사회기술훈련의효과에우울, 불안이미치는영향 적인것으로알려져있다. 3,4 The Program for the Education and Enrichment of Relational Skills( 이하 PEERS R ) 는 14주간에걸쳐진행되는교육형태의사회성기술훈련으로, Un

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재진 학
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1 Anxiety and Mood Vol 14, No 2 / pissn / eissn ORIGINAL ARTICLE 청소년자폐스펙트럼장애에서사회기술훈련의효과에미치는우울, 불안증상의영향 서울대학교의과대학서울대학교병원정신건강의학과, 1 디딤정신건강의학과의원, 2 서울대학교의과대학분당서울대학교병원정신건강의학과, 3 서울대학교의과대학 4 홍정경 1. 노동현 2. 오미애 3. 김주현 3. 봉귀영 3. 유희정 3,4 The Effects of Anxiety and Depression on Treatment Outcome of Social Skills Training in Adolescents with Autism Spectrum Disorder Jung Kyung Hong, MD 1, Dong-Hyun Noh, MD 2, Miae Oh, MD 3, Guiyoung Bong, MS 3, Ju-Hyun Kim, MS 3 and Hee Jeong Yoo, MD, PhD 3,4 Department of Psychiatry 1, Seoul National University Hospital, Seoul, Didim Psychiatric Clinic 2, Hwaseong, Department of Psychiatry 3, Seoul National University Bundang Hospital, Seongnam, Seoul National University College of Medicine 4, Seoul, Korea ABSTRACT Objective : The purpose of this study was to investigate effects of depression and anxiety on treatment response of social skills training in adolescents with autism spectrum disorders (ASD). Methods : A total of 107 teenagers that participated in the Program for the Education and Enrichment of Relational Skills (PEERS ) between 2011 and 2015 were analyzed using linear regression. Outcome measures used were the Korean version of Social Responsiveness Scale (SRS), the Test of Adolescent Social Skills Knowledge-Revised (TASSK-R), and the Korean version of Autism Diagnostic Observation Schedule (K-ADOS). Depression and anxiety were assessed by the Korean version of Child Depression Inventory (CDI), the Korean version of State and Trait Anxiety Inventory for Children (STAIC), and the Korean version of Child Behavior Checklist (K-CBCL). Results : As a result, depressive symptoms measured by CDI (p<0.05) and anxiety symptoms measured by STAIC (p<0.05) had significant influence on score change of social interaction domain of ADOS. It remained significant even after the baseline score was adjusted as covariates (p<0.05). Conclusion : We observed that pre-treatment anxiety and depressive symptoms of teenagers had significant effects on the treatment outcome of PEERS, especially in terms of face-to-face social interaction. (Anxiety and Mood 2018;14(2):99-105) KEY WORDS : PEERS Social skills training Autism spectrum disorder Adolescent Comorbidity Depression Anxiety. 서 론 자폐스펙트럼장애 (Austim spectrum disorder, 이하 ASD) Received : September 13, 2018 / Revised : October 19, 2018 Accepted : October 19, 2018 Address for correspondence Hee Jeong Yoo, M.D., Ph.D., Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel : , Fax : hjyoo@snu.ac.kr 본연구는분당서울대학교병원일반연구자연구비지원을받아수행된연구임 ( 연구번호 ). 는사회적의사소통과상호작용의결핍, 제한적관심사와반복적인행동을특징으로하는신경발달장애이다. 1 보통 2세전후에진단이가능하며, 대화기술의문제나사회적인관계를맺고유지하는능력등의핵심증상은평생에걸쳐지속된다. 또래관계형성이활발해지고개인에게큰비중을차지하게되는청소년기에접어들면서, 자폐스펙트럼장애를가진청소년들은대화기술의부족, 또래관계형성의어려움등으로더욱힘든시기를겪게된다. 2 집단치료를기반으로하는사회성기술훈련은평균이상의인지능력을가진고기능자폐스펙트럼장애아동과청소년에서사회적관계를맺는데필요한기술을향상시키는데효과 Anxiety and Mood Volume 14, No 2 October,

2 사회기술훈련의효과에우울, 불안이미치는영향 적인것으로알려져있다. 3,4 The Program for the Education and Enrichment of Relational Skills( 이하 PEERS R ) 는 14주간에걸쳐진행되는교육형태의사회성기술훈련으로, University of California, Los Angeles( 이하 UCLA) 에서개발되어여러차례의무작위배정시험을통해효과가검증된프로그램이다. 부모와청소년이각각집단형태로동일한기술을학습하고, 기술의일반화를위해과제형태로실생활에서연습하게구성되어있다. 5 다양한지역의아동들을대상으로한무작위배정연구들에서또래관계를맺고유지하는기술에관한지식, 실제로또래와함께어울리는빈도, 또래관계의질, 사회적반응성과유능성뿐아니라사회적불안을감소시키는등사회성의다양한측면에효과가있음이밝혀졌다 PEERS R 는문화적차이에대한수정을거쳐한국어로번역되었고, 무작위배정대조군시험을통해효과를검증하였다. 11 효과검증연구는총 47명의 12~18 세자폐스펙트럼장애를가진청소년을대상으로수행하였는데, 실험군에서의사소통, 사회적상호작용, 대인관계, 놀이와여가시간, 사회적지식, 그리고우울점수가치료후유의하게호전되었다. 현재치료지침서가출간되어임상적으로사용가능한상태이다. 12 자폐스펙트럼장애는다양한정신과적, 신경학적공존질환을갖고있는것으로알려져있으며, 13 그중우울과불안은대표적인공존증상가운데하나인것으로보고되고있다. 14 자폐스펙트럼장애에서불안장애의동반율은 8~84% 로보고되고있으며, 종류는단순공포증, 범불안장애, 분리불안장애, 사회공포증, 그리고강박증등으로다양하다. 15,16 특히불안증상은자폐스펙트럼장애의핵심증상인사회적상호작용의결함과서로양방향으로영향을미치는것으로알려졌다. 17 우울증상의경우, 자폐스페트럼장애환자들은다양한형태로나타낼수있는데, 갑자기기능수준이저하되거나, 사회적회피또는부적응행동이증가할경우에는우울증의병발가능성을염두에두어야한다. 18 다른일반적인우울장애와마찬가지로우울증의가족력이있거나, 중요한상실의경험, 보호자가바뀌는것, 환경의변화등이중요한유발요인이된다. 특히사회적인관계에서경험하는거절, 소외, 반복되는관계의실패, 실직, 학대와폭력등이중요한위험요인이되는경우가많다. 한편사회성결핍이적을수록, 인지적능력이좋을수록, 사회성결핍을스스로인식할수록우울증의발병률이높은것으로나타났다. 19 우울과불안증상이자폐스펙트럼장애의경과에영향을준다는보고들이많이있다. 한연구에서는아스퍼거증후군과고기능자폐증의전반적기능과동반질환의연관성을분석했는데, 불안장애, 기분장애, 혹은행동장애를앓고있는경우에서 2년사이유의한기능저하를보였다. 20 불안증상을동반한자폐스펙트럼장애청소년에대한연구에서는 이들이부정적사고 (negative thoughts), 행동문제 (behavioral problems), 삶의방해수준 (life interference) 이더많이나타난다고보고했다. 21 우울장애가병발한경우장기적경과에부정적영향을미칠수있으며, 자살위험, 심각한수준의위축, 불순응, 공격성등에놓이게될가능성도제시되었다. 22 인지행동치료기법및치료적인교육을기반으로하는사회기술훈련의경우, 성별과연령, 인지적인능력, 공존증상, 약물치료등다양한요소들이치료의효과에영향을준다는연구들이있어왔다. 3,23 그러나공존증상이사회기술훈련의치료효과에미치는영향에대한연구는많지않다. 한연구에서 Antshel 등은주의력결핍과잉행동장애 (attention deficit hyperactivity disorder, 이하 ADHD) 와불안장애 (anxiety disorder) 두가지공존질환에대해분석하였다. 불안장애를동반한군과공존질환이없는군에서만치료전후사회성점수변화가유의하게나타났는데, 불안증을동반한경우사회기술훈련의치료효과가더크게나타났다. 저자들은이에대해구조화된치료세팅 (structured setting) 과문제해결 (problem solving) 위주의프로그램구성이불안증의특성에잘맞았기때문일것이라고설명하였다. 24 Gates 등 23 은사회기술훈련에대한무작위대조연구 (randomized controlled trial, 이하 RCT) 들을모아메타분석을시행했는데, 사회기술훈련전후자가보고 (self-report) 한사회성 (social competence) 변화에대한조절분석 (moderator analysis) 상공존증상의영향은유의하지않았다. 우울과불안이삶의질이나증상에많은영향을준다는분명한사실에도불구하고, 그런증상들이특정한치료프로그램의효과에미치는영향을체계적으로분석한연구들은별로없었다. 이연구의목적은, PEERS R 프로그램을통한사회성개선효과에대해, 개시시점에공존증상으로갖고있는기저의우울, 불안증상이미치는영향을검증하는것이다. 이연구의가설은, 우울과불안증상이모두사회기술훈련에의한사회적상호작용개선과사회성척도의변화에유의미하게부정적인영향을미칠것이라는것이다. 대상및방법 연구대상자 2011 년 11월부터 2015년 10월까지분당서울대학교병원소아청소년정신의학클리닉에서 PEERS R 프로그램에참여하여끝까지완료한청소년들이본연구의분석대상이되었다. 선정기준은 1) 12~18 세로초등학교 6학년부터고등학교 3학년에재학중일것, 2) 사회적관계에서의어려움이있다고부모또는본인이보고한경우, 3) 이전에자폐스펙트럼장애로진 100 Anxiety and Mood Volume 14, No 2 October, 2018

3 홍정경등 단되었거나, 강하게의심되는사람, 4) 언어를유창하게구사할수있으며, 표준지능검사로측정한언어성지능지수가 65 또는그이상, 5) 청소년스스로가치료에자발적으로참여하고자하는의사와동기가충분한경우, 6) 주요정신질환 ( 조현병, 양극성장애, 자살사고를동반한심한주요우울장애, 기타정신병적질환 ) 의병력이없고, 현재도갖고있지않은경우, 7) 심각한공격성, 충동성, 도전적이거나반항적인행동이없는경우, 8) 치료참여가어려울정도의시각, 청각, 또는신체장애나의학적, 신경학적질환이없는청소년이었다. 총 122명이초기분석대상에포함되었으나, 치료후설문자료에결측치가많은 15명을제외하고총 107명이분석대상에포함되었다. 헬싱키선언 (Declaration of Helsinki) 에입각하여, 모든연구대상자와부모에게연구의목적과연구참여중일어날수있는정신적, 신체적위해를충분히설명하고, 피험자또는보호자로부터서면으로취득한동의서 (written informed consent) 를받았고, 연구계획에대하여분당서울대학교병원생명윤리심의위원회의승인을받았다 (IRB No. B-1308/ ). 진단및임상자료수집모든참가자들은자폐스펙트럼장애의확진을돕는도구인한국어판자폐증진단면담 -개정판 (Autism Diagnostic Interview-Revised, 이하 ADI-R) 25,26 및한국판자폐증진단관찰스케줄 (Autism Diagnostic Observation Schedule, 이하 ADOS) 27,28 을시행하였다. 지능지수는 Korean Educational Development Institute-Wechsler Intelligence Scale for Children-Revised( 이하 KEDI-WISC), 29 Korean-Wechsler Intelligence Scale for Children-III( 이하 K-WISC-III), 30 또는 Korean Wechsler Adult Intelligence Scale-IV( 이하 K-WAIS- IV) 31 로산출하였다. 소아정신과전문의가 ADOS, ADI-R, 지능검사및임상면담의결과들을통합하여임상적으로가장최적인진단 (clinical best estimate diagnosis) 를내렸다. 의무기록을검토하여과거력과약물투여에관한정보를수집하였고, 타기관에서약물치료중인참가자는보호자로하여금그내역을가져오도록요청하였다. 사회경제적상태는한국어판아동행동평가척도 (Korean version of the Child Behavior Checklist, 이하 K- CBCL) 32 의문항을통해조사하였다. 평가도구사회적상호작용및사회성척도치료전후에다음과같은도구들을사용하여기저치및치료후의변화를측정하였다. 기저치는치료전일주일이내에, 치료후변화는치료프로그램을모두마친뒤일주일이내에완료되도록하였다. 한국어판사회반응성척도사회반응성척도 (Social Responsiveness Scale, 이하 SRS) 는 4~18 세소아청소년을대상으로부모혹은선생님이평가하는설문지로 65개항목으로이루어져있다. 정량적인특징때문에치료전후비교도구로많이사용되고있다. 33 최근 Frazier 등이제시한 two-factor model이 Diagnostic and Statistical Manual of Mental Disorders( 이하 DSM-5) 에의거한자폐스펙트럼장애의진단적특징을더욱잘반영한다는연구결과에근거하여본연구에서도사회의사소통 / 상호작용 (Social Communication/Interaction factor, 이하 SRS-SCI), 제한적반복적행동 (Restricted/Repetitive Behavior factor, 이하 SRS- RRB) 두개요인으로나누어분석을시행하고자한다. 34,35 Test of Adolescent Social Skills Knowledge-Revised Test of Adolescent Social Skills Knowledge-Revised( 이하 TASSK-R) 은 PEERS R 프로그램 13개세션에서각각의핵심요소 2개씩을추려내서만든 26개항목의시험지이다. 이는프로그램개발자들이프로그램을통한사회적기술지식습득정도를평가하기위해만든평가도구이다. 5 한국판자폐증관찰스케줄자폐증관찰스케줄 (Autism Diagnostic Observation Schedule, ADOS) 은자폐증이의심되는개인을대상으로언어와의사소통 (language and communication), 주고받는사회적상호작용 (reciprocal social interaction), 놀이와상상력 (imagination), 상동적행동과제한된관심 (stereotyped behaviors and restricted interests) 등을훈련된검사자가직접대면하여평가하는반구조화된평가방법으로 ADI-R 과더불어자폐증의표준화진단적도구이다. 언어능력과발달단계에따라 4 가지모듈 (module) 중에서선택할수있으며, 본연구에서는 module3과 module4가사용되었다. 27,28 우울과불안증상한국형소아우울척도소아우울척도 (Child Depression Inventory, 이하 CDI) 는 27개항목으로이루어진자가보고형검사로 7~17 세소아와청소년에서사용할수있다. 한국판소아우울척도는좋은신뢰도와타당도를보이고있으며, 36 한국청소년대상 cutoff score 는 20점으로보고되었다. 37 Anxiety and Mood Volume 14, No 2 October,

4 사회기술훈련의효과에우울, 불안이미치는영향 한국형소아의상태특성불안척도소아의상태특성불안척도 (State and Trait Anxiety Inventory for Children, 이하 STAIC) 는각각 20개의문항으로상태와특성을각기측정하는자가보고설문지이다. 불안상태 (A-state) 는최근상태를반영하며, 불안특성 (A-trait) 은비교적장기간동안지속적유지되는개인의특성을반영한다. 38,39 한국어판아동청소년행동평가척도아동청소년행동평가척도 (Child Behavior Checklist, 이하 CBCL) 는부모- 보고설문지로아동청소년의행동과기분을여러영역으로나누어평가한다. 32,40 본연구에서는이중불안 / 우울, 위축 / 우울, 내현화문제 3가지점수를분석에이용하였다. 통계분석본연구대상에서 PEERS R 프로그램이유의한치료효과를나타내는지를먼저검정하기위해치료전과치료후점수를대응표본 t-검정 (paired t-test) 을통해비교하였다. 치료효과를나타내는지표로각평가도구의치료전과치료후의점수차 (difference score, 이하 DS) 를산출하였다. DS가양수일때증상의호전을의미하는데, TASSK-R 에서만은 DS 가음수일때호전을의미한다. 각평가도구의점수차에대해기저우울과불안점수가미치는영향을보기위해각각단순선형회귀분석 (linear regression) 을시행하였다. 통계분석은 IBM SPSS Statistics, version 23.0(2009 ; SPSS Inc., Chicago, IL, USA) 을사용하였다. 유의수준은모두 p<0.05 로설정하였다. 결과 표본특성연구참가자의인구사회학적및임상적특성을 Table 1에 표기하였다. 평균연령은 14.26±1.71 세였고, 평균언어성지능 지수는 99.11±15.79 였다. 약물복용중인자는 54.3% 였고, 가 장많이복용중인약물 ( 전체참여자의 35.2%) 은 ADHD 증상 을치료하기위한것으로추정되는중추신경자극제 (stimulant) Table 1. Demographic data (N=107) Variables Mean±SD or % Age (years) 14.26±1.71 Male (%) 94.4 SES 3.00±0.68 Parental age Father (years) 47.24±3.65 Mother (years) 45.20±4.39 Parental education Father (years) 15.62±2.28 Mother (years) 15.03±2.12 Intelligence Verbal IQ 99.11±15.79 Performance IQ 98.03±18.54 Full-scale IQ 97.93±16.00 CDI 18.16±9.42 STAIC-T 35.47±8.39 STAIC-S 36.57±8.44 K-CBCL-Anxiety/Depression 65.37±8.51 K-CBCL-Withdrawal/Depression 66.51±10.62 K-CBCL-Internalizing 66.71±10.45 Medication None (%) 45.7 Antidepressant (%) 18.1 Mood stabilizer (%) 6.7 Stimulant (%) 35.2 SES : Socioeconomic status, IQ : Intelligence quotient, CDI : Child Depression Inventory, STAIC-T/STAIC-S : State and Trait Anxiety Inventory for Children, K-CBCL : Korea-Child Behavior Checklist Table 2. Mean pre-treatment and post-treatment comparisons of outcome variables (standard deviation in parentheses) Variables Pre-treatment Post-treatment Pre-post t p SRS-SCI* (21.99) (22.03) 6.09 (18.81) SRS-RRB* (6.18) (6.34) 1.32 (5.53) TASSK-R* (3.19) (4.14) (4.41) <0.001 ADOS-communication 4.20 (1.30) 4.03 (1.25) 0.16 (0.84) ADOS-social interaction 8.43 (2.25) 8.25 (2.43) 0.18 (1.09) ADOS-behaviors and interests 0.95 (0.64) 0.77 (0.53) 0.18 (0.56) ADOS-imagination 0.72 (0.73) 0.66 (0.68) 0.07 (0.66) CDI (9.42) (9.42) 1.06 (7.12) STAIC-S (8.48) (7.82) 1.60 (7.11) Paired sample t-test. * : n s 103, : n s 61. SRS-SCI : Social Communication/Interaction factor of Social Responsiveness Scale, SRS- RRB : Restricted/Repetitive Behavior factor of Social Responsiveness Scale, TASSK-R : Test of Adolescent Social Skills Knowledge- Revise, ADOS : Autism Diagnostic Observation Schedule, CDI : Child Depression Inventory, STAIC-S : State and Trait Anxiety Inventory for Children-State 102 Anxiety and Mood Volume 14, No 2 October, 2018

5 홍정경등 였다. 항우울제 (antidepressant) 는 18.1% 에서복용중이었다. 치료전과치료후비교 PEERS R 프로그램의효과를검증하기위해대응표본 t-검정을통해치료전후점수를비교하였다. SRS-SCI, SRS-RRB, TASSK-R 에서모두치료후유의한차이를보였다 (SRS-SCI : t=3.28, p=0.001 ; SRS-RRB : t=2.43, p=0.017 ; TASSK-R : t=-14.31, p<0.001). ADOS 점수중에는상동적행동과제한된관심 (Stereotyped behaviors and restricted interests) 척도에서치료전과후유의한차이를보였다 (t=2.50, p=0.015). 자가보고우울점수인 CDI는치료전후차이가유의하지않았지만 (t=1.52, p=0.132), 불안점수인 STAIC-S 는치료후유의하게감소했다 (t=2.29, p=0.024) (Table 2). 우울, 불안점수가치료효과에미치는영향사회성점수 (SRS-SCI, SRS-RRB, TASSK-R, ADOS의 4 가지척도 ) 에대해우울, 불안점수 (CDI, STAIC-T, STAIC-S, K-CBCL 중불안 / 우울, 위축 / 우울, 내현화문제 ) 가영향을미치는지알아보기위해각각선형회귀분석을시행하였다 (Model 1). ADOS 4가지척도중주고받는사회적상호작용 (reciprocal social interaction) 척도에서만 CDI, STAIC-S, STAIC-T 이유의미한결과를보였다 (CDI : B=-0.027, p=0.040 ; STAIC-T : B=-0.043, p=0.008 ; STAIC-S : B=-0.044, p=0.004). SRS-SCI, SRS-RRB, TASSK-R 에서는모든우울, 불안점수가유의한영향을나타내지않았다. 이중유의한결과는 Table 3에정리하였다. 각평가도구의점수차 (DS) 는사회적상호작용 ADOS 하위척도를제외하고는모두자신의기저치점수와유의한상관관계를보였다. 이에각자기저치점수를보정한선형회귀분석도시행하였다 (Model 2). 기저치점수를보정한후, SRS-RRB 에서 K-CBCL 의불안 / 우울척도와내현화문제가유의한영향을보이는것으로나타났다 (K-CBCL 불안 / 우울 : B=-0.123, p=0.049 ; K-CBCL 내현화문제 : B=-0.123, p=0.016). 사회 적상호작용 ADOS 하위척도에대한 CDI, STAIC-T, STAIC- S의영향은기저치점수를보정한이후에도유의한수준으로유지되었다 (CD I : p=0.040 ; STAIC-T : p=0.009 ; STAIC-S : p=0.004) (Table 3). 고찰 이연구는청소년자페스펙트럼장애에서사회기술훈련치료효과에우울, 불안증상이미치는영향을알아보고자하였다. 그결과, 치료후에 ADOS를통해청소년을직접면담하여측정한사회적상호작용의변화정도에우울, 불안증상이유의미한영향을주는것으로나타났다. 또한치료전점수를보정한결과에서는 ADOS의유의한결과가유지되었을뿐아니라, SRS중제한적상동적행동의변화정도에도우울, 불안증상이유의미한영향을주는것으로나타났다. 이는본연구의가설과일치하는결과로, 자폐스펙트럼장애에서공존증상으로써의불안, 우울증상이치료를통한핵심증상의개선효과를감소시킬수있음을시사하는것이다. PEERS R 프로그램은사회성기술의일반화를촉진하기위해매주과제를부여함으로써청소년이프로그램내에서배운사회적기술을실제교우관계에적용하도록하는것을특징으로하며, 이과정에서부모의코칭을필요로한다. 불안, 우울증상이공존하는경우, 청소년이사회적인접촉을덜하고, 사회적인불안으로인해새로운또래, 즉잠재적인친구들에대한사회적인접근에어려움이많을뿐아니라, 대인관계에서거절에대해더민감할수있어서, 과제를수행하는데어려움이많았을수있겠다 ,41 연습효과의부족으로인해기술의일반화가일어나기어려운결과가본연구에서처럼실제상황에서의대화, 사회적기술, 비언어적행동의개선효과가저하되는결과로나타났을수있을것으로추론할수있다. 이는 ASD를가진사람들을위한사회성기술훈련에서공존하는우울, 불안증상을먼저치료하는것이치료효과를극대화할수있을가능성을시사하는결과라고생각한다. Table 3. Effects of depression and anxiety symptoms on outcome variables Outcome variables in DS Independent variables Model 1 Model 2 B SE r 2 p B SE r 2 r 2 p SRS-RRB K-CBCL-Anxiety/Depression K-CBCL-Internalizing ADOS-social interaction CDI STAIC-T STAIC-S Linear regression. DS : difference score, SRS-RRB : Restricted/Repetitive Behavior factor of Social Responsiveness Scale, ADOS : Autism Diagnostic Observation Schedule, K-CBCL : Korea-Child Behavior Checklist, CDI : Child Depression Inventory, STAIC-T/STA- IC-S : State and Trait Anxiety Inventory for Children-Trait/State. Model 1 : No covariates are controlled, Model 2 : Controlled pretreatment SRS-RBB or ADOS social score as covariates Anxiety and Mood Volume 14, No 2 October,

6 사회기술훈련의효과에우울, 불안이미치는영향 위와같은결과는이전선행연구들중불안, 우울과같은공존증상이치료효과에부정적인영향을주지않는다고보고했던 Antshel이나 Gates와는다른결과를나타내는새로운결과이다. 23,24 본연구에서는, 대부분부모보고식검사를통해사회성을측정한기존연구들과달리, 직접대면평가한 ADOS 점수를통해치료효과를평가함으로서객관성을더하였고, ADOS점수의변화에는우울, 불안증상이영향을미치는결과를보였다. 또한이전의연구에서주의력결핍과잉행동장애나적대적반항장애 / 품행장애등의치료에서는공존질환이별로영향을주지않는다는보고들과도다소다른결과이다. 42 이는자폐스펙트럼장애가다른소아의정신질환들에비해더어린시절부터전반적인발달의영역에서광범위한이상을보이고, 스트레스에더취약하며, 특유의인지적융통성부족을동반하기때문에공존증상에대해서도더큰영향을받고, 인지적인교육과훈련을기반으로하는치료로충분한보상이일어나지않기때문일것으로추측한다. 43,44 한편본연구에서기저의우울, 불안증상은 TASSK-R 로측정한사회적지식의습득정도와, SRS로측정한사회적반응성에는별다른영향을주지못하는것으로나타났다. 인지, 행동적인교육과정에바탕을둔치료프로그램에서지식의습득은주로언어성지능의영향을받는것으로나타났는데, 본연구에서도그런경향은다르지않았던것으로생각된다. 사회적반응성은생물학적으로결정되며, 가족내에서유전적인형질 (trait) 로받아들여지는특성이므로, 역시그변화정도에있어서도 ASD의고유증상이외의특성에의해서는크게영향을받지않은것으로보인다. 한편우울, 불안의영향이측정도구마다, 그리고결과측정변수마다다소비일관적으로나타난점에대해서는도구를평정하는주체의차이에서오는요인도생각해볼수있겠다. 즉, 청소년의특성상부모가평정한 CBCL이나 SRS는청소년이주관적으로느끼는내현화증상이나실제사회적상황에서의수행정도등을제대로측정해내지못했을가능성이있다. PEERS R 프로그램은청소년이학교와지역사회에서친구를사귀고유지하는사회성기술에초점을맞추고있다. 따라서사회성문제가가장중요한관심사가아닌청소년들, 즉주요우울장애등먼저치료해야할중요한동반질환이있는청소년들을선별과정에서이미배제하였다. 또한심한불안증상으로인해스스로동기를가지고치료를시작하기어려운청소년도배제되었다. 그결과연구대상자의임상적특성에서볼수있는바와같이자가보고척도로보고한불안, 우울증상의정도는척도의진단절단점근방에위치하며, 임상적으로유의미한진단을받을정도가아닌경우가대부분이었다. 따라서, 임상적으로의미있는수준의우울, 불안증상을가 진청소년의경우의매개효과에대해서는추후더많은연구 를통한조명이필요하다. 본연구의몇가지제한점은다음과같다. 치료전후불안 점수 (STAIC-S) 가유의미하게개선되었는데, 이는 PEERS R 프로그램이사회성뿐만아니라불안증상도호전시킨다고보 고된선행연구들과일치하는결과이다. 10,11 하지만본연구에서 는우울과불안증상이치료전과후에만측정되었기때문에, 치료를거치는중간과정에서이증상들의변화되는정도를지 속적으로추적하여영향력을분석하기는어려웠다. 둘째, 치료 기간동안에약물치료를통제하기어려웠으므로, 전반적인변 화에미치는약물의매개효과를완전히배제할수없었다. 셋 째, 참여자선정기준에서주요정신질환은배제했지만, 그외 사회불안장애, 주의력결핍과잉행동장애등공존질환에대한 분석이충분치않았다. 넷째, 부모와함께참여하는훈련프 로그램으로부모의우울, 불안, 효능감등이간접적인영향을 미칠것으로추정하나, 이에대한체계적인분석을하지못했 다는점이다. 마지막으로본연구참여자의대다수 (94.4%) 가 남성으로, 이는자폐스펙트럼장애유병률이성별에따른차 이 ( 남성 : 여성 =4:1) 가있는점을감안하더라도높은비율로생 각되어해석및적용시유의가필요하다. 결 론 본연구에서는자폐스펙트럼장애를가진청소년에서사회기 술훈련의치료효과에대한우울, 불안증상의영향을살펴보 았다. 자가보고, 부모보고, 훈련된전문가의객관적평가등각 기다른주체를통한여러가지평가도구를사용하였는데, 이 중 ADOS 를통해청소년을직접면담하고측정한사회적상호 작용의변화정도에우울, 불안점수가유의미한영향을주 는것으로나타났다. 자폐스펙트럼장애를가진사람들이사회 기술훈련을참여할때, 공존하는우울, 불안증상에대해평가 및치료를하는것이임상적으로도움이될것으로기대된다. 중심단어 : 청소년 자폐스펙트럼장애 사회기술훈련 동반 증상 우울 불안. REFERENCES 1. Association Psychiatric Association. Diagnostic and statistical manual of mental disorders: fifth edition (DSM-5). Washington, DC: American Psychiatric Association; Schall CM, McDonough JT. Autism spectrum disorders in adolescence and early adulthood: Characteristics and issues. J Vocat Rehabil 2010;32: McMahon CM, Lerner MD, Britton N. Group-based social skills interventions for adolescents with higher-functioning autism spectrum disorder: a review and looking to the future. Adolesc Health Med 104 Anxiety and Mood Volume 14, No 2 October, 2018

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ORIGINAL ARTICLE J Korean Acad Child Adolesc Psychiatry 2014;25(4): 고기능자폐스펙트럼장애에서제한된관심과 반복적인행동유무

ORIGINAL ARTICLE J Korean Acad Child Adolesc Psychiatry 2014;25(4):187-195 http://dx.doi.org/10.5765/jkacap.2014.25.4.187 고기능자폐스펙트럼장애에서제한된관심과 반복적인행동유무에따른임상양상의차이 서울대학교 의과대학 서울대학교병원 정신건강의학과 소아청소년분과 인하대학교