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Background Cyclothymic-hypersensitive temperament (CHT) has been related to both depression and bipolarity, as well as to suicidality. Recently, a psychometrically sound way of assessment has been validated in youth (Cyclothymic-Hypersensitive Temperament Questionnaire, CHTQ), but data on clinical populations are still scant. Aim of our study is to further explore the structure and other psychometric properties of the revised version of CHTQ and its clinical implications in clinical samples. Methods The study is based on a dataset of patients with unipolar depression, bipolar disorder and attention deficit and hyperactivity disorder (ADHD) (243 patients, 135 males, mean age 14.22 ± 2.16 years, age range 9–18 years), compared to a community sample of adolescents (398 subjects, 95 boys, mean age 15.47 ± 1.96 years, age range 10–18 years) Results The two-correlated factor structure of CHT has been confirmed, with a moodiness/hypersensitiveness factor, correlated with internalizing symptoms, and an impulsiveness/emotional dysregulation factor, correlated with externalizing symptoms. All CHTQ scores correlate with global functioning. CHTQ total scores discriminate patients from healthy controls. Only CHTQ impulsiveness/emotional dysregulation subscale score is higher in bipolar patients, compared to unipolar depression and ADHD, whereas neither CHTQ moodiness/hypersensitiveness subscale score nor CHTQ total score discriminate between clinical groups. Limitation Data on current mood states are unavailable. Patients were recruited in a third level clinic. The unipolar depression group is relatively small. Conclusion CHT may be a rapid and reliable screening and diagnostic tool in the clinical practice with youth, exploring the cyclothymic dimension in different psychiatric disorders.

Introduction Secure attachment in adolescence, related to caregiving quality, is a robust predictor of positive behavioral adjustment in early adulthood and beyond. Nevertheless, few attempts have been made to develop treatments to promote parent–adolescent attachment security. Methods Using a longitudinal, multicenter, randomized controlled trial design, two questionnaire-based studies were run in Italy (Study 1: n = 100 mothers of adolescents, 60% boys, Mage = 14.89, SD = 1.58; Study 2: n = 40 mothers and 40 adolescents, 60% boys, Mage = 14.90, SD = 1.91) to test the effectiveness of an attachment-based parenting intervention (i.e., Connect) in reducing adolescents’ behavioral problems and attachment insecurity 2 weeks post-intervention (t2) and at a 4-month follow-up (t3). It was further investigated whether a decrease in avoidant and anxious attachment at t2 would account for changes in externalizing and internalizing problems, respectively, at t3. All adolescents belonged to two-parent intact families. Results Mothers who completed Connect reported significantly fewer adolescent behavioral problems and lower adolescent attachment insecurity, compared to mothers in the waitlist group, at both t2 and t3 (Study 1). These findings were confirmed in a second subsample (Study 2), considering both mothers' and adolescents’ reports. Controlling for pre-intervention behavioral problems, reductions in internalizing and externalizing problems were observed in both studies at t3 via a decrease in anxious and avoidant attachment, respectively, at t2. Conclusions The findings point to the malleability of attachment security in adolescence and highlight the importance of targeting parenting quality to promote adolescent behavioral adjustment.

Background The failure to regulate emotions, namely emotional dysregulation (ED), is a relevant construct in adolescent psychiatry, in terms of prognostic and developmental implications. We developed and validated a novel self-report questionnaire for the assessment of ED, the RIPoSt-Y, both in clinical and non-clinical samples. Methods Items selection and subscales construction were conducted on healthy controls (n=374), while test-retest reliability was evaluated in a subsample (n=72); internal consistency was examined both in the control group and in two clinical samples, respectively including patients with Bipolar Spectrum Disorders (BSD; n=44) and ADHD (n=34). Construct, concurrent and convergent validity were also assessed. Results Thirty-one items were finally retained, and three subscales were identified (Affective Instability, Emotional Reactivity, Interpersonal Sensitivity). Test-retest was significant for each subscale with moderate-to-good correlations, and internal consistency showed good-to-excellent coefficients. Construct validity was supported by significant differences between patients and controls and gender-related differences. Concurrent validity was confirmed through significant associations with two subscales of the CHT-Q, while convergent validity proved to be significant with the CBCL/YSR dysregulation-profile. Cut-offs were also computed to discriminate clinically significant scores of ED. Limitations The use of a school-based survey to recruit controls could have biased our results; gender distributions between clinical and non-clinical samples were significantly different. Conclusions Our novel questionnaire proved to be a valid and reliable tool able to assess the presence of ED in youths and to characterize this fundamental construct in its multidimensional facets.

Callous-unemotional (CU) traits are associated with gaze pattern deficits in youths, though it has not yet been explored if environmental factors could influence this relationship. Since parenting can influence both CU traits and children's emotion processing, the current study sought to test whether parenting moderated the relation between gaze pattern deficits and CU traits in a sample of children with Disruptive Behavior Disorder. The sample included 92 boys (aged 7–12 years) with Conduct Disorder (N = 12) and Oppositional Defiant Disorder (N = 80). All children completed a task, during which they were presented with 24 images depicting happy, sad, fearful, disgusted, angry, and neutral facial expressions. Gaze pattern has been recorded throughout the task with an eye-tracker. Positive parenting moderated the association between CU traits and first fixation duration to the eyes of facial expressions depicting negative emotions. Negative parenting moderated the association between CU traits and fixation count and fixation duration to the eyes of negative emotions. Negative parenting along with reduced attention to emotional cues (i.e., eyes) may identify a group of youths with Disruptive Behavior Disorder diagnosis at risk for severe outcomes.

Universal prevention approaches have significantly reduced children's conduct problems and aggressive behavior in the school setting, but it has not been clear whether the effects generalize into children's behavior in home and community settings in later elementary school years. The present study examined this issue using a classroom-randomized design, with 1030 students in 70 fourth and fifth grade Italian classes. The intervention model is the Coping Power Universal and the classroom teachers delivered it. Coping Power Universal produced a significant reduction in both parents' and teachers' rated conduct problems, relative to control classes, indicating that universal prevention can produce significant reductions in children's conduct problems that generalize into the home and community settings. The intervention also increased children's prosocial behaviors in school and home settings. The Coping Power Universal is a short intervention model that is believed to be a useful strategy for children's behavioral problems in the broad population.

Previous studies indicated that a lack of empathy could be considered the core feature of callous-unemotional (CU) traits in children and adolescents. The present study is aimed at exploring relationships among CU traits, cognitive and emotional dimensions of empathy, emotion recognition (basic, social, and complex emotions), and history of maltreatment in a sample of youths with conduct disorder diagnosis. The sample consisted of 60 Italian male patients (age range 11-17 years, mean age 13.27±1.90 years) referred to the Department of Child and Adolescent Psychiatry (Pisa, Italy). In the whole sample, the levels of CU traits were significantly negatively associated with both cognitive and emotional dimensions of empathy; in addition, the CD patients with high levels of CU traits show significantly lower levels of empathic concern compared to those with low levels of CU traits. Clinical implications of the findings are discussed.

Background Increasing attention has been recently paid to precursors of bipolar disorder (BD). Symptoms of attention-deficit/hyperactivity disorder (ADHD) have been reported among the most common prodromes of BD. The aim of this study was to estimate the risk of BD in youths affected by ADHD based on prospective studies. Methods A systematic review was conducted according to the PRISMA guidelines. A meta-analysis of single proportions was performed to compute the overall occurrence of BD in ADHD individuals. Binary outcome data were used to calculate risk estimates of BD occurrence in ADHD subjects versus Healthy Controls (HC). Results An overall proportion of BD occurrence of 10.01% (95%-confidence interval [CI]: 6.47%-15.19%; I2 = 82.0%) was found among 1248 patients with ADHD over 10 prospective studies. A slightly higher proportion was found when excluding one study based on jack-knife sensitivity analysis (11.96%, 95%-CI: 9.15%-15.49%; I2 = 54.1%) and in three offspring studies (12.87%, 95%-CI: 8.91%-18.23%). BD occurrence was not significantly associated with mean follow-up duration (p-value = 0.2118). A greater risk of BD occurrence in ADHD versus HC from six studies was found (risk ratio: 8.97, 95%-CI: 4.26-18.87, p-value Limitations Few prospective studies have been retrieved in our search and most were not specifically aimed at assessing BD in followed-up ADHD patients. Conclusions Greater clinical attention should be paid to ADHD as an early precursor of BD since a substantial proportion of ADHD patients is expected to be diagnosed with BD during the developmental age.

Phantom Phone Signal (PPS) refers to the false perception of a mobile phone ringing, vibrating and blinking, when in fact it did not. A recent literature about PPS is growing, parallel to an increasing interest about its possible psychopathological implications. The present review aims to synthesize the current knowledge about the phenomenon, and to present a conceptual framework that integrates PPS as a putative index of psychopathology. Furthermore, we propose possible directions for further research. The phenomenon seems highly prevalent, irrespective of age and gender, although estimates are still inconsistent. We have analysed possible factors associated to PPS, disentangling them in person-related (i.e. characteristics of individuals who experience PPS) and phone use-related factors (i.e., time spent using the phone, time of the mobile in vibrating mode, the carrying location of the device, average number of call/message in a day, etc). Literature regarding the association between PPS and mental illness is limited, as most of the samples are not clinical and too sectorial. Preliminary data suggest that anxiety/depression and stress-related problems seem to be the psychopathological background favouring the experience of PPS. Despite PPS is a common phenomenon, it usually do not seem to significantly impact the people's quality of life. However, they deserve attention, given the huge diffusion of phone mobiles, particularly in children and adolescents, as it may be an index for emotional or stress-related difficulties. Future studies are needed to better clarify its frequency and its possible impact on everyday life. Studies in clinical samples may further clarify its psychopathological implications.

Early adolescence, with its several changes and demands, represents a delicate period of life. Several studies highlighted that during early adolescence, emotional and behavioral problems tend to increase. Using a person-centered approach, the present study explored the emotional and behavioral functioning profiles in a sample of Italian preadolescent students. Participants were 2959 youths (1533 males and 1426 females; age 10–14 years); they completed the Strengths and Difficulties Questionnaire (SDQ) and the Inventory of Callous Unemotional traits (ICU). Findings revealed four different profiles: "no psychopathology" (41.5%), "low psychopathology with sub-threshold hyperactivity" (33%), "predominantly internalizing" (19%), and "predominantly externalizing" (6.5%). The two latter clusters are characterized by high levels of SDQ Total Score. The “predominantly internalizing” is distinguished by a higher prevalence of females, and the “predominantly externalizing” by a higher prevalence of males and higher CU traits. A person-oriented approach allowed for identifying subgroups of early adolescents who may significantly vary in their configuration of internalizing and externalizing problems. Such subgroups may reflect youths for whom the creation of prevention and intervention programs could be more tailored.

In recent years, the study of eye movements has increasingly become a window into neurological function and processes. This paper reports data about applications of eye-tracking technology in the field of neurodevelopmental disorders, especially in studying the clinical characteristics of ADHD. These studies indicated that eye-tracking approach represents a non-invasive methodology to test specific domains, such as attention networks and inhibition control, in an objectively and reliable way in youths. Although the studies results are still not conclusive, eye-tracking represents a potential valid support for clinicians in identifying specific biomarkers to orient ADHD diagnosis and the best intervention strategies.

Recently, studies have focused on narcissism as a personality trait, which can be detected during childhood, and can lead to negative outcomes, such as emotional and behavioral problems. After illustrating the main hypotheses on the development of narcissistic traits in children, this paper aims to outline the relation between narcissism, self-esteem and emotional, and behavioral problems in children. Finally, are presented measures for the assessment of narcissistic traits in children and adolescents.

Objective: This study was the first attempt to explore the efficacy of a mindfulness protocol for children with attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and their parents. Method: Fifty male children with ADHD and ODD diagnosis, aged 8 to 12, were randomly assigned to the mindfulness intervention (n = 25) or the wait-list (n = 25) group. Outcome measures included children, parents’, and teachers’ reports and objective measures of attention. Results: Children from the intervention group had a greater reduction in hyperactive behaviors in the school context (effect size [ES] = 0.59) and a greater improvement in visual sustained attention (ES = 0.77) and in Avoidance and Fusion Questionnaire scores (ES = 0.43) than those in the wait-list control group. No significant effect of the intervention on aggressive behaviors was revealed. Conclusion: A mindfulness intervention for children and their parents showed partial beneficial effects in children with ADHD + ODD.

Background Although a better understanding of the prodromes of affective disorders in youth has important clinical and research implications, empirical data are still unconclusive. Cyclothymic-hypersensitive temperament (CHT) has been linked to both depression and bipolarity, as well as to suicidality. Its conceptualization is still debated, as well as a comprehensive, psychometrically sound way of assessment. Methods factor structure, reliability, measurement invariance, convergent and divergent validity of the previously published CHT questionnaire (a youth version derived from Temperament Evaluation in Memphis Pisa and San Diego (TEMPS) was assessed in a school-based sample of 2959 students aged from 10 to 14 years (mean age = 11.8 ± 0.97 years). Furthermore, accuracy, sensitivity and specificity were calculated for a new cut-off score related to the presence of general psychopathology symptoms. Results CHT is better conceptualized in a two-correlated factors model, a moodiness/hypersensitiveness factor, more associated with internalizing symptoms, and an impulsiveness/emotional dysregulation factor, more associated with externalizing symptoms. The revised 22-items version of the CHT questionnaire with a cut-off score of 15 for females and 17 for males results accurate, sensitive and specific enough for the recognition of cyclothymic adolescents with clinical symptoms. Limitation the cross sectional design and the self-report nature of the measures limit the findings. Discussion Cyclothymic-hypersensitive temperament is a relevant concept in the realm of affective disorder and can be reliably assessed in youths. It may describe youths with the coexistence of both internalizing and externalizing symptoms that can be difficult to diagnose with a DSM perspective.

Research suggests that callous unemotional (CU) traits are associated with poor emotion recognition due to impairments in attention to relevant emotional cues. To further investigate the mechanisms that underlie CU traits, this study focused on the relationship between levels of CU and children's attention to, and recognition of, facial emotions. Participants were 7- to 10-year-old Italian boys, 35 with a diagnosis of Disruptive Behavior Disorder (age: M = 8.93, SD = 1.35), and 23 healthy male controls (age: M = 8.86, SD = 1.35). Children viewed standardized emotional faces (happiness, sadness, fear, disgust, anger, and neutral) while eye-tracking technology was used to evaluate scan paths for each area of interest (eyes, face, mouth), and for each emotion. CU traits were assessed using parent and teacher ratings on the Antisocial Process Screening Device. In the whole sample, elevated levels of CU traits were associated with a lower ability to recognize sadness, a lower number of fixations, and a lower average length of each fixation, specifically to the eye area of sad faces. In children with Disruptive Behavior Disorder diagnoses, high levels of CU traits were associated with lower duration of fixations to the eye-region on the eye area of sad faces, which in turns predicted lower levels of sadness recognition. The findings confirm that poor emotion recognition is associated with impairments in attention to critical information about other people's emotions. The clinical implications are discussed.

Background Emotional dysregulation (ED) is a trans-nosographical condition characterized by mood instability, severe irritability, aggression, temper outburst, and hyper-arousal. Pathophysiology of emotional dysregulation and its potential biomarkers are an emerging field of interest. A Child Behaviour Checklist (CBCL) profile, defined as Dysregulation Profile (DP), has been correlated to ED in youth. We examined the association between the CBCL-DP and indices of sympathetic arousal in children with Oppositional Defiant Disorder (ODD) and healthy controls. Method The current study sought to compare the arousal level measured via electrodermal activity in response to emotional stimuli in three non-overlapping groups of children: (1) ODD+CBCL-DP ( n = 28), (2) ODD without CBCL-DP ( n = 35), and (3) typically developing controls ( n = 25). Results Analyses revealed a distinct electrodermal activity profile in the three groups. Specifically, children with ODD+CBCL-DP presented higher levels of sympathetic arousal for anger and sadness stimuli compared to the other two groups. Limitations The relatively small sample and the lack of assessing causality limit the generalizability of this study which results need to be replicated in larger, different samples. Conclusion The CBCL-DP was associated to higher levels of arousal for negative emotions, consistently with previous reports in individuals with depression and anxiety. Further work may identify potential longitudinal relationships between this profile and clinical outcomes.

Background Epidemiological studies worldwide indicate that teenagers are at risk of internalizing and externalizing problems that persist into adulthood. In our country, there are few epidemiological studies on adolescents internalizing and externalizing problems. These studies, however, were not conducted in all of Italy. The aim of this study, promoted by the Italian Society of Paediatrician (SIP), was to investigate: a) the lifestyle and the prevalence of internalizing and externalizing problems in Italian teenagers and b) the risk and protective factors in family and social contexts. A further aim was to analyse gender differences in the above-mentioned variables. Methods 11,527 adolescents aged 13 to 21 years were recruited among students of Italian high schools. Participants were contacted by school authorities inviting them to participate in an internet survey on youth health and lifestyle. If they agreed to participate, the adolescents filled out an on-line anonymous questionnaire. The questionnaire was composed of 60 multiple choice items to investigate nutrition, body perception and lifestyle, internet exposure and sexual behaviour, externalizing and internalizing problems, family context and social context. Participation in the study was completely voluntary. The statistical significance of gender differences was tested by means of Chi-square analyses. Results displayed that Italian female adolescents are at risk of internalizing problems while males are at higher risk of externalizing problems. Moreover, several risk factors emerged from the family context in terms of violence, physical and psychological abuse. Conclusions It is critical to make paediatricians and schools aware of the main points to improve prevention and healthcare in the teenage population. To our knowledge, this is the first study in the Italian context to enrol more than 11,000 adolescents.

The pilot study presented in this article investigated the role of moral-cognitive features in understanding aggressive and rule-breaking behaviours in adolescents with Disruptive Behaviour Disorder (DBD). We collected two samples. The community sample was composed of 85 adolescents, whereas the DBD sample was composed of 30 adolescents. Compared with a community sample, adolescents with DBD are more inclined to use moral disengagement (MD) to legitimize their aggressive and rule-breaking behaviours. Moreover, regression models showed that self-enhancement values and MD foster externalizing behaviours taking into account both gender and the group they belonged to, that is, either clinical or community sample. Instead, self-transcendence values could prevent externalizing problems by inhibiting MD. Implications of these findings for assessment and therapeutic interventions are discussed.

Although multi-component psychotherapeutic interventions are first-line treatments for Disruptive Behavior Disorders (DBD), pharmacotherapy is often associated for more severe patients. Our aim was to explore effectiveness of an associated pharmacotherapy in referred children with DBD receiving a one-year psychotherapeutic intervention. Aggression, callous unemotional (CU) traits and emotional dysregulation were outcome measures. The sample included 144 children, aged 8-12 years, 41 (29%) with an ADHD comorbidity. Fifty-five (38%) patients received an additional pharmacotherapy with one medication, methylphenidate, a second generation antipsychotic, or a mood stabilizer. Data were collected before and after the one-year treatment. According to the Child Behavior Checklist (CBCL), aggressive behaviors, rule-breaking behaviors and emotional dysregulation improved in the whole group, as well as parent- and child-reported CU traits. The hierarchical regression model showed that additional pharmacotherapy significantly predicted lower scores at the CBCL aggressive behaviors and emotional dysregulation, but not CU traits at the end of the treatment. The interaction between methylphenidate and ADHD comorbidity predicted lower aggressive behaviors after the treatment. In summary, this naturalistic investigation suggest that an additional pharmacotherapy significantly improved aggression and emotional dysregulation, but not CU traits. When ADHD was comorbid, methylphenidate was more effective than antipsychotics or mood stabilizers in reducing aggression.

Children with severe aggressive behavioral problems are one of the groups most frequently referred to mental health clinics, and they engage in behaviors that put them at risk for substance use problems and a host of other negative outcomes. The present study aimed to assess the long-term outcome (six-year follow up) of the Coping Power Program delivered in a mental health hospital for children with behavioral disorders. We recruited one hundred and twenty children (mean age = 9.9, SD = 0.85), twenty-three patients were lost during the follow-ups. The sample of the current study included sixty-seven youths with Oppositional Defiant Disorder, and thirty with Conduct Disorder. We used Child Behavior Check List, Inventory of Callous Unemotional traits and a youth survey to evaluate substance use. After the baseline evaluation they were allocated to Coping Power or to a generic multi-component treatment. Coping Power produced significant reduction in Callous Unemotional traits, relative to the control condition; Coping Power seems to be effective also in reducing the rate of substance use. However, no differences have been found in externalizing behavior reduction in the two groups. This study contributes to the successful dissemination of best-practice treatments in public mental health services for children.

Background A Child Behavior Checklist (CBCL) profile defined as Dysregulation Profile (DP) (scores 2 standard deviations or more in anxiety/depression, aggression, attention subscales) has been correlated to poor emotional and behavioral self-regulation. The clinical meaning and the prognostic implications of CBCL-DP are still debated, although it seems associated with severe psychopathology and poor adjustment. Method In the present study, we used the CBCL-DP score to examine the adolescent outcomes (psychiatric diagnosis, substance use, psychiatric hospitalization) in 80 referred children with disruptive behavior disorders –DBD- (Oppositional Defiant Disorder or conduct disorder), aged 8–9 years, 72 males (90%) and 8 females (10%), followed-up until the age of 14–15 years. Results Children with higher score on the CBCL-DP profile were at increased risk for presenting ADHD and mood disorders in adolescence. While ADHD in adolescence was predicted also by an ADHD diagnosis during childhood, CBCL-DP score was the only significant predictor of a mood disorder at 14–15 years. On the contrary, CBCL-DP score was not associated with a higher risk of conduct disorder, substance use and hospitalizations in adolescence. A cost-effective and reliable diagnostic measure such as the CBCL may be a part of the diagnostic procedure aimed to capture these at-risk children, to monitor their natural history up to adolescence, and to prevent the risk of a full-blown mood disorder. Limitations The small sample size and a selection bias of severe patients with DBD limit the generalization of the findings.

Although a frequent co-occurrence between bipolar disorder (BD) and conduct disorder (CD) in youth has been frequently reported, data about pharmacological management are scarce and focused on BD type I. Second generation antipsychotics are frequently used in clinical practice, but no comparative studies are available. The aim of this exploratory study was to compare efficacy and safety of risperidone and quetiapine in a sample of adolescents presenting a BD type II comorbid with CD. Twenty-two patients diagnosed with a structured interview according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (male/female ratio, 12/10; mean (SD) age 15.0 (1.4) years) were randomized in 2 treatment groups (quetiapine [n = 12] vs risperidone [n = 10]), treated with flexible doses, and followed up for 12 weeks. Efficacy measures assessed manic symptoms, aggression, anxiety, depression, global clinical severity, and impairment. Safety measures included body mass index, serum prolactin, extrapyramidal adverse effects, and electrocardiogram. At the end of the study, all patients improved in all efficacy measures. Both treatments showed similar efficacy in reducing manic symptoms and aggression. Quetiapine was more effective in improving anxiety and depressive symptoms. A change in body mass index was found, and in a post hoc analysis, it was significant only in the risperidone group. Prolactin significantly increased only in the risperidone group. In BD type II, CD comorbidity, quetiapine, or risperidone monotherapy may be effective and relatively safe, although the small sample size, the limited duration of the study, and the design (lack of a blind assessments and of a placebo group) make it difficult to draw definitive conclusions.

Multi-component interventions based on cognitive behavioral principles and practices have been found effective in reducing behavioral problems in children with disruptive behavior disorders (oppositional defiant disorder and conduct disorder). However, it is still unclear if these interventions can affect children's callous-unemotional traits, which are predictive of subsequent antisocial behavior. Furthermore, it could be important to identify empirically supported treatment protocols for specific disorders addressed by child mental health services. The present study aimed to test the following two hypotheses: first, the Coping Power (CP) treatment program is able to reduce externalizing behaviors in children with disruptive behavior disorders treated in a mental health care unit; second, the CP program can reduce children's callous unemotional traits. The sample included 98 Italian children, 33 treated with the CP program; 37 with a less focused multi-component intervention, and 28 with child psychotherapy. The results showed that the CP program was more effective than the other two treatments in reducing aggressive behaviors. Furthermore, only the CP program was associated with a decrease in children's callous unemotional traits. The CP program was also associated with lower rate of referrals to mental health services at one-year follow-up. These findings support the importance of disseminating manualized and focused intervention programs in mental health services.

A massive asymptomatic creatine kinase elevation (MACKE) has been described during antipsychotic exposure in adult psychotic patients without signs of neuroleptic malignant syndrome (NMS), or other most frequent reasons for high creatine kinase (CK) serum level (intramuscular injections, restraints, intense physical activity, dystonic reactions). In this article, we review this clinical condition, and report three cases of MACKE in nonpsychotic, drug-naïve youth during treatment with second generation antipsychotics. The diagnosis of MACKE should be considered after ruling out other possible common reasons of CK increase. The finding of MACKE should indicate a need for weekly monitoring of the CK level only when there are reasons to believe elevated CK is toxic or harmful. Further investigations are recommended when signs and symptoms raise a suspicion of NMS or rhabdomyolysis, including flu-like syndrome, fever, weakness, alteration of consciousness, muscle rigidity, tachycardia, hyper-/hypotension, and dark urine. A drug discontinuation should be considered when possible signs of NMS or rhabdomyolysis are suspected, or in cases of very high and persisting CK levels. Empirical evidence indicates that there is not a "safe" antipsychotic medication; therefore, a switch to another antipsychotic with a different profile is not necessarily a safe option. The spontaneously remitting or intermittent course suggests that the "true" MACKE should be kept distinct from both rhabdomyolysis and NMS. Raising awareness with MACKE may reduce the need for unnecessary diagnosis of NMS or rhabdomyolysis, which may otherwise lead to an unnecessary discontinuation of an effective therapeutic agent.

Background:Lithium is a first-line treatment for bipolar disorder in adults, but its mechanism of action is still far from clear. Furthermore, evidences of its use in pediatric populations are sparse, not only for bipolar disorders, but also for other possible indications.Objectives:To provide a synthesis of published data on the possible mechanisms of action of lithium, as well as on its use in pediatric samples, including pharmacokinetics, efficacy, and safety data.Methods:Clinical trials in pediatric samples with at least one standardized measure of efficacy/ effectiveness were included in this review. We considered: i) randomized and open label trials, ii) combination studies iii) augmentation studies iv) case series including at least 5 patients.Results:Different and non-alternative mechanisms of action can explain the clinical efficacy of lithium. Clinical studies in pediatric samples suggest that lithium is effective in managing manic symptoms/episodes of bipolar disorder, both in the acute phase and as maintenance strategy. Efficacy on depressive symptoms/phases of bipolar disorder is much less clear, while studies do not support its use in unipolar depression and severe mood dysregulation. Conversely, it may be effective on aggression in the context of conduct disorder. Other possible indications, with limited published evidence, are the acute attacks in Kleine-Levin syndrome, behavioral symptoms of X-fragile syndrome, and the management of clozapine- or chemotherapy- induced neutropenia. Generally, lithium resulted relatively safe.Conclusions:Lithium seems an effective and well-tolerated medication in pediatric bipolar disorder and aggression, while further evidences are needed for other clinical indications.

Attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are frequently co-occurring in youth, but data about the pharmacological management of this comorbidity are scarce, especially when impulsive aggression is prominent. Although stimulants are the first-line medication for ADHD, second-generation antipsychotics, namely, risperidone, are frequently used. We aimed to assess effectiveness and safety of monotherapy with the stimulant methylphenidate (MPH) and risperidone in a consecutive sample of 40 drug-naive male youths diagnosed as having ADHD-combined presentation, comorbid with ODD and aggression, without psychiatric comorbidities, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria and a structured clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version).Twenty males treated with MPH (mean age, 8.95 ± 1.67 years) and 20 males treated with risperidone (mean age, 9.35 ± 2.72 years), followed up to 6 months, were assessed according to efficacy measures (Child Behavior Checklist [CBCL], Clinical Global Impression-Severity [CGI-S] and Improvement [CGI-I], Children Global Assessment Scale), and safety measures. At the end of the follow-up, both medications were similarly effective based on CBCL subscales of aggression and rule-breaking behaviors, on Diagnostic and Statistical Manual of Mental Disorders-oriented oppositional defiant problems and conduct problems, and on CGI-S, CGI-I, and Children Global Assessment Scale, but only MPH was effective on CBCL attention problems and attention-deficit/hyperactivity problems. Risperidone was associated with weight gain and elevated prolactin levels.Although the nonrandomized, nonblind design limits the conclusions of our exploratory study, our findings suggest that when ADHD is comorbid with ODD and aggression MPH and risperidone are both effective on aggressive behavior, but only stimulants are effective on ADHD symptoms.

Conduct Disorder (CD) is a psychiatric diagnosis characterized by a repetitive and persistent pattern of behaviour in which the basic rights of others and major age-appropriate social norms or rules are violated. Callous Unemotional (CU) traits are a meaningful specifier in subtyping CD for more severe antisocial and aggressive behaviours in adult psychopathology; they represent the affective dimension of adult psychopathy, but they can be also detected in childhood and adolescence. The CU traits include lack of empathy, sense of guilt and shallow emotion, and their characterization in youth can improve our diagnostic, prognostic and therapeutic abilities. A strong genetic liability, in interaction with parenting and relevant environmental factors, can lead to elevated levels of CU traits in children. We pointed out that CU traits can be detected in early childhood, may remain stable along the adolescence, but a decrease following intensive and specialized treatment is possible. We here provide a narrative review of the available evidences on CU traits in three main domains: aetiology (encompassing genetic liability and environmental risk factors), presentation (early signs and longitudinal trajectories) and treatments.

The interplay between Callous Unemotional Traits (CU) and Moral Disengagement (MD) was examined in a sample of 90 adolescents with Disruptive Behavior Disorders. Using a person-centered approach, three CU and MD configurations were identified, attesting the strong relationship between these two moral dimensions. However, for some adolescents, CU and MD do not ‘move together’. Practical implications are discussed in terms of assessment and intervention.

Background Non suicidal self-injuries (NSSIs) are deliberate self-harm behaviors without suicidal intent, usually starting in adolescence, with increasing rates of occurrence both in epidemiological and clinical samples. Several studies associated cyclothymic-hypersensitive temperament (CHT) with self-harm behaviors and suicidal risk. Aim of this study is to explore the association between NSSIs and CHT in a clinical sample of adolescents. We hypothesized that CHT may differentiate NSSI from non-NSSI adolescents with mood disorders, when other psychopathological features are controlled for. Methods A consecutive sample of 89 adolescents with mood disorders were assessed for presence and phenomenology of NSSIs, CHT, demographics, comorbid categorical psychiatric diagnoses, dimensional psychopathology, impairment and previous suicide attempts. Results NSSIs were reported in 52% of the sample, with higher rates in females and in bipolar disorder. Regression analyses showed that CHT, but not age, gender, bipolar vs depression diagnosis, functional impairment, was associated with NSSIs. Discussion CHT may be in close association with NSSIs in adolescents with mood disorders. An assessment of CHT in adolescents referred for mood disorder may help to detect specific psychological features of NSSIs, which may improve diagnostic and treatment strategies. Limitations Given the cross-sectional design, a developmental relation between CHT and NSSIs cannot be determined. The small sample size and the selection bias of severely impaired patients limit the generalization of the results. More sophisticated measures of CHT may consent to explore other dimensions of the cyclothymic construct (i.e., emotional intensity, emotional reactivity, emotional stability, positive vs. negative emotions, interpersonal sensitivity, impulsivity).

Several studies demonstrated that maternal psychopathological risk is related to child’s maladjustment, but until recently research has relatively neglected fathers. Disruptive Behavior Disorder (DBD) and Eating disorders (ED) have a large prevalence during childhood but a few studies have focused on their association with paternal psychopathological risk. One-hundred and thirty-nine children and their fathers were recruited from pediatric hospitals and outpatient clinics and paired with a healthy control group (CG). Fathers were administered the SCL-90/R and the CBCL 6–18 to assess: 1) psychopathological risk of fathers of children with DBD, ED and CG; 2) significant differences between ED and DBD fathers’ psychopathological profiles; and 3) associations between specific fathers’ psychopathological symptoms and children’s emotional-behavioral problems. Fathers of children with ED showed a higher psychopathological risk than fathers of DBD offspring. Children with DBD showed higher externalizing symptoms. Paternal hostility was associated with internalizing problems in children with DBD. Paternal hostility showed a non-significant but clinically interesting association with internalizing problems in DBD children; interpersonal sensitivity was associated with internalizing problems in ED children. This study can constitute a contribution to a better understanding of the clinical characteristics of fathers of children with DBD and ED.

Children with high levels of aggressive behavior create a major management problem in school settings and interfere with the learning environment of their classmates. We report results from a group-randomized trial of a program aimed at preventing aggressive behaviors. The purpose of the current study, therefore, was to determine the extent to which an indicated prevention program, Coping Power Program, is capable of reducing behavioral problems and improving pro-social behavior when delivered as a universal classroom-based prevention intervention. Nine classes (five first grade and four second grade) were randomly assigned to intervention or control conditions. Findings showed a significant reduction in overall problematic behaviors and in inattention-hyperactivity problems for the intervention classes compared to the control classes. Students who received Coping Power Program intervention also showed more pro-social behaviors at postintervention. The implications of these findings for the implementation of strategies aimed at preventing aggressive behavior in school settings are discussed.

Bipolar Disorders (BD) are often comorbid with disruptive behaviour disorders (DBDs) (oppositional-defiant disorder or conduct disorder), with negative implications on treatment strategy and outcome. The aim of this study was to assess the efficacy of quetiapine monotherapy in adolescents with BD comorbid with conduct disorder (CD). A consecutive series of 40 adolescents (24 males and 16 females, age range 12-18 years, mean age 14.9 ± 2.0 years), diagnosed with a clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version [K-SADS-PL]) according to American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) criteria were included. All the patients were treated with quetiapine monotherapy (mean final dose 258 ± 124 mg/day, range 100-600 mg/day). At the end-point (3 months), 22 patients (55.0%) were responders (Clinical Global Impressions-Improvement [CGI-I] score of 1 or 2 and CGI-Severity [CGI-S] ≤ 3 and improvement of at least 30% Children's Global Assessment Scale [C-GAS] during 3 consecutive months). Both CGI-S and C-GAS significantly improved (p0.0001). Nine out of the 16 patients with suicidality (56.3%) had a reduction in this severe symptom during the follow-up. Nonresponders were more frequently males, and more frequently had an attention-deficit/hyperactivity disorder (ADHD) comorbidity. Eight patients (20.0%) experienced moderate to severe sedation and eight (20.0%) experienced increased appetite and weight gain. In these severely impaired adolescents, quetiapine monotherapy was well tolerated and effective in50% of the patients.

Background The Child Behavior Checklist Dysregulation Profile (CBCL-DP), (high scores in Anxious/Depressed, Attention Problems, and Aggressive Behavior subscales), has been related to poor emotional and behavioral self-regulation in children and adolescents. Our aim is to evaluate if it may be associated with auto-aggression in youth with oppositional defiant disorder (ODD). Method In 72 consecutively referred youths with ODD, emotional dysregulation was assessed with the CBCL-DP, auto-aggression and physical aggression against other persons with the Modified Overt Aggression Scale. Results Regression analysis showed that greater higher CBCL-DP scores were associated to higher levels of auto-aggression, even when controlling for the levels of physical aggression against others and CBCL Total score. Limitations The small sample size, the cross-sectional design, and the lack of a control group limit the generalization of our findings. Conclusions Referred ODD youths with higher scores of CBCL-DP are more likely to present auto-aggression, besides aggression against others. The CBCL could improve the screening and detection of these high-risk patients.

During the past decade, a substantial increase in the use of second generation antipsychotics (SGAs) has occurred for a number of juvenile psychiatric disorders, often as off-label prescriptions. Although they were thought to be safer than older, first generation antipsychotics, mainly due to a lower risk of neurological adverse reactions, recent studies have raised significant concerns regarding their safety regarding metabolic, endocrinological and cardiovascular side effects. Aim of this paper is to update with a narrative review, the latest findings on safety of SGAs in youths. Results suggest that different SGAs may present different safety profiles. Metabolic adverse events are the most frequent and troublesome, with increasing evidences of heightened risk for type II diabetes mellitus. Results are discussed with specific emphasis on possible strategies of an active monitoring, which could enable both paediatricians and child psychiatrists to a possible prevention, early detection, and a timely management of such effects.

Disruptive Behavior Disorders (DBDs) are stable and impairing disorders, heterogeneous in presentation, developmental pathways, and treatment needs. Disentangling subtypes according to psychopathological dimensions is helpful for timely diagnoses, precise prognoses and tailored interventions. Psychopathic traits are relevant in subtyping DBDs with severe antisocial and aggressive behaviors. Three psychopathy dimensions have been found: 1) an affective dimension, the callous-unemotional (CU) trait, with lack of empathy and remorse, and with short-lived emotions; 2) an interpersonal dimension, the narcissistic domain, with manipulative abilities, superficial charm, egocentricity and grandiosity; 3) a behavioral dimension, the impulsivity or impulsive-irresponsibility, with irresponsibility, proneness to boredom, and novelty seeking. Recently, research suggests that youth with CU traits, similarly to adults with psychopathy, can present a low-anxious “primary” and high-anxious “secondary” variants. Our aim is to critically review the main measures of psychopathic traits, including the three main dimensions (with specific emphasis on CU traits), and the “primary/secondary” distinction, focusing on the assessment in clinical settings. An assessment procedure is proposed, based on previous literature and personal clinical experience.

Recently, social anxiety disorder (SAD) and paranoia have been demonstrated to be closely related. However, data were primarily drawn from adult community samples or patients with schizophrenia. The present study used a cross-sectional design to evaluate a sample of adolescents with SAD (n = 30, mean age 15.3 ± 0.9 years) compared with an age- and sex-matched group of healthy controls (n = 26, mean age 15.9 ± 1.6 years). The SAD group displayed more frequent and intense paranoid thoughts than the control group (t = 4.16, p

Objective: Several studies suggested that in addition to child-driven factors (i.e., temperamental style), parenting behavior can, at least in part, influence the maintenance of Callous Unemotional (CU) traits in children; however, more information is needed to distinguish which styles (negative parenting or lack of positive parenting) predict increased levels of CU traits. The aim of the present treatment study was to examine which components of parenting are longitudinally associated with levels of CU traits in children with a disruptive behavior disorder diagnosis. Method: The current study examined cross-lagged reciprocal effects models between positive and negative parenting practices, and the levels of child CU traits over three time points, including both positive and negative dimensions of parenting in the same model. Participants were 126 Italian children with diagnosis of disruptive behavior disorder (oppositional defiant disorder or conduct disorder), 113 boys and 13 girls, 110 Caucasian, 48 with conduct disorder, and 78 with oppositional defiant disorder, treated with a multi-component intervention, based on cognitive behavioral principles and practices. Participants were all 9–10 years of age at the beginning of the study, and were followed-up until the age of 11–12 years (24 months in total, the first 12 under treatment) using parent report (Alabama Parenting Questionnaire and Child Behavior Check List) and child report (Inventory of Callous-Unemotional Traits) measures. Results: No significant cross-lagged path was found between negative parenting and CU traits; these two variables were also unrelated when positive parenting was considered in the same model. In contrast, reciprocal effects between positive parenting and CU were found: higher levels of positive parenting predicted lower levels of CU traits. Conclusions: The current findings suggest that the positive dimension of parenting may need to be targeted in the treatment of DBD children with higher CU traits.

Background The clinical presentation of bipolar disorders, though clearly recognized in adolescents, remains controversial in younger children and across cultures. The aim of this study was to compare the clinical presentation of bipolar disorders in Italian and American children between ages 5 and 12 years. Methods Sixty-seven children from six outpatient programs were enrolled (Italian sample: n=40; American sample: n=28) between January 2010 and June 2011. Children and their parents were interviewed by experienced clinicians using the Washington University in St. Louis Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present, Lifetime Version (WASH-U K-SADS). Results Italian children scored significantly higher on ratings of “elevated mood” (p=0.002), whereas American children scored significantly higher on ratings of “flight of ideas” (p=0.001) and “productivity” (p=0.001). Rates of comorbidity were different between groups. Limitations Data were acquired from several sites in Italy as compared to from a single American site. Medication and educational information were not systematically collected. Furthermore, the sample collected may only reflect characteristics of a less severely ill group of bipolar children. Conclusions Our comparison of Italian and American children with early onset bipolar disorders found that the phenotype of bipolar spectrum disorders is largely shared across cultures, although psychiatric comorbidities differed.

Background: The most severe forms of conduct disorder (CD) are disabling conditions, often resistant to treatment and likely to evolve into antisocial behaviours. Mood stabilizers and atypical antipsychotics are often used to treat severe cases of CD, as are antidepressants and psychostimulants less frequently, despite a relative lack of efficacy data. Use of lithium in hospitalized children and adolescents with CD has been evaluated in a small number of studies. Aim: To explore the efficacy and tolerability of lithium (administered either as monotherapy or in association with atypical antipsychotics) in children and adolescents with CD and to identify variables associated with positive or negative responses to such treatment. Methods: This retrospective study included 60 consecutive patients (46 males and 14 females; range 8–17 years; mean age 14.2 ± 2.4 years) who were treated with lithium for CD diagnosed on the basis of the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (K-SADS-PL) clinical interview and the DSM-IV criteria for CD. The sample consisted of 44 inpatients (who remained in hospital during the first 2 or 3 weeks of treatment and were then assessed as outpatients) and 16 outpatients; the follow-up period was 6–12 months (mean 8.4 ± 2.2 months). While all patients were initially treated with lithium, an atypical antipsychotic could be added if necessary to achieve satisfactory control of symptoms. Outcome measures included the Modified Overt Aggression Scale (MOAS), the Clinical Global Impression-Severity (CGI-S) and Clinical Global Impression-Improvement (CGI-I) scales, and the Aggression Questionnaire (which assessed the type of aggression, i.e. predatory vs affective). Patients were considered responders to pharmacological treatment at the end of the follow-up period if they satisfied all of the following criteria: ≥50% decrease in MOAS score, CGI-I score of 1 or 2 (‘very much improved’ or ‘much improved’) and CGI-S score of ≤3. Effect sizes were calculated for differences between pre- and post-treatment mean MOAS total and individual aggression dimension scores (an effect size >0.8 indicates good treatment efficacy). Results: At the end of follow-up, 29 of 60 patients (48.3%) were classified as responders (10 receiving lithium monotherapy and 19 receiving lithium plus atypical antipsychotic therapy). For the sample as a whole, mean total MOAS score improved significantly (p < 0.001) and the effect size (pre- vs posttreatment) was 1.03. Mean MOAS verbal, and physical towards objects and other persons aggression scores, both in patients taking lithium as monotherapy and those also taking an add-on atypical antipsychotic, also improved significantly (p < 0.001) and the effect size was ≥0.80 for all items. Improvement in mean MOAS self-aggression score (p < 0.001) and an effect size of 0.59 was found when an atypical antipsychotic was added to lithium therapy. Predictors of a positive response to treatment were less severe disease at baseline, lower MOAS aggression scores and an impulsive (affective, nonpredatory) type of aggression. Gastrointestinal adverse effects, polydipsia and increased urinary frequency, tremor and increased thyroid stimulating hormone levels were the most frequently reported adverse effects. Two patients discontinued treatment because of adverse effects (vomiting and thyroid dysfunction). Conclusion: Lithium alone or in combination with an atypical antipsychotic may reduce aggressive behaviours in children and adolescents with CD. The adverse effects of such therapy are relatively common but rarely severe.

Objective Studies on referred children and adolescents with conduct disorder (CD) have relevant implications for prevention and treatment. We addressed this issue in a large sample of youths with CD, considering age at onset, sex, and response to treatments as variables. Methods The sample consisted of 198 patients (153 males and 45 females; age range, 8-18 years; mean age, 13.2 ± 2.6 years), consecutively diagnosed as having CD during a 5-year period. The diagnoses were based on fulfillment of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, according to historical information, prolonged observations, and a clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version). Three subtypes of aggressive behaviors—"predatory" (controlled, planned, and goal-oriented), "affective" (impulsive, explosive, and unprofitable), and "mixed" (with both the features)—were considered in this study. Results Patients with prepubertal onset were younger at referral and had a poorer socioeconomic status. Their condition was more severe at the baseline, but their response to treatments did not differ from those with adolescent onset. Predatory and affective aggression and attention deficit hyperactivity disorder comorbidity were higher in children with prepubertal-onset CD. Regarding to sex, females were older and had a lower socioeconomic status. Their condition was more severe at the baseline and presented higher scores in self-aggression, but they responded better to treatments. Rates of attention deficit hyperactivity disorder were significantly lower in females, whereas other comorbidities (including substance abuse) were similar between sexes. Nonresponders to treatments received less frequently a psychosocial intervention, have more severe condition at the baseline, presented a more severe verbal and physical aggression, a lower affective/predatory index, and a higher rate of substance abuse. Conclusions Age at onset and sex may be critical variables for prognosis of CD. Psychosocial intervention can significantly improve the treatment response.

Callous-unemotional traits have been proposed as risk factors for a poorer prognosis in young people with disruptive behaviour disorders. Identification of factors that may cause or maintain elevated levels of such traits could help in developing targeted therapeutic interventions. Some previous studies have investigated the role of moral cognitive mechanisms, such as moral disengagement, but these previous studies focused primarily on normal or 'at-risk' samples.We aimed to evaluate associations and possible interactions between moral disengagement as a cognitive dimension and callous-unemotional traits as an affective dimension in adolescents with disruptive behaviour disorders.We recruited 55 adolescents with a disruptive behaviour disorder from a community care hospital in Pisa. They were evaluated at baseline and after one year with measures that included a moral disengagement scale, the Antisocial Process Screening Device, to assess callous traits, and the Youth Self-Report, to explore externalising behaviour problems.Structural equation modelling showed that higher initial moral disengagement scores were associated with later higher levels of callous-unemotional traits in adolescents and vice versa, even after, respectively, controlling for previous levels of callous traits and moral disengagement.As impairments in either cognitive or affective traits may predispose to problematic development of the other, our findings would suggest that screening at the earliest opportunity possible for both moral disengagement and callous-unemotional traits among children with disruptive behaviour disorders could help to map natural outcome pathways and thus tailor more accurate interventions for prevention of antisocial or criminal behaviour. Copyright © 2016 John WileySons, Ltd.

The present study investigated trajectories of Callous Unemotional (CU) traits in youth with Disruptive Behavior Disorder diagnosis followed-up from childhood to adolescence, to explore possible predictors of these trajectories, and to individuate adolescent clinical outcomes. A sample of 59 Italian referred children with Disruptive Behavior Disorder (53 boys and 6 girls, 21 with Conduct Disorder) was followed up from childhood to adolescence. CU traits were assessed with CU-scale of the Antisocial Process Screening Device-parent report. Latent growth curve models showed that CU traits are likely to decrease linearly from 9 to 15 years old, with a deceleration in adolescence (from 12 to 15). There was substantial individual variability in the rate of change of CU traits over time: patients with a minor decrease of CU symptoms during childhood were at increased risk for severe behavioral problems and substance use into adolescence. Although lower level of socio-economic status and lower level of parenting involvement were associated to elevated levels of CU traits at baseline evaluation, none of the considered clinical and environmental factors predicted the levels of CU traits. The current longitudinal research suggests that adolescent outcomes of Disruptive Behavior Disorder be influenced by CU traits trajectories during childhood.

The atypical antipsychotic quetiapine has been used in different psychotic and non-psychotic disorders in children and adolescents in randomized clinical trials, open-label studies and chart reviews. Most of these studies suggest that quetiapine may be a promising agent with a potential for use in young patients. The aim of this paper is to critically review available literature on quetiapine in the treatment of children and adolescents with a variety of psychiatric disorders, including psychotic disorders, bipolar disorders (manic and depressive episodes), conduct disorder, autism spectrum disorder, Tourette’s syndrome and personality disorders. Furthermore, we report on possible neurochemical pathways involved during treatment with quetiapine, and discuss some issues that are clinically relevant in daily practice, such as titration strategies, safety and tolerability, and monitoring possible side effects. Controlled studies support the short-term efficacy for treating psychosis, mania, and aggression within certain diagnostic categories. However, although quetiapine seems well tolerated in various pediatric populations during acute and intermediate treatments, and hyper-prolactinemia and extra-pyramidal side effects are consistently low among studies, weight gain and alterations in lipid profile need to be closely monitored. Furthermore, the distal benefit/risk ratio during long-term treatment remains to be determined.

Two Child Behaviour Checklist (CBCL) profiles were correlated to poor self-regulation, Deficient Emotional Self-Regulation (DESR) (elevation between 1 and 2 Standard Deviations (SD) in Anxiety/Depression, Aggression, Attention subscales), and Dysregulation Profile (DP) (elevation of 2 Standard Deviations or more). We explored youths with Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) whether these profiles are associated with specific clinical features. The sample included 57 patients with DESR profile and 41 with DP profile, ages 9 to 15 years, all assigned to a non-pharmacological Multimodal Treatment Program. No differences resulted between groups in demographic features, diagnosis ratio, and comorbidities with Attention Deficit Hyperactivity Disorder (ADHD), Bipolar Disorder (BD), and Anxiety Disorder. The DP group was associated with higher scores in Withdrawn, Social Problem, Thought, Rule Breaking, and Somatic CBCL subscales, and higher scores in Narcissism and Impulsivity (but not Callous-Unemotional (CU)), according to the Antisocial Process Screening Device (APSD). After treatment, patients with DESR improved their personality traits (Narcissistic and Callous-Unemotional, but not Impulsivity), while changes in CBCL scales were modest. Patients with DP improved scales of Attention, Aggression, Anxiety-Depression, Rule Breaking, Withdrawal, Social Problem and Thought, while personality features did not change. These results suggest diagnostic implications of CBCL profiles, and indications for targeted treatment strategies.

Disruptive Behavior Disorders (DBDs) are among the most common reasons for youth referrals to mental health clinics. Aim of this study is to compare short and medium term efficacy of a multimodal treatment program (MTP), compared to community care (treatment-as-usual, TAU). The sample included 135 youths with DBDs (113 males, age range 9-15 years, mean age 12±2.5 years) were assigned either to a MTP (n=64), or addressed to community care for a TAU (n=71). Outcome measures were the Child Behaviour Checklist (CBCL) and the Children's Global Assessment Scale (C-GAS). All subjects were assessed at the baseline (T0), after 1-year treatment (T1) and after a 2-year follow-up (T2). Compared with patients receiving TAU, youths in the MTP showed, both at T1 and T2, significantly lower scores on CBCL Externalizing Scale, Internalizing Scale, Anxious/Depressed, Social Problems, and Aggressive Behavior, and higher scores at the C-GAS. Improvement in Internalizing Scales was particularly evident, with a shift from the clinical to the non-clinical range. Rate of use of mental health services and scholastic failure were reduced in the MTP. It is suggested that the improvement of the Internalizing symptoms is a crucial component of the therapeutic process in this MTP.

Background: Child psychiatry has enjoyed a long tradition of using brief psychotherapy with children, but research on its efficacy and effectiveness in the setting of routine clinical care is remarkably sparse; the aim of this study was to evaluate the efficacy of an original model of brief psychodynamic psychotherapy (BPP) for children with emotional disorders in a clinical outpatient setting. Methods: A sample of 30 subjects (6.3–10.9 years old) was divided into an experimental BPP group and a control group. Each subject was evaluated at the beginning, after 6 months and at an 18-months follow-up. Outcome measures were Children’s Global Assessment Scale and Child Behavior Check-List. Statistical and clinical significance of change were evaluated. Results: At the first evaluation, the experimental group showed a better improvement in global functioning; at follow-up, the two groups improved to a comparable degree, but only the mean of the experimental group moved to a functional range. The experimental group showed a significant reduction in total behavioral problems and externalizing problems at the follow-up. Conclusions: The better improvement of the experimental group in two outcome measures suggests that BPP is efficient in emotional disorders. The hypothesis that BPP introduces changes at long term (sleeper effects) is suggested. The improvement in global functioning of the two groups is discussed in relation to specific characteristics of emotional disorders. Finally, limitations of the study are discussed and in particular the bias introduced by lack of randomization.

Objective: The main aim of the research is to study the early behavioral development in autistic children through home movies. Methods: fifteen home movies, regarding the first 2 years of life of autistic children are compared with the home movies of 15 normal children. The films of the two groups were mixed and rated by blind ratings with the Grid for the Assessment of Normal Behavior in Infants and Toddlers. The grid is composed of 17 items grouped into three developmental areas: social competence, intersubjectivity and symbolic activity. For every area, we have identified specific children’s behaviors. Results: Significant differences between the two groups are found both in the range of age 0–6 for intersubjectivity, and in the ranges of age 6–12 and 18–24 for symbolic activity. Conclusions: The authors pose some hypotheses about an early-appearing impairment of intersubjectivity, the ability to represent other’s state of mind, in subjects with autistic disorder.

Deficits in emotional reactivity are frequently reported in Disruptive Behavior Disorders (DBDs). A deficit in prosocial emotions, namely the callous unemotional traits (CU), may be a mediator of emotional reactivity. Our aim is to investigate subjective emotional reactivity towards visual stimuli with different affective valence in youths with DBDs and healthy controls. The clinical sample included 62 youths with DBDs (51 males, 8 to 16 years, mean 11.3±2.1 years), the control group 53 subjects (36 males, 8 to 16 years, mean 10.8±1.5 years). The groups were compared using the Child Behavior Checklist (CBCL), the Inventory of Callous-Unemotional Traits (ICU), and the International Affective Picture System (IAPS), which explores the affective (pleasant/unpleasant emotional reaction) and arousal (low/high intensity of emotion) dimensions. The DBD group presented higher scores in externalizing and internalizing CBCL scores, and in ICU callous and indifferent subscales. At the IAPS, DBD patients differed from controls in the affective valence of the images, rating less unpleasant neutral and negative images. The CU traits were the only predictor of emotional reactivity in the DBD sample. A less aversive way to interpret neutral and negative stimuli may explain why DBD patients are less responsive to negative reinforcements.

Objective: Predictors of poor response to treatments in youths with disruptive behavior disorders (DBDs), including conduct disorder (CD) and oppositional defiant disorder (ODD), are under-studied. Multimodal psychosocial interventions are the best option, but a significant portion of patients needs adjunctive pharmacotherapy. The concept of “psychopathy”, and namely, the callous (lack of empathy and guilt) and unemotional (shallow emotions) trait, has been considered a possible specifier indicating a more severe subgroup of patients. We explored whether the callous–unemotional trait (CU) may affect the response to multimodal treatment in referred youths with DBDs. Method: 118 youths (102 males, age range 6–14 years, mean age 11.1 ± 2.5 years) completed a 12-month multimodal intervention, 48 of whom (41%) needed an associated pharmacotherapy. The patients were assessed according to psychopathological profile (Child Behavior Checklist, CBCL), severity and improvement (Clinical Global Impression-Severity and Improvement scores, CGI-S and CGI-I), functional impairment (Children-Global Assessment Scale, C-GAS), and psychopathic dimension (Antisocial Process Screening Device, APSD), including CU dimension. Results: 58 patients (49.2%) were non-responders. They had more frequently a diagnosis of CD than ODD, presented a comorbid mood disorder, higher CBCL scores in rule-breaking behavior, and higher APSD (“psychopathic”) scores. Subjects with higher or lower CU differed only according to the rate of responders (35% vs. 60%, p

A crucial issue in youths with disruptive behavior disorders, including oppositional defiant disorder and conduct disorder, is the refractoriness to treatments. A multimodal approach with individual therapy to improve social skills and self-control and family and school interventions is the best psychosocial treatment. Predictors of poor response to psychosocial treatment remain understudied. We aimed at exploring whether callous (lack of empathy and guilt) and unemotional (shallow emotions) (CU) trait and type of aggression (predatory vs. affective) can affect response to psychosocial treatment in referred youths with disruptive behavior disorders.The sample consisted of 38 youths (28 boys and 10 girls, age range: 6-14 years, mean age: 13.1 ± 2.6 years) diagnosed as having oppositional defiant disorder or conduct disorder according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria and a clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version), who completed a 6-month therapeutic program at our hospital. Patients were assessed according to severity and improvement (Clinical Global Impressions-Severity score [CGI-S] and CGI-Improvement score), functional impairment (Children's Global Assessment Scale [C-GAS]), type of aggression, predatory versus affective (Aggression Questionnaire), and CU dimension (Antisocial Process Screening Device and the Inventory of CU Traits).Among the 38 patients, 21 (55.3%) were responders and 17 (44.7%) were nonresponders, according to CGI-Improvement score and CGI-S. Nonresponders were more impaired at the baseline according to CGI-S and C-GAS. Nonresponders presented higher scores of predatory aggression, whereas affective aggression did not differ between groups. Nonresponders presented higher scores in CU trait of Antisocial Process Screening Device and in Inventory of CU total score (callous trait), but these differences did not survive Bonferroni correction.Severity at the baseline and predatory aggression are negative predictors of psychosocial treatment, but the role of the callous trait needs more exploration in larger samples. Further research may increase our diagnostic and prognostic capacities, thus improving our treatment strategies.