum is one of the most studied and practiced institutions of semi-direct democracy around the world, in several latitudes and historical times, in different systems and political regimes... Show moreThe referendum is one of the most studied and practiced institutions of semi-direct democracy around the world, in several latitudes and historical times, in different systems and political regimes, at international, national, regional or local levels, with different legal frameworks and with various political consequences. However, Portugal, whose constitutional experience begins in 1820 with the liberal revolution, had its first democratic referendum only in 1998. This study try to conceptually characterize the referendum, in order to establish its fundamental typologies regarding the most relevant experiences in this field and to situate the case for and against the referendum as an expression of semi-direct democracy in the political and philosophical debate of different historical moments. In the next chapters, entirely dedicated to the Portuguese case, we shall present the historical evolution of the nation al and local referendum in the constitutional and political life in Portugal since 1820. An added emphasis will be given to the referendum experience of the Portuguese democracy born in 1974, particular attention being payed to the political debate about the formal introduction of the referendum in the 1976 Constitution and to the concrete experience of referendums proposed and held since then. Show less
The studies described in this thesis address a range of topics related to arousal, exploration, temporal attention, and the locus coeruleus-norepinephrine (LC-NE) system. Chapters 2 and 3 report... Show moreThe studies described in this thesis address a range of topics related to arousal, exploration, temporal attention, and the locus coeruleus-norepinephrine (LC-NE) system. Chapters 2 and 3 report two studies that investigated a recent theory about the role of the LC-NE system in the regulation of the exploration-exploitation trade-off. Chapter 4 reports a study on neurocognitive function in patients with dopamine-β-hydroxylase (DβH) deficiency. Chapter 5 reports an fMRI study on the neural correlates of perceptual curiosity. Chapter 6 and 7 reported several experiments investigating the effects of ‘accessory stimuli’ and temporal certainty on information processing, using scalp electrophysiology and sequential-sampling models of decision making. Taken together, the studies reported in this thesis suggest that arousal, exploration and temporal attention are closely related, which is likely due to a shared neural basis. Show less
Countries that wish to join the European Union (EU) need to implement all existing EU laws before they are admitted as full members. Since the body of EU law comprises more than 80 000 pages and... Show moreCountries that wish to join the European Union (EU) need to implement all existing EU laws before they are admitted as full members. Since the body of EU law comprises more than 80 000 pages and more than 2 000 directives, the adoption of EU law is a truly formidable task for any government. How have the eight countries from Central and Eastern Europe (CEE) that joined the EU in 2004 coped with this requirement of the enlargement process? Surprisingly, this thesis reveals that these post-communist states have been quite successful in adopting the EU directives. Moreover, there is interesting variation in the performance of the new member states with some countries, like Lithuania, doing particularly well, while other, like the Czech Republic, having more problems than average. The thesis argues that the general success of the process of legal adaptation to EU laws in CEE can be largely explained by the conditionality of the enl argement process (EU entry is only possible if and when the condition of implementing the EU rules is fulfilled). Combing statistical methods and case studies in three policy fields (electronic communications, nature protection, and social policy), the thesis concludes that the varying implementation performance in different countries and policy sectors can be explained by reference to the CEE governments’ level of support for the process of European integration, their administrative capacities and the threat of financial sanctions for non-implementation of the EU rules after accession. Show less
Weersvoorspellingen betreffen de toestand van de atmosfeer op een bepaald tijdstip en op een bepaalde locatie. Voorspellingen volgen een model. Maar geen enkel model kan alle variabelen insluiten... Show moreWeersvoorspellingen betreffen de toestand van de atmosfeer op een bepaald tijdstip en op een bepaalde locatie. Voorspellingen volgen een model. Maar geen enkel model kan alle variabelen insluiten die relevant zijn. Zo kan een weersvoorspelling niet de wind meenemen die wordt veroorzaakt door de vleugels van een vlinder, ook als dat de oorzaak is van een latere orkaan. Het is gebruikelijk om gezondheidswinst uit te drukken in termen van kwantiteit en kwaliteit van leven. Een utiliteit is een maat voor de waardering van de kwaliteit van leven. Dit proefschrift behandelt de samenstelling van gezondheidsutiliteiten volgens twee besliskundige modellen, namelijk verwachte nutstheorie (expected utility (EU)) en prospect theorie (PT). EU is een normatieve theorie die voorschrijft hoe rationele beslissingen genomen zouden moeten worden volgens iemands eigen preferenties. Echter er zijn dusdanig sterke en systematische empirische afwijkingen van EU gevonden, dat men voor descriptieve doeleinden is gaan zoeken naar verbeteringen. PT is zo een verbetering. Het is een puur descriptieve theorie en het heeft geen normatieve claims. PT breidt EU uit en omschrijft de fouten en inconsistenties ervan. Dit proefschrift analyseert beslissingen zowel met behulp van het normatieve model, EU, als met behulp van het descriptieve model, PT. Doel is meten van utiliteiten binnen de gezondheidszorg te verbeteren met behulp van descriptieve bevindingen van PT. Show less
In deze studie wordt de invloed van instituties en cultuur op het overheidsbeleid onderzocht. Aan de hand van twee case-studies naar het automobiliteitsbeleid in de steden Birmingham en München... Show moreIn deze studie wordt de invloed van instituties en cultuur op het overheidsbeleid onderzocht. Aan de hand van twee case-studies naar het automobiliteitsbeleid in de steden Birmingham en München wordt duidelijk dat lokale beleidsinstituties en culturen voor een grote mate van invloed zijn op de keuze voor het automobiliteitsbeleid. Een link wordt gelegd met de Nederlandse situatie en het thema van bestuurlijke vernieuwing. Show less
