4° ADHD Workshop - old.iss.itold.iss.it/binary/adhd/cont/abstract_ADHD_Cagliari_2012.pdf ·...

CAGLIARI 8/10 MARZO 2012

SALA CONGRESSICENTRO COMUNALE D'ARTE E CULTURA

“IL GHETTO”VIA SANTA CROCE, 18

CAGLIARI

Università degli Studi di CagliariDipartimento di Scienze Biomediche

Sezione Neuroscienze e Farmacologia Clinica

Azienda Ospedaliero-Universitaria di CagliariClinica di NeuroPsichiatria

Infantile

4° ADHD WorkshopDalle evidenze

alla pratica clinica

ABSTRACT

4°ADHD Workshop Dalle evidenze alla pratica clinica

Cagliari, 8-10 Marzo 2012

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Friday 9th of March

1. Self-esteem evaluation in children and adolescents suffering from ADHD ....................... 7

Reale Laura, Guarnera Manuela, Mannino Valeria, Armando Marco, Fatta Laura, Postorino

Valentina, De Peppo Lavinia, Vicari Stefano, Mazzone Luigi ..........................................................

2. Design and development of psycho educational interventions with parents and teachers

to cope with the adhd disorder: analysis of the effectiveness of the paths through a

quantitative and qualitative analysis of the interventions. ................................................. 9

Mannino Valeria, Costantino Antonella, Bissoli Claudio, Cropanese Isabella .................................

Pagnotta Giulia, Querci Michela, Santi Chiara ................................................................................

3. Sharing project of diagnostic and therapeutic pathways for ADHD in Lombardy ............ 10

Tiberti Alessandra, Effedri Paola, Filippini Elena; Daffi Gianluca. ...................................................

4. Assessment of BMI in an Italian ADHD community care. ............................................. 11

Germinario Elena, Chiarotti Flavia, Arcieri Romano, Panei Pietro .................................

5. Infection with cytomegalovirus and other herpes viruses as possible factors in the

development of attention deficit and hyperactivity disorder:preliminary results. ............... 12

Riccio M.P., Borgia G., Cascella R., Gentile I., Maiorano A., Marino M., Pascotto A., Scarica S.,

Zappulo E., Bravaccio C. ................................................................................................................

6. ADHD and Epilepsy in children with Tourette Syndrome: a triple comorbidity? ............. 13

Rizzo Renata, Gulisano Mariangela, Calì Paola Valeria, Curatolo Paolo ........................................

7. BMI andpsychopathological disorders in comorbiditieswith ADHD:correlation studyin a

populationof patients of campania region ..................................................................... 14

Sarnataro E., Bernardo P., Granata R., Grimaldi A., Maresca R., Pascotto A., Russo L., Tiano

C., Bravaccio C. .............................................................................................................................

8. Self-esteem and parental stress in children with ADHD ............................................... 15

Lamberti Marco, Boncoddo Maria, Siracusano Rosamaria, Germanò Eva, Ciuffo Massimo,

Cucinotta Francesca, Cedro Clemente, Gagliano Antonella. ..........................................................

9. ADHD patients: observational multicenter study in three Italian dedicated ADHD centers.

Preliminary data ......................................................................................................... 17

Sposato M.; Trinari E.; Cannarozzo M; Pincherle M.; Fini F.; Filippini V.; Mazzotta G.. ..................

10. Multimodal intervention in ADHD: the experience of Scientific Institute E.Medea of

Ostuni-Brindisi in the Apulia Region (Italy) .................................................................... 18

Fanizza Isabella, Massagli Angelo ..................................................................................................



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11. Research protocol in the diagnostic investigation on ADHD ...................................... 19

Ragazzo F., Benso F., Fiorella R., Stella S., Morando M., Castellani S., Gazzellini S. ...................

12. Clinical suggestions about parent training comparing two groups of children with ADHD,

ODD and LD. .............................................................................................................. 20

Galimberti G., Actis Perinetti B., Aggio F., Saccani M. ....................................................................

13. ADHD and AUTISM: a study in the ASL of Novara ..................................................... 21 Guccione Fulvio, Antonini Alessia, Vallana Marianna, Duella Sara, Tettamanti Elena ....................

14. Cognitive impairment in ADHD with language disorder in preschoolers:confront with

ADHD without language disorder and SLI. .................................................................... 22

Melegari Maria Grazia1, Manzi B., Costa A., Canzano L., Uberti Paola ..........................................

15. ADHD subtypes and comorbidity in Italy .................................................................. 23

Valenti Vera, Di Trani Michela, Galantini Chiara, Merati Silvia, Donfrancesco Renato ...................

16. Major Depression and Dysthymia in children with ADHD. .......................................... 24

Leo G., Leone D., Di Trani M, Martines F., Sferrazza A,Torrioli MG , Donfrancesco R. ..................

17. An ADHD complex case report ................................................................................ 25

Pagana Lucia; Bassi Bianca; Mariani Alessandro; Magnano Lara ..................................................

18. Systemic multimodal approach to ADHD children and their families ........................... 26

Cremaschi Silvana, Zappulla Giuseppe, Bortolossi Barbara, Sartor Graziella, Martignon Fabrizia.

19. Response Time Intra-subject Variability: commonalities between children with children

with Attention Deficit/Hyperactivity Disorder (ADHD) and children with Autism Spectrum

Disorders (ASD). ........................................................................................................ 27

Adamo N., Adelsberg S., Petkova E., Castellanos F. X.and Di Martino A.1 ....................................

20. ADHD and Autism Spectrum Disorder symptoms overlapping: social functioning

impairment ................................................................................................................ 28

Anchisi L., Carucci S1, Ambu G., Lecca L., Zuddas A. ....................................................................

21. Face emotion recognition: a preliminary analysis in Attention-Deficit Hyperactive

Disorder (ADHD) and Autism Spectrum Disorder (ASD) .................................................. 29

Peddis Cristina, Reale Laura, Petza Silvia, Liori Arianna, Carucci Sara, Zuddas Alessandro .........



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Saturday10th of March

1. Moderation by the Tryptophan Hydroxylase 2 (TPH2) gene on the continuity/discontinuity

of emotional Dysregulation symptoms throughout adolescence and the role of family

structure .................................................................................................................... 31

Nobile Maria M.D., ColomboPaola Ph.D., BellinaMonica D.Psych, Greco Andrea D.Psych.,

Monzani Dario D.Psych., Bianchi ValentinaD.Psych., Carletto Ombretta M.D. and Molteni

Massimo M.D. .................................................................................................................................

2. ADHD, intellectual disability and other comorbidities: analysis of findings at the CGH-

array in a small sample of subjects .............................................................................. 33

Di Vita G., Galesi O., Fichera M., Castiglia L., Torrisi A.M., Amata M.T., Costanzo A., Di Guardo

G., Musumeci S.A. .........................................................................................................................

3. Neuropsychological and neurobiological model of aggression in children with

externalizing disorders ............................................................................................... 35

Mazzone Luigi, De Peppo Lavinia, Vicari Stefano, Williams Riccardo, Postorino Valentina, Milone

Annarita, Lenzi Francesca, Pisano Simone, Manfredi Azzurra, Muratori Pietro, Masi Gabriele ......

4. Executive functions in Attention-Deficit/Hyperactivity Disorder ................................... 37

Menghini Deny, Varvara Pamela, Napolitano Carmen, Calcagni Marta , Armando Marcoand

Vicari Stefano ..................................................................................................................................

5. Influence of General Anxiety Disorder, state anxiety and depressive symptoms on

executive function in children with ADHD ..................................................................... 39

Armando M., Napolitano C., Calcagni M., Casini M.P., Menghini D., Vicari S. ................................

6. Evidences of SNAP25 single nucleotide polymorphisms associated with hyperactivity and

ASD disorders: future prospects related to ADHD. ......................................................... 41

Cosi A., Aggio F.A., Nossa M. , Paccione F., Magnaghi E, Tuci A., Galimberti G., Saccani M.,

Lenti C. and Guerini F.R. ................................................................................................................

7. Stress levels in parents of children with and without ADHD during the back-to-school

period: results of a non-clinical opinion survey ............................................................. 43

Gagliano A., Hernandez Otero I., Doddamani L., Haertling F., Dutray B., Ramnath G. ..................

8. Overlapping between oscillation frequencies of RTs and Beta/Theta EEG Frontal Ratio in

Pediatric Patients suffering from Sustained Attention Deficit after Acquired Brain Injury ... 45

Gazzellini Simone, Benso Francesco, Bauleo Graziella, Bisozzi Eleonora, Napolitano Antonio,

Clavarezza Valentina, Lispi Maria Luisaand Castelli Enrico1 ..........................................................



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9. Iron and ADHD: time to move beyond serum ferritin levels .......................................... 47

Margotta Milena M.D. Parisi Pasquale, M.D., Ph.D., Liguori Simona, Vanacore Nicola,

M.D.,Martines Francesca, Psy.D., Sargentini Vittorio, M.D., Cortese Samuele, M.D., Ph.D.

Donfrancesco Renato, M.D. ............................................................................................................

10. Major Depression and Dysthymia in children with ADHD ........................................... 49

Leo G, Leone D., Di Trani M, Martines F, Sferrazza A, Torrioli MG, Donfrancesco R. ....................

11. Defining Deficient Emotional Self-Regulation (DESR) in an Italian Sample of Youth with

ADHD Using a profile of the empirically derived Child Behavior Checklist ........................ 51

Marano, A., Innocenzi, M*, Donfrancesco, R. , Biederman, J. .........................................................

12. Comorbidity and psychosocial impairment in Deficient Emotional Self-Regulation

(DESR) and Attention/deficit hyperactivity disorder........................................................ 52

Innocenzi Margherita, Marano Assunta , Donfrancesco Renato ....................................................

13. Attention-deficit/hyperactivity disorder and alexithymia: a pilot study ........................ 54

Di Trani Michela, Donfrancesco Renato, Gregori Paola, Auguanno Giovanna, Melegari Maria

Grazia, Zaninotto Sabrina, Luby Joan .............................................................................................

14. A possible role of anti-Purkinje cell Abs as a biological marker in Attention

Deficit/Hyperactivity Disorder: a pilot study .................................................................. 55

Nativio Paola, Passarelli Francesca, Pascale Esterina,Villa Maria Pia and Donfrancesco Renato .

15. Temperament, Awareness and Acceptance and: new perspectives in Parent Training for

ADHD ........................................................................................................................ 57

Andriola E., Di Trani M. Donfrancesco Rb .......................................................................................

16. Temperament Feauteres as vulnerability factor ofAttention Deficit Hyperactivity Disorder

(ADHD) ...................................................................................................................... 59

Andriola E., Di Trani M., Porfirio M.C., Donfrancesco Rb ................................................................

17. Cognitive profile and scholastic learning difficulties in a sample of children with

Attention Deficit and Hyperactivity Disorder: clinical and treatment relapses.................... 60

Tacchi Annalisa , Grazi Amanda , Pfanner Chiara , Millepiedi Stefania , Manfredi Azzurra , Ricci

Federica , Di Emidio Fabiola , Lenzi Francesca , Masi Gabriele ....................................................

18. Preliminary data from a consecutive sample of ADHD children and adolescents enrolled

in Tuscany for pharmacological treatment. ................................................................... 62

Pfanner Chiara, Manfredi Azzurra, Lenzi Francesca, Di Emidio Fabiola, Tacchi Annalisa, Ricci

Federica, Berloffa Stefano, Millepiedi Stefania, Grazi Amanda, Masi Gabriele ...............................



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19. Efficacy and safety of methylphenidate and atomoxetine in ADHD: preliminary data from

a sample sample enrolled during 2011 in IRCCS Stella Maris .......................................... 63

Pfanner Chiara, Manfredi Azzurra, Lenzi Francesca, Di Emidio Fabiola, Tacchi Annalisa, Ricci

Federica, Berloffa Stefano, Millepiedi Stefania, Grazi Amanda, Masi Gabriele ...............................

20. Epidemiology of severe ADHD in an Italian sample of school aged children ................ 64

Miano Silvia, Leone Daniela Donfrancesco Renato ........................................................................



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7

Self-esteem evaluation in children and adolescents suffering from ADHD

Reale Laura1, Guarnera Manuela1, Mannino Valeria 1, Armando Marco2, Fatta Laura2, Postorino Valentina2,

De Peppo Lavinia2, Vicari Stefano2, Mazzone Luigi1,2

1

DivisionofChild Neurologyand Psychiatry,Department ofPediatrics, UniversityofCatania, Catania, 2

Child Neuropsychiatry Unit, Department of Neuroscience, I.R.C.C.S. Children's Hospital Bambino Gesù

Background: Teachers, general practitioners and parents often consider low self-esteem as an unspecific reason for psychiatric referral. Given how widely the “self-esteem” term is used in mental health field, it is surprising that self-esteem in children and adolescents is not more frequently quantified. This study has two objectives: 1) to analyse the characteristics of self-esteem in a sample of children and adolescents suffering from attention deficit/hyperactivity disorder (ADHD); and 2) to explore the relationships between self-esteem and age, ADHD symptoms severity and treatment strategies. Patients and Methods:Patients sample, referred to the clinic of Child and Adolescent Neuropsychiatry of the Paediatric Department at the University of Catania and to the Child Neuropsychiatry Unit at Children's Hospital Bambino Gesù of Rome, included 85 children and

adolescents (80males,5females;age range=8-15;mean age±SD=10.03±2.0) suffering from ADHD.

44 (40males,4 females;age range=8-15;mean age±SD=9.97±2.8) were drug-free and 41

(40males,1 females;age range=8-15;mean age±SD=10.70±2.0) receiving medication for at least 6

months; among the latter, 23 (23males,0females;age range=8-15;mean age±SD=10.03±2.3) were

Atomoxetine-treated and 18 (17males, 1females; age range=8-15;mean age±SD=9.85±2.2) received Methylphenidate. 26 subjects (26males,0females;age range=8-14;mean

age±SD=11.29±1.4) were included in the NC group. To explore the characteristics of self-concept and self-esteem the TMA (Self-esteem Multidimensional Test) was administered to both subjects suffering from ADHD and healthy controls. The test provides scores in 6 self-esteem dimensions and a global self-esteem related score (Personal,Skills,Emotional,School,Family,Body,Total). The average values of self-esteem of the normative sample are between 86 and 115. Results:Compared with NC, ADHD group had significantly lower scores on all self-esteem domains (Personal,Skills,Emotional,School,Family,Body,Total). Among ADHD drug-treated, Methylphenidate group showed significant higher self-esteem scores as compared to Atomoxetine group, except for the family domain.Age was not found to correlate significantly with TMA scores in all groups (ADHD:r=.04,P=.69;Ctrl:r=-.04,P=.82). Moreover, in ADHD group no significant correlation between all self-esteem domains and symptoms severity, assessed by SNAP-IV, was detected (r=-

.27,P=.07). Most of the ADHD patients had scores within the pathological range (TMATotal≤85); both ADHD Drug-free (47%) and Drug-treated (44%) groups showed significant higher rate of subjects in the pathological range as compared to NC group (8%)(P<.001). However, among ADHD drug-treated patients, the 39% and the 6% of children, in the Atomoxetine and Methylphenidate groups respectively, had pathological scores for the TMA Total, and, these rates were statistically different (P < .001).



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Conclusion: A lower self-esteem profile is more common in subjects suffering from ADHD than in

healthy controls, with no differences between drug-free and -treated subjects. Although from our

data a lower self-esteem seems to be a peculiar trait of ADHD regardless of the treatment type,

symptoms severity or age, the Methylphenidate group showed a lower percentage of subjects in the

pathological range as compared to the other ADHD groups



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Design and development of psycho educational interventions with parents and teachers to cope with the adhd disorder: analysis of the effectiveness of the

paths through a quantitative and qualitative analysis of the interventions.

Mannino Valeria, Costantino Antonella, Bissoli Claudio, Cropanese Isabella Pagnotta Giulia, Querci Michela, Santi Chiara

Unità Operativa di NeuroPsichiatria dell’Infanzia e dell’Adolescenza, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano.

In literature there are many studies indicating psycho educational interventions (Parent and Teacher Training) as being empirically valid and meaningful to deal with the ADHD disorder (Pelham and GA Fabiano, 2008.; Antshel KM, Barkley R 2008; Laforett DR et al. 2008; Pouretemad HR et al. 2009; Hautmann et al. 2009; Huang et al. 2009; Fabiano GA et al. 2009). Parents’ group training have been extensively studied: many data documenting the benefits in several domains such as the parent - child relation and parental stress. The training sessions with teachers are less studied in literature, and have less quantifiable data, but have sufficient empirical evidence to justify their application in the prevention and treatment of ADHD. Furthermore, as shown in the literature, the effectiveness of interventions is strongly influenced by the possibility of acting on the different contexts of the child's life. This makes it also possible to build a network of functional relationships between the service, the family and the school to address the problem globally ADHD. Thus giving effectiveness of these psycho educational interventions and pursuing a working methodology for a multimodal therapy, we have developed interventions with the faculties of teachers for the schools in our area based upon Behavioral-Cognitive Parent Training. The Parent and Teacher Training assume a direct role in the treatment of ADHD: the parent and teacher information acquire knowledge about ADHD, learn techniques to manage challenging behaviors of children. They become an integral part of the therapeutic actively participating, sharing and experimenting new solutions aiming to solve the problem. The group, with its peculiarity and differences in the role playing, then becomes a container producing changes throughout the decentralization of the problem from the child along with the activation of functional strategies linked to the relationship and solution to the task. Through the use of both qualitative and quantitative tools in this study we have analyzed the impact of our interventions upon the stress levels of care-givers (parents and teachers) and their sense of competence in dealing with problem-situations.In addition, by introducing a self-administered questionnaire we have detected what is most indicative from the group’s perception in relation to their drive to the change. The gathered feed backs were used to improve our interventions. Taking into account the different size of the available the data for the evolution of Parent Training (32 pairs of parents from 2009 to present) and evolution of the Teacher Training (18 teachers, two pilot projects in the 2011), the first qualitative and quantitative data results available will be presented and shared for discussion. The analysis of the study allows us to highlight some elements to develop effective interventions: the integrated intervention plays a decisive role to address the critical size of the problem of ADHD. To implement a methodology of network with and between medical - social services, school, and family, we think is the direction we need to follow to manage more efficiently the problem of ADHD. This also will also produce a better management of Neuro-Psychiatric unit in relation to the costs vs. benefit issue.



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Sharing project of diagnostic and therapeutic pathways for ADHD in Lombardy Testing of shared protocols for the formation of local Pediatricians upon the disorder and

for the training of NPIs on the supply of parent training services.

Tiberti Alessandra, Effedri Paola, Filippini Elena; Daffi Gianluca.

Pediatric Neuropsychiatry, Pediatric Hospital, “Spedali Civili” of Brescia.

Objectives: This paper aims at presenting the protocols for the training of pediatriciansandNPIs

of Lombard territory with respect to the paths of parent training for parents of ADHD children, to the diagnostic path and to the epidemiology and multimodal interventions. These protocols have been developed within the SHARING PROJECT OF DIAGNOSTIC AND THERAPEUTIC PATHWAYS FOR ADHD IN LOMBARDY from centersparticipating in theresearch alreadypresented in

2011. In particular, we highlight the use and dissemination in the Lombardy region of operating protocols that can ensure consistency in the psycho-educational interventions and meet the training needs expressed by the operators involved in the NPIs; these protocols are proposed as a model transferable to other contexts of intervention in the treatment of neuropsychiatric disorders. Patients & Methods: At this stage of the project, to date, the subjects involved in the training were Pediatricians belonging to the territories of the 18 NPI involved (in particular Brescia, Cremona, Lodi, Valle Camonica , Legnano, Pavia, Rho, Bosisio Parini, Lecco, Sondrio, Como, Mantova, Varese) and NPI operators involved in the project.The training sessions were organized for pediatricians from each center in the form of four-hour seminars run by the operators of the NPI reference. During these seminars, repeated according to standards agreed at the centers, we tried to implement the following skills: Knowing and recognizing the characteristic clinical picture of ADHD; Knowing the main differential diagnoses and co-morbidity factors; Knowing the epidemiological spread of the disease; Knowing the correct way of sending and accessing to regional centers; Knowing the major forms of multimodal treatment. The training courses for operators have been realized through three editions of the same path that consists of two sessions of eight hours each, followed by a follow-up time of 4 hours. The first day, managed by the operators of the participating centers, had as its purpose the sharing of current practices for the design and delivery of services of parent training; the second day, managed by Dr Sara Pezzica (AIDA Tuscany) and by Dr. Tiziana De Meo (Pediatric Neuropsychiatry in San Donà di Piave - ASSL No. 10 "Veneto Orientale”), had as its purpose the sharing of tools and strategies for the activation of pathways of parent training, following shared protocols; the third day, managed by Dr. Paola Effedri and Dr. Gianluca Daff (“Spedali Civili” of Brescia, Lead Center for Project), had as its aim the reflection on the possibility of developing a protocol shared system. Locations of the issues were the centers of Brescia, Milan Fatebenefratelli and Garbagnate Milanese. Results: The meetings were attended by about 350 Pediatricians of the territories and about 180 members of the Operators of the NPIs involved in the project.



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Assessment of BMI in an Italian ADHD community care.

Germinario Elena1, Chiarotti Flavia2 , Arcieri Romano1, Panei Pietro1.

1Dept. of Therapeutic Research and Medicines Evaluation, and 2Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità, Rome, Italy

Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed disorders in children and adolescents, with an estimated worldwide prevalence of over 5%,but in Italy the observed rate is 1-2% in several settings. One co-morbidity related to ADHD, as hypothesized by some research groups, is an increased body weight, or a higher prevalence of overweight; however, these findings have not confirmed by a recent study. Aims: To assess an association between overweight and attention-deficit/hyperactivity disorder (ADHD) in children who have been enrolled in the Italian ADHD National Registry. Patients and Methods:.The assessment of BMI (medium value +SD) was performed at baseline, stratifying by gender and age classes (<11years, >11- <15 years, >15 years). Data on height and weight was collected. Chart of Cacciari was used to analyze data (Cacciari E et al, Endocrinol Invest 2006; 29; 581-593) Results:At the end of January 2012, 2.083 children with ADHD were recruited in the Italian ADHD National Registry. Data about 1.637 (78.6%) children and adolescents were available to perform BMI. 1.451 (88.6%) were males and 186 (11.4%) were females. For males, BMI was equal to 20.38+3.68, for females BMI was 20.31+4.01. Stratifying BMI by gender and percentile classes (<3rd, >3-<50th, >50-<97th, >97th) no statistically significant difference was observed (p=0.94). However, when stratifying for overweight, a higher percentage in male group than in female group was observed, 23.3% vs 17.7%, respectively (p=0.09). Analyzing BMI by age classes, a statistically significant difference was detected (p<<0.01), because a higher percentage of cases with BMI over the 97th percentile was observed in the oldest population. When analyzing overweight, a higher percentage was observed in >15 years group than in other groups (<11years, >11- <15 years), 28.8%, 23.5% and 20.1% respectively (p=0.07). Analyzing obesity, only 37 (2.3%) cases have been identified as obese, 34 were males. When stratifying these data for age classes, no statistically significant difference among different groups was detected (p=0.13). Conclusions: In our ADHD population, the percentage of children and adolescents with overweight (20.5%) and obesity (2.3%) is lower than in Italian children and adolescents (22.9% and 11.1% respectively, source data from National Institute of Health, the OKKIO project 2010). Only the ADHD adolescents older than 15 years seem to have a higher probability to develop obesity. More information about the life style of these subjects are necessary to identify risk factors.



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Infection with cytomegalovirus and other herpes viruses as possible factors in the development of attention deficit and hyperactivity disorder:

preliminary results.

Riccio M.P.,** Borgia G., Cascella R., ** Gentile I., Maiorano A., Marino M., Pascotto A., ** Scarica S., **

Zappulo E., * Bravaccio C.

Cattedra di Neuropsichiatria Infantile- Dipartimento di Psichiatria, Neuropsichiatria Infantile, Audiofoniatria, Dermatovenereologia- Seconda Università degli Studi di Napoli, *Dipartimento di Pediatria &**Dipartimento

di Malattie Infettive “Federico II” di Napoli

Introduction: Infection with cytomegalovirus (CMV) is the most common congenital infection with a prevalence between 0.5% and 2% of all newborns. Transmission is by the mother or because she contracted a primary infection during pregnancy or because a previous infection is reactivated during pregnancy. In most cases (85-90%) the infection is asymptomatic at birth, although it is possible that there are followings. Clinical studies have reported cases of symptomatic congenital CMV infection associated with autism. Some authors describe the presence of behavioral disturbances in 10% of cases of congenital CMV infection. They also reported an association between congenital CMV infection and hyperactive behavior. Aims: To study systematically the role that CMV infection (congenital, or acquired thereafter) or infection by other herpes viruses (HSV-1 and 2, HHV6, Epstein Barr virus, Varicella, Measles, Rubella, Mumps, Polyomavirus and JKC) can have in children with neuropsychiatric problems, verifying the possible correlation between the presence of anti-CMV IgG and the development of attention deficit hyperactivity disorder and draw a possible advantage in clinical practice (screening at birth, prophylaxis with immunoglobulin, early antiretroviral therapy). Patients and methods: A prospective case-control study of patients aged less than 12 years diagnosed with attention deficit and hyperactivity disorder. The control group is made up of a cohort of age-matched subjects. There are currently enrolled 19 subjects with ADHD and 29 healthy controls. Enrollment is ongoing. We proceeded to the determination of CMV-DNA on a sterile urine sample taken in the morning, the determination of anti-CMV antibody titer (IgG and IgM) in serum following a peripheral blood sample withdrawal. Results and Conclusions: The preliminary study has not yet shown a statistically significant correlation between herpes viruses and ADHD.



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ADHD and Epilepsy in children with Tourette Syndrome: a triple comorbidity?

*Rizzo Renata, *Gulisano Mariangela, *Calì Paola Valeria, **Curatolo Paolo

*Section of Child Neuropsychiatry, Maternal Infantile and Radiological Sciences, Catania University, Catania,

** Section of Child Neuropsychiatry, Department of Neurosciences, University Tor Vergata, Rome

Aims: The comorbidity TS and epilepsy is rarely reported. We report a long term follow-up of 8 young patients presented a triple comorbidity : TS, ADHD and epilepsy. Patients and Methods: Our series includes 8 patients (7 males and 1 females) with a median age of 14.75 years (range 10-17) with definite diagnosis of TS according to DSM-IV-TR criteria, assessed at the Neuropediatric Unit of Catania University, Italy and followed up for a period of ten years. For the definition of epilepsy we considered the presence of at least two afebrile seizures; for the ADHD definition we considered excessive inattention, hyperactivity and impulsivity either alone or in combination. All the patients underwent a complete physical, neurological and neuropsychological examinations, routine laboratory examinations and MRI. All the patients had a routine awake EEG. Results: Neurological examination showed incoordination in 3 patients; 2 of them presented also clumsiness. All the patients showed soft neurological signs Tics: There were a positive family history either for tic or for TS in 4 patients. All the patients had a typical onset of TS; they presented first motor tics at the age of 6.37 years (age range 6-10 years); after a few years at the age of 9.78 years (age range 8-13 years) they started to present also vocal tics. One of them presented OCD and two of them presented behavioral disorder. Neuropsychological findings showed a normal IQs in 6 out 8 patients. Two patients showed mental retardation. TS was pharmacologically treated in five patients who presented severe impairment in their daily life with improvement of the symptoms. All of them are still take pharmacological treatment. 3 patients had mild tics and they didn’t take any medications. Seizures:There were a positive family history for epilepsy in 4 patients. All the patients presented idiopathic benign seizures. The seizure onset was after 4 years (age range 5-9) and in all the patients except in 2 seizures came before tics. MRIs were normal in all the sample. All of them had a good response to the therapy and obtained the complete resolution of the seizures. At the last follow up, after at least 7 years, 7 patients were seizure free; only one patient had occasionally seizures and he still take valproic acid. ADHD: 6 patients presented “combined ADHD” type, 2 showed predominantly hyperactive “ADHD-H” type. All the patients presented mild ADHD and for this reason they didn’t take any medications; all of them were treated with psychological therapy including psychoeducational input, cognitive behavioural therapy, either in individual or in group format. Parent and teachers received a specific training to learn how to manage with ADHD children. They obtained an improvement of the symptoms. Conclusion: The relationship between TS , ADHD and epilepsy is not fully understood. Our study hypothesize that it could be a relationship in the aetiology of TS, ADHD and epilepsy. The increased excitatory activity, DOPA and GABA mediated, could be the common aetiology than cause all the clinical symptoms.



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BMI andpsychopathological disorders in comorbiditieswith ADHD: correlation studying a populationof patients of campania region

Sarnataro E., Bernardo P., **Granata R., ***Grimaldi A., Maresca R., Pascotto A., Russo L., Tiano C.,

*Bravaccio C.

Cattedra di Neuropsichiatria Infantile- Dipartimento di Psichiatria, Neuropsichiatria Infantile, Audiofoniatria, Dermatovenereologia- Seconda Università degli Studi di Napoli, *Dipartimento di Pediatria “FedericoII” di

Napoli, ** Ospedale Moscati di Aversa (Ce), ***Ospedale “Santobono” di Napoli

Introduction: Attention deficit hyperactivity disorder is associated with several psychopathological disorders such as conduct disorder, oppositional defiant disorder, mood disorder, specific learning disabilities and mental retardation. In addition to these psychiatric comorbidities, recent studies in the literature suggest the presence of an association between the presence of ADHD and obesity; in fact, the prevalence of overweight and obesity was significantly higher in patients with ADHD compared to populations equivalent for sex and age, not affected by the disease.

Objectives: Toassess the correlation betweenBMI andpsychopathological disorders in

comorbiditieswith ADHD. Patients and methods: The subjects, with a first diagnosis of ADHD, visited at the regional reference centers in the Campania region, in the year 2010, and later in the year 2011, were valued not yet in drug treatment. We proceeded to the diagnostic evaluation for each patient as guidelines, with identification of comorbidities associated, and to the calculation of BMI (in kg/m2 body surface area) with the identification of four different sub-groups: underweight (BMI <20), normal weight (20 <BMI <25), overweight (25 <BMI <30), obese (BMI> 30). Results: The processing of the results obtained, for the year 2010, showed a very low percentage of patients with BMI over 30, fall in subgroup "Obese" and an equally low percentage of patients with BMI between 25 and 30, fall in subgroup "Overweight". The remaining percentage of the patients evaluated had a normal weight or an underweight condition. The evaluation of patients visited in the year 2011 has confirmed the same proportion in percentage of cases in the various subgroups indicated. Conclusions: Unlike what is reported in literature, in the subpopulation of reference of Campania Region, there was a prevalence of association between ADHD and the presence of underweight. In addition, the evaluation of the relationship between BMI and comorbidities associated with ADHD shows that patients who fall within the subgroup "Obese" or "Overweight" have mental retardation and depressive disorder as comorbidities.



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Self-esteem and parental stress in children with ADHD

Lamberti Marco, Boncoddo Maria, Siracusano Rosamaria, Germanò Eva, Ciuffo Massimo,

Cucinotta Francesca, Cedro Clemente, Gagliano Antonella.

Division of Child Neurology and Psychiatry, University of Messina, Italy

Aim:Attention-deficit/hyperactivitydisorder (ADHD) is a common child and adolescent disorder that is frequently associated with negative outcomes, such as emotional and behavioural problems and low self-esteem. Conversely, low self-esteem has been associated with feelings of inadequacy and frustration which in turn can result in the worsening of the behavioural symptoms. The behavioral problems could lead to poor peer relations, aggression, and learning problems which are associated with academic failure and, consequently, with a further risk for low self-esteem. This vicious circle can even have the effect of increasing the likelihood to develop psychiatric disorders.The current study examine the relation between ADHD and self-esteem, and observe how self-esteem impacts the relation between parental stress and ADHD symptoms. We hypothesized that children with ADHD experience lower self-esteem than children with other chronic and severe conditions, like epilepsy. Furthermore, we also wished to investigate the association between ADHD symptoms, parental stress and self-esteem. Patients & Methods: Data were collected from 20 children aged between 9 and 12 years, diagnosed as having ADHD (according with DSM-IV criteria) and their parents. The ADHD-RS and Conner's Scales (CPRS) were used to assess ADHD symptom severity, and the Multidimensional Self-esteem Test (MSET) was used to measure self-concept. MSET is a self-report instrument, which consist of 150 items, divided in six subscale, exploring Social Relations, Problems Solving, Emotions, Academic Success, Family Relations and Bodily Experience. The Parent Stress Inventory (PSI) was used as measure of the parents stress level. A group of 20 patients with epilepsy was recruited and assessed by means the same instruments. Both these groups were compared with a control group of 20 children, free from epilepsy, neurological disorders, academic and behavioural problems, homogeneous as regards gender, age, level of education and social-economic background.

Results: Among ADHD children, the symptoms severity and the presence of comorbid conditions (i.e. anxiety, academic difficulties, etc,) predicted lower self-esteem. Besides, there were significant differences between ADHD and Epileptic patients on self-concept scores. In particular, ADHD patients had lower scores in some MSET sub-scales (i.e. Social Relations and Academic Success). Results further revealed that the parental stress levels was related with the self-esteem scores in ADHD children.

Conclusions: The findings indicate that there is a need to assess self-esteem in children and adolescents with ADHD, especially those with comorbid conditions such as anxiety and academic difficulties. Even if it is well known that parents of children with attention-deficit/hyperactivitydisorder experience elevated levels of caregiver stress, it could be helpful investigate the relation between parental distress and self-esteem. Our results can have implications for treatments that target



16

ADHD children with low self-esteem and their parents, as these patients are at risk for many negative outcomes. A comprehensive treatment plan for children with ADHD and low self-esteem should also contain programs designed to help all parents identify and manage their own parenting stressors.



17

ADHD patients: observational multicenter study in three Italian dedicated ADHD centers. Preliminary data

Sposato M. °; Trinari E. °; Cannarozzo M.°; Pincherle M.*; Fini F.*; Filippini V.*; Mazzotta G. §.

(°Regione Umbria; *Regione Marche; §Director of Childhood and Adolescent Neuropsychiatry Unit,

University of Perugia)

Introduction: ADHD is a strongly compromising syndrome with a significant impact on the quality of life of both children and their families; moreover, it is a condition with an important social impact in terms of monetary costs which both the community and the child’s family are burdened with. Costs are higher for those subjects with a higher number of comorbidities 1.The Italian Register for ADHD was born in 2007;it is coordinated by the Drug Department of the Italian National Institute of Health, in collaboration with the Italian Drug Agency (AIFA), and has the following aims: control over diagnostic accuracy and appropriateness of drug prescription, drug vigilance, patient follow-up and collection of epidemiological data.In concomitance with the institution of the register, AIFA has authorized the establishment of regional dedicated centers, with the scope of finalizing the register’s objectives and coordinate multimodal treatment measures. Objectives: the aim of the present work is to describe the epidemiological data regarding children and adolescents who were referred to three dedicated ADHD centers belonging to the Umbria-Marche chapter of the Italian Society of Childhood and Adolescent Neuropsychiatry (SINPIA).We conducted an observational multicenter study among a homogeneous population of subjects referred to the center in Terni for the Umbria region and Macerata and Ascoli Piceno for the Marche region, with the objective of highlighting the insurgence of adverse events related to the administration of Atomoxetine (ATX) or Metilphenidate (MTH), estimate the frequency of suspension of treatment and the related motivations, estimate the presence of comorbidity and evaluate the efficacy of the pharmacological treatment. Materials & methods: 92 patients were observed (81 males and 11 females; age between 7 and 18 years) enrolled in the register during the period between June 2007 and December 2011. Among these patients, 72% were in intermittent treatment with MTH, 26% with ATX and 2% switched from ATX to MTH. The patients were classified on the basis of subtype and comorbidity. Treatment duration varied between 1 and 48 months. 33% of the patients eventually dropped out from the register; none of the drop-outs were due to insurgence of adverse events. Clinical progression was evaluated through the Children Global Assessment Scale (C-GAS)2. Results: preliminary data show no treatment suspension due to insurgence of adverse events, good therapy compliance (61 patients out of 92 continued pharmacological treatment) and a positive clinical progression. References:1)Mazzotta et al. : The economic impact of attention deficit hyperactivity disorder in a study group of children in Umbria; Gior Neuropsich Età Evol 2008;28:45-56. 2) Shaffer et al: A children global assessment scale (C-GAS), Arch Gen Psychiatry,1984; 40:1228-1231



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Multimodal intervention in ADHD: the experience of Scientific Institute E.Medea of Ostuni-Brindisi in the Apulia Region (Italy)

Fanizza Isabella, Massagli Angelo

Department of Neurorehabilitation 2 – Child Psychiatry, Scientific Institute I.R.C.C.S. “Eugenio Medea”

Regional Branch of Ostuni – Brindisi, Italy

Background: We know that multimodal approach is the more appropriate intervention in ADHD as evidenced, among others, by the famous MTA Study (Multimodal Treatment of Children with ADHD. Arch Psychiatry in January, 1999, 56: 1073 -86). The ADHD Reference Centers (created in Italy by the Health Ministry in 2007 to control drug therapy), can or deal directly patients or supervise and treat cases of territorial child psychiatry when they need drug therapy. AIMS: check, through evaluation of our ADHD Reference Center, the actual implementation of multimodal treatment in children with this disorder in our area. Evaluate effectiveness of the two drugs used in Italy for ADHD (Methylphenidate or Atomoxetine). Patients& Methods: We made an observational study of 166 patients that came to our Center since 2007 (year of the beginning of the National Register and of the authorization for marketing of the specific drugs for ADHD from Italian Health Ministry) to 2010. They came from Apulia Region, affected by Attention Deficit Hyperactivity Disorder (ADHD), diagnosed by child psychiatrists according to the DSM IV-TR criteria. Results: In our sample, only 35 patients (21%) underwent multimodal intervention including a pharmacological approach, specific for the disease, and psychoeducational treatment. Furthermore, only 5 patients had parent training cycle, while the others had only family counseling. Among these 35 patients, 24 were treated with Atomoxetine, 9 with Methylphenidate only, 2 were first treated with Atomoxetine and then with Methylphenidate due to the ineffectiveness of the first treatment. Among patients treated with Atomoxetine, 16 (61%) showed no clinical improvement, 8 (30%) showed a slight improvement (reduction of 1 point in CGI score) and in 2 patients (7.6%) occurred a worsening of the clinical picture with emphasis on hyperactivity. Among patients treated with methylphenidate, 7 (63%) showed significant clinical improvement (reduction of 2 points in CGI score), while 4 (36%) showed a slight improvement (reduction of 1 point in CGI score). Conclusion: Although has been proven by scientific literature and confirmed by the SINPIA guidelines importance of carrying out multimodal treatment in ADHD, involving the specific pharmacological treatment, psycho-educational work and parent training, data we analyzed show that at the present time, in our area, such treatment, actually, is applied only in a minority of cases. Therefore, compared with a high number of children receiving this diagnosis, only a few are able to implement the multimodal treatment strategy. We think that the main reason for this is that the locally available resources are few. To overcome this drawback you need to increase update especially for parent training, allowing to territorial child psychiatrists handle also the pharmacotherapy. Finally, about the drug treatment, Methylphenidate is confirmed as the drug of first choice in terms of efficacy and tolerability compared with Atomoxetine.



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Research protocol in the diagnostic investigation on ADHD

Ragazzo F.*, Benso F.**, Fiorella R.*, Stella S.*, Morando M.**, Castellani S.**, Gazzellini S.°

* Centro di Riferimento ADHD Savigliano, ** Università di Genova, ° Ospedale Bambin Gesù Roma

The regional point of reference for ADHD, constituted inside ASL1 of Savigliano (CN) in 2007, has made 166 ADHD diagnosis; including 58 treated with drugs (Atomoxetine or Methilphenidate). In order to ameliorate the clinical definition of the ADHD diagnosis and to orienting both pharmacological and rehabilitative treatment, our teamwork (child neuropsychiatrist, psychologists and professional educators) has settled down a new pathway of clinical evaluation. This pathway foresees three steps:

1) clinical and neuropsychiatric assessment 2) psychological tests administration (specific for ADHD and its co-morbidities); 3) neuropsychological tasks, focused particularly on the attentional networks and executive

functions. To research aims, tasks supplied from Benso, Morando and Castellani (University of Genoa) are administered. Referring these tasks, we’re working in order to calibrate them basing on the most recently studies. First, we’re focusing on the evaluation of the efficiency of attentive neural networks (i.e. alert, orienting, and executive control) using computerized tasks; our tasks measure just one attentive aspect at time in order to avoid possible interactions and to find more pure parameters referring different attentive aspects activated by the tasks. Second, we’re evaluating the “white noise” of the “default mode networks” and the intra-individual variability by studying RTs ex-Gaussian distribution (standardizing and analyzing mu, sigma and tau parameters). By this way, we have first standardized ex-Gaussian values from subjects attending IInd, IIIrd, IVth and Vth classes of primary school, and then the same tasks were administered to ADHD subjects before and after drug treatment. Third, using the same RTs, we’re studying the temporal series in order to find eventual periodical attention disorder. Finally, we’re investigating correlation between questionnaires attentional network and general measures on executive functions (paper and pencil tests). The final goal is to set a battery tests able to recognize relevant indexes that could be placed at the base of a more objective ADHD diagnosis.



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Clinical suggestions about parent training comparing two groups of children with ADHD, ODD and LD.

Galimberti G.*, Actis Perinetti B.*, Aggio F.*, Saccani M.*

*Department of Child and Adolescent Psychiatry, San Paolo Hospital, University of Milan.

Aims: Parent Training (CBPT) has a long, successful history as a treatment for children with ADHD (Pelham et al.,1998) and ODD (Brestan & Eyberg, 1998). According to a previous study (Aggio et al., 2008) mothers of ADHD-ODD children show higher maternal depression, parenting stress, lax parenting and significant correlations between overreactive parenting and depression, external LCB, sense of competence and parental stress in the ADHD+ODD group. Therefore we hypothesize that ADHD families may benefit from an expanded version of parent training that includes sessions directly targeting parental affective and cognitive factors. The present study compares two groups and suggests. clinical issues about tailored intervention. Patients: 2 groups of parents. The first group was composed by 8 couples of 10-11-years-old children with ADHD and ODD (n=3) and ADHD C (n=5); the second group was composed by 4 couples of from 7 to 9 years old children with ADHD and LD (n=3) and ADHD and ODD (n=1). Methods: We used a typical sequence of 10 sessions for PT (Vio, Marzocchi & Offredi, 2009) in addition with emotional self-regulation, attunement and anger management. We administered to the first group questionnaires pertaining to: child behaviour and parental cognitions about their behaviour. We administered to second group as pre and post test Conners’ Parent Rating Scale, PSI-SF, BDI and BAI in order to evaluate PT efficacy. Moreover parents were asked to complete ADHD Adult Symptoms Questionnaire. Results: Preliminary results show improvements in parental reports of sense of competence and parental cognitions about themselves and their children. Conclusion: Child age, ADHD comorbidity and families expectations and characteristics are essential issues to create tailored interventions and PT with specific sessions about affective and cognitive factors are likely to be more responsive to ADHD families and needs.



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ADHD and AUTISM: a study in the ASL of Novara

Guccione Fulvio, Antonini Alessia, Vallana Marianna, Duella Sara, Tettamanti Elena

Centro di Riferimento ADHD ASL Novara Ospedale di Borgomanero

Objective: Aim of the present study is to estimate the presence of ADHD symptom in patients with diagnosis of autism. Both DSM IV and ICD 10 exclude the possibility to make a diagnosis of ADHD when exist a diagnosis of autism. A large number of study (Pondè e al. 2010; Holtman M. e. al. 2007 Sverd, J. 2003) in literature reveal that could exist a possible comorbidty between autism and symptoms of ADHD. I particular Pondè and colleagues (2010) show that the 78% of subjects wit a diagnosis of autism met the DSM IV criteria for ADHD. Leyfer O.T. and colleagues (2006) show that 55% of autistic patients present typical symptom of ADHD and that 38% met the DSM IV criteria for ADHD. Aim of the present study is to explore the presence of ADHD symptom in patients with diagnosis of autism. Method:Seventeen individuals from 6 to 14 years old with a diagnosis of autism according to the ICD-10 (ICD10 F84 -F984.9), their parents and their teachers took part in the research. Actually, all participants were patients of the Novara district health authority.The symptomatology of the ADHD patients at the time of testing was investigated with specific test battery. In particular the battery used was: Sustained Attention Leiter-R, Rey-Osterrieth Complex Figure Test, Arithmetic and Digit span subtest from WISC III. Parents and teacher were asked to assess episodes of psychopathology in children and adolescents by two structurated scale: Conners’ Parent Ratig Scale, Conners’ Teacher Ratig Scale, Child Behavior CheckList T. Achenbach (CBCL). Conclusion: In accord with Pondè e al. (2010), the preliminary data of our sample, show that a significant number of patient with a diagnosis of autism show typical symptom of ADHD. Another hypothesis supported in literature is that different neuropsychiatric disorder seem to have a common genetic etiology. We think that an important step is to understand the real nature of clinical relation between autism and ADHD. A correct interpretation can be a useful starting point for planning rehabilitative treatments. References Holtmann M, Bolte S, Poustka F. Attention deficit hyperactivity disorder symptoms in pervasive developmental disorders: association with autistic behavior domains and coexisting psychopathology. Psychopathology 2007;40:172-177. Leyfer OT, Folstein SE, Bacalman S, et al. Comorbid psychiatric disorders in children with autism: interview development and rates of disorders. J Autism Dev Disord 2006;36:849-861. Lichtenstein P., Carlström E., Råstam, M., Gillberg, C., Anckarsäter H. (2010).The Genetics of Autism Spectrum Disorders and Related Neuropsychiatric Disorders in Childhood.Am J Psychiatry 2010;167:1357-1363. Pondè, M.P., Novaes, C.M., Losapio, M.F. (2010) Frequency of symptoms of attention deficit and hyperactivity disorder in autistic children. Arq. Neuro-Psiquiatr. [online]. 2010, vol.68, n.1, pp. 103-106. Sverd J.Psychiatric disorders in individuals with pervasive developmental disorder. J Psychiatr Practice 2003;9:111-127.



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Cognitive impairment in ADHD with language disorder in preschoolers: confront with ADHD without language disorder and SLI.

Melegari Maria Grazia 1, Manzi B.2, Costa A.3, Canzano L. 4, Uberti Paola 5

1ASL Roma A; 2 Consorzio Rirei 3 CRC Balbuzie; 4Onlus Tandem; 5ASL Roma C

Aims: The study of comorbidity has always been proposed as a field of great interest to investigate the association between ADHD with other disorders. The comorbidity between ADHD and language disorders (SLI) has been documented since the 80s (Beitchman et al., 1989) specifically in scholar age.– Till now, few studies up to date (less than 10) have been conducted with preschool children in respect to the relationship between SLI, ADHD and theimpairment of cognitive processes that can explain the interrelation between disorders in comorbidity. The present work wants to investigate different or common cognitive functioning patterns between sub groups ADHD without (ADHD) or with language disorder ( ADHDL) and between ADHDL and SLI in preschoolers. Method: 33 ADHD preschoolers with and without comorbidity with SLI (29 males; 4 females; mean age months 65,87); 32 SLI preschoolers with expressive language disorder (29 males; 4 females, mean age months 66,56). 35 preschoolers (10 males; 13 female, mean age months 65,18) without psychiatric disorders, as control group, participated to study. Clinical samples were selected according to symptoms criteria required DSM-IV for diagnosis and comorbidity using adapted age psychiatric (PAPA) and language assessment. Exclusion and inclusion criteria were considered. Neuropsychological assessment: EFs and verbal-non verbal processing tasks were administrated to study different and common impairment in clinic groups. Statistical analyses: 1° step: three discriminative function analyses (ADHDL vs. ADHD, vs. SLI and vs. control group) in order to detect differences between groups. 2° step: three Univariate Analyses of Variance ( ADHL, SLI, ADHD vs. control) were also computed in order to identify common features in the groups. Results: The percentage of explained variance among groups: 80.6% in the ADHDL-Control, 53% for ADHDL-ADHD and 53% for ADHD-SLI comparisons. The percentage of variance explained by discriminating functions in all comparisons was significant (p < .01), except for ADHDL-ADHD that showed a trend toward statistical significance (p =.10). All variables discriminated ADHDL from other groups. The stronger discriminating variables between ADHDL and Control: phonological processing,Working Memory and categorical fluency. All variables - except Shifting and Stroop test - had a coefficient > .30. 2nd step: a significant difference (p<.01) was found in all variables, with means ADHD significantly lower than control The most discriminating variables ADHDL vs SLI: Working Memory (.60) and Stroop test. In all tests SLI children had a better score than ADHDL. 2nd step: visual and verbal processing, verbal fluency, short-term memory, sustained attention, inhibition response were common variables to ADHDL and SLI that significantly differed (p<.05) them from control. Phonological processing, Working Memory, Shifting, verbal fluency, sentences repetition are the most discriminating variables between ADHD and ADHDL. 2nd step: all variables except Shifting differed significantly (p<.05) two ADHD subgroups from control. Conclusion:.Our research highlights more severe impairment of some cognitive functions in ADHDL in regard of ADHD and common processing weakness between ADHDL and SLI.



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ADHD subtypes and comorbidity in Italy

Valenti Vera ¹, Di Trani Michela ², Galantini Chiara ¹, Merati Silvia ¹, Donfrancesco Renato ³

1-Ospedale Fatebenefratelli, Milano, 2- Università “La Sapienza”, Roma, 3- Ospedale S. Pertini ASL RM/B

Roma

Introduction: Literature data suggest that ADHD combined subtype could be between 50% and 75% of ADHD children population, inattentive subtype about 20%-30% and ADHD Hyperactive subtype under 15%. From 1995 to 2004 several studies were conduct about ADHD subtypes in children outpatient in USA, Germany, Venezuela, Turkey, Colombia etc. with almost the same proportion between the different ADHD subtypes (as outpatients). Little is known about distribution and comorbidity of ADHD subtypes in Italy. Materials and Methods: 521 consecutive and drug naive children are diagnosed as ADHD according to DSM IV criteria in two Italian clinics: Fatebenefratelli Center For ADHD in Milan (Vera Valenti) and La Scarpetta Center for ADHD in Rome (Renato Donfrancesco). The subjects were aged in months 108.67 (sd 31.58) , 446 were male and 75 female, had a mean IQ of 101.65 (sd 15.47) and SES mean score of 74.54 (sd 22.64). SES were assessed By Hollingshead Scale, IQ by WISC III and ADHD by SNAP scale and K-SADS PL 1.0 interview. Moreover all diagnosis were performed accordin SINPIA and ISS guidelines for ADHD. Psychiatric comorbidity was assessed by K Sads PL 1.0 , Dyslexia by using the Italian tests for Dyslexia Prove di Lettura MT and the Standardized List of Words of Job-Tressoldi. Spelling Disorder was assessed by the writing test Dettato Ortografico of Tressoldi e Cornoldi and Math skills were assessed by AC-MT Test of Cornoldi et al. . Dyslexia and Discalculia were diagnosed according to DSM IV criteria and Spelling Disorder according to ICD 10-R Criteria. Michela Di Trani performed descriptive statistics and regression by SPSS. Results: The subtypes frequency found was: ADHD Combined Subtype 52.2%, ADHD Inattentive Subtype 34.4% and ADHD Hyperactive subtype 13.4 %. Regression showed Sex, Age, Distimic Disorder, MDD, ODD , GAD and SES were not significantly associated to a specific subtype. On the contrary CD predicts ADHD Combined Subtype (B=0.988; p= 0.022). A second regression study, about IQ and Specific Learning disordes, showed a non significant association of Dyslexia and Discalculia with ADHD subtypes, but spelling Disorder predicts ADHD Combined Subtype (B=0.625; p=0.038). Conclusions: ADHD Subtypes distribution (in outpatiens) in Italy is in agreement with International literature data. In Italy CD and Spelling Disorder are associated more frequently with Combined ADHD Subtype.



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Major Depression and Dysthymia in children with ADHD.

Leo G.**, Leone D.**, Di Trani M***, Martines F*, Sferrazza A**,Torrioli MG **, Donfrancesco R.*

*Sandro Pertini Hospital, Roma; **Università Cattolica del Sacro Cuore, Roma;

***Università degli Studi “Sapienza”, Roma

Introduction: in the last years a number of epidemiologic studies have documented the concurrence of depressive symptoms in ADHD patients. The aim of this study was to analyze the prevalence of Major Depression (MDD) and Dysthymia (DD) in an Italian sample of children with ADHD and to find out if there was any correlation with age, gender, IQ, SES, family history of psychiatric disorders, ADHD subtypes and severity of symptoms.

Methods:We studied 367 consecutive drug-naïve Caucasianoutpatients with ADHD (322 males and 45females, mean age of 105,5 months), diagnosed in a Regional Center for ADHD in Rome, from January 2006 to December 2010. All the children received a diagnostic assessment using ADHD-Rating Scale (ADHD-RS) (DuPaul et al., 1998) adapted for the Italian population (Marzocchi and Cornoldi, 2000),filled out by parents and school teachers. Both children and parents separately received a semi-structured psychiatric interview, the Schedule for Affective Disorders and Schizophrenia for School-Age Children- Present and Lifetime Version (K-SADS-PL) (Kaufman et al., 1997), by an experienced child psychiatrist (RD). All children underwent a Wechsler Intelligence Scale for Children III(WISC III) and patients with IQ < 70 were excluded. Socioeconomic status (SES) was measured using the 3-point Hollingshead scale. For each patient a detailed personal and family history was taken. All the psychiatric diagnosis were made according to DSM IV diagnostic criteria.

Results:In our sample of 365 ADHD children 7,1% presented a DD and 92,3% of them were males. No statistically significative difference was found between patients with or without DD in terms of age (p=0,146), gender (p=0,456), TIQ (p=0,826), SES (p=0,312), ADHD subtype (p=0,355), family history of psychiatric disorders (p=0,946) and severity of ADHD based on total SDAG score, SDAG-I and SDAG-A (respectivelly p=0,773, p=0,718, p=0,296). Comorbid DDM was found in 4,4 % of 365 patients. No statistically significative difference was found between patients with or without MDD in terms of age (p=0,707), gender (p=0,083, TIQ (p=0,293), SES (p=0,050), ADHD subtype (p=0,264) and family history of psychiatric disorders (p=0,660).Considering the severity of ADHD symptoms using the Inattention SDAG score we found a significative difference between children with MDD and children without MDD ( p= 0,027), as the first group has an higher score meaning worst symptoms, while no significative differences were found on the total SDAG score and the Hyperactivity SDAG score ( p=0,380 e p=0,813).

Conclusions: In our Italian sample of ADHD children we found no significative difference in terms

of age, gender, IQ, SES, family history, ADHD subtype between patients with or without MDD or DD

but the comorbidity of ADHD and MDD was associated with marked and worst symptoms of

inattention.



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An ADHD complex case report

Pagana Lucia; Bassi Bianca; Mariani Alessandro *; Magnano Lara

Università degli Studi di Torino - Dipartimento di Neuropsichiatria Infantile Azienda Ospedaliera OIRM-Sant’Anna, Torino;*ASL TO 5, Torino

We would like to describe the complexity of ADHD diagnosis in a case report. John is an eight years old boy, first-born in England whose parents are from Brazil and have a high social level. His anamnesis is silent until 3 years old; when he had a partial seizure (the father’s family shows a history of epilepsy).At the age of 4¾, due to school concerns about J.’s aggressiveness towards other children,parents took him to a health center in England. There his Mum mentioned a similar behavior also at home, since the birth of his young brother ( 3 years younger). At the clinic the boy didn’t show any sign of disruptive behavior. The English Consultant Pediatrician prescribed an observation at school which outcomes drove the diagnosis of ADHD. Hence J. was dosed with Methylphenidate daily (2.5 mg bd to 5 mg bd) and provided with behavior-family therapy. During this therapy it was reported by family with many improvements, especially at school.After a month, J. developed tics, therefore Mum herself stopped the medication. On that, Clinicians decided to reduce the drug dosage and to start again the therapy more gradually. J. stopped having tics and showed a lot of improvements at school, however the mother kept finding very difficult to control him at home as she signaled his violent outbursts, mainly directed at her and his young brother.After a year parents themself stopped again Methylphenidate, because he developed again severe tics. Clinicians, then, decided to change the therapy with Atomoxetine. J.’s parents started a parenting course that was attended especially by the mother. After two years of Atomoxetine therapy, J. continued having severe temper outbursts and aggressive behavior at home, while, at school, he improved completely and he had good school reports. J. moved to Italy with his family at 8 years old, for father’s work business. These days J. came in our Department with the parents’ request to have the prescription of Atomoxetine.In that circumstance the mother looked shocked and desperate for her family situation. For this reason she reported to take antidepressants since quite long time. Since the boy showed almost all the atomoxetine side effects we decided, with parents agreement, to gradually wash him out from medication, to give him a transition therapy with little doses of clorpromazyn and to re assess the case. At MRI that we have prescribed, J. has shown a little area of heterotopia in the frontal-parietal junction; moreover at EEG he has presented frontal sharp-waves. Looking at the boy’s therapy history the Methylphenidate at small doses seemed to work more effectively and still could be a valid solution. Nonetheless nobody has ever evaluated the comorbidity of the boy and his cognitive profile. Another question mark is related to the relatives’ relationship impacts and effects to this disorder. Is it nowadays ADHD the main diagnosis? How can we take care of all the aspects of this complex situation? What is the better medication therapy to provide?



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Systemic multimodal approach to ADHD children and their families

Cremaschi Silvana, Zappulla Giuseppe, Bortolossi Barbara, Sartor Graziella, Martignon Fabrizia.

SOC Child Neuropsychiatry, ASL Udine

Background:The purpose of this study is to present the our clinical experience in a NPIA Territorial Service, based on a multimodal approach on children with ADHD diagnosys. Multimodal therapy involves families and children’s main life context. The systemic approach is based on the belief that personal development results from the interaction between genotype, phenotype and “ecotype”.We will try to demonstrate the effectiveness of multimodal therapeutic approach associated to familiar psychotherapy in children diagnosed with ADHD based on DSM IV and ICD 10 criteria. Our Personal Multimodal Therapeutic approach can be articulated in the following interventions: parent training, theacher training, familiar psycotherapy, neuropsicological training, autoregulation training, psycopharmacological treatment. Different interventions can be chosen and associated according to personal, familiar and environment impairment and resources. Material and methods:80 children diagnosed with ADHD; 80 ADHD children families; 20 teacher equipes involved in managing with severe impaired ADHD children in their classrooms ( Level> 4 based on 6th Axe in ICD 10 Classification). Children received ADHD diagnosis based on ICD 10 and DSM IV R criteria. Psycodiagnosy has been focused on nuclear symptomes, functional impairment, cognitive and neuropsycological skills, self esteem level and social skills.Quality of Families interactions has been measured by PIR GAS. Autoregulation training and pedagogic intervention : focused on children from 6 to 8 years old and 8 to 11 years old. Trainers: neuropsycomotor therapist and language therapist with pedagogic competences Neuropsycological training: smalls groups of children (3-4 subjects ) focused on children from 6 to 8 years old and 8 to 11 years old. Trainers: neuropsycomotor therapist and language therapist with pedagogic competences Parent training: based on cognitive-behavioural approach with addictional special focus on systemic context and interaction. Trainers: psychologist and psychiatric nurse Theacher training: based on cognitive-behavioural approach with addictional special focus on systemic context and interaction ( based on impairment levels: 6th axe / ICD 10 > 4). Trainers: psychologist and psychiatric nurse Family Psycotherapy in families with PIR GAS < 40. Psycofarmacologic therapy: administred only to severely impaired children( ICD 10; 6th axe) Results and discussion:Our multimodal approach is still taking place. Parents and children relationship and family interactions will be evaluated at the end of parent training and familiar psychotherapy.Preliminar data suggest the opportunity to keep together, within a unique clinical service a diagnostic assessment and therapeutic interventions.



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Response Time Intra-subject Variability: commonalities between children with children with Attention Deficit/Hyperactivity Disorder (ADHD) and children with

Autism Spectrum Disorders (ASD).

Adamo N.1, Adelsberg S.1, Petkova E.2,3, Castellanos F. X.1,3 and Di Martino A.1

(1)NYU Child Study Center at the NYU Langone Medical Center, Phyllis Green and Randolph Cwen

Institute for Pediatric Neuroscience, New York, NY, (2)Division of Biostatistics , NYU Child Study Center, New York, NY, (3)Nathan Kline Institute for Psychiatric Research, Orangeburg, NY

Background. A substantial number of children with autism spectrum disorders (ASD) present with Attention Deficit Hyperactivity Disorder (ADHD) that worsen their global functioning and represent and treatment challenge. Yet, to date, the mechanisms underlying ADHD–like symptoms in ASD are under-explored. A potential candidate for investigation is response time intra-subject variability (RT-ISV). Consistent findings of increased RT-ISV in typical individuals with ADHD. Earlier studies have directly compared RT-ISV in children with ASD and ADHD yielding contradictory results. Objective. We aimed to examine whether RT-ISV distinguishes children with typical ADHD from those with ASD and whether it characterizes a subgroup of children with ASD who present with ADHD–like symptoms (ASD+). Methods. A group of 129 children aged between 7 and 11.9 years participated in this study IRB approved at the NYU Child Study Center. The sample included 47 children with ADHD (40 boys), 46 with ASD (42 boys), and 36 typically developing children (TDC, 19 boys). RT data were collected during a fixed-sequence 5.5-min version of the Sustained Attention to Response Task (SART). We measured RT-ISV both as standard deviation of RT (SD-RT) and as amplitude of frequency fluctuations measured with Morlet Wavelet Transform. We assessed between groups differences in SD-RT with one-way ANOVA, and subsequently we computed post-hoc pair-wise group comparisons, Bonferroni corrected. We then applied Functional Data Analyses, a data-driven analytical approach, to compare the amplitude of all 400 frequencies detected by the SART across groups (ASD, ADHD, and TDC). We added age, sex, and full IQ as covariates into the model to control for their effect on the frequency spectrum examined. Secondary group comparisons were also conducted after dividing the ASD group in 23 children with ASD+ and 23 ASD- per DSM-IV total T-score 65 on the Conners Parent Rating Scales (CPRS). Results. The three groups did not differ in SD-RT. However, relative to TDC, children with ADHD and children with ASD showed similar increases in the fastest components of RT-ISV within the frequency spectrum examined (0.25-0.34 Hz for the ADHD, and 0.26-0.34 Hz for the ASD, respectively). ADHD and ASD groups did not differ from each other in any frequencies detected by the SART. Secondary analyses showed that only ASD+ and ADHD groups had significantly increased amplitude of RT fluctuations relative to TDC (>0.25 Hz for both the ADHD and ASD groups). Children with ASD- did not differ significantly from any of the other groups. Amplitude of frequencies slower than 0.25 Hz did not differ between groups.Conclusions. Our results suggest that 1) increases of RT fluctuations > 0.25 Hz (i.e., cycles of ~4 sec) can serve as a potential marker of ADHD symptoms regardless of diagnostic categorical boundaries, and 2) children with ADHD and those with ASD+ may, at least in part share common physiopathological mechanisms. Fluctuations in RT may reflect intrinsic brain activity occurring in similar frequency ranges. Future work will need to directly examine the relationship between RT-ISV and fluctuations of brain intrinsic spontaneous activity.



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ADHD and Autism Spectrum Disorder symptoms overlapping: social functioning impairment

Anchisi L.1, 2, Carucci S.1, Ambu G.1, Lecca L.3, Zuddas A.1

1 Center for Pharmacological Therapies in Child and Adolescent Neuropsychiatry. Dept Biomedical Science, University of Cagliari & Cagliari University Hospital, Cagliari, Italy

2 Dept Clinical and Sperimental of Medicine and Pharmacology, University of Messina, Italy 3 Azienda Ospedaliera Carlo Poma, Mantova, Italy

Background: ADHD (Attention Deficit Hyperactivity Disorder) is a disorder that affects children and adolescents in their daily life. With a continuum from early childhood to adolescence and adulthood, these children show problems to attune their behavior to other people and to the environment. Although their interest in social relations, they apparently present a deficit of comprehension of the consequences of their behaviors to other. These features may show some overlap with Autism Spectrum Disorders (ASD) symptoms, such as lack of reciprocity. Little is known about quality and etiology of social difficulties, as well as the relationship with impairment of social reciprocity in ASD. Objectives: To explore social functioning of a sample of ADHD children and adolescents by using the Social Responsiveness Scale (SRS) and compare it to ASD and TDC.

Methods: Data were collected from 234 children aged 4-13 and IQ >70. 93 children were ADHD, 32 ASD, and 109 matched TDC. Subjects were evaluated by SRS, CPRS, C-GAS and CGI. Results: Comparisons among ADHD (n: 93, 39.7%), ASD (n: 32, 13.7%) and controls (n: 109, 46.6%) revealed no differences in IQ, gender and age. As a group, ADHD patients significantly differed from ASD in global impairment assessed by C-GAS (49.1±5.7 vs 45.6±5.4, p=0.008) and in rate of comorbid diagnosis with ODD (p< 0.001). SRS Total T score in ADHD and in ASD were comparable and significantly higher than TDC (p<0.001). Stratifying the ADHD group on the basis of total SRS T score, 81,7% of ADHD showed a total SRS score > 60 (ADHD+) and 18,2% <60 (ADHD-). SRS total and subscales scores in ADHD- were comparable to TDC and significantly different from ASD except for Social Awareness. ADHD+ and ASD mean scores at each SRS subscale were similar.

ADHD+ Total SRS scores significantly correlated to all Conners subscales except for Psychosomatic. Social Motivation did not correlate with Oppositional and Hyperactivity.

ADHD+ significantly differed from TDC on any subscale of CPRS, while ADHD- revealed CPRS mean scores comparable to TDC on subscales Anxious/shy, Perfectionism and Social Problems. MPH treatment for 9-12 months showed a significant improvement on total SRS score.

Discussion and Conclusions: This study highlights a significant impairment in social responsive behavior in ADHD. A subgroup of ADHD patients shows higher levels of ASD symptoms, with a SRS profile similar to ASD and higher levels on anxiety symptoms. Recognition of social deficit in a subgroup of ADHD may help to consider specific targets for a comprehensive therapeutic intervention. Key words: ADHD, ASD, social reciprocity



29

Face emotion recognition: a preliminary analysis in Attention-Deficit Hyperactive Disorder (ADHD) and Autism Spectrum Disorder (ASD)

Peddis Cristina, Reale Laura, Petza Silvia, Liori Arianna, Carucci Sara, Zuddas Alessandro

Child Neuropsychiatry , Cagliari University Hospital & Dept. Biomedical Science, University of Cagliari

Background:Social cognition is a crucial component of healthy adjustment, and deficits have been

reported in a range of psychiatric disorders. A core deficit in children with autism spectrum

disorders (ASD) relates to a difficulty in recognizing mental states, beliefs, desires and intentions of

other people, that may result in deficits in recognition of faces and facial expressions of other

people.

Accurate interpretation of information derived from facial expression is a prerequisite for successful

nonverbal communication, but speed of processing is equally crucial, as personal communication

proceeds on a real-time basis.

Emerging lines of research are examining difficulties in emotion processing as an aspect

characterizing also Attention-Deficit/Hyperactivity Disorder (ADHD).

Aims:This study aimed to examine whether there is a specific face emotion pattern recognition in

ADHD and ASD by using the Amsterdam Neuropsychological Tasks battery.

Methods:Facial Recognition (FR), Identification Facial emotion (IFE, 8 tasks) and Matching Facial

Emotion (MFE, 4 tasks) assessed in 35 drug-free ADHD (mean age=10.83±2.2 years), 31 ASD

(mean age=9.58±1.5 years) and 36 Typically-Developing (TDC) (mean age=10.63±1.9 years)

matched controls. ASD and ADHD subjects were diagnosed according to the DSM-IV-TR. Accuracy

(errors) and Response-Time in correct answer (hRT) were analyzed by ANOVA; age, IQ and

severity (CGI, C-GAS) effects was evaluated by Pearson's correlation analysis.

Results:In FR, both ADHD (P=.03) and ASD (P=.001) showed a longer hRT; ADHD showed

significantly lower accuracy than TDC, and ASD significantly lower that ADHD.In IFE, all groups

had similar error rates in recognizing Happy, Sad, Angry, Disgusted and Surprise faces, whereas in

recognizing Fear, Shame and Contempt, ADHD made more errors than TDC, and ASD more than

ADHD (Fear: P=.003 ; Shame: P=.03 ; Contempt: P=.04). hRT for Happy and Sad faces was similar

among groups, hRT for Anger, Fear, Shame and Contempt was similar in ADHD and TDC, but

shorter than ASD, whereas hRT for Disgust and Surprise were similarly longer than TDC in both

ADHD and ASD.In MFE, hTR was similar among groups for Sadness and Fear, but significantly



30

longer in Happiness (P<.001) and Anger (P=.04) in ASD than ADHD and TDC; more errors were

observed in ASD and ADHD compared to TCD (P<.001). A negative correlation with age on FR,

IFE and MFE hRT was observed in ADHD and TDC (P<.05), only in FR in ASD (P=.02).

Discussion:Preliminary results indicate that both ASD and ADHD children show a greater

impairment in FR, IFE and MFE tasks than TDC.

ASD subjects abilities in identifying a facial emotion appear poorer than TDC, because apart from

decoding the signal, performance also depends on the quality of their internal meta-representation,

which is thought to be impaired in ASD.

In ADHD, this finding may be related to an impaired processing of nonverbal cues, as previously

reported, and to inattention and impulsivity or to alterations in motivational processes, which are

cardinal features of ADHD subjects.

No relationship with IQ level and symptoms severity in both ASD and ADHD groups reveal that

deficit in face and emotion recognition could not be attributed to general cognitive abilities or

impairment due to the condition, but may be considered a peculiar trait of these developmental

disorders.

These data highlight the utility to administer these neuropsychological tasks to better characterize

strengths and difficulties on these cognitive functions in ADHD and ASD children, in order to

develop specific and efficient treatment strategies, thus facilitating the development of adequate

social abilities as well as an appropriate functioning in family, school and community environment.

Key words: face emotion recognition, ADHD, ASD.



31

Moderation by the Tryptophan Hydroxylase 2 (TPH2) gene on the continuity/discontinuity of emotional Dysregulation symptoms throughout

adolescence and the role of family structure

Nobile Maria1M.D., Colombo Paola1Ph.D., Bellina Monica1D.Psych, Greco Andrea2D.Psych.,

Monzani Dario2D.Psych., Bianchi Valentina1D.Psych., Carletto Ombretta3M.D. and Molteni Massimo1M.D.

1. Department of Child Psychiatry, ‘Eugenio Medea’ Scientific Institute, Bosisio Parini, Italy.

2. Department of Psychology, Università degli Studi di Milano Bicocca, Milan, Italy

3. Department of Child Psychiatry, ‘Eugenio Medea’ Scientific Institute, Conegliano, Italy.

Aims: Deficient emotional self-regulation (DESR)or emotional dysregulation profile (DP) has only

recently been the focus of scientific investigation. Deficient emotional self-regulation refers to: 1)

deficits in self-regulating the physiological arousal caused by strong emotions; 2) difficulties

inhibiting inappropriate behavior in response to either positive or negative emotions; 3) problems

refocusing attention from strong emotions; and 4) disorganization of coordinated behavior in

response to emotional activation. Clinically, DESR traits include low frustration tolerance,

impatience, quickness to anger, and being easily excited to emotional reactions (for a review see

Spencer et al. 2011). The DP have been found to be a very heritable trait that increases

susceptibility for later psychopathology, including severe mood problems and aggressive behaviour.

Tryptophan hydroxylase (TPH) is the rate-limiting enzyme in the 5-HT synthesis. Recent studies

found a newly-identified second isoform of the tryptophan hydroxylase gene (TPH2) preferentially

involved in 5-HT regulation in human CNS. A common single nucleotide polymorphism (SNP G-

703T, rs 4570625) in the transcriptional control region of TPH2 has been reported to modulate

amygdala responsiveness to affective stimuli, and has been found to be associated with emotional

dysregulation (Gutknecht et al., 2007).

The effect of TPH2 on the stability/instability of emotional dysregulation problems throughout

critical developmental period like adolescence, taking into account the effects of chronic societal

stressors, has yet to be examined. In this study we investigated the moderating role of a TPH2

(SNP G-703T, rs 4570625) polymorphism on the stability/instability of internalizing problems

throughout adolescence, taking also into account the possible interaction with family structure.



32

Patients & Methods: This is a five-years follow-up study of the genetic section of the PrISMA

(Progetto Italiano Salute Mentale Adolescenti) project. The final study population included 287

subjects aged 15-19.

To test for moderated mediation, we performed a path analysis using Mplus 6.11 (Muthén &

Muthèn, 1998-2010) and the bootstrapping procedure described by Preacher et al. (2007) to test

conditional indirect effects. More specifically, we tested if TPH2 moderates the path from family

structure at time 1 and Dysregulation Profile at time 1 and the path from Dysregulation Profile at

time 1 and Dysregulation Profile externalizing at time 2.

Results: Family structure at time 1 influenced Dysregulation Profile at time 1 (B= 9.176, p= .002)

and that this effect is moderated by TPH2 (B= -9.200, p= .002). Dysregulation Profile at time 1

influenced positively subsequent Dyregulation Profile at time 2 (B= .079, p= .000). Nonetheless, this

effect was not moderated by TPH2 (B= -.008, p= .651). Subsequently we tested the indirect effect

by estimating conditional indirect effects at both levels of the moderator variable (0= GG; 1= GT-

TT). The indirect effect of family structure on Dysregulation Profile at time 2 was significant (95% CI

.249 to 1.218) only among participants with a GG TPH2’s polymorphism. For adolescents with a

GT-TT TPH2’s polymorphism there were no indirect effect of family structure at time 1 on

Dyregulation Profile at time 2.

Conclusions: In conclusion,adolescents with a GG TPH2’s polymorphism and with only one parent

scored higher in Dysregulation Profile at time 2 than did participants with two parents. This effect is

mediated through levels of Dysregulation Profile at time 1. This longitudinal study contributes to the

understanding of the processes underlying the continuity/discontinuity of emotional Dysregulation

problems during adolescence and underscore early adolescence behavioral problems as an

important focus for primary and secondary intervention.



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ADHD, intellectual disability and other comorbidities: analysis of findings at the CGH-array in a small sample of subjects

Di Vita G., Galesi O., Fichera M., Castiglia L., Torrisi A.M.,

Amata M.T., Costanzo A., Di Guardo G., Musumeci S.A.

The Oasi Research Institute (Troina, Italy)

Objective: to describe a sample of ADHD, ID and/or other comorbidities and preliminary findings

of a CGH-array analysis.

Patients & Methods:We describe the preliminary findings of a CGH-array analysis performed in a

sample of ADHD children/adolescents referred to the Oasi Research Institute (Troina, Italy)

characterized by non homogeneous intellectual functioning and, sometimes with specific

comorbidity (mental retardation or borderline intellectual functioning are the general features of

patients referred to the Institute).

Fifty-nine children/adolescents (54 males and 5 females) were considered:

Nineteen with mental retardation (18 mild and 1 moderate): 4 with fragile-X syndrome; 3 with EEG

abnormalities; 2 with Tourette disorder (one of whom had also EMG abnormalities); 1 with

oppositional defiant disorder; 1 with mood disorder n.o.s.

Fifteen with borderline intellectual functioning (one of them with Klinefelter syndrome): five with

EEG abnormalities (two of whom also with oppositional defiant disorder); 3 with mood

disorder n.o.s.

Nineteen with specific developmental disorders: 3 with EEG abnormalities; 3 with mood disorder

n.o.s.; 2 with tics; 1 with neuroradiological signs such as cortical/subcortical microdysplasia;

1 with nodular subependimal heterotopias adjacent to the frontal horn of the left lateral

ventricle.

Two with EEG abnormalities associated, respectively, to neuroradiological abnormalities and to

mood disorder n.o.s.

Two with autistic spectrum disorder (one high-functioning, the other with moderate mental

retardation and signs of perinatal hypoxic/ischemic encephalopathy).

One with Tourette disorder.

One with behavior disorder (CD).

A subsample of 21 children/adolescents were recruited as they had been already analyzed by

CGH-array because of some peculiarities of their basal disorder or, more recently, because they



34

were included in a specific research protocol. For another subsample of 15 subjects, CGH-array is

being currently performed.

Tools: specific diagnostic protocol for ADHD; CGH-array; EEG, neuroimaging.

Results e Conclusions: Our preliminary results show that in 11 out of the 21 subjects analyzed by

CGH-array CNVs have been found that have not been described yet in the general population (non-

polymorphic): 6 out of these 11 subjects have mild mental retardation, 4 males (one of whom in

particular shows a duplication in the critical region of Williams syndrome) and 2 F; 3 out of 11 show

borderline intellectual functioning; one has a learning impairment n.o.s and subependimal

heterotopias adjacent to the frontal horn of the left lateral ventricle; finally, another one is affected

by high-functioning autistic spectrum disorder.

In 6 out of the 11 patients, CNVs have been inherited by only one parent.

Conclusions: Our findings, even if they are still incomplete and refer to a non homogeneous

sample, need careful consideration, specially for the analysis of genes in the regions of interest and

for the possible correlations with intellectual disability (in the patients in whom ADHD represents a

comorbid condition) and, in one case, for a possible correlation with abnormalities of the

development of the central nervous system.



35

Neuropsychological and neurobiological model of aggression in children with externalizing disorders

Mazzone Luigi1

, De Peppo Lavinia1

, Vicari Stefano1

, Williams Riccardo 2

,Postorino Valentina 2

,

Milone Annarita 3

, Lenzi Francesca 3

, Pisano Simone 3

, Manfredi Azzurra 3

, Muratori Pietro 3

, Masi Gabriele 3

1. Child Neuropsychiatry Unit, Department of Neuroscience, IRCCS Children's Hospital Bambino Gesù

2. Universityof Rome "La Sapienza"

3. IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry

Background: Children suffering from externalizing disorders, such as conduct disorder

(CD),Oppositional defiant disorder (ODD) or attention-deficit hyperactivity disorder (ADHD), show

high rates and different types of aggressive and antisocial behaviors.Previous studies have

supported the distinction between two broad different types of aggression: reactive and

instrumental. Reactive aggression (also referred as affective aggression) is triggered by a

frustrating or threatening event and involves unplanned, enraged attacks on the object perceived to

be the source of the threat/frustration. In contrast, instrumental aggression (also referred to as

proactive aggression) is purposeful and goal-directed. Although, the neurobiological basis of these

two types of aggression remain unclear, animal and human works have identified some circuits that

seems to distinguish reactive from proactive aggression. In particular, reactive aggression appears

to be mediated by a basic threat system that runs from medial amygdaloidal areas downward,

largely via the stria terminalis to the medial hypothalamus, and from there to the dorsal half of the

periaqueductal gray. This system is regulated by orbital, medial, and ventrolateral frontal cortex.

Whereas, instrumental aggression seems to be mediated by the amygdala and the orbitofrontal

cortex. . As reported in literature, the two types of aggression are linked to different

psychopathological pattern; reactive aggression is related to emotions deregulation whereas

instrumental aggression occurring in patients with psychopathic traits. To notice, is that a subset of

children affected by externalizing disorders also displays strikingcallousness, including lack of

guilt,empathy, or remorse and the presence of these traits has longed been linked to higher rates of

antisocial behaviour and impairment in stimulus-reinforcement learning. However, the association

between the various externalizing disorders and the different types of aggression remain

unclear.Finally, the presence of reactive or instrumental aggression in patients with externalizing

disorders have important effects on prognosis and response to therapeutic and pharmacological

treatments.. Aim of our study is to explore peculiar aggressive behavior related to different

externalizing disorders. Indeed, we would like to understand the neuropsychological mechanisms

and neurobiological circuits underlying the pathological aggression. An identification of peculiar

patterns associated with various type of externalizing disorders might help to specify different

treatment approach.

Methodology: All participants suffering from ADHD,ODD, and CD or comorbidity ADHD plus

ODDO or DC, will be submitted to a battery of psychological instruments for a comprehensive



36

evaluation of behaviour and neuropsychological functions. Particularly, to evaluate the presence of

externalizing symptoms parents, children and an experienced clinician will complete CBCL, K-

SADS-PL,Conners Rating Scales Revised and Disruptive Behavior Disorder Rating Scale. IQ will

be assess using Wechsler Intelligence Scale for Children - III to exclude subjects with a mental

retardation. To evaluate the aggressive behavior and psychopathic traits, a battery of rating scales

will be completed, such as Aggression Questionnaire, Reactive-Proactive Aggression

Questionnaire and Modified Overt Aggression Scale The Antisocial Process Screening Device and

Inventory of Callous Unemotional Traits,.To assess the neuropsychological functions all the children

will complete computer tasks. In particular, working memory (spatial and verbal), inhibition (by a

task of stop signal), emotion recognition (by International Affective Picture System-IAPS) and

stimulus-reinforcement learning (by Passive Avoidance Learning Task-PALT), will be evaluated.

Conclusions: We expect to find that peculiar aggressive behavior would be related to different

externalizing disorders. Indeed, we would like to shed light on the neuropsychological mechanisms

and neurobiological circuits underlying the pathological aggression.



37

Executive functions in Attention-Deficit/Hyperactivity Disorder

Menghini Deny 1, Varvara Pamela 1, Napolitano Carmen 1, Calcagni Marta 1,

Armando Marco 1and Vicari Stefano 1

1 Children’s Hospital Bambino Gesù, Rome, Italy

Introduction and Aims: Studies on Executive Functions (EF) have documented several deficits in

ADHD, but the nature of the neuropsychological deficits remains elusive and findings heterogeneous

(Yerves et al., 2009). For example, while some authors have proposed that reduced behavioral

inhibition control is the core deficit of ADHD and that attention deficits are secondary (Nigg, 2001; Willcutt

et al., 2005, Barkley, 1997), others do not support the hypothesis of behavioral inhibition (Sergeant et al.,

1998).

By investigating several aspects of EF, the present study was aimed at better understanding the

neuropsychological profile of ADHD children, compared with a group of typically developing (TD)

children.

Patients and Methods: Sixty ADHD and 34 TD children underwent to a neuropsychological battery

tapping auditory and visual Attention, verbal and visual-spatial Categorization, Planning, verbal and

visual-spatial Short-term and Working Memory, verbal and visual-spatial Shifting, verbal and motor

Response Inhibition. T-test was performed to compare ADHD children and TD children on EF measures.

Results: In ADHD children were documented deficits in selective and sustained auditory Attention,

verbal Inhibition and Planning. However, some aspects of EF were preserved (i.e. selective visual

Attention, motor response Inhibition, Shifting, Categorization and Short-term and Working Memory). After

Bonferroni correction ADHD group showed significantly different z-scores in selective auditory Attention,

verbal Inhibition and Planning.

Our results documented that EF are not homogenously impaired in ADHD children and that only some

abilities should be considered as the “core deficit” of EF in ADHD children.

Conclusion:The specific profile of EF emerged in ADHD children need to be taken into account during

the diagnostic phase and the rehabilitation phase.



38

References

Barkley RA (1997). Behavioral inhibition, sustained attention, and executive functions: constructing a

unifying theory of ADHD. Psychological Bulletin, 121, 65-94.

Sergeant JA, Oosterlaan J, Van der Meere J (1998). Hyperactivity: passed the point of no return? A

cognitive energetic analysis.In Handbook of Disruptive Behavior Disorders.Edited by Quay HC,

Hogan AE. New York: Plenum Press.

Willcutt EG, Doyle AE, Nigg JT, Faraone SV, Pennington BF (2005). Validity of the executive function

theory of ADHD: a meta-analytic review. Biol. Psychiatry 57, 1336–1346.

Nigg JT (2001). Is ADHD a disinhibitory disorder? Psychol. Bull. 127, 571–598.

Yerys BE, Wallace GL, Sokoloff Jl, Shook DA, James JD, Kenworthy L. (2009). Attention deficit –

hyperactivity disorder symptoms moderate cognition and behaviour in children with autism

spectrum disorders. Autism Res. 2 (6):322-33.



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Influence of General Anxiety Disorder, state anxiety and depressive symptoms on executive function in children with ADHD

Armando M., Napolitano C., Calcagni M., Casini M.P., Menghini D., Vicari S.

Children’s Hospital Bambino Gesù, Rome, Italy

Introduction: ADHD is often in comorbidity with anxiety disorders, with rates approaching 25% in

many samples. ADHD and anxiety disorders (ANX) seem to haveopposite neurocognitive

patterns, specially on executive functions (EF).The aim of this study is to define a specific

profile of ADHD and ADHD with ANX in executive function.

Methods: The sample consist of 60 patients and 30 controls matched for sociodemographic

variables and IQ. 30 children fullfilled diagnostic criteria for ADHD and General Anxiety Disorder

(ADHD+ANX) and 30 for ADHD only. All clinical children were identified through the U.O.C.

Neuropsichiatria Infantile, Ospedale Pediatrico Bambino Gesù in Rome with suspect ADHD

symptomatology.

Results:There were two significantly differences between groups on measures of EF.

The first one was in a verbal selective attentiontask, in which ADHD + ANX and children with ADHD

only performed more poorly on this task to the control group and the performance of these two

clinical groups differed significantly from each other. The ADHD had more false alarms than ADHD

+ANX (F= 6,41; p=0,003). No group difference was detected for correct responses (F=2,43 p=0,09)

and misses (F=2,42 p=0,09). The second statistically significant result was a difference between

groups in a planning task. While Children with ADHD only performed planning faster than Controls

and ADHD+ANX, the performance of these two groups did not differ statistically significantly from

each other (f= 8,07; p=0,001). However there were no group differences for number of correct

response (F= 3,42; p=0,03). In the other domains (i.e. sustained attention, Stroop interference

effect, alertness and inhibition of an ongoing response) the performance of the two clinical groups

did not differ statistically significantly from each other. These results are not influenced by levels of

anxiety and depressive symptoms during the assessment period.



40

Conclusion: According to literature our results demonstrate that in EF anxiety might act as a

moderating factor against some neurocognitive impairments in ADHD.



41

Evidences of SNAP25 single nucleotide polymorphisms associated with hyperactivity and ASD disorders: future prospects related to ADHD.

Cosi A.1, Aggio F.A.1, Nossa M. 1, Paccione F. 1, Magnaghi E.1, Tuci A.1, Galimberti G.1, Saccani M.1, Lenti

C.1 and Guerini F.R.2

1. Department of Child and Adolescent Psychiatry, San Paolo Hospital, University of Milan.

2. Don C. Gnocchi Foundation ONLUS, Milan.

Aims: Attention Deficit Hyperactivity Disorder (ADHD) is characterized by persistent and pervasive symptoms of inattention, hyperactivity, and impulsivity. ADHD is not a genetic disorder in any simple sense. Twin study suggesting heritability estimates of 60 to 90%. Synaptosomal-associated protein 25 (SNAP25) is an essential component for synaptic vesicle mediated release of neurotransmitters, a gene involved in neurotransmission and regulation of calcium homeostasis. Deficiencies or abnormal structure or function of SNAP25 protein, possibly arising through genetic variations in the relevant DNA code, has been suggested to play role in the pathology of several neurobehavioral disorders including ADHD and autism spectrum disorders (ASD), and a number of polymorphisms in the SNAP25 gene has been studied for association with the disorder. In particular, two specific SNPs localized in the 3’ untraslated region of SNAP25 gene (rs3746544 and rs 1051312) were associated to ADHD. According to a previous study (Guerini et al., 2011) the finding that polymorphism of the SNAP25 gene are associated with the degree of hyperactivity in children with ASD, we investigate the hypothesis that alteration of mechanism play a pivotal role in the events leading to ADHD and ASD-associated behavioral impairment. Patients and methods: We will select 15-20 probands with a clinically diagnosed ADHD between the age of 6 and 18 years, followed by the Department of Child and Adolescent Psychiatry, San Paolo Hospital, University of Milan. The diagnosis was made according to DSM IV criteria, and all patients were affected by a combined ADHD type. Genetical data will be analized in relationship with clinical outcomes and compared to a group of ASD children( followed by the Pediatric Neuropsychiatry Institute, University of Sassari) and a group of healthy sex-matched children. All ADHD children were thoroughly examined; in particular all patients underwent in-depth clinical and neurological evaluations, mental status examination, neuropsychological evaluation (using the WISC III, Leiter–R, CPT II, according to the specific clinical picture), and questionnaires (CPRS and CTRS and CBCL). SNP’s will be typed using genomic DNA isolated from peripheral blood. Results and conclusions:The symptoms of ADHD create significant problems for over half of all children with autism and may be both under-recognized and under-treated by pediatricians. That children with ASD compounded by ADHD symptoms scored significantly lower in all areas of life quality (social, communication, etc.) and functioning (school, physical, emotional, etc.) compared to children with ASD alone. Molecular genetic studies in ADHD should contribute to a greater understanding of the pathophysiology of the disorder (genetics of the vulnerability), and could help to select a more rational type of treatment (pharmacogenetic).In addition, the development of pharmacogenetics



42

could help to identify predictors of clinical response for a specific type of treatment, which would be clearly helpful in clinical practice.



43

Stress levels in parents of children with and without ADHD during the back-to-school period: results of a non-clinical opinion survey

Gagliano A.a, Hernandez Otero I.b, Doddamani L.c, Haertling F.d, Dutray B.e, Ramnath G.f

aDivisionof Child and Adolescent Psychiatry, University of Messina, Italy; [email protected]

bUniversity Hospital Virgen de la Victoria, Hospital Maritimo,

Malaga;[email protected]

cJames Paget University Hospital NHS Trust, Great Yarmouth, UK; [email protected]

dSocial-psychiatric Centre for Children and Adolescents, Wolfsgangstrasse68, Frankfurt, Germany;

[email protected]

eCentre Hospitalier de Rouffach, Rouffach, France; [email protected]

fKennemer Gasthuis, Haarlem, the Netherlands; [email protected]

Aims: The back-to-school stress survey was a non-clinical opinion survey designed to compare

stress in parents of children with and without ADHD in six European countries (France, Germany,

Italy, the Netherlands, Spain and the UK) and Canada during the back-to-school period.

Patients and Methods: The survey questionnaire was based on a modified Holmes and Rahe

stress scale. Parents of children with and without ADHD were asked to rate potentially stress-

causing situations, such as ensuring the child was ready for school in the morning, using closed-

ended questions on a scale ranging from 1 (low stress) to 10 (high stress). To ensure a fair

comparison, benchmark stress scores were established by determining the levels of stress

experienced by both groups of parents during standard stress-causing experiences, for example

being late for an appointment.

Results: A total of 1558 parents participated, 715 in the ADHD group and 843 in the non-ADHD

group. Mean (SD) age was 41.2 (7.29) years and 40.8 (7.15) years, respectively. 69.1% and 56.5%

of participants were female, respectively, and 90.6% had ≤2 children at home. In the ADHD group,

92.9% of participants had one child with ADHD and 6.7% had two children with ADHD. The mean

(SD) age of the eldest child with ADHD was 11.4 (3.25) years; 75.8% were male and 60.9% had ≥1

co-morbid condition, including learning disorders/dyslexia (19.9%), conduct disorder (15.1%) and

autism spectrum disorder (12.3%). A total of 51.0% of children used ADHD medication; 42.6% had

a medication break during the school holiday, predominantly at the physician’s suggestion



44

(50.3%),and of these 38.1% re-started medication immediately before returning to school. In

general, parents of children with ADHD had higher stress levels, which were increased (p<0.001) in

the back-to-school period compared with parents of children without ADHD.

Conclusions: These results provide insight into the stresses experienced by parents of children

with ADHD during the back-to-school period. A sub-analysis of data relating specifically to Italian

parents will also be presented.

Study sponsored by Shire Pharmaceuticals.



45

Overlapping between oscillation frequencies of RTs and Beta/Theta EEG Frontal Ratio in Pediatric Patients suffering from Sustained Attention Deficit

after Acquired Brain Injury

Gazzellini Simone 1, Benso Francesco 2, Bauleo Graziella 1, Bisozzi Eleonora 1, Napolitano Antonio 3,

Clavarezza Valentina 2, Lispi Maria Luisa 1and Castelli Enrico 1

1. Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children’s Hospital, Rome, Italy; 2. University of Genoa, Genoa, Italy; 3. Clinical Technology Innovations Research Area, Bambino Gesù Children’s Hospital, Rome,

Italy

Aims. Previous experimental evidence describes excessive cortical EEG slowing over central, midline and frontal regions in ADHD (Lubar & Lubar, 1994). Neurofeedback would improve attention sustained performance and symptoms of inattention (Rossiter & LaVaque, 1995; Linden et al., 1996) and impulsivity (Carmody et al. 2001), by increasing production of EEG activity in faster frequency ranges (Sensory Motor Rythm (SMR) 13-15 Hz; beta1 16-20 Hz) and suppressing activity at slower speeds (theta 4-8 Hz). Furthermore, intra-individual reaction times (RTs) variability was observed in case of sustained attention deficit and during the execution of continuous performance tasks (Di Martino et al., 2008; Gilden & Hancock, 2007; Yordanova et al., 2011; Sonuga-Barke & Castellanos, 2007;). In particular, an intra-individual RTs variability of about .05 Hz, corresponding to attentional lapses with a period of about 20 seconds, was reported (Castellanos et al., 2005). The main aim of the present study is to link these two research fields in order to investigate how the beta/theta ratio varies in patients with RTs periodical oscillation. In particular, we investigated the hypothesis that if beta1/theta or SMR/theta ratios were actually the EEG correlates of the behavioral symptoms, then we should find oscillations of the beta/theta (or SMR/theta) ratio and of RTs around the same frequency. Moreover, since previous studies are exclusively on ADHD, we have extended the investigation to children suffering from Acquired Brain Injury (ABI), with subsequent diagnosis of sustained attention deficit. Participants. Five young patients (mean age 12.1; st_dev 4.8) suffering from sustained attention deficit after acquired brain injury and with frontal lobe lesion and five healthy participants as control with a one to one matching according to age and sex. Instruments. Four attentional tasks (automatic and voluntary orientation, Flanker and modified-CPT) lasting 15 minutes each. Contemporary the EEG signal was recorded. Results. The Fourier transform on RTs and on the ratios between the powers of SMR (12-14.5 Hz) and Theta (4-7 Hz) and of Beta1 (15-18 Hz) and Theta, and the subsequent ANOVA on the peaks, revealed a main oscillation frequency of .02 Hz on both RTs and EEG for all patients but not for the healthy controls. Morlet analysis showed that peaks at .02 Hz were stable during tasks execution on both RTs and EEG. Conclusions. Even though preliminary, the results confirm and extend previous observations of RTs periodical oscillation in patients with frontal lobe lesions and provide evidence in favour of the frontal beta/theta ratio as a neurophysiological correlate of RTs oscillation in sustained attention deficit. By extending the evidence of regular oscillation from behavioural data to QEEG signal, this



46

study represents a first step towards bridging the gap between RTs variability and QEEG oscillations.



47

Iron and ADHD: time to move beyond serum ferritin levels

Margotta Milena M.D.¹ Parisi Pasquale, M.D., Ph.D.1, Liguori Simona ¹, Vanacore Nicola, M.D.3, Martines

Francesca, Psy.D.1, Sargentini Vittorio, M.D.4, Cortese Samuele, M.D., Ph.D.5 Donfrancesco Renato, M.D.2

1 Child Neurology, Chair of Pediatrics, II Faculty of Medicine “Sapienza University”, Rome, Italy. 2 S. Pertini Hospital, ASL RM/B, Rome, Italy

3National Centre of Epidemiology and Biostatistics, National Health Institute, Rome, Italy 4 ASL RM/A, Rome, Italy

5 Phyllis Green and Randolph Cowen Institute for Pediatric Neuroscience, New York University Child Study

Center, NYC, NY, USA

Introduction: Intriguing albeit preliminary observations suggest that iron deficiency may be

involved in the pathophysiology of ADHD, at least in a subset of patients. The aim of this study is:1)

to compare serum ferritin levels in a sample of stimulant-naïve children with ADHD and matched

controls; 2) to assess the association of serum ferritin to ADHD symptoms severity, ADHD

subtypes, and IQ.

Methods: The ADHD and the control group included 101 and 93 children, respectively (total 194

children). All 6-14 year old children newly consecutively diagnosed with ADHD in the Outpatient

Service of “ASL Roma A” from January 2009 to December 2010e (stimulant naïve) were included

in the present study. Exclusion criteria: 1) IQ<70 (WISC III) 2) Any neurological diseases. 3) Any

chronic conditions or diseases. A control group matched for age and gender was randomly

recruited among the children seen by family pediatricians in routine care in the same local area.

The family pediatricians collaborating with the authors were asked to refer children suitable as

control participants for our study. Therefore, the pediatricians were asked to refer only healthy

children, i.e. children without chronic or acute medical conditions as well as without known mental

disorders according to their medical records. Psychiatric diagnoses were established according to

DSM-IV-TR criteria (American Psychiatric Association, 2000) and confirmed by K-SADS-PL and

SINPIA Guidelines. The parents and school teachers of all the children in the ADHD group were

also asked to fill out the ADHD-Rating Scale (ADHD-RS)adapted for the Italian population. The

children of the control Group were carefully interviewed by the local pediatricians who were

specifically trained in the diagnosis of ADHD according the DSM-IV-TR. ADHD in the control

participants was ruled out on the base of clinical interview.

Serum ferritin levels were determined with the ELISA method.

Results: Serum ferritin did not significantly differ between children with ADHD and controls, as well

as among ADHD subtypes. Correlations between serum ferritin levels and Full Scale IQ, Verbal IQ,

Performance IQ, ADHD-RS total, ADHD-RS Hyperactive-Impulsive, or ADHD-RS Inattentive scores

were not significant.



48

Conclusions: This is the largest controlled study that assessed ferritin levels in stimulant-naïve

ADHD children.Our findings do not support a significant relationship between serum ferritin levels

and ADHD.However, our results based on peripheral measures of iron do not rule out a possible

implication of brain iron deficiency in ADHD.



49

Major Depression and Dysthymia in children with ADHD

Leo G.**, Leone D.**, Di Trani M***, Martines F*, Sferrazza A**, Torrioli MG **, Donfrancesco R.*

*Sandro Pertini Hospital Roma

**Università Cattolica del Sacro CuoreRoma

***Università degli Studi “Sapienza”, Roma

Introduction: in the last years a number of epidemiologic studies have documented the

concurrence of depressive symptoms in ADHD patients. The aim of this study was to analize the

prevalence of Major Depression (MDD) and Dysthymia (DD) in an Italian sample of children with

ADHD and to find out if there was any correlation with age, gender, IQ, SES, family history of

psychiatric disorders, ADHD subtypes and severity of symptoms.

Methods:We studied 367 consecutive drug-naïve Caucasianoutpatients with ADHD (322 males

and 45females, mean age of 105,5 months), diagnosed in a Regional Center for ADHD in

Rome, from January 2006 to December 2010. All the children received a diagnostic assessment

using ADHD-Rating Scale (ADHD-RS) (DuPaul et al., 1998) adapted for the Italian population

(Marzocchi and Cornoldi, 2000),filled out by parents and school teachers. Both children and parents

separately received a semi-structured psychiatric interview, the Schedule for Affective Disorders

and Schizophrenia for School-Age Children- Present and Lifetime Version (K-SADS-PL) (Kaufman

et al., 1997), by an experienced child psychiatrist (RD). All children underwent a Wechsler

Intelligence Scale for Children III(WISC III) and patients with IQ < 70 were excluded.

Socioeconomic status (SES) was measured using the 3-point Hollingshead scale. For each patient

a detailed personal and family history was taken. All the psychiatric diagnosis were made according

to DSM IV diagnostic criteria.

Results:in our sample of 365 ADHD children 7,1% presented a DD and 92,3% of them were

males. No statistically significative difference was found between patients with or without DD in

terms of age (p=0,146), gender (p=0,456), TIQ (p=0,826), SES (p=0,312), ADHD subtype (p=0,355),

family history of psychiatric disorders (p=0,946) and severity of ADHD based on total SDAG score,

SDAG-I and SDAG-A (respectivelly p=0,773, p=0,718, p=0,296).

Comorbid DDM was found in 4,4 % of 365 patients. No statistically significative difference was

found between patients with or without MDD in terms of age (p=0,707), gender (p=0,083, TIQ

(p=0,293), SES (p=0,050), ADHD subtype (p=0,264) and family history of psychiatric disorders

(p=0,660).

Considering the severity of ADHD symptoms using the Inattention SDAG score we found a

significative difference between children with MDD and children without MDD ( p= 0,027), as the

first group has an higher score meaning worst symptoms, while no significative differences were

found on the total SDAG score and the Hyperactivity SDAG score ( p=0,380 e p=0,813).



50

Conclusions: in our Italian sample of ADHD children we found no significative difference in terms of

age, gender, IQ, SES, family history, ADHD subtype between patients with or without MDD or DD

but the comorbidity of ADHD and MDD was associated with marked and worst symptoms of

inattention.



51

Defining Deficient Emotional Self-Regulation (DESR) in an Italian Sample of Youth with ADHD Using a profile of the empirically derived Child Behavior

Checklist

Marano, A.*, Innocenzi, M.**, Donfrancesco, R. **, Biederman, J.φα

*Department of Social and Developmental Psychology , University of Rome Sapienza , Rome

** S. Pertini Hospital ASL RM/B, Rome φ Department of Psychiatry, Massachusetts General Hospital, Department of Psychiatry

αHarvad Medical School, Boston

Aims: The goal of the current study was to investigate sensitivity and specificity of AAA-DESR

(Deficient emotional self-regulation, Spencer et al., 2011) profile in children with ADHD. The DESR

operational definition was obtained through the aggregate cut-off greater than 180 but less than 210

on the anxiety / depression, attention and aggressions (AAA) of CBCL (Achenbach & Rescorla

2001) subscales to define DESR.

Methods: The sample consisted of 358 children and adolescents aged 6–17 years old of both

sexes with (N = 190) and without diagnosis of ADHD (N = 168). All children were assesses with the

Child Behaviour Checklist (CBCL; Achenbach 1991), the Schedule for Affective Disorders and

Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL1.0; Kaufman et

al., 1997) and the Children's Global Assessment Scale (C-GAS; Schaffer et al., 1983) by just one

experienced child psychiatrist. All children in the ADHD group also received an additional clinical

diagnostic assessment by an expert clinician that included the ADHD-Rating Scale (ADHD-RS;

DuPaul et al., 1998) adapted for the Italian population (Marzocchi & Cornoldi, 2000), completed by

parents and teachers; the Wechsler Intelligence Scale for Children-Revised (WISC-III; Wechsler,

2006) and children with IQ < 75 were excluded. Medical history and electroencephalogram were

also used to exclude co-morbid medical and neurological conditions. We used the AAA-CBCL

aggregate cut off to define DESR as proposed by Spencer et al. (2011). Sensitivity and specificity

was evaluated using the Receiver Operating Characteristic (ROC) curve analysis (Metz, 1978;

Zweig & Campbell, 1993).

Results: Our findings that 40.0 % of children with ADHD met criteria for our definition of DESR

based on CBCL, compared with only 3.6% of controls subjects. These results are almost identical

to findings reported by Spencer and colleagues using the same definition of DESR in an American

sample (2011). Receiver operating characteristic (ROC) showed that the AAA-CBCL aggregate cut

off discriminated (Sensitivity 97.3; specificity 79.7; Criterion ≥ 179≤ 210) subsample of DESR

cases from non-DESR cases, in children with ADHD. Children with ADHD plus DESR had higher

severity than ADHD (p <0,05 for CGAS).

Conclusions: These results replicate Spencer and colleagues work (2011) findings in an Italian sample and

support the utility of the CBCL for the identification of DESR in children with ADHD.



52

Comorbidity and psychosocial impairment in Deficient Emotional Self-Regulation (DESR) and Attention/deficit hyperactivity disorder

Innocenzi Margherita *, Marano Assunta **, Donfrancesco Renato *

* S. Pertini Hospital ASL RM/B, Rome

**Department of Social and Developmental Psychology, University of Rome Sapienza, Rome

Aims:Children having ADHD associated to emotion-regulation problems (DESR): Spencer et al

(2011) documented that a profile consisting of moderate (1SD) elevations on the CBCL (Achenbach

& Rescorla 2001) Attention, Aggression, and Anxious/Depressed subscales (CBCL-DESR profile: ≥

180 ≤ 210) identifies a sizeable minority of children with ADHD and that its presence is associated

to higher levels of impairment than other children with ADHD without DESR. The purpose of this

study is evaluate the clinical severity and psychopathology comorbidity of ADHD children and

adolescents with a CBCL-DESR profile.

Methods: The sample consisted of 358 children and adolescents aged 6–17 years old of both

sexes with (N = 190) and without diagnosis of ADHD (N = 168). All the children and all the parents

of the clinical and control group received the Children Behavioural Checklist (CBCL, Achenbach

1991), a semi-structured psychiatric interview, the Schedule for Affective Disorders and


al., 1997) and the Children's Global Assessment Scale (C-GAS; Schaffer et al., 1983) by just one

experienced child psychiatrist (RD).

The inclusion criteria for the control group were absence of ADHD by Affective Disorders and


al., 1997), the inclusion criteria for ADHD group were diagnosed using the same instrument (K-

SADS-PL1.0; Kaufman et al., 1997). All the children in the ADHD group also received an additional

clinical diagnostic assessment by an expert clinician that included the ADHD-Rating Scale (ADHD-

RS; DuPaul et al., 1998) adapted for the Italian population (Marzocchi & Cornoldi, 2000), completed

by parents and teachers; the Wechsler Intelligence Scale for Children-Revised (WISC III; Wechsler,

2006) and children with IQ < 75 were excluded. Medical history and electroencephalogram were

also used to exclude co-morbid medical and neurological conditions.

Results: Our findings show that ADHD children and adolescents with a CBCL-DESR profile have

an higher clinical severity (Mean= 58.17; S.D.=9,98) compared to ADHD children and adolescents

with a CBCL-NON DESR profile (Mean= 70.34 S.D.=19,63) evaluated by C-GAS (p < 0.001).

In line with earlier research, ADHD children and adolescents with a CBCL-DESR profile showed

more comorbid (mainly oppositional defiant disorders and conduct disorders) compared to ADHD

children and adolescents with a CBCL-NON DESR profile.

Conclusions:Our results suggest that DESR is a emotional component of ADHD that is associated

with later severe psychopathology and psychosocial impairment. In our sample the emotional



53

component of DESR children and adolescents is related a pattern of disobedient, hostile, and

defiant behavior toward authority figures that different significantly from ADHD children and

adolescents pattern.

Keywords: Emotional Self-Regulation, comorbidity, psychosocial impairment



54

Attention-deficit/hyperactivity disorder and alexithymia: a pilot study

Di Trani Michela¹, Donfrancesco Renato², Gregori Paola³, Auguanno Giovanna³, Melegari Maria Grazia³,

Zaninotto Sabrina4, Luby Joan5

¹ Department of Clinical and Dynamic Psychology, University of Rome “Sapienza”

² S. Pertini Hospital ASL RM/B, Rome

³ La Scarpetta Hospital, ASL RM/A, Rome 4 ICR Villa delle Querce, Nemi (Rome)

5 Washington University School of Medicine

Aims.Alexithymia is defined by a difficulty identifying and communicating one’s own emotions, a

cognitive style oriented towards the objective aspects of experience and constrained imaginative

processes. Although the relationship between alexithymia and psychopathology has been studied

extensively in adults, research is lacking on alexithymia in childhood psychopathology.

The aim of this study, conducted in a group of ADHD children, was to investigate whether

alexithymia was significantly associated with ADHD and, if so, to what extent it was associated with

the severity of this disorder.

Methods. The Italian version of the Alexithymia Questionnaire for Children was administered to a

sample of 50 children with a DSM-IV diagnosis of ADHD, as assessed by the K-SADS PL, and to

100 healthy, age- and sex-matched children without ADHD, who were enrolled as controls.

Results. The total alexithymia score as well as the Difficulty in Identifying Feelings Factor and

Externally Oriented Thinking Factor were significantly associated with ADHD. The total alexithymia

score and the Difficulty in Identifying Feelings Factor were also significantly associated with

symptoms of hyperactivity/impulsivity. No significant relationship between alexithymia and

inattentiveness emerged.

Conclusions. These results provide preliminary data on the relationship between alexithymia and

ADHD. The findings point to an association between difficulty in identifying emotions and

hyperactivity and impulsivity. Further investigation of alexithymia in ADHD is indicated as this is not

a recognized correlate of the disorder.



55

A possible role of anti-Purkinje cell Abs as a biological marker in Attention Deficit/Hyperactivity Disorder: a pilot study

1NativioPaola, 1 Passarelli Francesca, 1 Pascale Esterina,²Villa Maria Pia and ³ Donfrancesco Renato

1- Università La Sapienza, Rome

2- S. AndreaHospital Sapienza University Rome

3-S. Pertini Hospital ASL RM/B Rome

Introduction: An autoimmune hypothesis has been suggested for several disorders with childhood

onset. Many volumetric studies reported reduced cerebellar volumes and developmental

alterations of cerebellum in ADHD children (Mackie et al., 2007). Cerebellum is thought to play an

important role in cognition including shift in attention and emotional regulation, so a deficit in

cerebellum activity could have has a result the Cerebellum Cognitive and Affective Syndrome, that

has some similar features compared to ADHD. The aim of the study was to evaluate the

possible association between anti-Yo, anti-Hu antibodies and ADHD syndrome as a marker of an

immune response directed against the cerebellum.

Material and methods: We studied 72 consecutive drug-naïve Caucasian outpatients with ADHD

(61 males and 11 female, mean age of months 113.66 sd 27.62 ), diagnosed at the S. Pertini

Hospital in Rome.

The control group included 58 healthy Caucasian children matched for age and sex, (47 males and

11 female, age in months 115.10 sd 18.68, randomly recruited from a community-based survey,

attending two elementary and junior high schools from the same urban area of Rome.

The two groups were matched for sex (CHI²1,21 p = n.s.) and age (ANOVA F=1.10 p= n.s.).

Both children and parents in the clinical sample of ADHD patients separately received a psychiatric

interview, K-SADS-PL 1.0. All the children (the ADHD group and Control group) also received the

ADHD-Rating Scale filled out by parents and school teachers; that confirmed the ADHD

diagnosis according with DSM-IV criteria in children with ADHD and excluded the same

diagnosis in the control group. All children with IQ<70 were excluded (WISC- III ). The two group

of children were also matched for Social Economic Status. Comorbidity of ADHD children were:

Distimic Disorder 15 %, MDD 6.7%, BPD 26.7%, ODD 55 %, CD 23.3%, Dyslexia 11.7%,

Generalized Anxiety Disorder 5 %.

Antibodies directed against Yo (PCA-1), Hu (ANNA 1), and Ri (ANNA 2) are detected by indirect

immunofluorescence assay (IFA). The presence of specific antibodies is determined by their

specific reactions to the cerebellar neurons (Purkinje, molecular or granular cells) and myenteric

plexus neurons in the gut.

Results: Our study show that the existence of a granular staining of Purkinje cells cytoplasm

suggesting the presence of anti-Yo antibody. In the ADHD group of 72 children, 49 (68.05 %) are



56

positive for Anti-yo Antibody and 23 (21.95%) were negative. In the Control Group 4 of the children

has a positive reaction (6.89 %) and 54 negative (93.11%). This difference is significant at the

Fisher exact test (p< 0.0001). The The Hu and Ri antibody reaction was not detected in both

ADHD and control groups.

Conclusions: Our study suggests a possible association between anti-Yo antibodies and ADHD

Syndrome. Further studies are necessary to be completed with a more representative group

of subjects.



57

Temperament, Awareness and Acceptance and: new perspectives in Parent Training for ADHD

Andriola E.a, Di Trani M.cDonfrancesco R.b

aScuola Humanitas - Consorzio Interuniversitario Fortune

c Department of Dynamic and Clinical Psychology, University “Sapienza”, Rome, Italy

bSandro Pertini Hospital - Asl RM B Rome, Italy

Aims:ADHD is a chronic and pervasive disorder with onset in childhood and its features of

inattention and impulsivity tend to compromise the parent-child relationship and increase parental

stress. Over time, parents may develop maladaptive and counterproductive ways of managing

these problems. Therefore, evidence-based treatments for ADHD include direct work with parents

in order to change the inappropriate behavior and increase positive interactions with the child. . The

purpose of this preliminary analysis is to evaluate the feasibility and efficacy of a new technique of

parent training based on the analysis of temperament in parents and child. This new therapy want

to pay attention not only to behavior, rules and reinforcements, but on emotions and thoughts

related to relationship.

Method:Parents of 15 childrendiagnosed withADHDparticipated in the study. The mean ageof

childrenwas9.18 years[SD = 2.09] and themale to female ratiowas13:2. Parents wererecruitedas

volunteers, havesigned aninformed consentandwere informed about procedure and method in a

preliminary session.Wereexcluded from the searchchildren underdrug treatment, children

withmental retardation, families withoneparent andreconstituted families.Parentscompletedthe

followingquestionnaires: Temperamentand CharacterInventory-Revised (TCI-R) for theassessment

of histemperament;JuniorTemperamentand CharacterInventory (JTCI) for the assessmentofinfant

temperament; SDAG scale for evaluation of Inattentive and Hyperactivity symptoms. Parents

haveparticipated in tenmeetingsweekly in individual setting, and were carried outtwofollow-

upsessionsat 1 and 3months after the endof the training.The tools usedduring the trainingwere:

clinical interview, analysis of temperament, parent-child interactionvideo, metaphors, images,

experientialexercises andhomeworks. We comparedscores on theSDAGcompletedby parentsbefore

andafter treatment(3-month follow-up) usinganalysisof variance forrepeated measures. The SDAG

scores (total, inattention scale and hyperactivity scale) were estimated separately.

Results:We found significant differencesin the parent’s evaluation of ADHD symptomsbefore

andafter treatment. The SDAG scores decrease in thetotal scale[pre-test Mean =41.80(SD =5.12),

post-testMean =27.73(SD =7.44)] in theinattentionscale[pre-test Mean =21.73(SD =2.91)post-

testMean =07/14(SD =3.86)] and in thehyperactivityscale[pre-test Mean =20.73(SD =5.12), post-

testMean =13.67(SD =7.44)].



58

Conclusion:Thesepreliminary resultsencouragefurther researchon thisnew techniqueof

ParentTraining, to deepen theireffectiveness in treatingADHD.



59

Temperament Feauteres as vulnerability factor of Attention Deficit Hyperactivity Disorder (ADHD)

Andriola E.a, Di Trani M.c, Porfirio M.C.¹, Donfrancesco R.b

aScuola Humanitas- Consorzio Interuniversitario Fortune

c Department of Dynamic and Clinical Psychology, University “Sapienza”, Rome, Italy

¹ Tor Vergata University, Rome

bSandro Pertini Hospital - Asl RM B Rome, Italy

Aims:The Junior Temperament and Character Inventory (JTCI) has been developed for the

assessment of the personality in individuals aged 6-14 years according to the psychobiological

model of Cloninger. Moreover, in many international studies on temperament and psychopathology,

there are consistent data showing a strong correlation between JTCI personality dimensions and

psychopathology in children and adolescents. So, temperament and character dimensions could

predict emotional and behavioral problems, including Attention Deficit Hyperactivity Disorder

(ADHD), during development across the lifespan. The aim of the present study was confirm the

interactions between temperament features and ADHD, as reported in previous research.

Method:Temperament was assessed in a total of 95 children previously diagnosed as ADHD

children (87 boys, 8 girls, mean age= 10.20 years, SD=2.30) and in 203 children without ADHD

(187 boys, 16 girls, mean age= 10.07 years, SD=1.94), using the Junior Temperament and

Character Inventory (JTCI). The diagnosis of ADHD was conducted in according with the SINPIA

guidelines. In order to compare the two groups on temperament and character features, statistical

analyses were performed, including Analysis of Variance ANOVA.

Results:Regarding temperament domain, ADHD children showed higher scores on Novelty

Seeking (ADHD children m=11.60, SD=3.42; control group m=7.23, SD=3.58; F=99.27, p=.00) and

lower scores on Reward Dependence (ADHD children m=5.38, SD=2.15; control group m=5.89,

SD=1.70; F=4.85, p=.03) and Persistence (ADHD children m=1.44, SD=1.28; control group children

m=2.90, SD=1.62, F=59.94, p=.00), than children with no ADHD diagnosis. Moreover, regarding

character domain, ADHD children showed lower Self-directness (ADHD children m=8.43, SD=3.46;

control group m=13.92, SD=4.01; F=131.90, p=.00), than children with no ADHD diagnosis.

Conclusion:our findings replicate data from previous studies that observed the temperament trait

Novelty Seeking as associated with child attention problems.



60

Cognitive profile and scholastic learning difficulties in a sample of children with Attention Deficit and Hyperactivity Disorder: clinical and treatment

relapses

Tacchi Annalisa *,Grazi Amanda *,Pfanner Chiara *, Millepiedi Stefania **, Manfredi Azzurra *,Ricci Federica

*, Di Emidio Fabiola *, Lenzi Francesca *, Masi Gabriele *

*IRCCS "Stella Maris", Calambrone (Pisa) ** USL 11 Empoli [email protected]. i t

Aims: ADHD is a highly comorbid condition, and each comorbidity that can modulate severity, prognosis and response to treatments (Bauermeister et al. 2007). A frequent association between ADHD and Specific Learning Disorders (LD) is currently reported, with variable values, ranging from 25 to 50% (Mayes et al 2000;Willcutt et al.2010). The aim of the study is to define the specific characteristics of neuropsychological and cognitive functioning of children ADHD clinical sample and test for the presence of a specific pattern of scholastic learning difficulties (in reading, writing, calculating). Patients and methods: Children diagnosed with ADHD, combined subtype, according to DSM-IV criteria, referred to the IRCCS Stella Maris, received a comprehensive evaluation, including global intellectual functioning, neuropsychological assessment (focused on attention and memory) and educational learning (reading, writing, calculating). Results: Some common features in the profile of cognitive functioning of these children emerge from the analysis of the sample, with some specific falls in the sub-tests of WISC-III battery. In addition, ADHD children frequently have difficulty in some specific areas of scholastic abilities, like written expression and mathematics. Conclusions: Overall, these data are in line with those found in the literature documenting that children with combined ADHD shows a pattern typical of the cognitive profile according to the WISC-III (Mayes et al 2006), and specifical difficulties in the learning abilities (Semrud-Clikeman et al 2011; Marzocchi et al.2007). Bauermeister J.J., Shrout E.,Ramirez R. (2007) “ADHD Correlates, Comorbidity, and

Impairment in Community and Treated Samples of Children and Adolescents” Journal

of Abnormal Child Psychology 35:883-98

Germano E., Gagliano A., Curatolo P. (2012) “Comorbidity of ADHD and Dyslexia”

Developmental Neuropsychology 35:5;475-93

Marzocchi G.M., Re A.M., Cornoldi C. (2007) “Disturbo di attenzione e di iperatt ività”

in “Difficoltà e disturbi dell’apprendimento” I l Mulino, Bologna

Mayes S.D. Calhoun S.L: (2006) “WISC-IV and WISC-III pofi les in children with

ADHD” J Atten Disord 2006 Feb;9(3):486-93

Semrud-Clikeman M., Bledsoe J (2011) “Updates on Attention Deficit Hyperactivity Disorder and



61

Learning Disorder” Curr Psychiatry Rep 13:364-73Willcutt E.G., Batjemann R.S., McGrath L.M.

(2010) “Etyology and Neuropsychology of Comorbidity between RD and ADHD: the case for

Multiple-Deficit Models” Cortex 96(10) 1345-61



62

Preliminary data from a consecutive sample of ADHD children and adolescents enrolled in Tuscany for pharmacological treatment.

Pfanner Chiara, Manfredi Azzurra, Lenzi Francesca, Di Emidio Fabiola, Tacchi Annalisa, Ricci Federica,

Berloffa Stefano, Millepiedi Stefania, Grazi Amanda, Masi Gabriele

IRCCS Stella Maris Scientific Institute for Child Neurology and Psychiatry, Pisa (Italy)

Aims: This work aimed to describe the demographic (age and gender) and the clinical

characteristics (presentation, comorbidities, pharmacological and non-pharmacological treatments)

of a consecutive sample of ADHD patients referred to the IRCCS Stella Maris- University of Pisa for

pharmacological treatment. These data were compared with data from ADHD patients included In

the Italian register for ADHD.

Patients and methods:132 patients, aged between 6 and 18 years, referred to the “IRCSS Stella

Maris” of Pisa, were included. This is a subsample of patients born in Tuscany; Patients born

outside Tuscany were not included in the analysis. The diagnostic procedure included:

Clinical interview: K-SADS,

Rating scales: CONNER’s, ADHD-RS, CBCL, CGI-S, CGI-I

Cognitive assessment: WISC-III; CPM; LEITER-R

Learning tests: Reading and Requirements; Text comprehension; Writing; Mathematics; Attention/ Executive functions:TCM, Attenzione e concentrazione» (S. di Nuovo ed. Erickson), BIA, TOL

The sample received a pharmacological treatment and was followed- up for at least six months. Patients from Tuscany were compared with patients from the Italian register of ADHD according to demographic, clinical and treatment characteristics.

Results: The analysis show that the Tuscan sample is demographically comparable to the whole

Italian sample. Significant differences have been found in the clinical and comorbidity patterns (less

rates of violence and antisocial behaviors), in the rate of non pharmacological treatment (less

frequency of parent training) and in the methylphenidate/atomoxetine ratio (higher predominance of

methylphenidate over atomoxetine).

Conclusions:These results show that our children are prevalently treated with methylphenidate,

they receive more frequently counseling and child training,m and are less severely impaired

compared to the National sample.



63

Efficacy and safety of methylphenidate and atomoxetine in ADHD: preliminary data from a sample sample enrolled during 2011 in IRCCS Stella Maris

Pfanner Chiara, Manfredi Azzurra, Lenzi Francesca, Di Emidio Fabiola, Tacchi Annalisa, Ricci Federica,

Berloffa Stefano, Millepiedi Stefania, Grazi Amanda, Masi Gabriele

IRCCS Stella Maris Scientific Institute for Child Neurology and Psychiatry, Pisa (Italy)

Aims: Methylphenidate (MPH) and atomoxetine (ATX) are the two first-choice drugs approved by the Italian Drug Committee for the treatment of ADHD. Their prescription is available and strictly controlled in some referred centers only. The aim of this study is to explore efficacy and safety of a six-month MPH and ATX treatment in our ADHD sample of patients born in Tuscany and included in the Regional register for pharmacological treatment for ADHD (patients born outside Tuscany were not included).

Patients and methods: During 2011, 132 patients, aged 6-18, fulfilling a diagnosis of ADHD according to DSM-IV-TR (APA, 2000) and a specific diagnostic procedure were consecutively enrolled at the IRCCS Stella Maris, University of Pisa, and evaluated in a six-month follow-up.

Results and conclusions: 108 patients (81.8%) were treated with MPH and 24 patients (18.2%) with ATX. Both subgroups showed a significant clinical improvement confirmed by Clinical Global Impression (CGI-I, CGI-S), C-GAS and ADHD-RS total scores after six-month treatment.

No relevant adverse events were observed in both samples. Relatively frequent, but mild, side effects for MPH were sleep disturbances, decreased appetite and headache, while for ATX the most frequently disturbances were nausea and sedation.



64

Epidemiology of severe ADHD in an Italian sample of school aged children

1Miano Silvia, ³ Leone Daniela 2Donfrancesco Renato

1Department of Pediatrics, Sleep Disorder Centre, University of Rome La Sapienza-S. Andrea Hospital,

Rome, Italy .2 Sandro Pertini Hospital – ASL RM/B Roma ³ Policlinicio Gemelli - Rome

Introduction: The aim of our study is value the prevalence of severe ADHD on a significant sample of Italian children and the number of patient that might need drug. Materials and Methods: The sample consisted of 1893 children recruited from 17 schools in Tuscany and Lazio in 2002-2003. According to the Italian census of 1991 (Istituto Nazionale di Statistica. Popolazione e Abitazioni: fascicolo nazionale Italia. Roma: 1991)1222 (64.55%) subjects were recruited from municipalities with less than 50,000 people, 375 (19.81%) from municipalities between 50,000 and 250,000 people, and 296 (15.64%) from municipalities with over 250,000 people.. b)The children attended school from 2nd to 8th grades. The number was balanced grade by grade based on the data of the Ministry of Public Education. These data showed an equal distribution of children attending schools from 2nd to 8th grades. c) In addition, the schools were chosen according to the percentages of Italian school classified per number of children: (data of the Ministry of Public Educatìon). The sample included little and rural schools with a total of 27 pupils and schools with over 400 pupiis.45.01% of Italian pupils attended schools with, less than 250 pupils and 54.99% of children attended schools with more than 250 pupils. In our study the percentage of children recruited from schools with less than 250 pupils was 44.59% (844 subjects) and 55.41% (1049 subjects) from school with 250 or more pupils. Procedure and measures: First step: ADHD Rating Scale was filled out by school teachers and parents of all the participants. Children with six H or I symptoms as "present “very often", formed the risk group. The use of the “very often" frequency of symptoms rather than “often” was chosen to identify only the group of children at risk of severe ADHD. In this group children with also at least, 2 symptoms “very often” at home in the ADHD-RS-P go to the second step: children were separately assessed by K-SADS-PL. IQ was measured by WISC-R and children with IQ <70 were excluded. C-GAS score lower than 60 was the cut-off because this value indicates a major impact of ADHD. Results: Error among 102 children who resulted risk-free, and Cohen's kappa coefficient of reliability were calculated. We examined 102 children (48 males, mean age 106.73 -107.02 months) selected using a random table, from the 1,821 children with SDAI score below the cut-off, for ADHD. 1 children had a diagnosis of ADHD with a C-GAS of 60. This score identify the children with a non- severe ADHD so no children with a severe simptomatology was found. Consequently, the error of our method to identify children with a serious ADHD was below 0.98%. Inter-rater reliability (2 experimenters): Cohen's kappa coefficient of the K-SADS PL 1.0 was 0.81. The agreement between the interviewers was 89.66%. Severe ADHD children were 32 (1.69%), 14 0.73 %) inattentive subtype, 7(0.37%) hyperactive subtype, 11 (0.58 %) combined subtype (K-SADS 1.0 PL –DSM IV-subtype). C-GAS confirmed the clinical impact of all these diagnosis, with a score varying between 59 and 40. 28 children were male and 4 children were female, ratio 7 :1. False positive were 2, because their symptomatology was better explained by using another diagnosis. The mean age was in months 114.96s.d. 22.07,



65

and the mean I.Q. (WISC-R) was 96.85, s.d. 15.53. From 2nd grade through 5th grade 24 (2.22 %) children were diagnosed as ADHD, 10 (0.93 %) inattentive subtype, 5(0.46 %) hyperactive subtype, 9 (0.83 %) combined subtype. From 6th grade through 8th grade 8children were diagnosed as ADHD ( 0.98%). 4 (0.49 %) inattentive subtype, 2(0.25%) hyperactive subtype, 2 (0.25%) combined subtype. Conclusion:The percentage of severe ADHD in school children in Italy is high and over 1.5% of school population need a drug therapy.

Sara CarucciGianluigi Melis

Mariangela Piredda

Università degli Studi di CagliariDipartimento di Scienze Biomediche

Sezione Neuroscienze e Farmacologia Clinica

Azienda Ospedaliero-Universitaria di CagliariClinica di NeuroPsichiatria Infantile

Via Ospedale 119 - 09124 CagliariTel. 070 609 3509/3442 Fax 070 652593

[email protected]

COMITATO SCIENTIFICO

SEGRETERIA SCIENTIFICA

Maurizio BonatiIstituto Mario Negri, Milano

Antonella CostantinoIRCCS Osp. Maggiore Policlinico Mangiagalli

e Regina Elena, Milano

Gabriele MasiIRCCS Stella Maris, Calambrone-Pisa

Pietro PaneiIstituto Superiore di Sanità, Roma

Alessandro ZuddasUniversità degli Studi di Cagliari

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