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Gabriele Masi,1 Pamela Fantozzi,1 Arianna Villafranca,1 Annalisa Tacchi,1 Federica Ricci,1 Laura Ruglioni,1 Emanuela Inguaggiato,1 Chiara Pfanner,1 Samuele Cortese2 1IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy; 2Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK 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

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

During adolescence, a secure parent-adolescent relationship promotes youths' adjustment and psychological well-being. In this scenario, several studies have demonstrated the effectiveness of the CONNECT program, a 10-session, attachment-based parenting intervention that helps parents understand and reframe their parent-adolescent interactions, reducing adolescents' insecure attachment and behavioral problems. Furthermore, recent years have witnessed a significant increase in the implementation of effective online versions of psychological interventions, emphasizing the opportunity for more agile and easier dissemination of evidence-based protocols. Therefore, this study aims to identify changes in adolescents' attachment insecurity, behavioral problems, and parent-child affect regulation strategies, providing preliminary findings on an online, 10-session, attachment-based parenting intervention (eCONNECT). A total of 24 parents (20 mothers, 4 fathers; M age = 49.33, SD = 5.32) of adolescents (M age = 13.83 years, SD = 1.76, 45.8% girls) were assessed on their adolescents' attachment insecurity (avoidance and anxiety) and behavioral problems (externalizing and internalizing), and on their affect regulation strategies in the parent-child interaction (adaptive reflection, suppression, and affect dysregulation) at three time points: before intervention (t0), after intervention (t1), and at a 2-month follow-up (t2). Mixed-effects regression models highlighted a reduction in adolescents' internalizing problems (d = 0.11), externalizing problems (d = 0.29), and attachment avoidance (d = 0.26) after the intervention. Moreover, the reduction in externalizing problems and attachment avoidance remained stable at follow-up. Additionally, our findings highlighted a reduction in parent-child affect dysregulation. Results add preliminary evidence on the implementation suitability of an online attachment-based parenting intervention to change at-risk adolescents' developmental trajectories by reducing attachment insecurity, behavioral problems, and parent-child affect regulation.

Although Attention Deficit Hyperactivity Disorder (ADHD) has been related to an increased risk for behavioral addictions, the relationship between ADHD and Internet Gaming Disorder (IGD) is still debated. The aim of this study is to address this topic by exploring the prevalence of IGD in a consecutive sample of ADHD youth, compared to a normal control group, and by assessing selected psychopathological and cognitive features in ADHD patients with and without IGD. One hundred and eight patients with ADHD (mean age 11.7 ± 2.6 years, 96 males) and 147 normal controls (NC) (mean age 13.9 ± 3.0 years, 114 males) were included in the study and received structured measures for IGD. In the ADHD group, 44% of the sample were above the IGD cut-off, compared to 9.5% in the NC group. ADHD patients with IGD presented with greater severity and impairment, more severe ADHD symptomatology, more internalizing symptoms, particularly withdrawal/depression and socialization problems, and more prominence of addiction and evasion dimensions. A binary logistic regression showed that the degree of inattention presented a greater weight in determining IGD. These findings may be helpful for identifying, among ADHD patients, those at higher risk for developing a superimposed IGD.

Introduction: Secure attachment in adolescence, related to caregiving quality, is a robust predictor of positive behavioral adjustment in early adulthood and beyond. Nevertheless, few attempts have been made to develop treatments to promote parent-adolescent attachment security., Methods: Using a longitudinal, multicenter, randomized controlled trial design, two questionnaire-based studies were run in Italy (Study 1: n = 100 mothers of adolescents, 60% boys, M age  = 14.89, SD = 1.58; Study 2: n = 40 mothers and 40 adolescents, 60% boys, M age  = 14.90, SD = 1.91) to test the effectiveness of an attachment-based parenting intervention (i.e., Connect) in reducing adolescents' behavioral problems and attachment insecurity 2 weeks post-intervention (t2) and at a 4-month follow-up (t3). It was further investigated whether a decrease in avoidant and anxious attachment at t2 would account for changes in externalizing and internalizing problems, respectively, at t3. All adolescents belonged to two-parent intact families., Results: Mothers who completed Connect reported significantly fewer adolescent behavioral problems and lower adolescent attachment insecurity, compared to mothers in the waitlist group, at both t2 and t3 (Study 1). These findings were confirmed in a second subsample (Study 2), considering both mothers' and adolescents' reports. Controlling for pre-intervention behavioral problems, reductions in internalizing and externalizing problems were observed in both studies at t3 via a decrease in anxious and avoidant attachment, respectively, at t2., Conclusions: The findings point to the malleability of attachment security in adolescence and highlight the importance of targeting parenting quality to promote adolescent behavioral adjustment., (Copyright © 2021 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.)

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 "pure" or with ASD and/or ODD/CD) and assessed by means of either parent- or self-reported questionnaires, namely the BRIEF-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.

Research suggests that callous unemotional (CU) traits are associated with poor emotion recognition due to impairments in attention to relevant emotional cues. To further investigate the mechanisms that underlie CU traits, this study focused on the relationship between levels of CU and children's attention to, and recognition of, facial emotions. Participants were 7- to 10-year-old Italian boys, 35 with a diagnosis of Disruptive Behavior Disorder (age: M = 8.93, SD = 1.35), and 23 healthy male controls (age: M = 8.86, SD = 1.35). Children viewed standardized emotional faces (happiness, sadness, fear, disgust, anger, and neutral) while eye-tracking technology was used to evaluate scan paths for each area of interest (eyes, face, mouth), and for each emotion. CU traits were assessed using parent and teacher ratings on the Antisocial Process Screening Device. In the whole sample, elevated levels of CU traits were associated with a lower ability to recognize sadness, a lower number of fixations, and a lower average length of each fixation, specifically to the eye area of sad faces. In children with Disruptive Behavior Disorder diagnoses, high levels of CU traits were associated with lower duration of fixations to the eye-region on the eye area of sad faces, which in turns predicted lower levels of sadness recognition. The findings confirm that poor emotion recognition is associated with impairments in attention to critical information about other people's emotions. The clinical implications are discussed., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

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., (Copyright © 2018 Elsevier B.V. All rights reserved.)

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

Aim: Preschoolers with behavioural difficulties, both at clinical and sub-clinical levels, are at higher risk for several negative outcomes. The current paper reports the results from a randomized clinical trial evaluating an adaptation of the Coping Power for preschool-aged children. In the present study, Coping Power is adapted as a universal prevention intervention, in which teachers deliver a curriculum that is designed to improve children's social competence and reduce problem behaviours., Methods: Ten nursery school classes (164 children, mean age 54.40 months) from two Italian schools were randomly assigned to Coping Power or to the control group, which received the standard academic curriculum provided in Italian nursery schools. Teachers in the five intervention classes implemented weekly lessons and extension activities over a 6-month period. Teacher and parent reports of child behaviour assessments were collected at the beginning and end of the school year. At each assessment period, teachers completed the Strengths and Difficulties Questionnaire., Results: The findings suggest that after exposure to Coping Power, intervention children showed lower levels of behavioural difficulties, rated both by parents and teachers., Conclusions: The results of this study are promising and can be interpreted as providing initial support for the efficacy of the preschool version of Coping Power., (© 2016 John Wiley & Sons Australia, Ltd.)

Several studies demonstrated that maternal psychopathological risk is related to child's maladjustment, but until recently research has relatively neglected fathers. Disruptive Behavior Disorder (DBD) and Eating disorders (ED) have a large prevalence during childhood but a few studies have focused on their association with paternal psychopathological risk. One-hundred and thirty-nine children and their fathers were recruited from pediatric hospitals and outpatient clinics and paired with a healthy control group (CG). Fathers were administered the SCL-90/R and the CBCL 6-18 to assess: 1) psychopathological risk of fathers of children with DBD, ED and CG; 2) significant differences between ED and DBD fathers' psychopathological profiles; and 3) associations between specific fathers' psychopathological symptoms and children's emotional-behavioral problems. Fathers of children with ED showed a higher psychopathological risk than fathers of DBD offspring. Children with DBD showed higher externalizing symptoms. Paternal hostility was associated with internalizing problems in children with DBD. Paternal hostility showed a non-significant but clinically interesting association with internalizing problems in DBD children; interpersonal sensitivity was associated with internalizing problems in ED children. This study can constitute a contribution to a better understanding of the clinical characteristics of fathers of children with DBD and ED., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

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

The pilot study presented in this article investigated the role of moral-cognitive features in understanding aggressive and rule-breaking behaviours in adolescents with Disruptive Behaviour Disorder (DBD). We collected two samples. The community sample was composed of 85 adolescents, whereas the DBD sample was composed of 30 adolescents. Compared with a community sample, adolescents with DBD are more inclined to use moral disengagement (MD) to legitimize their aggressive and rule-breaking behaviours. Moreover, regression models showed that self-enhancement values and MD foster externalizing behaviours taking into account both gender and the group they belonged to, that is, either clinical or community sample. Instead, self-transcendence values could prevent externalizing problems by inhibiting MD. Implications of these findings for assessment and therapeutic interventions are discussed., (© The Author(s) 2015.)

Aggressive behaviors in schools have the potential to cause serious harm to students' emotional and social well-being and to limit their ability to achieve their full academic potential. Prevention programs developed to reduce children's aggressive behaviors in school settings can provide interventions at a universal or targeted level. The main aim of our randomized control study was to examine the efficacy of Coping Power, adapted as a universal prevention program, in reducing children's behavioral problems and improving school grades. Nine classes participated (184 students, mean age 91 months) from two elementary state schools in Tuscany, Italy. Study findings showed a significant reduction in behavioral problems and an improvement in school grades for the intervention classes relative to the control classes. This study suggests the Coping Power program can be delivered in school settings at both universal and targeted prevention levels, and that in this multi-tiered prevention model, teachers, educators and school psychologists can learn a set of intervention skills which can be delivered with flexibility, thus reducing some of the complexity and costs of schools using multiple interventions.

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

Disruptive Behavior Disorders (DBDs) are among the most common reasons for youth referrals to mental health clinics. Aim of this study is to compare short and medium term efficacy of a multimodal treatment program (MTP), compared to community care (treatment-as-usual, TAU). The sample included 135 youths with DBDs (113 males, age range 9-15 years, mean age 12±2.5 years) were assigned either to a MTP (n=64), or addressed to community care for a TAU (n=71). Outcome measures were the Child Behaviour Checklist (CBCL) and the Children's Global Assessment Scale (C-GAS). All subjects were assessed at the baseline (T0), after 1-year treatment (T1) and after a 2-year follow-up (T2). Compared with patients receiving TAU, youths in the MTP showed, both at T1 and T2, significantly lower scores on CBCL Externalizing Scale, Internalizing Scale, Anxious/Depressed, Social Problems, and Aggressive Behavior, and higher scores at the C-GAS. Improvement in Internalizing Scales was particularly evident, with a shift from the clinical to the non-clinical range. Rate of use of mental health services and scholastic failure were reduced in the MTP. It is suggested that the improvement of the Internalizing symptoms is a crucial component of the therapeutic process in this MTP., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: Predictors of poor response to treatments in youths with disruptive behavior disorders (DBDs), including conduct disorder (CD) and oppositional defiant disorder (ODD), are under-studied. Multimodal psychosocial interventions are the best option, but a significant portion of patients needs adjunctive pharmacotherapy. The concept of "psychopathy", and namely, the callous (lack of empathy and guilt) and unemotional (shallow emotions) trait, has been considered a possible specifier indicating a more severe subgroup of patients. We explored whether the callous-unemotional trait (CU) may affect the response to multimodal treatment in referred youths with DBDs., Method: 118 youths (102 males, age range 6-14years, mean age 11.1±2.5years) completed a 12-month multimodal intervention, 48 of whom (41%) needed an associated pharmacotherapy. The patients were assessed according to psychopathological profile (Child Behavior Checklist, CBCL), severity and improvement (Clinical Global Impression-Severity and Improvement scores, CGI-S and CGI-I), functional impairment (Children-Global Assessment Scale, C-GAS), and psychopathic dimension (Antisocial Process Screening Device, APSD), including CU dimension., Results: 58 patients (49.2%) were non-responders. They had more frequently a diagnosis of CD than ODD, presented a comorbid mood disorder, higher CBCL scores in rule-breaking behavior, and higher APSD ("psychopathic") scores. Subjects with higher or lower CU differed only according to the rate of responders (35% vs. 60%, p<.05). The linear blockwise regression indicated that pre-treatment functional impairment (C-GAS) and baseline CU trait were predictors of non-response. The logistic regression indicated that only the value of baseline APSD-CU trait was a predictor of non-response., Conclusions: A careful assessment of baseline clinical functioning and psychopathological features, namely the psychopathic traits, can identify the most problematic patients, and has specific prognostic and treatment implications., (Copyright © 2013 Elsevier Inc. All rights reserved.)

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