4 ADHD Workshop. Dalle evidenze alla pratica clinica CAGLIARI 8/10 MARZO 2012

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1 Università degli Studi di Cagliari Dipartimento di Scienze Biomediche Sezione Neuroscienze e Farmacologia Clinica Azienda Ospedaliero-Universitaria di Cagliari Clinica di NeuroPsichiatria Infantile 4 ADHD Workshop Dalle evidenze alla pratica clinica CAGLIARI 8/10 MARZO 2012 SALA CONGRESSI CENTRO COMUNALE D'ARTE E CULTURA IL GHETTO VIA SANTA CROCE, 18 CAGLIARI

2 ABSTRACT

3 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 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 Sharing project of diagnostic and therapeutic pathways for ADHD in Lombardy Tiberti Alessandra, Effedri Paola, Filippini Elena; Daffi Gianluca Assessment of BMI in an Italian ADHD community care Germinario Elena, Chiarotti Flavia, Arcieri Romano, Panei Pietro 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 ADHD and Epilepsy in children with Tourette Syndrome: a triple comorbidity? Rizzo Renata, Gulisano Mariangela, Calì Paola Valeria, Curatolo Paolo BMI andpsychopathological disorders in comorbiditieswith ADHD:correlation studyin a populationof patients of campania region Sarnataro E., Bernardo P., Granata R., Grimaldi A., Maresca R., Pascotto A., Russo L., Tiano C., Bravaccio C 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 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 Multimodal intervention in ADHD: the experience of Scientific Institute E.Medea of Ostuni-Brindisi in the Apulia Region (Italy) Fanizza Isabella, Massagli Angelo... 1

4 11. Research protocol in the diagnostic investigation on ADHD Ragazzo F., Benso F., Fiorella R., Stella S., Morando M., Castellani S., Gazzellini S Clinical suggestions about parent training comparing two groups of children with ADHD, ODD and LD Galimberti G., Actis Perinetti B., Aggio F., Saccani M ADHD and AUTISM: a study in the ASL of Novara Guccione Fulvio, Antonini Alessia, Vallana Marianna, Duella Sara, Tettamanti Elena Cognitive impairment in ADHD with language disorder in preschoolers:confront with ADHD without language disorder and SLI Melegari Maria Grazia 1, Manzi B., Costa A., Canzano L., Uberti Paola ADHD subtypes and comorbidity in Italy Valenti Vera, Di Trani Michela, Galantini Chiara, Merati Silvia, Donfrancesco Renato Major Depression and Dysthymia in children with ADHD Leo G., Leone D., Di Trani M, Martines F., Sferrazza A,Torrioli MG, Donfrancesco R An ADHD complex case report Pagana Lucia; Bassi Bianca; Mariani Alessandro; Magnano Lara Systemic multimodal approach to ADHD children and their families 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) Adamo N., Adelsberg S., Petkova E., Castellanos F. X.and Di Martino A ADHD and Autism Spectrum Disorder symptoms overlapping: social functioning impairment Anchisi L., Carucci S 1, Ambu G., Lecca L., Zuddas A 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... 2

5 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 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 ADHD, intellectual disability and other comorbidities: analysis of findings at the CGHarray 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 Neuropsychological and neurobiological model of aggression in children with externalizing disorders Mazzone Luigi, De Peppo Lavinia, Vicari Stefano, Williams Riccardo, Postorino Valentina, Milone Annarita, Lenzi Francesca, Pisano Simone, Manfredi Azzurra, Muratori Pietro, Masi Gabriele Executive functions in Attention-Deficit/Hyperactivity Disorder Menghini Deny, Varvara Pamela, Napolitano Carmen, Calcagni Marta, Armando Marcoand Vicari Stefano 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 Evidences of SNAP25 single nucleotide polymorphisms associated with hyperactivity and ASD disorders: future prospects related to ADHD Cosi A., Aggio F.A., Nossa M., Paccione F., Magnaghi E, Tuci A., Galimberti G., Saccani M., Lenti C. and Guerini F.R 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., Hernandez Otero I., Doddamani L., Haertling F., Dutray B., Ramnath G 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, Benso Francesco, Bauleo Graziella, Bisozzi Eleonora, Napolitano Antonio, Clavarezza Valentina, Lispi Maria Luisaand Castelli Enrico

6 9. Iron and ADHD: time to move beyond serum ferritin levels 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 Major Depression and Dysthymia in children with ADHD Leo G, Leone D., Di Trani M, Martines F, Sferrazza A, Torrioli MG, Donfrancesco R 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 Comorbidity and psychosocial impairment in Deficient Emotional Self-Regulation (DESR) and Attention/deficit hyperactivity disorder Innocenzi Margherita, Marano Assunta, Donfrancesco Renato Attention-deficit/hyperactivity disorder and alexithymia: a pilot study Di Trani Michela, Donfrancesco Renato, Gregori Paola, Auguanno Giovanna, Melegari Maria Grazia, Zaninotto Sabrina, Luby Joan A possible role of anti-purkinje cell Abs as a biological marker in Attention Deficit/Hyperactivity Disorder: a pilot study 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 Andriola E., Di Trani M. Donfrancesco R b Temperament Feauteres as vulnerability factor ofattention Deficit Hyperactivity Disorder (ADHD) Andriola E., Di Trani M., Porfirio M.C., Donfrancesco R b 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 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... 4

7 19. 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 Epidemiology of severe ADHD in an Italian sample of school aged children Miano Silvia, Leone Daniela Donfrancesco Renato... 5

8 6 4 ADHD Workshop

9 Self-esteem evaluation in children and adolescents suffering from ADHD Reale Laura 1, Guarnera Manuela 1, Mannino Valeria 1, Armando Marco 2, Fatta Laura 2, Postorino Valentina 2, De Peppo Lavinia 2, Vicari Stefano 2, Mazzone Luigi 1,2 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). 7

10 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 8

11 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. 9

12 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 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. 10

13 Assessment of BMI in an Italian ADHD community care. Germinario Elena 1, Chiarotti Flavia 2, Arcieri Romano 1, Panei Pietro 1. 1 Dept. of Therapeutic Research and Medicines Evaluation, and 2 Department 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; ) Results:At the end of January 2012, children with ADHD were recruited in the Italian ADHD National Registry. Data about (78.6%) children and adolescents were available to perform BMI (88.6%) were males and 186 (11.4%) were females. For males, BMI was equal to , for females BMI was Stratifying BMI by gender and percentile classes (<3 rd, >3-<50 th, >50-<97 th, >97 th ) 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 97 th 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. 11

14 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. 12

15 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 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. 13

16 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. 14

17 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 socialeconomic 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 15

18 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. 16

19 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 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: ) Shaffer et al: A children global assessment scale (C-GAS), Arch Gen Psychiatry,1984; 40:

20 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: ). 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 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. 18

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