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Francesco Precenzano,1,* Maria Ruberto,2,* Lucia Parisi,3 Margherita Salerno,4 Agata Maltese,3 Beatrice Gallai,5 Rosa Marotta,6 Serena Marianna Lavano,7 Francesco Lavano,6 Michele Roccella3 1Clinic of Child and Adolescent Neuropsychiatry, Headache Center for Children and Adolescent. Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania Luigi Vanvitelli, 2Department of Medical-Surgical and Dental Specialties, Università degli Studi della Campania Luigi Vanvitelli, Naples, 3Department of Psychological, Pedagogical and Educational Sciences, 4Sciences for Mother and Child Health Promotion, University of Palermo, Palermo, 5Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, 6Department of Medical and Surgery Sciences, 7Department of Health Sciences, University “Magna Graecia”, Catanzaro, Italy *These authors contributed equally to this work Abstract: Routinely in the clinical practice, children affected by migraine without aura (MwA) tend to exhibit severe and persistent difficulties within cognitive processes such as attention, memory, and visual–motor integration (VMI) skills. The aim of this study was to assess the visual–spatial and visual–motor abilities among a sample of children with MwA and the effects of a specific computerized training. The study population was composed of 84 patients affected by MwA (39 girls and 45 boys; mean age: 8.91±2.46 years), and they were randomly divided into two groups (group A and group B) comparable for age (P=0.581), gender (P=0.826), socioeconomic status (SES), migraine frequency (P=0.415), and intensity (P=0.323). At baseline (T0), the two groups were comparable for movement assessment battery for children (M-ABC) and VMI performances. After 6 months of treatment (T1), group A showed lower scores in the dexterity item of M-ABC test (P

Maria Esposito,1 Beatrice Gallai,2 Michele Roccella,3 Rosa Marotta,4 Francesco Lavano,4 Serena Marianna Lavano,4 Giovanni Mazzotta,5 Domenico Bove,6 Michele Sorrentino,1 Francesco Precenzano,1 Marco Carotenuto1 1Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Second University of Naples, Naples, Italy; 2Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 3Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 4Department of Psychiatry, “Magna Graecia” University of Catanzaro, Catanzaro, Italy; 5Unit of Child and Adolescent Neuropsychiatry, AUSL Umbria 2, Terni, Italy; 6Centro per la Diagnosi e Cura dei Disturbi dell’apprendimento e del Comportamento Associazione per la ricerca scientifica Fusis, Alvignano, Italy Introduction: Childhood obesity has become a worldwide epidemic in Western and in developing countries and has been accompanied by many serious and severe comorbidities, such as diabetes, hypertension, sleep apnea syndrome, depression, dyslipidemia, impaired glucose homeostasis, steatohepatitis, and intracranial hypertension, as well as medical concerns unique to youth, such as accelerated pubertal and skeletal development and orthopedic disorders. To date, no specific studies about the psychological assessment in pediatric obesity are present. Therefore, the aim of this study was to evaluate the putative relationship between psychological troubles and obesity in a sample of school-aged children. Materials and methods: The study population consists of 148 obese subjects (body mass index [BMI] >95th percentile) (69 males, mean age 8.9±1.23 years) consecutively referred from clinical pediatricians to the Child and Adolescent Neuropsychiatry department at the Second University of Naples. In all subjects, weight, height, and BMI z-score were evaluated. In order to assess the anxiety levels and the presence of depressive symptoms, the Children Depression Inventory (CDI) and the Italian Self-Administered Psychiatric Scales for Children and Adolescents (SAFA) were administered. The control group consisted of 273 healthy children (129 males and 144 females) (mean age 9.1±1.8 years), enrolled in schools within the Campania region of Italy. Results: No significant differences between the two study groups were found for age (8.9±1.23 years in the obese sample and 9.1±1.8 years in the control group) (P=0.228) or sex (ratio male/female: 69/79 in the obese group versus 129/144 in the control group) (P=0.983). Obviously, significant difference was found for the BMI z-score (2.46±0.31 in the obese group vs 0.73±0.51 in the control group) (P

Maria Esposito,1 Maria Ruberto,2 Francesca Gimigliano,1,2 Rosa Marotta,3 Beatrice Gallai,4 Lucia Parisi,5 Serena Marianna Lavano,3 Michele Roccella,5 Marco Carotenuto11Center for Childhood Headache, Child and Adolescent Neuropsychiatry Clinic, Department of Mental Health, Physical and Preventive Medicine, 2Department of Odonto-Stomathologic Disciplines, Pathology – Orthopedic Sciences, Second University of Naples, Naples, Italy; 3Department of Psychiatry, “Magna Graecia” University of Catanzaro, Catanzaro, Italy; 4Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 5Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, ItalyBackground: Migraine without aura (MoA) is a painful syndrome, particularly in childhood; it is often accompanied by severe impairments, including emotional dysfunction, absenteeism from school, and poor academic performance, as well as issues relating to poor cognitive function, sleep habits, and motor coordination.Materials and methods: The study population consisted of 71 patients affected by MoA (32 females, 39 males) (mean age: 9.13±1.94 years); the control group consisted of 93 normally developing children (44 females, 49 males) (mean age: 8.97±2.03 years) recruited in the Campania school region. The entire population underwent a clinical evaluation to assess total intelligence quotient level, visual-motor integration (VMI) skills, and motor coordination performance, the later using the Movement Assessment Battery for Children (M-ABC). Children underwent training using the Wii-balance board and Nintendo Wii Fit Plus™ software (Nintendo Co, Ltd, Kyoto, Japan); training lasted for 12 weeks and consisted of three 30-minute sessions per week at their home.Results: The two starting populations (MoA and controls) were not significantly different for age (P=0.899) and sex (P=0.611). M-ABC and VMI performances at baseline (T0) were significantly different in dexterity, balance, and total score for M-ABC (P

Maria Esposito,1 Lucia Parisi,2 Beatrice Gallai,3 Rosa Marotta,4 Anna Di Dona,1 Serena Marianna Lavano,2 Michele Roccella,4 Marco Carotenuto11Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Second University of Naples, Naples, Italy; 2Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 3Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 4Department of Psychiatry, The Magna Graecia University of Catanzaro, Catanzaro, ItalyBackground: In recent years, great attention has been given to the presence of psychological problems and psychiatric comorbidity that are also present in children affected by primary headaches. The relationship between pain and attachment has been identified, and it may be that pain perception may change in relation with specific attachment styles. The aim of the present study was to assess the prevalent attachment style and verify its putative relationship and correlation with the main characteristics of migraine attacks, in school-aged children affected by migraine without aura (MoA).Materials and methods: The study population consisted of 219 children (103 males, 116 females) aged between 6 and 11 years (mean 8.96 ± 2.14 years), consecutively referred for MoA compared with 381 healthy controls (174 males, 207 females; mean age 9.01 ± 1.75 years) randomly selected from schools. All the children were classified according to the attachment typologies of the Italian modified version of the Separation Anxiety Test; monthly headache frequency and mean headache duration were assessed from daily headache diaries kept by all the children. Headache intensity was assessed on a visual analogue scale. The chi-square test and t-test, where appropriate, were applied, and the Spearman rank correlation test was applied to explore the relationship between the types of attachment style and clinical aspects of MoA.Results: The MoA group showed a significantly higher prevalence of type A (avoidant) attachment (P

Maria Esposito,1 Francesca Gimigliano,1,2 Maria Ruberto,2 Rosa Marotta,3 Beatrice Gallai,4 Lucia Parisi,5 Serena Marianna Lavano,3 Giovanni Mazzotta,6 Michele Roccella,5 Marco Carotenuto1 1Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Second University of Naples, Naples, Italy; 2Department of Odontostomathologic Disciplines, Head Pathology, Orthopedic Sciences, Second University of Naples, Italy; 3Department of Psychiatry, Magna Graecia University of Catanzaro, Catanzaro, Italy; 4Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 5Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 6Unit of Child and Adolescent Neuropsychiatry, AUSL Umbria, Terni, Italy Background: According to the Rome III criteria, encopresis without constipation was defined as nonretentive fecal soiling (FNRFS) with not yet well understood etiology. Treatment approaches reported in the literature with varying results include biofeedback, hypnosis, reflexology, and Internet-based educational programs. In developmental age, another behavioral treatment could be identified in the psychomotor approach, which is called psychomotricity in the European countries, or is also known as play therapy. The aim of the present study was to verify the safety and efficacy of play therapy plus toilet training in a small sample of prepubertal children affected by FNRFS. Materials and methods: Twenty-six patients (group 1; 16 males, mean age of 5.92 ± 0.84 years) underwent a psychomotor approach therapy program in association with toilet training for 6 months, and the other 26 subjects (group 2; 17 males, mean age of 5.76 ± 0.69) underwent the sole toilet training program for 6 months. During the observational time period (T0) and after 6 months (T1) of both treatments, the patients were evaluated for FNRFS frequency and for the behavioral assessment. Results: At T0, the FNRFS mean frequency per month for group 1 was 20.115 episodes/month (standard deviation [SD] ± 3.024) and for group 2 was 20.423 (SD ± 1.879) (P = 0.661). At T1 the mean frequency per month was 6.461 (SD ± 1.333) episodes/month and 12.038 (SD ± 1.341), respectively (P < 0.001). Moreover, the delta percent average of the frequency between T0 and T1 was 67.121 ± 8.527 for group 1 and 40.518 ± 9.259 for group 2 (P < 0.001). At T1, a significant improvement in scores on the behavioral scale was identified. Conclusion: Our preliminary results show the importance of a multidisciplinary approach, and suggest the positive effect of an additional psychomotor approach, as this holds a new and interesting rehabilitative purpose for children in a toilet training program, even if further research is necessary. Keyword: encopresis, psychomotricity, children, toilet training, rehabilitation

Maria Esposito,1 Michele Roccella,2 Beatrice Gallai,3 Lucia Parisi,2 Serena Marianna Lavano,4 Rosa Marotta,4 Marco Carotenuto1 1Center for Childhood Headache, Second University of Naples, Naples, Italy; 2Department of Psychology, University of Palermo, Palermo, Italy; 3Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 4Department of Psychiatry, Magna Graecia University of Catanzaro, Catanzaro, Italy Background: Empirical evidence of the important role of the family in primary pediatric headache has grown significantly in the last few years, although the interconnections between the dysfunctional process and the family interaction are still unclear. Even though the role of parenting in childhood migraine is well known, no studies about the personality of parents of migraine children have been conducted. The aim of the present study was to assess, using an objective measure, the personality profile of mothers of children affected by migraine without aura (MoA). Materials and methods: A total of 269 mothers of MoA children (153 male, 116 female, aged between 6 and 12 years; mean 8.93 ± 3.57 years) were compared with the findings obtained from a sample of mothers of 587 healthy children (316 male, 271 female, mean age 8.74 ± 3.57 years) randomly selected from schools in the Campania, Umbria, Calabria, and Sicily regions. Each mother filled out the Minnesota Multiphasic Personality Inventory – second edition (MMPI-2), widely used to diagnose personality and psychological disorders. The t-test was used to compare age and MMPI-2 clinical basic and content scales between mothers of MoA and typical developing children, and Pearson’s correlation test was used to evaluate the relation between MMPI-2 scores of mothers of MoA children and frequency, intensity, and duration of migraine attacks of their children. Results: Mothers of MoA children showed significantly higher scores in the paranoia and social introversion clinical basic subscales, and in the anxiety, obsessiveness, depression, health concerns, bizarre mentation, cynicism, type A, low self-esteem, work interference, and negative treatment indicator clinical content subscales (P < 0.001 for all variables). Moreover, Pearson’s correlation analysis showed a significant relationship between MoA frequency of children and anxiety (r = 0.4903, P = 0.024) and low self-esteem (r = 0.5130, P = 0.017), while the MoA duration of children was related with hypochondriasis (r = 0.6155, P = 0.003), hysteria (r = 0.6235, P = 0.003), paranoia (r = 0.5102, P = 0.018), psychasthenia (r = 0.4806, P = 0.027), schizophrenia (r = 0.4350, P = 0.049), anxiety (r = 0.4332, P = 0.050), and health concerns (r = 0.7039, P < 0.001) MMPI-2 scores of their mothers. Conclusion: This could be considered a preliminary study that indicates the potential value of maternal personality assessment for better comprehension and clinical management of children affected by migraine, though further studies on the other primary headaches are necessary. Keywords: MMPI-2, childhood migraine, maternal personality

Maria Esposito,1 Lorenzo Antinolfi,1 Beatrice Gallai,2 Lucia Parisi,3 Michele Roccella,3 Rosa Marotta,4 Serena Marianna Lavano,4 Giovanni Mazzotta,5 Francesco Precenzano,1 Marco Carotenuto1 1Sleep Clinic for Developmental Age, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental and Physical Health and Preventive Medicine, Second University of Naples, Naples, Italy; 2Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 3Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 4Department of Psychiatry, Magna Graecia University of Catanzaro, Catanzaro, Italy; 5Unit of Child and Adolescent Neuropsychiatry, AUSL Umbria 2, Terni, Italy Introduction: The role of sleep in cognitive processes can be considered clear and well established. Different reports have disclosed the association between sleep and cognition in adults and in children, as well as the impact of disturbed sleep on various aspects of neuropsychological functioning and behavior in children and adolescents. Behavioral and cognitive dysfunctions can also be considered as related to alterations in the executive functions (EF) system. In particular, the EF concept refers to self-regulatory cognitive processes that are associated with monitoring and controlling both thought and goal directed behaviors. The aim of the present study is to assess the impact of the obstructive sleep apnea syndrome (OSAS) on EF in a large sample of school aged children. Materials and methods: The study population comprised 79 children (51 males and 28 females) aged 7–12 years (mean 9.14 ± 2.36 years) with OSAS and 92 healthy children (63 males and 29 females, mean age 9.08 ± 2.44 years). To identify the severity of OSAS, an overnight respiratory evaluation was performed. All subjects filled out the Italian version of the Modified Card Sorting Test to screen EFs. Moreover, to check the degree of subjective perceived daytime sleepiness, all subjects were administered the Pediatric Daytime Sleepiness Scale (PDSS). Results: No significant differences between the two study groups were found for age (P = 0.871), gender (P = 0.704), z-score of body mass index (P = 0.656), total intelligence quotient (P = 0.358), and PDSS scores (P = 0.232). The OSAS children showed a significantly higher rate of total errors (P < 0.001), perseverative errors (P < 0.001), nonperseverative errors (P < 0.001), percentage of total errors (P < 0.001), percentage of perseverative errors (P < 0.001), and percentage of nonperseverative errors (P< 0.001). On the other hand, OSAS children showed a significant reduction in the number of completed categories (P = 0.036), total correct sorts (P = 0.001), and categorizing efficiency (P < 0.001). The Pearson's correlation analysis revealed a significant positive relationship between all error parameters and apnea-hypopnea index, oxygen desaturation index, and percentage of mean desaturation of O2 with a specular negative relationship between the error parameters and the mean oxygen saturation values, such as a significant negative relationship between apnea-hypopnea index, oxygen desaturation index, percent of mean desaturation of O2, and the number of completed categories. Conclusion: Our study identified differences in the executive functioning of children affected by OSAS and is the first to identify a correlation between alteration in respiratory nocturnal parameters and EF that has not yet been reported in developmental age. These findings can be considered as the strength and novelty of the present report in a large pediatric population. Keywords: OSAS, polysomnography, executive functions, sleep, sleepiness, children

Maria Esposito,1 Beatrice Gallai,2 Lucia Parisi,3 Laura Castaldo,1 Rosa Marotta,4 Serena Marianna Lavano,4 Giovanni Mazzotta,5 Michele Roccella,3 Marco Carotenuto11Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Second University of Naples, Naples, Italy; 2Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 3Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 4Department of Psychiatry, "Magna Graecia" University of Catanzaro, Catanzaro, Italy; 5Unit of Child and Adolescent Neuropsychiatry, AUSL Umbria 2, Terni, ItalyIntroduction: Self-esteem is related to the broadly understood concept of self-schemas and is a crucial mechanism for a correct psychological development in children and adolescents. The impact of the many psychological difficulties linked to the migraine without aura (MoA) and recurrent headache attacks, such as anger and separation anxiety, on self-esteem has not yet been well investigated. The aims of the present study were to assess self-esteem levels in an objective way and to verify their possible relationship and correlation with the frequency and intensity of migraine attacks, in a population of children and adolescents affected by MoA.Methods: The study population was comprised of 185 children (88 males [M], 97 females [F]) aged between 6 and 12 years (mean 9.04 ± 2.41 years) referred consecutively for MoA to the Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Second University of Naples and of 203 healthy controls (95 M, 108 F) with mean age 9.16 ± 2.37 years, recruited from schools in Campania. The monthly headache frequency and the mean headache duration were assessed from daily headache diaries kept by all the children, and MoA intensity was assessed on a VAS (visual analog scale). To further evaluate their level of self-concept, all subjects filled out the Multidimensional Self-Concept Scale (MSCS).Results: The two study groups were comparable for age (P = 0.621), sex (P = 0.960), and z-score BMI (P = 0.102). The MoA group showed a significant reduction in the MSCS total score (P < 0.001) and in the Social (P < 0.001), Affect (P < 0.001), Family (P < 0.001), and Physical (P < 0.001) domains of the MSCS compared with the control group. The Pearson's correlation analysis showed a significantly negative relationship between MoA clinical characteristics and MSCS scores, and similarly the frequency of attacks was significantly negatively related with the Social (r = −0.3176; P < 0.001), Competence (r = −0.2349; P = 0.001), Physical (r = −0.2378; P = 0.001), and total (r = −0.2825; P < 0.001) scores of the MSCS. On the other hand, the MoA duration was significantly negatively related with the Social (r = −0.1878; P = 0.01), Competence (r = −0.2270; P = 0.002), Physical (r = −0.1976; P = 0.007), and total (r = −0.1903; P = 0.009) scores of the MSCS.Conclusion: Our study first identified differences in self-esteem levels, with an objective tool, in children affected by MoA compared with controls, suggesting the need for evaluation of self-esteem for better psychological pediatric management of children with migraine.Keywords: children, self-esteem, MSCS

Maria Esposito,1 Rosa Marotta,2 Beatrice Gallai,3 Lucia Parisi,4 Giuseppina Patriciello,1 Serena Marianna Lavano,2 Giovanni Mazzotta,5 Michele Roccella,4 Marco Carotenuto11Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Second University of Naples, Naples, Italy; 2Department of Psychiatry, "Magna Graecia" University of Catanzaro, Catanzaro, Italy; 3Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 4Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 5Unit of Child and Adolescent Neuropsychiatry, AUSL Umbria 2, Terni, ItalyBackground: Children with migraine seem to be more anxious, sensitive, deliberate, cautious, fearful, vulnerable to frustration, tidy, and less physically enduring than comparisons. To the best our knowledge no studies about the temperamental and the characterial dimension aspects in childhood migraine was conducted. Therefore, the aim of the present study was to describe the temperamental and character aspects in a sample of children affected by migraine without aura (MoA) and their relationship with clinical aspects of MoA such as frequency, duration, and severity of attacks.Materials and methods: In our study, 486 children affected by MoA (239 male, 247 female) aged 7–12 years, (mean 10.04 ± 2.53 years) and 518 typical developing children comparable for age (P = 0.227) and sex (P = 0.892) were enrolled to assess their temperamental characteristics. The mothers of all subjects filled out the Junior Temperament and Character Inventory: Parent Version.Results: Children affected by migraine show a higher prevalence of harm avoidance and persistence temperamental domains (P < 0.001) and significantly lower prevalence of the self-directedness character trait (P = 0.023) with respect to the comparisons, according to Cloninger's model. The Spearman rank correlation analysis shows a significant relationship between migraine characteristics and temperamental domains.Conclusion: The present study first identified differences in temperamental characteristics in children affected by MoA with respect to the comparisons, suggesting the need for this evaluation in order for better psychological pediatric management of children with migraine, with possible consequences and impact on the future outcomes of these subjects.Keywords: migraine without aura, children, temperament, JTCI

Maria Esposito,1 Beatrice Gallai,2 Lucia Parisi,3 Michele Roccella,3 Rosa Marotta,4 Serena Marianna Lavano,4 Giovanni Mazzotta,5 Giuseppina Patriciello,1 Francesco Precenzano,1 Marco Carotenuto1 1Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Second University of Naples, Italy; 2Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Italy; 3Child Neuropsychiatry, Department of Psychology, University of Palermo, Italy; 4Department of Psychiatry, "Magna Graecia" University of Catanzaro, Catanzaro, Italy; 5Unit of Child and Adolescent Neuropsychiatry, AUSL Umbria 2, Terni, Italy Background: Primary monosymptomatic nocturnal enuresis (PMNE) is a common problem in the developmental ages; it is the involuntary loss of urine during the night in children older than 5 years of age. Several clinical observations have suggested an association between bedwetting and developmental delays in motricity, language development, learning disability, physical growth, and skeletal maturation. The aim of the present study is to evaluate the prevalence of fine motor coordination and visuomotor integration abnormalities in prepubertal children with PMNE. Methods: The study population included 31 children (16 males, 15 females; mean age 8.14 years ± 1.36 years), and the control group comprised 61 typical developing children (32 males, 29 females; mean age 8.03 years ± 1.44 years). The whole population underwent a clinical evaluation to assess total intelligence quotient level, visuomotor integration (VMI) skills, and motor coordination performance (using the Movement Assessment Battery for Children, or M-ABC). Results: No significant differences between the two study groups were found for age (P = 0.725), gender (P = 0.886), z-body mass index (P = 0.149), or intellectual abilities (total intelligence quotient) (P = 0.163). The PMNE group showed a higher prevalence of borderline performance on M-ABC evaluation and in pathologic performance on VMI Total Task compared to controls (P < 0.001). No significant differences between the two study groups were found for pathologic performances on the M-ABC (P = 0.07), VMI Visual Task (P = 0.793), and VMI Motor Task (P = 0.213). Conclusion: Our findings pinpointed that PMNE should not be considered as a voiding disorder alone and, consequently, the children affected should be referred to specific rehabilitative programs that aim to improve motor coordination and visuomotor integration. Keywords: primary monosymptomatic nocturnal enuresis, visuomotor integration, childhood rehabilitation, VMI, M-ABC

Maria Esposito,1 Beatrice Gallai,2 Lucia Parisi,3 Michele Roccella,3 Rosa Marotta,4 Serena Marianna Lavano,4 Antonella Gritti,5 Giovanni Mazzotta,6 Marco Carotenuto11Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical, and Preventive Medicine, Second University of Naples, Naples, 2Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, 3Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, 4Department of Psychiatry, "Magna Graecia" University of Catanzaro, Catanzaro, 5Suor Orsola Benincasa University, Naples, 6Unit of Child and Adolescent Neuropsychiatry, Azienda Sanitaria Locale 4, Terni, ItalyBackground: Migraine without aura is a primary headache which is frequent and disabling in the developmental age group. No reports are available concerning the prevalence and impact of migraine in children on the degree of stress experienced by parents. The aim of this study was to evaluate the prevalence of maternal stress in a large pediatric sample of individuals affected by migraine without aura.Methods: The study population consisted of 218 children (112 boys, 106 girls) of mean age 8.32 ± 2.06 (range 6–13) years suffering from migraine without aura and a control group of 405 typical developing children (207 boys, 198 girls) of mean age 8.54 ± 2.47 years. Mothers of children in each group answered the Parent Stress Index-Short Form (PSI-SF) questionnaire to assess parental stress levels.Results: The two groups were matched for age (P = 0.262), gender (P = 0.983), and body mass index adjusted for age (P = 0.106). Mothers of children with migraine without aura reported higher mean PSI-SF scores related to the Parental Distress domain (P < 0.001), Dysfunctional Parent-Child Interaction domain (P < 0.001), Difficult Child subscale (P < 0.001), and Total Stress domain than mothers of controls (P < 0.001). No differences between the two groups were found for Defensive Responding subscale scores.Conclusion: Our study may be the first to highlight the presence of high levels of stress in parents of children affected by migraine without aura.Keywords: parental stress, childhood migraine, migraine without aura, children

Maria Esposito,1 Beatrice Gallai,2 Lucia Parisi,3 Michele Roccella,3 Rosa Marotta,4 Serena Marianna Lavano,4 Giovanni Mazzotta,5 Marco Carotenuto11Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Second University of Naples, Naples, Italy; 2Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy; 3Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 4Department of Psychiatry, “Magna Graecia” University of Catanzaro, Catanzaro, Italy; 5Unit of Child and Adolescent Neuropsychiatry, AUSL Umbria 2, Terni, ItalyIntroduction: Primary nocturnal enuresis (PNE) is a common problem in developmental age with an estimated overall prevalence ranging from 1.6% to 15%, and possible persistence during adolescence. There is a growing interest in the sleep habits of children affected by PNE, which is derived from the contradictory data present in clinical literature. The aim of the present study was to evaluate the presence of sleep disturbances in a population of children affected by PNE, and to identify whether PNE could be considered as a risk factor for sleep disturbances among children.Materials and methods: A total of 190 PNE children (97 males, 93 females) aged 7–15 years, (mean 9.64 ± 1.35 years), and 766 typically developing children matched for age (P = 0.131) and gender (P = 0.963) were enrolled. To evaluate the presence of sleep habits and disturbances, all of the subjects’ mothers filled out the Sleep Disturbances Scale for Children (SDSC), a questionnaire consisting of six subscales: Disorders in Initiating and Maintaining Sleep (DIMS), Sleep Breathing Disorders (SBD), Disorders of Arousal (DA), Sleep–Wake Transition Disorders (SWTD), Disorders of Excessive Somnolence (DOES), and Nocturnal Hyperhidrosis (SHY). The results were divided into “pathological” and “normal” scores using a cut-off value (pathological score = at least three episodes per week), according to the validation criteria of the test. Then, the Chi-square test was used to calculate the statistical difference and a univariate logistic regression analysis was applied to determine the role of PNE as a risk factor for the development of each category of sleep disorders and to calculate the odds ratio (OR).Results: PNE children show a higher prevalence of all sleep disturbances (41.03% DIMS; 85.12% SBD; 63.29% DA; 67.53% SWTD; 31.28% DOES; 37.92% SHY; 25.33% SDSC total score), and according to OR results (SDSC total score OR = 8.293, 95% confidence interval [CI] = 5.079–13.540; DIMS OR = 7.639, 95% CI = 5.192–11.238; SBD OR = 35.633, 95% CI = 22.717–55.893; DA OR = 13.734, 95% CI = 9.476–19.906; SWTD OR = 14.238, 95% CI = 9.829–20.625; DOES OR = 5.602, 95% CI = 3.721–8.432; SHY OR = 6.808, 95% CI = 4.608–10.059), PNE could be considered as a risk factor for the development of sleep disorders.Conclusion: Among PNE children, sleep could be strongly altered, thus helping to affirm the hypothesis that PNE tends to alter sleep architecture, or it could itself be the consequence of an abnormal sleep structure. The findings also point to the existence of a potential increase in the risk of developing sleep disorders in the presence of PNE.Keywords: primary nocturnal enuresis, SDSC, sleep

Maria Esposito,1 Michele Roccella,2 Lucia Parisi,2 Beatrice Gallai,3 Marco Carotenuto11Center for Childhood Headache, Unit of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical, and Preventive Medicine, Second University of Naples, Naples, Italy; 2Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 3Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, ItalyBackground: The relationship between sleep and headache is meaningful and complex. Children affected by migraines tend to show many sleep disorders, such as insufficient sleep duration and excessive daytime somnolence. Therefore, the aim of this study is to assess the rate of reported sleep habits and self-reported sleepiness in a large pediatric sample of individuals affected by migraine without aura (MoA).Methods: The study population consisted of 271 children aged between 6 and 13 years affected by MoA. The control group was composed of 305 typically developing children. To assess the sleep habits of all individuals (MoA and control), parents filled out the Sleep Disturbance Scale for Children, and to check the degree of subjective perceived daytime sleepiness, all subjects were administered the Pediatric Daytime Sleepiness Scale.Results: The two study groups were matched for age (P = 0.124), sex distribution (P = 0.775), and body mass index z-score (P = 0.107). Parents of children affected by MoA reported a higher total score of sleep disorder symptoms (P < 0.001), disorders of initiating and maintaining (P < 0.001), and disorders of arousal (P < 0.001) than did parents of controls. No significant differences were found in disorders of excessive somnolence. Conversely, in the Pediatric Daytime Sleepiness Scale, migraine children had higher scores (24.67 ± 3.19 vs 11.94 ± 4.81; P < 0.001) and a reduction in referred total sleep time mean duration (469.83 ± 98.112 vs 527.94 ± 83.02; P < 0.001) than typically developing children.Conclusion: Our study identified differences in sleep habits and found a high prevalence of daytime somnolence in children affected by MoA, suggesting the need for routine sleep screening in the pediatric management of children with migraines.Keywords: excessive daytime sleepiness, drowsiness, sleep disorders, migraine without aura, children

Marco Carotenuto,1 Beatrice Gallai,2 Lucia Parisi,3 Michele Roccella,3 Maria Esposito11Sleep Clinic for Developmental Age, Clinic of Child and Adolescent Neuropsychiatry, Second University of Naples, Naples, 2Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, 3Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, ItalyBackground: The purpose of this study was to assess the efficacy of acupressure therapy in a sample of adolescents with insomnia using a standard polysomnographic evaluation.Methods: For this study, 25 adolescents affected by psychophysiological insomnia (mean age 15.04 ± 1.18 years, 12 boys) were enrolled. A device known as the Sea-Band® was used by the patients in order to improve their symptoms related to difficulty in falling asleep. All subjects enrolled underwent two sets of consecutive overnight polysomnographic studies in the Sleep Laboratory of the Clinic of Child and Adolescent Neuropsychiatry, comprising two studies at baseline (before treatment) and another two studies at the end of 6 months of treatment.Results: At the end of 6 months of treatment, there was a significant increase in all macrostructural parameters of sleep duration, and a reduction in sleep onset latency, wake after sleep onset, and stage 2 sleep. Moreover, the study group showed a significant increase in percent sleep efficiency (P < 0.001) and in slow wave sleep representation.Conclusion: Acupressure is a noninvasive, safe, and effective method for the management of insomnia in adolescents, with good compliance and no adverse effects.Keywords: insomnia, adolescence, acupressure, polysomnography

Maria Esposito,1 Antonio Pascotto,1 Beatrice Gallai,3 Lucia Parisi,2 Michele Roccella,2 Rosa Marotta,4 Serena Marianna Lavano,4 Antonella Gritti,5 Giovanni Mazzotta,6 Marco Carotenuto11Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Second University of Naples, Naples, 2Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, 3Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, 4Department of Psychiatry, “Magna Graecia” University of Catanzaro, Catanzaro, 5Suor Orsola Benincasa University, Napoli, 6Unit of Child and Adolescent Neuropsychiatry, Azienda Sanitaria Locale 4, Terni, ItalyBackground: The purpose of this study was to assess the cognitive functioning of children affected by headache, pinpointing the differences in intelligence style between subjects affected by migraine without aura and subjects with tension-type headache.Methods: The study population consisted of 147 children (mean age 10.82 ± 2.17 years) with headache, recruited from the Headache Center for Developmental Age, Child and Adolescent Neuropsychiatry Clinic, Second University of Naples. Cognitive profiling was performed using Weschler Intelligence Scale for Children Third Edition throughout the sample. According to the International Classification of Headache Disorders II criteria for pediatric age, subjects were divided into a migraine without aura group (n = 75; 43 boys, 32 girls) and a tension-type headache group (n = 72; 49 boys, 23 girls). The results were compared with the findings obtained from a sample of 137 healthy control subjects recruited from schools in the Campania region, matched for age and gender.Results: No difference in full intelligence quotient was found between the groups, but the children with tension-type headache had a lower verbal intelligence quotient and a higher performance intelligence quotient than the healthy controls and children with migraine. Factor analysis data showed that the children with migraine seemed to have lower perceptual organization than the children affected by tension-type headache.Conclusion: To our knowledge, studies on cognitive functioning in children affected by headache in the interictal phase are scarce, and our results suggest a new perspective in understanding of the neuropsychological aspects of young patients affected by headaches.Keywords: childhood headache, intelligence quotient, Weschler Intelligence Scale for Children Third Edition, intelligence, migraine

Marco Carotenuto,1 Maria Esposito,1 Lucia Parisi,2 Beatrice Gallai,3 Rosa Marotta,4 Antonio Pascotto,1 Michele Roccella21Sleep Clinic for Developmental Age, Clinic of Child and Adolescent Neuropsychiatry, Second University of Naples, Naples, Italy; 2Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy; 3Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, 4Department of Psychiatry, "Magna Graecia" University of Catanzaro, Catanzaro, ItalyBackground: The relationship between sleep and mood regulation is well known, and some reports suggest a key role of sleep-related breathing disorders (SRBD) in the development of the symptomatology of depression, even if no conclusive data are actually found in the clinical literature. The aim of this study was to assess the relationship between SRBD and depressive symptoms in a population of school-aged children.Methods: The study population comprised 94 children affected by SRBD and 107 healthy children. To identify the severity of SRBD, an overnight respiratory evaluation was performed. All subjects filled out the Italian version of the Children Depression Inventory (CDI) to screen for the presence of depressive symptoms.Results: The group with SRBD showed higher CDI scores than the group without SRBD, with a positive correlation found between CDI scores, apnea-hypopnea index, and oxygen desaturation index values. Logistic regression showed that an apnea-hypopnea index ≥ 3 and an oxygen desaturation index ≥ 1 could be risk factors for development of depressive symptoms. According to receiver-operating characteristic curve analysis, the cutoff point for the apnea-hypopnea index that could cause a pathological CDI score (≥19) was >5.66, and the cutoff point for the oxygen desaturation index was >4.2. The limitations of this study are that our data are derived from one single psychometric test and not from a complete psychiatric evaluation, and our subjects came from a small group in southern Italy.Conclusion: Our results suggest the importance of mood assessment in children affected by SRBD.Keywords: depression, sleep-related breathing disorders, cardiorespiratory monitoring, children