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1 KISEP Original Articles Korean J Child & Adol Psychiatr 13:129~138 ADHD 최적치료 지침을 위한 예비연구 * PRELIMINARY STUDY FOR ADHD TREATMENT GUIDELINE 이영식 ** 김은영 ** 나 철 ** Young-Sik Lee, M.D., ** Eun-Young Kim, M.D., ** Chul Ra, M.D. ** 목 적 방 법 결 과 결 론 중심 단어 서 론 Department of Psychiatry, College of Medicine, Chung Ang University, Seoul Corresponding author

3 연구대상 및 방법 1. 연구대상 2. 연구방법 1) 진단 검사도구 파악 2) 약물치료 현황파악 3) 비 약물치료 현황파악 Table 1. Present practise and the necessity of the diagnostic workup for ADHDn=32 Diagnostic workup Present practice Necessity Routinely Selectively Not Routinely Selectively Not Conner s scale 45.2% % % % % %02 CBCL 45.2% % % % % %03 SCT 51.6% % % % % %02 Intelligence test 58.1% % % % % %01 Projective test 22.6% % % % % %02 ADS 30.0% % % % % %04 TOVA 16.1% % % % % %07 CPT 03.3% % % % % %08 WCST 06.5% % % % % %10 Stroop test 03.2% % % % % %12 Trail making test 06.7% % % % % %11 MRI/CT 000 % % % % % %04 SPECT 000 % % % % % %11 EEGsimple 25.8% % % % % %01 EEGspecific 03.2% % % % % %03 ERP 000 % % % % % %13 CBC,U/A,LFT 40.0% % % % % %02 ECG 41.9% % % % % %00 TFT 12.9% % % % % %01 Pb level 03.2% % % % % %05 Chromosome test 000 % % % % % %06 CBCLChild Behavior Checklist, SCTSentence Completion Test, ADSADHD Diagnostic System, TOVATest of Variables of Attention, CPTContinuous Performance Test, WCSTWisconsin Card Sorting Test, TFTThyroid Function Test

2%14 32.3%10 22.6%07 66.7%20 26.7%08 06.7%02 CBCL 45.2%14 25.8%08 29.0%09 46.7%14 43.3%13 10.0%03 SCT 51.6%16 45.2%14 03.2%01 56.7%17 36.7%11 06.7%02 Intelligence test 58.1%18 41.9%13 000 %00 80.

4 Table 2. Main trend of clinician s prescription for ADHD n=32 Drug classification Psychostimulant Antidepressant Mood stabilizer53.1% Antipsychotics71.9% Others Percentage of prescription metylphenidate100%, pemoline65.6% imipramine90.6%, fluoxetine65.6%, sertraline31.3%,moclobemide31.3%, nortriptyline25.0%, velafaxine12.5% Valproate43.8%, carbamazepine40.6%, lithium9.4% haloperidol65.6%, pimozide31.3%, risperidone21.9% Clonidine84.4% 3. 자료분석 연 구 결 과 1. 진단도구 및 의학적 검사 약물치료 실시현황 1) 전반적 약물사용 경험 - - 2) 공존질병이 없는 ADHD의 경우 3) 감정장애가 동반된 ADHD의 경우 4) 틱 장애가 동반된 ADHD의 경우

3%,moclobemide31.3%, nortriptyline25.0%, velafaxine12.5% Valproate43.8%, carbamazepine40.6%, lithium9.4% haloperidol65.6%, pimozide31.

5 Table 3. Clinician s drug choice in variable situationsn=32 Without co-morbidity With emotional disorders With Tic disorder Situations 1st choice 2nd choice With aggression, conduct disorder MPH100% MPH43.8% AD34.4% MPHAD21.9% Stimulant25.0% Clonidine21.9% Antipsychotics21.9% Imipramine9.4% StimulantAntipsychotics6.3% ClonidineAntipsychotics6.3% MPH65.6% MPHAntipsychotics12.5% MPHMood stabilizer6.3% MPHAntidepressants6.3% Others9.4% Pemoline53.1% Imipramine34.4% SSRI6.3% Clonidine6.3%) Risperidone3.1% 1st2nd process MPHAD41.9% MPHMPH41.9% no choice of MPH16.1% MPH MPHAP/MS/AD/clonidine45.2% MPHNonstimulants19.4% MPHothersMPHothers 19.4% No choice of MPH in 1st, 2nd choice process9.4% Adolescent nonspecific50.0% SSRI34.4% Pemoline9.4% AD9.4% MS6.3% Clonodine6.3% Clomopramine, Clonazepam3.1% MPHMethylphenidate, APAntipsychotics, ADAntidepressant, SSRISelective Serotonine Reuptake Inhibitor MSMood Stabilizer - 5) 파탄적행동장애가 동반된 ADHD의 경우 6) 청소년 ADHD의 경우

8% AD34.4% MPHAD21.9% Stimulant25.0% Clonidine21.9% Antipsychotics21.9% Imipramine9.4% StimulantAntipsychotics6.3% ClonidineAntipsychotics6.3% MPH65.6% MPHAntipsychotics12.5% MPHMood stabilizer6.

6 Table 4. Clinician s present practise and opinion of necessity about the non-pharmacological treatment modalitiesn=32 Treatment modality Present practise Necessity Yes No Yes No Individual psychotherapy/play therapy 75.0% % % %22 Individual CBT 65.6% % % %14 Individual parents counselling 96.9% % % %03 Child group therapy 37.5% % % %22 Parents group therapy 43.8% % % %12 CBTcognitive-behavioral therapy 3. 기타 치료의 실시현황 및 실시 필요성 고 찰 - 1. 진단적 접근에 관하여

practise Necessity Yes No Yes No Individual psychotherapy/play therapy 75.0%24 25.0%08 31.3%10 68.8%22 Individual CBT 65.6%21 34.4%11 56.

7 Stage 1 Stage 2 *Non-medication *Treatment alternatives * monotherapy MPH100% partial response or nonresponse * Pemoline53.1% * Imipramine34.4% * SSRI6.3% * Clonidine6.3% * Risperidone3.1% * MPHAD41.9% * MPH43.8% *AD IMP8SSRI334.4% * MPH+AD 21.9% * MPHMPH41.9% * no MPHno MPH16.1% Stage 0 *Nonstimulants66% * Stimulants25% *StimulantsTic Medication9.4% *1, 2 stimulants 19.4% *1, 2 stimulants 38.7% *1 2 stimulants 61.3% * MPH65.6% * MPHAP12.5% * MPHMS6.3% * MPHAD6.3% * others 9.4% *MPHMPHAP/MS/AD/clonidine45.2% *MPHNonstimulants19.4% *MPHothersMPHothers 19.4% * 15.6% *1, 2 MPH 62.5% *1 MPH 25.8% *1, 2 MPH 9.4% * No difference50% * SSRI34.4% * Pemoline9.4% * AD9.4% * anticonvulsants6.3% * clonidine6.3% without cormorbid disorders with emotional disorders with Tic disorders with aggression adolescents Fig. 1. Algorithm for the medication treatments of ADHD without/with cormorbid psychiatric disorders in this study. 135

7% *1 2 stimulants 61.3% * MPH65.6% * MPHAP12.5% * MPHMS6.3% * MPHAD6.3% * others 9.4% *MPHMPHAP/MS/AD/clonidine45.2% *MPHNonstimulants19.4% *MPHothersMPHothers 19.4% * 15.6% *1, 2 MPH 62.

8 약물치료 이외의 치료에 관하여

9 References 1) 대한신경정신의학회(1998): 소아기 행동장애, 신 경정신과학. 하나의학사, pp573 2) Anderson JC, William S, McGee R, Silva PA(1987): DSM-III disordrs in preadolescent children:prevalence in a large sample from the general population. Arch Gen Psychiatry 24: ) 조수철, 신윤오(1994):파탄적 행동장애의 유병율 에 대한 연구. 소아청소년정신 의학 5: ) Popper CW, Steingard RJ(1994):Disorders usually first diagnosed in infancy, childhood, or adolescence. Textbook of psychiatry, ed by Hales RE, Yudofsky SC, Talbott JA, Washington DC, American Psychiatric Press, pp ) Arnold LE, Jensen PS(1995):Attention-deficit disorders, Comprehensive textbook of psychiatry, 6th ed, ed by Kaplan HI, Sadock BJ, Baltimore, Williams & Wilkins, pp ) 홍강의, 김종흔, 신민섭, 안동현(1996):주의산만, 과잉운동을 주소로 소아정신과 를 방문한 아동의 진단적 분류와 평가. 소아청소년 정신의학 7: ) Sleator EK, Ullman RK(1981):Can the Physician Diagnose Hyperactivity in the Office?. Pediatrics 67: ) Charles Popper, Scott A West(1999):Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. In Textbook of Psychiatry, 3rd ed. American Psychiatric Press, Washington DC, London, p834 9) Charles Popper, Scott A West(1999):Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. In Textbook of Psychiatry, 3rd ed. American Psychiatric Press, Washington DC, London, p835 10) 오경자(1990):주의력 결핍 과잉 활동 장애의 평 가. 소아청소년정신의학 1: ) Taylor(1995):Dysfunctions of Attention. Developmental Psychopathology vol. 2 : Risk, Disorder, and Adaptation, ed by Cicchetti D & Cihen DJ, New York, A Wiley-Interscience Publication, pp ) 조수철(1999):소아정신질환의 개념. 서울대학교 출판부: ) 안동현, 홍강의(1990) : 주의력 결핍장애 아동의 치료. 소아청소년정신의학 1: ) Costello EJ, Edelbrock C, Costello AJ, Dulcan MK, Barne BJ, Brent D(1988):Psychopathology in Pediatric primary care -New Hidden Morbidity. Pediatrics 81: ) John H(2000):National Institute of Health Consensus Development Conference Statement : Diagnosis and Treatment of Attention-Deficit/ Hyperactivity Disorder (ADHD). J AM Acad Child Adolesc Psychiatry 39: ) Kaplan HI, Sadock BJ(1998):Attention-Deficit Disorders.:Treatment. Synopsis of Psychiatry. 8th ed., Baltimore, Williams and Wilkins, pp

Arch Gen Psychiatry 24:211-220 3) 조수철, 신윤오(1994):파탄적 행동장애의 유병율 에 대한 연구. 소아청소년정신 의학 5:141-149 4) Popper CW, Steingard RJ(1994):Disorders usually first diagnosed in infancy, childhood, or adolescence.

10 17) Larry S. Goldman, Myron Genel, Rebecca J. Bezman, Priscilla J. Slanetz(1998):Diagnosis and Treament of Attention-Deficit/Hyperactivity Disorder in Child and Adolescents. J Am Med Assoc 279: ) Gilbert DA, Altshuler KZ, Rago WV(1998):Texas Medication Algorithm Project:definitions, rationale, and methods to develop medication algorithms. J Clin Psychiatry 59: ) Steven RP, Lawrence LG, M. LC, Andrew S, Caryn C, C. KC, James TC, Ja mes MS, Carroll WH, Maria EL, Molly L, Marcia GT(2000):The Texas Children s Medication Algorithm Project:Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part I. J AM Acad Child Adolesc Psychiatry 39: ) 신민섭, 박수현(1997) : 주의력결핍/과잉운동장애 아동의 신경심리학적 평가. 소아청소년정신의학 8: ) 이혜련 오경자 홍강의(1998):한국어판 아동행동 조사표, 하나의학사 22) Dupey TR, Greenberg LM(1993):T.O.V.A. Manual. U. A.D., LA 23) Diamond LH(1996):Developing disease-specific drug treatment protocols. In : Manolakis PG. ed. APhA Guide to Drug Treatment Protocols:A Resource for Creating and Using Disease Specific Pathways. Washington, DC:American Pharmaceutical Association ABSTRACT Korean J Child & Adol Psychiatr 13:129~138, 2002 PRELIMINARY STUDY FOR ADHD TREATMENT GUIDELINE Young-Sik Lee, M.D., Eun-Young Kim, M.D., Chul Ra, M.D. Department of Psychiatry, College of Medicine, Chung Ang University, Seoul Objectives:In order to treatment guideline of ADHD, present clinical practise of child psychiatrists and their opinion of optimal intervention were evaluated. Methods:Structured questionnaire items about diagnostic workup, drug choice of 5 different situations according to different co-morbid disorders, and non - pharmacological treatment were applied to 32 child psychiatrists working at university and general hospital. we compared the data with Texas Algorithm Project guideline. Results:(1) Intelligence Test, Sentence Completion Test, sustained attention test, and Conner's questionnaire were the basic routine test that must be performed. (2) Main trend of medication in this study was not different from TAP guideline. (3) In case of co-morbid tic disorder, first recommending drug is still psychostimulant in the TAP guideline. But in this study initial psychostimulant prescription was not main trend. (4) In case of MPH non-response co-morbid disruptive behavior disorder, MPH medication combined with other drug were more common than switching to other drug as suggested the TAP guidelines. (5) In non-pharmacological treatment, most child psychiatrists reported the importance of parent management. Conclusion:There were some difference in medication trend in this study compared with TAP guideline. Further study and conference are needed for experts consensus in Korea. KEY WORDS:Attention Deficit Hyperactivity Disorder(ADHD) Treatment Guideline Texas Algorithm Project(TAP)

J Clin Psychiatry 59:345-351 19) Steven RP, Lawrence LG, M. LC, Andrew S, Caryn C, C.

Table 1. The variables of T.O.V.A. inattention impulsivity disinhibition variability inconsistency 200msec., 291

Table 1. The variables of T.O.V.A. inattention impulsivity disinhibition variability inconsistency 200msec., 291 KISEP Original Articles 11 2 2000 Korean J Child & Adol Psychiatr 11290~296 주의산만을주소로소아정신과를내원한 아동의인지적특성 - T.O.V.A. 양상을중심으로 - T.O.V.A. PROFILES OF CLINICALLY REFERRED CHILDREN WITH SYMPTOMS OF INATTENTION