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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.

Background Empathy has long been considered a multidimensional construct, encompassing cognitive, affective and behavioral domains. Deficits in empathic competences in early childhood contribute to psychopathology, and have been variably implicated in several clinical conditions, such as autism spectrum disorders (ASD) and conduct disorders. Aim To identify and describe empirically validated questionnaires assessing empathy in children and adolescents and to provide a summary of related theoretical perspectives on empathy definitional issues. Methods A systematic review of the literature was conducted. Three bibliographic databases were searched. A total of 47 studies were selected for final analysis and 16 distinct measures were identified and described. Results Questionable to excellent levels of internal consistency were observed, while few studies assessed test-retest reliability. Although construct definitions only partially overlapped, affective and cognitive domains of empathy were the commonest internal factors that were often separately evaluated. New facets of the construct (i.e., somatic empathy and sympathy) and specific clinical populations (i.e., ASD) could be specifically addressed through more recent instruments. Conclusion The combination of different assessment methods is recommended in order to foresee further improvements in this field and try to overcome the problem of limited convergence with more objective measures.

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.

The purpose of this article is to discuss the Royal College of Psychiatrists' Report 230, “Attention deficit hyperactivity disorder (ADHD) in individuals with intellectual disability,„ which aims t...

Evidence from everyday life suggests that differences in social behaviors between males and females exist, both in animal and in humans. These differences can be related to socio-cultural determinants, but also to specialized portions of the brain (the social brain), from the neurotransmitter to the neural network level. The high vulnerability of this system is expressed by the wide range of neuropsychiatric disorders associated with social dysfunctions, particularly social withdrawal. The principal psychiatric disorders with prominent social withdrawal are described, including hikikomori-like syndromes, and anxiety, depressive, autistic, schizophrenic, and personality disorders. It is hypothesized that social withdrawal can be partially independent from other symptoms and likely reflect alterations in the social brain itself, leading to a similar, transdiagnostic social dysfunction, reflecting defects in the social brain across a variety of psychopathological conditions. An overview is provided of gender effects in the biological determinants of social behavior, including: the anatomical structures of the social brain; the dimorphic brain structures, and the modulation of their development by sex steroids; gender differences in "social" neurotransmitters (vasopressin and oxytocin), and in their response to social stress. A better comprehension of gender differences in the phenotypes of social disorders and in the neural bases of social behaviors may provide new insights for timely, focused, innovative, and gender-specific treatments.

Background: It is currently debated whether specific psychiatric disorders or Internalizing versus Externalizing psychopathological dimensions are associated to Internet Addiction Disorder (IAD). W...

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.

This study aimed to further validate the self-reported version of the Proposed Specifiers Conduct Disorder (PSCD) scale, testing the associations between the PSCD with a scale that measures emotional/behavioral difficulties and prosocial behaviors (Strength and Difficulties Questionnaire, SDQ). A total of 536 Italian students (47.76% male, 11–14 years) completed the PSCD, while their caregivers and teachers completed the SDQ. A series of confirmatory factor analyses to test the best fitting model were run. The internal consistency of the PSCD was evaluated, and the correlations between the PSCD self-reported scores and SDQ Parent and Teacher report scores were examined. A bi-factor model was fitted with a refined 19-item version of the scale, which showed adequate fit indices. The PSCD total score was strongly associated with higher parent- and teacher-rated conduct problems, hyperactivity, and lower prosocial behavioral symptoms. In conclusion, this study indicated that the self-report PSCD shows preliminary promise as a reliable, easy-to-use tool, for measuring psychopathic traits in Italian children and young adolescents.

Background. The literature on time perception in individuals with ADHD is extensive but inconsistent, probably reflecting the use of different tasks and performances indexes. Methods. A sample of 40 children/adolescents (20 with ADHD, 20 neurotypical) was engaged in two identical psychophysical tasks measuring auditory time thresholds for both subsecond (0.5-1s) and suprasecond (0.75-3s) stimuli. Results. Results showed a severe impairment in ADHD for subsecond thresholds (Log10BF=1.9). The deficit remained strong even when non-verbal IQ was regressed out and correlation with age suggests a developmental delay. Suprasecond thresholds were indistinguishable between the two groups (Log10BF = –0.5) and not correlated with subsecond thresholds. Conclusions. Since much evidence suggest that perception of subsecond stimuli does not load on cognitive control and working memory, the current results are consistent with a pure timing deficit in individuals with ADHD.

Background: Beside the core symptoms, patients with attention-deficit/hyperactivity disorder (ADHD) frequently show relevant difficulty in developing relationships with peers. Although ADHD symptoms may account for social impairment, deficits in cognitive and/or affective empathy have also been involved. Our aim was to investigate the effect of methylphenidate (MPH) treatment on affective and cognitive empathy. Methods: Sixty-one drug-naïve youths with ADHD (age range 6 to 17 years, mean 10.3 ± 2.8 years, 51 males) naturalistically treated with MPH monotherapy were followed up for 6 months for ADHD symptoms and empathy, measured with the Basic Empathy Scale. Results: After being treated with MPH, the patients showed a significant improvement in affective and cognitive empathy scores. Linear regression models showed that changes in inattention symptoms predicted changes in affective but not in cognitive empathy, while changes in the hyperactivity/impulsivity symptoms did not predict changes in affective or cognitive empathy. Conclusions: Our study provides a further contribution for a better understanding of the possible effects of the MPH on youth’s characteristics.

Background: Severe suicide ideation or attempts and non-suicidal self-injury (NSSI) present both differences and relevant overlaps, including frequent co-occurrence and shared risk factors. Specific categorical diagnoses, namely bipolar disorder (BD), may affect clinical features and natural histories of suicidal or not suicidal self-harm behaviour. Our study aimed to compare suicidality (severe suicidal ideation or suicidal attempts) and NSSI in referred bipolar adolescents. Methods: The sample included 95 bipolar adolescents (32 males, 63 females) aged 11 to 18 years. Thirty adolescents with suicide attempts/suicidal ideation and BD (SASIB) were compared with structured measures to 35 adolescents with NSSI and BD, without suicidal ideation or attempts (NSSIB), and to 30 adolescents with BD, without suicidal ideation or attempts or NSSI (CB). Results: Compared to CB, suicidality and NSSI were both associated with female sex, borderline personality disorder and self-reported internalizing disorders, anxiety/depression and thought disorders. The NSSI were specifically associated with somatic problems. Severe suicidal ideation and suicide attempts were associated with adverse life events, immigration, bullying, eating disorders, social problems, depressive feelings, performance and social anxiety, and feelings of rejection. Conclusions: Both shared and differential features between suicidal and not suicidal adolescents may represent possible targets for diagnostic and preventative interventions.

Autism Spectrum Disorder (ASD) is a multicomplex disorder characterized by an umbrella of specific issues in the areas of social communication, restricted interests, and repetitive behaviors [...]

LEGO®-based therapy is a social skills development program aimed at children with autism spectrum disorder (ASD). A systematic review of the literature was conducted using PRISMA guidelines. PubMed, Scopus and Web of Science bibliographic databases were searched from their date of inception to August 2020. The review included 19 studies. Studies were classified according to experimental designs (e.g., Randomized Control Trial, Non-Randomized Studies of Interventions and case report and series) and a narrative synthesis of each was provided, along with a critical discussion of the strengths and weaknesses of the available literature on the topic. Although LEGO®-based therapy appears a promising treatment for social interaction in ASD, the findings of LEGO®-based therapy studies should be interpreted and generalized with caution, due to the low quality of the studies and the small sample sizes.

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.

Purpose Methylphenidate (MPH), the first-line medication in children with attention-deficit/hyperactivity disorder (ADHD), is associated with increased risk of sleep disorders. Melatonin has both hypnotic and chronobiotic properties that influence circadian rhythm sleep disorders. This study explores the effectiveness of melatonin in children with ADHD who developed sleep problems after starting MPH. Patients and methods This study, based on a clinical database, included 74 children (69 males, mean age 11.6±2.2 years) naturalistically treated with MPH (mean dosage 33.5±13.5 mg/d). The severity of sleep disorder (sleep onset delay) was recorded at baseline and after a follow-up of at least 4 weeks using a seven-point Likert scale according to the Clinical Global Impression Severity score. Effectiveness of melatonin on sleep (mean dosage 1.85±0.84 mg/d) after 4 weeks was assessed using a seven-point Likert scale according to the Clinical Global Impression Improvement (CGI-I) score, and patients who scored 1 (very much improved) or 2 (much improved) were considered responders. Results Clinical severity of sleep disorders was 3.41±0.70 at the baseline and 2.13±1.05 after the follow-up (P

Background and objective Frontal lobe epilepsy (FLE) is often associated with psychiatric features, although the factors predisposing to the concurrence of these conditions have yet to be determined, especially in younger children. We aimed at defining possible clinical and electroencephalography (EEG) features that may enhance the psychiatric risk in pediatric FLE. Method We performed a structured psychiatric assessment of 59 children with FLE, using both categorical and dimensional approaches, correlated psychopathology with epilepsy data, and cognitive development. Results About 1/3 of patients with FLE displayed intellectual disability (ID), and more than 2/3 displayed psychiatric disorders, including depression, disruptive behaviors, anxiety, and bipolar/psychotic disorders. Psychiatric dimensions such as impulse control problems, attentional deficits, social problems, and aggressive behaviors were frequent features of FLE. Intellectual disability was associated with an earlier onset of psychiatric disorders and more frequent disruptive behavior disorders and aggressiveness. Long-standing epilepsy and bilateral or anterior frontal EEG abnormalities also increased the risk of psychopathology. Finally, right-hemisphere lesions were associated with disruptive behavior disorders, fast EEG rhythms with attention/memory problems, and phases of seizure remission with impulse control problems. Conclusions Clinical and EEG markers of increased psychopathological risk may help in defining consistent at-risk subgroups within FLE and improving early diagnosis, prognosis, and treatment. Categorical and dimensional approaches to psychiatric diagnosis may generate new research hypotheses and support the investigation of the complex pathophysiological bases shared by different neurodevelopmental disturbances.

Emotional dysregulation (ED) is currently the most frequently used term to describe children with an impaired regulation of emotional states. Recent research studies speculate whether ED may be a neurodevelopmental disorder itself, a shared risk factor, or a common key feature of several psychiatric disorders, including, among others, attention deficit hyperactivity disorder (ADHD), and bipolar spectrum disorders (BSD). The association between ADHD and ED is one of the main reasons of misconceptions in the definition of boundaries between ADHD and BSD, leading to the frequent misdiagnosis of ADHD as BSD. Since ED is a multidimensional concept, a novel instrument—the Reactivity, Intensity, Polarity and Stability (RIPoSt) scale—was recently developed to assess the different dimensions of ED, which could help in detecting specific ED profiles in clinical youths. Our study included 154 patients, aged 13.8 ± 2.3 years, diagnosed with either ADHD, BSD, or comorbid condition, and a school-based sample of 40 healthy control (HC) adolescents, aged 12.5 ± 1.2 years. The RIPoSt scale and the Child Behavior Checklist were administered to both groups. Our results indicate that affective instability and negative emotionality subscales, as well as negative emotional dysregulation, are higher in BSD, both pure and comorbid with ADHD, while emotional impulsivity is higher in the comorbid condition and similar in the ADHD and BSD alone group; all clinical groups scored higher than HC. Conversely, positive emotionality is similar among clinical groups and within them and HC. Our findings also support the validity of the RIPoSt questionnaire, since the instrument proved to have good-to-excellent internal consistency, and strongly significant positive correlations were found with the CBCL-Dysregulation Profile, which is a commonly used, indirect measure of ED. Hence, the five subscales of the RIPoSt can be reliably used as an effective tool to study the emotional dysregulation in different clinical conditions, to help disentangle the complex relationship between ADHD and juvenile BSD and to provide clinicians with crucial evidence for better diagnostic characterization and therapeutic indications.

In the last decades, the conceptualization of schizophrenia has dramatically changed, moving from a neurodegenerative process occurring in early adult life to a neurodevelopmental disorder starting be-fore birth, showing a variety of premorbid and prodromal symptoms and, in relatively few cases, evolving in the full-blown psychotic syndrome. High rates of co-occurring different neurodevelopmental disorders such as Autism spectrum disorder and ADHD, predating the onset of SCZ, and neurobio-logical underpinning with significant similarities, support the notion of a pan-developmental disturbance consisting of impairments in neuromotor, receptive language, social and cognitive development. Con-sidering that many SCZ risk factors may be similar to symptoms of other neurodevelopmental psychi-atric disorders, transition processes from child & adolescent to adult systems of care should include both high risk people as well as subject with other neurodevelopmental psychiatric disorders with different levels of severity. This descriptive mini-review discuss the need of innovative clinical approaches, re-considering specific diagnostic categories, stimulating a careful analysis of risk factors and promoting the appropriate use of new and safer medications.

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.

Background: When COVID-19 was declared as a pandemic, many countries imposed severe lockdowns that changed families’ routines and negatively impacted on parents’ and children’s mental health. Several studies on families with children with autism spectrum disorder (ASD) revealed that lockdown increased the difficulties faced by individuals with ASD, as well as parental distress. No studies have analyzed the interplay between parental distress, children’s emotional responses, and adaptive behaviors in children with ASD considering the period of the mandatory lockdown. Furthermore, we compared families with children on the spectrum and families with typically developing (TD) children in terms of their distress, children’s emotional responses, and behavioral adaptation. Methods: In this study, 120 parents of children aged 5–10 years (53 with ASD) participated. Results: In the four tested models, children’s positive and negative emotional responses mediated the impact of parental distress on children’s playing activities. In the ASD group, parents reported that their children expressed more positive emotions, but fewer playing activities, than TD children. Families with children on the spectrum reported greater behavioral problems during the lockdown and more parental distress. Conclusions: Our findings inform the interventions designed for parents to reduce distress and to develop coping strategies to better manage the caregiver–child relationship.

Although childhood-onset psychiatric disorders are often considered as distinct and separate from each other, they frequently co-occur, with partial overlapping symptomatology. Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) commonly co-occur with each other and with other mental disorders, particularly disruptive behavior disorders, oppositional defiant disorder/conduct disorder (ODD/CD). Whether these associated comorbidities represent a spectrum of distinct clinical phenotypes is matter of research. The aim of our study was to describe the clinical phenotypes of youths with ADHD with and without ASD and/or ODD/CD, based on neuropsychological and psychopathological variables. One-hundred fifty-one participants with ADHD were prospectively recruited and assigned to four clinical groups, and assessed by means of parent-reported questionnaires, the child behavior checklist and the behavior rating inventory of executive functions. The ADHD alone group presented a greater impairment in metacognitive executive functions, ADHD+ASD patients presented higher internalizing problems and deficits in Shifting tasks, and ADHD+ODD/CD subjects presented emotional-behavioral dysregulation. Moreover, ADHD+ASD+ODD/CD individuals exhibited greater internalizing and externalizing problems, and specific neuropsychological impairments in the domains of emotional regulation. Our study supports the need to implement the evaluation of the psychopathological and neuropsychological functioning profiles, and to characterize specific endophenotypes for a finely customized establishment of treatment strategies.

Attention deficit hyperactivity disorder (ADHD) is commonly associated with sleep problems, possibly due to shared pathophysiology. Microstructural sleep electroencephalographic (EEG) alterations may likely represent markers of disordered cortical maturation in ADHD, although literature data are still conflicting, deserving further assessment. After having systematically reviewed the literature, we included 11 studies from 598 abstracts, and assessed 23 parameters of cyclic alternating pattern (CAP), four parameters of sleep EEG power and one parameter of sleep graphoelements through 29 meta-analyses and, when possible, univariate meta-regressions. Slow wave activity (SWA) in ADHD was significantly higher in early childhood and lower in late childhood/adolescence compared to controls, with an inversion point at 10 years. Total CAP rate and CAP A1 index in non-rapid eye movement (NREM) stage 2 sleep, and CAP A1 rate in NREM sleep were significantly lower in ADHD patients than controls. SWA and CAP A1 changes are therefore possible markers of altered cortical maturation in ADHD, consistently with the neuropsychological deficits characterizing the disorder, likely fostering earlier detection of at-risk/milder conditions, and more tailored therapeutic interventions.

Suicidal ideation and attempts in adolescents are closely associated to bipolar disorders (BD). Growing evidence also suggests that high functioning autism spectrum disorders (HF-ASD) are at increased risk for suicidal ideation and behaviors. Although BD and HF-ASD are frequently comorbid, no studies explored suicidality in these individuals. This exploratory study addressed this issue in a clinical group of inpatient adolescents referred to a psychiatric emergency unit. Seventeen adolescents with BD and HF-ASD and severe suicidal ideation or attempts (BD-ASD-S), were compared to 17 adolescents with BD and HF-ASD without suicidal ideation or attempts (BD-ASD-noS), and to 18 adolescents with BD and suicidal ideation or attempts without ASD (BD-noASD-S), using a structured assessment methodology. Individuals with BD-ASD-S had a higher intelligence quotient, more severe clinical impairment, more lethality in suicide attempts, more internalizing symptoms, less impulsiveness, and lower social competence. Severity of ASD traits in individuals and parents did not correlate with suicidal risk. Some dimensions of resilience were protective in terms of repulsion by life and attraction to death. Main limitations are the small sample size, the lack of a control group of typically developing adolescents. However, a better understanding of the specificities of bipolar HF-ASD individuals with suicidality may improve prevention and treatment strategies.

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.

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.

Gabriele Masi,1 Annarita Milone,1 Giulia Scrinzi,2 Maria Mucci,1 Valentina Viglione,1 Gabriella Bruni,1 Stefano Berloffa,1 Simone Pisano3 1IRCCS Stella Maris Foundation, Developmental Psychiatry and Psychopharmacology Unit, Pisa, Italy; 2Child Neuropsychiatry Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy; 3Clinic of Child and Adolescent Neuropsychiatry, Department of Medicine and Surgery, University of Salerno, Salerno, Italy Background: Although lithium is currently approved for the treatment of bipolar disorders in youth, long term data, are still scant. The aim of this study was to describe the safety and efficacy of lithium in referred bipolar adolescents, who were followed up at the 4th (T1) and 8th (T2) month of treatment.Methods: The design was naturalistic and retrospective, based on a clinical database, including 30 patients (18 males, mean age 14.2±2.1 years).Results: Mean blood level of lithium was 0.69±0.20 mEq/L at T1 and 0.70±0.18 mEq/L at T2. Both Clinical Global Impression-Severity (CGI-S) and Children Global Assessment Scale (C-GAS) scores improved from baseline (CGI-S 5.7±0.5, C-GAS 35.1±3.7) to T1 (CGI-S 4.2±0.70, C-GAS 46.4±6.5; P

Emotional dysregulation (ED) is a dysfunction in modifying an emotional state in an adaptive and goal oriented way, with excitability, ease anger, and mood lability. It is present in up to 70% of adults with ADHD, regardless of other comorbidities, and substantially worsens the psychosocial outcomes of the disorder. Besides fronto-parietal circuits mediating top-down control, brain regions involved in bottom-up processes (e.g., amygdala, orbitofrontal cortex, and ventral striatum) are implicated in ED. We performed a systematic review/meta-analysis of double-blind randomized controlled trials of ADHD medications to assess their effects on ED in adults with ADHD. We searched an extensive set of databases, international trials registries, and contacted study authors/drug companies for unpublished data. We retained 21 trials. We found small-to-moderate effects (methylphenidate: SMD = 0.34, 95% CI = 0.23–0.45; atomoxetine: SMD = 0.24, 95% CI = 0.15–0.34; lisdexamfetamine: SMD = 0.50, 95% CI = 0.21–0.8). We suggest that, whilst ADHD medications are effective on ADHD core symptoms, they may be less effective on bottom-up mechanisms underlying ED. Further research on novel pharmacological and non-pharmacological strategies for ED in adults with ADHD is warranted. PROSPERO: CRD42017068426.

In recent years, there has been growing interest in investigating the effect of specific pharmacological treatments for ADHD not only on its core symptoms, but also on social skills in youths. This stands especially true for ADHD patients displaying impulsive aggressiveness and antisocial behaviors, being the comorbidity with Disruptive Behavior Disorders, one of the most frequently observed in clinical settings. This systematic review aimed to synthesize research findings on this topic following PRISMA guidelines and to identify gaps in current knowledge, future directions, and treatment implications. Search strategies included the following terms: ADHD; methylphenidate and other ADHD drugs; empathy, theory of mind and emotion recognition. Full-text articles were retrieved and data from individual studies were collected. Thirteen studies were finally included in our systematic review. Ten studies assessing changes in empathy and/or theory of mind in patients with ADHD treated after pharmacological interventions were identified. Similarly, seven partially overlapping studies assessing changes in emotion recognition were retrieved. Despite a great heterogeneity in the methodological characteristics of the included studies, most of them reported an improvement in emphatic and theory of mind abilities in youths with ADHD treated with psychostimulants and nonstimulant drugs, as well as positive but less consistent results about emotion recognition performances.

Maria-Cristina Porfirio,1 Juliana Paula Gomes de Almeida,2 Maddalena Stornelli,1 Silvia Giovinazzo,1 Diane Purper-Ouakil,3 Gabriele Masi4 1Unit of Child Neurology and Psychiatry, “Tor Vergata” University of Rome, Italy; 2Unit of Child Neurology, Irmandade Santa Casa de Misericordia Hospital São Paulo, Brazil; 3Unit of Child and Adolescent Psychiatry, Saint Eloi Hospital, Montpellier, France; 4IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy Abstract: In the last two decades, second-generation antipsychotics (SGAs) were more frequently used than typical antipsychotics for treating both psychotic and nonpsychotic psychiatric disorders in both children and adolescents, because of their lower risk of adverse neurological effects, that is, extrapyramidal symptoms. Recent studies have pointed out their effect on weight gain and increased visceral adiposity as they induce metabolic syndrome. Patients receiving SGAs often need to be treated with other substances to counteract metabolic side effects. In this paper, we point out the possible protective effect of add-on melatonin treatment in preventing, mitigating, or even reversing SGAs metabolic effects, improving quality of life and providing safer long-term treatments in pediatric patients. Melatonin is an endogenous indolamine secreted during darkness by the pineal gland; it plays a key role in regulating the circadian rhythm, generated by the suprachiasmatic nuclei (SCN) of the hypothalamus, and has many other biological functions, including chronobiotic, antioxidant and neuroprotective properties, anti-inflammatory and free radical scavenging effects, and diminishing oxidative injury and fat distribution. It has been hypothesized that SGAs cause adverse metabolic effects that may be restored by nightly administration of melatonin because of its influence on autonomic and hormonal outputs. Interestingly, atypical anti-psychotics (AAPs) can cause several sleep disorders, and circadian misalignment can influence hormones involved in the metabolic regulation, such as insulin, leptin, and ghrelin; furthermore, a relationship between obesity and sleep curtailment has been demonstrated, as well as sleep deprivation in rats has been associated with hyperphagia. Metabolic effects of melatonin, both central and peripheral, direct and indirect, target most metabolic disorders reported during and after SGA treatment in children, adolescents, and adults. Further systematic studies on psychiatric patients are needed to explore the effect of add-on melatonin on metabolic side effects of SGAs, independent of energy intake, diet, and exercise. Keywords: melatonin, metabolic syndrome, second-generation antipsychotics

OBJECTIVE To meta-analytically examine the trends and correlates of antipsychotic use in youth with mood disorders. METHODS Systematic literature search without language restriction in PubMed/MEDLINE/PsycINFO from database inception through March 2015 using the following search terms: (antipsychotic* OR neuroleptic* OR "dopamine blocker*" OR antidopaminergic) AND (child* OR adolescen* OR pediatric OR youth) AND (prescription* OR prescrib* OR use OR utilization OR database OR pharmacoepidemiolog* OR frequency OR rate OR rates). Random effects meta-analysis and meta-regression analyses were conducted. STUDY SELECTION Included were studies reporting on the frequency of (1) mood disorders in antipsychotic-treated youth (≤ 19 years) and (2) antipsychotic use in youth with mood disorders. DATA ABSTRACTION Two independent investigators abstracted data on study, patient, and treatment characteristics. RESULTS Forty-one studies were meta-analyzed (N = 518,919, mean ± SD age = 12.8 ± 1.8 years, males = 65.7%). Altogether, 24.2% of antipsychotic-treated youth had a mood disorder diagnosis (studies = 34, depression spectrum disorder = 10.9%, bipolar spectrum disorder = 13.6%). In longitudinal studies, the overall proportion increased significantly from 17.3% in 2000 (range, 1996-2009) to 24.5% in 2006 (range, 2004-2011) (odds ratio [OR] = 1.50; 95% confidence interval [CI], 1.26-1.79; P < .0001). This increase was driven entirely by bipolar spectrum diagnoses (2001 = 11.1%, 2006 = 16.3%, P < .0001), rather than depression spectrum diagnoses (2001 = 9.1%, 2007 = 9.2%, P = .77). Among youth with mood disorders (8 studies), 24.0% received antipsychotics (depression spectrum disorder = 4.6%; bipolar spectrum disorder = 44.0%). CONCLUSIONS The proportion of youth with mood disorder diagnoses increased significantly among antipsychotic-treated youth, driven entirely by an increase in youth with bipolar spectrum disorders. Progress in understanding the reasons for these trends and for an evaluation of the appropriateness of the observed antipsychotic prescribing requires more detailed information than is available in traditional pharmacoepidemiologic databases.

Background Task-based functional magnetic resonance imaging (fMRI) studies of adult attention-deficit/hyperactivity disorder (ADHD) have revealed various ADHD-related dysfunctional brain regions, with heterogeneous findings across studies. Here, we used novel meta-analytic data-driven approaches to characterize the function and connectivity profile of ADHD-related dysfunctional regions consistently detected across studies. Methods We first conducted an activation likelihood estimation meta-analysis of 24 task-based fMRI studies in adults with ADHD. Each ADHD-related dysfunctional region resulting from the activation likelihood estimation meta-analysis was then analyzed using functional decoding based on ~7500 fMRI experiments in the BrainMap database. This approach allows mapping brain regions to functions not necessarily tested in individual studies, thus suggesting possible novel functions for those regions. Additionally, ADHD-related dysfunctional regions were clustered based on their functional coactivation profiles across all the experiments stored in BrainMap (meta-analytic connectivity modeling). Results ADHD-related hypoactivation was found in the left putamen, left inferior frontal gyrus (pars opercularis), left temporal pole, and right caudate. Functional decoding mapped the left putamen to cognitive aspects of music perception/reproduction and the left temporal lobe to language semantics; both these regions clustered together on the basis of their meta-analytic functional connectivity. Left inferior gyrus mapped to executive function tasks; right caudate mapped to both executive function tasks and music-related processes. Conclusions Our study provides meta-analytic support to the hypothesis that, in addition to well-known deficits in typical executive functions, impairment in processes related to music perception/reproduction and language semantics may be involved in the pathophysiology of adult ADHD.

Background/Objective Sleep problems are commonly reported by individuals with Autism Spectrum Disorder (ASD). However, to date, no quantitative evidence synthesis of available studies has been performed to quantify sleep alterations in adults with ASD. We performed a systematic review and meta-analysis of objective (ie, based on actigraphy or polysomnography [PSG]) and subjective (ie, based on sleep diaries/questionnaires) studies comparing sleep parameters in adults with ASD and in a typically developing (TD) control group. Methods PubMed, OVID databases and Web of Knowledge were systematically searched up to February 2019 with no language restrictions. Original studies including adults with a diagnosis of ASD according to DSM, ICD, or based on standard diagnostic tools (eg, ADOS), and a TD control group were included. Random-effects models were used. Study quality was evaluated with the Newcastle Ottawa Scale (NOS). Analyses were conducted using Comprehensive Meta-Analysis. Results From initial pool of 1948 references, 14 publications including 8 datasets, (194 ASD and 277 controls) met the inclusion criteria. Compared to controls, individuals with ASD were significantly more impaired in six out of 11 subjective parameters, including lower sleep efficiency (SE, SMD = −0.87, CI = −1.14 – 0.60) and in 10 out of 17 objective outcomes, including longer sleep onset latency (PSG) (SMD = 0.86, CI = 0.29–1.07) and wake after sleep onset (WASO, actigraphy) (SMD = 0.57, CI = 0.28–0.87). The mean NOS score was 4.88/6. Conclusions Individuals with ASD demonstrated impaired sleep compared to controls in most subjective and objective measures.

Objective: Meta-analytic evidence shows alterations of peripheral inflammatory cytokines in adults with depressive disorders. By contrast, no evidence synthesis on alterations of peripheral inflammatory cytokines in children/adolescents with depressive disorders is available to date. To fill this gap, we conducted a systematic review and meta-analysis of case–control studies comparing serum cytokine levels in children/adolescents with depressive disorders and healthy controls.Methods: Based on a preregistered protocol (PROSPERO-CRD42018095418), we searched PubMed, Ovid, and Web of Knowledge from inception through July 21, 2018, with no language restrictions, and contacted study authors for unpublished data/information. Random-effects model was used to compute effect size for each cytokine. The Newcastle–Ottawa Scale was used to asses study bias.Results: From a pool of 4231 nonduplicate, potentially relevant references, 8 studies were retained for the qualitative synthesis and 5 for the meta-analysis. TNF-α was higher in participants with depressive disorders versus controls, falling short of statistical significance.Conclusions: Overall, due to the small number of studies, in contrast to the literature in adults, further evidence is needed to confirm possible inflammatory alterations associated with depression in youth.

Background: Bipolar disorder (BD) co-occurs with autism spectrum disorder (ASD) in adults in the 10–30% of the cases, and the prevalence rates are similar in high- (HFA) and low-functioning autism (LFA). Familial studies also showed a link between the two conditions, especially for HFA forms, suggesting a possible common genetic liability. In clinical practice HFA and LFA may present different diagnostic issues. In HFA adults, autistic symptoms may have been misinterpreted as “character” or “personality.” When mood symptoms co-occur, the peculiar clinical picture may easily be misdiagnosed with significant implications for the management. In LFA the restricted repertoire of communication and behavior brings to atypical presentations of mood symptoms, which are often not recognized and attributed to the underlying neurodevelopmental condition. Controlled data on pharmacological treatments in BD-ASD comorbidity are virtually absent, and the information derives from open observations, case series, and chart reviews. Mood stabilizers should be considered the first choice, and antipsychotics with 5-HT2a antagonism have been shown useful in controlling psychotic and behavioral symptoms. Some evidence of efficacy for the treatment of anxiety, obsessive-compulsive symptoms, and depression is reported for SSRI antidepressants. The use of these drugs should be carefully monitored, because hypomanic or manic switches have been observed in up to 54% of the treated subjects.

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.

On 11 March 2020, a national lockdown was imposed by the Italian government to contain the spread of COVID19 disease. This is an observational longitudinal study conducted at Fondazione Stella Maris (FSM), Italy to investigate lockdown-related emotional and behavioural changes in paediatric neuropsychiatric population. Families having children (1.5&ndash, 18 years) with neuropsychiatric disorders referred to FSM have been contacted and proposed to fulfil two online questionnaires (General questionnaire and Child Behaviour Check List (CBCL)) to (i) compare (paired two-sample t-tests) the CBCL scores during lockdown with previous ones, and (ii) investigate the influence (multiple linear regression models) of variables such as age, diagnosis grouping (neurological, neurodevelopmental, emotional, and behavioural disorders) and financial hardship. One hundred and forty-one parents fulfilled the questionnaires. Anxiety and somatic problems increased in 1.5&ndash, 5 years subpopulation, while obsessive-compulsive, post-traumatic and thought problems increased in 6&ndash, 18 years subpopulation. In the regression models, younger age in the 1.5&ndash, 5 years subpopulation resulted as &ldquo, protective&rdquo, while financial hardship experienced by families during lockdown was related to psychiatric symptoms increasing in the 6&ndash, 18 years subpopulation. Some considerations, based on first clinical impressions, are provided in text together with comments in relation to previous and emerging literature on the topic.

Psychogenic nonepileptic seizures (PNES) are episodic manifestations that mimic epileptic seizures (ES) although not associated with electroencephalogram (EEG) abnormalities. Psychogenic nonepileptic seizures and ES, however, can often cooccur. Emotional distress in adolescents can trigger PNES, but the psychopathological and personality features are still unknown. The aim of this study was to explore psychopathological features in a sample of referred youth with PNES, with or without ES, compared with a control group with ES. Thirty-four patients aged 12 to 21 years, 19 females and 15 males, were included in the study, 15 patients with PNES, 7 with PNES and ES, and 12 with ES. The three groups were compared according to psychiatric categorical diagnoses, psychopathological dimensions, life stressors, and personality traits, including alexithymia, interpersonal reactivity, and resilience, all assessed with structured measures. Patients with PNES, with or without ES, were more severely impaired, had a higher incidence of mood disorders, more frequent lifetime traumatic experiences, and lower resilience. All the three groups presented alexythimic traits and emotional dysregulation. Major limitations are the small sample size and the lack of a control group of healthy subjects. Disentagling psychopathological characteristics in PNES can help clinicians to focus diagnostic approaches and therapeutic interventions.

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.

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.

Background: Bipolar Disorders (BD) in youth are a heterogeneous condition with different phenomenology, patterns of comorbidity and outcomes. Our aim was to explore the effects of gender, age at onset (prepubertal- vs. adolescent-onset) of BD, and elements associated with attention deficit hyperactivity disorder (ADHD) and Substance Use Disorder (SUD) comorbidities, severe suicidal ideation or attempts, and poorer response to pharmacological treatments. Method: 117 youth (69 males and 57 females, age range 7 to 18 years, mean age 14.5 &plusmn, 2.6 years) consecutively referred for (hypo)manic episodes according to the Diagnostic and Statistical Manual of Mental Disorders, 54th ed (DSM 5) were included. Results: Gender differences were not evident for any of the selected features. Prepubertal-onset BD was associated with higher rates of ADHD and externalizing disorders. SUD was higher in adolescent-onset BD and was associated with externalizing comorbidities and lower response to treatments. None of the selected measures differentiated patients with or without suicidality. At a 6-month follow up, 51.3% of the patients were responders to treatments, without difference between those receiving and not receiving a psychotherapy. Clinical severity at baseline and comorbidity with Conduct Disorder (CD) and SUD were associated with poorer response. Logistic regression indicated that baseline severity and number of externalizing disorders were associated with a poorer outcome. Conclusions: Disentangling broader clinical conditions in more specific phenotypes can help timely and focused preventative and therapeutic interventions.

Executive functions have been previously shown to correlate with empathic attitudes and prosocial behaviors. People with higher levels of executive functions, as a whole, may better regulate their emotions and reduce perceived distress during the empathetic processes. Our goal was to explore the relationship between empathy and executive functioning in a sample of children and adolescents diagnosed with Attention Deficit and Hyperactivity Disorder alone or associated with comorbid Disruptive Behavior Disorders and/or Autism Spectrum Disorder. We also aimed to examine the role of empathic dimensions and executive skills in regulating externalizing behaviors. The 151 participants with ADHD were assigned to four groups according to their psychiatric comorbidity (either &ldquo, pure&rdquo, or with ASD and/or ODD/CD) and assessed by means of either parent- or self-reported questionnaires, namely the BRIEF&minus, 2, the BES, and the IRI. No questionnaire was found to discriminate between the four groups. Affective Empathy was found to positively correlate with Emotional and Behavioral Regulation competences. Furthermore, Aggressiveness and Oppositional Defiant Problems were positively associated with Executive Emotional and Behavioral Regulation competences. On the other hand, Rule-Breaking Behaviors and Conduct Problems were negatively associated with Affective Empathy and with Behavioral skills. Our study provides an additional contribution for a better understanding of the complex relationship between empathic competence and executive functions, showing that executive functioning and empathic attitudes interact with each other to regulate aggressive behaviors. This study further corroborates developmental models of empathy and their clinical implications, for which externalizing behaviors could be attenuated by enhancing executive functioning skills.

Background Emotional dysregulation (ED) and callous unemotional (CU) traits can be associated with ADHD in youth, influencing its natural history and outcome, but their effect on medication efficacy is unexplored. We examined whether two measures of baseline ED and CU traits, the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) and the Antisocial Process Screening Device (APSD), respectively, were predictors of change of ADHD-Rating Scale (ADHD-RS) after a 4-week methylphenidate (MPH) monotherapy. Methods 43 patients (37 males, 8–16 years, mean 9.9 ± 2.7 years) were included. Hierarchical linear regression models were used to explore whether CBCL-DP and APSD might predict ADHD-RS score, controlling for baseline severity. Results Baseline CBCL-DP predicted higher post-treatment ADHD-RS scores in total and hyperactivity-impulsivity, but not in inattention subscale. Baseline APSD was not significantly related to ADHD-RS scores at the follow-up. Limitations Small sample size, lack of gender diversity, non-blind design and short period of observation. Conclusion ED, assessed with that CBCL-DP, might be a negative predictor of change of hyperactive-impulsive symptoms after MPH treatment and should be systematically assessed at baseline.

Gabriele Masi,1 Simone Pisano,2 Paola Brovedani,1 Gioia Maccaferri,1 Azzurra Manfredi,1 Annarita Milone,1 Annalaura Nocentini,3 Lisa Polidori,1 Laura Ruglioni,1 Pietro Muratori1 1IRCCS Fondazione Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy; 2Clinic of Child and Adolescent Neuropsychiatry, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy; 3Department of Sciences of Education and Psychology, University of Florence, Florence, Italy Purpose: Our aims were to explore the developmental trajectories of callous–unemotional (CU) traits using a growth curve analysis in Italian children with disruptive behavior disorders treated with a multimodal intervention, and to test both predictors and distal outcomes of CU traits trajectories. Patients and method: One hundred and sixty-eight children were enrolled, of whom 24 were lost in the follow-up and 144 were followed up from ages 8–9 to 14–15 years with four assessment points. Patients included 128 males (88.9%) with a mean age of 8.7 years, 96 with oppositional defiant disorder (66.7%) and 48 with conduct disorder (CD) (33.3%). The developmental trajectories of CU traits were assessed with the Inventory of Callous–Unemotional Traits (ICU). Results: Our findings revealed that CU features were likely to fit a quadratic model from childhood to adolescence. The CU traits tended to decrease during childhood, with stabilization in adolescence and a significant variability in the growth curves. Pretreatment CD and higher levels of externalizing behavioral problems were associated with higher level of CU traits at baseline, whereas positive parenting was associated with lower levels. No significant effects were found for all the other predictors (socioeconomic status, negative parenting, combined pharmacotherapy). Regarding outcomes into adolescence, both higher levels of CU traits at the baseline and a lower decrease of CU traits across time points predicted a higher risk of CD diagnosis, and higher rate of referrals to mental health services and of substance use. Furthermore, pretreatment CD and negative parenting predicted a higher risk of substance use into adolescence. Conclusion: Our findings suggest that a close monitoring of CU traits in referred children with disruptive behavior disorders may help to detect the patients at higher risk of poor outcome. Keywords: conduct disorder, oppositional defiant disorder, callous–unemotional traits, aggressive behavior, child psychiatry, psychopathy

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.